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The Journal of Bone and Joint Surgery (American). 2006;88:457-468. doi:10.2106/JBJS.E.01099 © 2006 The Journal of Bone and Joint Surgery, Inc. What's New in Sports Medicine
1 Wright State University, 30 East Apple Street, Suite L-200, Dayton, OH 45409.
E-mail address:
ljrubino{at}hotmail.com
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
It is with a great sense of honor and pleasure that we present this year's update for the subspecialty of sports medicine. Our field was once again the most popular fellowship choice among graduating orthopaedic residents this past year. While many of us are wrestling with exactly what our ever-expanding field includes, especially while we prepare for the upcoming specialty certification that looms near, we can all agree that our primary concern should be the treatment of athletes. Whether these athletes come from the playground, the sandlot, or the stadium, we share this one common thread. This update is based on scientific and organizational activities in sports medicine that took place from September 2004 to August 2005. It includes a summary of the Annual and Specialty Day meetings of the American Orthopaedic Society for Sports Medicine (AOSSM), the Arthroscopy Association of North America (AANA), and the American Academy of Orthopaedic Surgeons (AAOS). These meetings featured over 200 scientific presentations focusing on sports medicine. In addition, the three most influential journals in our field—specifically, The Journal of Bone and Joint Surgery (American Volume), The American Journal of Sports Medicine, and Arthroscopy—will be reviewed.
Posterolateral Corner Appropriate management of the posterolateral corner of the knee is integral to the successful treatment of a multiple-ligament knee injury. Recognition of these injuries, especially on the basis of physical examination findings (for example, external rotation asymmetry as demonstrated with use of the dial test) and magnetic resonance imaging findings, is improving. Reconstruction of injured lateral-side structures is generally recommended over primary repair alone; however, primary repair with augmentation is still the best option for acute injuries (i.e., those treated within the first two weeks). Postoperative early range-of-motion protocols are important for successful outcomes. Biomechanical studies have shown that the loads across the lateral collateral ligament are higher in extension and that the popliteus and popliteofibular ligaments are subjected to higher loads with higher degrees of flexion1. Anatomically based repairs are more sound, both biomechanically and clinically.
Posterior Cruciate Ligament Lower-grade posterior cruciate ligament injuries are still best treated nonoperatively. A recent study demonstrated that, despite objective laxity, patients with grade-I or II posterior cruciate ligament injuries were able to perform gait and drop-landing activities similar to uninjured controls3. Additionally, subjective results in patients with posterior cruciate ligament deficiency were not correlated with objective laxity measurements. However, a recent cadaveric study demonstrated that stress increased in both the medial and the lateral meniscus with complete disruption of the posterior cruciate ligament and normalized after reconstruction of the posterior cruciate ligament4. If the posterior cruciate ligament does need to be reconstructed, the status of the posterolateral corner must be properly evaluated and treated. Failure to address the posterolateral corner has been shown to cause the failure of posterior cruciate ligament (and anterior cruciate ligament) reconstructions. Magnetic resonance imaging studies have shown that the prevalence of bone-bruising in patients with posterior cruciate ligament injuries is as high as that in patients with anterior cruciate ligament injuries but that the bruising pattern is more variable in the former group. The presence of the bruising should alert the surgeon to other potential injury sites. Sekiya and colleagues evaluated the biomechanical effect of reconstructing both the posterior cruciate ligament and the posterolateral corner in patients with combined injuries5. The reconstructions nearly restored native knee kinematics and demonstrated load-sharing among the grafts, creating a potentially protective effect against early posterior cruciate ligament failure, with increased force transmitted to the posterolateral corner reconstruction. Other causes of failure of posterior cruciate ligament reconstructions include incorrect tunnel placement and the failure to address varus malalignment. Lower graft/femoral tunnel angles can be obtained with the outside-in as compared with the inside-out technique of establishing femoral tunnels6. Kim et al., in a biomechanical study, demonstrated that central and lateral tibial tunnels exhibited lower stress between the ligament and the so-called killer turn7.
