Editorial Commentary: Acellular Collagen Matrix Patch Augmentation of Large Rotator Cuff Tear Repair Results in Improved Healing.

Despite a high retear rate, repair of large rotator cuff tendon tear repairs shows good clinical outcomes. Unfortunately, these results often deteriorate with time, and large tears, not to mention progressively symptomatic retears, especially in compromised rotator cuff tissue, remain a problem. The solution could include augmenting repair with a patch such as an acellular collagen matrix. Proper patient selection is needed to achieve a benefit justifying the added expense and operative time associated with adding a patch. Biomechanically, such patches are strong and increase suture retention, as well as repair construct strength and stiffness. Patches provide a significant healing effect. Recent research and meta-analysis support the use of patches on rotator cuff tendon tears 3 cm or larger, whereas smaller tears (1-2 cm in length) appear to heal without the need for a patch.

Editorial Commentary: Dasatinib With Quercetin Shows Promise in Decreasing Age-Related Senescence in the Rotator Cuff Tendon-Can It Work Elsewhere?

Cellular senescence is a fundamental mechanism seen in all age-related diseases. Human supraspinatus tendon and adjacent bursal specimens evaluated for cellular senescence by immunohistochemistry and gene expression show more senescent cells in older patients. This confirms the observation that older patients are more likely to have rotator cuff pathology, and older age is associated with lower rates of rotator cuff healing and more frequent tendon retears. Senolytic drugs can selectively eliminate senescent cells without a localized or systemic impact. Tendon and bursal specimens co-cultured and then incubated with dasatinib and quercetin for 48 hours show a significant decrease in senescent cells. This suggests that these drugs may slow biological aging in rotator cuff tendons and offer the possibility of a clinically effective treatment for the aging rotator cuff tendon. Moreover, this concept is promising for the development of future effective therapies addressing tissue senescence.

Editorial Commentary: Quadriceps Tendon Suture Anchor Repair Provides Better Patient-Reported Outcomes Than Transosseous Tunnel Repair: Defining the New Gold Standard.

Quadriceps tendon suture anchor repair provides biomechanically greater and more consistent failure loads than transosseous tunnel repair, including less cyclic displacement (gap formation). Although satisfactory clinical outcomes are found with both repair techniques, few studies provide a side-to-side comparison. However, recent research demonstrates better clinical outcomes in using suture anchors, with equal failure rates. Suture anchor repair is minimally invasive requiring smaller incisions, less patellar dissection, and eliminates patellar tunnel drilling that can breach the anterior cortex, create stress risers, result in osteolysis from nonabsorbable intraosseous sutures and longitudinal patellar fractures. Suture anchor quadriceps tendon repair should now be considered the gold standard.

Editorial Commentary: Suture Type or Technique Has Little Influence on Outcome After Acute Lower-Extremity Tendon Rupture.

Operative repair of Achilles tendon rupture significantly decreases the rerupture rate, regardless of type of surgical suture technique. Likewise, regarding repair of either the quadriceps or patellar tendon, surgical repair technique does not significantly influence the generally excellent outcomes achieved, whereas too-early mobilization should be avoided. In terms of the use of suture versus suture tape, load to failure is similar. Many factors impact tendon rupture repair success, including postoperative care, the quality of the tendon, underlying medical issues, and patient compliance, but suture type or technique has little influence on outcome after acute lower-extremity tendon rupture.

Editorial Commentary: Lateral Extra-Articular Tenodesis Results in Better Stability After Anterior Cruciate Ligament Reconstruction for Patients With High-Grade Pivot Shifts.

