Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

The fungal metabolite 4-hydroxyphenylacetic acid from Neofusicoccum parvum modulates defence responses in grapevine.

In a consequence of global warming, grapevine trunk diseases (GTDs) have become a pertinent problem to viticulture, because endophytic fungi can turn necrotrophic upon host stress killing the plant. In Neofusicoccum parvum Bt-67, plant-derived ferulic acid makes the fungus release Fusicoccin aglycone triggering plant cell death. Now, we show that the absence of ferulic acid lets the fungus secrete 4-hydroxyphenylacetic acid (4-HPA), mimicking the effect of auxins on grapevine defence and facilitating fungal spread. Using Vitis suspension cells, we dissected the mode of action of 4-HPA during defence triggered by the bacterial cell-death elicitor, harpin. Early responses (cytoskeletal remodelling and calcium influx) are inhibited, as well as the expression of Stilbene Synthase 27 and phytoalexin accumulation. In contrast to other auxins, 4-HPA quells transcripts for the auxin conjugating GRETCHEN HAGEN 3. We suggest that 4-HPA is a key component of the endophytic phase of N. parvum Bt-67 preventing host cell death. Therefore, our study paves the way to understand how GTDs regulate their latent phase for successful colonisation, before turning necrotrophic and killing the vines.

Differential carbohydrate-active enzymes and secondary metabolite production by the grapevine trunk pathogen Neofusicoccum parvum Bt-67 grown on host and non-host biomass.

Neofusicoccum parvum is one of the most aggressive Botryosphaeriaceae species associated with grapevine trunk diseases. This species may secrete enzymes capable of overcoming the plant barriers, leading to wood colonization. In addition to their roles in pathogenicity, there is an interest in taking advantage of N. parvum carbohydrate-active enzymes (CAZymes), related to plant cell wall degradation, for lignocellulose biorefining. Furthermore, N. parvum produces toxic secondary metabolites that may contribute to its virulence. In order to increase knowledge on the mechanisms underlying pathogenicity and virulence, as well as the exploration of its metabolism and CAZymes for lignocellulose biorefining, we evaluated the N. parvum strain Bt-67 capacity in producing lignocellulolytic enzymes and secondary metabolites when grown in vitro with two lignocellulosic biomasses: grapevine canes (GP) and wheat straw (WS). For this purpose, a multiphasic study combining enzymology, transcriptomic, and metabolomic analyses was performed. Enzyme assays showed higher xylanase, xylosidase, arabinofuranosidase, and glucosidase activities when the fungus was grown with WS. Fourier transform infrared (FTIR) spectroscopy confirmed the lignocellulosic biomass degradation caused by the secreted enzymes. Transcriptomics indicated that the N. parvum Bt-67 gene expression profiles in the presence of both biomasses were similar. In total, 134 genes coding CAZymes were up-regulated, where 94 of them were expressed in both biomass growth conditions. Lytic polysaccharide monooxygenases (LPMOs), glucosidases, and endoglucanases were the most represented CAZymes and correlated with the enzymatic activities obtained. The secondary metabolite production, analyzed by high-performance liquid chromatography-ultraviolet/visible spectophotometry-mass spectrometry (HPLC-UV/Vis-MS), was variable depending on the carbon source. The diversity of differentially produced metabolites was higher when N. parvum Bt-67 was grown with GP. Overall, these results provide insight into the influence of lignocellulosic biomass on virulence factor expressions. Moreover, this study opens the possibility of optimizing the enzyme production from N. parvum with potential use for lignocellulose biorefining.

Ferulic acid is a putative surrender signal to stimulate programmed cell death in grapevines after infection with Neofusicoccum parvum.

An apoplectic breakdown from grapevine trunk diseases (GTDs) has become a serious challenge to viticulture as a consequence of drought stress. We hypothesize that fungal aggressiveness is controlled by a chemical communication between the host and colonizing fungus. We introduce the new concept of a 'plant surrender signal' accumulating in host plants under stress and facilitating the aggressive behaviour of the strain Neofusicoccum parvum (Bt-67) causing Botryosphaeriaceae-related dieback in grapevines. Using a cell-based experimental system (Vitis cells) and bioactivity-guided fractionation, we identify trans-ferulic acid, a monolignol precursor, as a 'surrender signal'. We show that this signal specifically activates the secretion of the fungal phytotoxin fusicoccin A aglycone. We show further that this phytotoxin, mediated by 14-3-3 proteins, activates programmed cell death in Vitis cells. We arrive at a model showing a chemical communication facilitating fusicoccin A secretion that drives necrotrophic behaviour during Botryosphaeriaceae-Vitis interaction through trans-ferulic acid. We thus hypothesize that channelling the phenylpropanoid pathway from this lignin precursor to the trans-resveratrol phytoalexin could be a target for future therapy.

