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© 2003 The Journal of Bone and Joint Surgery, Inc.
What's New in Sports Medicine
Christopher D. Harner, MD One of the distinctive aspects of orthopaedic sports medicine is its cross-disciplinary interaction with many different medical specialties, most allied health-care professions, and all orthopaedic subspecialties. In addition, because of our involvement with a relatively young, athletic, and active patient population, we are continually exposed to the public via the media. Although not always intended or sought after, this unique predicament drives our subspecialty to develop high-quality and relevant basic science and clinical research studies, new technology, and educational curricula. Over the past fifteen years in orthopaedic sports medicine, we have seen an explosion in basic-science and clinical research, educational programs in residencies and fellowships, and the evolution of a true body of knowledge. Those who remain doubtful are referred to the two educational curricula that have been developed by the American Orthopaedic Society for Sports Medicine 1 . The first was developed for the membership (i.e., the practicing orthopaedist) and the second, for sports medicine fellows. These curricula took years to develop and reflect our subspecialty's leadership and commitment to education and patient care. This update will cover the past year's highlights in education, research, and organizational activities in orthopaedic sports medicine. It is designed to give the orthopaedist in practice or training an update of where we are now and where we are headed in the future. ABOS Data on Sports Medicine Last year, we reported on the ten most commonly performed procedures according to the American Board of Orthopaedic Surgery (ABOS). The results of our investigation demonstrated that four of the ten most commonly performed procedures were related to sports medicine, with meniscectomy being the most frequent. Those rankings were based on case lists submitted by the candidates who had completed Part II of the ABOS Certification Examination during the year 2001. Since then, additional data have again demonstrated the widespread practice of sports medicine by generalists and specialists alike. Among a total of 741 Board applicants in 2001, an average of 126 (range, sixteen to 435) cases were performed per candidate. The most commonly declared specialty was general orthopaedics (388 candidates), followed by hand/upper extremity (eighty-nine) and sports medicine (sixty-eight). The average number of sports medicine cases per candidate was actually quite comparable between applicants who declared themselves to be generalists and those who declared themselves to be sports medicine specialists (Table I).
Furthermore, adult reconstruction surgeons also performed a substantial number of arthroscopic procedures on the knee (e.g., meniscectomy and débridement). Total knee arthroplasty was the most commonly performed procedure, and total hip arthroplasty was third. These data are somewhat concerning as one can assume that the arthritic changes in this subgroup of patients are substantial. As such, the efficacy of arthroscopy in this setting is questionable. This information, combined with recent information on arthroscopy in the degenerative knee 2 , suggests that we must reevaluate our use of arthroscopy in these patients. Finally, new data were released on complication rates among ABOS candidates. Although not specific to sports medicine, these data are important for all of us and will likely cause concern. What is interesting is that the complication rate has not changed over the past six years. In 2001, the declared complication rate averaged sixteen per candidate, with infection being the most common complication. Disturbingly, however, wrong-side surgery represented a total of eight complications in 2001. This total has not changed over the past five years, despite the "Sign Your Site" campaign by the American Academy of Orthopaedic Surgeons to eliminate this completely preventable error. The Year in Review-Meetings and Journals As in previous years, we reviewed the conference proceedings from the major orthopaedic sports medicine meetings that were held in 2002, including the Annual and Specialty Day Meetings of the American Orthopaedic Society for Sports Medicine (AOSSM), the Annual Meeting of the Arthroscopy Association of North America (AANA), and the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). At these four meetings, there were just over 200 scientific presentations that focused primarily on sports medicine. Clinical studies again represented the majority of these abstracts, comprising approximately 64% of the total number of papers presented. While basic-science studies still represent a substantial percentage (27%) of the current research in sports medicine, an increasing number of studies have combined the two genres by assessing the effects of various interventions, such as sport-specific training programs, on both clinical outcomes and neuromuscular function. While there are numerous publications specific to sports medicine, we have again chosen to focus on three of the most influential journals in the field, specifically, The American Journal of Sports Medicine, The Journal of Bone and Joint Surgery, and Arthroscopy. As part of this annual review, we considered over 200 articles, published between September 2001 and August 2002, that pertained to the field of sports medicine. Of these, approximately one-quarter (fifty-one) were identified as prospective studies while only seventeen represented randomized, controlled trials. It is evident, after this thorough review of the year's literature, that prospective, randomized studies continue to comprise an overwhelming minority of orthopaedic research. What's New in the Knee?
