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Table of Contents
doi : 10.1016/S0749-8063(21)00185-7
Volume 37, Issue 4, April 2021, Pages A9-A10, A12, A14, A16
Cover Image & Video Link
doi : 10.1016/S0749-8063(21)00186-9
Volume 37, Issue 4, April 2021, Page A16
Instructions for Authors
doi : 10.1016/S0749-8063(21)00191-2
Volume 37, Issue 4, April 2021, Page A37
Misinterpretation of P Values and Statistical Power Creates a False Sense of Certainty: Statistical Significance, Lack of Significance, and the Uncertainty Challenge
Mark P.CoteP.T., D.P.T., M.S.C.T.R.James H.LubowitzM.D.Jefferson C.BrandM.D.Michael J.RossiM.D., M.S.
doi : 10.1016/j.arthro.2021.02.010
Volume 37, Issue 4, April 2021, Pages 1057-1063
Despite great advances in our understanding of statistics, a focus on statistical significance and P values, or lack of significance and power, persists. Unfortunately, this dichotomizes research findings comparing differences between groups or treatments as either significant or not significant. This creates a false and incorrect sense of certainty. Statistics provide us a measure of the degree of uncertainty or random error in our data. To improve the way in which we communicate and understand our results, we must include in reporting a probability, or estimate, of our degree of certainty (or uncertainty). This will allow us to better determine the risks and benefits of a treatment or intervention. Approaches that allow us to estimate, account for, and report our degree of uncertainty include use of confidence intervals, P-value functions, and Bayesian inference (which incorporates prior knowledge in our analysis of new research data). Surprise values (S values, which convert P values to the number of successive identical results of flips of a fair coin) express outcomes in an intuitive manner less susceptible to dichotomizing results as significant or not significant. In the future, researchers may report P values (if they wish) but could go further and provide a confidence interval, draw a P-value function graph, or run a Bayesian analysis. Authors could calculate and report an S value. It is insufficient to mindlessly report results as significant versus not significant without providing a quantitative estimate of the uncertainty of the data.
Regarding “Arthroscopic Bankart Repair With and Without Curettage of the Glenoid Edge: A Prospective, Randomized, Controlled Study”
AaronGazendamM.D.MoinKhanM.D., M.Sc., F.R.C.S.C.
doi : 10.1016/j.arthro.2021.01.030
Volume 37, Issue 4, April 2021, Pages 1064-1065
Author Reply to “Regarding ‘Arthroscopic Bankart Repair With and Without Curettage of the Glenoid Edge: A Prospective, Randomized, Controlled Study’”
Sanjay S.DesaiM.S., M.Ch.(UK), D.N.B., D.Orth.VishwajeetSinghM.S. (Ortho): Shoulder & Knee FellowHari KrishnaMataM.S. (Ortho): Shoulder & Knee Fellow
doi : 10.1016/j.arthro.2021.01.029
Volume 37, Issue 4, April 2021, Page 1065
Ankle Arthroscopy: Correct Portals and Noninvasive Distraction
JacobConnellyM.D.Richard D.FerkelM.D.
doi : 10.1016/j.arthro.2021.02.023
Volume 37, Issue 4, April 2021, Pages 1066-1067
Noninvasive ankle distraction technique is the standard of care for ankle arthroscopic surgery. Noninvasive distraction can be performed safely and with fewer complications when compared side-by-side with the nondistraction dorsiflexion technique. Moreover, distraction techniques allow a single surgeon to operate in the most convenient supine position and in a “hands-free” manner, with adequate space to avoid iatrogenic chondral damage. In addition, distraction allows for dedicated inflow and outflow portals to sufficiently irrigate the joint. Although the nondistraction technique allows excellent visualization of the anterior joint, it fails to provide appropriate visualization of the entire joint, using both anterior and posterior portals. Pathology that is best accessed from the posterior portal includes posterior osteochondral lesions, loose bodies, tears of the transverse ligament, acute ankle fractures, posterior tibial osteophytes, and occasionally an os trigonum. Fortunately, noninvasive distraction techniques plantarflex the ankle, also providing optimal access to the talus through the anterior approach. With the added use of posterolateral and occasionally posteromedial portals, near-universal access to lesions about the ankle can be obtained. In this infographic, the authors present the current indications for noninvasive ankle distraction arthroscopy and illustrate the importance of proper portal placement in obtaining the access and visualization necessary to easily and safely address pathology throughout the entire ankle and subtalar joint.
The Potential Effect of Lowering the Threshold of Statistical Significance From P < .05 to P < .005 in Orthopaedic Sports Medicine
SheridanEvansB.S.aJ. MichaelAndersonB.S.aAustin L.JohnsonB.S.aJake X.CheckettsD.O.bJaredScottD.O.bKevinMiddlemistD.O.bKeithFishbeckD.O.bMattVassarPh.D.a
doi : 10.1016/j.arthro.2020.11.041
Volume 37, Issue 4, April 2021, Pages 1068-1074
To determine how changing the P value threshold of statistical significance from .05 to .005 could affect the statistical significance of findings in previously published orthopaedic sports medicine randomized controlled trials (RCTs).
