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© 2001 The Journal of Bone and Joint Surgery, Inc.
What's New in Sports Medicine?Over the past thirty years, the subspecialty of sports medicine has evolved into a major component of the practice of orthopaedic surgery. Since its genesis in the early 1970s, sports medicine has evolved from the province of a small group of orthopaedists covering athletic teams into a major body of knowledge fueled by clinicians, scientists, and industry. Well-established educational curricula defining and prioritizing all areas of sports medicine now exist at the resident, fellowship, and subspecialty-society levels. The purpose of this article is to review and to put into perspective recent scientific and educational advancements in sports medicine. This overview is based on papers presented in 2000 at both the annual and subspecialty meetings of the American Orthopaedic Society for Sports Medicine (AOSSM), the Arthroscopy Association of North America (AANA), the Orthopaedic Research Society (ORS), and the American Academy of Orthopaedic Surgeons (AAOS). Papers published from September 1999 through August 2000 in the American Journal of Sports Medicine (six volumes), Arthroscopy (twelve volumes), and The Journal of Bone and Joint Surgery (twelve volumes) are reviewed, and their major contributions to orthopaedic sports medicine are summarized. This general overview of papers and presentations is followed by a summary of new developments in the study of the knee and shoulder as well as in other aspects of sports medicine, a discussion of emerging technologies in basic-science research, and an update on educational and socioeconomic issues. The Year in Review Between September 1999 and August 2000, research in orthopaedic sports medicine was featured in over 250 oral presentations at the annual and Specialty Day meetings of the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, the Orthopaedic Research Society, and the American Academy of Orthopaedic Surgeons. Almost two-thirds of the studies focused on surgical techniques or clinical outcomes data, with just over a third focusing on basic-science research. Sixteen (less than 11%) of more than 150 clinical presentations were identified as prospective studies. There is little question that the long-term clinical relevance of these findings will be strengthened as the specialty more widely integrates prospective studies. The knee joint continues to dominate these meetings, although an increasing emphasis on the shoulder is apparent. Studies on sports-related injuries involving the elbow, ankle, neck, spine, and head are appearing more frequently, but these structures still do not receive the amount of attention that the knee and shoulder do. The knee has remained the forerunner in the published literature as well, with approximately two-thirds of the more than 150 sports-medicine manuscripts published in The Journal of Bone and Joint Surgery, the American Journal of Sports Medicine, and Arthroscopy featuring the knee. Of these, 60% were clinical investigations and 40% were basic-science articles. What's New in the Knee The anterior cruciate ligament continues to dominate the peer-reviewed sports-medicine literature. Almost one-half of the oral presentations and published manuscripts in the American Journal of Sports Medicine and Arthroscopy involved the anterior cruciate ligament or anterior cruciate ligament reconstruction. Meniscal and articular cartilage are also gaining attention. On the other hand, the posterior cruciate ligament, medial collateral ligament, and posterolateral corner continue to receive less coverage. This is most likely due to their relatively lower frequency of injury as well as a lack of industry interest. Industry has successfully generated a myriad of approaches to anterior cruciate ligament reconstruction. However, in the absence of more in-depth randomized trials, it is difficult for the orthopaedic surgeon to determine which approaches will have a lasting impact. The typical scenario seems to be that a busy orthopaedic sports-medicine surgeon with a "new" idea approaches (or is approached by) an equipment company. A "new device" is invented, stock options are offered, and public relations is provided by the company. "Scientific" studies are conducted, and, "presto-change-o", we have the best anterior cruciate ligament replacement without the support of clinical outcomes research. This is especially common in association with anterior cruciate-ligament graft fixation devices. As orthopaedic surgeons, we tend to focus on initial fixation strength instead of crucial factors such as the relationship between graft tension and remodeling. The ultimate success or failure of a graft replacement hinges on more complex issues than the type of fixation device that was used. Only through sound basic-science studies followed by prospective, randomized trials with five to ten years of follow-up will we achieve a full understanding of these issues. One major step toward the goal of standardizing knee research was taken by the International Knee Documentation Committee (IKDC) this year. The Committee redesigned the original IKDC Knee Ligament Form as a knee-specific, rather than a disease-specific, instrument for the assessment of symptoms, function, and sports activity. The redesigned form was field-tested on more than 590 patients with a variety of knee problems and was found to be a reliable and valid knee-specific assessment tool. Use of this instrument will permit orthopaedic surgeons from around the world to compare the outcomes of treatment of different knee pathologies. The use of