Anterior Cruciate Ligament A prospective evaluation of risk factors in female athletes documented a 2.5-times higher knee abduction moment at landing and a 20% higher ground-reaction force with decreased stance time in athletes who had sustained an anterior cruciate ligament injury9. Despite the discrepancy in the rates of anterior cruciate ligament injury between male and female athletes, the overall prevalence of anterior cruciate ligament injuries remains low and there are no recommendations to limit sports activity among female athletes in any way10. Additional factors associated with anterior cruciate ligament injuries include a positive family history of anterior cruciate ligament injury (with patients who have a positive history being two times more likely to sustain an anterior cruciate ligament injury), muscular fatigue associated with increased anterior tibial shear force, and increased valgus and decreased knee flexion angles at landing. The role of estrogen and estradiol concentration continues to be studied. Some studies have demonstrated a relationship between the prevalence of anterior cruciate ligament tears and cyclic estrogen surges, and other studies have refuted this temporal relationship. The effect of estrogen on anterior cruciate ligament fibroblasts was evaluated in an animal model that demonstrated the presence of estrogen receptors in ovine anterior cruciate ligament fibroblasts; however, there was no significant difference in anterior cruciate ligament fibroblast proliferation or collagen synthesis, regardless of the concentration of 17ß-estradiol11. On the basis of the results of that study, and given the low turnover of collagen in ligaments, it is thought to be unlikely that a two to three-day-per-month increase in circulating estrogen would result in clinically important alterations in the material properties of the anterior cruciate ligament in vivo. Finally, the importance of the femoral notch and its relationship to anterior cruciate ligament injuries has been questioned. A prospective study followed 305 National Basketball Association (NBA) players over eleven years after evaluation of the notch size and notch-width index12. These data were compared with those from the NBA's league-wide injury database, and the notch size and notch-width index were not found to be predictive of anterior cruciate ligament injury in these athletes. The choice of graft material for anterior cruciate ligament reconstruction continues to be a source of debate. Excellent results have been reported in association with bone-patellar tendon-bone autograft, hamstring autograft, quadriceps autograft, and allograft. When allograft is used, it is extremely important to be familiar with the rules and screening procedures of the tissue bank from which the graft is obtained. Early failure of anterior cruciate ligament reconstructions continues to be related to graft fixation, and many fixation devices are available. Regardless of the method chosen, it is imperative that stable initial graft fixation be achieved. Supplementary staple fixation in the tibia has been associated with improved laxity measurements and clinical stability two years after reconstruction of the anterior cruciate ligament with a hamstring graft. However, this improvement comes at the cost of increased pain during kneeling. The stability of the reconstructed anterior cruciate ligament depends on many factors, including fixation strength, tunnel placement, and graft tension. The exact tension that is required for stability of an anterior cruciate ligament graft remains unknown; however, studies have indicated that an initial graft tension of >45 N is required to restore objective laxity measurements. Many authors are currently investigating the need for a double-bundle anterior cruciate ligament reconstruction. The idea that a double-bundle reconstruction may more accurately restore knee kinematics in flexion as well as extension has stimulated much interest in the indications for, feasibility of, and results of this type of reconstruction13. To date, there is no clear indication that the use of a double-bundle technique will improve the clinical results of anterior cruciate ligament reconstruction. Attempts to encourage faster tendon-to-bone healing following anterior cruciate ligament reconstruction continue to be made. The addition of bone morphogenetic protein-7 (BMP-7) to the bone tunnels at the time of reconstruction with use of a patellar tendon graft was associated with earlier and better bone-healing and better biomechanical properties of the reconstructed anterior cruciate ligament. These findings suggest that BMP-7 augmentation is beneficial for anterior cruciate ligament reconstruction, especially for athletes who are seeking an earlier return to play. A rabbit study demonstrated that coating hamstring tendon grafts with mesenchymal stem cells resulted in a tendon-bone interface that more closely resembled the natural tendon-bone interface as well as in a higher failure load and stiffness at eight weeks. Another animal study demonstrated that the addition of a bone dowel in the tibial tunnel with standard soft-tissue graft fixation increased initial fixation stiffness and increased fit, which is known to enhance tendon graft-to-bone healing. The appropriate treatment of partial thickness injuries and stretch injuries of the anterior cruciate ligament also remains unclear. Arthroscopic thermal shrinkage for the treatment of anterior cruciate ligament laxity and partial thickness tears has been associated with long-term catastrophic failure and is no longer recommended. One study showed that the addition of exogenous growth factors had a beneficial effect on the healing of stretch injuries of the anterior cruciate ligament. There is a trend toward early reconstruction of the anterior cruciate ligament-deficient knee, especially in younger, more active patients. Many reports in the literature have documented favorable results in association with this approach. Early reconstruction has been shown to result in less late meniscal surgery and reduced knee laxity and symptomatic instability. However, reconstruction does not appear to reduce the risk of late radiographic degenerative changes. Another study demonstrated that reconstruction of the anterior cruciate ligament was associated with a decreased rate of reoperation (p < 00001) and that younger age was a strong predictor of failure of nonoperative treatment of anterior cruciate ligament injuries14. A thirty-five-year follow-up study of elite East German athletes documented the ability to return to sports after nonoperative treatment of an anterior cruciate ligament injury; however, 95% of the athletes had meniscal and cartilage damage over the next twenty years, and many were at high risk for needing a joint arthroplasty15. The anterior cruciate ligament is frequently involved in multiple-ligament knee injuries, and the most common injury combination involves the anterior cruciate and medial collateral ligaments. Early repair of ligament injuries is associated with a lower risk of articular and medial meniscal tears than late repair is. The risk of meniscal injuries increases when anterior cruciate ligament reconstruction is performed more than six months after the injury, and chondral damage is more common if reconstruction is performed more than one year after the injury16. The postoperative treatment of anterior cruciate ligament reconstructions is of paramount importance for obtaining and maintaining good functional outcomes. Early accelerated and early nonaccelerated rehabilitation protocols have been associated with similar increases in anterior cruciate ligament laxity two years postoperatively, and both protocols have produced similar outcomes in terms of clinical results, patient satisfaction, function, and biomarkers of cartilage metabolism. Postoperative functional bracing has not proven to be beneficial after anterior cruciate ligament reconstruction. Continued concerns about weakness in flexion and internal rotation after reconstruction of the anterior cruciate ligament with a hamstring autograft has led some authors to question the need to include the gracilis when harvesting the hamstring tendons. Despite the findings of magnetic resonance imaging studies and animal studies that have documented regeneration of the hamstrings, weakness in high degrees of flexion persists. A posterior mini-incision technique for harvesting hamstring grafts has been shown to be easy, to provide excellent cosmesis, and to have no problems with cutting grafts short. A two to eight-year follow-up study showed reliable and durable stability and good clinical ratings in association with the use of this method.
