Author(s): Scott C Montgomery, Mark D Miller
Document types: General Information
Section: SPECIALTY UPDATE
Publication title: Journal of Bone and Joint Surgery. (American volume). Boston: Mar 2005. Vol. 87, Iss. 3; pg. 686, 9 pgs
Source type: Periodical
ISSN/ISBN: 00219355
It is once again an honor and a privilege to be asked to present this update for the subspecialty of sports medicine. Sports medicine continues to be an expanding subspecialty field that crosses many boundaries. As mentioned in previous updates, however, our central mission remains the same-the care of the athlete.
This update is based on scientific and organizational activities in sports medicine that took place from September 2003 to August 2004. It includes a summary of the Annual and Specialty Day Meetings of the American Orthopaedic Society for Sports Medicine (AOSSM), the Arthroscopy Association of North America (AANA), and the American Academy of Orthopaedic Surgeons (AAOS). These meetings featured more than 200 scientific presentations, including both clinical and basic-science studies, that focused primarily on sports medicine.
The three most influential journals in our field will be reviewed again this year, specifically, The Journal of Bone and joint Surgery, The American Journal of Sports Medicine, and Arthroscopy.
The Knee
Anterior Cruciate Ligament
The optimum graft choice for anterior cruciate ligament reconstruction remains controversial. Several recent randomized, controlled studies showed equivalent results in association with both bone-patellar tendon-bone and quadrupled hamstring grafts, effectively endorsing a "double gold standard." An additional randomized, prospective trial from Australia showed satisfactory functional outcomes in association with both types of grafts after three years of follow-up1. As in other studies, however, the authors noted increased kneeling pain in the bone-patellar tendon-bone group and slightly increased laxity and femoral tunnel widening in the hamstring group. Recent histological studies have shown that neither type of graft regenerates to a normal functional tendon. In two independent studies involving the use of magnetic resonance imaging and ultrasound examination following bone-patellar tendon-bone graft harvest, the patellar tendon had not normalized by six to ten years postoperativel2,3. Both groups of authors concluded that reharvesting the graft was not recommended. In a separate animal study, the hamstring tendons were noted to regenerate by nine to twelve months, but with inferior biomechanical and histological characteristics4.
A number of recent cadaveric studies critically examined steps in the surgical technique for anterior cruciate ligament reconstruction in an attempt to draw conclusions regarding clinical outcomes. Methods for the fixation of both soft-tissue and bone-patellar tendon-bone grafts were critically examined. A high-stiffness graft construct (resulting in better fixation) was noted to be important for postoperative stability because it allowed for less graft tension5. The authors of two separate cadaveric studies concluded that both twisting and braiding reduced the initial strength and stiffness of quadrupled hamstring grafts6,7. In contrast, in the same issue of The American Journal of Sports Medicine, the authors of a third study concluded that graft rotation of as much as 540° did not result in the loss of initial strength of bone-patellar tendon-bone grafts and may be a solution for graft-tunnel mismatch8. The authors of a two-part study concluded that the initial fixation strength of a doubled tibialis anterior tendon graft was not increased in association with the use of serial dilators over extraction-drilled bone tunnels, and thus they did not recommend the use of dilation. Also, that same group of investigators concluded that preconditioning of soft-tissue anterior cruciate ligament grafts could not eliminate the intrinsic viscoelasticity, and thus they challenged the necessity of preconditioning.
A great deal of research has focused on risk factors and gender issues related to noncontact anterior cruciate ligament injuries. The findings of a prospective cohort study of cadets entering the United States Military Academy agreed with the findings of previous studies supporting the multifactorial nature of noncontact anterior cruciate ligament injuries, including small femoral notch width, generalized ligamentous laxity, higher body-mass index, and female gender9. Female athletes traditionally have landed from a jump with the knee in extension and valgus angulation as compared with their male counterparts. Neuromuscular training has resulted in lower injury rates as reported in several papers and podium presentations. One study involving three-dimensional kinematic testing showed that female athletes change the way that they land from a jump following the onset of the pubertal growth spurt, possibly contributing to the increased susceptibility to anterior cruciate ligament tears10. Another study suggested that quadriceps loading was the key intrinsic force associated with these noncontact injuries. Prophylactic knee bracing following anterior cruciate ligament reconstruction has not previously been found to be effective. One recent study that was presented at the 2004 Annual Meeting of the AAOS, however, suggested that post-operative bracing may reduce the rate of reinjury in skiers.