Magnetic resonance imaging of the torn anterior lateral ligament (ALL) is inconsistent and subject to significant intra- and interobserver variability. Like that of an anterior cruciate ligament (ACL), an ALL tear can vary in degree (first, second, or third) and location (tibial or femoral side). These variations may impact the appropriate surgical intervention. Relevant biomechanical data indicate that the deep iliotibial band fibers are more important than the ALL in controlling pivot shift. Lateral compartment overconstraint after ALL reconstruction does not appear to be a biomechanical or clinical issue. An ALL reconstruction creates a nonisometric construct (tight in extension and lax in flexion), allowing physiologic internal tibial rotation at 90° flexion, whereas lateral extra-articular tenodesis (LET) is more isometric, limiting physiologic internal tibial rotation at 90° flexion. The indications for a combined ACL/ALL reconstruction are evolving, but a Segond fracture and ligamentous hyperlaxity of ≥5 using the modified Beighton system seem reasonable. An ACL/LET reconstruction results in better stability for patients with high-grade pivot shifts.

Arthroscopic Repair of Medium to Large Rotator Cuff Tears With a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents.

PURPOSE: The primary purpose of this study was to evaluate the repair integrity on magnetic resonance imaging (MRI), and secondarily, clinical outcomes, of medium to large (2-4 cm) rotator cuff tears treated using an arthroscopic triple-loaded medially based single-row repair technique augmented laterally with bone marrow vents. METHODS: This is a retrospective outcomes study of patients with full-thickness medium to large (2-4 cm) rotator cuff tears repaired by 4 surgeons at a single institution over a 2-year period with a minimum of 24 months' follow-up. A single-row repair with tension-minimizing medially based triple-loaded anchors and laterally placed bone marrow vents was used. Patients completed a satisfaction and pain survey, the Western Ontario Rotator Cuff index questionnaire, and a Short Form-36 version 2 survey to evaluate clinical outcomes. MRI was obtained at a minimum of 24 months follow-up to assess repair integrity. RESULTS: A total of 64 males and 27 females with a mean age of 59.7 (range, 34-82) were included. The mean tear size was 2.6 cm in anteroposterior dimension, treated with a mean of 2.2 anchors. Eighty-three of 91 shoulders (91%) reported being completely satisfied with their result. The median Western Ontario Rotator Cuff score was 95.2% of normal, with a significant difference found between those with an intact repair and those with a full-thickness recurrent defect (median, 95.9% vs. 73.8%; P = .003). Postoperative MRI obtained at a median of 32 months (range, 24-48) demonstrated an intact repair in 84 of 91 shoulders (92%), with failure defined as a full-thickness defect of the tendon. CONCLUSIONS: Arthroscopic repair of medium to large rotator cuff tears using triple-loaded medially based single-row repair augmented with marrow vents resulted in a 92% healing rate by MRI and excellent patient-reported outcomes LEVEL OF EVIDENCE: Level IV, retrospective case series.

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: Glenoid Track Instability Management Score or Instability Severity Index Score-Will This Decrease Latarjet Abuse?

Open treatment of anterior shoulder instability using a coracoid transfer, such as the Latarjet procedure, is associated with low recurrence rates but with significant complications such as nerve injury, arthrosis, and graft osteolysis. However, an arthroscopic Bankart procedure, although less invasive and with a low complication rate, has the possibility of a higher recurrent instability rate. Scoring systems such as the Instability Severity Index Score, created to select patients for an arthroscopic Bankart procedure or coracoid transfer, have varying levels of success. Often, the scoring system selects a relatively high percentage of patients for the coracoid transfer, possibly undermining its widespread adoption. The relation between glenoid and humeral bone loss has produced the concept of "on-track" and "off-track," which impacts recurrent instability rates. Merging the on-track and off-track concept with the new Glenoid Track Instability Management Score may produce an algorithm that more accurately assesses the need for the Latarjet procedure or arthroscopic stabilization.

The Biomechanical Performance of the Latest All-Inside Meniscal Repair Devices.