Cost of Arthroscopic Rotator Cuff Repairs Is Primarily Driven by Procedure-Level Factors: A Single-Institution Analysis of an Ambulatory Surgery Center
Jesse H.MorrisM.D.Azeem T.MalikM.B.B.S.SarahHatefM.P.H.Andrew S.NeviaserM.D.Julie Y.BishopM.D.Gregory L.CvetanovichM.D.
doi : 10.1016/j.arthro.2020.11.033
Volume 37, Issue 4, April 2021, Pages 1075-1083
To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.
Editorial Commentary: Cost Associated With Arthroscopic Rotator Cuff Repair Can Be Largely Controlled by the Surgeon
Daniel J.Solomon(Associate Editor)
doi : 10.1016/j.arthro.2020.12.222
Volume 37, Issue 4, April 2021, Pages 1084-1085
Surgeons must rely on cost and charge data to inform a patient outcome–optimized value-based approach to arthroscopic rotator cuff repairs. Using biologic and regenerative procedures to augment repairs only when necessary and optimizing anchor number are 2 obvious ways surgeons can help control cost of these procedures. Addition of biologics, such as patches and tissue augmentation, nearly doubled the charges for the procedure.
Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up
Joseph D.LamplotM.D.aSarav S.ShahM.D.bJustin M.ChanB.A.cKyle J.HancockM.D.cJosephGentileM.D.dScott A.RodeoM.D.cAnsworth A.AllenM.D.cRiley J.WilliamsM.D.cDavid W.AltchekM.D.cDavid M.DinesM.D.cRussell F.WarrenM.D.cFrank A.CordascoM.D.cLawrence V.GulottaM.D.cJoshua S.DinesM.D.c
doi : 10.1016/j.arthro.2020.11.045
Volume 37, Issue 4, April 2021, Pages 1086-1095.e1
To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.
Editorial Commentary: Acute Repair of the Acromioclavicular Joint Capsule and Ligaments and Deltotrapezial Fascia Could Allow Biological Healing of High-Grade Acromioclavicular Separation—Coracoclavicular Ligament Graft Augmentation Could Be Indicated if Time to Surgery Is Greater Than 3 Weeks
RaffaeleGarofaloM.D.aAlessandroCastagnaPh.D., M.D.b
doi : 10.1016/j.arthro.2021.02.001
Volume 37, Issue 4, April 2021, Pages 1096-1098
Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.
A Proficiency-Based Progression Simulation Training Curriculum to Acquire the Skills Needed in Performing Arthroscopic Bankart and Rotator Cuff Repairs—Implementation and Impact
Richard L.AngeloM.D., Ph.D.aPatSt PierreM.D.bJoeTauroM.D.cAnthony G.GallagherPh.D., D.Sc.de
doi : 10.1016/j.arthro.2020.11.040
Volume 37, Issue 4, April 2021, Pages 1099-1106.e5
To investigate the impact of a proficiency-based progression (PBP) curriculum employed to teach trainees in the skills needed to demonstrate proficiency for an arthroscopic Bankart repair (ABR) and an arthroscopic rotator cuff repair (ARCR) by objectively comparing pre- and immediate postcourse performances.
Editorial Commentary: Proficiency-Based Progression Surgical Simulation Training Is an Efficient Adjunct to High-Volume Clinical Experience
Rachel M.FrankM.D.
doi : 10.1016/j.arthro.2021.02.013
Volume 37, Issue 4, April 2021, Pages 1107-1109
The optimal way to train a future surgeon has been debated for years, with strategies ranging from the well-known “see one, do one, teach one” approach to more novel approaches that rely on metrics and proficiency. Recent research shows that surgical training with a proficiency-based progression curriculum is an efficient strategy for teaching arthroscopy procedural skills, and, further, may improve patient safety by reducing the technical errors that might otherwise occur before proficiency is achieved. While every surgical specialty has its nuances that must be mastered to provide safe, effective, and efficient care, for a variety of reasons, the skills needed to perform arthroscopy are incredibly difficult to learn, let alone achieve proficiency or master. “On-the-job” training for orthopaedic residents has become more difficult in today’s fast-paced, work hour–limited, volume-rewarded society. Proficiency-based progression is a piece of the puzzle, but for now, it is not a complete substitute for high-volume, clinical experience and exposure to the countless variables that may affect a "real-life" surgical procedure.
Chronic Preoperative Opioids Are Associated With Revision After Rotator Cuff Repair
SarahBhattacharjeeB.S.aBriaJordanB.A.aAndrewSohnB.A.aHenrySeidelB.S.aMichael J.LeeM.D.bJasonStrelzowM.D.bLewis L.ShiM.D.b
doi : 10.1016/j.arthro.2020.11.046
Volume 37, Issue 4, April 2021, Pages 1110-1114.e5
We sought to clarify the relationship between chronic preoperative opioids and complications following rotator cuff repair. Specifically, we assessed revision, a definitive postoperative end point for surgical outcome.