The care of skeletally immature athletes who have anterior cruciate ligament injuries continues to be a source of considerable controversy. While previous studies have demonstrated that a delay in surgical treatment is associated with a higher prevalence of medial meniscal tears, a more recent study showed encouraging results when reconstruction was delayed until within one month before physeal closure. Although the numbers in the study were small, the authors found no increase in the rate of additional knee injuries and concluded that absolute activity restriction was the key. Other authors have advocated a more aggressive approach. Several studies have challenged the traditional recommendation of using a soft-tissue graft and avoiding drilling across the femoral physis. Two recent studies by the same authors showed good results in association with the use of hamstring autograft with a partial physeal sparing technique for the management of Tanner stage-2 and 3 children and with a complete physeal sparing technique for the management of Tanner stage-1 preadolescent children. No angular deformity or limb-length discrepancy was noted at the time of skeletal maturity in either group. The authors of one recent study concluded that good results could be obtained in association with transphyseal reconstruction of the anterior cruciate ligament with use of a bone-patellar tendon-bone autograft in Tanner stage-3 and 4 children11. Particular care was taken to ensure that the bone plug was not within the physis. No angular deformity or limb-length discrepancy was noted at the time of skeletal maturity, although hip-to-ankle standing radiographs were not examined in that study.
Several recent studies have improved our understanding of the natural history of the anterior cruciate ligamentdeficient knee. Two dynamic magnetic resonance imaging studies confirmed that there is greater anterior subluxation of the lateral tibial plateau than of the medial tibial plateau in the anterior cruciate ligament-deficient knee, which could lead to future degenerative changes. One gait-analysis study showed that a valgus shoe wedge could prevent the lateralthrust gait associated with the anterior cruciate ligament-deficient knee.
Assessing the success of anterior cruciate ligament reconstruction surgery postoperatively continues to be an important focus of research. The authors of one recent study examined the correlation between objective and subjective measurements and concluded that the pivot-shift examination was a better measure of "functional instability" than the Lachman and instrumented knee laxity examinations following reconstructive surgery12. In a recent study published in The Journal of Bone and Joint Surgery, four-strand hamstring reconstruction was associated with good functional results at two years despite an 11% failure rate as determined on the basis of objective measurements13. The authors concluded that the findings of instrumented knee examinations do not correlate with functional knee scores postoperatively. The authors of two separate studies concluded that anterior cruciate ligament reconstruction failed to restore normal tibiofemoral knee kinematics. In one study, dynamic magnetic resonance imaging demonstrated that the lateral side of the tibia was 5 mm more anterior than the medial side at all flexion angles. In the other study, stereoradiographs demonstrated that the reconstructed knees of downhill runners were externally rotated and adducted more than those of controls at all time-points. In both studies, anterior-posterior laxity was reduced to within normal limits but rotation was not. The long-term consequences of these findings are unknown.
Several new trends have appeared in the recent literature. Two studies showed that growth factors positively influenced the healing and structural properties of both soft-tissue and bone-patellar tendon-bone grafts. Additionally, bone-marrow stromal cells were shown to improve tendon-to-bone healing in an animal model. A retrospective study of a small number of patients managed with bilateral anterior cruciate ligament reconstruction showed no difference with regard to return to functional and objective measurements as compared with the findings for patients managed with unilateral reconstruction14. The authors concluded that bilateral reconstruction was a safe and cost-effective approach. Other studies have demonstrated that thermal shrinkage of "partial" cruciate ligament tears or loose grafts can have catastrophic results.
Other Knee Ligaments
Posterior cruciate ligament and posterolateral corner injuries continue to be sources of research interest, perhaps because of their unique clinical presentations. Isolated posterior cruciate ligament injuries are still best treated nonoperatively. Combined ligament injuries involving either cruciate ligament and the posterolateral corner are a strong indication for surgery as late instability and poor results have been reported following nonoperative treatment. One study that was presented at the 2004 Annual Meeting of the AAOS demonstrated superior results in association with the use of posterolateral corner reconstruction rather than primary repair for the treatment of acute injuries15. While the ideal reconstruction technique for posterior cruciate ligament injuries remains controversial, clinical and biomechanical support for both the transtibial and tibial inlay methods continues to appear in the literature. Although the results of earlier studies suggested that the tibial inlay method was superior to the transtibial technique, the authors of a recent biomechanical study found no difference, with both methods restoring posterior tibial translation to within 1.5 to 2 mm16. Another biomechanical study suggested that the "effective graft length" played a role, with shorter grafts being stiffer, thus supporting the use of inlay-type grafts. One recent clinical study involving the use of a tibial inlay technique with a single-bundle femoral tunnel showed good results after two to ten years of follow-up17. Long-term results are not yet known. Posterior cruciate ligament deficiency significantly increases patellofemoral contact pressures as shown in a study that was published in The American Journal of Sports Medicine18. The authors found that contact pressures did not significantly change after posterior cruciate reconstruction, suggesting that long-term degenerative disease would likely result despite reconstruction.