The fungal elicitor eutypine from Eutypa lata activates basal immunity through its phenolic side chains.

Grapevine trunk diseases (GTDs) affect grape production and reduce vineyard longevity worldwide. Since the causative fungi also occur in asymptomatic trunks, we address disease outbreak in terms of altered chemical communication between host and endophyte. Here, we identified four chemically similar secondary metabolites secreted by the GTD-associated fungus Eutypa lata to analyse their modes of action in a grapevine cell culture of Vitis rupestris, where microtubules were tagged by GFP. Treatment with the metabolite eutypine activated defence responses, evident from extracellular alkalinisation and induction of defence genes. Eutypinol, instead, eliminated microtubules, in contrast to the other three compounds. Furthermore, we evaluated the effect of four corresponding chemical analogues of these compounds, sharing the phenolic but lacking the alkyne moiety. These analogues were able to induce similar defence responses in V. rupestris cells, albeit at reduced amplitude. Since closely related moieties differing only in details of the side groups at the phenolic ring differ significantly with respect to the response of the host cell, we propose that these fungal compounds act through a specific binding site at the membrane of grapevine cells. We corroborate this specificity by combination experiments, where the eutypine and the eutypinol analogues behave competitively with respect to the elicited responses. In summary, Eutypa lata secretes compounds that elicit host defence in a specific manner by interfering with early events of immunity signalling. This supports the notion that a real understanding of GTDs has to address inter-organismic chemical communication.

Olecranon fractures: applied anatomy, clinical assessment and evidence-based management.

Olecranon fractures are common injuries, making up 10% of all fractures of the upper limb. They usually result from a fall from standing height in older people, or from a direct blow in young people. The olecranon's superficial location, with poor soft tissue and muscle protection, make it liable to fracture following direct impact. Factors such as the degree of initial force and the quality of the patient's bone result in a range of injury patterns, from simple undisplaced fractures to complex open fracture dislocations. In the context of high energy trauma, the patient should first be assessed for life-threatening injuries. A thorough history and clinical examination including neurovascular assessment should then be completed. Antero-posterior and lateral X-rays are sufficient to confirm the diagnosis. Initial management includes immobilisation in an above elbow backslab, a sling and analgesia. Owing to the pull of the triceps muscle which attaches to the tip of the olecranon, fracture displacement is common and surgical intervention is often required, usually with good outcomes. Surgical techniques include tension band wiring, open reduction internal fixation with a pre-contoured locking plate and tension band suture fixation. Undisplaced fractures or displaced fractures in older patients can be managed conservatively with an above elbow cast for 4 weeks. This article covers applied anatomy, initial presentation, clinical assessment and evidence-based management.

Cellulose nanocarriers via miniemulsion allow Pathogen-Specific agrochemical delivery.

The current spraying of agrochemicals is unselective and ineffective, consuming a high amount of fungicides, which endangers the environment and human health. Cellulose-based nanocarriers (NCs) are a promising tool in sustainable agriculture and suitable vehicles for stimuli-responsive release of agrochemicals to target cellulase-segregating fungi, which cause severe plant diseases such as Apple Canker. Herein, cellulose was modified with undec-10-enoic acid to a hydrophobic and cross-linkable derivative, from which NCs were prepared via thiol-ene addition in miniemulsion. During the crosslinking reaction, the NCs were loaded in situ with hydrophobic fungicides, Captan and Pyraclostrobin. NCs with average sizes ranging from 200 to 300 nm and an agrochemical-load of 20 wt% were obtained. Cellulose-degrading fungi, e.g. Neonectria. ditissima which is responsible for Apple Canker, lead to the release of fungicides from the aqueous NC dispersions suppressing fungal growth. In contrast, the non-cellulase segregating fungi, e.g. Cylindrocladium buxicola, do not degrade the agrochemical-loaded NCs. This selective action against Apple Canker fungi, N. ditissima, proves the efficacy of NC-mediated drug delivery triggered by degradation in the exclusive presence of cellulolytic fungi. Cellulose NCs represent a sustainable alternative to the current unselective spraying of agrochemicals that treats many crop diseases ineffectively.