Editorial Commentary: Rotator Cuff Repair Outcomes Are Influenced by Chronic Opioid Use
J. EmoryChapmanJr.M.D.(Editorial Board)
doi : 10.1016/j.arthro.2020.12.219
Volume 37, Issue 4, April 2021, Pages 1115-1116
The creation of pain as the fifth vital sign in 2001 led to an unforeseen and dramatic increase in postoperative narcotic use. It became clear that chronic opioid use was associated with overdoses and deaths, and state medical licensing boards began to require completion of narcotic Continuing Medical Education courses to maintain licensure. Despite the overwhelming evidence of adverse effects of narcotic usage in both the pre- and postoperative periods, this continues to be a persistent problem in all areas of orthopaedic surgery. The magnitude of the problem is significant and now opioid-specific training is a mandated component of the American Board of Orthopaedic Surgery Maintenance of Certification for their Web-based Longitudinal Assessment of continuing medical education. Large database studies are helpful in identifying trends and factors that influence outcomes, potentially cut cost of care, and hopefully help us find a way out of this ongoing dilemma. This dilemma has taken a long time to create and will require a concerted disciplined effort to eliminate.
Superior Capsule Reconstruction Using Fascia Lata Allograft Compared With Double- and Single-Layer Dermal Allograft: A Biomechanical Study
KellyE. ClineM.D.aJames E.TiboneM.D.aHanselIhnM.D.bMasakiAkedaM.D.bByung-SungKimM.D.bMichelle H.McGarryM.S.bTeruhisaMihataM.D., Ph.D.bcThay Q.LeePh.D.b
doi : 10.1016/j.arthro.2020.11.054
Volume 37, Issue 4, April 2021, Pages 1117-1125
To biomechanically characterize superior capsule reconstruction (SCR) using fascia lata allograft, double-layer dermal allograft, and single-layer dermal allograft for a clinically relevant massive irreparable rotator cuff tear involving the entire supraspinatus and 50% of the infraspinatus tendons.
Editorial Commentary: Mechanics Versus Biology: Both Are Relevant Principles in Understanding Superior Capsular Reconstruction
Stephen C.WeberM.D.
doi : 10.1016/j.arthro.2020.12.227
Volume 37, Issue 4, April 2021, Pages 1126-1127
The topic of superior capsular reconstruction remains controversial. Whereas identifying the best time-zero graft configuration for this procedure remains important, the success or failure of the procedure will be dependent on the biology, not just the bench performance. Any conforming object placed in the subacromial space at time zero could center the humeral head and decrease superior translation compared with a massive rotator cuff tear but may not restore translation to normal. It does appear that a thicker graft is better in this regard, but how much thicker is better is unclear. Most of all, whether the mechanical benefits of a thicker graft will be offset by a thicker and potentially less biologically compatible construct is also unclear. In most orthopaedic settings, autografts remain consistently superior to allografts. The contrast in results may be better explained by biology, and the excellent superior capsular reconstruction results reported with autograft have not been replicated universally with dermal allograft.
Decreased Glenoid Retroversion Is a Risk Factor for Failure of Primary Arthroscopic Bankart Repair in Individuals With Subcritical Bone Loss Versus No Bone Loss
Ryan T.LiM.D.aAndrewSheeanM.D.bKevinWilsonM.D.cDarren deSAM.D.dGillianKaneB.S.eBrysonLesniakM.D.eAlbertLinM.D.e
doi : 10.1016/j.arthro.2020.11.055
Volume 37, Issue 4, April 2021, Pages 1128-1133
To determine whether glenoid retroversion is an independent risk factor for failure after arthroscopic Bankart repair.
Hydrogen Peroxide Does Not Significantly Reduce Cutibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair
KotaroYamakadoM.D., Ph.D.
doi : 10.1016/j.arthro.2020.12.186
Volume 37, Issue 4, April 2021, Pages 1134-1140
To evaluate the efficacy of application of the 3% hydrogen peroxide (HP)–soaked gauze as an addition to the standard preoperative sterile skin preparation for Cutibacterium acnes suture contamination in arthroscopic rotator cuff repairs.
Editorial Commentary: Hydrogen Peroxide in the Perioperative Skin Preparation is a No Brainer for Shoulder Surgery (Despite Imperfect Data)
SurenaNamdariM.D., M.Sc.
doi : 10.1016/j.arthro.2021.01.010
Volume 37, Issue 4, April 2021, Pages 1141-1142
Although the clinical impact of positive cultures at the time of primary shoulder surgery remain unknown, much effort has been placed on identifying agents for skin preparation that reduce Cutibacterium acnes skin colonization. Although several randomized controlled trials of hydrogen peroxide use as part of the skin preparation exist, they are plagued by small sample sizes that lead to inadequate power or statistical fragility. Despite the lack of perfect data, our clinical experience and break-even analyses indicate value to routine use of hydrogen peroxide as part of the perioperative skin preparation prior to shoulder surgery.
Machine Learning Algorithms Predict Clinically Significant Improvements in Satisfaction After Hip Arthroscopy
Kyle N.KunzeM.D.Evan M.PolceB.S.JonathanRasioB.S.Shane J.NhoM.D., M.S.
doi : 10.1016/j.arthro.2020.11.027
Volume 37, Issue 4, April 2021, Pages 1143-1151
To develop machine learning algorithms to predict failure to achieve clinically significant satisfaction after hip arthroscopy.
