Kerem Bilsel

Background and Objectives: Nonunion remains an important clinical concern after nonoperative treatment of humeral shaft fractures. Although several patient- and fracture-related variables have been proposed as determinants of healing, their independent contributions remain uncertain. This study aimed to identify patient- and fracture-related factors independently associated with nonunion after nonoperative treatment of humeral shaft fractures. Materials and Methods: This single-center retrospective cohort study included adults with humeral shaft fractures treated nonoperatively between January 2015 and January 2025. Fractures were classified using the AO/OTA system. Patients with periprosthetic, pathological, pediatric, intra-articular fractures, previous nonunion, or insufficient follow-up were excluded. Treatment consisted of functional bracing after initial immobilization. Nonunion was defined as absence of clinical and radiographic union at or beyond 9 months after injury, with no radiographic progression over at least 3 months, persistent fracture-site pain, and absent bridging callus. Demographic characteristics, comorbidities, fracture-related variables, and radiographic parameters were recorded. Multivariable logistic regression was used to evaluate adjusted associations with nonunion, with Firth’s penalized regression performed as a sensitivity analysis. Results: Among 242 patients, union occurred in 207 (85.5%), while 35 (14.5%) developed nonunion. In the adjusted model, older age (OR = 1.76 per 10-year increase; 95% CI: 1.28–2.40), smoking (OR = 14.33; 95% CI: 4.16–49.32), and proximal-third fracture location (OR = 3.77; 95% CI: 1.38–10.31) were associated with nonunion. Firth’s penalized regression yielded similar findings. The association with diabetes mellitus was uncertain (OR = 2.63; 95% CI: 0.94–7.30). Conclusions: Older age, smoking, and proximal-third fracture location were associated with nonunion after nonoperative treatment of humeral shaft fractures. These exploratory associations may inform patient counseling and follow-up, but the limited number of events and wide confidence intervals warrant cautious interpretation.

Purpose: To establish evidence‐based consensus recommendations for the management of partial‐thickness posterosuperior rotator cuff tears (PT‐PS‐RCTs). This second part addresses treatment strategies, rehabilitation, return to sport and complications. Methods: This European Society for Sports Traumatology, Knee Surgery and Arthroscopy–European Shoulder Associates (ESSKA‐ESA) Formal Consensus was conducted according to the ESSKA Formal Consensus Methodology. A Steering Group (13 shoulder surgeons) developed 33 questions and statements based on a standardized literature review and assigned recommendation grades (A–D) according to the level of evidence. Statements were evaluated by an independent Rating Group (20 shoulder surgeons) through a three‐round consensus process. Results: Twenty‐one Question–Statement (Q–S) pairs achieved strong agreement, generating 30 individual recommendations (1 Grade A, 6 Grade B, 10 Grade C and 13 Grade D). Grade A evidence identified an increased risk of postoperative stiffness after trans‐tendon repair of articular‐sided PT‐PS‐RCTs compared with tear completion. Grade B evidence supported conservative treatment for at least 6 months, platelet‐rich plasma injections and management of stiffness before surgery; both trans‐tendon/in‐situ repair and tear‐completion‐and‐repair showed similar return‐to‐sport rates, although tear‐completion‐and‐repair had slightly higher retear rates. The most commonly reported patient‐reported outcome measures were the American Shoulder and Elbow Surgeons, Constant–Murley and visual analogue scale scores. Conclusion: Management should be individualized according to patient characteristics (activity level, sports participation), symptoms, tear morphology and tissue quality rather than based on a single treatment algorithm. Non‐surgical treatment is the preferred initial approach, whereas no surgical technique has demonstrated consistent superiority across all clinical scenarios. These recommendations provide clinicians with a practical framework to guide treatment decisions and standardize the management of PT‐PS‐RCTs in daily clinical practice. Level of Evidence: Level I, formal consensus.

