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Surgical Materials

Fixation devices, biological augmentations, and irrigation solutions used in shoulder surgery, with a focus on biomechanical stability and healing potential.

133 citationsUpdated Oct 2026

Overview

Surgical materials in orthopaedics encompass a diverse array of implants, sutures, and biological substitutes, each with distinct mechanical and biological profiles. The characteristics of the ideal bone graft substitute vary considerably depending on the intended site of application and clinical setting [4]. Bone substitutes display a wide range in structural properties and compression strength, indicating suitability for different clinical indications [9]. Commercially available extracellular matrix (ECM) materials possess defined mechanical and biological characteristics with delineated indications for clinical use [38]. While absorbable implants offer the major clinical advantage of negating the need for subsequent removal, the mechanical strength of early-generation devices was insufficient for some orthopaedic applications [17]. Biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions in the pediatric population, though they are associated with high short-term complication rates and donor-site morbidity [18].

Complications related to suture anchors and tacks are categorized as technique-related or device-related issues [3]. Prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations [3]. Potential complications have been identified when using surgical devices containing polymerized lactic acid (PLA) [15]. Caution must be advised in the use of an absorbable shoulder fixation device, with post-operative pain and stiffness assessed carefully [43]. Complications are ubiquitous with all methods for managing segmental bone defects but can be limited with careful surgical judgment, patient optimization, and technique [32]. Reoperation rates exceed 20% among patients with clavicle fracture, with the vast majority of reoperations performed for device removal [68].

Clinical outcome studies comparing suture materials remain elusive [1]. There is little reason not to use stronger suture material, which is an option within the surgeon's control [1]. However, the greater strength of repair may not translate into improved clinical outcome due to increased suture bulk [5]. Some suture materials may provide a superior alternative to wire for cerclage fixation techniques with select clinical application [39]. Initial experience using the “Double-Barrel” Knot in different procedures has yielded encouraging results, though its biomechanical properties are currently under evaluation [19]. Current indications for 3D printing in orthopedics include education for patients, providers, and trainees, in addition to surgical planning [8]. The development of patient-specific implants using 3D printing continues to be explored [8]. Understanding the current evidence and appropriate indications of emerging technologies is of critical importance for their utilization [16].

Anatomy & Pathophysiology

Bony Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft [84]. The articular head is spherical with a diameter of 37 to 57 mm [84]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [84]. Humeral version averages 29.8 degrees, ranging from 10 to 55 degrees [84]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [84]. The anatomic neck is located at the junction of the articular surface and the tuberosities [84]. The surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [84]. Fractures involving the anatomic neck are prognostically worse than those involving other regions due to potential disruption of the vascular supply to the humeral head [84].

The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [84]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [84]. The glenoid is a convex structure of shallow depth shaped like an inverted pear [84]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [84].

The scapula is triangular when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly [87]. The glenoid is connected with the flat body of the scapula by the scapular neck [87]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [87]. The highest concentration of bony mass in the scapula is located in the glenoid, the scapular neck, and the lateral border of the scapular body [87]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar and the spinal pillar [87]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [87]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [87]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [87]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [87].

The clavicle is the first bone to ossify at the fifth week of gestation and is the only long bone to ossify by intramembranous ossification [88]. The medial epiphysis of the clavicle is the last ossification center to fuse, occurring at age 20 to 25 years [88]. The primary blood supply to the clavicle is periosteal, and no nutrient artery is present [88]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [88]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [88]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [88]. Failure of fusion of the acromial ossification centers results in os acromiale [88].

The subchondral bone of the glenoid is relatively flat, and the articular concavity is augmented by cartilage and a circumferential labrum [88]. The glenoid averages 5 degrees of retroversion in relation to the axis of the scapular body [88]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [88]. The humeral head averages 19 degrees of retroversion and 41 degrees of inclination [88]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [88]. The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [88].

The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [88]. The posterior sternoclavicular joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [88]. The acromioclavicular joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [88]. The superior and posterior acromioclavicular ligaments are the primary stabilizers to anterior and posterior translation of the clavicle [88]. The coracoclavicular ligaments are the primary stabilizers to superior translation of the distal clavicle [88].

The humeral shaft extends from the level of the insertion of the pectoralis major muscle proximally to the supracondylar ridge distally [86]. The upper portion of the humeral shaft is cylindrical and becomes more flattened in an anteroposterior direction as it proceeds distally [86]. The glenoid cavity is a shallow socket, approximately one-third the size of the humeral head [86]. The neck-shaft angle of the proximal humerus measures an average of 135 degrees [86]. The humeral head is retroverted an average of 30 degrees [86].

The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [86]. The teres major is not a rotator cuff muscle [86]. The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [86]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [86].

The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [101]. The scapula is anteverted on the chest wall approximately 30 degrees relative to the body [101]. The glenoid is retroverted approximately 5 degrees relative to the scapular body [101]. Os acromiale is incomplete fusion of secondary ossification centers, most commonly between the mesoacromion and meta-acromion [101]. The coracoid process serves as an attachment for the coracoacromial ligament, coracoclavicular ligaments, conjoined tendon, and pectoralis minor [101]. The suprascapular artery passes superior to the superior transverse scapular ligament and the suprascapular nerve passes inferior to the ligament through the suprascapular notch [101]. At the spinoglenoid notch, both the artery and nerve are inferior to the inferior transverse scapular ligament [101].

The humeral head is retroverted 30 degrees relative to the transepicondylar axis of the humerus [101]. The head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [101]. The anatomic neck is located directly below the humeral head and serves as an attachment for the shoulder capsule [101]. The surgical neck is more distal than the anatomic neck and is more often involved in fractures [101]. The transverse humeral ligament is an important stabilizer of the biceps tendon [101]. The glenohumeral joint is a ball-and-socket joint with the greatest range of motion in the body [101].

The sternoclavicular joint is a double gliding joint with an articular disc and is the only true joint connecting the upper extremity with the axial skeleton [101]. The posterior sternoclavicular ligament is the strongest and primary restraint to anteroposterior instability [101]. The sternoclavicular joint rotates 30 degrees with shoulder motion [101]. The acromioclavicular joint is a plane/gliding joint with a fibrocartilaginous disc [101]. The posterior and superior acromioclavicular ligaments are considered the strongest [101]. The trapezoid ligament is located approximately 25 mm from the acromioclavicular joint [101]. The conoid ligament is located approximately 45 mm from the acromioclavicular joint and is stronger than the trapezoid ligament [101].

The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [98]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [98]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [98]. The average neck-shaft angle is 45 degrees, with a range of 30 to 50 degrees [98]. Arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [98]. The normal position of the glenoid surface in relation to the axis of the scapular body ranges from 2 degrees of anteversion to 7 degrees of retroversion [98]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [98].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [98]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction [98]. A significant increase in lateral humeral offset causes excessive tension on the soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [98]. Humeral articular malposition of more than 4 mm led to increased subacromial contact [98]. An offset of 8 mm in any direction significantly decreased passive range of motion [98]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the method used for measurement [98].

The glenoid diameter ranges from 18 to 30 mm superiorly and 21 to 35 mm inferiorly in the anteroposterior direction [98]. The superoinferior height of the glenoid ranges from 30 to 48 mm [98]. The average inclination of the glenoid is 4.2 degrees, with a range of -7 to 20 degrees [98]. The inclination of the humeral head ranges from 30 to 55 degrees [98]. The average version of the glenoid is 1.5 degrees retroversion, with a range of 10.5 degrees anteversion to 9.5 degrees retroversion [98]. The surface area of the glenoid ranges from 4 to 6 mm [98]. The surface area of the humeral head ranges from 11 to 19 mm [98]. The cartilage thickness of the glenoid is 2.16 mm [98]. The cartilage thickness of the humeral head is 1.44 mm [98]. The radius of curvature of the glenoid ranges from 22 to 28 mm [98]. The radius of curvature of the humeral head ranges from 23 to 28 mm [98]. The medial humeral offset in the coronal plane ranges from 4 to 14 mm [98]. The posterior humeral offset in the transverse plane ranges from -2 to 10 mm [98].