Arthroscopic Surgery for Osteoarthritis Not surprisingly, that study made headlines, including "Arthritis Surgery in Ailing Knees Is Cited as a Sham," "Surgery for Osteoarthritis of the Knee Proven Worthless," and "The Three Billion Dollar Hoax." With the fear that the casual reader might interpret these headlines to pertain to all arthroscopic knee surgery, official position statements were soon released by the various sports medicine societies. In a letter to the editor that was published in the New York Times on July 18, 2002, Vernon Tolo, MD, President of the AAOS, and Peter J. Fowler, MD, President of the AOSSM, wrote that "It is a mistake to use a research publication that is focused on osteoarthritisto suggest that knee arthroscopy is ineffective for treating knee pain caused by torn cartilage or ligaments, conditions far more likely to have arthroscopic treatment than is osteoarthritis. Over the past 25 years, thousands of clinical research publications have confirmed the effectiveness of arthroscopic knee surgery in relieving knee pain for millions of Americans." The AANA statement added that there is "a sub-group of patients with knee arthritis that can be significantly helped with appropriate arthroscopic surgery. . . . The public—our patients—must be reassured that, in the hands of the conscientious orthopaedic surgeon familiar with the patient selection criteria for degenerative arthritis, arthroscopic surgery can be a dependable procedure, capable of producing long-lasting relief." This study also sparked discussion regarding the ethics underlying the use of placebo surgery in a scientific study. In an editorial that followed the article, Horng and Miller 4 cautioned that "clinical trials are not designed to promote the medical best interests of enrolled patients." They noted that ethical principles that may be appropriate for clinical research are not identical to those of clinical practice. The authors of the editorial identified three criteria that are necessary for clinical trials: (1) they must have scientific merit, (2) the risks to participants must be minimized and justifiable by the benefits to the patients as well as the potential scientific value of the knowledge to be gained, and (3) informed consent must be obtained. To their credit, Moseley et al. involved an ethicist in the design of their study 2 . Furthermore, while going to extensive efforts to simulate the placebo surgery—even splashing water in a bucket—the authors minimized risk to their patients by utilizing sedation combined with a narcotic rather than general endotracheal anesthesia in the placebo group. Allograft Contamination Approximately 800,000 musculoskeletal allografts were distributed last year by numerous tissue-processing firms for use in a variety of surgical procedures. Sports medicine surgeons perform many of these procedures, the most common of which is anterior cruciate ligament reconstruction. During the past year, allograft contamination and associated infection has become the center of much attention. In November 2001, a twenty-three-year-old Minnesota man who had had a reconstructive knee procedure died as the result of a postoperative infection that was attributed to infected allograft tissue 5 . This and other case reports of allograft-associated infections with serious morbidity and mortality prompted investigations by the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC). In April, 2002, the CDC released an update of allograft-associated bacterial infections in the United States 6 . From November 2001 to March 2002, the CDC received twenty-six reports of bacterial infections associated with the implantation of musculoskeletal allograft tissue, thirteen of which were caused by Clostridium species. In the vast majority of cases, there was evidence suggesting that the allograft was the source of infection. The number of reported cases of infection continues to grow. As of November 2002, more than seventy cases of allograft-associated bacterial infections involving twelve tissue banks had been reported since the investigation began in November 2001. In addition, at the Forty-second Interscience Conference on Antimicrobial Agents and Chemotherapy, Tugwell et al. reported that thirty-eight patients had received allograft tissue that was contaminated with the hepatitis-C virus from a donor whose viral infection had not been detected by a Portland, Oregon tissue bank 7 . At least six patients have contracted hepatitis-C virus from the contaminated allograft tissue, including one patient who received an allograft patellar