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© 2004 The Journal of Bone and Joint Surgery, Inc. What's New in Sports Medicine1 University of Virginia, McCue Center—3rd Floor, Emmet Street and Massie Road, Charlottesville, VA 22903. E-mail address: mdm3p{at}virginia.edu
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
It is indeed an honor to be asked to present this update for the subspecialty of sports medicine. I would be remiss if I did not recognize the previous author of this section, Dr. Christopher Harner. When I embarked on this academic project, I did not have a good appreciation for the work that would be involved or how large the shoes were that I was being asked to fill. Sports medicine continues to grow as a subspecialty, and, as has been pointed out in previous updates, it crosses many boundaries. Therefore, before embarking upon a year-inreview article for orthopaedic sports medicine, it may be useful first to define what sports medicine really means. The central focus for the practice of sports medicine is the care of the athlete. Athletes come in a variety of shapes and sizes and represent a variety of sports, competitive levels, and nationalities, and we have dedicated our professional careers to their care. The American Board of Orthopaedic Surgery (ABOS) and the American Board of Medical Specialties (ABMS) have defined orthopaedic sports medicine to include expertise in the areas summarized in Table I. As orthopaedic sports medicine subspecialists, we have a variety of operative tools and techniques available to help us in this mission. The arthroscope is one such tool, but being an accomplished arthroscopist does not make one an orthopaedic sports medicine subspecialist.
As we embark upon difficult decisions regarding subspecialty certification, it is important for us to focus on these critical concepts. The ABMS formally approved subspecialty certification in orthopaedic sports medicine on March 20, 2003. Subspecialty certification is intended to be an extension of the current academic and scientific environment and will be built by the contributions of the orthopaedic sports medicine community. The ABOS will administer the new certification in a one-day written examination that is expected to be initiated as soon as the spring of 2006. What this means, and how this is accomplished, will in large part be decided by us as subspecialists; all are encouraged to get involved! This update is based on scientific and organizational activities in sports medicine that took place from September 2002 to August 2003. 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), the American Academy of Orthopaedic Surgeons (AAOS), and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). These meetings featured more than 250 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.
Anterior Cruciate Ligament There continues to be a great deal of controversy regarding the optimum type of graft to be used for anterior cruciate ligament reconstruction. Most studies have supported the premise that there are now two "gold standards," with bone-patellar ligament-bone and hamstring autografts being equally effective. One recent prospective, randomized study comparing these two graft choices demonstrated that knee laxity and knee flexion strength were superior in the bone-patellar ligament-bone group1. It is important to note, however, that a two-strand rather than a four-strand hamstring graft was used in that study. A meta-analysis concluded that bone-patellar ligament-bone grafts had better stability and a lower rate of failure than hamstring grafts did but were associated with an increased rate of anterior knee pain2. Other studies, including two in the same issue of The American Journal of Sports Medicine in which the meta-analysis appeared, suggested that both grafts are equally effective. The results of anterior cruciate ligament reconstruction continue to improve, largely because of improvements in surgical technique. Tunnel placement continues to be an important consideration. More posterior placement of both the tibial and femoral tunnels has resulted in improved function and reduced graft impingement. The location of the tibial tunnel in the coronal plane should also be considered. Placing the femoral tunnel at 60° in the coronal plane lowers graft tension in flexion when the transtibial technique is used3. A biomechanical study demonstrated that the risk of patellar fractures associated with bone-patellar ligament-bone graft harvesting was reduced in specimens with round bone plugs that were created with a curved chisel4. Thermal treatment of "partial" or "stretched" ligaments or grafts should be discouraged. In an animal study, anterior cruciate ligament ruptures occurred at an average of approximately two months following surgery in all eighteen dogs that had been so treated5. Other, unpublished studies have also raised concern about the use of thermal devices for this purpose. A great deal of research continues to be focused on injury prevention and gender issues associated with the anterior cruciate ligament. Jump and proprioception training have been successful in reducing injuries, especially in the female population. One study demonstrated that collegiate female athletes who were involved in high-risk sports exhibited less muscular protection of the knee ligaments during external loading than did male athletes6. Other considerations such as hormonal factors remain controversial. One recent study suggested that receptors for the hormone relaxin are present in the anterior cruciate ligament of women but not men, which may contribute to the increased rate of anterior cruciate ligament injuries in women7. One encouraging finding was that although the prevalence of anterior cruciate ligament tears is higher in women, the reported overall prevalence of associated meniscal and chondral injuries is lower8. Pediatric anterior cruciate ligament injuries, including tibial eminence fractures and midsubstance tears, continue to be a focus of interest. One study demonstrated that soft-tissue interposition is not responsible for irreducibility of type-III tibial eminence fractures. That study demonstrated that the anterior cruciate ligament and the anterior horn of the lateral meniscus were both attached to the fragments and that by "pulling in different directions" these structures prevented closed reduction of these fractures9. Another factor in these injuries is meniscal entrapment, especially entrapment of the anterior horn of the medial meniscus. The prevalence of midsubstance anterior cruciate ligament injuries in children appears to be on the rise. Although nonoperative management of these injuries is often advocated, one recent study demonstrated that a delay in surgical treatment was associated with a higher prevalence of medial meniscal tears10. Anterior cruciate ligament reconstruction in the very young child should be modified to avoid drilling across the femoral physis. Several reports presented at the Annual Meeting of the AOSSM in San Diego in July 2003 demonstrated that it is safe to drill a central vertical tibial tunnel as long as soft-tissue grafts are used. Other surgeons have developed techniques to avoid both physes, with encouraging results11.
