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What's New in Sports Medicine

¹ Department of Orthopaedics, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, P.O. Box 800159, Charlottesville, VA 22908-0159. E-mail address for M.D. Miller: 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.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

	Introduction

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This is an important year for the subspecialty of sports medicine. The sports medicine subspecialty certification process officially kicks off this summer with the first-ever Review Course for Subspecialty Certification in Orthopaedic Sports Medicine. This course, jointly sponsored by the American Orthopaedic Society for Sports Medicine (AOSSM) and the American Academy of Orthopaedic Surgeons (AAOS), will be held on August 3 through 5, 2007, at the Fairmont Hotel in Chicago. The preliminary program will be mailed to all AOSSM members in mid-February. One can find more details on the AOSSM website (www.sportsmed.org). The examination will be administered at Prometric Technology Centers beginning in the Fall of 2007. Applications to take the examination are available online (www.abos.org). The completed application must be submitted with a $500 application and credentialing fee, letters of reference, and a complete list of all operative cases from a consecutive twelve-month period between February 1, 2005 and January 31, 2007. All applications are due on February 1, 2007. Late applications can be received by February 28, 2007 for an additional $500 fee. A $1000 examination fee (in addition to the application and credentialing fee) will be due in May 2007. We hope that this update, in conjunction with previous updates and AAOS/AOSSM resources that are available, can be used to further prepare for this examination.

This update is based on scientific and organizational activities in sports medicine that took place from September 2005 to August 2006. It includes a summary of the Annual and Specialty Day meetings of the AOSSM, the Arthroscopy Association of North America (AANA) and the AAOS. These meetings featured more than 200 scientific presentations focusing on sports medicine. In addition, as in past years, important articles from three 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.

	Knee

Top Introduction Knee Shoulder Hand and Wrist Elbow Foot and Ankle Spine Hip Cartilage Injury Prevention Evidence-Based Orthopaedics Upcoming Meetings and Events Sports Medicine Fellowships AOSSM Research Evidence-Based Articles Related... References

 
Anterior Cruciate Ligament
Reconstruction of the anterior cruciate ligament is one of the most common procedures performed by orthopaedic surgeons and remains a focal point for new research in sports medicine. Published studies abound on this topic, with particular attention being paid to graft choice, fixation options, prevention programs, the advent of double-bundle reconstruction, and the outcomes of revision procedures. The ability of the reconstructed anterior cruciate ligament to both control and prevent recurrent pivoting episodes predictably and durably over time is the goal driving this research.

Three main graft choices are commonly used for anterior cruciate ligament reconstruction. Autograft bone-patellar tendon-bone, hamstring, and various allograft options are the most commonly used grafts. Quadriceps tendon autograft, although less commonly used, is also effective. The benefits and detriments of each of these graft choices persist and have been outlined extensively in the literature. The quality of anterior tibialis allograft has been recently questioned if the tissue is cryopreserved, and this will likely lead to more study of the use of allograft for anterior cruciate ligament reconstruction. In a thirteen-year follow-up trial of anterior cruciate ligament reconstructions involving the use of bone-patellar tendon-bone autograft, good outcomes were achieved with respect to knee stability and functional scores¹. However, half of the patients had loss of extension, likely signaling early degenerative joint disease. Furthermore, there was increased laxity and rerupture in those who had undergone partial medial menisectomy at the time of the index procedure. These findings underscore the importance of the meniscus as a secondary knee stabilizer. Proponents of bone-patellar tendon-bone autograft cite improved initial fixation strength as an advantage of this graft choice. Recent advances in hamstring fixation, however, rival interference screw fixation for the bone-patellar tendon-bone graft and have led to increased use of hamstrings as a graft choice. Hamstring proponents also note decreased postoperative morbidity with this option. Transfemoral cross-pin fixation has produced good outcomes clinically, and the biomechanical fixation strength approaches or exceeds interference screw fixation. Cross-pin fixation also decreases tunnel widening in comparison with other hamstring fixation methods because the point of fixation is closer to the aperture of the femoral tunnel. Patients who were evaluated sixteen months after undergoing a hamstring autograft procedure with cross-pin fixation showed no clinical differences compared with a similar group of patients who had undergone a bone-patellar tendon-bone autograft reconstruction². In another study, bioabsorbable cross-pins had a 16% deformation or fracture rate occurring around the time of graft incorporation, although no clinical importance was noted with respect to knee stability and overall outcome³. In a meta-analysis of thirty-two hamstring and thirty-two bone-patellar tendon-bone graft studies, four-bundle hamstring grafts had higher stability rates than did patellar tendon autografts and demonstrated fixation-dependent stability⁴. Several studies showed no difference between the outcomes associated with hamstring autograft and those associated with bone-patellar tendon-bone graft, with decreased joint degeneration in knees that were reconstructed with hamstring tendons.

As the use of hamstring tendons increases, so does the investigation of postoperative knee flexion deficits secondary to their harvest. While the regeneration of the tendons has been well established, the function of the regenerated musculotendinous unit has been questioned. The gracilis and semitendinosus muscles retain their contractile capabilities after harvest, but deficits appear to persist in deep flexion. One study showed decreased flexion strength, torque, and flexor work at two years of follow-up⁵. The clinical implications of these findings are not fully defined and will continue to be a focus of additional investigation. The use of patellar tendon autograft has been linked to recurrent anterior knee pain and patellar tendon shortening secondary to healing of the graft site. However, no change in patellofemoral biomechanics was shown with tendon shortening of 10% after harvest.

