Editorial Commentary: Is the Lateral Center-Edge Angle Sufficient for the Approximation of Acetabular Coverage?

The lateral center-edge angle is a robust technique with proven clinical applicability for quantifying acetabular coverage. However, it measures only the lateral coverage of the femoral head without consideration of other important portions of the acetabulum such as the anterior or posterior wall. Three-dimensional acetabular coverage measurement techniques capable of quantifying the entire acetabulum have become available, thus posing the question of whether we should still rely on the lateral center-edge angle for the assessment of acetabular coverage.     

Editorial Commentary: Silly Biceps,Tenodesis Is for Kids!

There is now a strong consensus that the best surgical treatment of a SLAP lesion is often something different from a primary direct repair, especially in older patients in whom postoperative stiffness and persistent pain have led most of us to perform a biceps tenodesis instead. However, treatment of younger patients and especially the overhead athlete group is more problematic and thus controversial. This study demonstrates that biceps tenodesis in these patients can be more successful and have a higher return to sport than SLAP repair alone. There may also be a role for biceps tenodesis AND a SLAP repair but the numbers presented in this paper preclude an analysis of exactly who that group is. When it comes to the treatment of patients with SLAP lesions for whom a very well executed rehabilitation program has failed, understanding the symptoms and demographics of your patients is critical to surgical decision making. The pendulum may swing toward tenodesis, but beware: The correct answer is usually near the center of the arc!     

Editorial Commentary: Similar Outcomes Among Surgical Techniques for Unstable Acromioclavicular Injuries: Is There More to the Story?

There are many ways to perform stabilization of unstable acromioclavicular injuries, and there are generally good results with all surgical techniques. Unfortunately, the literature is weak on comparing surgical results with nonsurgical management, so we still have not defined which patients need surgery and which patients do not.     

Editorial Commentary: Intra-Articular Injections for Painful Knee Osteoarthritis: What Is the Current Treatment Paradigm?

Intra-articular corticosteroids are useful for acute and short-term pain relief, whereas hyaluronic acid is useful for a longer-term treatment effect for patients with knee osteoarthritis. More rigorous research using homogeneous preparations and techniques and randomizing larger numbers of knee osteoarthritis patients are warranted before recommending any wider acceptance of platelet-rich plasma and stem cell therapies. This is of utmost importance, especially with several new injectables such as anti–nerve growth factor antibodies, Wnt pathway inhibitors, and capsaicin showing promise to enter the market soon.     

Editorial Commentary: Readmission Rate After Hip Arthroscopy: Is There a Cause for Concern?

Readmission after hip arthroscopic surgery is an undesired and unusual event. The causes may range from wound-related issues, deep infection, increasing pain, complications of surgery, to medical events. It adds to the economic burden of the procedure and causes unnecessary anguish to the patients and indeed clinicians. It is also one of the less-studied areas of hip arthroscopic surgery because of its rarity. There would be benefit in being able to identify the risk factors of readmission such that pre-emptive measures can be put in place to prevent or indeed counsel the patients before the surgery. In certain cases, readmission may remain an unpreventable event. In our experience, the readmission rate after hip arthroscopy is 0.5%, whereas patients with elevated body mass index are at greater risk.     

Editorial Commentary: Arthroscopic Latarjet: Is It Ready for Prime Time?

Latarjet coracoid transfer has traditionally been performed utilizing an open approach in patients with recurrent instability and significant glenoid bone (i.e. >20%). Recent literature has examined clinical outcomes after arthroscopic Latarjet using suture button fixation, demonstrating low recurrence and complication rates when performed by an experienced senior surgeon. Despite demonstrating specific technical and outcome advantages, the arthroscopic approach has previously been shown to be limited by a steep learning curve and complications rates unaffected by surgical experience. These limitations should be addressed prior to widespread adoption.     

Chronic Allograft Dysfunction—Is There a Treatment?

Background

The major causes of renal transplant loss are death and chronic allograft dysfunction (CAD). The aims of this study were to determine the incidence of CAD in our population and the relation between allograft survival and immunosuppressive regimens.

Methods

We studied retrospectively 473 patients who received deceased donor kidney transplants with at least 1 allograft biopsy between January 1990 and May 2007. Clinical data included age, gender, biopsy data, and immunosuppression before and after kidney biopsy. Mean age was 45.4 ± 12.7 years including 65% males with a mean follow-up of 6.7 ± 4.5 years. CAD was observed in 177 of 473 biopsies: 48 patients showed interstitial fibrosis (IF); 101 chronic rejection (CR); 16 transplant glomerulopathy (TG); and 12, CR and TG. Mean follow-up since the discovery of the histologic feature was 60.5 ± 50.5 months for IF; 38.3 ± 40.8 for CR, and 18.2 ± 19.2 for TG.