The formation of the humerus begins with the appearance of the cartilage anlage by the fifth week of gestation [92]. The primary ossification center for the humerus appears at about the sixth week of gestation [92]. By birth, the entire humeral diaphysis is completely ossified [92]. The proximal humerus is primarily cartilaginous at birth, with ossification centers detectable by ultrasonography as early as the 38th week of gestation [92]. The ossification center for the humeral head is usually present at birth [92]. The greater tuberosity ossification center appears by 1 to 3 years of age [92]. The lesser tuberosity ossification center appears by 5 years of age [92]. The proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [92]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [92].

Mean humeral retroversion is around 26 degrees in healthy adults [92]. Humeral retroversion averages 65 degrees in infants and young children and gradually decreases, approaching adult values by 11 years of age [92]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis [92]. The proximal humeral physis accounts for approximately 40% of the growth of the entire upper extremity [92]. Less than 75% of humeral growth occurs before 2 years of age [92]. More than 85% of humeral growth occurs by 8 years of age [92].

Soft Tissue Anatomy

The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus [93]. The subscapularis is inserted into the lesser tuberosity [93]. The rotator cuff is made up of the subscapularis in front, supraspinatus above, and infraspinatus and teres minor behind [93]. The rotator cuff stabilizes the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [93].

The coracoacromial arch is a fibro-osseous canopy formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [93]. The subacromial bursa separates the tendons from the coracoacromial arch and allows them to glide [93]. The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [89]. The subscapular bursa communicates with the joint cavity between the superior and middle glenohumeral ligaments [89]. The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [89]. The subscapular bursa is linked to the coracoid process by a suspensory ligament [89]. In 28% of specimens dissected by Colas and colleagues, the subscapular bursae merged with the subcoracoid bursae, forming a unique wide bursa [89]. The subscapular bursa often houses loose bodies in the shoulder [89]. Synovitis of the shoulder may be most intense in the subscapular bursa, where small fringes or villi can project into the joint cavity [89]. A bursa may be present between the infraspinatus muscle and the capsule, though it is uncommon and not in communication with the joint cavity [89].

DePalma described six common variations or types of recesses in the anterior capsule [89]. Type 1 recesses (30.2%) have one synovial recess above the middle glenohumeral ligament [89]. Type 2 recesses (2.0%) have one synovial recess below the middle glenohumeral ligament [89]. Type 3 recesses (40.6%) have one recess above and one below the middle glenohumeral ligament [89]. Type 4 recesses (9.0%) have one large recess above the inferior ligament, with the middle glenohumeral ligament being absent [89]. Type 5 recesses (5.1%) have the middle glenohumeral ligament manifested as two small synovial folds [89]. Type 6 recesses (11.4%) have no synovial recesses, although all the ligaments are well defined [89]. DePalma believed that if the capsule arises at the labrum or glenoid border of the scapula, few, if any, recesses would be present [

Classification

Suture Anchor and Tack Complications: Complications associated with suture anchors and tacks are categorized as either technique-related or device-related issues [3].

Bone Graft Substitutes: The characteristics of the ideal bone graft substitute vary depending on the intended site of application and the clinical setting [4]. Bone substitutes display a wide range in structural properties and compression strength, indicating suitability for different clinical indications [9]. No single alternative graft material provides all three components for bone regeneration, and clinical applications are dictated by their particular structural and biochemical properties [66]. The use of artificial bone grafts is expected to increase, but their effectiveness remains a subject of debate due to unclear definitions or limited market surveillance [71]. Not all biocomposite anchors are the same, as they have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone [72]. The cement substance is the important factor differentiating the bone matrix from other calcifying fibrous tissues [138].

Suture Material Biomechanics: The construct efficiency of multi-strand repairs varies with respect to different repair techniques and suture materials [33]. The type of suture material has a significant effect on the biomechanical behavior of the suture-tendon interface [160]. Significant differences were found between ultimate failure loads of various suture types and sizes, with new polyblend materials showing distinct mechanical properties [124]. Differences exist between traditional and newer suture materials when tying various types of knots under arthroscopic conditions [129]. The Kessler configuration exploits the full strength of the suture material as failure occurs by material failure in the gap [141]. The self-tensioning suture showed dynamic properties, demonstrating a decrease in loop length when soaked in a saline bath compared with other suture types [146]. FiberTape consistently displayed less creep, greater stiffness, and less extensibility than other suture types [147]. The force sustained at a gap of 3 mm did not differ between four-strand and eight-strand repairs (35 N for both groups), indicating that the two repairs are equally susceptible to rupture if a gap of 3 mm or greater forms [150].

Screw Configuration: Common screw types resist physiological shear loads in a bicortical configuration, but 3.75 mm screws incurred significant displacements at 200 N in unicortical configurations [162].

Freeze-Dried Allogeneic Segmental Cortical-Bone Grafts: Freeze-dried allogeneic segmental cortical-bone grafts are classified according to the kind of repair as Types 1, 2, and 3 [216]. In a Type-1 normal repair of freeze-dried grafts, a fusiform callus forms at the graft-host junctions within four weeks, junctions undergo gradual consolidation between eight and twelve weeks, and the callus decreases in size between twelve and sixteen weeks [216]. In a Type-2 (incomplete) repair of freeze-dried allografts, resorption of the graft is evident by the fourth week, and by the eighth week the graft's original diameter is diminished by 50 per cent [216]. In a second form of Type-2 repair of freeze-dried allografts, the initial resorptive phase occurs between four and eight weeks and is not followed by enough new-bone formation to reconstitute the continuity of the skeletal defect [216].

Acetabular Defect Classification: The acetabular defect classification system uses four radiographic parameters: component location relative to Kohler's line, superior migration of the hip center of rotation above the superior obturator line, degree of ischial osteolysis, and teardrop osteolysis [45]. In type I and II acetabular defects, there is sufficient support from the host bone to provide initial stability for a cementless acetabular component with or without allograft [45]. Type III acetabular defects are characterized by more than 3 cm of superior migration, where the remaining acetabular rim will not provide adequate initial component stability to achieve reliable biologic fixation [45]. A type IIIA acetabular defect is associated with superolateral migration and has less than 15 mm of ischial lysis below the level of the superior obturator line [45]. A type IIIB acetabular defect has superomedial migration, with the component extending medial to Kohler line and often greater than 15 mm of ischial lysis below the obturator line [45]. There is often severe teardrop osteolysis with type IIIB acetabular defects [45].

Pediatric Bone Lesions: The reliability of the modified Neer classification has not been evaluated in pediatric bone lesions [29]. The MSTS score has been used in few studies of pediatric bone lesions and has not been validated in children [29].

Denis Zone I Osteotomy: A vertical osteotomy in Denis zone I imitating an FFP type-IIB fracture (61-B3 fracture according to the OTA classification) involves a 4 mm wide osteotomy that spans the complete craniocaudal length of the sacrum while leaving the posterior cortex and posterior sacroiliac ligaments intact [214].

Clinical Presentation

Clinical assessment of surgical materials and implant outcomes requires careful preoperative evaluation and planning for rational decision making in the management of glenoid bone loss [11]. Both cement techniques for glenoid replacement have provided excellent clinical outcomes to date [2]. In the context of soft tissue and suture anchor management, prevention of suture anchor and tack complications depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations [3].

Implant and Graft Outcomes

Biomechanical studies show that glenoid reconstruction with distal tibial allograft provides near anatomic reconstruction, leading to increased stability, improved contact area, and decreased loading pressures [26]. Clinical and radiological outcomes are similar in both short-stem designs with and without proximal porous coating [7]. Further possibilities such as the development of patient-specific implants continue to be explored [8].

In a study of glenoid tricortical iliac crest structural bone graft enhanced with resorbable cement, five of 6 patients had a complete healing of the bone graft using the described technique [10]. No radiolucent lines associated with resorption of cement were observed in this study [10]. Methyl methacrylate caused no gross reaction that could be recognized clinically or roentgenographically in thirty-three patients, after being in contact with bone for periods as long as fourteen years and four months [14]. A patient demonstrated a satisfactory clinical outcome after 6 months and 2 years postoperatively following a cement-impression technique using femoral head allograft [28].

Complications and Monitoring

The overall complication rate in the series of massive bone allograft with free vascularized fibular flap was significant, but the fragile condition of these patients should be taken into account [12]. Two traumatic fractures were observed in the series of seven patients using this technique [12]. Only two out of seven patients required a single reintervention, and only one patient underwent several additional procedures which resulted in good outcome without sequelae [12]. The overall reintervention rate is low, particularly when only considering surgical revisions resulting from mechanical complications following one-stage techniques [12]. The complication rates of the technique, free vascularized fibula fitted into an allograft, are significantly lower than those reported by isolated allografts, in the short but above all long-term [12].