Anti-phytopathogen terpenoid glycosides from the root bark of Chytranthus macrobotrys and Radlkofera calodendron.

Chytranthus macrobotrys and Radlkofera calodendron are two Sapindaceae characterized by a lack of phytochemical data. Both root barks from the two Sapindaceae species were processed by ethanol extraction followed by the isolation of their primary constituents by liquid chromatography. This process yielded four previously undescribed terpenoid glycosides together with eight known analogues. Extracts and isolated compounds from C. macrobotrys and R. calodendron were then screened for antimicrobial activity against fifteen phytopathogens. The biological screening also involved extracts and pure compounds from Blighia unijugata and Blighia welwitschii, two Sapindaceae previously studied by our group. Phytopathogens were chosen based on their economic impact on agriculture worldwide. The selection was composed primarily of fungal species including; Pyricularia oryzae, Gaeumannomyces graminis var. tritici, Zymoseptoria tritici, Fusarium oxysporum, Botrytis cinerea, Pythium spp., Trichoderma spp. and Rhizoctonia solani. Furthermore, pure terpenoid glycosides were tested for the first time against wood-inhabiting phytopathogens such as; Phaeomoniella chlamydospora, Phaeoacremonium minimum, Fomitiporia mediterranea, Eutype lata and Xylella fastidiosa. Raw extracts exhibited different levels of activity dependent on the organism. Some pure compounds, including 3-O-α-L-arabinopyranosyl-(1 â†’ 4)-ß-D-xylopyranosyl-(1 â†’ 3)-α-L-rhamnopyranosyl-(1 â†’ 2)-α-L-arabinopyranosylhederagenin, 3-O-α-L-rhamnopyranosyl-(1 â†’ 2)-α-L-arabinopyranosylhederagenin (α-hederin), 3-O-ß-D-glucopyranosyl-(1 â†’ 3)-α-L-rhamnopyranosyl-(1 â†’ 2)-α-L-arabinopyranosylhederagenin (macranthoside A) and 3-O-α-L-arabinopyranosyl-(1 â†’ 3)-α-L-rhamnopyranosyl-(1 â†’ 2)-α-L-arabinopyranosylhederagenin (clemontanoside C), exhibited significant growth inhibitions on Pyricularia oryzae, Gaeumannomyces graminis var. tritici, Fomitiporia mediterranea and Zymoseptoria tritici. Monodesmoside triterpene saponins, in particular, exhibited MIC (IC100) values as low as 25 µg/ml and IC50 values as low as 10 µg/ml against these phytopathogens. Structure-activity relationships, as well as plant-microbe interactions, were discussed.

Fungicide-loaded and biodegradable xylan-based nanocarriers.

The delivery of agrochemicals is typically achieved by the spraying of fossil-based polymer dispersions, which might accumulate in the soil and increase microplastic pollution. A potentially sustainable alternative is the use of biodegradable nano- or micro-formulations based on biopolymers, which can be degraded selectively by fungal enzymes to release encapsulated agrochemicals. To date, no hemicellulose nanocarriers for drug delivery in plants have been reported. Xylan is a renewable and abundant feedstock occurring naturally in high amounts in hemicellulose - a major component of the plant cell wall. Herein, xylan from corncobs was used to produce the first fungicide-loaded xylan-based nanocarriers by interfacial polyaddition in an inverse miniemulsion using toluene diisocyanate (TDI) as a crosslinking agent. The nanocarriers were redispersed in water and the aqueous dispersions were proven to be active in vitro against several pathogenic fungi, which are responsible for fungal plant diseases in horticulture or agriculture. Besides, empty xylan-based nanocarriers stimulated the growth of fungal mycelium, which indicated the degradation of xylan in the presence of the fungi, and underlined the degradation as a trigger to release a loaded agrochemical. This first example of crosslinked xylan-based nanocarriers expands the library of biodegradable and biobased nanocarriers for agrochemical release and might play a crucial role for future formulations in plant protection.

