Editorial Commentary: For Post-Hip Arthroplasty Iliopsoas Tendonitis, Psoas Tenotomy Is the Preferred First-Line Treatment, Even in Cases of Cup Overhang.

Iliopsoas impingement pathology is one of the causes of persistent pain after total hip arthroplasty. It is reported as occurring in approximately 4% of cases; this may be significantly greater (in cases of postarthroplasty pain of unknown etiology). Inflammation is a result of impingement of the tendon against the acetabular component. This may occur with anteroinferior prominence when the cup is properly positioned in anteversion or when the cup is oversized. Other causes of impingement include a cup-reinforcement ring or acetabular cage, a collared femoral component, screws penetrating through the ilium, cement extrusion, anterior wall hypoplasia, or increased femoral offset. When conservative treatment does not achieve the best outcome, the 2 main therapeutic options are psoas tenotomy or revision of the cup component. Tenotomy can be performed either arthroscopically or by an open approach and may be considered the best option for many patients, even in cases with anterior component prominence, as it is less invasive, presents fewer complications, and has faster recovery. The debate is open. The level of tenotomy remains controversial, with risks and benefits of both a lesser trochanter and transcapsular approach.

Editorial Commentary: Shoulder Biceps Tenodesis Versus Tenotomy: Both Show Good Results and Have Different Indications.

Shoulder long head biceps pathology is one of the most common causes of shoulder pain. The fact that there are many surgical techniques available has led to discussion of which should be the best treatment; although, in general terms, the two main options are tenotomy or tenodesis. Tenotomy is a simple technique, with a low rate of complications and a very good cost-benefit ratio, faster recovery, and less use of narcotic pain medications. Tenodesis has a lower risk of "Popeye deformity" and theoretically better biomechanics and strength, but few studies confirm superior outcomes in cases of biceps disease without concomitant lesions. In addition, there is no consensus as to which technique provides the best result: open or arthroscopic technique, subpectoral or fixation in the bicipital groove, soft tissue, or bony fixation. Generally, all techniques function at least two years after the surgery. We indicate arthroscopic suprapectoral bone tenodesis fixed with a screw in very selected cases: 20 patients <50 years old with good bone quality and engaged in work or sports that require flexion and supination strength. On the other hand, in chronic rupture with Popeye deformity and pain after rehabilitation, we perform open subpectoral tenodesis due to residual retraction, making suprapectoral fixation impossible or overtensioned. The correct length-tension of the long head biceps during tenodesis is critical; inappropriate tensioning can result in undesirable outcomes.

Editorial Commentary: Shoulder Superior Capsular Reconstruction With Dermal Allograft Is Useful for Active Patients With Massive Irreparable Rotator Cuff Tear.

Shoulder superior capsular reconstruction (SCR) with dermal allograft improves clinical outcomes in active patients with massive irreparable rotator cuff tear. SCR functions to restore the glenohumeral joint position, including humeral head depression, thus improving contact pressures. SCR is best indicated in patients with lower grades of rotator cuff arthropathy (Hamada grades 1 and 2) who are <65 years old and without pseudoparalysis. However, SCR can be indicated in very active patients older than 65. In our experience, ≤70% of the times that a SCR surgery has been indicated, a direct complete repair of the supraspinatus tendon can be achieved during surgery. Thus, indications are narrow. Finally, optimal SCR graft tensioning is a complicated but a very important consideration. If the graft is unstressed, it won't function, and if it is too tight, it will tear.

Outside-in arthroscopic psoas release for anterior iliopsoas impingement after primary total hip arthroplasty.