Knee dislocations are devastating injuries that usually result from high-energy trauma. The recommended treatment for these injuries continues to be early operative management. A recent cadaveric study emphasized the difficulty of properly tensioning the cruciate ligaments during a multiple-ligament reconstruction. The authors of an intermediate-term follow-up study concluded that patients who had been managed within three weeks after a dislocation had higher subjective scores and better objective restoration of knee stability than did those who had had delayed treatment. The return to high-demand activities is much more variable following multiple-ligament reconstruction than it is following other types of knee reconstructions19.
Meniscal Tears
Meniscal tears can be grouped into two types-acute tears in young patients and degenerative tears in older patients. The first type of tear is often associated with other intra-articular knee abnormalities and is more amenable to repair. Degenerative tears, on the other hand, are better treated with observation and partial meniscectomy if mechanical symptoms are present. The results of a recent randomized study showed increased accuracy in the detection of recurrent meniscal tears with use of either intravenous or intra-articular contrast-enhanced magnetic resonance imaging as compared with plain magnetic resonance imaging20.
Meniscal repair is strongly recommended for patients undergoing a concurrent anterior cruciate ligament reconstruction. Recently, however, a nonrandomized nine-year follow-up study showed no improvement in the outcomes for young, active patients managed with anterior cruciate ligament reconstruction along with a meniscal repair as compared with those for patients managed with partial meniscectomy21. The authors still recommended repair if possible. They suggested, however, that some menisci will not function normally despite healing. The authors of another recent study concluded that repeat meniscal repair was successful in 72% of patients after seven years of follow-up22. Although many new repair devices are available, the gold standard remains the vertical mattress suture. Recent studies have suggested that the newer-design, flexible, all-inside anchors (FastT-Fix [Smith and Nephew Endoscopy, Andover, Massachusetts] and Rapid Loc [DePuy Mitek, Norwood, Massachusetts] ) allowed tensioning and were comparable with conventional vertical suture techniques. A recent prospective study showed that Meniscal Arrows (formerly manufactured by Bionix, Blue Bell, Pennsylvania, and now manufactured by Linvatec, Largo, Florida) were as effective as horizontal mattress sutures during concurrent anterior cruciate ligament reconstruction; however, the protocol called for five weeks of non-weight-bearing. Despite good early results in association with the all-inside devices, there is still concern with regard to long-term chondral damage, especially in patients with smaller or tighter knees23. The use of a fibrin clot for meniscal repairs is still recommended, and recent data have shown improvement in the healing of tears in even the avascular zone with the addition of autologous chondrocytes or growth factors.
Meniscal transplantation is a salvage operation that is indicated for young patients with substantial compromise of the existing meniscus or those who have had a total meniscectomy. Two recent studies demonstrated that this procedure was associated with encouraging intermediate-term results in terms of the reduction of knee pain and the improvement of function24,25. The authors showed acceptable results even in patients managed with concomitant osteochondral autograft transfer and knee ligament reconstruction, but they stressed proper selection in this difficult population. Graft shrinkage, displacement, and tearing continue to be a clinical challenge at the time of intermediate-term follow-up.
Articular Cartilage Injuries
The treatment of focal articular cartilage defects remains a hot topic in sports medicine. Options include microfracture, osteochondral autograft cylinder (plug) transfer, autologous cartilage implantation, and the use of allografts. A recent randomized, multicenter study from Europe showed no difference with regard to clinical, macroscopic, or histological results, after two years of follow-up, between patients managed with microfracture and those managed with autologous chondrocyte implantation26. One study of autologous chondrocyte implantation demonstrated good healing despite a sequential decrease in the number of chondrocytes in the defect27. The authors questioned the role of chondrocytes in the formation of repair tissue. No consensus exists with regard to the best treatment of these injuries, and factors such as cost, resource utilization, and disease transmission all play a role in the discussion of treatment options.
Allograft tissue has abundant uses in orthopaedics and sports medicine, including ligament reconstruction, bone-grafting, and, more recently, osteoarticular replacement. Recent studies have examined the viability and safety of this tissue. Three recent studies examined chondrocyte viability in fresh osteoarticular allografts and showed that chondrocyte viability decreased significantly within as few as fourteen days, with structural properties declining more slowly over a period of sixty days. Another study showed a 26% decrease in chondrocyte viability after seventeen days and a 48% decrease after forty-two days. The authors of a study on the safety of allograft tissue concluded that freeze-drying of retroviral-infected cortical bone and tendon did not inactivate retrovirus28.
