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© 2002 The Journal of Bone and Joint Surgery, Inc.
What's New in Sports Medicine
The subspecialty of sports medicine continues to emerge as one of the major components of orthopaedic surgery. Although still relatively young in comparison with other subspecialties, such as hand, total joint replacement, and pediatrics, sports medicine has grown to become a major part of orthopaedic residency programs and clinical practice. Data supporting this claim comes from the American Board of Orthopaedic Surgery (ABOS), the certifying body of orthopaedics that exists to serve the interest of both the public and the medical profession. Part of the process of certification involves the oral examination (Part II), which is based on the candidate's operative cases over a six-month period of time. This process yields a comprehensive data set on the practices of approximately 700 candidates per year. A summary of these data over the three-year period from 1998 through 2000 has revealed that three of the top five procedures performed, and four of the top ten, are sports-related ( Table I ).
These statistics reflect the extent to which sports medicine has become a major subspecialty of orthopaedic surgery. Data such as these provide us with powerful information on the current state of orthopaedic practice. Furthermore, the information will be especially useful for the design of resident and fellow education, the initial written examination (Part I) for ABOS certification, and examinations for subspecialty certification and ultimately in the evaluation of the performance of our profession. Our update this year will be based on scientific and organizational activities in sports medicine from September 2000 to August 2001. It will include 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), the Orthopaedic Research Society (ORS), and the American Academy of Orthopaedic Surgeons (AAOS). To give a general overview of the articles published in sports medicine, we reviewed The American Journal of Sports Medicine (AJSM), Arthroscopy, and The Journal of Bone and Joint Surgery (JBJS), which are among the most influential journals in orthopaedic sports medicine. Finally, "hot topics" in sports-medicine education and organizational activities will be summarized. The Year in Review: Abstracts and Scientific Meetings Although the specialty of sports medicine consists of a well-defined and specific body of knowledge, it also encompasses a number of other specialties, such as shoulder, elbow, and hand surgery as well as arthritis and joint surgery. As such, much research can be dually classified. However, we have limited our discussion to that which most would agree can be uniquely classified as sports medicine, particularly when we discuss work from multidisciplinary orthopaedic sources such as the AAOS and JBJS . We reviewed the over 200 scientific presentations at the AOSSM Annual and Specialty Day Meetings and the AANA, AAOS, and the ORS Annual Meetings. Just over 50% of the scientific studies presented at these meetings were clinical in nature, another 25% to 30% were basic science, and the remainder were multidisciplinary, such as assessments of neuromuscular function or image analyses in selected patient groups. The distribution, of course, varied by meeting, with the ORS presentations consisting primarily of basic-science studies and several functional studies and >60% of the presentations at the AANA meeting consisting of clinical studies. The presentations at the AOSSM and AAOS meetings fell somewhere in between. A total of eight studies (<5%) presented at these meetings were identified as randomized, controlled investigations. The Year in Review: Articles According to a survey completed last year by 558 AOSSM members and 601 nonmembers with an expressed interest in sports medicine, the most-read journals in the field include AJSM (read by 97%), JBJS (74%), JAAOS (72%), Arthroscopy (62%), and The Physician and Sportsmedicine (35%). In our review last year, we discussed the need for more randomized, controlled studies in the specialty of sports medicine. This year, ten such studies were published in AJSM and seven appeared in Arthroscopy. Review of the over 100 articles that appeared in AJSM last year revealed that approximately 60% were clinical in nature and about 30% were basic-science studies. Of note, approximately 10% were functional studies in which neuromuscular function was assessed in various patient populations. More than half (sixty-four) of the articles were related to the knee, with almost half of those featuring the anterior cruciate ligament. With regard to other topics, however, AJSM is noteworthy for the variety of subjects and sport-specific articles featured. Topics ranged from hip, ankle, and elbow injuries to cervical spine and head injuries. Furthermore, at least sixteen different sports were featured over the course of the year; these included popular favorites such as hockey, soccer, and football as well as special niches such as rock-climbing, rowing, and pole-vaulting. The articles published in Arthroscopy in this time-frame were in large part clinical, with <20% consisting of basic-science studies. However, this is in large part due to the fact that the journal also offers Case Reports and Technical Reports sections in addition to original scientific articles. Nearly two-thirds of the articles in the journal concerned knee surgery, with the majority featuring the anterior or posterior cruciate ligament. Another 24% of the articles were on the shoulder, and the remainder dealt with topics such as hip, elbow, and ankle arthroscopy. In JBJS this year, one or two articles in each issue (approximately 10%) were sports-related. Knee surgery was the subject of the majority of these papers, with the anterior cruciate ligament again the primary topic of focus. What's Hot