tendon. These recent reports have raised questions regarding the methods and regulations involved in tissue-processing. Efforts to improve the safety of allograft tissue have been made. FDA inspections of Cryolife, Inc., a human-tissue-processing firm, began in December 2001, spurred by evidence that Cryolife had distributed contaminated human tissue allografts responsible for allograft-associated infections. These inspections culminated in an FDA-issued recall, in August 2002, of all distributed human soft-tissue allografts, except allograft heart valves, that had been processed by Cryolife on or after October 3, 2001 8 . In reference to this recall, FDA commissioner Lester M. Crawford stated that, "This order not only protects patients from the unacceptable level of risk associated with tissue processed by Cryolife, it sends a clear signal that FDA stands ready to take whatever action is necessary to ensure the safety of human tissue" 8,9 . FDA and CDC investigations of reported allograft-associated infections are ongoing. The field of sports medicine is intimately entwined in this recent quandary of allograft contamination. Along with reconstructive limb and joint revision surgery, sports medicine represents one of the highest-risk areas of orthopaedic surgery with regard to allograft-associated infection. Of the initial thirteen infections caused by Clostridium species as reported by the CDC, eight were associated with allograft tendons used for anterior cruciate ligament reconstruction and one was associated with an allograft meniscus 6 . There is an overwhelming need for a set of guiding principles that will help orthopaedic surgeons to obtain the highest-quality allografts, maximize the efficacy of these grafts, and ensure patient safety. In February 2002, the AAOS formed the Tissue Banking Project Team to address this problem. Their goal, working in conjunction with the FDA and the CDC, is to assess current tissue-banking procedures relative to orthopaedic practice and to develop guidelines for the safe use of allograft tissue. Until such matters are addressed, the use of allograft tissue in sports medicine must be approached with great care and vigilance. Certain steps that currently can be taken to optimize outcome and to maximize patient safety are (1) to obtain informed consent from the patient prior to surgery and to clearly explain the risks and benefits of and the alternatives to the use of allograft tissue; (2) to obtain allograft tissue from tissue-processing agencies that are accredited by the American Association of Tissue Banks (AATB), a peer group organization that works closely with FDA officials to provide both tissue-processing standards and accreditation to tissue banks across the country (a list of accredited tissue banks can be found on the AATB Web site http://www.aatb.org or can be obtained by calling the AATB at 1-800-635-2282); (3) to monitor and respond promptly to signs and symptoms of postoperative infection in patients in whom allograft tissue has been implanted; and (4) to facilitate a thorough investigation by reporting cases of allograft-associated infection to the tissue processors, the FDA's Medwatch System, and the CDC (telephone: 1-800-893-0485) 6 . Anterior Cruciate Ligament Research During the past year, our subspecialty continued to evolve with high-quality clinical and basic-science research on the anterior cruciate ligament. This research included several prospective, randomized trials; long-term studies with more than five years of follow-up; and formalized research efforts to study mechanisms of anterior cruciate ligament injury and ultimately prevention. Three prospective, randomized clinical studies compared the use of bone-patellar tendon-bone grafts with the use of hamstring grafts for anterior cruciate ligament reconstruction 10-12 . All three studies demonstrated that these graft choices provided comparable long-term (two to three-year) results with regard to patient satisfaction, knee function, and activity level. A significant disparity in donor-site morbidity was reported, with the use of the hamstring tendon more likely to result in decreased knee flexion strength 10,11 and the use of the bone-patellar tendon-bone graft more likely to result in patellofemoral pain 11,12 . Also related to the topic of graft choice is the use of allograft or autograft for anterior cruciate ligament reconstruction. One recent study compared the long-term (eight to fourteen-year) results for patients who had received either an autogenous or an allogeneic bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction 13 . No significant differences were detected between these two types of graft in terms of either subjective, patient-reported outcomes or objective measures such as strength, function, and anterior laxity of the knee. These data suggest that either type of graft can be used for anterior cruciate ligament reconstruction with similar success. Other guiding factors, including patient preference (e.g., aesthetic appearance, risk of infection with allograft tissue) and the surgeon's comfort level must be taken into account during preoperative planning. Another new focus during the past year was on noncontact anterior cruciate ligament injuries. In recognition of the importance of understanding the mechanisms of injury to the anterior cruciate ligament, our leadership organized and funded an all-day workshop on noncontact anterior cruciate ligament injuries. Selected clinicians and basic scientists were invited to present their work on this topic. Twenty-four studies, on topics ranging from epidemiological risk factors to biomechanical and neuromuscular components and clinical outcomes, were presented. In the O'Donaghue award-winning study, more than 800 West Point cadets were prospectively followed for four years to determine potential factors associated with subsequent anterior cruciate ligament injuries 14 . Factors that were identified in female subjects included signs of hyperlaxity, a body weight >68 kg, and a body-mass index of >24.7. Radiographic criteria such as notch width were also associated with an increased risk of anterior cruciate ligament injury. Other risk factors that have been associated with the increased prevalence of anterior cruciate ligament injuries in female athletes include the gender-related differences in lower extremity positioning during landing. One study demonstrated that female subjects landed with the lower extremity more extended than did male subjects 15 . Furthermore, female subjects seemed to use different muscular shock-absorption strategies, utilizing a smaller hamstring force for a given quadriceps force. It would seem that these landing strategies can be influenced by training programs. In a study on the effects of a six-week jump-training regimen in volleyball players, it was found that the training did not alter the lower extremity joint flexion angles at the time of initial impact but did alter the maximum joint angles and thus the impact absorption in the ankle, knee, and hip joints 16 . Posterior Cruciate Ligament Research The posterior cruciate ligament continues to lag behind the anterior cruciate ligament with regard to solid clinical outcome studies. Interestingly, there appears to be more basic-science than clinical research involving the posterior cruciate ligament. While this has contributed a scientific rationale to our approach to posterior cruciate ligament injuries, there remain questions that only long-term prospective, randomized trials are likely to answer. Over the past twelve months, the focus of posterior cruciate ligament research continued to be the perpetual technical debate regarding the use of the tibial inlay technique or the endoscopic tibial tunnel technique for posterior cruciate ligament reconstruction. Under pure cyclic loading tests, the inlay technique seemed to result in decreased plastic deformation and failure of the graft 17 . However, multiple biomechanical studies comparing the effects of these two reconstruction techniques on knee kinematics and graft forces have demonstrated that neither technique clearly offers a superior biomechanical advantage 18-20 . Furthermore, a retrospective study revealed no significant subjective or objective differences after two years of follow-up. Obviously, there is a need for additional long-term clinical outcome studies that will focus not only on functional outcomes but also on technical issues such as surgical difficulties and postoperative complications. In addition to the continuing investigation of new soft-tissue reconstruction techniques, there are new basic-science data on the role of osseous realignment (osteotomy) in the treatment of posterior tibial subluxation. At the 2002 Annual Meeting of the AOSSM, Giffin et al. 21 presented their biomechanical work on increasing the sagittal slope in the posterior cruciate ligament-deficient knee. Increasing the slope by 5 mm (approximately 4° to 5°) led to a significant reduction of the posterior sag. This approach has clinical applications for patients who have chronic posterior cruciate ligament deficiency (or a failed posterior cruciate ligament