Meniscus The gold standard for meniscal repair remains the inside-out vertical mattress suture. Attempts at all-inside repairs have been made with meniscal arrows, and the results generally have been unfavorable. Six-year follow-up demonstrated inferior results compared with inside-out repairs17. Additionally, chondral damage has been reported after the placement of these arrows, with progression seen even after removal of the arrows18. Improved results have been reported in association with other all-inside techniques, specifically, the FasT-Fix. This device has shown higher pullout strength than conventional vertical mattress sutures under cyclic loading and load-to-failure testing. The two-year results of FasT-Fix repairs in the red-red or red-white zone are comparable with those of classic suture-repair techniques. The treatment of meniscal cysts remains controversial. These lesions are most commonly found laterally, and excellent results are obtainable with partial meniscectomy and cyst débridement. Recurrence appears to be related to overly conservative meniscectomy. The science and technology of meniscal transplantation continues to evolve. The indications for this procedure are gradually becoming clearer. On the basis of animal data, it appears that immediate transplantation following meniscectomy has a protective effect on articular cartilage, whereas delayed meniscal transplantation is associated with more severe articular cartilage changes than are seen without any transplant. If applicable to humans, this suggests that immediate meniscal transplantation may be beneficial in cases of meniscal damage necessitating a complete or near complete meniscectomy19. The five-year results associated with collagen meniscal implants were reported for eight patients. The meniscus-like tissue maintained its structure and functioned without any negative effects. The patients had improvement after the procedure and demonstrated no additional degenerative changes; however, the long-term chondroprotective effects remain unknown.
Cartilage Cartilage lesions remain troubling for both the physician and the patient. There are numerous options for treatment, depending on the nature of the lesion itself. Osteochondral autograft transplantation is an excellent option for the treatment of cartilage defects, particularly those in younger individuals with a short duration of symptoms. Animal data have shown that a minimally countersunk autograft can remodel and correct small incongruities; however, deeper seated grafts are unable to do so. If the lesion is unstable, it can be secured back to bone with use of bioabsorbable screws with good results21. If the lesions are not amenable to chondral repair or transplantation, then microfracture is the next best option. Protected weight-bearing allowed for complete filling of the defect with more mature cartilage and bone repair in a primate model22.
Despite the fact that many patients have had dramatic (although not
permanent) improvement, the treatment of osteoarthritis with knee arthroscopy
recently has fallen out of favor. Despite negative reports, recent literature
has shown that the presence of cartilage debris increases the expression of
tumor necrosis factor-alpha (TNF-
Basic Science
Patellofemoral Joint A four-year follow-up study of twenty-two patients who were managed with a mini-open medial reefing and arthroscopic lateral retinacular release for the treatment of recurrent patellar dislocations showed excellent patient satisfaction, with one case of instability and one case of subluxation. These results compare favorably, in terms of cosmesis and outcome, with those of more traditional and extensile surgical approaches to this difficult problem. Lateral release should be reserved for patients with objective evidence of patellar tilt. Acute patellar dislocations commonly involve an injury of the medial patellofemoral ligament. Multiple methods of reconstruction of the medial patellofemoral ligament have been described, all with good results, and medial patellofemoral ligament reconstruction alone has been shown to be as successful as distal realignment procedures. Regardless of the technique chosen to restore patellofemoral stability, it is clear that a lateral release alone is insufficient for the treatment of patellar instability. Treatment of patellar tendonitis remains difficult and is often unrewarding for the patient. The role of thermal microdébridement continues to evolve as a treatment for many chronic tendinopathies. A cadaveric study evaluating the effect of thermal microdébridement on the biomechanical properties of the patellar tendon demonstrated no significant difference between specimens treated with thermal microdébridement and controls with regard to ultimate stress at failure, elastic modulus, strain energy density, or strain at maximum load. Additional studies involving the use of an in vivo model will be required to completely assess the effects of thermal microdébridement on the biomechanical properties of human patellar tendons26. The diagnosis and operative treatment of "symptomatic" plica is perhaps too common. A case series described three symptomatic "bucket-handle tears" of the medial patellar plica in professional soccer players. All of these athletes had symptomatic relief following arthroscopic excision. The etiology of the symptomatic plica remains unknown.