PURPOSE: 1 of the causes of groin pain after total hip arthroplasty (THA) is impingement of the iliopsoas tendon. The purpose of this study was to present our results with outside-in arthroscopic tenotomy for iliopsoas impingement after THA. METHODS: We retrospectively reviewed 12 patients treated between 2009 and 2016 with a minimum follow-up of 2 years. Anterior acetabular component prominence was measured on a true lateral hip radiograph. A transcapsular tenotomy was performed near the edge of the acetabular component through an outside-in arthroscopic approach. The primary clinical outcomes evaluated were groin pain, assessed with a visual analogue scale (VAS), and the Harris Hip Score (HHS). Secondary outcomes included strength of hip flexion, measured with the Medical Research Council (MRC) scale. RESULTS: All patients had groin pain improvement, though one patient continued to have moderate pain. The mean VAS score was significantly lower postoperatively (1.08) than preoperatively (6.2) (p < 0.001). The mean HHS improved from 58.8 (range, 37-76) to 86.1 (range, 59-98) (p = 0.001). The average postoperative MRC Scale was 4.58. The mean anterior prominence was 7.25 mm (range 3-12 mm). In patients with <10 mm of component prominence, tenotomy provided groin pain resolution in all cases (n = 8). In patients with ⩾10 mm of prominence, symptoms resolved in 3 out of 4 cases. CONCLUSIONS: Outside-in arthroscopic iliopsoas release provided a high rate of success with no complications in this study, even in patients with moderate acetabular component prominence.

Interplay between the Adaptive Immune System and Insulin Resistance in Weight Loss Induced by Bariatric Surgery.

Low-grade chronic inflammation plays a pivotal role among other pathophysiological mechanisms involved in obesity. Innate and adaptive immune cells undergo systemic proinflammatory polarization that gives rise to an increased secretion of proinflammatory cytokines, which in turn leads to insulin resistance. Bariatric surgery is currently the most effective treatment for obesity, as it brings on significant weight loss, glucose metabolism improvement, and a decrease in systemic inflammation biomarkers. After bariatric surgery, several changes have been reported to occur in adaptive immunity, including reduction in CD4+ and CD8+ T cell counts, a decrease in the Th1/Th2 ratio, an increase in B regulatory cells, and reduction in proinflammatory cytokine secretion. Overall, there seems to be a major shift in several lymphocyte populations from a proinflammatory to an anti-inflammatory phenotype. Furthermore, increased antioxidant activity and reduced lipid and DNA oxidation products have been reported after bariatric surgery in circulating mononuclear cells. This paper highlights the shift in the adaptive immune system in response to weight loss and improved insulin sensitivity, as well as the interplay between immunological and metabolic adaptations as a result of bariatric surgery. Finally, based on data from research, we propose several mechanisms such as changes in adaptive immune cell phenotypes and their by-products, recruitment in adipose tissue, reduced oxidative stress, and modification in metabolic substrate availability as drivers to reduce low-grade chronic inflammation after bariatric surgery in severe obesity.

Test-retest reliability of the ASES-p shoulder scale.

INTRODUCTION: Shoulder disorders are common musculoskeletal problems. The self-assessed ASES questionnaire (ASES-p) is one of the most widely used tools for evaluating shoulder function. Its 11 items are divided in a function (10 items) and pain (1 item) dimension, assigned between 0 and 50 points each. Their sum is the scale's total score, with higher values indicating better health status. The current work explores the test-retest reliability of the Spanish version of the ASES-p score values. MATERIALS AND METHODS: The scale was administered twice to a sample of subjects with various shoulder pathologies, via telephone interviews performed at 3-7 days apart. Exact agreement was calculated on an item and score basis. Score variability was assessed with the 95% limits of agreement method (LoA). RESULTS: N = 161 subjects were initially contacted, and a total of 82 stable health status subjects provided valid test-retest replies. "Do usual sport" was the only item with missing data. Exact agreement oscillated between 67 and 89% per item. The 95% LoA ranged between -5.9 and 6.9 points for function; -13.2 to 11.9 for pain and -10.3 to 10.1 for the total ASES-p score. CONCLUSIONS: Test-retest reliability in stable patients was considered acceptable for the function and total scores, but not for pain. This may reflect usual pain behaviour, but it also implies that the pain evaluation should be further studied. The ASES-p pain subscore should not be used as the single measure for monitoring shoulder pain. Revisiting the "do usual sports" item may increase the scale's applicability.