hamstring grafts for reconstruction of the anterior cruciate ligament continues to receive increasing attention, as reflected in the number of abstracts and manuscripts published in the literature. In fact, 25% of the knee-related manuscripts published in the American Journal of Sports Medicine involved the biomechanics of hamstring grafts or the outcomes of their use in anterior cruciate ligament reconstruction. The general consensus seems to be that hamstring grafts provide outcomes similar to patellar tendon grafts while offering the advantage of decreased morbidity. At the Panther Sports Medicine Symposium in Pittsburgh in May 2000, a panel discussion among fourteen experienced surgeons from around the world revealed that eight of the panelists used hamstring grafts for a majority of their cases, with five preferring patellar tendon autografts and one using quadriceps tendon autografts exclusively. It is notable that twelve of the fourteen panelists reported using more than one type of graft depending upon the context of the injury; however, each still had a preferred graft, with ten panelists utilizing the same graft in over 90% of their cases. However, considerable variability still exists with respect to the many types of fixation devices used for hamstring grafts as compared with those for patellar tendon grafts. The development of an objective, standardized protocol for the evaluation of these fixation devices prior to their release would be a worthwhile endeavor. Over the past year, the spotlight has also been focused on the increasing prevalence of anterior cruciate ligament injuries in females. The injury rates have been described as reaching epidemic proportions, with the rate in female athletes reported to be three to eight times higher than that in male athletes who participate in equivalent sports. These differences were once suspected to be a result of notch size or geometric characteristics. In 1999, the American Orthopaedic Society for Sports Medicine, the Orthopaedic Research and Education Foundation, the National Athletic Trainers Association Research and Education Foundation, and the National Collegiate Athletic Association sponsored a conference in Hunt Valley, Maryland, on noncontact anterior cruciate ligament injuries. At this meeting, four categories of risk factors for anterior cruciate ligament injuries were identified: environmental, anatomic, hormonal, and biomechanical1. Recent studies have suggested that differences in neuromuscular function, quadriceps-to-hamstring ratios, and landing characteristics may actually play a larger role2. Early data have suggested that neuromuscular training with the goal of enhancing body control may decrease the prevalence of these injuries in women1. Differences in anterior cruciate ligament reconstruction techniques (including one-incision versus two-incision and one-tunnel versus two-tunnel techniques) have also been highlighted. Early clinical results have suggested that the two-tunnel technique may restore stability better than the one-tunnel technique does. However, no differences between the one and two-incision techniques have been shown in biomechanical or clinical studies. Alternatives to traditional single-bundle reconstruction of the posterior cruciate ligament also have received considerable publicity. Biomechanical data from several research groups have indicated that posterior cruciate ligament reconstruction with use of two femoral tunnels and one tibial tunnel restores normal knee biomechanics better than a single-bundle reconstruction does3. Tibial inlay reconstruction, in which a trough is created in the tibia for direct fixation of the bone block of the posterior cruciate ligament graft, has also become an increasingly popular subject at recent meetings and instructional courses; however, further biomechanical data are needed to assess the effectiveness of this technique. Clinical outcomes data for both techniques should be a priority for future investigations. There is little question that preservation of the menisci is critical for the prevention of degenerative changes over time. As a result, there has been great interest in the treatment of meniscal injuries. Meniscal repair techniques continue to be driven by a plethora of different fixation devices. For example, several biomechanical studies have focused on the pull-out strength of meniscal arrows and sutures4. Meniscal transplantation is also becoming more widely performed around the world. Current indications for this surgery include an age of less than forty years, isolated meniscectomy or combined anterior cruciate ligament deficiency with meniscectomy, recurrent pain and instability, intact articular cartilage, and normal alignment. Recent attention has focused on techniques for the sizing of allografts and the evaluation of transplants, with both clinical and basic-science studies indicating promising results following meniscal transplantation5. In summary, a review of the year's literature on the knee reveals considerable opportunities for future study. With the increasing number of procedures being performed, it will become increasingly important to assess more fully the effects of meniscal transplantation and the use of osteochondral allografts. There are also numerous opportunities for the study of the posterior cruciate ligament and posterolateral corner. Finally, studies of the patellofemoral joint have been relatively sparse, given the high prevalence of patellofemoral pain, arthritis, and instability. What's New in the Shoulder The number of peer-reviewed clinical and basic-science studies dealing with the shoulder continues to grow exponentially