Editorial Commentary: Biocomposite Implant Combined With Local Human Recombinant Parathyroid Hormone Enhances the Histological Quality and Biomechanical Strength of Rotator Cuff Repairs.

Rates of rotator cuff repair retear remain unacceptably high and are frequently the source of diminished shoulder function and patient dissatisfaction. Endocrinopathies have been implicated in these processes. Parathyroid hormone (PTH) activates chondrogenesis and angiogenesis at the enthesis and prevents fatty infiltration and atrophy in rotator cuff musculature. These facts have spurred interest in the therapeutic benefits of PTH as a means to enhance tendon healing and strengthen the bone in and around tendon repairs. New research demonstrates that recombinant human PTH delivered locally through a process of coupling it to a bioengineered scaffold "sheath" may be beneficial. The growth factor, encased within polycaprolactone (PCL), is slowly released as the PCL degrades to extend drug delivery time. The augmentation of rotator cuff repairs with this biocomposite material improves short-term structural tissue integrity and promotes the formation of more organized and stronger tendon-to-bone interface in a rabbit model.

Editorial Commentary: Decreased Superior Capsular Reconstruction Postoperative Graft Volume Is More Common in Patients With Advanced Rotator Cuff Arthropathy and Is Associated With Inferior Outcome: Cause or Effect?

Recent research has investigated the impact of graft condition on the outcomes of shoulder superior capsular reconstruction for irreparable rotator cuff tears. A decreased lateral graft volume compared with the medial graft volume is more common in patients with rotator cuff arthropathy and is associated with inferior clinical outcomes. This would suggest that aside from simply failing at the suture-graft junction, grafts with thinner lateral segments may exhibit diminished biomechanical strength over time. This may explain, in part, the discrepancy in outcomes between thinned grafts and grafts with preservation of tissue thickness. However, a significant association is also shown between grafts with lateral thinning and factors that portend worse clinical outcomes, including a higher Hamada grade, larger anteroposterior distance of the graft spanning the greater tuberosity, increased fatty infiltration in the infraspinatus and subscapularis muscles, and higher rate of subscapularis retears postoperatively. This would suggest that reductions in graft volume may be a product of worse initial pathology, which in and of itself may explain the worse postoperative outcomes. Thus, it remains unclear whether the findings represent cause or effect.

Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery.

BACKGROUND: There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve-based MCIDs and baseline-adjusted ROC curve MCIDs. METHODS: All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive). RESULTS: A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. CONCLUSION: When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Novel 3D MRI-based volumetric assessment of rotator cuff musculature demonstrates stronger correlation with preoperative functional status when compared to the Goutallier grading scheme.

BACKGROUND: The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3-dimensional (3D) magnetic resonance imaging (MRI) volumetric scores (VSs) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to (1) describe the correlation between GC and VSs for supraspinatus changes in RC tears, (2) characterize the chronicity of RC tears using a battery of 12 VS measurements, and (3) compare GC and VSs to determine which method most closely corresponds with preoperative patient-reported outcome measures (PROMs). METHODS: Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VSs included fat infiltration (FIS), muscle size (MSS), and relative volume contribution (RCS) for each RC muscle. Backward linear regression was performed to compare GC stage with preoperative PROMIS PF and PI to determine which VS measurement most closely correlated with preoperative PROMs. RESULTS: Eighty-two patients underwent RC repair (mean age 55 ± 8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, P < .001); strong negative correlations were observed between MSS (r = -0.800, P < .001) and RCS (r = -0.745, P < .001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, P = .343) and PI (r = -0.071, P = .528). On multivariate analysis, subscapularis MSS (ß >0, P = .064) was a positive predictor and subscapularis FIS (ß <0, P = .137), teres minor MSS (ß <0, P = .141), and FIS (ß <0, P = .070) were negative predictors of preoperative PF (r = 0.343, P = .044); in contrast, supraspinatus MSS (ß >0, P = .009) and FIS (ß >0, P = .073), teres minor FIS (ß >0, P = .072), and subscapularis FIS (ß >0, P = .065) were positive predictors of preoperative PI (r = 0.410, P = .006). CONCLUSION: Although the criterion standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VSs showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Editorial Commentary: A Biphasic (Calcified and Demineralized), Cancellous, Interpositional Allograft Augmenting Rotator Cuff Repair in an Ovine Model Does Not Show Harmful Inflammation or Foreign Body Reaction.

