Editorial Commentary: Biologically-Enhanced Patch Augmentation: The Perfect Marriage of Mechanical Stability and Biology for Rotator Cuff Healing? Unfortunately,Not Yet

Recurrent rotator cuff tears are a frequent cause of shoulder disability. To repair a rotator cuff, the surgeon faces both mechanical and biological challenges. Patch use as a scaffold for rotator cuff repair is well-described, as is biological augmentation, with clinical indications and efficacy being the subjects of ongoing study. However, a clinical report of dermal allograft patch augmentation combined with attempts at supercharging the biology is novel. This technique would benefit from controlled, prospective studies, with tight inclusion criteria.     

Editorial Commentary: Put Down Your Saw and Pick Up Your Scope! Or,Why Burn Down the Bridge When the Road Ahead Is Full of Potholes? Reverse Total Shoulder Replacement Versus Arthroscopic Rotator Cuff Repair

Are we doing too many reverse total shoulder replacements and not fixing enough repairable rotator cuff tears? A convincing argument can be made for attempting to repair most, not all, very large rotator cuff tears in patients who do not have a significant arthritic change in the shoulder. My experience over more than 25 years of arthroscopic rotator cuff repair (ARCR) is that the only good way to know if it is repairable is to try. But some patients really do not pass my “eyeball test” as to whether they can rehabilitate and heal enough to make an ARCR reasonable. Magnetic resonance imaging scans are useful, mostly to help me with tear pattern recognition, how much time and skill I might need for the repair, and to help me council my patients as to their ultimate functional recovery. I have had surprises both ways: some ARCRs that I thought would be easy turned out to be very challenging and others that I thought would be “mission impossible” turned out to be “mission accomplished”! The rationale for jumping ahead primarily to reverse total shoulder replacements reminds me of certain tax cut plans I have heard talk of lately. Sounds great now (well, maybe the complication rate is a little high) but there might be a price to pay down the road.     

Editorial Commentary: Doc,Is It All in My Head? With Rotator Cuff Tears,It Partially Is!

Psychosocial factors including anxiety, depression, and poor mental health negatively influence the baseline clinical expression of rotator cuff tearing. The same factors may influence clinical outcomes after rotator cuff repair surgery. Counseling patients preoperatively about postoperative expectations of rotator cuff repair surgery has a substantial positive impact on postoperative functional outcomes. As surgeons, we need to take the time to not just be technicians but counsel our patients and consider the impact of distress, anxiety, and expectations on the success of our treatments for rotator cuff tears.     

Editorial Commentary: What's in a Name: Is There a Difference Between Incomplete and Partial Rotator Cuff Repairs?

For the treatment of large to massive rotator cuff repairs, not all partial repairs are equivalent. The technique of rotator cuff repair in large to massive rotator cuff tears matters. By using mobilization techniques to mobilize the rotator cuff to obtain anatomic or near anatomic coverage, double-row techniques to increase footprint coverage, and medial mobilization to decrease tension on the repair, exposure of the humeral head can be minimized, which can improve outcomes.     

Editorial Commentary: Tendon-Derived Stem Cells Are in the Rotator Cuff Remnant and Decline With Age and Tear Chronicity—But the Clinical Relevance Is Not Known

The presence of tendon-derived stem cells (TDSCs) and progenitor cells in tendon tissue has been established previously. These cells are part of the mesenchymal adult stem cell line, are multipotent, and can differentiate into several mesenchymal cell lines: osteogenic, chondrogenic, adipogenic, and tenogenic. Mechanical loading may play an important role in the differentiation process and regulates cell differentiation via several signaling pathways. TDSCs can therefore differentiate into several tissues, and the potential for chondrogenic and osteogenic differentiation may be beneficial in tendon-bone regeneration. TDSCs are present in the tendon stumps, and numerous tests have shown that these cells are alive and have the potential to differentiate. Age is a predictor of TDSC activity, and in patients older than 60 years, cell viability and the potential to differentiate are reduced. Despite the theoretical potential that TDSCs may have for tendon healing and improved function, the potential for clinical applications is unclear.     

Editorial Commentary: Superior Capsule Reconstruction Using Dermal Allograft in Posterosuperior Rotator Cuff Tears—Do Patients Benefit and Allografts Heal?