The vascular anatomy of the acetabular labrum has been better defined. While there is an overall poor vascular supply to the labrum, the best and most consistent supply was found on the capsular side at the attachment to the osseous acetabulum27. Hip arthroscopy is becoming a more commonly used procedure to identify and treat conditions of the acetabular labrum. Arthroscopic débridement of acetabular labral tears has been associated with good results when patients with disability claims are excluded. A good correlation between improvement in the SF-36 and modified Harris hip scores after arthroscopic partial limbectomy has been established. Arthroscopic partial limbectomy was performed in one series of ten hips with early osteoarthritis and acetabular hypoplasia, with no evidence of progression of the osteoarthritis and good relief of pain. Acetabular labral tears with underlying chondral injury were found in a subset of high-level runners, suggesting an injury pattern common in this population. Femoroacetabular impingement is a relatively new diagnosis in patients with mechanical hip pain. Resection osteoplasty of the proximal part of the femur has been effective for reducing pain and may be performed either openly or arthroscopically. Regardless of surgical technique, the resection should not encompass >30% of the anterolateral quadrant of the head-neck junction of the femur because of the risk of fracture with larger resections28.
Snowboarder's ankle, a fracture of the lateral process of the talus, is commonly thought to be an ankle sprain and therefore is commonly missed. Patients are often referred to orthopaedists for the treatment of lingering problems associated with the "ankle sprain." Injuries tend to involve the board-leading leg and are more frequent in novice boarders. Elite boarders tend to sustain back and knee injuries more commonly than ankle and wrist injuries. Large fracture fragments of the lateral process should be fixed so that early weight-bearing can begin in a fracture boot29,30. Decreased peroneus longus muscle activity is associated with lateral ankle instability and recurrent ankle sprains. For patients requiring stabilization, the Brostrom lateral ankle reconstruction continues to be the standard treatment for recurrent lateral ankle instability. Multiple new techniques have been described to reconstruct the lateral side of the ankle with use of gracilis autograft and fixation with interference screws. Recently, arthroscopic thermal shrinkage was used for the treatment of refractory lateral ankle instability in twenty-two young, male soccer players, with eighteen of the twenty-two patients showing no evidence of ankle instability at forty-two months and twenty-one of the twenty-two patients returning to sports activity at the same level. The presence of focal chondral lesions of the ankle joint does not negatively affect the results of lateral ligament reconstruction when preoperative weight-bearing radiographs of the ankle do not show any joint-space narrowing. Autogenous osteochondral grafts in the talar dome have shown good results that have been predictably better in patients with smaller lesions. Ultrasound has proved to be effective for the evaluation of peroneal tendon tears. The advantages of ultrasound as compared with other imaging techniques are that it can be done in the office, it is quicker and less expensive, and it can be performed dynamically. The utility of ultrasound for the evaluation of the foot and ankle region as well as throughout the rest of the body remains dependent on the operator's ability and the physician's familiarity with reading and interpreting the results. Operative fixation of Jones fractures continues to be the treatment of choice for athletes. Numerous studies have confirmed that operative treatment with intramedullary fixation allows for a shorter time to union and a quicker return to desired activity. The minimum size of screw that is needed appears to be 4.0 mm. Return to sports activity is commonly possible at seven or eight weeks. Screws measuring <4 mm are discouraged because of increased failure rates. Numerous investigators have advocated operative treatment of Jones fractures in nonathletes as well31-33. Stress fractures in the foot continue to plague the endurance athlete, and muscle fatigue has been correlated with increased maximal force, peak pressure, and impulse under the second and third metatarsal heads and under the medial aspect of the midfoot toward the end of a fatiguing run. The demonstrated alteration of the rollover process with increased forefoot loading may help to explain the prevalence of stress fractures of the metatarsals under fatiguing loading conditions. Plantar fasciitis remains a difficult problem that is still best treated nonoperatively. Refractory cases treated with extracorporeal shock wave therapy continue to show good results. Repair of the ruptured Achilles tendon remains associated with a lower rerupture rate; however, repairs in patients who are less than thirty years of age have been associated with an increased rate of rerupture as compared with those in older patients. The use of caution in the postoperative rehabilitation regimen of these younger patients may decrease this rate.
The treatment of athletes who have pars defects remains nonoperative, although there have been reports of successful treatment of spondylolysis with posterior stabilization. Athletes with unilateral spondylolysis have increased stress at the contralateral pars and are susceptible to the development of contralateral pars fractures. The Brostrom lateral-side reconstruction remains the gold standard, and a technique to perform lateral ankle ligament repair safely in the skeletally immature patient with use of suture anchors has been described. Good results have been reported in association with percutaneous drilling of the symptomatic accessory navicular in young athletes, with excellent patient satisfaction and an 80% rate of bone-healing in patients with open physes.