every year. This growth in research has provided the opportunity for surgeons and industry to expand the repertoire of operative care through the development of new techniques and surgical instruments. Furthermore, a new journal (Techniques in Shoulder & Elbow Surgery, published by Lippincott, Williams and Wilkins) has emerged within the last year in order to address the tremendous interest in these new techniques in shoulder surgery. As with knee surgery a decade ago, a greater understanding of the shoulder and its pathology has led to refinement of surgical techniques and enormous interest in less invasive procedures. Arthroscopic techniques including Bankart stabilization, rotator cuff and SLAP (superior labrum anterior and posterior) repairs, and capsulorrhaphy continue to attract an immense amount of attention. Discussions regarding these relatively new procedures have dominated the podium presentations, instructional courses, and symposia at society meetings and have prompted continuing-education courses across the country. Unfortunately, the excitement surrounding a potentially promising new technology can easily result in its broad application by a vast number of surgeons before the full ramifications of the treatment are known. Arthroscopic stabilization and rotator cuff repair continue to be controversial topics in the clinical and basic-science literature. The outcome of arthroscopic stabilization for anterior instability continues to improve as a result of both our greater understanding of the underlying pathology and the refinement of surgical techniques. The results have even been reported to be equal to those of open procedures in some series6. However, the rate of recurrent instability following procedures performed by the less experienced orthopaedist is much more variable. Furthermore, the interpretation of the results must be made judiciously in studies lacking control groups or randomization of the subjects. Although the technical capability to perform arthroscopic stabilization now exists, the current literature does not support the broad application of this technique. Posterior instability of the glenohumeral joint has also received increased attention over the past several years. Open capsular shifts, as well as recently developed arthroscopic procedures, are currently being utilized with reported good results. Again, the results should be interpreted with caution, as the number of truly prospective studies is still quite small and randomized clinical trials are almost nonexistent. Finally, the surgical treatment of multidirectional glenohumeral instability has also become popular within the past year with the mass-marketing of thermal capsulorrhaphy. Although the early results achieved with this technique have been encouraging7, its final role in the armamentarium of shoulder surgeons has yet to be defined. In addition, basic-science studies currently are being performed to better define the true biomechanical and biological effects of these devices (see Emerging Technologies below). The latest developments in rotator cuff surgery have focused on arthroscopic repair. A number of published reports have contributed to the theoretical and technical foundations of this new and difficult procedure8. Although these techniques hold great promise, they are currently being performed in only a limited number of centers, and long-term outcome studies are greatly needed. At present it is difficult to determine if arthroscopic rotator cuff repair will have wide applicability among surgeons with varying skills. What's New in Other Athletic Injuries The American Journal of Sports Medicine has remained a leader in the field not only for reporting new basic-science and clinical findings on the knee and shoulder but also for providing the most sport and population-specific reports in the literature. Injuries resulting from rock-climbing, snowboarding, lacrosse, ice hockey, wrestling, and figure skating are just a few of the many topics addressed last year. Several target populations have also been addressed with increasing frequency in the literature, including the female athlete (three articles) and the adolescent athlete (five articles). The American Journal of Sports Medicine is to be commended for its coverage of a wide variety of sport-specific injuries, which reflects the multidisciplinary nature of the subspecialty. One of the nonorthopaedic issues that has received a great deal of attention is the evaluation and management of concussion in athletes. This interest has been fueled by a growing dissatisfaction with traditional strategies of concussion management that rely upon overly simplistic return-to-play guidelines9. This is particularly true at the professional level, where injuries to marquee athletes have prompted both the National Football League (NFL) and the National Hockey League (NHL) to designate significant resources to research on the diagnosis and treatment of concussion, with a focus on the prevention of repeat injury. The American Orthopaedic Society for Sports Medicine has been quite active on this issue, and, in December 1997, it sponsored a Concussion Workshop with representatives of the medical community who treat these injuries. The recommendations of the committee on patient assessment and return-to-play issues were published in 1999 in the American Journal of Sports Medicine10. Large-scale research with use of microcomputers to obtain a preseason baseline neuropsychological evaluation of the athlete is currently underway at the collegiate and high-school levels. These data will provide a basis for comparison in the event of a concussion during the