A survey of sports medicine surgeons was conducted to determine the current recommendation for dealing with a contaminated autograft at the time of anterior cruciate ligament reconstruction⁶. Of the 196 surgeons responding to the survey, 25% reported at least one contaminated graft in their surgical experience. In the cases of these contaminated grafts, 75% were cleansed and implanted and 25% were discarded and a second graft option was used. Of note, no cleansed graft resulted in an infection postoperatively. Sixty-five of the surgeons who had not had this experience gave a hypothetical management response, with 58% stating that they would cleanse the graft and then implant it, 34% stating they would choose a second autograft harvest, and 8% choosing to resort to allograft tissue.

The control of recurrent pivoting episodes following anterior cruciate ligament reconstruction has continued to be a focus of reconstruction efforts. Additionally, medial translation of the tibia on the femur in anterior cruciate ligament-deficient knees emphasizes the multidirectional deficits that exist with this injury. The placement of single-bundle grafts lower in the intercondylar notch has been shown to better control this motion and to reestablish the relationship of the anterior cruciate ligament to the posterior cruciate ligament. This is the same principle driving the investigation of double-bundle grafts for anterior cruciate ligament reconstruction. Advocates propose a reconstruction that more accurately replicates the native biomechanics of the anterior cruciate ligament. Ideal tunnel position and the correct knee flexion for graft tensioning continue to be debated. Proper tunnel placement and bundle tension are critical for preventing graft overload during knee motion. Two studies comparing double and single-bundle anterior cruciate ligament reconstructions demonstrated decreased laxity and pivot measurements in association with the double-bundle method, but no change in the clinical outcome was noted. Additional biomechanical and clinical trials are needed to fully define the clinical usefulness and technical recommendations for this developing technique.

Current reconstructive techniques have proven to be durable, with similar rates of reinjury compared with native anterior cruciate ligament tears in the contralateral knee. In the event of graft failure, revision anterior cruciate ligament reconstruction can be a challenge, with patients showing similar postoperative laxity measurements but decreased overall outcomes compared with those following primary reconstruction. These poorer outcomes are thought to be secondary to an increased number of cartilage and meniscal lesions at the time of revision surgery. Bone-grafting of tunnel defects in either a one or two-stage procedure is encouraged to improve fixation of the revision graft. The search for bioabsorbable fixation devices that can provide good initial fixation, degrade in a timely fashion, and be replaced with bone ingrowth continues. In a computed tomography follow-up study performed seven years after anterior cruciate ligament reconstruction with polylactic acid interference screws, all screws were absorbed but no bone ingrowth was noted at the screw site⁷.

The use of computer guidance, a resource that is gaining interest in the total joint literature, has been shown to increase the accuracy of femoral and tibial tunnel placement with a trend toward decreased laxity. Whether this trend leads to improved patient outcomes and validates the cost of such guidance systems has yet to be determined.

Home-based therapy programs following anterior cruciate ligament reconstruction have been shown to be more effective than formal therapy sessions for achieving postoperative range-of-motion goals, a finding that could decrease the overall cost of this procedure. Finally, the treatment of the skeletally immature patient who has an anterior cruciate ligament-deficient knee remains controversial. One follow-up study of forty-four patients who were evaluated five years after physeal-sparing anterior cruciate ligament reconstruction showed no growth disturbance or angular deformity, excellent functional outcomes, and a low revision rate⁸.

Posterior Cruciate Ligament
While nonoperative treatment of grade-I and II posterior cruciate ligament injuries remains the treatment of choice, the investigation of several issues related to the operative treatment of grade-III injuries persists. Debate continues over the use of single or double-bundle reconstruction, the use of a transtibial as opposed to an inlay technique for tibial fixation (the killer turn question), and the timing of ligament reconstruction. Similar to anterior cruciate ligament reconstruction, double-bundle posterior cruciate ligament reconstruction has enjoyed increased interest in the literature, with the underlying premise being that patients have a kinematically more normal knee with independent reconstruction of the anterolateral and posteromedial bundles of the posterior cruciate ligament. Little has been shown in the way of improved clinical outcomes in this area, however, and most patients still receive a single-bundle reconstruction. Regardless of whether a one or two-bundle reconstruction is performed, tunnel placement is critical to the success of this operation. Anterior femoral tunnel placement is superior to posterior positioning for the restoration of normal knee kinematics. In a cadaver model, a single anterolateral graft best reproduced normal posterior cruciate ligament force but resulted in increased laxity at 0° to 30° of flexion⁹. One recent study, presented at the meeting of the AOSSM, demonstrated that grade-III injuries with displacement of the tibia well posterior to the medial femoral condyle on posterior drawer testing were associated with combined posterior cruciate ligament and posterolateral corner disruption. In a laboratory study, double-bundle reconstruction restored better rotational control, with equivalent findings on stress radiographs, compared with single-bundle reconstruction. Of note, however, neither single nor double-bundle reconstruction controlled rotational or varus laxity with a combined posterior cruciate ligament-posterolateral corner injury, emphasizing the importance of recognition and proper reconstruction of this injury combination.