To improve the outcomes of arthroscopic rotator cuff (RC) repair, it is important to achieve tendon-to-bone healing at the repair site. Healed repairs are more likely to restore shoulder strength and lead to higher magnitudes of satisfaction. Patches or grafts that can be either secured to the bursal surface of the RC or interposed between the RC tendon and greater tuberosity at the time of repair have been described as adjuncts to RC repair. A cancellous, biphasic allograft tissue composed of 2 layers (calcified to promote osseointegration and demineralized to support soft-tissue ingrowth) has been shown to be safe in an ovine model, without a harmful inflammatory or foreign body response. Human trials may be a reasonable next step.

Editorial Commentary: High Variability Exists Among Different Techniques for Measuring Glenoid Bone Loss.

Glenoid bone loss is a predominant factor in determining proper surgical management for glenohumeral instability. Precise measurements of glenoid (and humeral) bone defects are fundamental, and millimeters matter. Three-dimensional computed tomography scans may provide the highest interobserver reliability for making these measurements. Yet, because imprecision in the range of millimeters is observed with even the most precise glenoid bone loss measurement techniques, it could be a mistake to over-rely, let alone solely rely, on glenoid bone loss measurement as the primary determinant for selecting one surgical procedure over another. Surgeons must measure glenoid bone loss but also thoughtfully consider patient age, associated soft-tissue injuries, and activity level, including throwing and participation in collision sports. When choosing the proper surgical procedure for a shoulder instability patient, we should not focus on only one variably measured parameter but, instead, on a comprehensive assessment of the patient.

Psychological Readiness to Return to Sport: Fear of Reinjury Is the Leading Reason for Failure to Return to Competitive Sport and Is Modifiable.

Many of our patients are athletes, and an ultimate goal is to help these athletes return to their preinjury level of activity or sport. Generally, we focus on patients' injuries and treatments, but there are modifiable factors that can improve patient outcomes independent of surgical technique. A factor frequently ignored is psychological readiness to return to sport. In patients including athletes, particularly teenagers, chronic, clinical depression is a prevalent and pathologic condition. In addition, in nondepressed patients (or in patients who are situationally depressed because of injury), the ability to deal with stressors may still govern clinical outcomes. Specific psychological traits of significance have been identified and defined, including self-efficacy; locus of control; resilience; catastrophizing; kinesiophobia; and fear of reinjury. (Fear of reinjury is the leading reason for failure to return to competitive sport, reduced activity levels after sports injury, and greater reinjury rates.) The traits may overlap and may be modifiable. Thus, like strength and functional testing, we should evaluate for signs or symptoms of depression, and we should measure psychological readiness to return to sport. With awareness, we can intervene or refer as indicated. Psychological readiness to return to sport represents an underexamined domain in which we can help our patients achieve best outcomes.

What to Do When It Is Anterior Cruciate Ligament Reconstruction Number Two.

Several factors contribute to the greater complexity of revision anterior cruciate ligament reconstruction compared with primary anterior cruciate ligament reconstructive surgery. Prior tunnels and hardware may compromise revision tunnel placement and secure fixation. This may necessitate two-stage revision or specific techniques to achieve anatomic revision tunnels. Prior autograft use may limit graft options. Individuals with a failed anterior cruciate ligament reconstruction are more likely to have risk factors for further failure. These may include malalignment, occult instability, knee hyperextension, or increased tibial slope. There are also higher rates of meniscus and cartilage injuries in revision anterior cruciate ligament reconstruction that may require intervention. Successful revision anterior cruciate ligament reconstruction requires thoughtful preoperative planning along with multiple potential intraoperative plans depending on the pathology encountered. It is important to provide the orthopaedic surgeon with an up-to-date, evidence-based overview of how to approach and execute a successful revision anterior cruciate ligament reconstruction.

Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations. QUESTIONS/PURPOSES: In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling. RESULTS: The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF. CONCLUSION: The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Editorial Commentary: Bone Marrow Aspirate Concentrate May Accelerate Anterior Cruciate Ligament Allograft Using Bone Patellar Tendon Bone Maturation on Magnetic Resonance Imaging, but Clinical Differences Have Not Been Demonstrated.

Accelerating graft healing in anterior cruciate ligament reconstruction (ACLR) continues to be an elusive proposition. In vivo assessments of graft histology are challenging to perform, especially in human subjects. Multiple authors have reported on the utility of magnetic resonance imaging as a noninvasive modality in characterizing postoperative changes, suggestive of graft maturation. However, previous literature, by and large, has been limited by heterogenous scanning protocols and underpowered comparisons of dissimilar treatment techniques, and these issues complicate efforts to assess the benefits (if any) of adjuncts focused on improving graft healing after ACLR. Particularly in cases of allograft ACLR, where concerns persist regarding the pace and quality of tissue healing and graft integration, the use of orthobiologic adjuncts represents a promising area for ongoing investigation. Although there has been great enthusiasm for the use of bone marrow aspirate concentrate as an adjunct in a variety of applications, high level evidence substantiating its use in ACLR is lacking. Even when significant differences between groups treated with and without such adjuncts may be apparent radiographically, demonstrating a concrete, clinical benefit will continue to be a difficult proposition.