PURPOSE: To evaluate the biomechanical characteristics of recently introduced meniscal repair devices with a hand-tied, inside-out meniscal suture in a human meniscus model. METHODS: In detached adult human menisci, vertical longitudinal cuts were created 3 mm from the synovial-meniscal junction, simulating a bucket-handle meniscal tear. Each cut was repaired using a single device. Group 1 received a vertical mattress suture of No. 2-0 OrthoCord; group 2, TrueSpan device with PEEK (polyether ether ketone) anchors containing No. 2-0 OrthoCord suture; group 3, TrueSpan device with biodegradable poly-lactide-co-glycolide (PLGA) anchors containing No. 2-0 OrthoCord suture; group 4, Meniscal Cinch II device; group 5, AIR meniscal repair device; and group 6, FasT-Fix 360 device. All samples were preloaded at 5 N and cycled 200 times between 5 and 20 N. The specimens that survived cyclic loading were destructively tested at 12.5 mm/s. Endpoints included maximum load, displacement, stiffness, and failure mode. RESULTS: The mean failure loads were as follows: 95.8 N for OrthoCord suture, 87.1 N for TrueSpan with PEEK, 84.6 N for TrueSpan with PLGA, 48.6 N for Meniscal Cinch II, 72.3 N for AIR, and 68.1 N for FasT-Fix 360. Repairs performed with OrthoCord suture (P = .002) and both TrueSpan devices (P < .03) but not the FasT-Fix 360 device or AIR device were statistically significantly stronger than Meniscal Cinch II repairs. Mean cyclic displacement measured 1.1 mm for OrthoCord, 1.5 mm for TrueSpan with PEEK, 1.5 mm for TrueSpan with PLGA, 2.1 mm for Meniscal Cinch II, 1.1 mm for AIR, and 1.4 mm for FasT-Fix 360. The Meniscal Cinch II device showed more displacement than all other devices (P < .05). The FasT-Fix 360, AIR, and Meniscal Cinch II devices failed by anchor pullout from the peripheral meniscus. OrthoCord and both TrueSpan devices failed by suture pulling through the bucket-handle tissue. CONCLUSIONS: OrthoCord suture is stronger than the AIR, FasT-Fix 360, and Meniscal Cinch II devices. The TrueSpan device with PEEK and TrueSpan device with PLGA are stronger than the Meniscal Cinch II device. The Meniscal Cinch II device failed during cyclic loading with greater cyclic displacement than the AIR device, FasT-Fix 360 device, OrthoCord, and TrueSpan device with PEEK. The Meniscal Cinch II, AIR, and FasT-Fix 360 devices failed by anchor pullout, whereas OrthoCord and both TrueSpan devices failed by suture pull-through. CLINICAL RELEVANCE: Some newly introduced all-inside meniscal repair devices show inferior failure strength compared with earlier versions that might adversely impact clinical outcomes.

Grafts and Patches in Rotator Cuff Surgery: Bioinductive Scaffolds, Augmentation, Interposition, and Superior Capsule Reconstruction.

Rotator cuff repair can be challenging because of the compromised state of the tendon tissue. These challenges range from simply degenerative tendons to complete tendon loss in patients which can impair soft-tissue healing. Various grafts and patches are currently available to help address these challenges. The ideal solution for the treatment of irreparable rotator cuff tears or those prone to retear remains controversial. Sometimes augmentation with a patch is appropriate. However, at times a completely retracted and immobile tendon remnant is found. Reconstruction of the superior capsule has demonstrated promising results in several short-term series. The indications for these procedures, the optimal surgical technique, and their limitations are evolving. This chapter discusses the current literature related to bioinductive scaffolds, graft augmentation, graft interposition, and superior capsular reconstruction.

Editorial Commentary: All-Suture Shoulder Glenoid Anchors: Can We Adequately Tension Them or Knot?

All-suture anchors require smaller drill holes (often under 2.0 mm) than comparable solid glenoid anchors (e.g., Gryphon: 2.5-mm drill). A smaller drill allows closer anchor approximation, but there is no indication that this improves repair biomechanics. In fact closely associated multiple fixation points are associated with glenoid fractures, and the same multiple fixation points can be achieved with double- or triple-loaded conventional anchors. All-suture anchors require deployment immediately adjacent to intact cortical bone. Without this, slack and pistoning of the suture ball anchor occur during cyclic loading and have been associated with bone cavitation, repair loosening, and gap formation. A mechanical tensioning mechanism more effectively removes the slack than hand tensioning by the surgeon. Drill length is another concern. All-suture anchor drills measure between 20 and 24 mm long. This length is commonly associated with far cortex penetration and places the suprascapular nerve and axillary nerve at increased risk of contact damage. Maximizing all-suture anchor performance is associated with mechanical deployment systems rather than hand traction applied by the surgeon. Finally, no current all-suture anchor is biodegradable, osteoconductive, or replaced by bone.