Another point of contention continues to be the choice of tibial fixation. Advocates of the tibial inlay technique cite elimination of the killer turn caused by graft abrasion at the proximal tibial tunnel aperture. Preservation of posterior cruciate ligament fibers at the tibial insertion may decrease this abrasion at the turn with the arthroscopic tibial tunnel technique. In addition, combined tibial fixation of the graft with a fixation point both distal and proximal in the tunnel provides better initial fixation and restores more normal kinematics than does distal tibial tunnel fixation alone. A recent two-year follow-up study showed no difference in outcome between the two techniques and showed that patients did not necessarily return to normal function with respect to the injured knee, regardless of the tibial fixation used¹⁰. In patients who have operative treatment of posterior cruciate ligament injuries, early reconstruction appears to maximize clinical results, as demonstrated in a recent follow-up study¹¹.

Posterolateral Corner
Recognition and appropriate treatment of injuries to the lateral side of the knee prevent long-term disability secondary to abnormal varus and rotational laxity and are important for preventing the failure of concomitant reconstruction of the cruciate ligaments. Reconstruction of the posterolateral corner requires an understanding of the critical structures in this region, from both an anatomical and a biomechanical standpoint, as well as of the surgical techniques that reproduce the stabilizing force of the native complex. The lateral collateral ligament, popliteofibular ligament, and popliteus tendon are the three critical structures in this region. The tensile strengths of these structures have been defined as 295, 298, and 700 N, respectively¹². These values establish a goal for reconstruction and graft choice strength. In a cadaver model, reconstruction of the lateral collateral ligament with fibular interference screw fixation consistently failed at the fibular fixation site and was associated with stiffness measurements that were significantly lower than those for the intact ligament. Lateral collateral ligament reconstruction should be protected to prevent postoperative loosening until graft incorporation at the fibular head. Tunnel convergence when the posterolateral corner is reconstructed in the case of a multiligamentous knee injury remains a concern. A cadaver study yielded recommendations for the placement of these tunnels to prevent encroachment with the anterior cruciate ligament tunnel¹³. The recommended femoral tunnel orientation was 0° in the coronal plane, <40° anterior in the axial plane, and <25 mm in depth. Current reconstruction techniques are effective, with patients in a recent two-year follow-up study demonstrating excellent functional results¹⁴. Patients who underwent an isolated reconstruction had better range of motion and decreased failure rates than those who had multiple ligamentous injuries.

Medial Collateral Ligament
Nonoperative treatment of medial collateral ligament injuries remains the standard of care. Debate continues, however, with regard to the proper treatment of combined medial collateral ligament and anterior cruciate ligament injuries. Some surgeons routinely repair or reconstruct grade-III medial collateral ligament injuries, whereas others treat them nonoperatively following anterior cruciate ligament reconstruction. A recent randomized, controlled, Level-I trial of concomitant anterior cruciate ligament and grade-III medial collateral ligament injuries addressed this issue¹⁵. One arm of the trial consisted of patients who underwent operative treatment of both injuries, whereas the second arm consisted of patients who underwent anterior cruciate ligament reconstruction and brace treatment of the medial collateral ligament injury. All anterior cruciate ligament reconstructions were performed with bone-patellar tendon-bone autograft secured with interference screw fixation. At the time of the final (two-year) follow-up, the two groups showed no differences in terms of functional outcome or laxity measurements and the investigators concluded that nonoperative treatment of medial collateral ligament injuries with simultaneous reconstruction of the anterior cruciate ligament should be the preferred method of treating this injury pattern. In the case of medial collateral ligament reconstruction, the use of semitendinosus autograft secured over a medial epicondylar post (the modified Bosworth technique) remains an excellent option, with attention being given to isometric placement of the post to prevent postoperative knee stiffness.

Meniscus
The role of the meniscus and the effects and treatment of meniscal pathology continue to be defined. The preservation of meniscal tissue when possible, and replacement if indicated, is the goal of meniscal surgery in the knee. The repair of tears with use of a variety of all-inside devices attempts to replicate the results achieved with inside-out techniques. A recent study of meniscal repair demonstrated good functional results after five to seventeen years of follow-up¹⁶. However, the prevention of degenerative changes in the joint was unclear. Meniscal transplantation remains a viable but controversial treatment option with evolving but still narrow indications. Finally, the creation of an artificial meniscal substitute has shown some promise but clearly remains in the early developmental stages.

