Editorial Commentary: Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Instability—Single or Double Bundle: Does It Really Matter?

Medial patellofemoral ligament reconstruction is considered by most surgeons to be the standard of care for patients with recurrent lateral patellar instability, although the choice of how and when to address concomitant bony pathology (trochlear dysplasia, patella alta, or coronal-plane malalignment—elevated tibial tubercle–trochlear groove distance) remains unclear. Medial patellofemoral ligament reconstruction works to re-establish the primary static restraint to lateral translation of the patella and reduce the risk of recurrent dislocation. Regardless of graft choice or construct, this operation works well to prevent recurrent instability. Despite the low recurrent instability rates, several significant complications can still occur, one of the most serious being patellar fracture. We continue to look for ways to improve stability and decrease risk with this operation.     

Editorial Commentary: Is Magnetic Resonance Imaging Imaged Knee Patellar Tracking Relevant in Assessing the Patient With Patellar Instability?

Patellar pain and instability are common presentations to surgeons, yet assessment is more a static art than a dynamic science. In addition to resource-intensive gait laboratory, computed tomography (CT) and magnetic resonance imaging (MRI) have been used to measure patellar tracking. CT has the limitation of radiation and MRI has the limitation of software processing times. With an updated MRI protocol and software, it is now possible to dynamically view patellar tracking. Determining how this will be used to help in the diagnosis and treatment of patients will be the next goal.     

Editorial Commentary: Which Came First,the Patella or the Trochlea? Morphological Relationships in Patients With Patellar Instability

Trochlear dysplasia and patella alta are known risk factors for patellar instability, yet the relation between the two has not been well understood. Morphologic abnormalities such as trochlear dysplasia and patella alta are known to alter patellofemoral kinematics, whereas altered contact pressures, in turn, have been associated with the development of trochlear dysplasia. As our current treatments aim to correct these deformities through increasingly complex procedures such as trochleoplasty and tuberosity distalization, we should consider this relation and the potential for changing the course of developing such morphologic abnormalities earlier in life. Further studies on the developmental cause of this disorder may help guide future treatments in the management of patellar instability.     

Editorial Commentary: Is the Pendulum “Swinging” Away From Patellar Fixation in Medial Patellofemoral Ligament Reconstruction?

Medial patellofemoral ligament (MPFL) reconstruction is the “workhorse” for surgical stabilization of recurrent patella instability. Complications of patella fixation (i.e., patella fracture) are rare but potentially catastrophic. Modifications to traditional MPFL reconstruction that avoid patella fixation are promising. These alternatives may be favored in high-risk scenarios such as revision, smaller pediatric cases, and patellofemoral arthroplasty with concomitant instability. Large-scale prospective and/or randomized studies are needed to differentiate between MPFL reconstruction techniques.     

Editorial Commentary: Medial Patellofemoral Ligament Reconstruction for Knee Patellar Instability: When Are Soft Tissue Procedures Not Enough?

Medial patellofemoral ligament reconstruction is commonly performed to treat patellofemoral instability by recreating the static soft tissue restraint to lateral patellar translation. Concurrent tibial tuberosity osteotomy can be indicated in the setting of bony malalignment, such as a lateralized tuberosity or patella alta; however, the exact indications for this have been difficult to define due to the multifactorial nature of this problem. Understanding the role of tuberosity lateralization and patella alta on the function of medial patellofemoral ligament grafts can help to identify the interplay of some factors that contribute to patellar stability and improve our understanding of when and how concurrent tibial tuberosity osteotomy may be indicated.     

Editorial Commentary: Optimizing Surgical Management of Ankle Fractures: Is Arthroscopy the Answer?