Editorial Commentary: Anchor Position Affects Glenoid Resorption Rates After Arthroscopic Bankart Repair: Shoulder Stabilization Surgery Is a Game of Millimeters.

The technical nuances of arthroscopic Bankart repair cannot be overstated. Previous literature has identified a number of risk factors for failure of arthroscopic stabilization procedures, and the implications of glenoid bone loss is widely recognized as a critical driver of postoperative outcomes. However, other technical considerations (inadequate number of suture anchors, improper position of suture anchors) have been acknowledged as risk factors for the failure of arthroscopic stabilization procedures. More recently, concerns have been raised regarding the observed rates of glenoid bone resorption following arthroscopic Bankart repair, which theoretically may predispose higher rates of clinical failure. Furthermore, certain techniques for placing anchors on the glenoid during arthroscopic Bankart repair may accelerate these resorptive changes. Precise measures of poststabilization surgery glenoid resorption coupled with comprehensive assessments of clinical outcomes are required to determine the optimal technique for anchor insertion during arthroscopic Bankart repair.

Editorial Commentary: Arthroscopic Release of Severe Elbow Contracture Is Safe and Effective: It Can Be Done, and It Should Be Done.

The surgical management of elbow contracture remains a challenging proposition, and both open and arthroscopic approaches have been described with varying degrees of success. In particular, previous series involving severe cases have left much to be desired in terms of clinical outcomes and complication rates. Herein lies an opportunity for innovation via alternative, arthroscopic approaches. In the hands of a single senior surgeon, arthroscopic elbow contracture release can be accomplished, even in the setting of severe, post-traumatic cases, with an expectation for substantial improvements in the arc of motion and comparable, if not better, complication rates than reported previously in other series. However, concerns regarding the reproducibility of these results persist and should compel future efforts to prove that these techniques can yield similar results among a group of surgeons.

Bone Block Augmentation of the Posterior Glenoid for Recurrent Posterior Shoulder Instability Is Associated With High Rates of Clinical Failure: A Systematic Review.

PURPOSE: To determine whether posterior glenoid bone block augmentation performed for the treatment of recurrent posterior shoulder instability succeeds in restoring stability and is associated with rates of complications or clinical failures comparable to other glenoid bone augmentation procedures. METHODS: A comprehensive search of PubMed, MEDLINE, and EMBASE databases was performed. Level of evidence studies I to IV pertaining to posterior bone block augmentation reporting on outcomes or complications were included. The search was carried out in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Screening of titles, abstracts, and manuscripts with application of inclusion and exclusion criteria yielded 17 full-text articles reporting on 269 shoulders undergoing bone block augmentation. Surgical technique varied between studies with regard to graft type (iliac crest, 13 studies; scapular spine, 2; acromion, 1; distal tibia allograft, 1), graft positioning (medial to 1.5 cm lateral to glenoid surface, equatorial to subequatorial), and open versus arthroscopic technique (open, 10 studies; arthroscopic, 4; both, 3). Four of the 8 studies with pre- and postoperative patient-reported outcomes (PROs) showed significant improvements in these outcomes at final follow-up. The postoperative outcomes ranged from 60 to 90 for Rowe scores (n = 7 studies) and 79 to 90 for Walch-Duplay scores (n = 7 studies). Complications were commonly encountered, with high rates of recurrent instability (0% to 73%) and revision procedures (0% to 67%) across different studies. CONCLUSION: Posterior bone block augmentation for recurrent posterior shoulder instability does not reliably yield substantial improvements in PROs, and complications are frequently observed. The substantial heterogeneity across studies and the small number of patients precludes any substantive judgements as to the superiority of one surgical technique over another. LEVEL OF EVIDENCE: IV, systematic review of level III and IV studies.

Magnetic resonance imaging does not reliably detect Kaplan fiber injury in the setting of anterior cruciate ligament tear.