Editorial Commentary: Predicting Satisfaction After Hip Arthroscopy Using Machine Learning: What Do Treadmills and Black Boxes Have to Do With Arthroscopy?
Benjamin G.DombM.D., Editorial BoardPhilip J.RosinskyM.D., Editorial Board
doi : 10.1016/j.arthro.2020.12.231
Volume 37, Issue 4, April 2021, Pages 1152-1154
The use of advanced statistical methods and artificial intelligence including machine learning enables researchers to identify preoperative characteristics predictive of patients achieving minimal clinically important differences in health outcomes after interventions including surgery. Machine learning uses algorithms to recognize patterns in data sets to predict outcomes. The advantages are the ability, using “big data” registries, to infer relations that otherwise would not be readily understood and the ability to continuously improve the model as new data are added. However, machine learning has limitations. Models are only as good as the data incorporated, and data may be misapplied owing to huge data sets and strong computing capabilities, in which spurious correlations may be suggested based on significant P values. Hence, common sense must be applied. The future of outcome prediction studies will most definitely rely on machine learning and artificial intelligence methods.
Treatment of the Wave Sign With Femoral Osteoplasty With and Without Chondrolabral Stabilization Using Suture Anchors
Justin L.MakovickaM.D.Jeffrey D.HassebrockM.D.AnikarChhabraM.D.JustinWilcoxM.S.Kostas J.EconomopoulosM.D.
doi : 10.1016/j.arthro.2020.11.048
Volume 37, Issue 4, April 2021, Pages 1155-1160
To discuss the surgical outcomes of patients identified to have the wave sign without an accompanying labral tear treated with and without stabilization of the chondrolabral junction in conjunction with femoral osteoplasty.
Editorial Commentary: Suture Anchor Fixation Eliminates the Wave Sign and Improves Outcomes for Hip Labrochondral Dysfunction. Do Not Equate Hip Labral Pathology With Shoulder Labral Tears
DerekOchiaiM.D., Editorial Board
doi : 10.1016/j.arthro.2021.01.012
Volume 37, Issue 4, April 2021, Pages 1161-1162
During hip arthroscopy, when a wave sign is encountered, it is a sign of labrochondral dysfunction, just like a traditional labral tear. Suture anchor fixation to the labrum can eliminate the wave sign and improve patient outcomes. Readers are urged not to equate hip labral pathology with shoulder labral tears, which have different pathomechanics, and subsequently may have different morphological characteristics.
Surgical Intervention for Femoroacetabular Impingement Can Lead to Improvements in Both Hip and Back Function in Patients With Coexisting Chronic Back Pain at 1-Year Follow-Up
YuhangSunM.D.Kamali A.ThompsonB.S., M.B.A.ChristonDardenM.D.ThomasYoumM.D.
doi : 10.1016/j.arthro.2020.11.043
Volume 37, Issue 4, April 2021, Pages 1163-1169.e1
To determine whether patients with coexisting lumbar back pain experience back pain improvement after undergoing hip arthroscopy for femoroacetabular impingement (FAI).
The Limited Reliability of Physical Examination and Imaging for Diagnosis of Iliopsoas Tendinitis
Jonathan D.HaskelM.D.aDaniel J.KaplanM.D.aJordan W.FriedB.M.aThomasYoumM.D.aMohammadSamimM.D.bChristopherBurkeM.B.Ch.B.b
doi : 10.1016/j.arthro.2020.12.184
Volume 37, Issue 4, April 2021, Pages 1170-1178
To determine if any association exists between physical examination, imaging findings [ultrasound (US) and magnetic resonance imaging (MRI)], and iliopsoas tendinitis (IPT) to characterize the reliability of these diagnostic modalities.
Editorial Commentary: The Cause of Groin Pain Is Difficult to Determine: The Elusive “Nether-Nether Region”
LyallJulian AshbergM.D., Editorial Board
doi : 10.1016/j.arthro.2021.01.017
Volume 37, Issue 4, April 2021, Pages 1179-1181
As one of the many causes of groin pain, iliopsoas tendinitis can be hard to identify and even harder to treat. It occurs in the setting of both the native hip joint and following total hip arthroplasty. Internal snapping, or coxa saltans, can result from the iliopsoas snapping over the anterior hip capsule or iliopectineal eminence and can be a source of labral pathology. The snapping can be painful or painless. Iliopsoas impingement over total hip components either from the cup or collar of a femoral stem are causes of anterior groin pain. However, there are multiple other causes of groin pain, both intra- and extra-articular, that can make finding the source of the pain difficult. Referred pain from the spine, gynecologic, and gastrointestinal systems can all cause pain in the groin. Core muscle injuries and athletic pubalgia can all cause groin pain and frequently mimic intra-articular hip pathology or iliopsoas tendinopathy. Ultrasound-guided diagnostic injection into the iliopsoas bursa or the juxtaposed hip joint (intra-articular injection) can be helpful in differentiating the source of the pain. Combining a clear history, detailed physical, basic and advanced imaging, as well as diagnostic injection is essential in diagnosing this elusive entity and guiding appropriate treatment.
