Editorial Commentary: Biceps Tenodesis Location May Not Matter: Go High…Go Low…Go Wherever You Want to Go!

Tenodesis of the long head of the biceps tendon has long been a source of dialogue, discussion, debate, and dogma. In general, the shoulder literature has been exhaustive regarding various biceps tenodesis techniques and outcomes, and studies have shown positive clinical outcomes of tenodesis, regardless of location, along the proximal humerus. Fewer studies have evaluated the outcomes of revision tenodesis; however, those that have looked at this have generally found that a revision to a subpectoral tenodesis site is usually quite successful.     

Editorial Commentary: Hip Arthroscopy in the Professional Athlete…Back in the Game

With improved outcomes and expanding indications, the rate of hip arthroscopy for treatment of numerous pathologies has increased. There is significant interest from patients and providers alike regarding return to meaningful play after surgical intervention, particularly for the professional athlete. Although each athlete and each sport have unique obstacles, the literature suggests hip arthroscopy has a high success rate and allows for elite athletes to return to play without significant differences in postoperative performance scores.     

Editorial Commentary: Is Arthroscopic Bone Grafting Nearly Equivalent to Open Bone Grafting for Glenoid Bone Defects in Recurrent Anterior Shoulder Instability?

Arthroscopic techniques are an emerging technology to deal with glenoid bone defects in patients with anterior shoulder instability, and improvements are being made to safely minimize the risk of injury to the anterior neurovascular structures including the axillary nerve. Arthroscopic glenoid reconstruction is a technically demanding procedure, but it does have promising short-term outcomes. I truly like the concept of anterior (and also posterior) bone grafting for defects of the glenoid, including the arthroscopic Latarjet. A free bone graft (iliac crest, distal tibia) is part of a logical surgical learning curve progression to treat bone defects from an arthroscopic standpoint. Before performing an arthroscopic Latarjet, I might suggest looking at performing free bone block fixation arthroscopically. But, for now, I still enjoy the success of an open bone grafting procedure and will continue to use open as my primary bone grafting (Latarjet, distal tibia, iliac crest), so as to optimize the position of the graft for successful long-term outcomes. We look forward to seeing more of the authors' work and a longer term follow-up of these patients to clearly delineate the development of osteoarthrosis, recurrent instability, and long-term stability of the bone graft and shoulder joint function.     

Editorial Commentary: Back to the Past—Anterior Cruciate Ligament Repair Revisited

There has been increasing scientific interest in primary anterior cruciate ligament (ACL) repair in recent years. The results of these procedures have improved significantly compared with the 1970s and 1980s. Nevertheless, the overall rerupture rates after ACL repair are worse than after ACL reconstruction, and patient-reported outcome measures do not improve after ACL repair, in contrast to those after ACL reconstruction. However, because primary ACL repair is performed in the acute phase, improvement in patient-reported outcome measures after surgery is not expected. We believe that in the future, primary ACL repair will be established next to ACL reconstruction and nonsurgical therapy. One possible indication is a proximal ACL rupture. Which surgical technique will prevail—and whether orthobiological treatments such as platelet-rich plasma or stem cells will improve postoperative outcomes after ACL repair—will need further clarification by clinical trials.     

Editorial Commentary: Glenoid Bone Loss Measurements in Shoulder Instability—Precise but Not Accurate

Glenoid defects are important to consider when choosing the surgical stabilization technique in shoulder instability patients. Several measurement methods to determine the extent of glenoid bone loss have been proposed and their reliability or precision proved. However, it must be considered that these defect extent measurements are only surrogate parameters trying to express the loss of biomechanical stability generated by a glenoid defect, which in fact they do not do accurately. Current defect measurement techniques are either linear based (1-dimensional) or area based (2-dimensional) but do not take into account the 3-dimensional shape of the glenoid concavity, which creates stability by means of the concavity-compression effect. Furthermore, none of the current measurement methods take into account the native glenoid concavity shape, which significantly differs between patients and therefore also affects the biomechanical consequence a glenoid defect generates. To improve the accuracy of current glenoid defect measurement techniques in expressing the loss of biomechanical stability generated by a glenoid defect, measurements should take into account the concave shape of the glenoid (3-dimensional measurements) and account for the baseline shape of the native glenoid (4-dimensional measurements).     

Editorial Commentary: Arthroscopic Shoulder Instability Surgery and Glenoid Bone Loss: A Paradigm Shift?

The successful treatment of shoulder instability, particularly in the setting of glenoid bone loss, is a challenging problem. There are several surgical options that are available for patients who have this clinical entity. Of these options, bone block procedures have become increasing common over the past several years, both for primary and revision surgery, with the aim to restore the native glenoid anatomy. The arthroscopic Eden–Hybinette procedure is a viable arthroscopic treatment option in patients who have anterior shoulder instability with anterior glenoid insufficiency. This technique has some distinct advantages over other bone block procedures, specifically the ability to avoid damage to the subscapularis and to preserve the coracoid process. In addition, the use of autograft has benefits over glenoid reconstruction procedures that use allograft, specifically pertaining to cost and availability.     

Editorial Commentary: Should We Worry About Progressive Glenoid Bone Loss After Arthroscopic Bankart Repair?

One of the key factors in shoulder stabilization surgery is how much glenoid bone loss is present. Too much glenoid bone loss, or the combination of glenoid bone loss combined with a humeral side Hill–Sachs deformity, can lead to an “off-track” lesion and significantly greater risk of recurrence. If the potential surgical solution for instability leads to greater glenoid bone loss, we could create more problems for our patients.     