Although inside-out meniscal repair remains the gold standard for the treatment of repairable meniscal lesions, multiple all-inside meniscal repair devices are currently available, and many have achieved good results in short to intermediate-term clinical follow-up studies. The advantages that have been cited for these devices include decreased operative time, the elimination of additional incisions, and a greatly reduced risk to neurovascular structures. Detractors of all-inside devices, particularly arrows and screws, question the potential chondral damage that can be caused by these devices over time. A new generation of flexible and tensionable all-inside devices has shown good results in short-term follow-up studies. The RapidLoc (Mitek, Raynham, Massachusetts), FasT-Fix (Smith and Nephew, Andover, Massachusetts) and BioStinger (CONMED Linvatec, Largo, Florida) devices all demonstrated 90% success rates in early follow-up studies^17-19. A vertically placed FasT-Fix was shown to have increased strength, stiffness, and load to failure as compared with horizontal inside-out and RapidLoc all-inside repairs. Although vertically placed inside-out repairs have been shown to be the strongest constructs, one study demonstrated increased resistance to shear stress in association with horizontal repair and demonstrated no significant difference between the two techniques with regard to resistance to distraction across the repair site²⁰. Another study showed compression rather than distraction across tear sites with knee range of motion. These findings may lead to hybrid repair configurations maximizing the benefit of both suture orientations. Predictors of meniscal repair failure were found to be bucket handle tears, complex tears, large tears (>2 cm in length), and chronic tears (more than three months old).

The treatment of a failed meniscal repair or an irreparable tear resulting in total or subtotal menisectomy in a young, active patient remains a challenging dilemma. The role of meniscal tissue in increasing conformity of the knee joint and serving as a secondary stabilizer is well understood. The lateral meniscus is especially important because of the convexity of the tibial plateau on that side. Lack of functional lateral meniscal tissue leads to point loading on the lateral femoral condyle and can lead to rapid articular cartilage wear. Prior to the development of advanced chondrosis, these patients may benefit from allograft meniscal transplantation. Several studies have demonstrated good short-term clinical results, with an allograft survival rate of 89% in arthritic knees in one series. An improvement in pain scores was seen in 96% of the patients, with the results of bone fixation exceeding those of suture-only fixation and with better results being seen when transplantion was performed prior to the radiographic detection of joint-space narrowing. Unfortunately, these good early results appear to decrease with longer follow-up, warranting continued investigation to improve these outcomes. Another option that remains in the developmental stage is meniscal replacement with a collagen scaffold. This scaffold would allow for the ingrowth of meniscal tissue and would avoid the risks associated with allograft transplantation. One canine model demonstrated "meniscus-like" tissue ingrowth into a collagen scaffold and provided better chondral protection than partial meniscectomy alone²¹. Another canine study showed tissue infiltration into a porous polymer meniscal implant but continued progression of osteoarthritis²². The search continues for a meniscal prosthesis that encourages tissue ingrowth with reproduction of meniscal biomechanics that will protect the overlying articular cartilage from degeneration over time. Proximal tibial osteotomy remains an option for the young active patient who has chondrosis and axial malalignment. It should be noted, however, that increased failure rates have been noted in association with the use of allograft bone, and attention should be paid to alteration of the tibial slope with this procedure.

Patella
Treatment options for several pathologic conditions of the knee extensor mechanism continue to be explored. Multiple modalities and techniques are available for the treatment of recurrent patellar dislocation and instability, patellofemoral pain, and recalcitrant patellar tendinosus, with no one method established as the standard of care.

Patellar dislocation and recurrent instability following unsuccessful nonoperative treatment may be addressed in several ways. Release of the lateral retinaculum and vastus lateralis was shown to decrease dislocation rates, to improve knee function, and to increase quadriceps strength in these patients. Concomitant or isolated medial patellofemoral ligament repair or reconstruction also has been shown to decrease instability episodes and to improve functional knee scores in several studies. Medial patellofemoral ligament reconstruction was more effective for medializing patellofemoral tracking mechanics than a tibial tubercle osteotomy in a cadaver model²³.

The treatment of patellofemoral pain has long been a challenge for orthopaedic surgeons. Multiple physical therapy modalities have been proposed with the goal of stabilizing patellar tracking and strengthening the dynamic stabilizers about the knee. In addition to knee-based programs for rehabilitation, a focus on hip strengthening in a therapy regimen has been shown to decrease symptoms associated with this problem. Nonoperative treatment of patellar tendinosis remains the standard of care, with surgical treatment showing no difference compared with a twelve-week training program of eccentric strengthening²⁴. In cases of failed nonoperative treatment, open débridement of the pathologic tissue has shown improvement in high-level athletes.

	Shoulder

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Glenoid Labrum
Numerous arthroscopic shoulder techniques, including Bankart repair, rotator cuff repair, and biceps tenodesis, have increased in popularity recently. In addition to these procedures, more novel approaches such as scapulothoracic bursoscopy and suprascapular nerve decompression have been pioneered. The results of both anterior and posterior arthroscopic labral repair continue to improve and have steadily approached the 90% to 95% success rates associated with traditional open procedures. Factors leading to an increased risk for repair failure are large glenoid bone defects, generalized hyperlaxity, and the use of three or fewer anchors. The proposed advantages of the arthroscopic technique include decreased or no hospital stay, fewer postoperative subscapularis complications, decreased pain, and less loss of motion. Two studies showed that the results associated with knotless suture anchor constructs rivaled those associated with standard anchors and open procedures, at least at the time of early follow-up. Recommendations for the treatment of traumatic anterior shoulder instability in collision athletes are less clear, with some authorities on the subject recommending arthroscopic Bankart repair and others performing open repairs for this unique subset of patients. Subscapularis function and integrity have been shown to be paramount for ultimate function, and their protection remains a definite advantage of arthroscopic techniques. In a cost analysis comparing arthroscopic and open techniques, arthroscopic treatment was shown to be less expensive²⁵. However, patients who underwent open repair were admitted overnight, leading to an increase in cost that would likely be normalized if all patients were managed on an outpatient basis. We recognize the importance of all shoulder structures in maintaining stability of the joint and know that anterior labral injury alone is not sufficient to cause recurrent instability. Injury to the anteroinferior capsule remains part of the essential lesion in this entity. Additionally, cadaver studies have shown that a tear of the rotator cuff decreases the stability of the glenohumeral joint and should be addressed in the treatment of this condition, particularly in older patients, in whom rotator cuff tears are more common after shoulder dislocation.