Other Knee Problems
Injections continue to be a mainstay of nonoperative treatment of early osteoarthritis of the knee. A recent meta-analysis of randomized, controlled trials that was published in The Journal of Bone and Joint Surgery confirmed the therapeutic efficacy and safety of intra-articular injections of hyaluronic acid for the treatment of osteoarthritis of the knee29. Other studies have suggested that hyaluronic acid injections offer no advantage compared with corticosteroid injections.
One recent cadaveric study demonstrated that increasing tibial slope by means of osteotomy may be beneficial for reducing tibial sag in a posterior cruciate ligament-deficient knee, whereas decreasing tibial slope may be protective in an anterior cruciate ligament-deficient knee30. Small changes in slope were not found to have an effect on sagittal plane translation.
Patellofemoral problems continue to be difficult to treat. The authors of one recent study noted that the effect of bracing was to reduce patellofemoral stress by increasing the patello-femoral contact area. A kinematic magnetic resonance imaging study indicated that the beneficial effects of McConnell medial glide taping may be related to factors other than altered patellar alignment31.
The Hip
Athletic pubalgia (chronic groin pain on exertion) can be difficult to diagnose and treat in young, active patients. A common finding in patients who are not responding to nonoperative treatment is a deficiency of the posterior wall of the inguinal canal. In a recent study, 131 athletes with groin pain that remained unrelieved after two to eight months of nonoperative treatment underwent laparoscopy32. All of the athletes were found to have a deficiency in the posterior wall of the inguinal canal, which was repaired laparoscopically. The average time to return to play was two to three weeks, and only one patient had had a recurrence at the time of the five-year follow-up.
Coxa saltans (snapping hip syndrome) can be either external or internal and can affect athletes. External snapping hip typically is caused by a tight iliotibial band and usually can be treated with physical therapy alone. Surgical z-plasty of the iliotibial band is rarely necessary, but one recent study demonstrated that good, predictable results can be achieved in properly selected patients33. Internal snapping hip results from a tight iliopsoas tendon and usually responds favorably to nonoperative therapy. Primary iliopsoas lengthening for the treatment of refractory cases has been associated with good clinical results but also has been associated with a high (40%) rate of complications14.
The Ankle and Foot
Achilles tendinopathy typically is treated with nonoperative modalities before surgery is considered. The use of corticosteroid injections into or around the Achilles tendon remains controversial. One recent animal study suggested that the injection of corticosteroid into the Achilles tendon or even into the retrocalcaneal bursa could weaken the tendon and should be done with caution. The same study strongly warned against bilateral injections because the systemic effect could further weaken the tendon. The authors of a three-year clinical follow-up study concluded that low-volume, fluoroscopically guided injections into the peritendinous space of the Achilles tendon was safe and effective35.
The treatment of acute Achilles tendon ruptures remains controversial. Although studies have shown a higher rate of rerupture in association with nonoperative treatment and although current recommendations favor primary operative repair, several groups have reported encouraging results, with a good rate of early return to activity and an acceptably low rate of rerupture, in association with a strict nonoperative protocol. Another group of investigators reported that acute primary repair of Achilles tendon ruptures followed by early weight-bearing was associated with shorter rehabilitation times without compromising the outcome36.The current trend following primary repair is toward early range of motion and weight-bearing.
Traumatic plantar fascia rupture is a rare injury that is most often seen in running athletes, but it can occur in athletes who participate in jumping sports as well. In a recent study, patients were managed with non-weight-bearing in a below-theknee cast for two to three weeks followed by weight-bearing in a boot for an additional two to three weeks37. The mean time to return to activities was nine weeks, and no reruptures were noted in any of the eighteen patients after 3.5 years of follow-up. Plantar fasciitis usually responds to a stretching program. Use of extracorporeal shock-wave treatment is gaining popularity for the treatment of refractory cases.
The Shoulder
Instability and Labral Tears
The diagnosis and treatment of the unstable shoulder has evolved with recent advances in imaging methods, implants, and arthroscopic techniques. A study assessing the validity of various physical examination tests demonstrated that anterior instability is most accurately diagnosed on the basis of a combination of positive results on the apprehension test, the relocation test, and the surprise test (apprehension after releasing the posterior force from a relocation test)38. The pitfalls associated with the use of magnetic resonance imaging for the evaluation of elite overhead athletes were recently explored in a study of individuals with asymptomatic shoulders39. In that study, 40% of dominant shoulders had evidence of a partial or full-thickness rotator cuff tear and 25% had a posterior-superior ossification (a Bennett lesion) but no shoulder-related problems developed in any of the patients during the subsequent five-year period. The authors concluded that magnetic resonance imaging alone should not be used to diagnose shoulder abnormalities in this asymptomatic population.