procedure) with medial compartment arthritis. By making corrections in both the sagittal and coronal planes (i.e., biplanar osteotomy), the surgeon can reduce the tibia, engage the medial meniscus, and unload the medial compartment. This approach is currently being used in several clinics in North America. Clinical Outcomes in Sports Medicine In health care, there has been a growing interest in the use of patient-oriented outcomes information. Outcomes management has been defined as "the process of data collection, analysis and interpretation of the effectiveness and efficiency of patient treatment for the purposes of improving the quality of care and lowering health care costs" 22 . Outcomes information can be used to assist in patient management decisions (i.e., to determine whether the patient is better or worse), to aid in quality-improvement initiatives (i.e., to assess organizational performance), to assess clinician performance, and to provide evidence for the effectiveness of interventions. The ABOS is now considering the use of patient-oriented outcomes information to assess the competence of orthopaedic surgeons as part of the credentialing process. Evidence-based practice is the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients 23 . Clinical outcome studies are necessary to evaluate the benefits and effectiveness of new biological and biomechanical solutions to orthopaedic sports medicine conditions. These studies must utilize a randomized design with an appropriate control group and an adequate duration of follow-up. Additionally, these studies must include appropriate outcome measures. Recently, the World Health Organization released the International Classification for Functioning (ICF), which is a model of functioning that provides a useful framework for identifying meaningful clinical outcomes 24 . Important clinical outcomes in sports medicine not only should include measures at the tissue and organ levels (e.g., body structure and function in the ICF model) but also should include measures of how the intervention impacts the individual's activity and participation in life situations (e.g., activity and participation in the ICF model). Health-related quality-of-life (HRQL) instruments can be used to measure an individual's perception of his or her activity and participation as defined by the ICF model. Through its support of the International Knee Documentation Committee (IKDC), the American Orthopaedic Society for Sports Medicine has supported the development of the IKDC Subjective Knee Form, which is a knee-specific health-related quality-of-life instrument that is appropriate for measuring symptoms, function, and sports activity for individuals with a variety of knee conditions, including ligamentous and meniscal injuries, patellofemoral pain, articular cartilage lesions, and arthritis. This instrument has been demonstrated to be reliable, valid, and responsive 25,26 . Importantly, the items on the IKDC Subjective Knee Form do not function differently between young and old individuals, male and female individuals, and individuals with different knee conditions; therefore this instrument can serve as a "common currency" for measuring an individual's perception of his or her clinical outcome. Further research is underway to establish age and gender-specific norms and to compare the reliability, validity, and responsiveness of this instrument with those of other condition-specific health-related quality-of-life measures for the knee. It is hoped that the IKDC Subjective Knee Form will be incorporated into research studies as a clinical outcome measure with which to validate advances in orthopaedic sports medicine practice. What's New in the Shoulder and Upper Extremity
Rotator Cuff The most effective minimally invasive technique for rotator cuff repair remains a matter of debate. The results of a biomechanical study comparing arthroscopic and mini-open techniques in cadaveric shoulders were presented at the Annual Meeting of the AOSSM in 2002 31 . The presenters found that a mini-open repair with double-row fixation was superior to a single row of suture anchors. However, a recent clinical study comparing an all-arthroscopic technique with a mini-open technique showed that differences in outcome depended on the size rather than the technique of repair 32 . It is likely that the experience and technical ability of the individual surgeon greatly influence the clinical outcome of these technically demanding procedures. Prospective, long-term clinical outcome studies are needed to further evaluate these techniques.