Editorial Commentary: Threshold Values for Treatment Success—Rotator Cuff Repair Success Lies in the Eye of the Beholder

Successful treatment is the shared goal of patients, surgeons, and clinicians. In the realm of rotator cuff repair, identifying threshold values provides insight into the relation between scores generated from commonly used outcome measures and patient-rated success. These thresholds are useful for separating clinical significance from statistical significance and can help direct future research that aims to examine the effects of different treatments in the context of success. It is important to note that threshold values are sensitive to the sample from which they were drawn. Given the inherent subjectivity of patient-rated success and the diverse nature of patients with rotator cuff tears, there is no single threshold for success but rather a spectrum of threshold values, all of which are dependent on the underlying characteristics of the patients from whom the values were generated.     

Editorial Commentary: Bone Marrow Aspirate Concentrate: Time to Harvest Locally?

Cell therapies hold great promise as primary and adjuvant treatments for a range of musculoskeletal conditions. Bone marrow harvested from the iliac crest represents the gold-standard source of progenitor cells with a recognized ability to release trophic factors, modulate local immune environments, and differentiate into multiple musculoskeletal cell types in vitro. Identifying accessible locations that limit donor-site morbidity while increasing efficiency during aspiration of bone marrow is essential. There is increasing evidence to suggest that the number of progenitor cells present in bone marrow aspirated from multiple sites, including the proximal humerus and ilium, is at least equivalent to that from the iliac crest. Because many of these sources lie within the surgical field, the requirement for iliac crest harvest and the risks associated with secondary harvest sites can be mitigated. Although there is a clear need for further studies evaluating the biological attributes and clinical benefit of bone marrow aspirate concentrate in a range of clinical settings, the use of local harvesting sites is likely to reduce morbidity and improve the experience for patients.     

Editorial Commentary: Can We Evaluate Glenoid Bone With Magnetic Resonance Imaging? Yes,If You Have the Right Sequence

Glenoid bone loss must be recognized when treating patients with shoulder instability to appropriately determine surgical treatment with either a soft-tissue stabilization or bony augmentation procedure. Three-dimensional reconstructions from computed tomography scans currently are the clinical gold standard for accurately evaluating glenoid bone loss. Novel advances in magnetic resonance imaging sequences and processing may allow for obtaining complete bony information from a single preoperative imaging study.     

Editorial Commentary: Are Shoulder Glenoid Labral Teardrop Lesions Reasons for Surgeons to Cry?

In the world of glenoid labral chondral injuries, perhaps the most recognizable by magnetic resonance imaging is the “teardrop” version, and the glenoid labral teardrop lesion is the glenoid chondral lesion most frequently associated with shoulder instability.     

Editorial Commentary: Double Bundle the Coracoclavicular Ligaments for Success: The More the Better?

Injuries to the acromioclavicular joint are common across all levels of sport and activity. Overall, a consensus exists regarding Rockwood grade I and II injuries (conservative approach) and Rockwood grades IV to VI (best treated surgically). However, grade III injuries are heterogeneous and thus respond differently to nonoperative and operative treatment. Regardless of the acromioclavicular injury grade, these are widely prevalent injuries, and there is a lack a consensus as to which operative fixation methods yield the best outcomes for patients. Although K-wires and plates were historically used to achieve rigid fixation, recent evidence supports the use of soft tissue grafts to reconstruct the coracoclavicular ligaments and restore vertical and anteroposterior and rotational stability with a more biological approach.     

Editorial Commentary: Caveat Flexor—To Release or Not to Release the Iliopsoas,That Is the Question

In nonarthritic patients with femoroacetabular impingement syndrome, borderline dysplasia, and symptomatic iliopsoas snapping, arthroscopic iliopsoas fractional lengthening carries a significant risk of postarthroscopic instability. The iliopsoas is a dynamic stabilizer of the anterior hip. Thus, although statistically significant and clinically important improvements in hip function have the potential to be achieved with iliopsoas fractional lengthening, surgeons must be supremely confident in their ability to perform a secure capsular plication, labral preservation (not debridement), comprehensive cam correction, avoidance of intra-abdominal fluid extravasation, release of all iliopsoas tendon bands (if bifid or trifid), and ensure that femoral version is normal or low, neck-shaft angle is not excessively valgus, the dysplasia magnitude is no more than mild, and that there is no excessive soft tissue hypermobility. If these goals can be met, then excellent outcomes can be achieved. If not, then an iliopsoas fractional lengthening should not be performed.     

Editorial Commentary: Hip Capsule: To Repair or Not?

Arthroscopic hip capsular repair is an area of intense interest. Basic science studies suggest that adverse changes in capsular stability/restraint may occur with capsulotomy and capsulectomy, that repair may ameliorate these changes, and, most recently, that the repaired capsule usually heals. Clinical studies suggest that in some conditions, most notably mild dysplasia, capsular repair or plication may improve short-term outcomes, but in general, the role of capsular closure is less clear. At present, perhaps a selective approach is merited, with capsular closure performed in patients with dysplasia, focal or generalized hyperlaxity, and/or increased femoral anteversion. The comparative outcomes from smaller, more vertically oriented capsulotomies with less violation of the iliofemoral ligament deserve investigation.