Bio-Based Lignin Nanocarriers Loaded with Fungicides as a Versatile Platform for Drug Delivery in Plants.

Lignin-based nano- and microcarriers are a promising biodegradable drug delivery platform inside of plants. Many wood-decaying fungi are capable of degrading the wood component lignin by segregated lignases. These fungi are responsible for severe financial damage in agriculture, and many of these plant diseases cannot be treated today. However, enzymatic degradation is also an attractive handle to achieve a controlled release of drugs from artificial lignin vehicles. Herein, chemically cross-linked lignin nanocarriers (NCs) were prepared by aza-Michael addition in miniemulsion, followed by solvent evaporation. The cross-linking of lignin was achieved with the bio-based amines (spermine and spermidine). Several fungicides-namely, azoxystrobin, pyraclostrobin, tebuconazole, and boscalid-were encapsulated in situ during the miniemulsion polymerization, demonstrating the versatility of the method. Lignin NCs with diameters of 200-300 nm (determined by dynamic light scattering) were obtained, with high encapsulation efficiencies (70-99%, depending on the drug solubility). Lignin NCs successfully inhibited the growth of Phaeomoniella chlamydospora and Phaeoacremonium minimum, which are lignase-producing fungi associated with the worldwide occurring fungal grapevine trunk disease Esca. In planta studies proved their efficiency for at least 4 years after a single injection into Vitis vinifera ("Portugieser") plants on a test vineyard in Germany. The lignin NCs are of high interest as biodegradable delivery vehicles to be applied by trunk injection against the devastating fungal disease Esca but might also be promising against other fungal plant diseases.

Hunting modulators of plant defence: the grapevine trunk disease fungus Eutypa lata secretes an amplifier for plant basal immunity.

Grapevine trunk diseases (GTDs) are progressively affecting vineyard longevity and productivity worldwide. To be able to understand and combat these diseases, we need a different concept of the signals exchanged between the grapevine and fungi than the well-studied pathogen-associated molecular pattern and effector concepts. We screened extracts from fungi associated with GTDs for their association with basal defence responses in suspension cells of grapevine. By activity-guided fractionation of the two selected extracts, O-methylmellein was identified as a candidate modulator of grapevine immunity. O-Methylmellein could not induce immune responses by itself (i.e. does not act as an elicitor), but could amplify some of the defence responses triggered by the bacterial elicitor flg22, such as the induction level of defence genes and actin remodelling. These findings show that Eutypa lata, exemplarily selected as an endophytic fungus linked with GTDs, can secrete compounds that act as amplifiers of basal immunity. Thus, in addition to elicitors that can trigger basal immunity, and effectors that down-modulate antibacterial basal immunity, once it had been activated, E. lata seems to secrete a third type of chemical signal that amplifies basal immunity and may play a role in the context of consortia of mutually competing microorganisms.

Targeted Drug Delivery in Plants: Enzyme-Responsive Lignin Nanocarriers for the Curative Treatment of the Worldwide Grapevine Trunk Disease Esca.

Nanocarrier (NC)-mediated drug delivery is widely researched in medicine but to date has not been used in agriculture. The first curative NC-based treatment of the worldwide occurring grapevine trunk disease Esca, with more than 2 billion infected plants causing a loss yearly of $1.5 billion, is presented. To date, only repetitive spraying of fungicides is used to reduce chances of infection. This long-term treatment against Esca uses minimal amounts of fungicide encapsulated in biobased and biodegradable lignin NCs. A single trunk injection of <10 mg fungicide results in curing of an infected plant. Only upon Esca infection, ligninolytic enzymes, secreted by the Esca-associated fungi, degrade the lignin NC to release the fungicide. The specific antifungal activity is confirmed in vitro and in planta (in Vitis vinifera L. cv. 'Portugieser'). All treated plants prove to exhibit significantly fewer symptoms several weeks after treatment, and their condition is monitored for 5 years (2014-2018), proving a long-term curative effect of this NC treatment. This study proves the efficacy of this NC-mediated drug delivery for agriculture, using a minimum amount of fungicides. It is believed that this concept can be extended to other plant diseases worldwide to reduce extensive spraying of agrochemicals.