The on-field treatment of cervical spine injuries in football players still includes leaving the helmet and shoulder pads on. Facemask removal is the standard of care. The physician and trainer covering events need to be familiar with the various types of helmets and straps that may be encountered. Football helmets and facemasks were tested by having certified athletic trainers remove the equipment under various conditions34. The Shockblocker loop strap was consistently superior in all variables tested, regardless of the tool used or the helmet to which it was attached. The cordless screwdriver created less movement, was faster, and was less difficult to use compared with cutting tools. Trial failure was more common with cutting tools than with the screwdriver. However, familiarity and competence with the cutting tools for facemask removal are necessary because facemasks often are not easily removed with a screwdriver because of age, rust, or infrequent or inadequate maintenance.
De Quervain stenosing tenosynovitis has been commonly found in professional volleyball players and is likely related to training time and consequent microtrauma. First-line treatment remains nonoperative, with activity restriction, nonsteroidal anti-inflammatory drugs, or steroid injections. No benefit has been noted in association with the combination of nonsteroidal anti-inflammatory drugs and a steroid injection in the first dorsal compartment. Professional catchers have more subjective hand symptoms, particularly weakness in the gloved hand, than players at other positions do. Microvascular changes have been found in the hands of otherwise healthy professional baseball players in all positions, with a higher prevalence in catchers, before the development of clinically important ischemia. Repetitive trauma resulting from the impact of the baseball also leads to digital hypertrophy in the index finger of the gloved hand of catchers. Gloves currently used by professional catchers do not adequately protect the hand from repetitive trauma. Immature competitive climbers demonstrate adaptive changes in the fingers due to increased stress; however, there is no increase in the prevalence of osteoarthritis in these athletes.
Rotator Cuff Techniques and indications for arthroscopic rotator cuff repair continue to evolve. Certainly, mini-open repair has supplanted traditional open repair, with equivalent outcomes and less morbidity. Controversy still exists with regard to the use of the mini-open technique as opposed to the all-arthroscopic technique. Many investigators have reported varying degrees of success or failure in association with both open and arthroscopic rotator cuff repairs. The importance of a learning curve in arthroscopic cuff repair has been advanced by some authors. Regardless of the method of repair, securing the cuff back to the anatomic footprint is important for successful results. With more surgeons interested in arthroscopic rotator cuff repair, newer techniques and devices continue to evolve to facilitate the arthroscopic treatment of rotator cuff disease. The end-splitting knot-tightener was shown to provide the most secure arthroscopic knots, and there was no difference between these knots and hand-tied knots. Some newer devices alleviate the need for arthroscopic knot-tying altogether. A comparison between a transosseous tunnel repair and various arthroscopic techniques demonstrated that the arthroscopic, doubly loaded suture anchor provided more stable initial fixation than the open transosseous repair did35. It is important to repair the rotator cuff to the anatomic footprint. The transosseous tunnel technique created more contact and greater overall pressure distribution over a defined footprint when compared with suture anchor techniques36. In contrast, Millett et al. proposed the mattress double-anchor repair of the rotator cuff, which allows for dissipation of the stress of the repair, more points of fixation, and compression of the repaired cuff into the footprint37. This procedure allows for an all-arthroscopic repair, with less suture management, and simulates a traditional transosseous repair. Also, there are conflicting data on single as opposed to double-row rotator cuff repairs, and this issue is not resolved at this time. The use of polymerase chain reaction for the evaluation of the torn rotator cuff margin and the surrounding bursa demonstrated that both the cuff and the bursa had increased mRNA levels of type-I and III collagen and that the cuff margin also showed increased aggrecan mRNA levels, suggesting that both the margin of the torn rotator cuff and the bursa are actively remodeling and may be contributing to the healing process following repair. Recurrence or retearing of the rotator cuff continues to be reported following both open and arthroscopic repair. The importance of this finding is unclear. It seems that the loss of cuff integrity has little effect on outcomes when compared with those in patients with an intact cuff. In fact, patients with a retear still showed improvement in all clinical areas assessed, including strength. The use of orthobiologic devices continues to be heavily researched. Gorman reported an immunologic reaction in 22% (seven) of thirty-two patients who had undergone a rotator cuff repair in which the Restore patch had been used for augmentation. Malcarney et al. reported an inflammatory response and breakdown of the cuff repair in four (16%) of twenty-five patients who had been managed with the Restore patch38. Importantly, those studies documented that the reactions were not an infectious process and that they subsided with time and local care. Nonoperative care remains the first line of treatment for supraspinatus tendinopathy. A recent report questioned the benefit of the addition of betamethasone to the injection, citing no benefit compared with a Xylocaine injection alone. A randomized, double-blinded, placebo-controlled trial established the efficacy of topical glyceryl nitrate for the treatment of supraspinatus tendinopathy. Paoloni et al. reported significantly reduced pain with activity (p = 0.03), at night (p = 0.03), and at rest as well as increased range of motion and strength as compared with the results of tendon rehabilitation alone at twenty-four weeks39. Subacromial and intra-articular shoulder injections are commonly performed in the office setting. Recently, the reliability of intra-articular injection has been called into question. One study demonstrated that anterior placement of a spinal needle into the glenohumeral joint was done correctly in only 26% of patients40. This finding was in contrast with those of a previous cadaveric study that showed this to be the most accurate position from which to enter the glenohumeral joint. Numerous reports have documented the difficulty of accurately and reproducibly entering the glenohumeral joint. Some investigators have recommended that the intra-articular injection be placed under fluoroscopic guidance to ensure accurate delivery of the medication.
