Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability.

Posterior instability, although an uncommon shoulder pathology, is reported most frequently in the athletic population. Arthroscopic repair has emerged as the main surgical treatment modality for posterior instability. However, when compared with arthroscopic repair for anterior instability, the results of this procedure remain suboptimal. The creation of iatrogenic defects in the capsule, due to cannula placement, is a possible culprit. Because these defects typically do not heal satisfactorily, they become stress risers within the capsule itself, which may lead to recurrent instability or an otherwise compromised repair construct. Therefore, we find that routine intraoperative repair of these defects after repair can reduce the risk of injury and possibly improve long-term outcomes. In this article, we illustrate the repair of a posterior segmental tear using all-suture knotless implants with closure of the posterior and posterior-inferior portals after stabilization.

The Number of Surgeons Using Superior Capsular Reconstruction for Rotator Cuff Repair Is Declining.

Purpose: To investigate surgeon preferences for graft use, including biologic augmentation and superior capsular reconstruction (SCR) associated with surgical treatment of rotator cuff repair (RCR). Methods: A 26-question survey was completed by arthroscopic shoulder surgeons. Surgeon demographics were evaluated. Surgeons were queried about shoulder arthroscopic graft use and rationale then responses were analyzed based on demographics. Results: In total, 260 surgeons completed the survey. Fifty-one percent of surgeons reported a decrease in the volume of SCR use in the past 5 years. Less than 3% of surgeons used SCR in >90% of irreparable RCR cases, compared with 38% using SCR in <10% of irreparable cases (P < .05). Surgeons performing >100 RCR annually (42%; P < .05) and those employed in the hospital setting (44%; P < .05) reported an overall increase in the use of SCR. More international surgeons (67%) decreased their use of SCR compared with U.S. surgeons (44%; P < .05). In contrast, bioinductive graft use is generally on the rise, with 48% of surgeons reporting increased use since first use, although used in <10% of cases by 54% of surgeons. Sixty-eight percent of surgeons performing >100 RCRs annually used bioinductive grafts (P < .05). Fewer international surgeons (30%) performed biologic augmentation (P < .05). Suboptimal published outcomes (40%) and no perceived patient benefit (40%) were most cited for decreased SCR use. Surgeons reporting increased use cited improved personal patient outcomes (72%). Conclusions: Arthroscopic surgeons report decrease in volume of SCR use in the past 5 years. Surgeon's personal experience of patient outcome and suboptimal published results were the strongest factors impacting decision-making. In contrast, bioinductive graft use is increasing. However, most surgeons use these grafts in a relatively small percentage of cases. Clinical Relevance: Evaluation of scientific data, personal experience, and influences on surgical practice will give a comprehensive understanding of current RCR practices.

Optimizing Anchor Placement for Cone-Shaped Rotator Cuff Tears.

There are various technique preferences when performing arthroscopic rotator cuff repair. Currently, most surgeons address all intra-articular pathology as well as assess the extent of a rotator cuff tear with the arthroscope in the joint prior to moving to the subacromial space, where they will initiate footprint preparation, anchor placement, and rotator cuff repair. Although this technique often yields good or at least acceptable visualization of the footprint, it does not always provide an optimal view of the medial footprint even when using a "50-yard line view" from a lateral portal. This can particularly be an issue with "cone-shaped" supraspinatus tears in which a smaller full-thickness bursal-sided tear often expands to a much larger articular-sided component. When surgeons are visualizing with the scope in the subacromial space, it is much more difficult to obtain a full appreciation of the extent of the articular-sided tear as well as optimal visualization of the medial footprint right up to the articular margin for both bone preparation and anchor placement. This article describes the benefit of keeping the arthroscope in the joint to facilitate footprint preparation and medial-row suture anchor placement prior to going to the subacromial space. This small technical modification can often offer surgeons far superior visualization of the entire greater tuberosity footprint especially when encountering a cone-shaped tear or high-grade articular-sided tear that requires repair. To further enhance viewing of the footprint with the scope intra-articularly, proficiency in using a 70° scope directed laterally will typically allow surgeons the most ideal view achievable. Once anchors are placed into the medial row, the arthroscope is inserted into the subacromial space to complete the repair.

Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic resulted in the unprecedented widespread cancellation of scheduled elective primary total joint arthroplasty (TJA) in the United States. The impact of postponing scheduled total hip arthroplasty and total knee arthroplasty procedures on patients has not been well studied and may have physical, emotional, and financial consequences. METHODS: All patients whose elective primary TJA procedures at a tertiary academic medical center were postponed because of COVID-19 were surveyed. Seventy-four patients agreed to answer 13 questions concerning the physical, mental, and financial impact of surgery cancellation. Statistical analysis, including Pearson correlation coefficients, cross-tabulation analysis, and chi squares, was performed. RESULTS: 13.5% of patients strongly disagreed with the use of "elective" to describe their cancelled TJA surgery and 25.7% of patients reported substantial physical and/or mental deterioration due to postponement. Younger individuals experienced greater change in their symptoms (P = 0.034), anxiety about their pain (P = 0.010), and frustration/anger (P = 0.043). Poor quality of life, mood, and lower HOOS/KOOS Jr interval scores were correlated with greater financial strain, disagreement with the postponement, and disagreement with the use of "elective" to describe surgery. Disagreement with the use of "elective" to describe surgery was associated with greater financial strain (P = 0.013) and disagreement with the decision to postpone surgery (P = 0.008). In addition, greater financial strain was associated with disagreement with postponement (P = 0.014). CONCLUSION: The cancellation of elective TJA during the COVID-19 pandemic had a variety of consequences for patients. One in four patients reported experiencing substantial physical and/or emotional deterioration. Associations of poor quality of life and mood with greater financial strain and disagreement with the term "elective" were seen. These results help quantify the deleterious effects of cancelling elective surgery and identify at-risk patients should another postponement of surgery occur. LEVEL OF EVIDENCE: Level II-Prospective cohort study.

ARCO Consensus on the Pathogenesis of Non-traumatic Osteonecrosis of the Femoral Head.

Osteonecrosis of the femoral head (ONFH) is a devastating disease frequently leading to femoral head collapse and hip arthritis. Specifically, non-traumatic ONFH primarily affects young and middle-aged adults. Although compromised local circulation of the femoral head seems to be pathognomonic for the disease, the pathogenesis is perplexing and continues to be an area of scrutiny and research. Comprehension of the pathogenesis is of crucial importance for developing and guiding treatments for the disease. Therefore, we provide an up-to-date consensus on the pathogenesis of non-traumatic ONFH.

Cash-Based Stem-Cell Clinics: The Modern Day Snake Oil Salesman? A Report of Two Cases of Patients Harmed by Intra-articular Stem Cell Injections.

CASE: The use of biologics is rapidly expanding. Over the past decade, there has been a significant increase in the number of cash-based "stem cell"/regenerative medicine clinics in the United States. These clinics provide cash-based services touting stem cell injections to cure a myriad of conditions. Largely, these clinics are unregulated and using injections in a non-Food and Drug Administration-approved manner. We report on 2 patients who presented with symptoms suggestive of septic arthritis following stem cell injections by cash-based local stem cell clinics. Case 1 involved a patient who developed septic arthritis following an injection of umbilical cord blood-derived cellular products (Genentech) and required an antibiotic spacer followed by a total hip arthroplasty. Case 2 involved a patient who developed a likely immune-mediated reaction following an injection of morselized human placental allograft tissue by a local chiropractic office at a cost of approximately $8,000. CONCLUSIONS: We present these cases to bring increased awareness to the issue and call for increased regulation of this practice.

Haloenol pyranones and morpholinones as antineoplastic agents of prostate cancer.

Haloenol pyran-2-ones and morpholin-2-ones were synthesized and evaluated as inhibitors of cell growth in two different prostate human cancer cell lines (PC-3 and LNCaP). Analogs derived from L- and D-phenylglycine were found to be the most effective antagonists of LNCaP and PC-3 cell growth. Additional studies reveal that the inhibitors induced G2/M arrest and the (S)-enantiomer of the phenylglycine-based derivatives was a more potent inhibitor of cytosolic iPLA(2)ß.