Other Knee Ligaments Vehicular trauma is believed to be a major factor related to the increased prevalence of traumatic knee dislocations. Air bags, which now allow accident victims to survive previously fatal injuries, ironically may be responsible for this phenomenon. Surgical repair or reconstruction of the cruciate ligaments was superior to nonoperative treatment of these injuries in one recent European study14. Good results have been reported in association with bicruciate reconstructions in the United States as well15.
Meniscal Tears The most ideal method for meniscal repair continues to be vertical mattress sutures, which usually are placed with an inside-out technique. All-inside techniques are very popular, but there have been numerous reports of complications in association with the devices used with this method. The newest all-inside devices (FasT-Fix [Smith and Nephew Endoscopy, Andover, Massachusetts] and Rapid Loc [Mitek, Norwood, Massachusetts]) allow tensioning of the sutures, which is an attractive feature. One recent study showed that the FasT-Fix device was biomechanically equivalent to vertical sutures and was significantly stronger than meniscal arrows16. Partial meniscectomy traditionally has been accomplished with baskets and shavers. A new technique that utilizes high-pressure fluid has become popular but has not been studied extensively. The use of thermal devices for partial meniscectomy does not appear to lead to the adverse consequences that have been associated with the use of thermal probes for the treatment of ligaments or articular cartilage because the depth of penetration is reported to be only 2 mm17. Nevertheless, thermal techniques do not appear to offer any advantages compared with conventional mechanical techniques. The mere presence of a meniscal tear in the degenerative knee, however, is not an indication for arthroscopy. One recent study demonstrated that meniscal tears were a very common magnetic resonance imaging finding in asymptomatic patients and that there was no difference in pain or function between osteoarthritic patients with or without meniscal tears18. The presence of mechanical symptoms, and not pain alone, is important for determining the indications for arthroscopy. Although there has been some concern about shrinkage or degeneration of allograft menisci, meniscal transplantation has recently shown some intermediate-term success.
Articular Cartilage Injuries The use of thermal devices for the treatment of articular cartilage injuries has been associated with chondrocyte death and therefore has been discouraged. A recent study showed that the use of these devices also was associated with decreased matrix metabolism20.
Osteoarthritis Although unicompartmental knee replacement has seen a resurgence in popularity24, there is still a role for osteotomy in the treatment of isolated one-compartment osteoarthritis. A recent study25 demonstrated a ten-year survival rate of 90% (with conversion to total knee arthroplasty as the end point) when the radiographic valgus angle at one year was between 8° and 16°. Medial opening-wedge osteotomies have been popular for the treatment of medial compartment arthritis and offer several advantages compared with traditional lateral closing-wedge osteotomies. Options for bone-grafting during these procedures include autogenous iliac crest grafts, allografts (wedges, cancellous grafts, or femoral head grafts), and grafting the defect with hydroxyapatite wedges26. Several unpublished studies have pointed out that osteotomies are associated with a high rate of complications.
Other Knee Problems Surgical treatment of refractory patellar tendinosis (jumper's knee), including excision of pathological tissue and drilling of the inferior pole of the patella, resulted in good or excellent results in 85% of patients in one study30. The results were less predictable in volleyball players.