The surgical management of ankle fractures can be an unforgiving endeavor. Subtle malreductions in fracture fragments lead to significant deviations in joint reactive forces and, consequently, accelerated arthritis. The diagnosis of associated ligamentous pathology, such as deltoid and syndesmotic injuries, is often difficult and ideal surgical management is debated. Ankle fractures that are seemingly optimally managed using traditional surgical techniques may remain persistently painful and function poorly—a scenario that begs the question, was there more to the injury than met the eye (or radiographs)? Here, unrecognized concomitant intra-articular injuries and subtle surgical malreductions have been implicated. In my practice, concurrent ankle arthroscopy at the time of definitive acute ankle fracture reduction and fixation results in improved accuracy of reduction, evaluation and management of concomitant syndesmotic and ligamentous injuries, assessment and treatment of occult intra-articular injuries, options for less-invasive fixation techniques through arthroscopic reduction, and a means to provide prognostic patient information. I typically reserve its use for fracture patterns that have been more closely associated with intra-articular injuries: high-energy mechanism injuries, Weber B and C fibula fractures, and those with a high likelihood of syndesmotic disruption based on preoperative imaging. Despite these intuitive advantages, concurrent ankle arthroscopy for acute fracture fixation is not routinely performed by most orthopedic surgeons, and a relative dearth of literature regarding its use and clinical impact remains.     

Editorial Commentary: Network Geometry of Nonoperative Management of Patellar Tendinopathy—Can the Shape of the Evidence Inform Practice?

Recent research has examined the comparative effectiveness of nonoperative treatments for patellar tendinopathy using a network meta-analysis method. This method allows analysis of a network of clinical trials individually studying different treatment options in comparison to an eccentric exercise control; however, most treatments have not been compared head to head. Although leukocyte-rich platelet-rich plasma is statistically ranked as the treatment with the highest improvements in pain and function, concerns over the assumption of transitivity (on which network meta-analysis is based) and the lack of connection or comparisons among treatments suggest that future studies comparing treatments head to head are needed.     

Editorial Commentary: The Medial Patellofemoral Complex Is Composed of the Medial Patellofemoral Ligament and the Medial Quadriceps Tendon–Femoral Ligament: Do We Need to Reconstruct Both?

The medial patellofemoral ligament (MPFL) has been known as the primary soft-tissue restraint to lateral patellar translation. More recent anatomic studies have identified additional fibers that extend to the quadriceps tendon (medial quadriceps tendon–femoral ligament [MQTFL]), leading to the use of the term “medial patellofemoral complex” (MPFC) to describe the broad and variable attachment of this complex on the patella and quadriceps tendon. Whereas many techniques and outcomes of traditional MPFL reconstruction have been described, fewer reports exist on anatomic MPFC reconstruction to recreate both bundles of this complex. To date, the specific biomechanical roles of, and indications for, reconstruction of the MPFL versus MQTFL fibers have not been defined. One primary benefit of MQTFL reconstruction has been to avoid the risk of patella fracture, which is not obviated in the setting of concurrent patellar fixation when reconstructing both components of the MPFC. The risks and benefits comparing fixation on the patella, quadriceps tendon, or both with anatomic double-bundle reconstruction remain to be determined. Additional studies are needed to understand the differences between reconstructing the proximal and distal fibers of the MPFC with regard to graft length changes and femoral attachment sites, in order to optimally recreate the function of each graft bundle in the surgical treatment of patellar instability.     

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BackgroundThorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.MethodsA thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.ResultsAntiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.ConclusionFurther high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.     

Editorial Commentary: Socket or Knock It? Considerations in Patellar Fixation During Medial Patellofemoral Ligament Reconstruction

The medial patellofemoral ligament (MPFL) is the primary static stabilizer to lateral patellar translation, and reconstruction of this ligament has been shown to be successful in reducing dislocation rates and improving functional outcomes in the treatment of patellar instability. Recent studies have warned that complication rates after MPFL reconstruction can be as high as 25%, with patellar fracture being one of the most catastrophic complications that can occur after this procedure. While the use of a bone socket versus cortical fixation on the patella does not appear to influence outcomes, surgeons should take into account the factors of graft and tunnel positioning, graft length/tension, and the need for concurrent procedures in each individual patient when performing this procedure. Any violation of the patella, whether as a socket or for anchor placement, should avoid the anterior cortex and maintain an adequate bony bridge that should be modified according to the patient's anatomy. The optimal technique for MPFL reconstruction continues to evolve, and further studies are needed to identify the ideal type and position of patellar fixation to minimize risks of complications and optimize surgical outcomes when performing MPFL reconstruction in the treatment of patellar instability.     