Shoulder Instability The debate continues regarding open versus arthroscopic treatment of shoulder instability. A recent study of open stabilization in fifty-eight American football players with traumatic anterior shoulder instability demonstrated no postoperative dislocations and two postoperative subluxations after an average duration of follow-up of thirty-seven months 34 . Although the initial results of arthroscopic stabilization techniques suggested higher rates of recurrent instability, recent clinical studies have demonstrated results comparable with those of open techniques. A study of arthroscopic stabilization presented at the 2002 Annual Meeting of the AOSSM demonstrated a 91% success rate in high-demand collision athletes after an average duration of follow-up of 38.9 months 35 . These improved results likely reflect advances in implant technology, arthroscopic technique, and patient selection. With these advances, the indications for arthroscopic stabilization are expanding. Surgeons are now performing arthroscopic stabilization procedures in patients with recurrent instability and in patients who participate in collision sports, but long-term follow-up studies are lacking. Long-term data will help to further modify patient-selection criteria and characterize the durability of various arthroscopic techniques. Thermal capsulorrhaphy remains a popular topic in sports medicine. This relatively new modality has become popularized by its simplicity and minimal morbidity in treating instability of the shoulder. Despite its growing popularity, very little basic-science and clinical information is available to support its selection over more traditional means of stabilization. Clinical results have varied widely, ranging from early stiffness and loss of motion to recurrent instability. The factors responsible for this variation are not yet understood. Two studies presented at the 2002 Annual Meeting of the AOSSM demonstrated unacceptably high failure rates of approximately 30% 36,37 . While a recent study suggested that thermal capsulorrhaphy has no deleterious effects on the proprioception or function of the shoulder 38 , there is much to learn regarding the long-term biological and biomechanical effects of thermal energy on the shoulder joint and the clinical relevance of these effects. The classification of shoulder instability has been variable and remains a controversial topic. Many characteristics have been used to classify shoulder instability, including the duration, etiology, and direction of instability. In many cases, however, these elements of instability do not adequately communicate the nature of the injury. In 2002, Gerber and Nyffeler 39 described a classification system that differentiates between static instabilities, dynamic instabilities, and voluntary dislocation. The use of this system should have diagnostic, therapeutic, and prognostic value and should improve communication among orthopaedic surgeons regarding shoulder instability.
Medial Elbow Instability
As reported at the 2002 Annual Meeting of the AOSSM, magnetic resonance imaging-documented partial ulnar collateral ligament injuries and abnormalities are common in asymptomatic baseball pitchers
40 . It is thus recommended that additional diagnostic studies be performed, prior to surgery, to determine if these findings are responsible for a patient's medial elbow symptoms. A recent study suggested that valgus stress radiography can help to determine whether surgical treatment of an ulnar collateral ligament injury is warranted
41 . Patients with a Jobe et al. 43 first described double-strand reconstruction of the ulnar collateral ligament with use of a free tendon graft that was secured to the medial epicondyle and the proximal aspect of the ulna in a figure-of-eight fashion. With this technique, complications can arise from detachment of the origin of the flexor-pronator muscle group, transposition of the ulnar nerve, and extensive drilling of the medial epicondyle. Concern also exists regarding the adequacy of graft-tensioning during fixation of the graft. Recent studies have focused on techniques of ulnar collateral ligament reconstruction that minimize the potential for complications, particularly those related to the medial epicondyle and the ulnar nerve. In a study published in 2002, Rohrbough et al. 44 both described and reported the clinical results of the docking technique for ulnar collateral ligament reconstruction. This modification of Jobe's original procedure involves a muscle-splitting approach to the ulnar collateral ligament, sparing the flexor origin. It also involves the use of one, rather than three, holes in the medial epicondyle, avoids the need to transpose the ulnar nerve, and simplifies the method of graft-tensioning prior to fixation. At an average of 3.3 years following ulnar collateral ligament reconstruction with use of the docking technique, 92% of patients had an excellent result and had returned to or exceeded their previous level of play. A similar study presented at the 2002 Annual Meeting of the AOSSM demonstrated that twenty-four of twenty-five elite throwing athletes who had undergone ulnar collateral ligament reconstruction with use of the docking technique were able to return to their preinjury level of play 45 . These reports suggest that the docking technique may offer superior results compared with those of Jobe's original procedure while minimizing the associated risks. What's New in Other Areas
Hip and Groin Injuries Intra-articular hip pathology can now be addressed successfully with hip arthroscopy, flexible instrumentation, and appropriate rehabilitation. In athletes, the most common indication for hip arthroscopy has been labral pathology. Arthrography has provided a valuable tool for the diagnosis of elusive causes of disabling hip pain, including labral and chondral damage and rupture of the ligamentum teres. It has also provided an alternative to open techniques to remove loose bodies or impinging osteophytes 47 . In a study of twenty-eight professional athletes with traumatic labral tears, it was found that treatment with arthroscopic débridement and thermal stabilization resulted in immediate pain relief in all patients. Return to play was achieved by all players over three to twelve weeks 48 . However, as further research on the use of thermal stabilization in the shoulder has raised a variety of concerns, we must urge caution before proceeding too aggressively with the use of this technique in the hip. Nevertheless, results suggest that early and proper diagnosis of labral pathology in combination with appropriate patient selection is key in the treatment of these injuries as the prognosis for return to play appears to be good.