The treatment of a first-time traumatic anterior dislocation remains controversial. A recent four-year follow-up study showed a recurrence rate of as high as 75% in the eleven to eighteen-year-old age-group. Although it has been noted that the rate of recurrence increases with younger age at the time of presentation, the current trend is still toward nonoperative treatment unless recurrent instability is experienced. Recent studies from Japan have suggested that early immobilization of the shoulder in external rotation may reduce the prevalence of recurrent instability. One recent five-year follow-up study compared open capsulolabral repairs with arthroscopic repairs involving transglenoid sutures40. Among athletes involved in contact sports, a higher rate of redislocation was noted in shoulders that had been treated with arthroscopic repair whereas decreased external rotation was noted in shoulders that had been treated with open repair. The decrease in external rotation in the open-treatment group was echoed by the findings of a prospective, randomized study that was published in Arthroscopy41. In that study, the arthroscopically treated group did not have a higher redislocation rate; however, suture anchors were used, the patients were not athletes involved in contact sports, and the duration of follow-up was only two years. Accelerated rehabilitation following Bankart repair was described in a recent study of nonathletes, with the investigators reporting an increased return to activities and no change in intermediate-term outcomes.
The diagnosis and treatment of atraumatic multidirectional instability remains a challenge. Recent research has demonstrated that the criteria used for the diagnosis of multidirectional instability and the use of laxity testing vary greatly from study to study, making uniform treatment recommendations difficult and comparisons between outcomes less valid42. According to one study, the surgical repair of instability can significantly improve the proprioception of the affected and contralateral shoulders43. Numerous studies have highlighted the unacceptably high failure rate associated with the use of thermal capsulorrhaphy alone for the surgical treatment of this instability. One recent follow-up study demonstrated a 17% rate of recurrence and a 50% rate of inability to return to previous levels of overhead activity following thermal capsulorrhaphy44. Reports of capsular necrosis and severe chondrolysis following thermal capsulorrhaphy are even more concerning. The current trend is away from the use of thermal capsulorrhaphy in patients with atraumatic instability. The use of arthroscopic suture plication for the treatment of atraumatic instability has been associated with good early results. There has been a renewed interest in the role of the rotator interval in instability. While many authors have recommended routine arthroscopic closure for all cases of instability, there is still concern about restricted motion in patients managed with selective capsulorrhaphy. Just as instability exists along a spectrum ranging from asymptomatic to clinically debilitating, no absolute values can be given for how much capsular volume should be reduced. Avoiding both overtightening and undertightening of the capsule remains a critical challenge for the surgeon.
Internal impingement in the throwing athlete generally is believed to be related to either posterior capsular contraction or anterior capsular laxity. Initial treatment should include posterior capsular stretching, particularly in patients with limited internal rotation (glenohumeral internal rotation deficit [GIRD]). Operative treatment remains controversial, with one group recommending posterior capsular release and the other recommending anterior plication or thermal capsulorrhaphy.
The diagnosis of SLAP tears (tears of the superior portion of the labrum from anterior to posterior) with use of current imaging and physical examination techniques continues to be a challenge. One recent study described an anatomic variation that is characterized by articular cartilage over the superior glenoid tubercle and a mobile labrum overlying intact cartilage45. The authors noted that this variation is not an indication for surgical repair.
A recent cadaveric study demonstrated that the initial fixation strength of bioabsorbable tacks was comparable with that of metal suture anchors46. According to another study, the angle of suture anchor placement in the glenoid rim should be within 20° of orthogonal to the rim and at 30° to the articular surface in order to maximize pull-out strength46. According to that same study, the anterior-inferior quadrant (the area of Bankart repair) is the most critical area for anchor stability because it has the weakest bone. Another study presented at the 2004 Annual Meeting of the AAOS suggested that better results can be achieved in association with fixation that avoids placing portals through the rotator cuff and involves the rotator interval instead. Finally, arthroscopic decompression of spinoglenoid ganglion cysts was reported to be successful in a paper that was presented at the 2004 AOSSM Specialty Day.
Rotator Cuff Injuries
Impingement and rotator cuff pathology comprise a substantial percentage of the lesions associated with shoulder pain that are seen by sports medicine physicians. Arthroscopic subacromial decompression continues to be a safe and reliable method for reducing impingement and for allowing sufficient space for the irritated or torn rotator cuff tendons to function. However, there is still debate about whether routine subacromial decompression is needed for every patient who is managed with rotator cuff repair.