Impingement/Acromion
Pediatrics
Instability Arthroscopic repair can be a reliable procedure for the treatment of some labral lesions in overhead athletes. However, the rate of return of baseball players who have overuse injuries is lower than that of overhead athletes with traumatic injuries41. The surgical treatment of shoulder instability traditionally has been performed as an open procedure. Recent literature has shown equivalent results in terms of stability and has shown more favorable patient outcomes in association with arthroscopic stabilization, even in high-demand and collision athletes42-44. The treatment of shoulder dislocations in young patients traditionally has been nonoperative, with a high risk for recurrent dislocations based on age. A randomized, prospective trial established arthroscopy and labral repair (rather than nonoperative measures) as the appropriate treatment for first-time shoulder dislocations in young, active patients, with a difference between the groups with regard to the rate of redislocation45. Good results also have been reported following the treatment of chronic anterior instability with arthroscopic reduction and fixation of osseous Bankart lesions with suture anchors46. Closure of the rotator cuff interval appears to be integral to the success and durability of arthroscopic anterior stabilization surgery. Closure of the rotator cuff interval is more effective than thermal capsulorrhaphy for stabilizing multidirectional laxity in the glenohumeral joint without the associated risks inherent with the thermal probe. The axillary nerve is always at risk during instability surgery and is closest to the capsule between the 5 and 7 o'clock positions. Despite the increased ability to treat shoulder abnormalities arthroscopically, open procedures continue to be commonly performed. A meta-analysis demonstrated that open repair is more successful in terms of the rate of recurrent instability and the return to activity47. Clearly, controversy exists with regard to the best way to treat shoulder instability. When attempting to reduce the intracapsular volume, an open, lateral capsular shift is more successful than arthroscopic plication is, and open procedures are particularly appropriate for the treatment of multidirectional instability that requires a larger capsular shift. The absolute amount of volume reduction that is required in order to achieve stability remains unknown48. A modified anterior capsular shift with a longitudinal incision of the capsule medially and osseous fixation of the inferior flap to the glenoid and labrum in the 1 to 3 o'clock position has been associated with efficacy and durability for the treatment of atraumatic anterior-inferior shoulder instability49.
Posterior Instability
Scapula
Biceps
Throwers continue to have medial-side elbow problems, including medial collateral ligament insufficiency, chronic valgus overload, posteromedial impingement, and posteromedial osteophytes. The diagnosis of medial-side elbow disorders is difficult in throwing athletes. Evaluation of asymptomatic elbows in professional baseball players with use of magnetic resonance imaging demonstrated that 87% of the elbows had medial collateral ligament abnormalities and 81% had findings consistent with posteromedial impingement. These baseline findings must be considered when magnetic resonance imaging is used as a factor in treatment decisions. A cadaveric study established that medial collateral ligament insufficiency altered the contact area and pressure between the posteromedial aspect of the trochlea and the olecranon, helping to explain the development of posteromedial osteophytes. The "moving valgus stress test" has been described as a physical examination technique that is highly sensitive and specific for diagnosing insufficiency of the medial collateral ligament or other abnormalities associated with chronic valgus overload of the elbow51.
Chronic exertional compartment syndrome continues to be a diagnostic dilemma. Invasive compartment-pressure monitoring is expensive and requires specialized equipment and substantial time. The sensitivity of near-infrared spectroscopy for the diagnosis of chronic exertional compartment syndrome has been found to be clinically equivalent to that of invasive intracompartmental pressure measurements52. Tibial stress fractures continue to be commonly seen and are best treated with activity modification. Treatment of recalcitrant stress fractures with intramedullary nailing has enabled patients to return to sports at an average of four months. This is an option for the treatment of chronic tibial stress fractures. In one case, a fracture occurred after corticotomy and intramedullary nailing of a chronic tibial stress fracture. The fracture was treated nonoperatively, and the patient was able to return to play at eight weeks; however, the dreaded black line persisted. Muscle trauma is the most common musculoskeletal injury at all levels of participation. Healing with a fibrotic response is common in patients with these injuries. The role of anti-inflammatory medications has been questioned with regard to decreased muscle regeneration and functional outcome. We continue to search for interventions that can facilitate the treatment of these injuries and encourage tissue repair. In a mouse model, the injection of suramin (an antifibrotic agent) into the site of a muscle injury decreased scar-tissue formation. In addition, suramin-treated muscles also had greater fast twitch and tetanic strength compared with controls. Research to identify the proper method and timing of intervention in the treatment of muscle injury continues. Despite our attempts to decrease the risk of deep venous thrombosis, this complication remains a substantial problem in the care of the orthopaedic patient. The association with arthroplasty has been well defined, but other common orthopaedic procedures, such as arthroscopy, have not been as well studied. A meta-analysis of deep venous thrombosis after knee arthroscopy demonstrated an overall rate of 9.9% and a proximal rate of 2.1% after knee arthroscopy without thromboprophylaxis. Additional reports in the chest literature have documented the prevalence of deep venous thrombosis after arthroscopy and the association with some nearly ubiquitous risk factors. To date, there are no formal recommendations for the prevention of deep venous thrombosis in patients undergoing arthroscopy; however, it seems prudent to treat certain high-risk patients with prophylaxis against deep venous thrombosis53. An analysis of injuries in ice-hockey players demonstrated that concussion was the most common injury, followed by sprains of the medial collateral ligament of the knee. Additionally, hockey players appear to be at risk for syndes-motic injuries rather than ankle sprains.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, ten level-I articles were identified that were relevant to sports medicine. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
The annual meeting of the Arthroscopy Association of North America (AANA) will be held from May 18 through 21, 2006, in Hollywood, Florida. The annual meeting of The American Orthopaedic Society for Sports Medicine (AOSSM) will be held from June 29 through July 2, 2006, in Hershey, Pennsylvania.