Editorial Commentary: Meniscus Message—What Is Possible or What Is Advisable?

Distal femoral varus osteotomy combined with meniscal allograft transplantation is a major surgical undertaking, not without risk and not to be taken on lightly by either the surgeon or the patient. It really is a salvage operation for a knee that is deteriorating and heading for arthroplasty at some future point. It is not an operation that should be offered to patients to allow them to return to sport. The fact that some patients do return to sport is good and is a credit to the operation and the patient’s tenacity with rehabilitation, but we must question the rationale of such activity, which will most likely hasten the demise of the joint.     

Editorial Commentary: Medial Patellofemoral Ligament Reconstruction: Are We Overtensioning the Graft?

While medial patellofemoral ligament reconstructions result in a high rate of return to sports, there is still a high reported complication rate. One area of controversy regarding the technique for the reconstruction is the knee flexion angle to use during graft fixation. Currently, more evidence is needed to determine whether there is a significant benefit to using a particular flexion angle during graft fixation.     

Editorial Commentary: Biceps Tendon Tenderness… Is It Enough to Guide Surgical Management?

Pathology of the long head of the biceps tendon is often encountered concurrently with rotator cuff tears. Although both preoperative and intraoperative evaluations may play a role in the decision-making process of when and how to treat the biceps, it can still be a conundrum. The more straightforward tests and reliable evaluation methods we have in our repertoire, the more likely the appropriate treatment choice to address the pathology will be made. The subpectoral biceps test is a helpful examination maneuver as part of the preoperative biceps evaluation.     

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: Proximal Hamstring Injuries—Is the Hip to Blame?

There is a growing understanding of the relation between femoroacetabular impingement (FAI) and injury to adjacent structures. Patients with proximal hamstring pathology appear to have a high prevalence of underlying FAI. The kinetic chain phenomenon is a potential explanation of the high correlation between proximal hamstring injury and underlying FAI of the hip.     

Editorial Commentary: Cartilage Restoration—What Is Currently Available?

In the past 30 years, bone marrow stimulation techniques such as microfracture (MF) have become a popular method to treat symptomatic focal articular cartilage lesions. Nonetheless, recent studies have not shown good long-term clinical outcomes, and MF has produced alterations in the subchondral bone architecture with degenerative changes. Autologous chondrocyte implantation (ACI) has shown good results at 20 years. Second- and third-generation ACI has shown superiority to MF and fewer complications than first-generation ACI. Each treatment option has its advantages and disadvantages. Recent research has shown that better filling of cartilage tissue occurs in patients treated with MF and collagen augmentation than in those treated with MF alone. Research from our clinic has shown that Hyaff scaffold combined with bone marrow aspirate concentrate in a 1-step technique yielded good results in patients with 10 years’ follow-up. We believe that high-quality randomized controlled trials are necessary to directly compare all cartilage restoration procedures.     

Editorial Commentary: The Number of Cartilage Treatment Options Continues to Grow,Despite the Lack of High-Quality Comparative Studies?

A growing number of knee cartilage repair studies continue to be published, employing both traditional and also novel and emerging surgical methods. Marrow stimulation, osteochondral transplantation, and autologous chondrocyte implantation via varied surgical techniques and delivery methods exist, as well as isolated, or concomitant, realignment procedures. However, while some value exists in small clinical cohorts (prospective and retrospective), we still lack high-quality comparative studies that better direct us toward the ideal cartilage repair treatment, specific to each individual patient situation including chondral defect (size, location, shape, etc.), the local environment (early degenerative knee changes, concomitant pathology), the surrounding environment (including individual physical conditioning and lower-limb alignment), and of course the patient’s tolerance to the pathology and individual physical demands. How do we sort this out? High-quality, and hopefully prospective and randomized, clinical trials are required.     

What Is the Optimal Interval Between Chemoradiation and Esophagectomy?

Locally advanced esophageal cancer requires multimodality therapy-most commonly induction chemoradiation followed by esophagectomy. There is a paucity of literature on the optimal time interval between induction treatment and resection. Patient readiness and healthy tissue, as well as tumor responses to radiation, are factors to consider. Two recent retrospective large-center studies on this topic are reviewed.