A Secondary Injury of the Anterolateral Structure Plays a Minor Role in Anterior and Anterolateral Instability of Anterior Cruciate Ligament-Deficient Knees in the Case of Functional Iliotibial Band
JunjieXuPh.D., M.D.aKangHanM.D.aWeiSuM.D.aJiaJiangM.D.aXiaoyuYanM.D.aJiakuoYuM.D.bShikuiDongM.D.aJinzhongZhaoM.D.a
doi : 10.1016/j.arthro.2020.10.038
Volume 37, Issue 4, April 2021, Pages 1182-1191
To analyze the contribution of a secondary anterolateral structure (ALS) deficiency to knee instability based on anterior cruciate ligament (ACL) deficiency, in the condition of a functional iliotibial band (ITB).
Editorial Commentary: Knee Anterolateral Ligament Cadaveric, Biomechanical Analysis Should Include Tensioning of All Knee Dynamic Structures
Sung-HwanKimM.D., Ph.D.(Editorial Board)
doi : 10.1016/j.arthro.2020.12.229
Volume 37, Issue 4, April 2021, Pages 1192-1193
Although most reports in the literature suggest that the knee anterolateral structures contribute to the anterolateral rotational stability of the knee, the extent of its contribution is still controversial. There are many dynamic structures that also affect the stability of the knee joint, including the iliotibial band and quadriceps muscle. Although not all of the dynamic structures surrounding the knee influence stability associated with the anterior cruciate ligament, we recommend that cadaveric, biomechanical analysis of the knee anterolateral ligament and related structures include tensioning of all knee dynamic structures to avoid potential biases.
Role of Age on Success of Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears
Harmen D.VermeijdenM.D.aXiuyi A.YangM.S.aJelle P.van der ListM.D.abGregory S.DiFeliceM.D.a
doi : 10.1016/j.arthro.2020.11.024
Volume 37, Issue 4, April 2021, Pages 1194-1201
To assess failure rates and patient-reported outcomes measures following arthroscopic primary anterior cruciate ligament (ACL) repair of proximal tears in different age groups.
Editorial Commentary: Anterior Cruciate Ligament Suture Repair Could Have High Failure Rates in Active Athletes of All Ages
Kate E.WebsterPh.D.
doi : 10.1016/j.arthro.2021.01.054
Volume 37, Issue 4, April 2021, Pages 1202-1203
When it comes to anterior cruciate ligament (ACL) injury and surgery, age is a proxy for early return to strenuous sports. In addition, premature return to sport is a risk factor for reinjury after ACL surgery. Thus, when considering ACL suture repair as an alternative to ACL graft reconstruction, we must consider that failure rates may be influenced by patient demographic variables, particularly age and activity. In the end, treatment options for young patients who are highly active and eager to make a timely return to sport after ACL injury require careful evaluation.
Linear Anterior-Posterior Computed Tomography Parameters Used to Quantify Trochlear Dysplasia Are More Reliable Than Angular Measurements
Peter WilhelmFerlicPh.D.abArminRunerM.D.cChristopherSeeberM.D.aMariaTh?niM.D.dAnnaSpicherM.D.aMichael ChristianLiebensteinerPh.D.a
doi : 10.1016/j.arthro.2020.11.032
Volume 37, Issue 4, April 2021, Pages 1204-1211
(1) To evaluate the reliability of 9 commonly used quantitative parameters of the trochlear morphology on computed tomography (CT) and (2) to analyze for differences in the reliability regarding patient subgroups (patellofemoral instability [PFI] vs non-PFI).
Editorial Commentary: Trochlear Dysplasia Is Difficult to Measure, No Matter How You Slice It
Miho J.TanakaM.D., Editorial Board
doi : 10.1016/j.arthro.2020.12.220
Volume 37, Issue 4, April 2021, Pages 1212-1213
Trochlear dysplasia is one of the primary morphologic abnormalities associated with patellar instability. Although qualitative classifications based on trochlear shape such as the Dejour classification exist, radiographic measurements to quantify the severity of trochlear dysplasia are numerous and varied. Each measurement addresses a different element of the complex and wide-ranging presentations that exist along a spectrum of abnormalities in trochlear morphology, and the reported reliability of such measurements are mixed. Overall, our understanding of trochlear dysplasia continues to evolve, and the ability to quantify the morphology of the trochlea, as well as its influence on patellar stability, remains a work in progress. Future directions include developing improved 3-dimensional descriptions of trochlear anatomy, as well as standardizing measurement methods and image slice selection, to better evaluate trochlear morphology in the assessment of patellar instability.
Delayed Anterior Cruciate Ligament Reconstruction Increases the Risk of Abnormal Prereconstruction Laxity, Cartilage, and Medial Meniscus Injuries
RiccardoCristianiM.D.aPer-MatsJanarvM.D., Ph.D.aBj?rnEngstr?mM.D., Ph.D.aGunnarEdmanM.D., Ph.D.bMagnusForssbladM.D., Ph.D.bAndersSt?lmanM.D., Ph.D.a
doi : 10.1016/j.arthro.2020.11.030
Volume 37, Issue 4, April 2021, Pages 1214-1220
To determine the association between a delay in anterior cruciate ligament reconstruction (ACLR), age, sex, body mass index (BMI) and cartilage injuries, meniscus injuries, meniscus repair, and abnormal prereconstruction laxity.
