Editorial Commentary: The Medial Patellofemoral Ligament Is Not Isometric and Anatomic Reconstruction Is Important,But Just a Small Piece of the Patellar Instability Puzzle

Medial patellofemoral ligament (MPFL) reconstruction has proven to be a reliable procedure to reduce patellar instability events in patients with recurrent patellar instability. As our reconstruction techniques have evolved to address pathology in a diverse patient population, there continues to be an obsessive focus on the precise anatomy of the MPFL origin on the medial knee, due in large part to concerns that improper femoral tunnel position may result in excessive graft anisometry and failure. However, recurrent patellar instability involves many complexities and should not be simply reduced to a single point on the medial knee.     

Editorial Commentary: Assessing Outcomes in Terms of Fulfillment of Patient Expectations Is Complementary to Traditional Measures Including Satisfaction

The topic of patients’ expectations is receiving increasing attention as a patient-centered variable in preoperative orthopaedic assessment. Formally querying patients about expectations is necessary because surgeons may not be aware of these expectations, which often derive from multiple sources outside encounters with surgeons. Validated patient-derived surveys now exist for diverse orthopaedic surgeries to preoperatively measure expectations for improvement in symptoms and physical and psychological well-being. Assessing results of surgery in terms of fulfillment of these expectations is a patient-centered outcome that complements traditional measurements of satisfaction and pre- to postoperative change in symptoms and function. Validated follow-up surveys also now exist that ask patients for each item they expected before surgery, how much improvement have they actually received after surgery. The amount of improvement expected versus the amount of improvement received constitutes a measure of fulfilled expectations. The advantages of fulfillment of expectations as an outcome are that it prospectively includes both pre- and postoperative patients’ perspectives and, because it is composed of multiple items, it can identify which symptoms and functions have improved to expected levels and which have not, thus providing the rationale for why patients rate outcomes the way they do. Therefore, measured in this way, postoperative fulfillment of expectations is a unique and novel patient-centered assessment for the comprehensive evaluation of orthopaedic surgical outcomes.     

Editorial Commentary: Shoulder Superior Capsule Reconstruction Leads to Good Outcomes Despite Ambiguous Graft Healing Suggesting a Spacer Effect

Massive, retracted rotator cuff tears with poor tissue quality continue to pose a problem for the shoulder surgeon. Augmentation of such repairs with grafts, patches, spacers, or biologics is being closely investigated to help improve clinical outcomes and healing rates. Specifically, superior capsule reconstruction augmentation of such rotator cuff tears may lead to good outcomes. However, we do not truly understand how much native cuff tissue or graft healing is actually taking place. Clinically, superior capsule reconstruction augmentation of rotator cuff repair may simply be serving as a spacer.     

Editorial Commentary: Age-Appropriate Expectations Are Critical When Analyzing Knee Anterior Cruciate Ligament Reconstruction Outcomes: Age Is More Than Just a Number

In patients undergoing anterior cruciate ligament (ACL) reconstruction, age affects treatment and postoperative recovery decisions, as well as failure rates and outcomes. However, how age affects postoperative patient-reported outcomes and the appropriateness of using the International Knee Documentation Committee patient acceptable symptoms state score in the >40-year-old patient population has received little attention. This study assesses commonly used patient-reported outcomes in older patients undergoing ACL reconstruction and aims to redefine a more suitable patient acceptable symptoms state score for this patient population. As our understanding of both the importance of ACL reconstruction on knee biomechanics and joint stability, as well as the increased rate of ACL reconstruction in older patients grows, having age-appropriate outcomes expectations is critical to both counseling patients and developing future research aims. Future application of outcomes scores in clinical practice and in the research, arena must take into account patient age and function after ACL reconstruction.     

Editorial Commentary: Arthroscopic Outcomes Are Equal to Open Popliteus Tendon Reconstructions,but Do Not Forget That the Goal Is a Stable Posterior Cruciate Ligament Reconstruction

Arthroscopic popliteus tendon reconstructions were found to be equally as efficacious as open popliteus reconstructions in restoring external rotation stability. However, when the procedure was combined with a posterior cruciate ligament (PCL) reconstruction, the PCL reconstruction still had increases of 4 to 5 mm of posterior tibial translation in side-to-side differences on posterior stress radiographs. Thus, the goal of restoring stability for combined popliteus tendon and PCL reconstructions is still elusive.     

Editorial Commentary: Gait Symmetry After Anterior Cruciate Ligament Reconstruction Is Improved Using Functional Rehabilitation Braces That Resist Knee Motion

The effort of the rehabilitation journey to solve the several known functional and clinical problems after anterior cruciate ligament reconstruction should be directed toward implementing effective recovery strategies starting the day after surgery. Resistance training is a reliable approach to restore general knee function, but in the early postoperative stages, it may be difficult to apply proper loading strategies to obtain tangible improvements owing to surgery-related impairments. Accordingly, applying continuous light resistance during functional tasks such as gait may help to address this issue. As such, bracing models that provide resistance to knee motion have recently been developed and have been shown to help in restoring a proper walking pattern in terms of moment and range-of-motion symmetry. Therefore, the adoption of such bracing models may be regarded as a suitable option to consider to boost the achievement of rehabilitative milestones, therefore generally improving rehabilitation quality.     