PURPOSE: There has been a continued effort to better understand the role Kaplan fiber injury plays in persistent instability following ACL tears. However, the prevalence of these injuries remains poorly understood. Therefore, the purpose of this study was to define the prevalence of Kaplan fiber injury in the setting of complete anterior cruciate ligament tear using a commonly used grading system for assessing ligament injuries. The inter-rater reliability of this commonly used grading system and the relationship between Kaplan fiber injury and injury to other structures commonly found in conjunction with ACL tears was also evaluated. METHODS: All isolated, complete anterior cruciate ligament tears confirmed on magnetic resonance imaging within 90 days of injury between 2014 and 2020 at a single institution were included for analysis. Each scan was read by two, fellowship-trained musculoskeletal radiologists. Kaplan fiber injury was evaluated using a previously described grading scheme. Kappa, [Formula: see text], of inter-rater agreement was determined for all magnetic resonance image scans. Kruskal Wallis test was performed to assess for associations between Kaplan fiber injury and magnet strength (1.5 T vs. 3.0 T), patient gender, the presence of medial and/or lateral meniscal tears, and/or posterolateral tibial bone bruise. RESULTS: Between 2014 and 2020, 131 patients (94 males, 37 females) with a complete anterior cruciate ligament tear were included in the final analysis. The mean age of the cohort was 27.8 ± 6.8 years. Kaplan fiber injuries were identified in 51 of 131 (38.9%, CI 31.0-47.5%) scans with complete anterior cruciate ligament injuries (Grade 1: 28, Grade 2: 18, and Grade 3: 5). Inter-rater agreement for Kaplan fiber injury was fair ([Formula: see text] with 43 (32.8%) scans requiring third reviewer adjudication. There were no significant associations between Kaplan fiber injury and gender, magnet strength, meniscal tears, or posterolateral tibial bone bruise. CONCLUSION: The prevalence of Kaplan fiber injuries was comparable to previously described rates; however, the classification system used to report Kaplan fiber injury was associated with low inter-rater reliability. The presence of Kaplan fiber injury was not associated with other injuries commonly observed in conjunction with ACL tear. The previously proposed Kaplan fiber injury classification system is not reproducible nor is it likely to aid surgeons in distinguishing higher grades of rotatory knee instability. LEVEL OF EVIDENCE: Level IV.

Editorial Commentary: Remplissage Is Not Needed When Performing the Latarjet Procedure in the Setting of Off-Track Hill-Sachs Lesions: One of the Classics Continues to Get Better With Age (and Some Help From New Data).

The glenoid track paradigm has played a pivotal role in the development of a contemporary approach to shoulder stabilization surgery. A number of studies have validated the importance of bipolar bone loss in the pathogenesis of recurrent anterior shoulder instability and defined the limitations of soft tissue-based, arthroscopic surgical approaches. The glenoid track paradigm has also helped to clarify the indications for coracoid transfer procedures, although some question persists as to the necessity of addressing an "off-track" Hill-Sachs lesion with remplissage concurrently with the Latarjet procedure for large glenoid bone defects. The best available evidence would suggest that the Latarjet procedure can be expected to yield favorable clinical outcomes even in the setting of an off-track Hill-Sachs lesion, thereby obviating the necessity of concomitant remplissage for cases involving advanced degrees of bipolar bone loss.

Editorial Commentary: Systematic Review and Meta-analysis Demonstrates Improved Healing When Platelet-Rich Plasma Is Incorporated into Double Row Rotator Cuff Repairs: More of the Same or Something New?

Numerous recently published systematic reviews and meta-analyses have sought to clarify the effect, if any, of platelet-rich plasma as an adjuvant to rotator cuff repair on healing rates and clinical outcomes. As time has gone on, these types of studies have become more focused in their analysis of particular features and aspects of the surgical procedure, as well as the formulation and application of the platelet-rich plasma itself. The current article further clarifies the matter and provides compelling evidence to this effect when platelet-rich plasma is used as an adjuvant to linked, double-row rotator cuff repairs.

Editorial Commentary: Platelet-Rich Plasma Has Advantages Over Corticosteroid for Nonoperative Treatment of Rotator Cuff Pathology: Another Step in the Right Direction.

Lack of high-quality evidence has limited the widespread acceptance of platelet-rich plasma, bone marrow aspirate, and other therapeutics, collectively referred to as "orthobiologics," for partial-thickness rotator cuff tears and associated tendinopathies. The existing literature is limited, among other things, by underpowered studies and imprecise descriptions of the administration and/or formulation of the platelet-rich plasma being investigated. However, recent research favors platelet-rich plasma over corticosteroid injections in the nonoperative treatment of rotator cuff pathology. In light of evidence showing a deleterious effect of corticosteroids on subsequent surgical interventions, surgeons should continue to be wary of subacromial corticosteroid injections if alternatives such as platelet-rich plasma exist. A corticosteroid injection may have been the "go-to" nonoperative intervention in the past, but platelet-rich plasma may be a more effective arrow in our quiver. Of course, the conspicuous cost differential between these 2 different injections remains a very real consideration. However, this should be weighed against the increased risk (and cost) of a revision repair in the event that a surgical repair is performed subsequent to a corticosteroid injection.