Correction to: Effect of patient positioning in axillary nerve safety during arthroscopic inferior glenohumeral ligament plication.

The author claims that his name is incorrectly listed on PubMed. The first name should be Jorge and the last name should be Díaz Heredia. On SpringerLink the name is listed correctly, but on PubMed he is listed as Heredia JD.

Constant-Murley Score: systematic review and standardized evaluation in different shoulder pathologies.

PURPOSE: The objective of this study was to evaluate the psychometric properties of the Constant-Murley Score (CMS) in various shoulder pathologies, based on a systematic review and expert standardized evaluations. METHODS: A systematic review was performed in MEDLINE and EMBASE databases. Titles and abstracts were reviewed and finally the included articles were grouped according to patients' pathologies. Two expert evaluators independently assessed the CMS properties of reliability, validity, responsiveness to change, interpretability and burden score in each group, using the EMPRO (Evaluating Measures of Patient Reported Outcomes) tool. The CMS properties were assessed per attribute and overall for each considered group. Only the concept and measurement model was assessed globally. RESULTS: Five individual pathologies (i.e. subacromial, fractures, arthritis, instability and frozen shoulder) and two additional groups (i.e. various pathologies and healthy subjects) were considered. Overall EMPRO scores ranged from 58.6 for subacromial to 30.6 points for instability. Responsiveness to change was the only quality to obtain at least 50 points across all groups, but for frozen shoulder. Insufficient information was obtained in relation to the concept and measurement model and great variability was seen in the other evaluated attributes. CONCLUSIONS: The current evidence does not support the CMS as a gold standard in shoulder evaluation. Its use is advisable for subacromial pathology; but data are inconclusive for other shoulder conditions. Prospective studies exploring the psychometric properties of the scale, particularly for fractures, arthritis, instability and frozen shoulder are needed. LEVEL OF EVIDENCE: Systematic review.

Correction to: The all-inside meniscal repair technique has less risk of injury to the lateral geniculate artery than the inside-out repair technique when suturing the lateral meniscus.

The author claims that his name is incorrectly listed on PubMed. The first name should be Jorge and the last name should be Díaz Heredia.

The all-inside meniscal repair technique has less risk of injury to the lateral geniculate artery than the inside-out repair technique when suturing the lateral meniscus.

PURPOSE: To evaluate the risk of injury to the inferior lateral geniculate artery with two different techniques for lateral meniscus repair. METHODS: Eight cadaveric knees were used. Inside-out sutures and an all-inside suture device were placed at the most lateral edge of the popliteal hiatus, and 15 and 30 mm anterior to this point. The minimum distances between the sutures and the inferior lateral geniculate artery were measured through a limited lateral arthrotomy. Artery penetration or collapse due to the sutures was also evaluated. RESULTS: The median distance between the sutures and the artery when inserted at the lateral edge of the popliteal hiatus was 1.5 mm (interquartile range: 1.3) for the inside-out technique and 1.5 mm (1.3) for the all-inside technique (differences not significant, n.s.). When the sutures were inserted 15 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.1) and 1.3 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). When the sutures were inserted 30 mm anterior to the popliteal hiatus the distances were 1.0 mm (1.0) and 1.5 mm (1.0) for the inside-out technique and the all-inside technique, respectively (n.s.). The artery was punctured with two of the inside-out sutures placed 15 mm from the popliteal hiatus, no puncturing occurred in the all-inside technique (n.s.). Tying of the inside-out sutures resulted in obliteration of the artery in four of eight sutures placed at 15 mm from the popliteal hiatus and three of eight sutures at 30 mm; no obliteration of the artery was found using the all-inside device (significant differences, p = 0.002). CONCLUSIONS: Although both all-inside and inside-out lateral meniscal repair techniques place sutures very close to the lateral geniculate artery, the inside-out technique is riskier as extra-articular knot tying can cause artery obliteration when suturing the part of the meniscus immediately lateral to the popliteal hiatus. Therefore, all-inside meniscal repair technique shows less risk of injury to the major blood supply of the lateral meniscus.