Sports Medicine continues to be the most popular fellowship in orthopaedic surgery, with almost half of all graduating residents seeking fellowships applying. Accreditation continues to be an important goal of all fellowships because this will eventually be a requirement to sit for the subspecialty certification examination. Unfortunately, the match, which is coordinated by the National Residency Matching Program, has recently been abandoned by the fellowship directors. Hopefully, a suitable substitute can be developed in order to fairly allow fellows the opportunity to seek quality programs.
Subspecialty certification is a reality. The first examination, developed by the American Board of Orthopaedic Surgery (ABOS), is expected to be administered in the fall of 2007. A pretest that can be used for fellowship preparation has been developed and is available through the American Orthopaedic Society for Sports Medicine (AOSSM). Additionally, the AOSSM is working with the American Academy of Orthopaedic Surgeons to develop a sports medicine review course that is tentatively planned for the summer of 2007. Please contact the AOSSM at 847-292-4900 for more information on this examination. The AOSSM is also involved in two new research endeavors; one is a three-year articular cartilage research initiative, and the other is a multicenter study on revision anterior cruciate ligament reconstruction. For more information on these projects please see the AOSSM web site at www.sportsmed.org.
Rompe JD, Decking J, Schoellner C, Theis
C. Repetitive low-energy shock wave treatment for chronic lateral
epicondylitis in tennis players. Am J Sports Med.2004
;32:734-43. Seventy-eight patients with recalcitrant lateral epicondylitis were enrolled in a randomized, placebo-controlled trial evaluating the effect of low-energy extracorporeal shock wave treatment given weekly for three weeks (treatment group; Group 1) or an identical placebo treatment (sham group; Group 2). At three and twelve months, there was significantly (p = 0.001) more improvement in terms of pain in Group 1 as compared with Group 2, although both groups demonstrated improvement over the course of the study. Extracorporeal shock wave therapy should be considered for the treatment of recalcitrant lateral epicondylitis. Witvrouw E, Danneels L, Van Tiggelen D, Willems
TM, Cambier D. Open versus closed kinetic chain exercises in
patellofemoral pain: a 5-year prospective randomized study. Am J
Sports Med.2004
;32:1122-30. This prospective, randomized trial investigated the long-term (five-year) effects of open kinetic chain and closed kinetic chain exercises in the treatment of patellofemoral pain syndrome. The results of both regimens were generally favorable in terms of strength, function, and subjective complaints, although only 20% of the patients reported being pain-free at five years. The open kinetic chain group had less pain on the visual analog scale at night, less swelling of the joint, and less pain descending stairs as compared with the closed kinetic chain group. Open kinetic chain exercises do not need to be avoided in the treatment of patellofemoral pain syndrome and should augment traditional closed kinetic chain exercises. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y. Reconstruction of the anterior cruciate ligament. Single-versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br.2004 ;86:515-20. This randomized, prospective study of 108 patients compared single and double-bundle multistranded anterior cruciate ligament reconstructions. The study demonstrated no difference between the groups in terms of anterior laxity at either 20° or 70° of flexion or in terms of proprioception. There was a decreased need for notchplasty in the double-bundle reconstruction group. The authors found no advantage with the double-bundle anterior cruciate ligament reconstruction. Harilainen A, Sandelin J, Jansson KA. Cross-pin femoral fixation versus metal interference screw fixation in anterior cruciate ligament reconstruction with hamstring tendons: results of a controlled prospective randomized study with 2-year follow-up. Arthroscopy.2005 ;21:25-33.[Medline] This randomized trial compared cross-pin fixation (TransFix cross pin; Arthrex, Naples, Florida) with metal interference screw fixation in patients undergoing reconstruction of the anterior cruciate ligament with use of hamstring tendons. The postoperative examiners and the patients were blinded with regard to the fixation method. After two years of follow-up, there were no significant or clinically relevant differences between the two methods of fixation of the graft in the femoral tunnel. Hill PF, Russell VJ, Salmon LJ, Pinczewski
LA. The influence of supplementary tibial fixation on laxity
measurements after anterior cruciate ligament reconstruction with hamstring
tendons in female patients. Am J Sports Med.2005