Editorial Commentary: Acetabular Labral Repair-Is A Knotless Anchor Better?

Knotless anchors have an important role in arthroscopic acetabular labral repair. Different anchors show 2 primary failure modes: suture breakage and suture pullout from the anchor ("eyelet failure"). Knotless anchors show minimal displacement at physiological loads and should perform well for arthroscopic labral repair. Surgeons should consider the suture-passing device size and use a device that creates as small of a labral hole as possible.

A Biomechanical Comparison of Six Suture Configurations for Soft Tissue-Based Graft Traction and Fixation.

PURPOSE: The purpose of this study was to compare 6 different graft fixation techniques to determine the preparation speed, fixation security, biomechanical strength, and resultant tissue trauma. METHODS: Six different techniques (10 samples each): #2 OrthoCord Krackow stitch, #2 FiberWire Krackow stitch, SpeedTrap, WhipKnot, Loop-in-loop stitch were created in the distal 3 cm of 9 cm bovine flexor tendons. The proximal 3 cm tendon segment was clamped in a testing machine and the distal suture ends secured by pneumatic grips. 3 preload cycles (10N-100N) and 50N static load was followed by 500 cycles (50N-200N) and then loaded to failure. Graft preparation times, 100 and 500 cycle displacement, maximum failure load, stiffness, and failure mode were recorded. RESULTS: Representative graft preparation times were: OrthoCord Krackow (247s), FiberWire Krackow (401s), FiberLoop (177s), SpeedTrap (42s), WhipKnot (39s), Loop-in-loop (45s). No WhipKnots survived cyclic loading. 100 cycle displacements were: OrthoCord Krackow (11.5 ± 3.9 mm), FiberWire Krackow (8.9 ± 1.2 mm), FiberLoop (14.2 ± 6.1 mm), SpeedTrap (8.8 ± 2.5 mm), Loop-in-loop (10.4 ± 2.9 mm). FiberLoop displaced significantly more than all others (P = .016). Maximum failure loads were: OrthoCord Krackow (364 ± 24N), FiberWire Krackow (375 ± 45N), FiberLoop (413 ± 95N), SpeedTrap (437 ± 65N), WhipKnot (153 ± 42N), Loop-in-loop (329 ± 112N). The most common failure mode was suture breaking. FiberWire containing constructs (Krackow and FiberLoop) shredded or cut through ("cheese wiring") prior to failure in a majority. CONCLUSIONS: SpeedTrap, WhipKnot and Loop-in-loop were quickest to create (under 1 minute). The Krackow, SpeedTrap, WhipKnot, and Loop-in-Loop did not damage the tendon during cyclic loading. SpeedTrap and Krackow had the least displacement. FiberLoop displaced more than all other groups (P = .016). No WhipKnot completed cyclic loading. The SpeedTrap (437N) and FiberLoop (413N) had the highest ultimate strength. CLINICAL RELEVANCE: While the SpeedTrap and FiberLoop are the strongest techniques, the FiberLoop shreds the tendon, displaced the most, and took longer to create. Based on these results, the SpeedTrap demonstrates the best overall performance.

Editorial Commentary: Don't Pig Out When Selecting a Shoulder, Rotator Cuff Augmentation Graft! Xenografts Are Not the Way to Go.

Porcine xenograft dermal onlay augmentation of rotator cuff repair does not provide improved cuff integrity or provide better clinical outcomes. The retear rate was actually higher in repairs augmented with a porcine xenograft than the control group. Adverse events occurred in 60% of the xenograft patients compared with 40% of the controls. The use of liquid platelet-rich plasma had no discernible impact. A total of 85% of the observed failures with the suture-bridging double-row repair were at the medial cuff (Cho type 2).