Anatomy and Biomechanics of the Unstable Shoulder.

PURPOSE: To review the anatomy of the shoulder joint and of the physiology of glenohumeral stability is essential to manage correctly shoulder instability. METHODS: It was reviewed a large number of recently published research studies related to the shoulder instability that received a higher Level of Evidence grade. RESULTS: It is reviewed the bony anatomy, the anatomy and function of the ligaments that act on this joint, the physiology and physiopathology of glenohumeral instability and the therapeutic implications of the injured structures. CONCLUSION: This knowledge allows the surgeon to evaluate the possible causes of instability, to assess which are the structures that must be reconstructed and to decide which surgical technique must be performed.

Management of Humeral Defects in Anterior Shoulder Instability.

BACKGROUND: A Hill Sachs lesion is a posterior-superior bony defect of the humeral head caused by a compression of the hard glenoid rim against the soft cancellous bone in the context of an anterior instability episode. The presence of these humeral defects increases with the number of dislocations and larger lesions are associated with a greater chance of development of recurrent instability and recurrence after surgery. Also its location and pattern, in particular the so-called engaging Hill-Sachs, are associated with poor prognosis. METHODS: There is a lack of consensus in terms of classification and management algorithm, although lesions greater than 25% of the humeral head had been suggested to need more than a simple Bankart repair to avoid recurrence. The concept of glenoid track has turned the attention to location and shape and not only size of the humeral defect. Moreover, the glenoid bone loss is crucial when choosing a treatment option as it contributes to decrease the glenoid track as well. A thorough revision of treatment options has been performed. RESULTS: Numerous treatment options have been proposed including remplissage, glenoid or humeral head augmentation, bone desimpaction, humeral rotational osteotomy and arthroplasty. CONCLUSION: Humeral defects treatment should be individualized. Determination of size and location of the defect and its relation with glenoid track is mandatory to achieve satisfactory results.

Screw Fixation of Os Acetabuli: An Arthroscopic Technique.

An os acetabuli (OA) increases the contact area and surface area of the acetabulum and is important to maintain congruity of the hip joint. Thus preservation of this ossicle is important to prevent loss of contact area and ensure containment of the femoral head. We describe an all-arthroscopic approach to the fixation of OA with a compression screw. Initially, the fibrous tissue is debrided between the acetabular rim and the OA, a guidewire is placed through the OA up to the acetabular rim, and a screw is inserted over the wire. Compression of the OA is achieved with bone-to-bone contact. This technique prevents loss of femoral head coverage, reducing the risk of subluxation and subsequent osteoarthritis.

Effect of patient positioning in axillary nerve safety during arthroscopic inferior glenohumeral ligament plication.

PURPOSE: To evaluate the risk of injuring the axillary nerve during an inferior glenohumeral ligament (IGHL) plication and finding out whether shoulder position (either beach chair position or lateral decubitus position) has any effect in this risk. METHODS: The axillary nerve (AN) was identified through a 3-cm posterior incision in 12 cadaveric shoulders. Under arthroscopic visualization, a curved indirect suture-passing device was placed through the posterior and anterior bands of the IGHL. The distances between the device and the AN were measured with the shoulder specimen placed at simulated lateral decubitus position and beach chair position. RESULTS: There were no cases of nerve injury nor the suture-passing device came closer than 10 mm to the nerve. There was an increase in the injury risk to the AN when inserting the device at the posterior band of the IGHL in the beach chair position [median 13 mm (range 10-21 mm)] compared to the risk in the lateral decubitus position [22.5 mm (20-26 mm), significant differences, p < 0.001]. When the device was inserted at the anterior band of the IGHL, there were no significant differences (n.s.) [lateral decubitus position: 18 mm (14-24 mm) vs. 16 mm (13-18 mm)]. When comparing differences between bands, there were no differences in the beach chair position, but the risk was lower for the posterior band in the lateral decubitus position (p < 0.001). CONCLUSIONS: During plication of the posterior band of the IGHL, the risk is higher if the procedure is performed in the beach chair position. The posterior plication is safer than the anterior plication in lateral decubitus position. CLINICAL RELEVANCE: This study helps the surgeon to better understand the proximity of the nerve to the IGHL and to highlight that the risk of nerve injury during capsular plication might be reduced in the lateral decubitus position.