Irreparable rotator cuff tears are challenging to treat, especially in highly active and young patients. Superior capsule reconstruction is a joint-preserving, anatomic, and arthroscopic option that has shown promising mid-term results. Over time, this procedure has undergone evolution in terms of patient selection and technical aspects, such as graft choices and fixation methods. Initially, superior capsule reconstruction was used for isolated irreparable tears of the supraspinatus tendon; now, the indication has widened to technically irreparable massive posterosuperior rotator cuff tears. The trend in North America and Europe has been toward using human dermal allografts, as opposed to fascia lata autografts, to avoid donor-site morbidity and reduce surgery time. How these modifications affect clinical outcomes and whether dermal allografts heal remains unknown.     

Editorial Commentary: Mental Health and Tobacco Use Influence Functional Outcomes—Quod erat demonstrandum,or Not?!?

Why does one patient achieve better results than another with nonoperative orthopaedic treatment? Aside from the specific underlying pathology of knee pain, there are demographic factors, including mental health, body mass index, tobacco use, and pain perception, that influence the clinical results and should be considered as part of the equation.     

Editorial Commentary: Want to Play in the National Football League? Not For Long If You Have an Untreated Cartilage Defect of the Knee

Although the epidemiology and risk factors for chondral injuries of the knee among prospective National Football League athletes have been reported, the effect of previously untreated chondral injuries on players' early National Football League career performance has been unclear to this point. Despite not requiring surgical treatment, players with these untreated injuries were drafted later, played and started fewer games, and exhibited lower fantasy scores—a surrogate marker for performance. Untreated chondral injuries of the knee can have potentially deleterious effects on the playing careers (and financial prospects) of professional American football players.     

Editorial Commentary: Meditation Results From Mindfulness and Results in Improved Surgical Performance: 10 Minutes per Day,the Apps Are Free,Why Not Try?

Meditation is a practice that is thousands of years old and has proponents across the spectrum, from artists to athletes. Meditation is not synonymous with mindfulness but is instead a technique to reach the state of mindfulness. Mindfulness itself can be simply described as the state of bringing one’s attention to the present moment. Attaining mindfulness allows a surgeon to maintain focus and avoid allowing outside stimuli to affect performance. Attaining mindfulness does not eliminate feelings of anger or frustration but allows a surgeon to respond to such emotions thoughtfully. Surgeons who respond mindlessly to frustration exhibit poor behavior, worse surgical outcomes, and increased exposure to liability. Today, daily mindfulness is attainable in an efficient manner using modern, application (app)-based technology, and positive effects of mindfulness on surgical and clinical performance have been reported across multiple specialties. Practicing mindfulness daily for 10 minutes, including the day of surgery, could improve performance. Mindfulness matters, the apps are free, so why not try?     

Editorial Commentary: Hype,Hope and Everything in Between. What Produces the Real Effect for Blood-derived Products Including Platelet-Rich Plasma?

Biological approaches have a promising future in the orthopaedic field because of their potential benefits that include their minimal invasiveness, potential for accelerated healing, and promise for rapid recovery. However, as the initial hype for these therapies starts to fade, it should be replaced by solid basic and clinical science research to tailor each compound to a determined patient/pathology. Blood contains several products that can be both beneficial and detrimental for every specific tissue, and therefore a one-fits-all approach should be avoided. Although beneficial effects have been consistently reported for certain pathologies such as lateral elbow tendinopathy, as an adjunct for rotator cuff repairs and the symptomatic treatment of osteoarthritis, other conditions' outcomes with biologic treatment remain nebulous such as for Achilles tendinopathy. To determine the real effect of these therapies, it is important to maintain strict inclusion criteria in an attempt to isolate the effect of one biologic product that already has many inherent intrinsic variables per se.     

Editorial Commentary: To Properly Apply Delphi Consensus Conclusions,Strengths and Weaknesses of the Process Require Consideration: Unified Expert Opinion or Toxic Fumes Resulting in a Strange Trance?

The Delphi Consensus Process is a tool to allow diverse expert opinion to be consolidated to better understand complex problems. The process has recently been applied to orthopaedic treatment options. While a piece of the puzzle, the strengths and weaknesses of this process must be understood to allow the orthopaedist to apply the conclusions of the Delphi Consensus process effectively. It is important to recognize that expert opinion has been upended time and time again by carefully collected clinical-outcome data. It is unclear whether the visions of the Oracle are due to wisdom or toxic fumes resulting in a strange trance.     