Heat-Related Illness Although deaths from heat-related illness are rare, constant surveillance and education are necessary to prevent heat-related problems. The key is prevention. According to the National Collegiate Athletic Association (NCAA) guidelines for the prevention of heat-related illness 1 , this should be done by taking the following steps: 1. A complete preseason medical history and physical evaluation of the health status of the athlete. These would enable the sports physician and his or her team to identify any predisposing factors for heat-related illness. 2. Preseason aerobic conditioning and acclimatization to the heat can help to prevent heat-related illness. The athlete should undergo gradual exposure to hot and/or humid environments for a period of seven to ten days to achieve heat acclimatization. Hydration should be maintained during this initial process and subsequent training. 3. Clothing and protective equipment must be taken into account in addition to the temperature and relative humidity. This is especially true of American football. 4. An understanding of the heat stress conditions and the environment in which the athlete is participating is crucial. The ambient temperature and humidity should be measured on a daily basis to assess the risk of heat stress. The wet bulb temperature, dry bulb temperature, and solar radiation should also all be measured. 5. Dehydration must be avoided. The best way to do this is to prevent its onset. Fluid replacement must be available to the athletes at all times. They should be encouraged to drink as much and as frequently as comfort allows. Water is the best source of rehydration and should be available at all practices and games. Carbohydrate/electrolyte drinks are also acceptable. It is critical, however, that the correct electrolyte concentration be obtained because if the percentage of electrolytes is too high, gastric emptying can be affected. 6. The body weight of each athlete must be recorded before and after every workout as this is an excellent way to monitor hydration. Those who lose 5% of their body weight over a period of several days should be evaluated medically, and their activity should be restricted until rehydration has occurred. 7. Athletes who are susceptible to heat-related illness should be identified. These include those who have not been acclimatized; those with excessive body fat, a history of heat-related illness, or a febrile condition (influenza or a viral condition); and anyone who is taking diuretics or stimulant medications.
The Knee In a slight role reversal, research on anterior cruciate ligament reconstruction is following in the footsteps of that on its posterior counterpart, the posterior cruciate ligament, as interest in the development of double-bundle techniques has recently been piqued. Biomechanical studies have suggested that the addition of a second bundle may provide advantages under rotational loads 3 ; however, little is known about the effects of this technique on clinical outcomes. With regard to the posterior cruciate ligament, both clinical and basic-science research has continued to focus on the development of more nearly anatomical reconstructions. Specifically, tibial inlay reconstruction has been the subject of much deliberation at several meetings this year. With this technique, a bone trough is created in the posterior aspect of the tibia, at the site of the insertion of the posterior cruciate ligament. The bone block of a patellar or Achilles tendon graft is then fixed directly into this trough. This is believed to eliminate the increased graft stresses that theoretically occur with the transtibial technique. Clinically, however, this technique necessitates a separate approach in proximity to the major neurovascular structures. Several biomechanical studies have suggested that this technique restores normal knee biomechanics more closely than does a traditional single-bundle reconstuction 4,5 . However, others have indicated that there is no significant difference in its effects on knee biomechanics 6 . Clinical outcome data after two years of follow-up at one institution did not reveal a clear advantage to either the inlay or the transtibial technique 7 . One may argue that, with no clearly proven advantages to the inlay reconstruction, the theoretical merits of the surgery may not warrant its added risks. However, with the equivocal biomechanical and clinical findings, the only way to truly compare the two techniques is in a randomized, controlled clinical trial. This is a difficult undertaking because of the relatively small number of injuries of the posterior cruciate ligament as well as the large variation in injury patterns (posterolateral corner, anterior cruciate ligament, etc.). Another topic of increasing interest has been the symptomatic patient with a chronic injury of the posterior cruciate ligament. Treatment of such patients is a major challenge because of the dual presentation of instability and malalignment, with isolated reconstruction of the posterior cruciate ligament unable to address the second issue. The use of sagittal slope osteotomy has recently emerged in the treatment of cruciate deficiency. Changing the sagittal slope of the tibia results in a compensatory change in tibial translation. This approach has provided the knee surgeon with another possible technique with which to treat chronic posterior and anterior cruciate ligament deficiency associated with arthritis. Although the technique has been utilized by a few surgeons in Europe, the clinical data are still pending. Several recent biomechanical studies performed at the University of Pittsburgh and the University of Western Ontario have demonstrated that increasing the tibial slope in this scenario can reduce the posterior tibial sag associated with posterior cruciate ligament deficiency 8,9 . Furthermore, there is a potential for simultaneous correction of associated coronal malalignment with a biplanar osteotomy. However, despite promising results in the laboratory, more outcome studies are needed to determine the procedure's effects over time. Finally, although arthroscopic débridement has been a mainstay in the management of degenerative osteoarthritis, there is little evidence documenting its efficacy compared with that of medical management or joint replacement; success rates have ranged from 50% to 80% at two to four years 10 . In a recent study from Ontario, 14,391 individuals over the age of fifty years who had been treated with arthroscopic knee débridement were assessed with regard to the rates of surgical complications and subsequent débridements, osteotomies, or joint replacements. The authors found that 9.2% of the patients required total knee arthroplasty within one year after the débridement and 18.4% of the patients underwent joint replacement within three years. The authors concluded that these rates suggest that arthroscopic débridement may be overutilized in the older population. These findings, along with the ABOS data in Table I, indicate the need for our profession to determine the appropriate role for knee arthroscopy in the management of degenerative arthritis.