Rotator cuff tears can be diagnosed both clinically and with use of imaging. A recent study showed that magnetic resonance imaging and ultrasound were associated with similar efficacy for the diagnosis of partial and full-thickness cuff tears by experienced technicians47. Ultrasound was found to be as effective as magnetic resonance imaging for determining tear size and thus can be useful if contraindications to magnetic resonance imaging are present. The use of ultrasound continues to be more popular in Europe.
There continues to be a strong push to transition from open to mini-open to arthroscopic rotator cuff repair. The advantages of the mini-open approach include less trauma to the anterior part of the deltoid, which can result in less atrophy and a quicker recovery but at the expense of visualization. The advantages of the all-arthroscopic approach include better visualization and mobilization of retracted cuff tendons, decreased trauma to the deltoid, decreased postoperative pain, and quicker rehabilitation. An increasing number of large and massive rotator cuff tears associated with retraction and atrophy are being mobilized and repaired with margin convergence and interval slide techniques. Arthroscopic repairs involve the use of suture anchors and require proficiency in suture management and arthroscopic knot-tying. Arthroscopic repairs continue to be technically challenging, although implants and techniques are improving. In a recent two-year follow-up study of large and massive rotator cuff tears that were repaired arthroscopically, >90% of the patients had a retear as demonstrated with ultrasound48. Nearly all patients had an excellent early clinical result that deteriorated somewhat by two years. The long-term results of arthroscopic rotator cuff repair are still not known and must be compared with the gold standard of open repair with a double row of suture anchors or a combination of anchors and trough fixation.
Ongoing research will result in additional improvements in both suture and anchor fixation and will eliminate the weakest links in the system. A recently described arthroscopic stitch combines simple horizontal and vertical stitches and provides strength comparable with that of a modified Mason-Allen locking stitch49. According to another study, suture anchor pull-out strength can be maximized by placing anchors in the proximal anterior and middle regions of the tuberosities, which are the areas with the highest bone mineral density50. Current knotless fixation systems are in their infancy and need long-term clinical follow-up. They are part of a wave of new technology in arthroscopic surgery that needs critical evaluation before it can replace the current gold standard.
The results of rotator cuff surgery can be affected by many factors. Obesity and body-mass index are directly related to rotator cuff disease and rotator cuff surgery. Medical comorbidities have a negative impact on preoperative shoulder function and likely affect postoperative results of rotator cuff repair. Surgeon-related factors are responsible for increased readmission rates, increased operative times, and increased durations of hospitalization. One animal model showed that the timing of rotator cuff surgery could be important, with the results of earlier repairs being better than those of late repairs51.
The Elbow
Lateral Epicondylitis
In two separate randomized, double-blind, placebo-controlled trials, both topical nitric oxide and low-energy shock-wave treatment were judged to be more effective than placebo for the treatment of chronic, refractory lateral epicondylitis52,53. The findings of the latter study, which involved low-energy shock-wave treatment, were in direct contrast to those of previously published studies that have shown no effect in randomized trials. This treatment modality, although safe, remains controversial.
Medial Collateral Ligament Injuries
Ulnar collateral ligament injuries in overhead athletes continue to receive tremendous attention in the literature and the news. Reconstruction techniques include the "Tommy John" technique described by Jobe, the docking technique proposed by Altcheck, and a newer interference screw technique described by Ahmad et al. Good success rates and a high level of return to play have been reported in association with the earlier techniques. A recent report on ulnar collateral ligament injuries and subsequent reconstructions in high-school pitchers demonstrated a high percentage of risk factors for overuse in this adolescent population54. Of the patients undergoing reconstruction, 75% returned to the sport and nearly half were still playing baseball three years later.
Other Areas
Nutritional supplements and the safety issues surrounding them continue to be major issues for sports physicians and athletes alike. Supplements are still not under governmental control and yet, despite warnings and case reports of serious adverse health effects and even death, athletes continue to take ergonomic aids for their perceived performance enhancement. The authors of a recent randomized, double-blind, placebo-controlled trial concluded that patients did not benefit from creatine supplementation during the first twelve weeks of rehabilitation following anterior cruciate ligament reconstruction55.