Results

CAD, which was more common in younger patients (P = .03), correlated upon univariate and multivariate analysis with CKD stage 5d development (P < .001). Deposition of C4d in peritubular capillaries was more frequent among CAD patients (P = .004), an association with particular relevance to recipients with CR (P = .02) and TG (P < .001). When we analyzed CAD subpopulation, we observed a positive correlation between allograft survival and immunosuppression modification after biopsy. Substitution of sirolimus (40/177) was shown in univariate, multivariate and Cox regression analyses to be a renal protector (P < .002). Allograft survival was also correlated with initial mycophenolate mofetil versus azathioprine, (62/177) immunosuppression (P < .001).

Conclusion

CAD, a frequent histologic feature, may benefit from sirolimus conversion.     

Editorial Commentary: Anterior Capsular Reconstruction for Subscapularis Deficiency: The Definitive Treatment or a Helpful Adjunct?

Anterior glenohumeral instability in the setting of irreparable subscapularis deficiency represents a difficult clinical scenario for the treating shoulder surgeon. Anterior capsular reconstruction with humeral dermal allograft improved glenohumeral translation stability and range of motion to near-normal values whereas pectoralis major tendon transfer was unable to do so. However, placement of a static spacer does not restore the dynamic force couple or shoulder kinematics. Further research is needed to evaluate the functional outcomes using this reconstruction technique.     

Editorial Commentary: Arthroscopic Partial Meniscectomy Is Not a First-Line Treatment for Degenerative Meniscus Tear: To Meniscectomize or Not to Meniscectomize?

A painful knee with a degenerative meniscal tear is a quite common problem in the middle-aged patient. Arthroscopic partial meniscectomy is too often used to alleviate pain and seems to work in the short-term. However, arthroscopic partial meniscectomy does not guarantee success, particularly in the long run, particularly in patients with greater grades of osteoarthritis, patients who are older than 60 years, female patients, patients with malalignment, and patients having lateral meniscectomy. There is a need for better science to recommend arthroscopic meniscectomy in those cases.     

Editorial Commentary: Is Medical Ozone Therapy Beneficial in the Treatment of Knee Osteoarthritis?

Osteoarthritis is a degenerative joint disease that is difficult to manage and a major cause of disability in the elderly population. The use of ozone for treatment of knee osteoarthritis (KOA) is controversial and of interest. Although the exact mechanism of ozone for the treatment of KOA is not fully understood, it has been shown that ozone administration may promote oxidative preconditioning or adaptation to oxidative stress, which in turn will result in the stimulation of antioxidant endogenous system which prevents tissue damage. A number of European studies show ozone injection for treatment of KOA results in pain relief, disappearance of edema, and improved mobility. Dosages and volume of injections vary among studies, risk of bias is generally high, and outcomes are inconsistent and not uniformly excellent. At present, there is insufficient evidence to support the effectiveness of ozone therapy for KOA.     

Editorial Commentary: Unguided Glenohumeral Injections—Do We Achieve Sufficient Accuracy?

Image-guided (fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging) and unguided glenohumeral injection techniques are frequently used for different diagnostic and therapeutic purposes in clinical practice. Guided injections are highly accurate, reproducible, and more often performed in routine practice. Nevertheless, these techniques are more cost intensive and time consuming, and require special imaging devices. In case of fluoroscopic- or computed tomography–guided injections, radiation exposure of the patient is a disadvantage. In contrast, unguided glenohumeral injection techniques do not have these drawbacks, but rather are based on the precise identification of anatomic landmarks and depend on the experience of the provider. That is the reason they are supposed to be less accurate and less reproducible than guided techniques. But recent studies showed comparable accuracy; therefore, the use of unguided glenohumeral injection techniques should be considered in daily clinical practice in the hands of experienced shoulder arthroscopists.     

Distal Margin Requirements After Preoperative Chemoradiotherapy for Distal Rectal Carcinomas: Are ≤ 1 cm Distal Margins Sufficient?