Skin paddle is a reliable method for postoperative monitoring of the fibular graft viability, providing immediate detection of early vascular failures and allowing early adapted treatment [12]. In one case, the radiographic behaviour suggests a fibular necrosis occurring in a patient in who graft monitoring using a skin paddle was not possible [12]. Potential complications have been identified when using surgical devices containing PLA [15]. All the problems were related to the delayed absorption of the Vicryl suture material and hence the prolonged presence of the suture in the hands of these children [62].

Long-term Follow-up and Specific Indications

At follow-up ranging from 8 to 18 years, 37 patients were clinically assessed as good, 9 as fair, and none as poor in the study of ankle-joint injuries [59]. Early clinical experience involving reamed autogenous bone graft in the management of nonunion, bone defects, and arthrodesis has been encouraging and has demonstrated the necessary properties to warrant regular consideration of reamed graft for these applications [37]. In a limited case series, the studied biphasic bone substitute demonstrated acceptable surgical outcomes for the treatment of benign bone lesions [35]. The bone substitutes tested display a wide range in structural properties and compression strength, indicating that they will be suitable for different clinical indications [9].

Absorbable implants offer major clinical advantages by negating the need for subsequent removal, though the mechanical strength of early-generation devices was insufficient for some orthopaedic applications [17]. The procedure resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula, with no infections or neuromuscular complications in the treatment of deltoid muscle contracture [111]. Early recurrence of disease is most common in individuals with Dupuytren's diathesis, and the use of full-thickness skin grafts may be helpful in this setting [108].

Regulatory and Standardization

The report outlines the need for a permanent organization to test surgical materials, conduct research, encourage standardization, and assist manufacturers [6]. The report recommends the establishment of the American Surgical Materials Association with funding from three sponsoring medical organizations [6].

Investigations

The primary objectives of shoulder imaging are to establish a diagnosis, determine the severity of pathoanatomy, assist in surgical planning, and illustrate the condition to the patient [51]. Standardized plain films are almost always sufficient to garner the information needed for shoulder care [51].

Plain radiography: At least two X-ray views should be obtained: an anteroposterior view in the plane of the glenoid and an axillary projection with the arm in abduction [110]. The axillary view taken with the arm in the functional position of elevation is referred to as the "truth view" because it demonstrates glenohumeral relationships in that position [51]. This standardized axillary view enables measurement of posterior subluxation or "functional decentering" that is not evident in images taken with the arm at the side [51]. The degree of posterior subluxation can be measured by the position of the humeral head center relative to the scapular plane, relative to the glenoid face, or by the point of contact of the humeral articular surface on the glenoid articular surface [51]. Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and "rocking horse" loosening of prosthetic glenoid components [51].

For proximal humerus fractures, the recommended series is the Neer trauma series, consisting of an AP view, a lateral view in the scapular plane, and a Velpeau modified axillary view [113]. The combination of these three views allows evaluation of the shoulder joint in three separate perpendicular planes [113]. Specific views are indicated for particular pathologies: the West Point view for anterior glenoid bone loss, the Stryker notch view for Hill-Sachs lesions after dislocation, the Apical oblique view for glenoid rim fracture in instability, the Zanca view for the acromioclavicular joint, and the Serendipity view for the sternoclavicular joint [122]. The axillary view is necessary in the evaluation of glenohumeral joint instability and may detect occult, locked posterior shoulder dislocation [122]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [122]. Type III acromial morphology has been shown to have a correlation with the presence of rotator cuff disease, although no direct causal relationship has been demonstrated [122]. The classification of acromial morphology has shown relatively poor interobserver reliability [122]. Normal acromiohumeral distance is 7 to 14 mm, and normal coracoclavicular distance is 1.1 to 1.3 cm [122]. Plain radiographs are an excellent starting point for most bone tumors [134].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [119]. It is useful to identify osteonecrosis of the humeral head, bone tumours, labral tears, and rotator cuff tears [110]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with MR arthrograms to provide a more detailed picture of joint surfaces [119]. T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [119]. The accuracy of MRI for identifying labral tears and rotator cuff tears is enhanced by combining the scan with arthrography [110]. Magnetic resonance accuracy in identifying labral and rotator cuff tears ranges from 70% to 100% [116]. In a meta-analysis of 6 studies including 4,667 shoulders, MRA had a sensitivity of 88% and specificity of 93% for detecting glenoid labral lesions [116]. In the same meta-analysis, MRI had a sensitivity of 76% and specificity of 87% for detecting glenoid labral lesions [116].

For full-thickness rotator cuff tears, the sensitivity of MRI is 100% and the specificity is 68% [122]. The positive predictive value of MRI is 85%, the negative predictive value is 100%, and the accuracy is 89% [122]. MR arthrography is considered the benchmark for evaluation of labral tears and is rarely indicated for evaluation of rotator cuff pathology [119]. MR arthrography increases the sensitivity for detecting tears and other lesions by distending the joint capsule and outlining cartilage, ligaments, and labrum with contrast [116]. Abduction and external rotation (ABER) positioning is utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [116]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of MRA in the neutral position [116]. MRA is more effective in identifying Perthes lesions when using the ABER position compared to the neutral position [116]. Full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [116]. MRAs can demonstrate a patulous capsule on coronal, sagittal, and axial imaging in patients with multidirectional instability [116]. Glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion are associated with increased posterior labral tears and symptomatic instability [116]. Glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, but there was no significant association between instability and increased humeral head subluxation [116]. The diagnosis of multidirectional instability is a clinical one, and the need for expensive or invasive imaging should be weighed against the information gained [116]. MRI is often helpful for soft-tissue tumors, bone masses with a soft-tissue component, and any malignant tumor [134]. Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [135].

CT: CT scans may offer increased precision in measuring glenoid version, but this precision does not necessarily improve surgical quality or clinical outcome [51]. CT scans have the disadvantage of being taken with the arm in the adducted position, unlike the axillary truth view [51]. CT is helpful for planning fracture surgery and shoulder joint replacement [110]. CT scanning may be necessary on occasion for detailing bony anatomy in proximal humerus fractures [113]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [122]. CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips [119].

Ultrasound: Ultrasound is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [110]. It can be useful in guiding injections or barbotage of calcific deposits in the rotator cuff [110]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating skeletal and soft-tissue structures of the shoulder [119]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [119]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [119]. However, it is highly operator-dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [119].

For the detection of full-thickness rotator cuff tears, the sensitivity of ultrasonography is 98% and the specificity is 80% [122]. The positive predictive value is 90%, the negative predictive value is 95%, and the accuracy is 94% [122]. Ultrasound, MRI, arthrogram, or arthroscopy may be valuable in evaluating the integrity of the rotator cuff in the acute setting of proximal humerus fractures [113].

Arthroscopy: Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, glenoid labrum detachment, and rotator cuff tears [110].

Other Considerations: The vast majority of musculoskeletal tumor patients can be diagnosed without invasive testing using appropriate radiographs and judicious advanced imaging [134]. Metal suppression magnetic resonance imaging techniques facilitate better-informed diagnostic decisions by addressing metal artifacts in orthopaedic MRI [49]. An algorithm for automated identification of total shoulder arthroplasty implants may provide a clinically meaningful adjunct in assisting with preoperative planning for failed TSA [166]. The improved imaging capability of newer generation micro-computed tomography scanners reduced the metal-induced artefact zone enough to permit assessment of bone-implant contact [169]. Bony incorporation of autograft and allograft as evaluated on CT scan after reverse shoulder arthroplasty with glenoid structural bone graft reconstruction is predictably high [140]. Opioid users had significantly increased rates of periprosthetic radiolucency and revision two years after reverse total shoulder arthroplasty [175].

Treatment

Sutures and Knots

Suture Material Selection: Clinical outcome studies comparing suture materials remain elusive, but there is little reason not to use stronger suture material, which is an option within the surgeon's control [1]. The construct efficiency of multi-strand repairs varies with respect to different repair techniques and suture materials [33]. Stainless steel suture is difficult to use, while the only disadvantage of monofilament polyglyconate is that it is absorbable [131, 132].