Due to the various ways in which athletes spend their time and the inherent differences in each sport, there has been a recent increase in the number of sports-specific studies in the literature. While too numerous to detail here, articles on specific injuries, risk profiles, and/or injury rates associated with various sports (including high-school, college, and professional football; amateur and professional baseball; cheerleading; golf; marathon running; ice hockey; rugby; swimming; soccer; women's lacrosse; skiing; snowboarding; skiboarding; pommel horse gymnastics; wakeboarding; team handball; and kitesurfing) were published in major sports-related orthopaedic journals in the past year. This follows a current trend in sport-specific training accompanied by injury prevention, recognition, treatment, and rehabilitation that is likely to continue.
Evidence-Based Orthopaedics
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eight level-I articles were identified that were relevant to sports medicine. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Upcoming Meetings and Events
The Arthroscopy Association of North America (AANA) Annual Meeting will be held on May 12 through 15, 2005, in Vancouver, Canada. The American Orthopaedic Society for Sports Medicine (AOSSM) Annual Meeting will be held on July 14 through 17, 2005, in Keystone, Colorado. The next meeting of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) will be held on April 3 through 7, 2005, in Hollywood, Florida.
Sports Medicine Fellowships
Sports Medicine continues to be the most popular fellowship in orthopaedic surgery, with over one-third of all graduating residents completing a fellowship in our field. There are currently ninety-five programs with 205 fellows per year across the country along with several international fellowships. There are several controversies that inevitably arise in any discussion about fellowship selection and experience. The first major issue is accreditation through the Accreditation Council for Graduate Medical Education (ACGME), the same governing body that accredits residency programs. Most subspecialties within orthopaedics (including spine, foot and ankle, trauma, oncology, and pediatric orthopaedics) do not offer accredited fellowship positions, whereas most hand fellowships are currently accredited. Currently, just over one-half of sports medicine fellowships are accredited. Accreditation will become more of a factor in subsequent years as orthopaedic sports subspecialty certification is implemented. In the future, following a certain grandfather period, candidates will have to have completed an accredited fellowship in order to sit for the subspecialty examination. The first examination (administered by the American Board of Orthopaedic Surgery) may be scheduled as early as the fall of 2006; however, it more likely will be delayed until the following year. The AOSSM, with the assistance of an educational grant from Arthrex, is actively developing educational material for candidates to prepare for this examination.
The second area of controversy involves the fellowship match program. In previous years, the match has been coordinated by the National Residency Matching Program (NRMP). The NRMP has been widely successful for residency placement and other fellowship fields, but it has not been as successful in sports medicine. This year, the fellowship match in sports medicine has been terminated because the majority of the programs were not participating. The AOSSM is aware of the difficulties that occurred this year and in previous years and will continue to work closely with the NRMP to rectify them. Subspecialty certification will inevitably lead to changes in the match process as well. Hopefully, in future years, a single unified selection process for fellows will exist.
Evidence-Based Articles Related to Sports Medicine
Harvey GP, Chelly JE, AlSamsam T, Coupe K. Patient-controlled ropivacaine analgesia after arthroscopic subacromial decompression. Arthroscopy. 2004;20:451-5.
This was a prospective, randomized, double-blind study of a consecutive group of twenty-four patients undergoing arthroscopic subacromial decompression. Some patients underwent concurrent rotator cuff repair or distal clavicular excision. Ropivacaine was used for its long active effect and reduced cardiac toxicity as compared with bupivacaine. The use of a patient-controlled anesthesia (PCA) ropivacaine infusion (Group I) resulted in a significant (34%) reduction of postoperative pain in the first forty-eight hours postoperatively as measured with a visual analog scale (p < 0.05) but had no effect on hydrocodone consumption. The authors concluded that patient-controlled anesthesia with use of subacromial infusions of 0.2% ropivacaine provided effective postoperative pain control.
Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85:185-92.
This prospective clinical study from Germany investigated the two-year results for forty patients with an articular cartilage lesion of the femoral condyle who had been randomized to treatment with either autologous osteochondral cylinder transplantation or autologous chondrocyte implantation. Forty patients were split evenly between the two groups and were examined after a minimum duration of follow-up of two years. Biopsy specimens from representative patients from both groups were evaluated with histological staining, immunohistochemistry, and scanning electron microscopy. Both treatments resulted in a decrease in symptoms. However, the improvement provided by the autologous chondrocyte implantation lagged behind that provided by the osteochondral cylinder transplantation. Histologically, the defects treated with autologous chondrocyte implantation were primarily filled with fibrocartilage, whereas the osteochondral cylinder transplants retained their hyaline character, although there was a persistent interface between the transplant and the surrounding original cartilage. Although the study was limited by the small numbers of patients and the short duration of follow-up, the authors concluded that osteochondral cylinder transplantation is appropriate for the treatment of these defects.