Traumatic posterior subluxation of the hip can have disastrous consequences in American football players. According to one recent study, patients who have severe pain after a fall on a flexed, adducted hip should be evaluated with oblique radiographs to rule out an associated posterior acetabular lip fracture and with magnetic resonance imaging to evaluate the presence and size of a hemarthrosis, which, if present, should be aspirated31.
Surgical treatment of Achilles tendon ruptures in athletes continues to be favored by most surgeons. One recent study suggested that in addition to an increase in the number of these injuries, the rates of rerupture and deep infection also have been on the rise over the last decade32. The authors attributed this finding to changes in their study population (increasing age, concurrent diabetes, steroid use, and smoking). Surgical débridement for the treatment of chronic Achilles tendinopathy is now considered to be an acceptable option for patients who have failed to respond to conservative treatment33. The unfused os trigonum can cause symptomatic posterior ankle pain, most commonly in ballet dancers. Abramowitz et al. reported that surgical excision through a posterolateral approach yielded good results in patients who had remained symptomatic after a minimum three-month trial of nonoperative treatment34.
Instability and Labral Tears Reliable classification of traumatic and atraumatic shoulder instability remains an important concept. Arthroscopic techniques for labral repair are becoming increasingly popular and successful. Earlier reports of failures associated with arthroscopic techniques were primarily related to nonanatomical repairs of the labrum. Improved techniques and implants have revolutionized the surgical treatment of shoulder instability35. These techniques also have been successfully used for the treatment of posterior shoulder instability36. One must be careful when comparing the results of arthroscopic treatment of instability with published reports of open repair. One recent study demonstrated a 17% rate of recurrence of instability (including subluxation) in association with open repairs after four to nine years of follow-up37. Treatment of atraumatic multidirectional instability in patients with systemic hyperlaxity remains a challenge. Capsulorrhaphy is an important treatment option for individuals in whom prolonged nonoperative management fails, and arthroscopic techniques continue to be refined. Thermal capsulorrhaphy has largely fallen out of favor for this group of patients, largely because of failure rates averaging  40%38. One
study showed that collagen structure can remain histologically abnormal for as
long as sixteen months following thermal
capsulorrhaphy39.
Arthroscopic plication has been advocated for this population of patients;
however, the amount of volume reduction that can be achieved with these
techniques is limited. The key unanswered question remains, "How much
volume reduction is clinically important?" One study demonstrated that
selective capsulorrhaphy limits passive glenohumeral motion; specifically,
anterosuperior plication decreased external rotation of the adducted arm by
30°, anteroinferior plication reduced abduction and external rotation by
about 20°, and posterosuperior plication limited internal rotation of the
adducted arm by approximately
16°40. While it is widely recognized that the risk of recurrent anterior instability following a first-time anterior shoulder dislocation is age-related, a three-year observational cohort study identified risk factors for early redislocation (within six weeks after the initial event). Patients at increased risk for early dislocation included individuals with high-energy injuries, patients with neurological defects, and patients with associated large rotator cuff tears or glenoid rim and/or greater tuberosity fractures41. Tears of the superior part of the labrum from anterior to posterior (SLAP tears) have been well described in the recent literature. Diagnosis of these lesions continues to present a challenge, and even arthroscopic identification of SLAP tears remains controversial. One recent study suggested that SLAP tears often are associated with concomitant Bankart or supraspinatus tears, depending on the patient's age42. It is important to recognize that anatomical variants in the anterosuperior part of the labrum exist and should not be addressed surgically43.
Rotator Cuff Injuries The imaging of rotator cuff tears continues to improve. Magnetic resonance imaging is helpful in the diagnosis of full-thickness rotator cuff tears, but the common finding of a partial-thickness tear should not influence surgical decision-making. Although ultrasound is not commonly used in this country, it is effective for the evaluation of rotator cuff integrity both preoperatively and postoperatively45. There has been a tremendous push toward arthroscopic treatment of rotator cuff injuries. The enthusiasm has been fueled by patients and surgeons alike. Although some studies have shown arthroscopic techniques to be as effective as open techniques, the jury is still out. Advocates of arthroscopic repair have suggested that the advantages of this method include better mobilization and release of the cuff, decreased surgical insult to the deltoid, decreased postoperative pain and stiffness, and the ability to address larger tears with "margin convergence."46 Disadvantages include the lack of bone-tendon fixation, technical difficulty with suture placement, suture management, and arthroscopic knot-tying. The transition from mini-open to arthroscopic techniques can be accomplished sequentially with a "proper transition strategy."46 The weak link following arthroscopic rotator cuff repairs is likely to be the suture and not the anchors47. Most arthroscopic techniques involve the use of simple or mattress sutures, which are not as strong as locking sutures. Anchor design is an important consideration, however, because some anchors may have sharp edges that can abrade suture48. Duplication of fixation techniques (i.e., two rows of anchors or the combined suture anchor and trough technique) appears to more reliably reproduce the anatomy of the rotator cuff insertion "footprint" and is stronger biomechanically49.