Knot Configuration and Biomechanics: The knots-outside suture configuration provides greater initial tensile strength compared to the knots-inside configuration [21]. However, there was no significant difference in relative tensile strength for either technique through 3 weeks of in vivo healing [21]. Reduced tensile strength was noted for both techniques at 1 week after repair, and tensile strength for both techniques was slightly better than that of the initial repair by 3 weeks [21]. With nonbarbed sutures, the knot technique was stronger than the grasping technique (41.70 N vs 30.38 N) [210]. A suture-bridge construct with the non-post limb preserved and the post limb cut at a 4 mm distance from the knot provides the best security [212].

Specific Knot Techniques: The Zhang knot is a sliding and locking configuration designed to meet the dual arthroscopic demands of high initial stability during tissue tensioning and secure final fixation [47]. Once the first half-hitch is locked and the loop limb is fully tightened, the Zhang knot achieves a definitive and irreversible state of security [47]. Any attempt to reverse or untie the Zhang knot at this stage risks suture damage or failure [47]. Initial experience using the "Double-Barrel" Knot in different procedures has yielded encouraging results, and the biomechanical properties of this knot are currently under evaluation [19].

Suture Anchors and Fixation Devices

Device Selection and Complications: Complications related to suture anchors and tacks can be categorized as technique-related or device-related issues, and prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations [3]. There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm [42]. Caution must be advised in the use of absorbable shoulder fixation devices, and post-operative pain and stiffness assessed carefully [43].

Insertion Technique: Inserting suture anchors at 90° is recommended due to the significantly larger ultimate failure load in both decorticated and non-decorticated bones [193].

Bone Grafts and Substitutes

Graft Material Properties: No single alternative graft material provides all three components for bone regeneration, and clinical applications for substitutes are dictated by their particular structural and biochemical properties [66]. Material-derived osteoinduction significantly enhanced bone healing orthotopically, and this material property appeared more sensitive for predicting orthotopic performance than physicochemical and structural characteristics [120].

Autografts: Biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions in the pediatric population at the expense of high short-term complication rates and donor-site morbidity [18]. A large technique series for preventing autograft-related complications showed promising functional outcomes and provided durable reconstruction [20]. In the early postoperative period, vascularized bone grafts resemble bones that have had a sham operation and those that have not been operated on, maintaining their strength and stiffness better than non-vascularized grafts during the first three months after the operation [81]. While serious problems persist, the technique allows for osseous union in the majority of cases for vascularized and non-vascularized segmental fibular canine autografts [80].

Allografts: Allografts may be comparable to autografts for crucial effectiveness outcomes, but insufficient evidence was found to judge crucial safety outcomes due to poor reporting of safety measures and outcomes [118]. Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes for chronic distal biceps tendon ruptures [63]. This report demonstrates that operations involving a nonmassive allograft about the olecranon process may display minimal side effects in comparison to massive allografts, specifically regarding nonunion [184]. This combined graft approach using dermal allograft and biceps tendon autograft may offer a durable and reproducible solution for managing irreparable rotator cuff tears in carefully selected patients [186]. In contrast, untreated allografts and nonvascular allografts showed delayed union and distal femoral collapse [46].

Substitutes and Combinations: The combination of DBM and PRP could serve as a safe bone graft substitute in clinical practice for non-union, achieving low incidence of postoperative complications and satisfactory bony healing rate, though larger and higher quality studies are needed to assess its routine use [179]. In a limited case series, the studied BCBS demonstrated acceptable surgical outcomes [35]. TE-OCA is comparable to OCA in multiple safety and efficacy measures of osteochondral defect repair [130]. The combination therapy of low intensity pulsed ultrasound with increased cortical porosity demonstrated marginal improvement in direct healing over other experimental treatment groups excluding autologous grafts [126].

Surgical Outcomes and Techniques: Biomechanical studies show that glenoid reconstruction with DTA provides near anatomic reconstruction, leading to increased stability, improved contact area, and decreased loading pressures [26]. The lost intrinsic stability can be restored by bone grafting, with effectiveness related to both graft height and contour [65]. Five of 6 patients had a complete healing of the bone graft using the described technique, and no radiolucent lines associated with resorption of cement were observed [10]. The application of free microvascular epiphyseal-plate transplantation clinically is minimum [31]. Only two out of seven patients required a single reintervention (non-union treatment in Patient 3, excision-suture of wound dehiscence in Patient 5) demonstrating good outcome without sequelae [12]. Only one patient (Patient 4) underwent several additional procedures (infection on the device, removal of the device then post-traumatic fracture) which resulted in good outcome without sequelae [12]. Despite relatively low mean subjective outcomes, objective measures were very good with no failures based on MARS criteria and full allograft dowel incorporation in ACL revision reconstruction [40].

Cement and Implants

Glenoid and Humeral Fixation: Both techniques have provided excellent clinical outcomes to date regarding the role of cement in glenoid replacement [2]. Clinical and radiological outcomes are similar in both short-stem designs regarding proximal porous coating in short-stem humeral arthroplasty [7]. The technique of glenoid implantation is the guarantee of the glenoid survival, which is synonymous with good clinical results [67]. Given its outstanding clinical outcomes observed in the current patient series, advocating for this fixation device holds considerable clinical significance in enhancing patients' prognoses [30].

Prosthesis Mechanics and Contraindications: The modulus of elasticity varies by a factor of 200,000 between the metal prosthesis (about 200,000 MPa) and the surrounding intact articular cartilage (0.5 to 0.9 MPa); this creates a major discontinuity in the deformation of the joint surface under load at the margin of the prosthesis [106]. Registry data indicate a 2.5-year revision rate for resurfacing prostheses; this is more than three times the revision rate for stemmed hemiarthroplasty [106]. Severe glenoid cartilage lesions emerged as a contraindication for partial humeral head resurfacing [133]. To date, no adverse clinical reactions to the patch have been observed, although no randomized clinical trials have been performed [58].

Bone Defect and Infection Management

Chronic Osteomyelitis Principles: Chronic osteomyelitis is very difficult if not impossible to completely eradicate, with recurrences occurring years after the original diagnosis [102]. The aim of treatment for chronic osteomyelitis is resolution of symptoms and restoration of function [102]. The most important step for a successful outcome in chronic osteomyelitis is prompt diagnosis [102]. Management of chronic osteomyelitis can be very complex and requires a multidisciplinary approach [102]. "Orthoplastic" care refers to the collaboration of orthopedic trauma surgeons and plastic surgeons for the optimal management of patients requiring complex reconstructive procedures following trauma, osteomyelitis, or tumors [102]. The main goals of treatment for chronic osteomyelitis are removal of all the devitalized tissue and pathogens and elimination of the inflammatory process, dead space management, stimulation of bone repair when an aseptic environment has been established, restoration of the mechanical axis of the limb and previous functional capacity, and reduction of the risk of recurrence [102]. These goals can be achieved with a combination of aggressive surgical debridement and management of the dead space, along with targeted, effective antibiotic treatment [102]. Treatment and definition of a successful outcome for chronic osteomyelitis should be individualized [102].

Diagnosis and Pre-treatment: Chronic osteomyelitis remains a serious health problem worldwide and represents an economic burden to any health system, because of its high incidence of hospitalization, need for multiple procedures, and high risk of recurrence [103]. Before the initiation of treatment for chronic osteomyelitis, causal host disorders such as diabetes and peripheral vascular disease should be addressed [103]. Prevention of osteomyelitis is of paramount importance, as in the case of open fractures, the diabetic foot, and the implantation of orthopedic devices [103]. The gold standard for the diagnosis of chronic osteomyelitis is positive bone cultures and histopathologic examination of the bone [103]. FDG-PET combined with CT appears to be the most accurate imaging technique for detecting osteomyelitis, especially in the axial skeleton [103]. If FDG-PET combined with CT is unavailable, leukocyte scintigraphy can be used with satisfactory diagnostic accuracy in the peripheral skeleton [103]. The management of chronic osteomyelitis is challenging and complicated by the presence of sequestra, biofilms, impaired local vascularity, compromised tissue envelopes, and multiple comorbidities [103]. For optimal treatment of chronic osteomyelitis, a multidisciplinary approach is advocated [103]. Treatment for chronic osteomyelitis should be individualized according to severity of disease, chronicity, clinical, and radiologic response to treatment [103]. Treatment for chronic osteomyelitis should ideally include a combined antimicrobial and surgical treatment, with effective management of the dead space and soft tissue reconstruction where required [103]. Regardless of all the advances in this field, the risk of recurrence and risk of amputation remain high for chronic osteomyelitis [103]. The length of follow-up for chronic osteomyelitis remains a subject of debate, but should be at least 5 years to ensure the absence of subclinical infection [103]. "Cure" of the disease on the other hand cannot be safely declared as once osteomyelitis has been established, complete eradication of the infection is extremely difficult if not impossible [103].