Editorial Commentary: Machine Learning in Medicine Requires Clinician Input,Faces Barriers,and High-Quality Evidence Is Required to Demonstrate Improved Patient Outcomes

Machine learning (ML) and artificial intelligence (AI) may be described as advanced statistical techniques using algorithms to “learn” to evaluate and predict relationships between input and results without explicit human programming, often with high accuracy. The potentials and pitfalls of ML continue to be explored as predictive modeling grows in popularity. While use of and optimism for AI continues to increase in orthopaedic surgery, there remains little high-quality evidence of its ability to improve patient outcome. It is up to us as clinicians to provide context for ML models and guide the use of these technologies to optimize the outcome for our patients. Barriers to widespread adoption of ML include poor quality data, limits to compliant data sharing, few clinicians who are expert in ML statistical techniques, and computing costs including technology, infrastructure, personnel, energy, and updates.     

Editorial Commentary: The Anterior Cruciate Ligament Is a Dynamic Structure

The anterior cruciate ligament (ACL) is a dynamic structure composed of distinct bundles that function synergistically to facilitate normal knee kinematics in concert with bony morphology. Characterized by individual uniqueness, the ACL is inherently subject to both anatomic and morphological variations as well as physiologic aging. No locus on the lateral wall of the intercondylar notch is truly isometric through full range of motion, suggesting the ACL is a dynamic structure. Future studies should explore dynamic ACL behavior in vivo.     

Editorial Commentary: Return to Play Following Revision Anterior Cruciate Ligament Reconstruction

In many cases, athletes return to play after anterior cruciate ligament (ACL) reconstruction. In such cases, after a second ACL tear, these athletes may again expert full return to play after ACL revision. Unfortunately, results after revision ACL reconstruction are inferior to results after primary surgery. Sport specific data is difficult to determine, as are predictors of positive outcomes which include concomitant pathology or psychological factors. Chances of return to the same level may be 60% or less.     

Editorial Commentary: Supporting Patients Psychologically and Reducing Kinesiophobia May Improve Anterior Cruciate Ligament Reconstruction Outcomes

Athletes face an uphill battle after an anterior cruciate ligament tear if they want to return to their sport. Almost one-third of patients never return to their preinjury level of sport involvement, and many athletes dread this outcome. Although this distress is an understandable reaction, it can be demotivating, and psychological engagement in the recovery process is crucial to achieving desired outcomes. In particular, psychological readiness to return to sport is associated with greater likelihood of returning to sport. However, other psychological factors, including kinesiophobia, can negatively impact readiness to return to sport preoperatively and postoperatively. Supporting patients psychologically and reducing kinesiophobia throughout the recovery process may be essential to improving outcomes after an anterior cruciate ligament tear.     

Editorial Commentary: Timing of Anterior Cruciate Ligament Reconstruction Is Just as Important as a Correct Surgical Procedure

The timing between anterior cruciate ligament (ACL) injury and surgical treatment may determine secondary injuries and abnormal laxity. Specifically, a knee without a functioning ACL is more at risk of a future episode of instability and the development of injuries to other joint structures. Ultimately, this may result in degenerative joint disease. Associated medial or lateral meniscus, cartilage or multiligamentous lesions indicate earlier ACL reconstruction. In particular, the possibility of an effective meniscus repair is a key indicator for early surgery. Patient selection is the key to success of ACL surgery, and it is deeply linked to surgical timing. Also, in the case of athletic patients, professional or otherwise, surgery must be as performed early to allow a rapid recovery of activity.     

Editorial Commentary: Arthroscopic Subscapularis Repair: Bridging Successful Tendon Healing and Improved Patient Outcomes

Open repair has been regarded as the gold standard for the treatment of subscapularis tendon tears. However, recent studies on newer arthroscopic techniques and published results of arthroscopic repair have shown promising results. As such, there exists a growing interest in understanding the best fixation technique to obtain successful functional and patient-reported clinical outcomes. While the literature shows superior outcomes after double-row repair for posterosuperior rotator cuff tears compared with single-row repair, the evidence is inconclusive for subscapularis tears. We believe that arthroscopic double-row transosseous equivalent repair of full-thickness subscapularis tears leads to superior clinical outcomes with higher healing rates and will become the standard of care in the future.     