The Athlete's Shoulder In addition, several AANA and AOSSM courses offered at the AAOS Orthopaedic Learning Center focused on teaching arthroscopic shoulder techniques both with didactic instruction and in cadaver wet laboratories. These courses are taught by experts in the field of shoulder surgery demonstrating their latest techniques, all with the support of industry representatives sent to help familiarize course participants with the various instruments, devices, and implants that have flooded the market. This approach fosters an excellent learning environment in which orthopaedic surgeons first practice these often technically difficult procedures on cadavera, not live patients. While the early results following arthroscopic treatment of shoulder instability were variable, more recent studies have shown outcomes comparable with those of open procedures 12,13 . Nonetheless, open shoulder surgery still plays a definite role in the treatment of shoulder instability. For revisions of shoulders with instability, for instability associated with a Hill-Sachs lesion, and for instability associated with glenoid deficiency, open surgery is still-and probably will remain-the gold standard for years to come 14 . In addition, while some studies have suggested that arthroscopic results are approaching those of open procedures, it is unclear whether these outcomes are reproducible in the hands of less experienced arthroscopists. Thermal techniques for treating shoulder instability have continued to receive major attention over the past year. However, the enthusiasm for thermal capsulorrhaphy has been tempered by longer-term results as well as by our increased understanding of the limits of the technique derived from basic-science research. It seems that a combined approach, utilizing both arthroscopic suture techniques and thermal capsulorrhaphy, may yield better results than either procedure alone 12,13 . With an understanding of the limits of thermal techniques, results can be optimized and complications can be minimized. Another interesting application of capsulorrhaphy has been in the management of throwers with internal impingement. In one study 15 , the authors found improved outcomes in baseball pitchers with internal impingement when thermal treatment had been used to treat the subtle anterior microinstability that is often seen in these patients. Outcome studies are continuing to bridge the gap between clinical practice and evidence-based research. As the field of shoulder surgery in athletes expands and evolves, the practicing orthopaedic and sports-medicine surgeon will be better prepared to provide the highest level of care available to athletes with shoulder problems.
Sports-Medicine Education The specialty also is looking at refining its continuing medical-education curriculum to guide its educational process as well as to help members track their educational activities. As a living document, the guidelines require periodic review to keep up with the latest developments affecting sports medicine. An area of growing interest that will receive special attention is pain management as it relates to surgery, performance, and general health. The specialty also is continuing its pursuit of a curriculum builder that will allow the leadership to monitor its educational offerings, vis-à-vis the curriculum, and will allow members and attendees to track their participation. The specialty's active interest in research continues to be expressed in new and innovative ways. The AOSSM has partnered with the NCAA to help to develop a new online injury surveillance system. The new system will replace the current injury surveillance system and allow all NCAA schools to directly report injuries in all sports. As partners, the orthopaedic sports-medicine community will have access to the database, and thus have a large data resource, for research. The specialty has also thrown its considerable weight toward developing a collective research project on one of the more vexing issues facing the specialty: non-contact anterior cruciate ligament injuries. The AOSSM, under the auspices of its Research Committee, has initiated a two-phase project that will solicit research proposals on neuromuscular and biomechanical factors in the genesis and prevention of non-contact anterior cruciate ligament injuries. A grant for $250,000 has been tentatively earmarked for this project, with the expectation that the broader orthopaedic sports-medicine community will contribute toward this important research. Finally, the specialty's quest for subspecialty certification continues to progress through the appropriate channels. The ABOS has forwarded a formal application to the American Board of Medical Specialties (ABMS). That application has been distributed to the ABMS member specialty boards for review and input and will be considered by the ABMS later in 2002. Other News · The leadership of AJSM has changed hands. Dr. Robert Leach retired in 2001 after serving as its editor since 1991. The torch has been passed to Dr. Bruce Reider of the University of Chicago, who has been a member of the AOSSM since 1983 and has held multiple leadership positions within the society. Congratulations and best wishes to you, Dr. Reider. · Congratulations to the first inductees into the AOSSM Hall of Fame: Fred L. Allman, MD, Martin E. Blazina, MD, Joseph D. Godfrey, MD, Jack C. Hughston, MD, John C. Kennedy, MD, Robert K. Kerlan, MD, Robert L. Larson, MD, Don M. O'Donoghue, MD, Donald Slocum, MD, and Marcus J. Stewart, MD. · Finally, on a sad note, the world of sports medicine lost one of its most influential members and leaders. On November 29, 2001, Dr. Hugh Tullos died in a motor-vehicle accident in Mason, Texas. Dr. Tullos was one of the founding members of the AOSSM and the International Society of the Knee. He was especially known for his work in joint replacement and upper extremity injuries. He will be missed in the world of sports medicine. Note: The authors would like to acknowledge Jon Sekiya, MD, and Irv Bomberger, PhD, for their contributions to this manuscript.
References
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