Future Directions: Future directions in the management of osteomyelitis include the development of species-specific antibiotics, exploring new pathways of binding sites of microorganisms, exploiting biofilms, and improving the understanding of mechanisms of genome mutations leading to resistance to specific antibiotics [103]. The use of novel biocompatible, biodegradable antibiotic carriers, combining osteoinductive and osteoconductive properties, and compatible with a wider range of antibiotics could be a solution in the management of bone defects [103]. Antimicrobial implant coatings may be an option preventing implant colonization and biofilm formation [103].

Septic Nonunions: Septic nonunions are one of the most challenging reconstructive procedures facing the orthopedic traumatologist [104]. These patients deserve the expertise of a team fluent in their management [104]. Often, infected nonunions are limb-threatening conditions [104]. Given the seriousness of this condition, our approach is to maximize the treatment decisions toward eradicating infection [104]. Hardware removal, wide debridement, soft tissue coverage as needed, culture-specific local and IV antibiotics, and bony stabilization that minimized foreign material at the site of infection are utilized in the initial phase of a multistage management protocol for septic nonunions [104]. Local antibiotic delivery is typically with antibiotic beads between serial debridements and with antibiotic PMMA spacers or antibiotic rods after definitive wound closure at the conclusion of this stage [104]. Stabilization is with an antibiotic rod when applicable (e.g., diaphyseal tibia nonunion), otherwise with external fixation [104]. The second phase of management is dedicated to culture-specific antibiotic treatment [104]. An infectious disease team experienced in the management of osteomyelitis associated with fractures is critical to direct the selection and duration of antibiotic therapy and manage any encountered side effects [104]. Close communication between orthopedic and ID teams is important as unexpected events often necessitate changes in management plans [104]. The second phase ends when clinical, laboratory, and radiographic signs of infection are absent, usually after 6 weeks of therapy [104]. The third phase in the management of infected nonunions typically mimics the management of atrophic aseptic nonunions [104]. One important decision at this juncture is whether to discontinue antibiotic therapy prior to nonunion repair or to continue therapy through and after

Dead Space Management Options: The Masquelet technique is associated with less costs compared to bone transport from the health economic perspective [13]. The induced membrane possesses angiogenic, osteoinductive and inductive properties [13]. Biodegradable antibiotic delivery devices release most of their incorporated antibiotic content after degradation, can carry a wider range of antibiotic agents, leave no substratum for bacterial colonization, and are easy to use [48]. Biodegradable antibiotic delivery devices are associated with increased risk of antibiotic resistance, persistent drainage from wounds and seromas, and some release acidic degradation products limiting the volume that can be used [48]. Bioactive glass has antimicrobial, osteoconductive, and angiogenic properties and integrates with bone and soft tissue [48]. Good soft tissue coverage is required for bioactive glass [48]. Local flaps provide well-vascularized, healthy tissue covering the defect improving bone and wound healing, but pedicle length limits the distance flap can be transferred to and there is donor site morbidity [48]. Vascularized free flaps provide well-vascularized, healthy tissue covering the defect improving bone and wound healing, but require microsurgical anastomoses with high risk of complications and failure of graft, prolonged operating time, and are contraindicated in peripheral arterial disease [48].

Bone Grafting Strategies: Primary bone grafting is a single-stage procedure with superior osteoconductive, osteoinductive, and osteogenic properties of the graft, and antibiotics can be added for local release [54]. Primary bone grafting is associated with donor site morbidity, limited availability, risk of early resorption, risk of relapse of infection, and slow and unreliable graft incorporation [54]. Bone graft substitutes have no donor site morbidity and antibiotics can be added for local release [54]. Bone graft substitutes are associated with persistent drainage from wounds and seromas, and the release of antibiotics is usually uncontrolled [54]. The induced membrane (Masquelet) technique combines the advantages of antibiotic-impregnated cement spacers with those of delayed bone grafting, the induced membrane is highly vascularized and rich in growth and osteoinductive factors, and it provides a confined space for the application of the bone graft [54]. The induced membrane (Masquelet) technique is a two-stage procedure, associated with increased risk of antibiotic resistance, limited availability of bone graft, and can be associated with prolonged healing and recovery time [54].

Fixation and Reconstruction: Fixation devices and bone transport have a site of corticotomy with good blood supply reducing the risk of healing complications, and are a minimally invasive technique with less trauma to soft tissues [54]. Fixation devices and bone transport are limited by neurovascular bundle distraction, contracture or pain for distraction >2 cm, frequent pin-site complications, need for specialized skills and equipment, and high incidence of re-interventions [54]. Megaprosthesis allows early restoration of function and is a single-stage surgery [54]. Megaprosthesis is only available at specialized centers, has high associated costs, risk of dislocation, risk of recurrence, and no options for revision surgery [54].

Complications

Sutures and Knots

Knot tying weakens suture material, and locating knots at the laceration site subjects them to full tensile load, reducing ultimate tensile strength compared to knots placed outside the repair site [21]. In experimental models, four suture strands alone occupied an average of 7% of the available cross-sectional area, while four knots at the laceration site occupied 18%-26% of the total cross-sectional area [21]. Vicryl suture material decays rapidly, losing its original characteristics by 4–6 weeks [181], though problems in pediatric hand skin closure have been linked to delayed absorption and prolonged presence [62]. Patients should not be told they are allergic to surgical catgut unless a generalised allergic response occurs, rather than solely a wound complication [57]. Narrow tape sutures provide reliable tissue apposition and fixation while decreasing potential adverse effects from knot prominence [142].

Suture Anchors and Tacks

Potential complications have been identified when using surgical devices containing poly(lactic acid) (PLA) [15].

Bone Grafts and Substitutes

Autologous bone graft harvest is frequently associated with complications [44]. Biologic reconstructions with viable bone autograft provide more durable long-term reconstructions but carry high short-term complication rates and donor-site morbidity [18]. Untreated and nonvascular allografts showed delayed union and distal femoral collapse in an orthotopic rat model [46]. Fresh tissue-antigen-matched grafts were the least likely to be associated with long-term complications, as antigen-mismatching and freezing had cumulative deleterious effects on cartilage [145]. Retrieved human allografts had an average duration in situ of twenty-eight months when retrieved for graft-associated complications and thirty months for tumor-associated complications [152]. Fifty-four (74%) of retrieved human allografts were retrieved during the first three years after implantation [152]. The use of artificial bone grafts is expected to increase, but their effectiveness remains debated due to unclear definitions or limited market surveillance [71].

The induced membrane (Masquelet) technique is a two-stage procedure associated with an increased risk of antibiotic resistance, limited availability of bone graft, and prolonged healing and recovery time [54]. Fixation devices and bone transport are associated with frequent pin-site complications, a high incidence of re-interventions, and distraction often limited by the neurovascular bundle [54]. Megaprosthesis carries a risk of dislocation, risk of recurrence, and no options for revision surgery [54]. Biodegradable antibiotic delivery devices are associated with an increased risk of antibiotic resistance, persistent drainage from wounds and seromas, and the release of acidic degradation products limiting the volume that can be used [48]. Vascularized free flaps carry a high risk of complications and failure of graft due to the need for microsurgical anastomoses [48]. Local flaps are associated with donor site morbidity and pedicle length limits the distance the flap can be transferred [48].

In a series of seven patients using massive bone allograft with free vascularized fibular flap, the overall complication rate was significant, though the fragile condition of the patients should be taken into account [12]. One case of fibular necrosis occurred where graft monitoring using a skin paddle was not possible [12]. Two traumatic fractures were observed in this series [12]. The complication rates of free vascularized fibula fitted into an allograft are significantly lower than those reported by isolated allografts in the short and long-term [12]. Only two out of seven patients required a single reintervention [12]. One patient underwent several additional procedures including infection on the device, removal of the device, and post-traumatic fracture [12]. The overall reintervention rate for massive bone allograft with free vascularized fibular flap is low, particularly when considering surgical revisions resulting from mechanical complications following one-stage techniques [12]. A technique series for preventing autograft-related complications using intercalary frozen autograft augmented with intramedullary cement and bridging plates showed promising functional outcomes and provided durable reconstruction [20]. The authors used a specific method for taking iliac-bone graft more than 200 times in the past two years with no hematomas requiring drainage, no wound infections, no muscle herniation, and no need for later removal of the wire [170]. No secondary procedures were required because of fracture, resorption, or infection in a series of eight patients treated with autoclaved segment and fresh autogenous cancellous bone for chondrosarcoma [182].

