Editorial Commentary: Do We Need to Treat All Lesions Operatively in Elbow Terrible Triad?

Arthroscopic reduction and fixation techniques in elbow surgery are evolving, and more and more literature is describing good outcomes of new arthroscopic fixation methods for coronoid fractures, lateral collateral ligament tears, radial head fractures, or capsular avulsions. The possible next step could be to use all these different techniques in cases in which all the described lesions can be seen. However, the question is if this approach is too aggressive. Although it is technically feasible to perform, this approach may not be necessary.     

Gallstones and Bariatric Surgery: To Treat or Not to Treat?

Background

Obesity and rapid weight loss after bariatric surgery are risk factors for gallstone disease.

Objectives

The present study sought to evaluate the feasibility of selective concomitant cholecystectomy only in patients with symptomatic disease and study risk factors for the development of symptomatic gallstones after bariatric surgery.

Methods

Between January 2010 and December 2012, 734 consecutive patients presenting to our institution underwent bariatric surgery. From these, 81 patients were excluded due to prior or concurrent cholecystectomy. The remaining 653 patients with in situ gallbladder were followed for 12 months and were clinically screened for symptomatic or complicated cholelithiasis. Clinical and demographic characteristics were compared at baseline and 12 months after surgery.

Results

Of the 653 patients with in situ gallbladder, only 24 (3.3 %) developed symptomatic gallstones and only nine presented complicated disease. None of the patients with asymptomatic disease at the time of surgery progressed to symptomatic or complicated disease. Patients who developed symptomatic disease were not significantly different, although there was a trend toward longer obesity evolution, lower insulin levels, and lower hepatic enzymes level. A multivariate regression analysis revealed that patients with gastric sleeve were more likely to develop symptomatic gallstones.

Conclusions

Although further studies are required, the management of gallstones in morbidly obese patients should not be different from normal-weight patients. Therefore, performing a laparoscopic cholecystectomy only in symptomatic patients is an effective approach and asymptomatic gallstones should not be treated at the time of bariatric surgery.

     

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.     

Editorial Commentary: Arthroscopic Subscapularis Repair: Are We Any Further Forward?

Arthroscopic repair is a well-established treatment option for tears of the subscapularis tendon. However, it is clear that to further our understanding, additional study is required to more clearly define the influence of tear morphology, repair type, and associated pathologies and procedures on outcomes. It should be noted that there is rather sparse literature reporting long-term outcomes—10 years or more—after surgery. Future studies should focus on these aspects and use validated and widely used outcome measures to detect important differences and allow comparison with previous studies.     

Editorial Commentary: Tranexamic Acid: Okay,It Reduces the Bleeding,but Are We Sure Topical Use Is Not Harmful to the Cartilage?

Numerous studies have estimated the role of hemarthrosis and intra-articular drains in anterior cruciate ligament (ACL) reconstructive procedures. Long-standing hemarthrosis and related pain can disrupt rehabilitation and lead to arthrofibrosis. A significant number of orthopaedic surgeons use intra-articular suction drains following arthroscopic ACL reconstruction. Hemarthrosis and pain have undesirable effects on the functional outcomes of ACL reconstruction in the early postoperative period.     

Editorial Commentary: Suprascapular Neuropathy in Overhead Athletes: To Release or Not to Release?

A growing body of evidence has demonstrated that repetitive overhead athletes with shoulder pathology often have associated infraspinatus atrophy and suprascapular neuropathy. Although decompression of the suprascapular nerve has not been shown to clearly impact outcomes in the general population, release of the nerve in overhead athletes with documented evidence of impingement may improve outcomes in this high-demand population.     

Editorial Commentary: The Hip Capsule: To Close or Not to Close? Is That Still the Question?

The question of capsule closure or no closure after hip arthroscopy remains controversial as we try to decipher best practice and which patients should and should not have a repair. Closure seems of particular importance in younger patients and with larger capsulotomies. In my practice, I routinely repair the capsule after hip arthroscopy, except in patients with significant stiffness. Capsule repair may not be vital in some patients, as a smaller capsulotomy could sometimes heal on its own, but my patients and I certainly do not want to learn the hard way.     

Editorial Commentary: Cartilage Damage in the Hip: Can We Predict Outcome?

Cartilage damage is frequently seen during hip arthroscopy for femoroacetabular impingement or trauma. Currently, microfracture is the most common procedure for treating severe chondral defects. Studies have suggested that the presence of acetabular cartilage lesions can cause poor outcomes. Defects of the femoral head are seen less frequently, and less research exists on how these lesions contribute to outcomes. Although the presence of cartilage damage may be a predictor of poorer outcomes, one must also consider the treatment and postoperative rehabilitation as the main factors in outcomes.     

Editorial Commentary: Open or Arthroscopic Surgery? Practice Makes Perfect…We Do Best What We Do Most Often

The reported outcomes of Bankart procedures performed after 2000 are significantly better than those reported prior to that date. The cause of this improvement can be found in adherence to the specific steps outlined in the Arthroscopy Association of North America Proficiency-Based Training program, improvements in instrumentation and implants and more appropriate patient selection. What is defined as an arthroscopic Bankart has also expanded. Patient-selection criteria have also changed dramatically over the past 2 decades, reflecting a better understanding of anterior shoulder instability and altering the choice of patients who should receive arthroscopic Bankart procedures. The arthroscopic Bankart with dual suture anchor remplissage is arguably the current arthroscopic gold standard for anterior shoulder “off-track” instability.     

Editorial Commentary: Can We Really See the Calcified Cartilage Layer When Debriding Focal Cartilage Defects?

Cell-based cartilage restoration techniques have made huge leaps in recent years; however, many hurdles still lay ahead, one of which is the fundamental task of preparing the cartilage lesion site. Although it is one of the first skills an arthroscopist learns during training, it seems that current techniques and instrumentation still yield inconsistent results, which can hinder patient outcomes.     

Editorial Commentary: Not Repairing the Hip Capsule After Arthroscopy—What Were We Thinking?

There has been an exponential increase in attention paid to the hip capsule as it relates to arthroscopic procedures. Violation of the hip capsule during arthroscopy has clear biomechanical consequences for the joint, and evidence that the capsule should be repaired following most arthroscopic hip procedures, and also in revision settings, is becoming insurmountable.     

Editorial Commentary: Are We Running Out of Treatments for Osteoarthritis of the Knee?

A considerable body of literature with high-level evidence has been published in the past 15 years calling into question the value of arthroscopic surgery in treating osteoarthritis of the knee (OAK). This, plus recent guidelines advising against the use of conservative treatments such as hyaluronic viscosupplementation, threatens to limit patient access to treatment for a chronic disease state with no known cure. The disease burden of OAK is considerable and represents one of the largest health care dollar expenditures in the United States and the world. Orthopaedic surgeons are the primary specialty dealing with OAK and manage this disease from inception to the final endpoint of total joint arthroplasty. As the population ages and the incidence of OAK increases, we must find ways to improve our ability to show efficacy in our treatments and also promote innovative modalities and applications to ameliorate the disability and dysfunction associated with OAK. Arthroscopy is recognized as a global leader in the presentation of evidence and debate surrounding all treatments for OAK and plays an important role in improving knowledge and treatment efficacy.     

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: 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.