The accurate diagnosis of superior labral anterior posterior (SLAP) tears remains an elusive goal. The search continues for a more reliable clinical examination to increase the likelihood of finding correlative pathology at the time of arthroscopy. While the O'Brien, Speed, and crank tests all continue to be used for this purpose, the supination-external rotation test and forced abduction test have been added to the clinician's battery to detect biceps anchor injuries. The combination of these examinations with the improved quality of arthrogram-enhanced magnetic resonance imaging will aid in increasing the accuracy of diagnosis of this problem.

Rotator Cuff
The arthroscopic repair of rotator cuff tears has gained popularity yearly, with recent studies showing no difference between arthroscopic techniques and mini-open techniques with regard to clinical outcomes after two, three, and four years of follow-up^26-28. Interestingly, these outcomes may not be affected by subacromial decompression, which has long been thought to be necessary for repair success. In another study, arthroscopic repair was associated with less fatty atrophy of the rotator cuff musculature postoperatively as compared with open techniques. Advances in available instrumentation, implants, and surgical techniques, including the introduction of a new device that was developed to measure the thickness of partial tears, have complemented this trend. In addition, a better understanding of tear morphology and rotator cuff characteristics such as mobility and tissue quality has more fully defined the unique properties that may be present with any tear. Chronic tears begin to show decreased muscle volume, increased fat content, and increased stiffness as early as twelve weeks after the injury²⁹. These changes decrease the mobility of the tissues and can hinder the surgeon's ability to achieve a dependable repair. The resultant functionally different musculotendinous unit highlights the need for early diagnosis and treatment of rotator cuff pathology.

Improving initial fixation and increasing the overall contact area have led to changes in recommendations regarding suture constructs. Initial load to failure is increased in association with more anchors, double-row fixation, and suture patterns that grab more tissue, such as the mattress or Kessler-type suture. In a comparison of ten knot configurations that are used for arthroscopic repair, the Dines knot provided superior knot and loop security with decreased suture material and knot size³⁰. Double-row repair concepts designed to increase initial fixation strength and footprint size have recently increased in popularity and have shown excellent early clinical results. One study demonstrated increased ultimate tensile load and initial fixation strength when a double-row technique was compared with single-row constructs. This finding was demonstrated to be particularly important in association with rotator cuff repairs under tension. No difference in clinical outcome was observed when this technique was compared with single-row fixation in an outcomes study, although structural integrity was shown to be improved on magnetic resonance images at three years of follow-up³¹. Certainly, continued investigation into this technique is warranted as new devices are made available with the goal of improving the proficiency of double-row fixation. While cuff integrity after repair remains the goal of treatment, many patients will demonstrate functional improvement even in the presence of a recurrent rotator cuff tear as long as seven years after surgery.

The treatment of a massive chronic rotator cuff tear continues to be a challenge. Recent interest in the use of various tissue-augmentation patches either to span an irreparable defect or to reinforce a repair in the presence of poor tissue quality has increased. These patches are readily available and may consist of human, porcine, or bovine skin or porcine intestinal submucosa, among other materials. All have varying characteristics, depending on their tissue of origin. Of these, patches of dermal origin have an increased load to failure compared with submucosa-based grafts. In a dog model, however, patch supplementation of a rotator cuff that was repaired under tension produced no increase in strength in comparison with simple repair³². While these patches theoretically serve to increase the available collagen framework for ultimate healing, they have not consistently shown improvement in healing rates or clinical outcomes, and their ultimate role in the repair of rotator cuff tears or other tendon defects remains undefined.

A trend in the treatment of shoulder pathology has been the improvement of the quality and diagnostic accuracy of magnetic resonance imaging, which can be used to predict rotator cuff tear morphology and configuration through the assessment of the maximum tear length and width as seen on coronal and sagittal images. This allows for more accurate preoperative planning and a more efficient surgical repair. Recognition of the importance of partial and complete subscapularis tears has grown, and techniques for the repair of these injuries are being refined. A narrowed coracohumeral distance as measured on magnetic resonance imaging may indicate subtle subscapularis pathology. Magnetic resonance imaging also has been used to quantify the accuracy of subacromial injections, with postinjection imaging confirming the relative inaccuracy of these injections. Injections from a posterior site reached the subacromial bursa 76% of the time, whereas injections given anteromedially had a 69% success rate³³. This finding questions the clinical usefulness of subacromial injection for the confirmation of subacromial pathology.