Purpose: To establish evidence‐based consensus recommendations regarding the diagnosis and treatment of partial‐thickness posterosuperior rotator cuff tears (PT‐PS‐RCTs). This part addresses the definition, classification, natural history and diagnosis of these controversial conditions in shoulder surgery. Methods: This official European Society of Sports Medicine, Knee Surgery and Arthroscopy–European Shoulder Associates (ESSKA‐ESA) Formal Consensus was conducted according to the ESSKA Formal Consensus Methodology. A Steering Group developed 33 questions, followed by a standardized literature search and evidence review. For each question, a consensus statement was drafted and assigned recommendation grades (A–D) according to the level of evidence. An independent Rating Group evaluated all statements until strong agreement was achieved. Results: Twelve recommendations were generated with three Grade A, three Grade B, two Grade C, five Grade D and strong agreement. Grade A was found for the use of multiple classification systems in unison to characterize these injuries and for the distinction between acute and chronic tears. Scientific presumption level (Grade B) was found for the increased incidence of articular injuries in overhead and contact athletes and for the absence of a link between calcifying tendinitis and PT‐PS‐RCTs. Grade C was found to define the risk and timeframe of tear progression and the ideal imaging modality. Conclusion: This ESSKA‐ESA Formal Consensus recommends that PT‐PS‐RCTs should be classified according to tear location, depth and tendon involvement. The aetiology of these injuries is multifactorial, and their progression is unpredictable. Current imaging modalities have limitations in characterizing these lesions. The present consensus provides clinicians with a practical evidence‐based framework for the diagnosis and classification of PT‐PS‐RCTs while identifying key priorities for future clinical research. Level of Evidence: Level I formal consensus.

Football-specific loading may be associated with different dominant and nondominant (D and ND) side patterns in hamstring stiffness and clinical flexibility. This study compared D and ND side patterns in semitendinosus (ST), semimembranosus (SM), and biceps femoris (BF) stiffness and in active knee extension (AKE) and straight leg raise (SLR) measurements between amateur football players and healthy controls. This cross-sectional study included 50 amateur football players and 50 healthy controls without organized athletic participation. Bilateral ST, SM, and BF stiffness values were measured using shear wave elastography (SWE). Clinical hamstring flexibility was assessed with AKE and SLR tests. D and ND side differences were examined within each group, and side difference patterns were compared between groups. In football players, SM stiffness was higher on the dominant side (D-ND estimate, 1.25 kPa, p = 0.012). In controls, BF stiffness was higher on the nondominant side (D-ND estimate, - 0.90 kPa, p = 0.044). In the primary between group comparison, only the BF D-ND difference differed significantly, with opposite directions of side difference between groups (between group estimate, 1.74 kPa, p = 0.013). Controls also showed dominant side AKE and SLR differences of 1.00° and 1.50°, both below reported measurement error thresholds. D and ND side patterns in hamstring stiffness and clinical flexibility varied according to the muscle, test, and group studied. The main between group difference emerged through BF stiffness, whereas the AKE and SLR differences observed in controls were limited in magnitude.

Football’s repetitive lower-extremity biomechanics may drive functional adaptations in the hamstrings and spinopelvic alignment. We hypothesised that footballers would display greater hamstring stiffness and morphometric differences in SPPs, attributable to sport-specific loading, compared with non-athletes. This study therefore investigates the interrelationships among hamstring stiffness, flexibility, and spinopelvic alignment to clarify football-induced adaptations. This cross-sectional study included 50 licensed amateur male football players (Group A; mean age 21.74 ± 2.91 years) and 50 healthy males with no licensed sports participation (Group B; mean age 23.14 ± 2.98 years). Measurements comprised radiographic assessment of SPPs, Shear-Wave elastography (SWE) to quantify hamstring muscle stiffness, and clinical flexibility tests (CFTs) which consist of the Active Knee Extension (AKE) test, the Straight Leg Raise (SLR) test, and the Sit-and-Reach (SR) test. No significant differences were detected between the groups in SPPs. All hamstring SWE values (except for the left Biceps Femoris, p = 0.615) and all CFT values were significantly higher in Group A (p < 0.001), indicating the ‘high stiffness/high flexibility’ paradox. Within Group A, SPPs were not associated with either SWE values or CFT values (p > 0.05). Likewise, no correlations were found between SWE values and CFT values in either group (p > 0.05). Footballers exhibited higher hamstring stiffness yet showed no spinopelvic morphometric differences compared with non-athletes. The absence of SWE–CFT correlations suggests that these methods assess distinct physiological properties. The observed “high stiffness/high flexibility” paradox in footballers indicates sport-specific functional adaptations. Future longitudinal studies are needed to clarify the long-term effects of this phenomenon.