Implants, Cement, and Hardware

Reoperation rates for clavicle fracture exceed 20%, with the vast majority of reoperations being performed for device removal [68]. About one in five patients had a complication and one in ten required further surgery after reverse total shoulder arthroplasty [173]. Postoperative neuropathy in the ipsilateral lower extremity occurred in 1.7% of 3126 consecutive total hip replacements overall [174]. The prevalence of postoperative neuropathy was 5.2% after primary arthroplasties done for congenital dislocation or dysplasia of the hip [174]. The prevalence of postoperative neuropathy was 3.2% after revisions for all diagnoses [174]. The sciatic nerve was involved in all but five extremities with postoperative neuropathy after total hip replacement [174]. All patients who had complete recovery of neurological function after total hip replacement neuropathy had it by twenty-one months [174].

Hardware failure in the setting of flail chest surgical fixation is rare, with a study of 650 operative cases reporting 1.2% fixation failure [125]. A study of 650 operative cases for flail chest reported 1.4% plate removal due to discomfort and chest stiffness [125]. Plates and screws can become loose or break, causing local discomfort in slim individuals or leading to a nonunion [125]. The use of smooth intramedullary wires should be avoided due to the risk of migration into adjacent organs [125]. The use of absorbable plates may be associated with foreign body reaction and fluid accumulation and is generally not recommended [125]. Despite major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis for radial head arthroplasty [78]. Both techniques for glenoid replacement using cement have provided excellent clinical outcomes to date [2]. Five of 6 patients had a complete healing of the bone graft using a technique involving resorbable cement, and no radiolucent lines associated with resorption of cement were observed [10]. Clinical and radiological outcomes are similar in both short-stem designs regarding proximal porous coating in humeral arthroplasty [7]. There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic rotator cuff repair using metallic or biodegradable suture anchors for rotator cuff tears < 5 cm [42]. Fusion construct or type of bone graft does not affect time to union or complication rates in scapulothoracic fusion for facioscapulohumeral dystrophy [139].

Infection and Wound Complications

The literature suggests a 1.2% risk of superficial wound infections with surgical fixation for flail chest [125]. The literature suggests a 3% risk of serious infections with surgical fixation for flail chest [125]. Superficial infections can be treated with oral or systemic antibiotics without the need for surgical debridement [125]. Deep infections without empyema may be amendable to antibiotics alone, or may require local irrigation and debridement with hardware removal in the setting of chronic infection adjacent to orthopedic hardware [125]. Pneumonia and sepsis are the two most common causes of mortality in patients with flail chest injuries [125]. The risk of empyema is higher in the presence of a retained hemothorax, retained chest tubes for an extended length of time, chest tubes placed under semi-sterile conditions, or deep infection adjacent to orthopedic implants [125]. Empyema is treated with antibiotics, irrigation/debridement, and decortication of the pleural cavity [125].

Inflammation may destroy the integrity of orthopaedic hardware, which may be evident on physical, radiographic, or intraoperative examination [23]. The decision to replace or retain hardware in the setting of infection may be contingent on the integrity of both native and artificial structures, distribution of infection, chronicity of infection, and response to previous débridement [23]. Patients may need to be treated with long-term antibiotic therapy or more aggressive modalities such as arthrodesis or amputation when efforts to treat skeletal infection fail [23].

Recovery

Light activity (weeks): The evidence base does not specify a defined week range for the initiation of desk work, driving, or light activities of daily living.

Full activity (months): The evidence base does not specify a defined month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence base does not specify a defined month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The evidence base does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or sling and brace removal timing.

Functional milestones: The evidence base does not provide validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks such as Constant, ASES, or WOMAC scores.

Other Considerations: Long-term follow-up data indicates that anatomic total shoulder arthroplasty provides pain relief and improved quality of life with a 10-year survival rate of 96% [153]. In a series of seven patients using free vascularized fibular flap combined with massive bone allograft, the overall complication rate was significant, though the fragile condition of these patients should be taken into account [12]. Within this series, two traumatic fractures were observed [12], and one case showed radiographic behaviour suggesting fibular necrosis where graft monitoring using a skin paddle was not possible [12]. Only two out of seven patients required a single reintervention, demonstrating good outcome without sequelae [12], while only one patient underwent several additional procedures for infection on the device, removal of the device, and post-traumatic fracture, which also resulted in good outcome without sequelae [12]. The complication rates of the technique involving free vascularized fibula fitted into an allograft are significantly lower than those reported by isolated allografts, in the short but above all long-term [12]. A large technique series for preventing autograft-related complications using intercalary frozen autograft augmented with intramedullary cement and bridging plates fixation showed promising functional outcomes and provided durable reconstruction [20]. In a limited case series, the studied BCBS demonstrated acceptable surgical outcomes for the treatment of benign bone lesions [35]. At follow-up ranging from 8 to 18 years, 37 patients were clinically assessed as good, 9 as fair, and none as poor for ankle-joint injuries [59]. The two-year follow-up of the performed surgical procedure led to a posteriorly stable glenohumeral joint and a persisting vital bone graft using a local vascularized scapula bone graft [64]. Roentgenograms revealed apparent complete regeneration of both articular surfaces of the transplanted joint while preserving original contours in a case report with ten-year follow-up [79]. The patient demonstrated a satisfactory clinical outcome after 6 months and 2 years postoperatively following a cement-impression technique using femoral head allograft for restoring glenoid bone stock [28]. Given its outstanding clinical outcomes observed in the current patient series, advocating for the modified PHILOS system utilizing a single bone cement calcar screw holds considerable clinical significance in enhancing patients' prognoses [30]. These findings are consistent with or superior to prior published reports of all-polyethylene glenoids regarding long-term survival rate of hybrid all-polyethylene glenoid anatomic total shoulder arthroplasty implants at 2- and 5-years postoperatively [34]. The clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups regarding baseplate screw penetration [163]. Optimizing treatment relies on long-term results, careful patient selection, and realistic expectations for osteochondral allografts in shoulder surgical procedures [222]. The subsequent repair of fresh allografts is not adversely affected by immunosuppressive therapy [223]. Results suggested that the peak tissue response associated with nerve dissection occurred 2–3 weeks after treatment and that the repair process started subsequently [224]. Clinical recurrence was related to the electron microscopic findings of myofibroblasts in the nodules and fibroblasts containing prominent microtubules in the fascia, rather than the age of the patient, duration, or severity of disease [56]. The autologous ICBGT procedure biomechanically improves anterior shoulder stability in long-term follow-up whereas the usage of allografts did not show any bone-mediated biomechanical effect at follow-up due to resorption [73]. Not all biocomposite anchors are the same; they have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone [72]. New implants must withstand vigorous challenges, and future extensive and long-term studies can enable improved implants using human tissue [70]. The repair construct selected had a significant influence on failure at ultimate load (p = 0.005) [154]. In an experimental model of flexor tendon repair, the four suture strands alone occupied an average of 7% of the available cross-sectional area [21], while locating the four knots at the laceration site occupied 18%-26% of the total cross-sectional area [21]. The relative area occupied by suture material at the repair site is a function of many variables, including the tendon cross-sectional area, suture material, suture technique, and number of throws per knot [21]. Reduced tensile strength was noted for both techniques at 1 week after repair [21], and tensile strength for both techniques was noted to be slightly better than that of the initial repair by 3 weeks [21].