;33:94-101. This prospective study of tibial fixation in female patients undergoing anterior cruciate ligament reconstruction with use of hamstring tendons showed that double fixation of the tibial graft with an interference screw and staple reinforcement effectively reduced anterior laxity at two years postoperatively as assessed with both the Lachman test and KT-1000 testing. This double tibial fixation addresses the concern of laxity that has been seen in female patients after tibial interference screw fixation, which is thought to be associated with the decreased bone density in such patients. The improvement in fixation strength and laxity measurements comes at a cost of increased anterior knee pain with kneeling due to the staple fixation. Spindler KP, Kuhn JE, Freedman KB, Matthews CE,
Dittus RS, Harrell FE Jr. Anterior cruciate ligament
reconstruction autograft choice: bone-tendon-bone versus hamstring: does it
really matter? A systematic review. Am J Sports Med.2004
;32:1986-95. This was a review of nine randomized, controlled trials comparing anterior cruciate ligament reconstructions performed with bone-patellar tendon-bone autografts and hamstring autografts. The study evaluated the variables of instrumented laxity and subjective data. The differences in the data were often quite small and were not reproduced between the randomized, controlled trials. A slight increase in anterior laxity was found in association with the hamstring reconstructions, and anterior knee pain with kneeling was found more frequently in the patellar tendon autograft group. Subjective differences between the two reconstructions were not seen consistently. Overall, the choice of graft type for anterior cruciate ligament reconstruction does not appear to be the primary determinant of outcome. Rather, the status of the meniscus and articular cartilage at the time of surgery has a more profound influence on the outcome of anterior cruciate ligament reconstruction than the graft type does. Nicholas SJ, D'Amato MJ, Mullaney MJ, Tyler TF,
Kolstad K, McHugh MP. A prospectively randomized double-blind
study on the effect of initial graft tension on knee stability after anterior
cruciate ligament reconstruction. Am J Sports Med.2004
;32:1881-6. This prospective, randomized, double-blind clinical trial of forty-nine patients evaluated the effect of different graft tensions in bone-patellar tendon-bone anterior cruciate ligament reconstructions. The grafts were tensioned at either 45 or 90 N, and the range of motion and KT-1000 measurements were evaluated. Better arthrometric stability was obtained in the high-tension group without overconstraint of the knee. Five of the patients in the low-tension group had abnormal side-to-side laxity (as indicated by a >5-mm difference in anterior tibial displacement). However, at an average of twenty months postoperatively, no difference in functional outcome was noted between the groups. Although the exact tension that is appropriate for anterior cruciate ligament reconstruction remains unknown, it appears that 45 N of tension is not sufficient to restore normal knee stability. McDevitt ER, Taylor DC, Miller MD, Gerber JP,
Ziemke G, Hinkin D, Uhorchak JM, Arciero RA, Pierre PS.
Functional bracing after anterior cruciate ligament reconstruction: a
prospective, randomized, multicenter study. Am J Sports
Med.2004
;32:1887-92. This prospective, randomized, multicenter study evaluated functional bracing after anterior cruciate ligament reconstruction. Patients with chondral, meniscal, or multiple-ligament injuries were excluded. After two years of follow-up, there was no difference between the groups with or without bracing in terms of stability, functional testing, International Knee Documentation Committee score, Lysholm score, range of motion, or isokinetic strength-testing. Therefore, bracing generally is not recommended in the setting of anterior cruciate ligament reconstruction. Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols
CE, Fleming BC, Poole AR, Roos H. Rehabilitation after anterior
cruciate ligament reconstruction: a prospective, randomized, double-blind
comparison of programs administered over 2 different time intervals.
Am J Sports Med.2005
;33:347-59. Accelerated and nonaccelerated rehabilitation protocols for anterior cruciate ligament reconstruction were compared in a prospective, randomized, double-blinded trial. All knees were reconstructed with an autologous bone-patellar tendon-bone graft. Both protocols were associated with similar outcomes in terms of clinical findings, patient satisfaction, function, and biomarkers of cartilage metabolism. Regardless of the rehabilitation protocol, two-year follow-up showed an increase in anterior laxity on KT-1000 testing as compared with immediate postoperative values. Nash CE, Mickan SM, Del Mar CB, Glasziou PP. Resting injured limbs delays recovery: a systematic review. J Fam Pract.2004 ;53:706-12.[Medline] This review of the literature demonstrated that mobilization of an injured but stable limb is associated with generally better results than immobilization is. These improved results include earlier return to work or sports activity, decreased pain and swelling, and increased range of motion. The traditional belief that an injured limb benefits from immobilization appears to be inaccurate, and, in fact, mobilization is associated with generally better clinical results.
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Introduction
Knee
) and that arthroscopic lavage may
reduce symptoms in osteoarthritic knees by removing cartilage debris and
decreasing the expression of
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