Airaksinen OV, Kyrklund N, Latvala K, Kouri JP, Gronblad M, Kolari P. Efficacy of cold gel for soft tissue injuries: a prospective randomized double-blinded trial. Am J Sports Med. 2003;31:680-4.
In this prospective, randomized, double-blind study from Norway, seventy-four sports-related soft-tissue injuries were treated with a cold gel (Group I) or a placebo gel (Group II) that was applied to the skin four times daily for fourteen days. Clinical assessments were made after seven, fourteen, and twenty-eight days. The cold gel treatment was associated with significantly lower pain scores and higher patient satisfaction at all time-points. Cold gel therapy provides an effective and safe option for the treatment of sports-related soft-tissue injuries.
Meighan AA, Keating JF, Will E. Outcome after reconstruction of the anterior cruciate ligament in athletic patients. A comparison of early versus delayed surgery. J Bone Joint Surg Br. 2003;85:521-4.
In this prospective, randomized study from Scotland, patients with anterior cruciate ligament injuries were managed with either early reconstruction (within two weeks) or delayed reconstruction (within eight to twelve weeks) with use of a quadrupled hamstring graft in order to determine whether early reconstruction was associated with any functional advantages. Both groups were assessed with validated outcome measures at the time of the one-year follow-up. Although the authors found significant improvement in range of motion and quadriceps strength in the delayed-treatment group after two and twelve weeks of follow-up, they found no differences between the two groups at the time of the one-year follow-up. The authors concluded that no functional advantages are gained by early reconstruction. Although the duration of follow-up was short, the study design was good.
Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. 2003;31:268-75.
In this study from Germany, forty-five running athletes who had had intractable plantar heel pain for more than twelve months were randomized into two groups. One group received three applications of 2100 impulses of low-energy shock waves, and the other group received sham treatment. At six and twelve months of follow-up, there was significantly greater improvement in the visual analog scores for pain in the group that had received low-energy shock-wave therapy. The authors concluded that low-energy shock waves are safe and effective for the management of this population. The findings of this study add support to the use of shock-wave therapy for runners with chronic plantar fasciitis.
Otsuka H, Ishibashi Y, Tsuda E, Sasaki K, Toh S. Comparison of three techniques of anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Differences in anterior tibial translation and tunnel enlargement with each technique. Am J Sports Med. 2003;31:282-8.
In this prospective cohort study from Japan, sixty patients were randomized into three groups: a nonanatomic fixation group, an anatomic fixation group with outside-in fixation (with bone plug grafted into the tibial tunnel), and an anatomic fixation group with all-inside fixation. At the time of the two-year follow-up, there were no differences in clinical stability or outcome among the three groups. There was a decrease in tibial tunnel enlargement on postoperative radiographs in the anatomic fixation groups. The authors concluded that although the tibial tunnel was more enlarged in the nonanatomic fixation group, it had no clinical effect on knee stability at the time of the two-year follow-up.
Turbeville SD, Cowan LD, Owen WL, Asal NR, Anderson MA. Risk factors for injury in high school football players. Am J Sports Med. 2003;31:974-80.
In this two-year prospective investigation of risk factors for injury in 717 high-school football players in the Oklahoma City, Oklahoma, School District, the authors found that physical characteristics such as body-mass index and strength were not associated with a risk of injury. Both increased playing experience and a history of injury in the previous season were significantly associated with increased risk. Notably, linemen were at the highest risk of injury, especially knee injury and season-ending injury. The findings of this study can help us to better understand the injury patterns and prevention strategies for this group of young athletes.
Dhawan A, Doukas WC, Papazis JA, Scoville CR. Effect of drain use in the early postoperative period after arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Am J Sports Med. 2003;31:419-24.
In this prospective, randomized clinical trial, twenty-one patients who had been managed with bone-patellar tendon-bone anterior cruciate ligament reconstruction were managed either with a drain for twenty-four hours or with no drain. The authors found that the use of a drain provided no benefits in terms of range of motion, effusion, or pain-control, and, therefore, they did not recommend such treatment.
[Reference]
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[Author Affiliation]
BY SCOTT C. MONTGOMERY, MD, AND MARK D. MILLER, MD
Investigation performed at the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
[Author Affiliation]
Scott C. Montgomery, MD
Mark D. Miller, MD
Department of Orthopaedic Surgery, McCue Center, University of Virginia, P.O. Box 800243, Charlottesville, VA 22908. E-mail address for S.C. Montgomery: sm6rd@hscmail.mcc.virginia.edu. E-mail address for M.D. Miller: mdm3p@hscmail.mcc.virginia.edu
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
doi:10.2106/JBJS.D.02789

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