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Editorial Commentary: Shoulder Glenoid Suture Anchor Insertion Depth: The Tip of an Iceberg

      Abstract

      The term “translational research” means that the results of a bench-top analysis could quickly be applied, or translated, to the clinical setting. Nevertheless, cadaveric analysis is applicable primarily to the conditions tested. Care should be taken to consider that when it comes to investigation of shoulder glenoid suture anchor insertion, there are many variables and outcome measures to consider.
      It is with great pleasure that I comment on the article “Slight Reduction in the Insertion Depth for an All-Suture Anchor Decreases Cyclic Displacement in the Shoulder Glenoid” by Ruder, Dickinson, Habet, Peindl, D'Alessandro, and Fleischli.
      • Ruder J.A.
      • Dickinson E.Y.
      • Habet N.
      • Peindl R.D.
      • D'Alessandro D.F.
      • Fleischli J.E.
      Slight reduction in the insertion depth for an all-suture anchor decreases cyclic displacement in the shoulder glenoid.
      This cadaveric study is an excellent example of translational research, because the results of the bench study could quickly translate to the clinical setting.
      • Brand J.C.
      • Rossi M.J.
      • Lubowitz J.H.
      Award winning research recognized.
      Readers who use all-suture anchors might quickly change their clinical practice after reading this article, while bearing in mind the limitations of the study that are well noted by the authors: mean age of the cadaveric specimens of 58 years, nonaqueous room-temperature conditions, testing of only one type of all-suture anchor, and potential variability in the force of hand setting of the suture anchors. And as always, future research is required to validate our literature.
      What I really like about this article is that it well exemplifies the precision of arthroscopic and related surgeons. Millimeters matter, and hypothesis-driven research performed with a goal of achieving incremental improvements in our outcomes is a point of pride. And more than a point of pride, the goal of continuous quality improvement is egosyntonic (harmonious with an individual's needs) for surgeons. Whether or not surgeons conduct formal research for publication, we are always tweaking our techniques and testing hypotheses (whether knowingly or subconsciously) to make things better for patients. Rather than simply following “manufacturers' recommended settings” (or other recommendations), we improve our outcomes by trial and error.
      The article also illustrates a challenge of science, in general, and of clinical medicine in particular. Variables abound, as do measures of outcome. When it comes to the optimal insertion depth of an anchor, any anchor,
      • Barber F.A.
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      • Hapa O.
      • Horoz L.
      • Barber F.A.
      • Hüsemoğlu B.
      • Özkan M.
      • Havitçioğlu H.
      Suture anchor fixation in osteoporotic bone: A biomechanical study in an ovine model.
      • McCullough P.C.
      • Jones H.L.
      • Lue J.
      • Parekh J.
      • Noble P.C.
      What is the optimal minimum penetration depth for “all-inside” meniscal repairs?.
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      • et al.
      Biomechanical performance of hip labral repair techniques.
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      we strive to translate the results of laboratory analysis (or generalize the results of clinical research or experience) to the one single individual we are treating, and one single anchor we are inserting at that moment.
      With regard to the insertion depth of all-suture anchors investigated by Ruder et al.,
      • Ruder J.A.
      • Dickinson E.Y.
      • Habet N.
      • Peindl R.D.
      • D'Alessandro D.F.
      • Fleischli J.E.
      Slight reduction in the insertion depth for an all-suture anchor decreases cyclic displacement in the shoulder glenoid.
      the primary outcome measure is cyclic displacement, but also investigated is ultimate pullout strength and mode of failure, and these results are affected by variables including, but not limited to, the anchor, the cancellous and cortical bone density, the cortical bone thickness, the force applied when setting the anchor, the location of anchor placement around the glenoid rim, the angle of anchor insertion, and the depth of anchor insertion, which is predicated on, but not entirely determined, by the critical independent variable tested by Ruder et al., that is, the depth of drill insertion. Moreover, the conclusion of the study is affected by the authors' definition of both clinical failure (3 mm and/or 5 mm of anchor displacement) and catastrophic failure, and practically speaking, the authors base their conclusion on a “compromise between minimizing false deployment of the anchors and maximizing the biomechanical properties in terms of ultimate failure and displacement with cyclic loading.” Altered “compromises” could lead to “slight,”
      • Ruder J.A.
      • Dickinson E.Y.
      • Habet N.
      • Peindl R.D.
      • D'Alessandro D.F.
      • Fleischli J.E.
      Slight reduction in the insertion depth for an all-suture anchor decreases cyclic displacement in the shoulder glenoid.
      to quote from the article title, differences in the conclusion.
      Readers, catch your breath.
      My point is that the focus throughout Ruder et al. on “insertion depth” and “cyclic displacement” is just the tip of the iceberg. It is one thing to read that 17-mm drill depth could be better than 21 mm for all-suture glenoid anchors. It is another to change one's clinical practice. It is fortunate for our patients that surgeons read journals, test hypotheses, and thoughtfully consider thought-provoking research, and most of all are trained to question, rather than adhere, to doctrinaire tenets and teachings, whether recommended by a manufacturer or published in Arthroscopy. That said, it seems that under the circumstances tested, “Slight Reduction in the Insertion Depth for an All-Suture Anchor” definitely “Decreases Cyclic Displacement in the Shoulder Glenoid.”
      • Ruder J.A.
      • Dickinson E.Y.
      • Habet N.
      • Peindl R.D.
      • D'Alessandro D.F.
      • Fleischli J.E.
      Slight reduction in the insertion depth for an all-suture anchor decreases cyclic displacement in the shoulder glenoid.

      Supplementary Data

      References

        • Ruder J.A.
        • Dickinson E.Y.
        • Habet N.
        • Peindl R.D.
        • D'Alessandro D.F.
        • Fleischli J.E.
        Slight reduction in the insertion depth for an all-suture anchor decreases cyclic displacement in the shoulder glenoid.
        Arthroscopy. 2018; 34: 1384-1390
        • Brand J.C.
        • Rossi M.J.
        • Lubowitz J.H.
        Award winning research recognized.
        Arthroscopy. 2018; 34: 1-4
        • Barber F.A.
        Editorial commentary: Feeling the pressure! A biomechanical analysis of all-inside and inside-out knee meniscus repair.
        Arthroscopy. 2017; 33: 1849-1851
        • Hapa O.
        • Horoz L.
        • Barber F.A.
        • Hüsemoğlu B.
        • Özkan M.
        • Havitçioğlu H.
        Suture anchor fixation in osteoporotic bone: A biomechanical study in an ovine model.
        Arthroscopy. 2017; 33: 68-74
        • McCullough P.C.
        • Jones H.L.
        • Lue J.
        • Parekh J.
        • Noble P.C.
        What is the optimal minimum penetration depth for “all-inside” meniscal repairs?.
        Arthroscopy. 2016; 32: 1624-1630
        • Hapa O.
        • Barber F.A.
        • Başçı O.
        • et al.
        Biomechanical performance of hip labral repair techniques.
        Arthroscopy. 2016; 32: 1010-1016
        • Schon J.M.
        • Katthagen J.C.
        • Dupre C.N.
        • et al.
        Quantitative and computed tomography anatomic analysis of glenoid fixation for superior capsule reconstruction: A cadaveric study.
        Arthroscopy. 2017; 33: 1131-1137

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