Acromioclavicular Joint and Clavicle
Acromioclavicular joint pathology, whether the result of degenerative processes or posttraumatic conditions, can cause considerable pain and dysfunction. Coplaning of the clavicle and the medial edge of the acromion has long been used to treat impingement of the rotator cuff by inferior osteophytes. This has raised concerns of destabilization of the joint. In one study, patients managed with coplaning of the joint had outcomes similar to those managed with arthroscopic decompression and open distal clavicular excision at the time of the six-year follow-up³⁴. Multiple methods for reconstruction of the displaced and symptomatic acromioclavicular joint have been described over time. Anatomic and nonanatomic repairs involving the use of autograft or allograft tissue or screw fixation have all been successfully attempted. Several studies have demonstrated that anatomic repair with soft-tissue grafts results in the most stable reconstruction, with anterior-to-posterior translation being similar to that in the native joint.

While nonoperative treatment of most clavicular fractures remains the gold standard, the indications for open reduction and internal fixation continue to evolve. Decreased strength following nonoperative treatment has been identified as a possible indication for fixation of these fractures at the time of the injury, particularly in young, active patients with displaced midshaft fractures.

Biceps Tendon
Multiple options are available for the treatment of pathology of the long head of the biceps. Tenodesis remains the mainstay when the tendinopathy involves 50% of the tendon. The method of proximal fixation varies greatly, with arthroscopic, arthroscopically assisted, and open methods all being used commonly. No differences in outcomes have been shown in association with the use of suture anchors, a soft-tissue sling, or a tenodesis screw³⁵. Surgeon comfort with a particular method seems to be the most important factor in choosing a technique. Additional research is needed to identify the construct with the best initial fixation.

Shoulder Biomechanics
The biomechanical profile of the overhand thrower continues to attract interest. Attempts to more fully understand this complex activity have aimed to improve the care of athletes who depend on this motion for their vocations or avocations. Pitchers have been shown to have increased external rotation and decreased internal rotation with the same or decreased total arc of motion in the throwing shoulder as in the contralateral, nonthrowing shoulder. This internal rotation deficit and posterior capsular tightness contribute to the entity of internal cuff impingement. Capsular contractures, however, do not appear to be the sole cause of this altered mobility pattern. The safety of various pitch selections in pitchers is still debated, with a recent study of collegiate pitchers demonstrating no difference in shoulder kinematics between throwing curveballs and fastballs³⁶. Shoulder joint kinetics and angular velocity were lower for the change-up as compared with the fastball, curveball, and slider. The protection of the young pitcher remains paramount. Pitching practices correlate with shoulder and elbow injury in the adolescent pitcher, with the highest correlation seen in those pitching with pain and fatigue. Other factors correlating with injury included the number of games pitched per week and the numbers of pitches and innings pitched per game. Attention should be given to strict enforcement of daily and weekly pitch and inning counts, with close monitoring of any discomfort experienced by these athletes.

	Hand and Wrist

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Interest in the arthroscopic treatment of wrist injuries, including triangular fibrocartilage complex tears, dorsoradiocarpal ligament tears, and posttraumatic radiocarpal contracture, continues to increase. Arthroscopic repair of the triangular fibrocartilage complex has become more popular over the past several years. Increased age, decreased grip strength, decreased wrist motion, and increased ulnar variance are predictors of a less favorable outcome³⁷.

Additionally, in athletes with refractory ulnar-sided wrist pain, erosion of the floor of the sixth dorsal compartment should be considered. In a case series of golfers and tennis players, débridement of the compartment with interposition of local soft tissue was shown to reduce symptoms significantly³⁸.

	Elbow

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The treatment of lateral epicondylitis remains challenging. Nonoperative treatment with physical therapy and a tennis elbow brace remains the standard of care. Patients who have a positive result on the extensor grip test fare better after this intervention than do those who have a negative result. Despite extensive nonoperative treatment, some patients with refractory pain require surgical intervention to address the pain. Suture anchor repair of the extensor carpi radialis brevis to the lateral epicondyle after débridement has led to improved postoperative grip strength and decreased pain after four years of follow-up³⁹.

As in other locations, osteochondral defects of the elbow present particular problems with respect to pain, dysfunction, and effective treatment. Two studies demonstrated good results following the treatment of these troublesome lesions with osteochondral autograft. In another study, the interference screw technique was shown to be stronger than the use of two bone tunnels and similar to the use of native tendon for the repair of distal biceps ruptures in a cadaver model⁴⁰.

	Foot and Ankle

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Ankle sprains remain one of the most common injuries in all of competitive sports. A recent study demonstrated the incidence to be one per 1000 athlete exposures, with the highest incidence being in female basketball players. Another study demonstrated that an increased body mass index and a history of previous lateral ankle injury increased the risk of sprain in male athletes. Balance training decreased the rate of ankle sprains, with a risk reduction to one-half, in a randomized, controlled, Level-I trial of 765 high school soccer and basketball players⁴¹. Chronic lateral ankle ligament injury resulting in insufficient restraint can lead to varus hindfoot alignment and is the leading cause of posttraumatic osteoarthritis after soft-tissue injury about the ankle. A Brostrom reconstruction of the lateral ankle ligaments remains the mainstay of treatment, with excellent long-term results after twenty-six years of follow-up.