season and will facilitate the assessment of recovery patterns following concussion11. This information will also help to provide answers to increasingly more specific questions regarding recovery from concussion such as: (1) Are there different subtypes of concussion that result in different recovery patterns? and (2) What are the most important clinical markers for predicting recovery following concussion? It is hoped that this research will lead to the establishment of more scientifically based guidelines for an athlete's return to play following concussion. Emerging Technologies As mentioned above, the popularity of thermocapsular shrinkage for the treatment of shoulder instability has grown rapidly since the introduction of this technique just over ten years ago. Thermal energy is also applied increasingly in the arthroscopic treatment of a variety of conditions, including inaccessible posterior meniscal tears, partial-thickness cartilage defects, patellofemoral instability, and grade-II laxity of the cruciate ligaments. However, there have been no peer-reviewed articles on clinical outcomes, and scientific studies are only beginning to identify and define settings for the proper use of tissue shrinkage12. Recent data from a sheep model indicated that treatment of partial-thickness cartilage defects with radiofrequency resulted in early chondrocyte death that persisted and expanded throughout the twenty-four weeks of the study13. Findings such as these indicate that considerable caution must be exercised before we widely and indiscriminately adopt these techniques. Carefully performed basic-science research is ongoing and is critical to the final clinical release of this technology. It is no surprise that biomechanical studies continue to play a significant role in the mechanically oriented field of orthopaedic sports medicine. However, the usefulness of traditional cadaveric biomechanical studies may be diminishing as we begin the new millennium. The future may now lie in the study of in vivo biomechanics, with recent developments such as cine magnetic resonance imaging and the point-cluster technique for obtaining multiple degrees-of-freedom joint kinematics14. The role of technology in the clinical setting is growing exponentially as well, with computer-guided navigational devices and robotic-assisted anterior cruciate ligament reconstruction receiving considerable attention, both within the specialty and in the national media. The future of orthopaedic sports-medicine research is also likely to involve the correlation of biomechanics with the biological response of tissues. It is becoming increasingly clear that the field is entering a new era, where biological tools such as stem cells, genes, and growth factors may supplement the orthopaedic surgeon's traditional tools15. Soft-tissue injuries of cartilage, ligaments, and tendons are much slower to heal than osseous injuries are. In a specialty where "return to play" often drives clinical management, the appeal of techniques that can speed the healing of meniscal tears, ligaments, and graft substitutes is enormous. Gene-therapy studies have shown that we are now capable of placing marker genes into the anterior cruciate ligament, either directly or via myoblasts and fibroblasts16. Other studies17 have demonstrated the potential use of gene therapy to stimulate chondrogenesis or to prevent matrix degeneration in the treatment of osteoarthritis. Studies involving stem cells and growth factors have shown promising results as well, particularly for the treatment of muscular and ligamentous injuries18. It certainly appears that, although the field is still very young, tissue-engineering will play a major role in the future. What's New in Education The American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America continue to be the primary sources of continuing education in sports medicine for both the specialist and the generalist. The educational offerings for both of these groups include annual meetings, Specialty Day meetings held in conjunction with the American Academy of Orthopaedic Surgeons, and numerous other didactic meetings that cover the current topics in sports-medicine research, education, and clinical practice. In addition, both societies offer numerous courses throughout the year in order to allow participants to develop, update, and improve their psychomotor skills in knee and shoulder surgery. The American Orthopaedic Society for Sports Medicine continues to interact with the American College of Sports Medicine and the American Medical Society for Sports Medicine to foster progress in both the orthopaedic and nonorthopaedic aspects of sports-medicine education. Advanced team-physician and sport-specific courses are offered twice a year to bring together physicians of all specialties, athletic trainers, and physical therapists. Yearly courses have been held in conjunction with the National Basketball Association, National Hockey League, National Football League, and professional soccer leagues. By attending these courses, the sports-medicine specialist as well as the general orthopaedist can maintain his or her expertise in sports medicine. During the past year, the American Orthopaedic Society for Sports Medicine has been very active in its educational endeavors. Highlights have included the development of an educational curriculum for its membership, an updated revision of the orthopaedic sports-medicine fellowship curriculum, and the submission to the Board of a formal application for subspecialty certification in orthopaedic sports medicine (formerly known as a Certificate of Added Qualification, or CAQ). On