Background:Sphincter-sparing alternatives to abdominoperineal resection (APR) in the treatment of rectal cancer often are underused out of concern for inadequate distal margins and local failure. The present study addresses whether sphincter-sparing techniques with distal margins 1 cm adversely influence oncological outcome in patients given preoperative chemoradiotherapy.Methods:Thirty-seven patients with rectal cancer 8 cm from the anal verge were enrolled in the study. Preoperative external beam radiotherapy (5400 Gy) was administered together with continuous infusion of 5-fluorouracil (300 mg/m²/day). Surgical resection was performed in 36 patients with pathological assessment of tumor response and margins. Patients with sphincter-sparing resection and distal margins > 1 cm or 1 cm and those who underwent APR were compared.Results:Thirty-six patients completed preoperative chemoradiotherapy, with successful sphincter-preservation in 28 patients. At a median follow-up of 33 months, there were 12 recurrences overall, which included 11 distant failures and four pelvic failures. Disease-free survival (DFS) was not different between those who had an APR compared with sphincter-sparing resection with distal margins 1 cm. DFS was worse (P < .02) when radial margins were 3 mm compared with > 3 mm.Conclusions:Sphincter preservation is feasible in more than 75% of patients with tumors 8 cm from the anal verge after preoperative chemoradiotherapy. Sphincter-sparing surgery with distal margins 1 cm can be used without adversely influencing local recurrence or DFS. Limited radial margins ( 3 mm), however, are associated with increased disease recurrence.Presented at the 1998 Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 18, 1998     

Editorial Commentary: Balloons for Rotator Cuff Tears: A Viable Treatment or Just a Bunch of Hot Air?

Rotator cuff tears are very common. They can be either traumatic or degenerative in nature. Many tears can be successfully treated nonoperatively with physical therapy or home exercises. For patients in whom conservative measures fail, there are a variety of ways to repair the rotator cuff. Despite our advances in knowledge about rotator cuff tears, improved technology, and advanced repair techniques, failure rates after surgery are still high. Large tears that are deemed irreparable can be treated with partial repair, debridement, tendon transfers such as a latissimus dorsi transfer or lower trapezius transfer, biceps tenotomy or tenodesis, superior capsular reconstruction, bridge grafting, or even arthroplasty options such as a hemiarthroplasty or reverse total shoulder arthroplasty. No technique has proved vastly superior to another, and there are many advantages and disadvantages of each surgical procedure. Add balloon spacer implantation to that list. A surgeon can now place a subacromial balloon spacer to help improve functional outcomes and reduce pain in patients with irreparable rotator cuff tears. Studies have shown promising results, with improvements in strength and range of motion, as well as reductions in pain. Outcomes have only been studied in the short term, so much is still unknown about the full effects of this treatment. More studies are needed to find out whether the results persist into the long term and to confirm that complications do not arise that may complicate future procedures such as a reverse total shoulder arthroplasty.     

Editorial Commentary: Intra-articular Injection for Osteoarthritis—Is It Hip or Not?

Intra-articular injections are commonly used in the treatment algorithm for osteoarthritis of the hip. A number of different adjuvants can be used, such as corticosteroids, hyaluronic acid, and platelet-rich plasma, but there is no consensus regarding indications for or anticipated outcomes of each of these interventions. Recent data suggest that corticosteroids provide the best relief in the short term whereas platelet-rich plasma may be more beneficial in the mid term, but the results are variable. Ultimately, more rigorous studies are needed to evaluate these adjuvants, in particular biologics, while remaining fastidious with our indications for injection therapy.     

Editorial Commentary: Is an Arthroscopic Single-Row Repair Effective for the Treatment of Chronically Retracted,Full-thickness Subscapularis Tears?

Retraction and scarring of subscapularis tears make arthroscopic fixation technically challenging. The ideal arthroscopic technique is still under debate, with new studies examining the importance of repairing the “leading edge.” Regardless of single- or double-row fixation, it is our opinion that restoring the native anatomy as well as any concomitant biceps pathology is essential for postoperative success.     

Editorial Commentary: Trochleoplasty: Is It Really That Fearsome and Dangerous a Technique?

Trochleoplasty in patellofemoral instability has always been controversial. Most authors recognize the fundamental role of trochlear dysplasia in the genesis of patellar dislocation, and some strongly defend correcting the abnormality, yet others find it too dangerous or unnecessary. Misunderstanding or undervaluation of trochlear dysplasia leads to inappropriate or failed patellofemoral (PF) surgery, the iatrogenic complications of which are well known. Many surgeons miss a key aspect of trochlear dysplasia: the overhang or the prominence of the trochlea relative to the anterior femoral cortex, characterized by a supra-trochlear spur. Trochleoplasty should not be performed as a secondary or revision procedure, but as a primary procedure with clear indications, and the key to improved outcomes is to ensure the right indication for each patient, which can only be determined by understanding the extent of dysplasia in both the axial and sagittal planes.