Treatment of Achilles tendon injuries remains a challenge. A meta-analysis of twelve clinical trials involving 800 patients confirmed that open treatment results in a decreased rerupture rate, but at the expense of an increase in the overall complication rate⁴². Percutaneous repair with functional bracing was associated with decreased complication rates and improved range of motion in comparison with open techniques. Another study demonstrated that percutaneous repair was associated with decreased complication rates but increased rates of rerupture and sural nerve problems postoperatively. No differences in functional outcomes were found at the time of the final follow-up. Sural nerve complications may be minimized with care being taken to expose the nerve during the percutaneous procedure.

	Spine

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Catastrophic cervical spine injury continues to occur in contact sports. In American football, recent changes have allowed for the easier enforcement of rules prohibiting the spear-tackling technique, which remains the most common mechanism of these injuries. In a recent compilation of thirteen years of data from the National Center for Catastrophic Sports Injury Research, the incidence of these injuries in American football was found to be fifteen per year, with about six of these injuries resulting in quadriplegia⁴³. The incidence was 1.1 per 100,000 exposures among high school football players and 4.7 per 100,000 exposures among collegiate players. Forty-three athletes had a cervical cord neurapraxia (incidence, 3.31 cases per year), with sixteen of these players returning to football and none suffering a permanent quadriplegic event. Defensive backs had the highest risk for catastrophic cervical spine injury. Attention should be given to the continued education of athletes and coaches, with focus on proper tackling technique to decrease the incidence of these injuries.

	Hip

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Arthroscopy of the hip has allowed for the treatment of intraarticular pathology in a joint that had been relatively inaccessible in the past. As arthroscopic treatment of various hip ailments continues to evolve, diagnosing pathology and defining operative indications take on increasing importance. The most effective use of hip arthroplasty continues to be for the treatment of mechanical symptoms caused by labral pathology. In one study, 80% of patients who had intra-articular snapping of the hip had labral tears as the underlying etiology, and all improved with arthroscopic débridement of the labrum. Patients with Czerny stage-II (intrasubstance tears) and stage-III (complete avulsions) labral injuries did equally well with arthroscopic treatment⁴⁴. Recently, imaging techniques have evolved to more accurately identify patients with treatable hip pathology. Magnetic resonance imaging arthrography with radial reformatting and true sagittal images has increased the sensitivity and accuracy of diagnosis of arthroscopically confirmed labral pathology. A new approach also has been described for the treatment of extra-articular snapping hip, with endoscopic release of the iliotibial band showing good results at the time of the most recent follow-up.

	Cartilage

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The search for an effective treatment of cartilage injury continues. Methods such as microfracture, autograft plug transfer, and chondrocyte cell culture implantation are the mainstays of treatment, and all have been associated with good results in properly selected patients. The use of radiofrequency energy to smooth articular cartilage defects has been associated with good visual results but with detrimental changes in the mechanical properties of the treated and surrounding cartilage. Additionally, a sheep model showed death of surrounding chondrocytes in association with the use of this modality⁴⁵. Microfracture has demonstrated good clinical results at two years of follow-up, with filling of the defects being demonstrated with magnetic resonance imaging. Patients with better results had a lower body mass index and a shorter duration of symptoms. In a Level-I study of athletes, the results of osteochondral autograft transfer were superior to those of microfracture at three years of follow-up⁴⁶. Correct placement of autograft plugs is paramount. Particular attention must be paid to the harvest and delivery of the plugs perpendicular to the joint surface. In the event of a less-than-perpendicular plug delivery, depth has been shown to be important for survival of the graft. In one study, less contact pressure was noted on the plug when one side was flush with the surrounding cartilage and the other was resting slightly lower as opposed to when one side of the plug was elevated⁴⁷. In another study, plugs showed good incorporation at two years of follow-up and grafts with increased diameter appeared to be more stable initially⁴⁸. In a rabbit model, decreased cartilage stiffness was noted from the time of osteochondral plug implantation to twelve weeks after surgery. This finding could have implications for postoperative rehabilitation and the decision to allow full weight-bearing prior to three months after surgery. For large defects, allograft plugs have the advantages of decreased donor-site morbidity and the avoidance of multiple-site harvesting. It should be noted that decreased chondrocyte viability has been demonstrated in association with standard storage techniques, a phenomenon that is independent of the cartilage-to-bone ratio⁴⁹. Implantation of cultured autogenous chondrocytes has produced "hyaline-like" cartilage in multiple studies and remains an option for the treatment of cartilage defects. Limitations include cost and the need for more than one surgical procedure. In a study of young high-level soccer players, this procedure provided durable and functional results and was associated with higher knee scores and decreased pain at three years of follow-up in comparison with débridement alone⁵⁰. The three most common adverse events for this procedure as reported by the United States Food and Drug Administration were graft failure, delamination, and local tissue hypertrophy. Finally, tissue-engineered chondral plugs may have a future in the treatment of articular defects. These plugs healed with 90% type-II collagen in a rabbit model, although questions persist with regard to their strength and resistance to shear forces in situ⁵¹.