Arthroscopic Revision Surgery for Failure of Open Latarjet Technique.

PURPOSE: To evaluate the efficacy in treating pain, limited range of motion, and continued instability of the Latarjet open technique via the use of arthroscopy. METHODS: A retrospective review of patients who underwent arthroscopic capsule plication after failure of an open Latarjet technique was performed. Revision surgery was indicated in cases of recurrent instability and associated pain. Only patients with a glenoid defect <25% were considered. The Constant and Rowe scores were administered, whereas pain was assessed with a visual analog scale before the reoperation and at 24 months after operation. Radiographs, computed tomography, and CT arthrography scans were performed. RESULTS: Twelve patients met the inclusion criteria. All patients had capsular distension and consequently were subjected to a capsuloplasty. Shoulder function, stability, and pain had all improved significantly at 24 months after arthroscopic revision (P < .0001). In particular, the Constant score increased from 44.9 (standard deviation [SD] 7.10) to 89.3 (SD 12.6) points, the Rowe score improved from 49.5 (SD 10.1) to 80.9 (SD 10.9), whereas the visual analog scale pain score decreased from 6.75 (SD 1.17) to 1.38 (SD 1.06). CONCLUSIONS: Primary open Latarjet with a glenoid bone defect <25% that failed due to capsular redundancy is amenable to successful treatment with arthroscopic capsuloplasty. CLINICAL RELEVANCE: Arthroscopic approaches can offer a good solution for treating previously failed open Latarjet procedures. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Posterior Lateral Meniscus Root Reattachment With Suture Anchors: An Arthroscopic Technique.

The posterior lateral meniscus root (PLMR) provides the circumferential tension required to stabilize the lateral meniscus. Thus, preservation of the PLMR is important to prevent an increase in tibiofemoral contact pressure, which could result in osteoarthritis. We describe an all-arthroscopic approach to the fixation of PLMR using suture anchors through associated posterolateral arthroscopic portals that result in a more favorable inclination of the anchors. Initially, the anatomical insertion site of the root on the tibial plateau is debrided, 1 to 2 anchors are placed through the posterolateral portals into the root's footprint area, and the meniscus is finally sutured from the posterolateral portals. Compression of the meniscus is achieved with bone contact. This technique achieves lateral meniscus root fixation, reducing the risk of subluxation of the meniscus and subsequent osteoarthritis.

Patient self-report section of the ASES questionnaire: a Spanish validation study using classical test theory and the Rasch model.

BACKGROUND: The aim of the current study was to validate the self-report section of the American Shoulder and Elbow Surgeons questionnaire (ASES-p) into Spanish. METHODS: Shoulder pathology patients were recruited and followed up to 6 months post treatment. The ASES-p, Constant, SF-36 and Barthel scales were filled-in pre and post treatment. Reliability was tested with Cronbach's alpha, convergent validity with Spearman's correlations coefficients. Confirmatory factor analysis (CFA) and the Rasch model were implemented for assessing structural validity and unidimensionality of the scale. Models with and without the pain item were considered. Responsiveness to change was explored via standardised effect sizes. RESULTS: Results were acceptable for both tested models. Cronbach's alpha was 0.91, total scale correlations with Constant and physical SF-36 dimensions were >0.50. Factor loadings for CFA were >0.40. The Rasch model confirmed unidimensionality of the scale, even though item 10 "do usual sport" was suggested as non-informative. Finally, patients with improved post treatment shoulder function and those receiving surgery had higher standardised effect sizes. CONCLUSIONS: The adapted Spanish ASES-p version is a valid and reliable tool for shoulder evaluation and its unidimensionality is supported by the data.