Lateral Epicondylitis A carefully controlled, randomized, multicenter trial demonstrated that extracorporeal shock wave therapy was not effective for the treatment of lateral epicondylitis50. The authors attributed the previously reported success with this treatment modality to inappropriate study designs.
Ulnar Collateral Ligament Injuries
Cryotherapy is a widely used postoperative modality. In an animal model, researchers at Wake Forest University proved that ice reduces edema by decreasing microvascular permeability52. The use of nutritional supplements continues to be a major concern for team physicians. There continues to be a lack of control and regulation regarding these supplements, despite the fact that some of them have been implicated in the untimely deaths of athletes. Physicians typically do not recommend a supplement unless it is known to be effective, but athletes often try any supplement or ergogenic aid that they perceive to be safe53. Head and neck injuries are a major concern to team physicians. Concussions remain the most common type of sports-related head injury. Loss of consciousness is not an element of mild or moderate (grade-I or II) concussions. The hallmarks of concussion are confusion and amnesia. Residual symptoms following a concussion are an important consideration because of the risk of the so-called second-impact syndrome. If athletes are allowed to return to play before symptoms (headache, confusion, nausea, and so on) resolve, they risk more serious injuries and even death54. Although classification schemes and return-to-play recommendations vary, current guidelines suggest that athletes should be excluded from competition for at least one week after the resolution of symptoms following a mild or moderate concussion and for at least one month if the athlete suffered a loss of consciousness55. One recent study suggested that any degree of postconcussion headache in high school athletes within seven days after injury is probably associated with an incomplete recovery from the concussion56. Neuropsychological testing has added some objectivity to the treatment of concussions. There have been several reports regarding high rates of back pain in rowers. This may be attributed to the increasing size of these athletes, initiation of the sport at a younger age, and increased training intensity57. Spondylolysis is a common problem in gymnasts, interior lineman, and weightlifters. The treatment of this condition has rarely included surgery, but one Japanese study demonstrated high rates of fusion and improved results following segmental wire fixation58.
In 2002, the editorial staff of The Journal reviewed a large number of research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over forty medical journals were reviewed to identify these articles, which all have a high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eleven grade-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.
Specialty Day for both the American Orthopaedic Society for Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA) will be held on March 13, 2004, at the Annual Meeting of the American Academy of Orthopaedic Surgeons in San Francisco, California. The AANA Annual Meeting will be held on April 22 through 25, 2004, in Orlando, Florida. The AOSSM Annual Meeting will be held on June 24 through 27, 2004, in Quebec City, Canada. 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 is the most popular fellowship in orthopaedic surgery. Approximately one-third of all graduating residents do a fellowship in our subspecialty. There are currently ninety-five programs with 205 fellows per year across the country, and several international fellowships are available to qualified applicants. There is inevitably some controversy and difference of opinion regarding fellowship opportunities. One major issue is accreditation through the Accreditation Council for Graduate Medical Education (ACGME). Just over one-half of the current fellowships are accredited. Accreditation will become more important when subspecialty certification becomes a reality. Because of the long lead-time between fellowship application and graduation, and the likelihood that ABOS certification will be required prior to subspecialty qualification, the timelines outlined in the introduction to this article need to be recognized by applicants for sports medicine fellowships starting now. The other controversy surrounds the fellowship match program. Although the match, coordinated by the National Residency Matching Program (NRMP), has been a huge success for residency programs and some fellowship programs, it has recently become a problem for sports medicine fellowship programs. Approximately 60% of these programs do not participate in the match, and many of the programs that do participate encourage applicants to drop out of the match or offer conflicting information to interviewees. The American Orthopaedic Society for Sports Medicine is aware of these difficulties and is working closely with the NRMP to rectify them. We hope to have a solution by the time that the next What's New in Sports Medicine is written.
Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ. 2002;325:468. This was a pooled analysis of five studies that demonstrated that stretching did not significantly reduce muscle soreness or the risk of injury. No conclusion could be reached about the effect of stretching on athletic performance because of the paucity of papers on this subject. This study was a good review of the literature and summarized what many of us have believed clinically. Hess T, Duchow J, Roland S, Kohn D. Single-versus two-incision technique in anterior cruciate ligament replacement: influence on postoperative muscle function. Am J Sports Med. 2002;30:27-31. This randomized, prospective study compared the results of one and two-incision techniques for anterior cruciate ligament reconstruction at one year. The authors found that the single-incision group had improved quadriceps and hamstring strength on isokinetic testing at three and six months postoperatively. The authors suggested that the single-incision group improved faster than the double-incision group did. They attributed these findings to vastus lateralis dissection. Other clinical parameters were essentially equal. This was a well-designed study, but it is of limited clinical utility because most surgeons currently use single-incision anterior cruciate ligament reconstructions and rarely use double-incision techniques. Stein DT, Ricciardi CA, Viehe T. The effectiveness of the use of electrocautery with chondroplasty in treating chondromalacic lesions: a randomized prospective study. Arthroscopy. 2002;18:190-3. This was a randomized, prospective study of 146 patients who had either chondroplasty or chondroplasty and electrocautery. The authors found that electrocautery offered little benefit in the treatment of chondral lesions and in fact may limit the chance of a successful outcome. This was an important study because the ideal treatment of chondral injuries remains controversial. Numerous recent articles have suggested that thermal devices have a negative effect on articular cartilage. This study suggested that electrocautery, like radiofrequency, should be used sparingly in the treatment of chondral injuries. Owens BD, Stickles BJ, Balikian P, Busconi BD. Prospective analysis of radiofrequency versus mechanical débridement of isolated patellar chondral lesions. Arthroscopy. 2002;18:151-5. This was a prospective, randomized study in which radiofrequency was compared with mechanical débridement for the treatment of patellar chondral lesions. The groups were studied at one and two years postoperatively. The authors suggested that the radiofrequency group had superior results following the treatment of grade-2 and 3 chondral lesions. These results are clearly better than those of other studies on the use of radiofrequency. Concerns about chondrocyte death extending well beyond the area treated with radiofrequency devices raise questions about the findings of the study itself. The best treatment for these injuries is unclear, and the long-term recommendations regarding the use of radiofrequency for the treatment of articular cartilage lesions remain extremely controversial. Hoenecke HR Jr, Pulido PA, Morris BA, Fronek J. The efficacy of continuous bupivacaine infiltration following anterior cruciate ligament reconstruction. Arthroscopy. 2002;18:854-8. This was a prospective, randomized, double-blind study in which continuous bupivacaine infiltration was compared with saline infiltration following anterior cruciate ligament reconstruction. In both groups, a disposable pump with an infusion rate of 2 mm/hour was used for forty-eight hours. The authors found significant differences between the groups with regard to visual analog scores for pain. The bupivacaine group used 37% less narcotics compared with the placebo group. There were no other differences between the groups, and no complications were noted in association with this technique. This was a well-done study, and it had further credibility because it was not funded by the pump manufacturer. This study suggests that the use of pain pumps may have some clinical utility. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;3:CD003762. This was a pooled analysis of several studies concerning the treatment of lateral ankle sprains. The findings included a shorter time to return to work for patients who had been treated with a semi-rigid cast compared with those who had been treated with a short-leg cast. Similarly, patients who had received functional treatment had better outcomes in terms of return to sports, return to work, short-term ankle swelling, objective instability, and satisfaction. There were no differences in terms of pain, long-term swelling, subjective instability, recurrent sprains, or range of motion. Although this study does provide some useful information to the clinician, most sports medicine specialists do not utilize casts for the treatment of lateral ankle sprains and therefore the usefulness of this study is somewhat limited. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med. 2001;29:722-8. This was a randomized study from Norway in which anterior cruciate ligament reconstructions that had been performed with hamstring grafts were compared with those that had been performed with patellar ligament grafts. The patients were evaluated at six, twelve, and twenty-four months. The two groups were comparable with regard to most study parameters. The subjective results and the results of single-leg hop tests were better for the hamstring group after six and twelve months, but no differences were found after twenty-four months. The hamstring group had better isokinetic knee extension strength at six months, but not at twelve and twenty-four months. The authors also found that there was significant weakness in isokinetic knee-flexion strength in the hamstring tendon group. Finally, anterior knee pain was not significantly different between the two groups, but kneeling pain was significantly less common in the hamstring group after twenty-four months. Numerous other studies have compared hamstring and patellar ligament grafts. Most of those studies, like the one described here, demonstrated small differences. Overall, both grafts are considered to be effective. Jacobson E, Forssblad M, Weidenhielm L, Renstrom P. Knee arthroscopy with the use of local anesthesia—an increased risk for repeat arthroscopy? A prospective, randomized study with a six-month follow-up. Am J Sports Med. 2002;30:61-5. This was a prospective, randomized study of 400 patients undergoing knee arthroscopy. The patients were allocated into three groups, with one-half being assigned to local anesthesia, one-quarter being assigned to spinal anesthesia, and one-quarter being assigned to general anesthesia. The patients were evaluated six months after surgery. The only parameter studied was repeat arthroscopy. Three of the 200 patients who underwent arthroscopy with local anesthesia required repeat surgery, but none of the patients in the other groups required repeat arthroscopy. The authors concluded there was no difference among the three groups with regard to the rate of satisfaction. This was an interesting paper, but it did not include a power analysis; therefore, the conclusions are difficult to endorse. Furthermore, parameters other than just repeat arthroscopy should be studied and a follow-up period of greater than six months may be more appropriate. Lam RY, Ng GY, Chien EP. Does wearing a functional knee brace affect hamstring reflex time in subjects with anterior cruciate ligament deficiency during muscle fatigue? Arch Phys Med Rehabil. 2002;83:1009-12. The authors of this study attempted to determine if a functional knee brace affects muscle fatigue and hamstring reflex time in subjects with anterior cruciate ligament deficiency. In a repeated-measures clinical trial, the authors found that a functional brace facilitated hamstring muscle reflex time but that muscle fatigue lengthened the hamstring reflex latency. Therefore, they suggested that the use of a knee brace was not protective during sporting activities for patients with anterior cruciate ligament-deficient knees. This article is another addition to the already large body of literature that suggests that anterior cruciate ligament functional braces provide no benefit. In fact, anterior cruciate ligament functional braces have been shown to be beneficial only for skiers. I believe that the authors' conclusion is correct and that functional braces should not be relied on for the protection of anterior cruciate ligament-deficient knees. Nau T, Lavoie P, Duval N. A new generation of artificial ligaments in reconstruction of the anterior cruciate ligament. Two-year follow-up of a randomised trial. J Bone Joint Surg Br. 2002;84:356-60. This was a randomized clinical trial in which reconstructions of the anterior cruciate ligament that had been performed with a patellar ligament autograft were compared with those that had been performed with a synthetic anterior cruciate ligament (ligament advancement reinforcement system; LARS, Arc sur Tille, France). After two years of follow-up, the authors found no difference between the two groups with regard to the failure rate. A close review of the results suggests that there was more laxity in the LARS group at six months but that the difference was not significant at twelve and twenty-four months. Nevertheless, the difference appeared to approach significance, and the small size of the samples makes this finding a cause for concern. The authors suggested that the LARS device may allow for an earlier return to activities, although they offered no supporting evidence. This article should cause concern, especially among surgeons in the United States, who have had extremely poor experiences in association with the use of synthetic ligaments for anterior cruciate ligament reconstruction. A longer follow-up study with additional subjects and an appropriate power analysis should be accomplished. Synthetic ligaments are not even available in the United States, a fact that should certainly raise our index of suspicion about the use of these devices. Stetson WB, Templin K. Two-versus three-portal technique for routine knee arthroscopy. Am J Sports Med. 2002;30:108-11. This was a prospective, randomized, double-blind study of only sixteen patients undergoing knee arthroscopy. The authors compared a two-incision technique with a three-incision technique. They found that the use of the third superomedial portal adversely affected quadriceps muscle strength, total strength, and Lysholm scores. Additionally, patients in whom the procedure was performed through a superomedial portal required more time before returning to work and normal activities. The authors recommended that the two-portal technique be used. This paper is somewhat useful, although most surgeons no longer use a superomedial portal. In fact, most arthroscopic pump equipment now allows the surgeon to perform arthroscopy with use of two standard portals. If a third portal is required, most surgeons prefer to use a superolateral rather than a superomedial portal for these very reasons. Nevertheless, concerns with the superomedial portal need to be expressed, and we discourage the use of this portal.
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Introduction
The Knee
2%) of patients, a second course of
treatment with hylan G-F 20 (Synvisc; Wyeth-Ayerst Pharmaceuticals,
Philadelphia, Pennsylvania) was shown to markedly increase the frequency of
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