Achilles Tendon Ruptures What's New in Education?
American Orthopaedic Society for Sports Medicine Developed by an independent third party with oversight from the AOSSM's Member Benefits and Development Committee, the 147-page loose-leaf publication provides separate profiles of each practice as well as an analysis of common themes found in the various expressions of orthopaedic sports medicine practice. The publication was developed as a resource for all orthopaedists who may have a special interest in orthopaedic sports medicine. The Society continues to provide a broad range of educational programming, frequently in partnership with other medical organizations and/or sports governing bodies. Last year, in addition to its Annual Meeting, Specialty Day Meeting, and AOSSM Surgical Skills Course, the Society held courses on hockey with the National Hockey League (NHL) and the NHL Team Physicians Society, courses on soccer with the Fédération Internationale de Football Association and the United States Soccer Federation, the Advanced Team Physician Course with the American Medical Society for Sports Medicine and the American College of Sports Medicine, and Frontiers in Sports Medicine with the AAOS. In the future, the Society will be jointly offering a football course with the National Football League (NFL) Team Physicians. In addition, the Society is planning to hold meetings on baseball and to revisit the hockey and soccer meetings, possibly in multinational venues. This wide array of educational offerings reflects a collegial approach to working with other professionals and organizations to enhance both the body of knowledge and practice in sports medicine.
Subspecialty Certification in Orthopaedic Sports Medicine Medical Errors The sports medicine community has joined with most of the rest of the orthopaedic profession as part of the AAOS Patient Safety Coalition. While the coalition is still in its formative stages, the sports medicine environment provides an important venue for evaluating, monitoring, and addressing issues related to patient safety. This issue is of growing importance as the profession and its members—especially those who work with elite athletes—are increasingly faced with both a litigious environment and a patient population with considerable economic value at risk. Similarly, the growth of sports medicine for younger and older populations has expanded the opportunity and the need to more closely evaluate the prevalence and impact of medical errors within these populations. In Memoriam: Alexandra "Sandy" Kirkley, MD, FRCSC, MSc (1962-2002) On September 8, 2002, Sandy Kirkley and her husband Michael were killed in a small plane crash. In her relatively brief career, Sandy had established herself as a national and international leader in orthopaedic sports medicine. She had proven to be a superb clinical investigator with a passion for application of the scientific method to clinical problems. In addition to her outstanding professional abilities, Sandy was known by her friends and colleagues as a loving and caring mother, wife, and physician. The world of orthopaedic sports medicine has lost a great leader, and our hearts go out to her family and close colleagues from the University of Western Ontario. Note: The authors would like to acknowledge the assistance of Irv Bomberger and James J. Irrgang, PhD, of the American Orthopaedic Society for Sports Medicine for their contributions to this manuscript.
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0.5-mm side-to-side difference in ulnohumeral distance under valgus stress radiography responded favorably to conservative treatment, whereas patients with a >1.0-mm difference did not. Furthermore, ultrasonography recently has been shown to be an accurate means of both assessing the integrity of the ulnar collateral ligament and characterizing the degree of medial elbow laxity under applied valgus stress
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