Differing Alterations of Two Esca Associated Fungi, Phaeoacremonium aleophilum and Phaeomoniella chlamydospora on Transcriptomic Level, to Co-Cultured Vitis vinifera L. calli.

The filamentous fungi Phaeoacremonium aleophilum (P.al, Teleomorph: Togninia minima) and Phaeomoniella chlamydospora (P.ch) are believed to be causal agents of wood symptoms associated with the Esca associated young vine decline. The occurrence of these diseases is dramatically increasing in vineyards all over the world whereas efficient therapeutic strategies are lacking. Both fungi occupy the same ecological niche within the grapevine trunk. We found them predominantly within the xylem vessels and surrounding cell walls which raises the question whether the transcriptional response towards plant cell secreted metabolites is comparable. In order to address this question we co-inoculated grapevine callus culture cells with the respective fungi and analyzed their transcriptomes by RNA sequencing. This experimental setup appears suitable since we aimed to investigate the effects caused by the plant thereby excluding all effects caused by other microorganisms omnipresent in planta and nutrient depletion. Bioinformatics analysis of the sequencing data revealed that 837 homologous genes were found to have comparable expression pattern whereas none of which was found to be differentially expressed in both strains upon exposure to the plant cells. Despite the fact that both fungi induced the transcription of oxido- reductases, likely to cope with reactive oxygen species produced by plant cells, the transcriptomics response of both fungi compared to each other is rather different in other domains. Within the transcriptome of P.ch beside increased transcript levels for oxido- reductases, plant cell wall degrading enzymes and detoxifying enzymes were found. On the other hand in P.al the transcription of some oxido- reductases was increased whereas others appeared to be repressed. In this fungus the confrontation to plant cells results in higher transcript levels of heat shock and chaperon-like proteins as well as genes encoding proteins involved in primary metabolism.

Interaction of Skatole and Androstenone in the Olfactory Perception of Boar Taint.

This study analyzed odor-odor interactions of two malodorous volatile substances, androstenone and skatole, that may accumulate in fat and meat of uncastrated male (boar) pigs. Therefore, fat samples were collected from 1000+ entire male pig carcasses for sensory evaluation and quantification of boar taint compounds using gas chromatography-mass spectrometry (GC-MS). Each sample was sniffed by 10 trained assessors, resulting in 11 000+ individual ratings, which were subjected to statistical analysis. Pearson correlations of chemical traits and sensory traits (panel average) were higher for skatole [r(1029) = 0.59; p < 0.001] than for androstenone [r(1029) = 0.44; p < 0.001]. Linear terms of androstenone and skatole as well as their interaction significantly (p < 0.05) contributed to perception of deviant smell (R(2) = 0.43). Standardized regression coefficients illustrate the higher importance of skatole (ß = 0.68) than androstenone (ß = 0.39). Interindividual differences in the responses of assessors to androstenone and skatole are confirmed. A new curved approach is suggested because it better accounts for the interaction of androstenone and skatole than the "safe box" approach. On the basis of these data, sorting strategies using instrumental measurements are discussed. An automated detection based on only skatole measurements is recommended because its performance is only slightly inferior to a sorting based on both androstenone and skatole. Sorting thresholds need to be calibrated against consumer acceptance though.

The accuracy of "subacromial grind test" in diagnosis of supraspinatus rotator cuff tears.

PURPOSE: The aim of this study is to assess the accuracy of a simple clinical test (subacromial grind test) in diagnosing supraspinatus tendon tears. PATIENTS AND METHODS: The test is considered positive if palpable crepitus or grinding is detected on passive internal and external rotation of the shoulder while abducted in the scapular plane. Data were collected prospectively on 47 patients undergoing shoulder arthroscopy, and the results of the test and arthroscopy compared. RESULTS: During arthroscopy, 17 patients had full thickness (FT) tears of supraspinatus tendon and 10 had partial thickness tears. For any supraspinatus tear, the sensitivity of the test was 63%, specificity 95%, positive predictive value 94%, negative predictive value 66% and overall accuracy 79%. For FT tears, the sensitivity was 82%, specificity 87%, positive predictive value 78%, negative predictive value 90% and overall accuracy 85%. CONCLUSION: We found that this is a useful single test for diagnosing FT supraspinatus tears. LEVEL OF EVIDENCE: Level IV diagnostic study.