Editorial Commentary: Timing of Anterior Cruciate Ligament Reconstruction Is Just as Important as a Correct Surgical Procedure
PieroVolpiM.D.
doi : 10.1016/j.arthro.2020.12.223
Volume 37, Issue 4, April 2021, Pages 1221-1222
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.
One-Stage Anatomical Revision Anterior Cruciate Ligament Reconstruction: Results According to Tunnel Overlaps
Jin-HwanAhnM.D., Ph.D.aDong-WookSonM.D., Ph.D.bHwa-JaeJeongM.D., Ph.D.bDae-WonParkM.D.bIn-GyuLeeM.D.b
doi : 10.1016/j.arthro.2020.11.029
Volume 37, Issue 4, April 2021, Pages 1223-1232
To present clinical results according to tunnel overlap in 1-stage anatomical revision anterior cruciate ligament reconstruction (ACLR).
Editorial Commentary: Anterior Cruciate Ligament Tunnel Aperture Overlap Determines Need for 1- Versus 2-Stage Revision: Setting the Stage
Mark D.MillerM.D.
doi : 10.1016/j.arthro.2021.01.033
Volume 37, Issue 4, April 2021, Pages 1233-1234
Despite general agreement that tunnel widening ?14 mm necessitates a 2-stage approach for revision anterior cruciate ligament (ACL) reconstruction, there is very little literature describing the effect of tunnel overlap between the previous tunnel and new tunnel with 1-stage ACL revisions. Tunnel overlap, particularly at the aperture, should be minimized without compromising anatomic tunnel location(s). This can often be accomplished with a 1-stage revision, but 2-stage revisions are sometimes required. Revision ACL reconstruction can be challenging and it is helpful for the surgeon to carefully plan preoperatively and have several options available to him/her intraoperatively, including the possibility of a 2-stage revision.
Primary Anterior Cruciate Ligament Repair Using Suture Tape Augmentation: A Case Series of 29 Patients With Minimum 2-Year Follow-Up
Denver A.BurtonM.D.aEliana J.SchaeferM.S.bHenry T.ShuB.S.cBlake M.BodendorferM.D.aEvan H.ArgintarM.D.d
doi : 10.1016/j.arthro.2020.11.034
Volume 37, Issue 4, April 2021, Pages 1235-1241
To evaluate clinical outcomes and patient-reported outcomes of patients who underwent primary anterior cruciate ligament (ACL) repair using suture tape augmentation.
Editorial Commentary: Repair the Anterior Cruciate Ligament When You Can: Add Suture Tape Augmentation and Dress for Success
Patrick A.SmithM.D.
doi : 10.1016/j.arthro.2020.12.218
Volume 37, Issue 4, April 2021, Pages 1242-1244
Preserving the native anterior cruciate ligament (ACL) through primary repair has seen a resurgence over the past few years—rightfully so—given the inherent advantages of repairing the ACL over reconstruction. The issue is how best to repair the ACL and protect it to optimize healing. Suture tape augmentation techniques have shown promising low failure rates, and recent biomechanical studies have demonstrated benefits of the suture tape and optimal fixation methods for ACL repair. So, I believe it is time for orthopaedic surgeons to strongly consider routine suture tape augmentation use for improved outcomes with primary ACL repair.
Maximum Ankle Plantarflexion and Dorsiflexion Allow for Optimal Arthroscopic Access to the Talar Dome: An Anatomic 3-Dimensional Radiography Study
LenaHirtlerM.A., M.D., Ph.D.aClausRathM.D.aPaulKüglerM.D.cLukasReissigM.D.aMadeleineWilleggerM.D., F.E.B.O.T.b
doi : 10.1016/j.arthro.2020.12.207
Volume 37, Issue 4, April 2021, Pages 1245-1257
(1) to improve the comprehension of the topographical position of the talar dome beneath the inferior articular surface of the tibia and, (2) to illustrate the changes of possible access to the articular surface of the talar dome during arthroscopic treatment of talar osteochondral defects in an anatomical model.
Editorial Commentary: How Far Can the Arthroscope Reach in the Ankle Joint?
JariDahmenM.D., B.Sc.aGino M.M. J.KerkhoffsM.D., Ph.D.aChristiaan J.A.van BergenM.D., Ph.D.b
doi : 10.1016/j.arthro.2021.01.020
Volume 37, Issue 4, April 2021, Pages 1258-1260
Surgical access to pathology of the talar dome (e.g., osteochondral lesions of the talus) can be limited because of the ankle joint congruity. When considering arthroscopic treatment, anterior arthroscopy with the ankle in plantar flexion or posterior arthroscopy with the ankle in dorsiflexion is used. The surgeon should carefully assess different clinical and radiologic aspects to plan the optimal operative approach. Meticulous physical examination, including ankle range of motion and possible palpation of a talar lesion, in combination with exact lesion localization on computed tomography or magnetic resonance imaging usually provide sufficient preoperative information. Most lesions with the anterior border localized on or anterior to the midline of the talus are accessible by anterior arthroscopy. In the case of preoperative doubt concerning the intraoperative accessibility, a computed tomography scan of the ankle in full plantarflexion is used to mirror arthroscopic reachability. Intraoperative surgical tricks to increase accessibility to the lesion may consist of an adjunct soft-tissue distraction device, reduction of the distal tibial rim, and treating the lesion from anteriorly to posteriorly, thereby gaining further exposure to the lesion throughout the procedure.