Anatomic Hip Capsular Reconstruction With Separate Suture Anchors.

The number of reports on the use of capsule suturing techniques during hip arthroscopy has increased in the last few years because of the important function played by the iliofemoral ligament (IFL). This study describes an arthroscopic technique whereby the hip capsule is opened by a limited vertical dissection of both the capsule itself and the IFL from their footprint on the acetabular rim, and the capsulolabral junction and the IFL's deep fibers are released. After the intra-articular procedure, the capsule is closed through 2 to 4 side-to-side sutures in the vertical arm of the capsulotomy and 1 to 2 suture anchors with sutures are passed through either side of the capsular confluence. This technique prevents a full transverse section of the IFL and allows complete capsular closure through reconstruction of the capsular footprint.

The Use of All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Management of Humeral and Glenoid Chondral Defects in the Shoulder.

Autologous matrix-induced chondrogenesis (AMIC) is often used for treating chondral defects in different joints. We describe an all-arthroscopic approach for the treatment of glenoid and humeral chondral lesions with this technique. AMIC starts with the use of microfractures of the damaged cartilage, followed by coverage of the defect with a type I/III collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) that is fixed with fibrin glue (Tissucol; Baxter, Warsaw, Poland). In a 1-step approach, the unstable cartilage is debrided, microfractures that penetrate up to the subchondral bone are performed, and the membranes are pasted to the lesion. Our technique reduces morbidity rates compared with traditional open surgery. The arthroscopic AMIC procedure is a viable, cost-effective treatment for the repair of chondral lesions of the shoulder.

The Effect of Knee Flexion Angle on the Neurovascular Safety of All-Inside Lateral Meniscus Repair: A Cadaveric Study.

PURPOSE: To evaluate if different knee flexion angles can modify the neurovascular injury risk during lateral meniscus repair. METHODS: Twenty cadaveric knees were studied. An all-inside suture device (FasT-Fix; Smith & Nephew, Andover, MA) was placed at the posterior horn and at the medial and lateral limits of the popliteal hiatus. The minimal distances between the device and the popliteal artery and peroneal nerve were measured with the knee at 90°, 45°, and 0° of flexion through a limited posterolateral arthrotomy. RESULTS: The distance between the device when inserted at the lateral edge of the popliteal hiatus and the peroneal nerve decreased from a median of 26 mm (interquartile range [IQR], 3.5 mm; range, 19 to 29 mm) at 90° to 21.5 mm (IQR, 4.5 mm; range, 14 to 25 mm) at 45° and 15.5 mm (IQR, 6.5 mm; range, 4 to 20 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the peroneal nerve decreased from 16 mm (IQR, 3.3 mm; range, 9 to 21 mm) at 90° to 12 mm (IQR, 4.3 mm; range, 9 to 16 mm) at 45° and 7 mm (IQR, 4.0; range, 4 to 15 mm) at 0° (significant differences, P < .001). The distance between the device when inserted at the medial edge of the popliteal hiatus and the popliteal artery decreased from 21 mm (IQR, 5.0 mm; range, 11 to 27 mm) at 90° to 19 mm (IQR, 5.0 mm; range, 10 to 23 mm) at 45° and 16 mm (IQR, 7.5 mm; range, 10 to 23 mm) at 0° (significant differences, P < .001). The distance between the device when inserted 5 mm lateral to the posterior root of the lateral meniscus and the popliteal artery decreased from 13 mm (IQR, 4.3 mm; range, 7 to 27 mm) at 90° to 10.5 mm (IQR, 4.3 mm; range, 4 to 19 mm) at 45° and 5.5 mm (IQR, 4.0 mm; range, 0 to 14 mm) at 0° (significant differences, P < .001). CONCLUSIONS: The risk of injury to the popliteal artery or to the peroneal nerve during all-inside repair of the posterior half of the lateral meniscus is lower at 90° of flexion and increases with knee extension to 45° and 0°. CLINICAL RELEVANCE: All-inside meniscal repair of the lateral meniscus is safer with the knee at 90° of flexion.