Editorial Commentary: Polyurethane Meniscal Scaffold: A Perfect Fit or Flop?

The goal of using a synthetic scaffold to establish a biomechanically functioning meniscus or provide an equivalent meniscus substitute is not achieved by the polycaprolactone-polyurethane Actifit scaffold. Recent research, that did not include a control group, shows that the revision rate is significant, and any improvements in patient outcomes could reflect the associated reconstructive surgery. Based on these data and similar published reports, it is premature to conclude that this implant is clinically indicated. The technique is currently more flop than fit.

Editorial Commentary: Musculotendinous Junction Mattress Sutures Are Inefficient.

Medial row sutures placed at the musculotendinous junction are more likely to cut through the tendon than those sutures placed 10 mm lateral to the junction. Even if there is little tendon left, putting the stitches at the junction is a bad idea. In this instance, a single-row repair is better.

Editorial Commentary: Feeling the Pressure! A Biomechanical Analysis of All-Inside and Inside-Out Knee Meniscus Repair.

A biomechanical, time-zero comparison found that both No. 2-0 UltraBraid inside-out sutures and FasT-Fix 360 all-inside devices used to repair a displaced bucket handle knee meniscus tear increased the contact area in deeper flexion angles (at 45°-60°) and reduced the peak contact pressure (at 45°-90°). No significance difference was observed between the inside-out and all-inside repair techniques.

Editorial Commentary: Are All-Suture Anchors as Good as Conventional Anchors?

Research in this issue, like other biomechanical testing, suggests that the all-suture anchors studied here seem strong enough for glenoid and acetabular applications. Testing suture anchors in nonbiologic material may be problematic unless that material is validated or there is a control. The cyclic loads used influence the data, and oscillating between 10 and 50 N does not allow for sufficient anchor performance differentiation. The next question is whether there will be any adverse events associated with the use of all-suture anchors clinically.

All-Suture Anchors: Biomechanical Analysis of Pullout Strength, Displacement, and Failure Mode.

PURPOSE: To evaluate the biomechanical and design characteristics of all-suture anchors. METHODS: All-suture anchors were tested in fresh porcine cortical bone and biphasic polyurethane foam blocks by cyclic loading (10-100 N for 200 cycles), followed by destructive testing parallel to the insertion axis at 12.5 mm/s. Endpoints included ultimate failure load, displacement at 100 and 200 cycles, stiffness, and failure mode. Anchors tested included JuggerKnot (1.4, 1.5, and 2.8), Iconix (1, 2, and 3), Y-knot (1.3, 1.8, and 2.8), Q-Fix (1.8 and 2.8), and Draw Tight (1.8 and 3.2). RESULTS: The mean ultimate failure strength of the triple-loaded anchors (564 ± 42 N) was significantly greater than the mean ultimate failure strength of the double-loaded anchors (465 ± 33 N) (P = .017), and the double-loaded anchors were stronger than the single-loaded anchors (256 ± 35 N) (P < .0001). No difference was found between the results in porcine bone and biphasic polyurethane foam. None of these anchors demonstrated 5 mm or 10 mm of displacement during cyclic loading. The Y-Knot demonstrated greater displacement than the JuggerKnot and Q-Fix (P = .025) but not the Iconix and Draw Tight (P > .05). The most common failure mode varied and was suture breaking for the Q-Fix (97%), JuggerKnot (81%), and Iconix anchors (58%), anchor pullout with the Draw Tight (76%), whereas the Y-Knot was 50% suture breaking and 50% anchor pullout. CONCLUSIONS: The ultimate failure load of an all-suture anchor is correlated directly with its number of sutures. With cyclic loading, the Y-Knot demonstrated greater displacement than the JuggerKnot and Q-Fix but not the Iconix and Draw Tight. JuggerKnot (81%) and Q-Fix (97%) anchors failed by suture breaking, whereas the Draw Tight anchor failed by anchor pullout (76%). CLINICAL RELEVANCE: All-suture anchors vary in strength and performance, and these factors may influence clinical success. Biphasic polyurethane foam is a validated model for suture anchor testing.