Editorial Commentary: Is Arthroscopic In Situ Repair Effective for Long-Term Functional Recovery and Pain Relief in Symptomatic Partial Rotator Cuff Tears?

Currently, although most evidence suggests that surgery is effective in treating symptomatic partial-thickness rotator cuff tears in patients with failure of nonoperative management and with a tear of more than 50% of the tendon thickness, there is little consensus on the best method of repair. Some surgeons would advocate completing the tear and repairing it, whereas others would advocate performing in situ repair. In our opinion, it is important to also consider treating the long head of the biceps tendon, which is frequently a source of pain at the time of or after surgery.     

Editorial Commentary: Invisible,Odorless, and Deadly: Do Computed Tomography Scans in Young Patients With Hip Pain Cause Cancer?

Does imaging of the pelvis using a set of radiographs and computed tomography (CT) cause cancer? A computer-based simulation study using 5 different imaging and radiation dose protocols has calculated the lifetime risk of malignancy for young adults for pelvic radiographs and CT scans. The cumulative lifetime-attributable risk of cancer was 0.2% for males and 0.35% for females. This appears low but the numbers needed to harm were 952 for males and 564 for females. However, the authors have based their calculations on the linear no-threshold model, which is controversial, and a linear relationship between dose and risk may not exist.     

Editorial Commentary: The Use of Allogenic Cells in Regenerative Medicine: Are Amniotic,Umbilical, and Other Allogenic Cell Sources Safe?

There are abundant data to suggest that the autologous transplantation of human progenitor cells is safe. However, the use of allogenic cells for human use has not been adequately researched and should not be considered safe at this time.     

Editorial Commentary: Animal Trials Using Stem Cells to Enhance Anterior Cruciate Ligament Treatment Are Interesting. But,Why Not More About Us Humans?

Although hampered by heterogeneous studies with low methodologic quality and high risk for bias, the current literature demonstrates the potential for enhanced healing of anterior cruciate ligament injuries during the early phase using adult stem cells in animal trials. There are only 2 published controlled clinical trials on the subject matter, and they have small sample sizes, undefined cell numbers, and unstandardized selection criteria and surgical techniques. There is a clear need for studies with higher levels of evidence that would include long-term, larger animal studies ultimately leading to improved clinical trials.     

Editorial Commentary: The “Mumford” & Sons: For Distal Clavicle Excisions,What Are Our Young Surgeons Doing,and How Well Are They Doing It?

The distal clavicle excision (DCE, also known as the “Mumford” procedure), either open or arthroscopic, is a time-honored procedure with generally excellent and predictable results. Surgeons have a choice to make regarding which technique to perform, and most surgeons choose the arthroscopic approach. This choice is justified, as complication rates are lower for arthroscopic DCE than for open DCE. A well-performed arthroscopic DCE should have a very low complication rate and high success rate.     

Editorial Commentary: Yet Another Arrow in the Quiver for Surgical Treatment of the Rotator Cuff–Deficient Shoulder: Will It Fly Fast and Far or Fall Short Like Other Options Have?

Rotator cuff tears are common. When indicated, surgical repair is a highly successful procedure. There are circumstances when there is not enough tendon to perform an anatomic repair because of tear size, retraction, and/or atrophy. This clinical scenario, massive irreparable rotator cuff tear, has no perfect solution. Many options exist in treating massive irreparable rotator cuff tears: partial tendon repairs, debridement, tuberoplasty, intercalary allograft repairs, tendon transfers, superior capsular reconstruction, hemiarthroplasty, arthrodesis, and reverse total shoulder arthroplasty. No superior technique has been described. Another treatment has been added to this list: inserting a biodegradable balloon within the subacromial space to reduce the articulation of the humeral head on the acromion and aid in recentering the humeral head to restore balance to the remaining rotator cuff and improve deltoid function.     

Editorial Commentary: The Gain in Pain After Hip Arthroscopic Surgery: What Is Clinically Relevant,and Is Pain Related to Function in Patients With Femoroacetabular Impingement Syndrome?

Hip arthroscopic surgery improves patient-reported outcomes in patients with femoroacetabular impingement syndrome and/or hip chondropathy. The minimal clinically important change on a pain visual analog scale has now been calculated in this patient group, and the pain level 1 year after surgery has been related to function. Next step: identifying what causes pain and decreased function 1 year after surgery.