Orthopaedic Randomized Controlled Trials Published in General Medical Journals Are Associated With Higher Altmetric Attention Scores and Social Media Attention Than Nonorthopaedic Randomized Controlled Trials
Evan M.PolceB.S.aKyle N.KunzeM.D.aDanielFarivarB.S.aMichael C.FuM.D.aBenedict U.NwachukwuM.D., M.B.A.bShane J.NhoM.D., M.S.aJorgeChahlaM.D., Ph.Da
doi : 10.1016/j.arthro.2020.09.015
Volume 37, Issue 4, April 2021, Pages 1261-1270
To (1) compare the Altmetric Attention Score (AAS) and citation rates between orthopaedic and nonorthopaedic randomized controlled trials (RCTs) from 5 high-impact medical journals and (2) identify general characteristics of these articles associated with greater exposure on social media platforms.
A Preferred Vendor Model Reduces the Costs of Sports Medicine Surgery
Matthew R.BoylanM.D., M.P.H.AnishaChaddaM.H.A.Joseph A.BoscoM.D.Laith M.JazrawiM.D.
doi : 10.1016/j.arthro.2020.10.051
Volume 37, Issue 4, April 2021, Pages 1271-1276
To report on our institution’s first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery.
Platelet-Rich Plasma Combined With Hyaluronic Acid Improves Pain and Function Compared With Hyaluronic Acid Alone in Knee Osteoarthritis: A Systematic Review and Meta-analysis
TheofilosKarasavvidisB.S.aTrifonTotlisM.D., Ph.D.abRonGilatM.D.cdBrian J.ColeM.D., M.B.A.c
doi : 10.1016/j.arthro.2020.11.052
Volume 37, Issue 4, April 2021, Pages 1277-1287.e1
To evaluate the efficacy of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) injections versus HA injections alone for the management of knee osteoarthritis (OA).
Editorial Commentary: Injections for Knee Osteoarthritis: Doc, You Gotta Help Me!
TimDwyerM.B.B.S., Ph.D.JaskarndipChahalM.D., M.Sc., M.B.A.
doi : 10.1016/j.arthro.2020.12.228
Volume 37, Issue 4, April 2021, Pages 1288-1289
Injections for the pain caused by knee osteoarthritis have been the focus of significant research for the last few decades. Systematic reviews and meta-analyses suggest that platelet-rich plasma (PRP) can provide up to 12 months of pain relief in these patients, superior to both cortisone and hyaluronic acid. There is also some evidence for a synergistic effect when combining both PRP and hyaluronic acid. Bone marrow aspirate concentrate (BMAC) has significantly greater levels of interleukin-1ra than PRP, as well as a small concentration of mesenchymal stromal cells. However, BMAC is yet unproven in its efficacy, and obtaining BMAC is not as simple as taking blood. Research into the use of expanded autologous and allogenic mesenchymal stem cells continues and shows future promise. For today, PRP remains the gold standard for the treatment of pain associated with knee osteoarthritis.
Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis
Martin S.DaveyM.B., B.Ch., M.Ch., M.R.C.S.abEoghan T.HurleyM.B., B.Ch., M.Ch.abUtkarshAnilM.D.aAkiniMosesM.D.aKamaliThompsonB.S.aMichaelAlaiaM.D.aEric J.StraussM.D.aKirk A.CampbellM.D.a
doi : 10.1016/j.arthro.2021.01.023
Volume 37, Issue 4, April 2021, Pages 1290-1300.e6
To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes.
Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review
Robert N.MatarM.D.Nihar S.ShahB.S.Brian M.GraweM.D.
doi : 10.1016/j.arthro.2020.11.039
Volume 37, Issue 4, April 2021, Pages 1301-1309.e1
To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care.
Editorial Commentary: Delivering the PROMIS for Patients With Shoulder Disorders—Fool’s Gold, a Mirage, or an Oasis
DavidKovacevicM.D.
doi : 10.1016/j.arthro.2020.12.230
Volume 37, Issue 4, April 2021, Pages 1310-1313
Comparative psychometric performance of Patient-Reported Outcome Measurement Information System (PROMIS) instruments to legacy patient-reported outcomes for shoulder disorders is relevant and timely, as numerous stakeholders are engaged in the process of capturing, comparing, and evaluating performance results at the individual and population health levels. Depending on the stakeholder type, patient-reported outcomes could be used for clinical research, reimbursement, point-of-care, or benchmarking for patient comparison with a matched population cohort or comparative surgeon scorecard. Identifying and using the appropriate patient-reported outcome measure may be dependent on the purpose for measurement and stakeholder engagement and, as such, could be considered fool’s gold, a mirage, or an oasis. At this time, PROMIS instruments are not a suitable replacement for legacy patient-reported outcomes when orthopaedic surgeons are looking to perform level I and level II clinical studies to develop future clinical practice guidelines grounded in strong evidence.