the basis of the ever-expanding body of knowledge in sports medicine and the constantly changing socioeconomic factors of medical practice, the leaders of the American Orthopaedic Society for Sports Medicine thought that the development of a Continuing Medical Education (CME) curriculum would significantly improve the educational strategy of physicians in the field. This curriculum was developed by the Education Committee over the past five years and was designed to both organize and prioritize topics for CME. The curriculum reflects the multidisciplinary aspects of sports medicine that the Society expects a sports-medicine specialist to know. It is currently being implemented and should have a profound effect on the education of all orthopaedists practicing sports medicine. The Fellowship Committee and Curriculum Subcommittee of the American Orthopaedic Society for Sports Medicine revised and updated the Orthopaedic Sports Medicine Fellowship curriculum. Currently, there are fifty-four sports-medicine fellowship programs accredited by the Residents Review Committee (RRC). In 1991, the Board of Directors and the Sports Medicine Fellowship Committee of the American Orthopaedic Society for Sports Medicine established a core curriculum and structure for sports-medicine fellowships. Over the past year, the Fellowship Committee and the collective leadership of the Society incorporated the format of the membership curriculum into the existing fellowship curriculum. This modification provides sports-medicine fellowship directors with a template for the standardized education of sports-medicine fellows to ensure consistent educational experiences. Copies of both the fellows' and the members' curricula can be obtained through the office of the American Orthopaedic Society for Sports Medicine or its web site, www.aossm.org. In an effort to gain insight into these and other issues, the Society distributed a Sports Medicine Survey to all 1187 members and to 2503 nonmembers. The nonmember segment consisted of members of the American Academy of Orthopaedic Surgeons who had expressed an interest in sports medicine. Overall, 555 members (47%) and 612 nonmembers (24%) responded to the survey, for a total of 1167 respondents. The results of this survey can be found on the Internet or by calling the Society office. The orthopaedic sports-medicine specialists indicated that over 57% of their activities are sports-related, with 42% devoted to clinical care, 7% related to team-physician coverage, 3% dedicated to research, and 5% devoted to other activities. Of those responding to the survey, 87% of Society members and 65% of orthopaedists in general believe that sports medicine represents a unique body of knowledge and area of practice. As the specialty has developed, there is also a growing awareness of the need to set standards for formalized training programs. The establishment of a Certificate of Subspecialization in Orthopaedic Sports Medicine has been carefully considered by the various committees, subcommittees, and membership of the Society. In the survey, 70% of members and 60% of nonmembers indicated that they would pursue certification if it were available. On the basis of these findings, the Society thought that there was sufficient interest and support to institute such certification. The next step will be the submission of the application to the American Board of Orthopaedic Surgery, and, if approved, submission to the American Board of Medical Specialties. The certification process is viewed by the leadership as another step, in conjunction with the CME and fellowship curricula, to establish a higher standard of knowledge and, ultimately, patient care. It is intended as an extension of formalized sports-medicine education rather than as a means of determining whether a physician can or should provide orthopaedic sports-medicine services to the athletic community. In addition, it also formally acknowledges those who have spent a year in an accredited fellowship as well as all orthopaedists who dedicate a significant component of their practice to sports medicine. To help meet the challenge of recognizing this new educational standard without interfering with the general orthopaedist's ability to provide sports-related care, the Board of the American Orthopaedic Society for Sports Medicine adopted the following certification policy in October 200019: The American Orthopaedic Society for Sports Medicine actively and fully supports the establishment of Subspecialty Certification in Orthopaedic Sports Medicine as the best means of achieving and maintaining a universally high standard of training in this area of orthopaedic practice. The American Orthopaedic Society for Sports Medicine strongly supports the right and ability of all orthopaedists, regardless of post-graduate training and education, to provide sports medicine services in the team, clinical and surgical settings. Certification cannot be used as a criterion for AOSSM membership or full participation in the Society. Tribute Finally, on a sad note, the arthroscopy and sports-medicine world has lost one of its great innovators and leaders. While skiing in Vail, Colorado, Dr. Richard Caspari died suddenly on January 19, 2000. Dr. Caspari had a profound influence on the field of sports medicine, contributing significantly to developments in arthroscopy, research, and the design of innovative techniques and implants. He was also highly active in fellowship training, surgical seminars, and various surgical societies. The world of sports medicine will miss him. His legacy will not be forgotten.
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