Editorial Commentary: Arthroscopic Glenoid Reconstruction With Subscapularis Tenodesis Results in Promising Clinical Outcomes, but Concerns Regarding Graft Resorption Rates Persist: A Long Way Toward a More Perfect Union.

The pros and cons of open and arthroscopic shoulder stabilization procedures have been studied exhaustively. Yet, in many situations, the rates of recurrent instability and overall complications associated with these techniques remain unacceptably high. Perhaps paradoxically, the refinement of arthroscopic shoulder stabilization techniques has only intensified the debate between proponents of either open or arthroscopic approaches, and although significant (however "significant" is defined), anteroinferior glenoid bone loss has historically been thought to constitute a relatively strong indication for an open bone augmentation procedure, surgeons, to their great credit, continue to push the limits of what can be accomplished arthroscopically. Arthroscopic glenoid reconstruction has emerged as a viable option that may represent "the best of both worlds." Although modifications to the originally described arthroscopic glenoid reconstruction technique are promising, concerns persist regarding the fate of the graft and the durability of the procedure beyond short-term follow-up.

Platelet-Rich Plasma: Fundamentals and Clinical Applications.

Platelet-rich plasma (PRP) is perhaps the most widely studied of the biologic therapies, with an ever-growing body of evidence supporting its safety and efficacy in decreasing inflammation and pain and promoting healing in the setting of both nonoperative and operative treatments. PRP is produced by the centrifugation of whole blood, isolating its constituent parts based on their unique densities. These density gradients can be selectively harvested so as to obtain different concentrations of various blood product components, such as platelets and leukocytes. A precise and consistent method for describing the essential characteristics of different PRP formulations is critical for both practical and research purposes. The concentration of platelets, method of activation, and the total number of red blood cells (RBCs), white blood cells (WBCs), and neutrophils relative to baseline values are all of particular importance in accurately describing a PRP formulation. The biologic activity of PRP is manifold: platelet α granules promote the release of various growth factors, including vascular endothelial growth factor and tissue growth factor ß, while inflammation is modulated through inhibition of the nuclear factor-κB pathway. PRP has been convincingly shown to be efficacious in the setting of patellar tendinopathies, knee osteoarthritis, and lateral epicondylitis. In fact, several recent randomized controlled trials have demonstrated the superiority of PRP over both corticosteroids and hyaluronic acid in treating knee OA-related symptoms. There is also substantial promise for the utility of PRP in treating partial hamstring tears and as an adjunct to rotator cuff (RC) repair, especially in the setting of small- to medium-sized tears, where it appears to exert substantial analgesic effects and promote enhanced rates of RC repair healing.

Proximal Hamstring Tendon Injuries: Diagnosis and Management.

Proximal hamstring tendon injuries are common among active and athletic populations and exist on a spectrum ranging from proximal tendinopathy to partial tears to complete avulsions. Imaging should include plain radiography as bony avulsions have been observed in skeletally immature patients. Magnetic resonance imaging is diagnostic in the setting of both partial tears and complete tears. A high-intensity (on T2-weighted images), crescent-shaped signal at the tendon-bone interface ("sickle sign") is indicative of a partial-thickness tear of the proximal hamstring tendons. In the setting of complete avulsions, magnetic resonance imaging is also useful in demonstrating the extent of tendon avulsion and quantifying the number of tendons torn. Nonoperative treatment for proximal tendinopathy, acute partial tears, and complete tears with minimal tendon retraction includes activity modification, eccentric stretching and strengthening, and potentially platelet rich plasma injections. Surgical repair should be considered for partial tears refractory to nonoperative management, acute tears with greater than 2 cm of distal retraction, and/or chronic retracted tears. The surgical approach is generally made through a transverse incision within the gluteal crease, which can be extended distally in a "T" configuration in the setting of chronic retracted tears. In the setting of chronic retracted tears, a sciatic nerve neurolysis may be required owing to scarring. Following the surgical procedure, a graduated rehabilitation protocol is commenced with the expectation for a return to full, unrestricted activities by 6 months postoperative, and excellent outcomes can be anticipated. Compared with repair of chronic tears, acute repairs have improved functional outcomes and lower re-tear rates.