Knotted Versus Knotless Anchors for Labral Repair in the Shoulder: A Systematic Review
Bogdan A.MatacheM.D.Eoghan T.HurleyM.B., B.Ch., M.Ch.Ajay C.KanakamedalaM.D.Laith M.JazrawiM.D.MandeepVirkM.D.Eric J.StraussM.D.Kirk A.CampbellM.D.
doi : 10.1016/j.arthro.2020.11.056
Volume 37, Issue 4, April 2021, Pages 1314-1321
To compare biomechanical and clinical outcomes between knotless and knotted anchors in arthroscopic labral repair, specifically in (1) Bankart repair, (2) SLAP repair, (3) posterior labral repair, and (4) remplissage augmentation of Bankart repair.
Editorial Commentary: No Difference in Knotted Versus Knotless Anchors for Labral Repair in the Shoulder
Matthias A.ZumsteinM.D.JuliaMueller-LebschiM.D.TomasRojasM.D.
doi : 10.1016/j.arthro.2021.01.052
Volume 37, Issue 4, April 2021, Page 1322
In comparing knotted versus knotless anchors for labral repair in the shoulder, there are no significant differences in clinical outcomes or biomechanical properties including load to failure.
Tranexamic Acid Use in Knee and Shoulder Arthroscopy Leads to Improved Outcomes and Fewer Hemarthrosis-Related Complications: A Systematic Review of Level I and II Studies
John W.BelkB.A.aEric C.McCartyM.D.aDarby A.HouckB.A.aJason L.DragooM.D.aFelix H.SavoieM.D.bStephen G.ThonM.D.a
doi : 10.1016/j.arthro.2020.11.051
Volume 37, Issue 4, April 2021, Pages 1323-1333
To systematically review the literature to compare the efficacy and safety of tranexamic acid (TXA) as a means to minimize hemarthrosis-related complications after arthroscopic procedures of the knee, hip, and shoulder.
Editorial Commentary: The Benefits of Tranexamic Acid May Outweigh Risks in Arthroscopy and Sports Medicine
Michael J.AlaiaM.D.(Editorial Board)Aaron M.GipsmanM.D.
doi : 10.1016/j.arthro.2021.01.027
Volume 37, Issue 4, April 2021, Pages 1334-1336
Tranexamic acid (TXA) is an antifibrinolytic that lowers the risk of hemarthrosis-related surgical complications and has been extensively studied in orthopaedic trauma surgery, primary and revision total joint replacement, open shoulder reconstruction, and spine surgery. Its use, however, has been minimally studied in orthopaedic sport medicine, and, in particular, arthroscopic surgery. Despite being an inexpensive medication with a minimal side effect profile, there has been a paucity of Level I and II studies to support or refute its use in some of the most common procedures performed in orthopaedic surgery. TXA may be of small benefit in routine partial meniscectomy or routine, outpatient, anterior cruciate ligament reconstruction. However, although there are potential risks and side effects of TXA, the risk is very low, the cost is very low, and even a small benefit may justify its use.
Computed Tomography Detects Hinge Fractures After Medial Opening Wedge High Tibial Osteotomy: A Systematic Review
Jun-HoKimM.D., Ph.D.aDo kyungLeeM.D.bYong-BeomParkM.D., Ph.D.c
doi : 10.1016/j.arthro.2020.11.031
Volume 37, Issue 4, April 2021, Pages 1337-1352
To quantify the increased detection rate of lateral hinge fractures (LHFs) owing to additional computed tomography (CT), determine factors associated with LHFs, and compare radiologic and clinical outcomes of LHFs after medial opening wedge biplanar high tibial osteotomy (MOW-HTO).
The Blight of the Type II Error: When No Difference Does Not Mean No Difference
Benjamin G.DombM.D.abcPayam W.SabetianM.D.b
doi : 10.1016/j.arthro.2021.01.057
Volume 37, Issue 4, April 2021, Pages 1353-1356
Much focus in research has been given to minimizing type I errors, where we incorrectly conclude that there is a difference between 2 treatments or populations. In contrast, our standard scientific method and power analysis allows for a much greater rate of type II errors, in which we fail to show a difference when, in fact, one exists (?20% rate of type II errors vs ?5% rate of type I errors). Additional factors that can cause type II errors may propel their prevalence to well in excess of 20%. Failure to reject the null hypothesis may be a tolerable outcome in a certain proportion of studies. However, type II errors may become dangerous when the conclusions of a study overreach, incorrectly stating that there is no difference, when, in fact, a difference exists. Type II errors resulting in overreaching conclusions may impede incremental advances in our field, as the advantages of small improvements may go undetected. To avert this danger in studies that fail to meet statistical significance, we as researchers (20% or more, vs 5% for type I errors) be precise in our conclusions stating simply that the null hypothesis could not be rejected.