Editorial Commentary: Another Take on the Anterolateral Ligament: High-Grade Are Worse Than Low-Grade Injuries,But the Categorization Is Problematic

The anatomy, function, and existence of the anterolateral ligament (ALL) is still hotly debated and a controversial topic. Currently both basic biomechanical and clinical studies are not providing sufficient and strong evidence to either support or refute that the ALL plays an important role for knee stability. One could argue that stability is provided by the anterolateral complex, including the iliotibial band, Kaplan fibers, and the anterolateral capsule, which may contain a structure called the ALL. Magnetic resonance imaging (MRI) is routinely performed in patients with anterior cruciate ligament (ACL) injury, but unfortunately ALL injuries cannot be reliably diagnosed in patients with concomitant ACL tears. When dividing ALL injuries into high and low grade using preoperative MRI and investigating clinical outcomes after double-bundle ACL reconstruction, patients with high-grade injuries have inferior outcomes and a significantly greater revision rates. However, the limitations of this research reduce the validity of these conclusions: high rate of loss to follow-up above accepted standard, unequal size of their study groups, fragility index of zero, the inaccuracy of diagnosing ALL injuries in the presence of ACL tears on MRI, and the dilemma with randomly classifying high- and low-grade ALL injury based on MRI.     

Editorial Commentary: Patient-Reported Outcomes Measurement Information System (PROMIS) Is Important Part of Future Clinical Research

The Patient-Reported Outcomes Measurement Information System (PROMIS) is more efficient than legacy measures and is generalizable across all patients and diseases. Patient-reported outcome scores may eventually become related to physician reimbursement and give patients a voice in their care.     

Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair

Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon–femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.     

Editorial Commentary: Medial Patellofemoral Ligament Reconstruction Alone Works Well When the Patient Has Normal Alignment,But Don't Forget to Move the Tibial Tubercle When Necessary!

Medial patellofemoral ligament reconstruction works very well, regardless of graft choice, for controlling lateral patella instability when performed correctly in patients with normal alignment, even in the face of trochlea dysplasia. However, sometimes a tibial tubercle transfer is necessary in patella instability surgery.     

Editorial Commentary: Recovery After Anterior Cruciate Ligament Reconstruction Is Optimal About 85% of the Time

Recovery after anterior cruciate ligament reconstruction is optimal about 85% of the time. Revision surgery, psychiatric history, preoperative chronic knee pain, and subsequent knee injury are associated with suboptimal recovery patterns. Sophisticated growth models can analyze patient recovery trajectories. Growth mixture models (GMM) treat a whole cohort as a single group and characterize that group over time, for example, over the course of knee injury and subsequent recovery after surgical reconstruction. Latent class growth analysis is a subcategory of GMM that sorts the cohort into subgroups and allows analysis regarding groups having, for example, standard, delayed, and suboptimal recoveries. This theoretically allows a physician to anticipate which patients are likely to follow a suboptimal trajectory of recovery, to track that recovery based on the model, and to form a treatment plan accordingly.     

Editorial Commentary: Combined Anterior Cruciate Ligament Reconstruction and Medial Meniscal Transplantation Improve Functional Outcomes When Properly Indicated

The anterior cruciate ligament (ACL) and medial meniscus both contribute to anteroposterior translation of the tibia. Biomechanical studies have found increased translation at both 30° and 90° when transecting the posterior horn of the medial meniscus, and clinically, medial meniscal deficiency has been shown to have a 46% increase in ACL graft strain at 90°. Medial meniscal deficiency is a risk factor for failure after ACL reconstruction, with a hazard ratio of 15.1. The combination of meniscal allograft transplantation and ACL reconstruction is technically demanding but results in mid- to long-term clinical improvement in well-indicated patients. Patients with medial meniscal deficiency and failed ACL reconstruction or with ACL deficiency and medial-sided knee pain due to meniscal deficiency are candidates for combined procedures. On the basis of our experience, acute meniscal injury is not an indication for primary meniscal transplantation in any setting. Surgeons should repair the meniscus if reparable or perform partial meniscectomy and see how the patient responds. There is insufficient evidence to show that early meniscal transplantation will be chondroprotective. We reserve this procedure for the indications previously described. Severe osteoarthritis (Kellgren-Lawrence grades III and IV) and Outerbridge grade IV focal chondral defects of the tibiofemoral compartment that are not amenable to cartilage repair are absolute contraindications to the combined procedure.     

Editorial Commentary: Timing of the Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction: Still a Debatable Issue

Anterior cruciate ligament (ACL) injuries frequently occur as the results of twisting injury of the knee. Accompanying damages to other structures at the time of injury determine the severity of the injury, subsequent surgical procedures, and hence, clinical outcomes. Anterolateral ligament (ALL) seems to act as a side-bar of the ACL rather than a major ligament that should be reconstructed separately. We should also consider the pros and cons of the adding ALL reconstruction procedures. There is insufficient evidence that can either support or refute that ALL plays an important role for knee stability. Determining the timing of the combined reconstruction is still a debatable issue, just like the efficacy of combined ACL and ALL reconstruction.