Clinical outcome and wound healing following carpal tunnel decompression: a comparison of two common suture materials.

INTRODUCTION: Debate exists amongst surgeons regarding the ideal suture material for skin closure in carpal tunnel decompression (CTD). This study compares wound related complications, patient satisfaction, and functional outcome following open carpal tunnel decompression in patients undergoing wound closure with either of two common absorbable and nonabsorbable suture types. MATERIALS AND METHODS: 53 patients underwent CTD with either 4/0 polypropylene (ProleneTM, n = 28) or 4/0 polyglactin (Vicryl RapideTM, n = 25) for skin closure. QuickDASH, VAS satisfaction scores, and Southampton wound scores were assessed preoperatively and at 2 and 6 weeks postoperatively. RESULTS: At 6 weeks the mean QuickDASH scores postoperatively were 18.54 and 17.70 for absorbable and nonabsorbable sutures, respectively, (P = 0.86). The mean VAS scores were 0.61 and 0.42 (P = 0.91), respectively. All patients achieved a Southampton wound score of 0 by 6 weeks except one, who achieved 1C in the nonabsorbable group, equivalent to mild erythema. There were no complications in either group. CONCLUSION: Both suture types are safe and effective materials for CTD, and we recommend surgeons to choose according to personal preference, handling properties, and resources available for suture removal.

Fast and solvent-free quantitation of boar taint odorants in pig fat by stable isotope dilution analysis-dynamic headspace-thermal desorption-gas chromatography/time-of-flight mass spectrometry.

Boar taint is a specific off-odour of boar meat products, known to be caused by at least three unpleasant odorants, with very low odour thresholds. Androstenone is a boar pheromone produced in the testes, whereas skatole and indole originate from the microbial breakdown of tryptophan in the intestinal tract. A new procedure, applying stable isotope dilution analysis (SIDA) and dynamic headspace-thermal desorption-gas chromatography/time-of-flight mass spectrometry (dynHS-TD-GC/TOFMS) for the simultaneous quantitation of these boar taint compounds in pig fat was elaborated and validated in this paper. The new method is characterised by a simple and solvent-free dynamic headspace sampling. The deuterated compounds d3-androstenone, d3-skatole and d6-indole were used as internal standards to eliminate matrix effects. The method validation performed revealed low limits of detection (LOD) and quantitation (LOQ) with high accuracy and precision, thus confirming the feasibility of the new dynHS-TD-GC/TOFMS approach for routine analysis.

Outcomes of Geriatric Hip Fractures Treated with AFFIXUS Hip Fracture Nail.

Geriatric hip fractures are one of the commonest fractures worldwide. The purpose of this study was to report the outcomes of a series of unstable geriatric hip fractures treated with AFFIXUS hip fracture nail. A retrospective study of 100 unstable geriatric hip fractures treated with AFFIXUS hip fracture nail is presented. The mean follow-up duration was 8 months (range 3-32). Of the patients 83% were female. The average age was 85 years. The fracture was treated by closed reduction and intramedullary fixation. The mean acute hospital stay was 17.6 days. Systemic complications occurred in 29 patients (29%) and local complications in 3 patients (3%) including lag screw cutout in one patient (1%), lag screw backout in one patient (1%), and deep infection in one patient (1%). Mechanical failures and periprosthetic fractures were not observed in our series. Fractures united in all patients. Preinjury activity level was recovered in 78% of the patients. The results of AFFIXUS hip fracture nail were satisfactory in most elderly patients. The unique design of the lag screw and its thread spacing had effectively reduced cut-out rate.

An overview of shoulder instability and its management.

The assessment and management of patients with instability of the shoulder joint can be challenging, due to the varying ways patients present, the array of different classification systems, the confusing terminology used and the differing potential management strategies. This review article aims to provide a clear explanation of the common concepts in shoulder instability and how they relate to the assessment and management of patients. There are sections covering the mechanisms of shoulder stability, the clinical assessment of patients and imaging techniques. Beyond that there is a discussion on the common classifications systems used and the typical management options. Some patients fall into reasonably well defined categories of classification and in these cases, the management plan is relatively easy to define. Unfortunately, other patients can elude simple classification and in these instances their management requires very careful consideration. Further research may help to facilitate a better understanding of management of the patients in this latter group.