Key Evidence

• [L5] Clinical outcome studies comparing suture materials remain elusive, but there is little reason not to use stronger suture material, and this is an option within the surgeon's control. [1] (10.1016/j.arthro.2019.12.009)
• [Paper] Both techniques have provided excellent clinical outcomes to date. [2] (10.1097/00132589-200209000-00005)
• [L4] Complications related to suture anchors and tacks can be categorized as technique-related or device-related issues, and prevention depends on the surgeon's familiarity with the devices and knowledge of their indications and limitations. [3] (10.1177/0363546505284240)
• [L5] The characteristics of the ideal bone graft substitute may vary considerably depending on the intended site of application and the clinical setting in which it is used. [4] (10.1016/s0894-1130(03)80013-3)
• [L3] The greater strength of repair may not translate into improved clinical outcome due to increased suture bulk. [5] (10.1142/s0218810417500113)
• [L5] The report outlines the need for a permanent organization to test surgical materials, conduct research, encourage standardization, and assist manufacturers, recommending the establishment of the American Surgical Materials Association with funding from three sponsoring medical organizations. [6] (10.2106/00004623-195436020-00026)
• [L3] Clinical and radiological outcomes are similar in both short-stem designs. [7] (10.1177/1758573218773533)
• [L5] Current indications include education for patients, providers, and trainees, in addition to surgical planning, while further possibilities such as the development of patient-specific implants continue to be explored. [8] (10.1002/jor.25388)
• [L5] The bone substitutes tested display a wide range in structural properties and compression strength, indicating that they will be suitable for different clinical indications. [9] (10.1186/1471-2474-12-34)
• [L4] Five of 6 patients had a complete healing of the bone graft using the described technique, and no radiolucent lines associated with resorption of cement were observed. [10] (10.1097/bte.0b013e31820b3517)
• [L5] This article discusses the importance of careful preoperative evaluation and planning for rational decision making and describes technical aspects of some reconstructive procedures preferred by the authors. [11] (10.1097/00132589-200112000-00005)
• [Paper] [12] (10.1016/j.otsr.2010.02.003)
• [L5] [13] (10.1186/s13018-026-06698-3)
• [L4] Methyl methacrylate caused no gross reaction that could be recognized clinically or roentgenographically in thirty-three patients, after being in contact with bone for periods as long as fourteen years and four months. [14] (10.2106/00004623-197254020-00005)
• [L4] We have identified potential complications when using surgical devices containing PLA. [15] (10.1067/mse.2003.16)
• [L5] Biologic reconstructions with viable bone autograft can provide more durable long-term reconstructions and growing reconstructions in the pediatric population at the expense of high short-term complication rates and donor-site morbidity. [18] (10.5435/jaaos-d-25-00228)
• [L5] Initial experience using this knot in different procedures has yielded encouraging results, and the biomechanical properties of this knot are currently under evaluation. [19] (10.1097/bth.0b013e318285b4e4)
• [L4] This large technique series for preventing autograft-related complications showed promising functional outcomes and provided durable reconstruction. [20] (10.1186/s13018-024-05240-7)
• [Paper] [21] (10.1016/s0363-5023(96)80301-7)
• [L1] Biomechanical studies show that glenoid reconstruction with DTA provides near anatomic reconstruction, leading to increased stability, improved contact area, and decreased loading pressures. [26] (10.1016/j.arthro.2025.05.007)
• [L5] The patient demonstrated a satisfactory clinical outcome after 6 months and 2 years postoperatively. [28] (10.1016/j.xrrt.2026.100870)
• [L1] [29] (10.2106/jbjs.22.00716)
• [L4] Given its outstanding clinical outcomes observed in the current patient series, advocating for this fixation device holds considerable clinical significance in enhancing patients' prognoses. [30] (10.1186/s12891-025-08854-y)
• [L5] The application of this technique clinically is minimum. [31] (10.2106/00004623-198466090-00016)
• [L5] Complications are ubiquitous with all methods but can be limited with careful surgical judgment, patient optimization, and technique. [32] (10.5435/jaaos-d-14-00018r1)
• [Paper] The construct efficiency of multi strand repairs varied with respect to different repair techniques and suture materials. [33] (10.1142/s2424835518500285)
• [L3] These findings are consistent with or superior to prior published reports of all-polyethylene glenoids. [34] (10.1177/2325967126s00537)
• [L4] In a limited case series, the studied BCBS demonstrated acceptable surgical outcomes. [35] (10.1186/s12891-022-05843-3)
• [Paper] There would appear to be other more pressing reasons against operating without indication. [36] (10.1016/s0020-1383(69)80037-9)
• [L5] Early clinical experience involving reamed autogenous bone graft in the management of nonunion, bone defects, and arthrodesis has been encouraging and has demonstrated the necessary properties to warrant regular consideration of reamed graft for these applications. [37] (10.5435/jaaos-d-16-00512)
• [L5] The paper reviews the mechanical and biological characteristics of commercially available ECM materials, delineates indications for their clinical use, and suggests future directions in developing ECM scaffolds for rotator cuff repair. [38] (10.1016/j.jse.2007.03.008)
• [L5] These results suggest that some suture materials may provide a superior alternative to wire for cerclage fixation techniques with select clinical application. [39] (10.1177/1758573217735323)
• [L4] Despite relatively low mean subjective outcomes, objective measures were very good with no failures based on MARS criteria and full allograft dowel incorporation. [40] (10.1177/2325967113s00072)
• [L4] A longer follow-up is necessary to assess and confirm the superiority of this pediatric reconstruction technique. [41] (10.1016/j.otsr.2015.06.027)
• [L3] There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm. [42] (10.1186/s12891-019-2834-3)
• [L4] Caution must be advised in the use of this device, and post-operative pain and stiffness assessed carefully. [43] (10.1016/s1058-2746(96)80108-x)
• [L5] [45] (10.1016/j.arth.2007.01.018)
• [Paper] In contrast, untreated allografts and nonvascular allografts showed delayed union and distal femoral collapse. [46] (10.1016/0363-5023(88)90225-0)
• [L5] [47] (10.1002/atn2.70108)
• [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. [49] (10.5435/jaaos-d-24-01057)
• [L4] Clinical recurrence was related to the electron microscopic findings of myofibroblasts in the nodules and fibroblasts containing prominent microtubules in the fascia, rather than the age of the patient, duration, or severity of disease. [56] (10.2106/00004623-198062030-00012)
• [L4] It is not warranted to tell patients that they are allergic unless there is a generalised allergic response and not solely a wound complication. [57] (10.1016/0266-7681(89)90131-9)
• [L5] To date, no adverse clinical reactions to the patch have been observed, although no randomized clinical trials have been performed. [58] (10.1016/j.arthro.2019.02.006)
• [L4] At follow-up ranging from 8 to 18 years, 37 patients were clinically assessed as good, 9 as fair, and none as poor. [59] (10.1016/s0020-1383(69)80036-7)
• [L1] All the problems were related to the delayed absorption of the Vicryl suture material and hence the prolonged presence of the suture in the hands of these children. [62] (10.1016/j.jhsb.2004.08.005)
• [L1] Currently, available evidence suggests that direct repair, autograft reconstruction, or allograft reconstruction are all viable treatment options with similar outcomes. [63] (10.1016/j.xrrt.2022.02.007)
• [L5] The two-year follow-up of the performed surgical procedure led to a posteriorly stable glenohumeral joint and a persisting vital bone graft. [64] (10.1016/j.xrrt.2026.100772)
• [Abstract] The lost intrinsic stability can be restored by bone grafting, with effectiveness related to both graft height and contour. [65] (10.1016/j.jse.2007.02.045)
• [L5] No single alternative graft material provides all three components for bone regeneration, and clinical applications for substitutes are dictated by their particular structural and biochemical properties. [66] (10.5435/00124635-199501000-00001)
• [L4] The technique of glenoid implantation is the guarantee of the glenoid survival, which is synonymous with good clinical results. [67] (10.1097/00132589-200306000-00005)
• [L3] However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. [68] (10.1186/s12891-022-05075-5)
• [L5] New implants must withstand vigorous challenges, and future extensive and long-term studies can enable improved implants using human tissue. [70] (10.1016/j.arthro.2019.05.001)
• [L5] The use of artificial bone grafts is expected to increase, but their effectiveness is still a subject of debate due to unclear definitions or limited market surveillance. [71] (10.1016/j.injury.2011.06.010)
• [L5] Not all biocomposite anchors are the same; they have different chemical compositions, resorption patterns, timelines, and ability to be replaced by bone. [72] (10.1016/j.arthro.2019.08.023)
• [L4] The autologous ICBGT procedure biomechanically improves anterior shoulder stability in long-term follow-up whereas the usage of allografts did not show any bone-mediated biomechanical effect at follow-up due to resorption. [73] (10.1016/j.jse.2021.03.029)
• [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. [78] (10.1016/j.jse.2010.05.022)
• [L4] While serious problems persist, the technique allows for osseous union in the majority of cases. [80] (10.2106/00004623-198567010-00013)
• [L5] In the early postoperative period, vascularized bone grafts resemble bones that have had a sham operation and those that have not been operated on, maintaining their strength and stiffness better than non-vascularized grafts during the first three months after the operation. [81] (10.2106/00004623-199072060-00002)
• [L5] Early recurrence of disease is most common in individuals with Dupuytren's diathesis, and the use of full-thickness skin grafts may be helpful in this setting. [108] (10.5435/00124635-199801000-00003)
• [L3] The procedure resolved pain, skin dimpling, palpable fibrous bands, and winging of the scapula, with no infections or neuromuscular complications. [111] (10.2106/00004623-199802000-00010)
• [L1] Allografts may be comparable to autografts for crucial effectiveness outcomes, but insufficient evidence was found to judge crucial safety outcomes due to poor reporting of safety measures and outcomes. [118] (10.1016/j.asmr.2020.07.017)
• [L3] The results of the present study showed that material-derived osteoinduction significantly enhanced bone healing orthotopically, and that this material property appeared more sensitive for predicting orthotopic performance than physicochemical and structural characteristics. [120] (10.1002/jor.20648)
• [L5] Significant differences were found between ultimate failure loads of various suture types and sizes, with new polyblend materials showing distinct mechanical properties. [124] (10.1007/s00167-010-1186-1)
• [L5] The combination therapy demonstrated marginal improvement in direct healing over other experimental treatment groups excluding autologous grafts. [126] (10.1186/1749-799x-3-20)
• [L5] The study demonstrates differences between traditional and newer suture materials when tying various types of knots under arthroscopic conditions. [129] (10.1177/0363546509332816)
• [L5] TE-OCA is comparable to OCA in multiple safety and efficacy measures of osteochondral defect repair. [130] (10.1177/03635465251409083)
• [Paper] The only disadvantages are that stainless steel is difficult to use and monofilament polyglyconate is absorbable. [131] (10.1016/0266-7681(89)90160-5)
• [L5] The only disadvantages are that stainless steel is difficult to use and monofilament polyglyconate is absorbable. [132] (10.1016/0266-7681_89_90160-5)
• [L3] Severe glenoid cartilage lesions emerged as a contraindication for partial humeral head resurfacing. [133] (10.1016/j.arthro.2019.11.057)
• [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. [135] (10.1177/0363546507306465)
• [L5] The cement substance, rather than collagen fibers, is the important factor differentiating the bone matrix from other calcifying fibrous tissues. [138] (10.2106/00004623-195234020-00013)
• [L3] Fusion construct or type of bone graft does not affect time to union or complication rates. [139] (10.1016/j.jse.2023.01.025)
• [L3] Bony incorporation of autograft and allograft as evaluated on CT scan is predictably high. [140] (10.5435/jaaos-d-23-00095)
• [L5] The Kessler configuration exploits the full strength of the suture material as failure occurs by material failure in the gap. [141] (10.1016/s0266-7681(05)80240-2)
• [L5] Narrow tape sutures provide reliable tissue apposition and fixation while decreasing potential adverse effects from knot prominence. [142] (10.1016/j.asmr.2021.07.014)
• [L5] Fresh tissue-antigen-matched grafts were the least likely to be associated with long-term complications, as antigen-mismatching and freezing had cumulative deleterious effects on cartilage. [145] (10.2106/00004623-198971090-00004)
• [L5] Compared with other suture types, the self-tensioning suture showed dynamic properties, demonstrating a decrease in loop length when soaked in a saline bath. [146] (10.1016/j.asmr.2023.100872)
• [L5] FiberTape consistently displayed less creep, greater stiffness, and less extensibility than the other suture types. [147] (10.1016/j.arthro.2019.08.048)
• [L3] However, the force sustained at a gap of 3 mm did not differ between groups (35 N for both groups), indicating that the two repairs are equally susceptible to rupture if a gap of 3 mm or greater forms. [150] (10.1053/jhsu.2000.6456)
• [L4] [152] (10.2106/00004623-200107000-00001)
• [L4] Anatomic total shoulder arthroplasty provides pain relief and improved quality of life with a 10-year survival rate of 96%. [153] (10.5435/jaaos-d-21-00302)
• [L5] The repair construct selected had a significant influence on failure at ultimate load (p = 0.005). [154] (10.1016/s1058-2746(96)80028-0)
• [L5] The type of suture material has a significant effect on the biomechanical behavior of the suture-tendon interface. [160] (10.1177/0363546508314793)
• [L5] Common screw types resist physiological shear loads in a bicortical configuration, but 3.75 mm screws incurred significant displacements at 200 N in unicortical configurations. [162] (10.1177/1758573217704817)
• [L3] However, the clinical outcomes of RTSA at a minimum follow-up of 1 year were similar in the high- and lower-risk groups. [163] (10.1016/j.jse.2021.10.024)
• [L5] This algorithm may provide a clinically meaningful adjunct in assisting with preoperative planning for the failed TSA and allows for scalable expansion with additional radiographic data and validation efforts. [166] (10.1016/j.jse.2023.03.028)
• [Paper] The improved imaging capability of the newer generation scanner reduced the metal-induced artefact zone enough to permit assessment of BIC. [169] (10.1002/jor.23716)
• [L4] The authors used this method more than 200 times in the past two years with no hematomas requiring drainage, no wound infections, no muscle herniation, and no need for later removal of the wire. [170] (10.2106/00004623-197860030-00030)
• [L3] About one in five patients had a complication and one in ten required further surgery. [173] (10.1302/0301-620x.104b3.bjj-2021-0856.r2)
• [L3] [174] (10.2106/00004623-197557030-00017)
• [L3] Additionally, opioid users had significantly increased rates of periprosthetic radiolucency and revision. [175] (10.1016/j.jse.2021.07.027)
• [L3] The combination of DBM and PRP could serve as a safe bone graft substitute in clinical practice for non-union, achieving low incidence of postoperative complications and satisfactory bony healing rate, though larger and higher quality studies are needed to assess its routine use. [179] (10.1186/s12891-021-04840-2)
• [Paper] Vicryl, while providing high initial strength, decayed very quickly and lost any semblance of its original characteristics by 4–6 weeks. [181] (10.1016/s0020-1383(03)00089-5)
• [L4] [182] (10.2106/00004623-197557080-00011)
• [Case_report] This report demonstrates that operations involving a nonmassive allograft about the olecranon process may display minimal side effects in comparison to massive allografts, specifically regarding nonunion. [184] (10.1016/j.xrrt.2021.12.006)
• [L5] This combined graft approach may offer a durable and reproducible solution for managing irreparable rotator cuff tears in carefully selected patients. [186] (10.1016/j.eats.2025.103824)
• [L5] The clinical relevance is that inserting suture anchors at 90° is recommended due to the significantly larger ultimate failure load in both decorticated and non-decorticated bones. [193] (10.1186/s13018-019-1209-7)
• [Paper] The knot technique was stronger than the grasping technique with nonbarbed sutures (41.70 N vs 30.38 N). [210] (10.1142/s2424835520500320)
• [L5] A suture-bridge construct with the non-post limb preserved and the post limb cut at a 4 mm distance from the knot provides the best security. [212] (10.1186/s13018-022-03180-8)
• [L5] [214] (10.1186/s12891-021-04933-y)
• [L5] [216] (10.2106/00004623-197860080-00011)
• [L4] Optimizing treatment relies on long-term results, careful patient selection, and realistic expectations. [222] (10.2106/jbjs.rvw.16.00001)
• [L5] The subsequent repair of fresh allografts is not adversely affected by immunosuppressive therapy. [223] (10.2106/00004623-198163030-00015)
• [Paper] Results suggested that the peak tissue response associated with nerve dissection occurred 2–3 weeks after treatment and that the repair process started subsequently. [224] (10.1142/s2424835520500186)

See Also

• Clavicle Fracture
• Fractures
• Os Acromiale
• Rotator Cuff
• Shoulder Instability
• Calcific Tendinitis
• Total shoulder arthroplasty
• Reverse Shoulder Arthroplasty
• Rotator Cuff Repair

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