Intra-articular injections of the shoulder and knee, whether for postoperative pain control or as a therapeutic or diagnostic modality, are common in most orthopaedic practices. In addition, some surgeons use intra-articular pain pumps in an effort to decrease pain after surgery and to facilitate outpatient surgical treatments. Two studies questioned the safety of intra-articular bupivacaine and its effect on articular chondrocytes. One rabbit shoulder infusion model and one bovine in vitro model demonstrated cytotoxicity of bupivacaine on these cells with only relatively short exposure to the compound (forty-eight hours and ten to thirty minutes, respectively)^52,53. Additional study is needed to determine the safety of other types of intra-articular injections.

	Injury Prevention

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While the successful treatment of sports injuries has long been a goal of sports medicine physicians, emphasis on injury prevention is equally important in the care of athletes at all levels. Noncontact anterior cruciate ligament injuries remain a concern, and the prevention of these injuries with plyometric training with a focus on landing and jumping biomechanics has increased in popularity over the past several years. Directional and reactive jumping influence knee biomechanics and affect stresses across the anterior cruciate ligament. Female athletes are at particular risk with increased knee valgus moments, decreased knee and hip flexion angles at the time of initial ground contact, increased landing forces, and an increased quadriceps-to-hamstrings ratio with drop-jump activities. Adolescents, regardless of gender, have shown increased valgus moments at the knee with drop-jump testing, and this group may be a target for prevention of anterior cruciate ligament injury. A plyometric and dynamic stabilization program was shown to decrease lower extremity valgus measurements and should be incorporated into prevention strategies. However, a prospective study of female high school basketball players who were managed with an in-season plyometric exercise program for twenty minutes twice a week showed no significant decrease in noncontact anterior cruciate ligament injuries⁵⁴.

Finally, the link between anterior cruciate ligament rupture and the menstrual cycle remains controversial, with one study showing an increased risk of anterior cruciate injury in the pre-ovulatory stage of the cycle. Another study demonstrated no difference in knee or ankle laxity with respect to serum estrogen or progesterone levels.

Stress fracture risk in the lower extremity continues to be defined. In female United States Marine Corps recruits, low aerobic fitness was correlated with an increased risk of stress fracture. Preliminary fitness training may be of benefit for these recruits prior to the start of formal boot camp activities. Female professional basketball players were shown to have a higher injury rate than their male counterparts over six seasons⁵⁵. Little difference was noted, however, when individual injuries were compared between the two groups over the same time-period.

	Evidence-Based Orthopaedics

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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 cited already in this Update, four 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.

	Upcoming Meetings and Events

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The annual meeting of the Arthroscopy Association of North America (AANA) will be held on April 26 through 29, 2007, in San Francisco, California. The annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) will be held on July 12 through 15, 2007, in Calgary, Alberta, Canada. The AOSSM/AAOS first annual review course for Subspecialty Certification in Sports Medicine will be held on August 3 through 5, 2007, in Chicago, Illinois.

	Sports Medicine Fellowships

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Sports medicine fellowships continue to be the most popular fellowship choice in orthopaedic surgery. Accreditation has become even more important because, beginning in 2012, one will be required to have graduated from an accredited fellowship in order to take the subspecialty certification examination. Unfortunately, there is still not a formal match for sports medicine fellowship programs. Several of the more sought-after fellowship programs have developed a "gentlemen's agreement" to allow applicants to interview at other programs prior to making a decision regarding their fellowship location, but there are no written guarantees. Clearly, the match should be restored or an effective alternative must be developed.

	AOSSM Research

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The AOSSM research agenda has expanded considerably over the last few years with both society-sponsored multicenter clinical trials as well as topic-oriented calls for proposals. Below is a summary of these new grant opportunities.

The AOSSM has embarked on a topic-oriented research focus. Every three years, a research topic is identified that could change the practice of AOSSM members. Abstracts of research plans are submitted, and the best proposals are presented at a one-day grant workshop. Full proposals are accepted a few months later, and $250,000 is awarded to fund the best proposal. The goal of this program is twofold: (1) to fund research programs that are of interest to the AOSSM, and (2) to help high-quality research projects to develop enough pilot data to compete for major grant funding such as through the National Institutes of Health (NIH). The first topic funded by the AOSSM was noncontact anterior cruciate ligament injury mechanisms. Although only one investigator was funded, three individuals who submitted grant proposals went on to obtain NIH funding. The second topic was articular cartilage, for which final abstracts have been received and currently are under review. The AOSSM is in the process of developing the topic for the next round of submissions, and this information will be made available on the AOSSM web site once it is finalized. The AOSSM is sponsoring several multicenter trials, including the Multicenter Anterior Cruciate Ligament Revision Study (MARS), the Multicenter Evaluation of the Responsiveness of the International Knee Documentation Committee (MERI), and a study of the treatment of anterior cruciate ligament injuries in pediatric patients.

Other research opportunities include investigator-initiated proposals such as the AOSSM Young Investigator Grant, which awards amounts of up to $40,000 for pilot projects, and the Sandy Kirkley Clinical Outcome Research Grant, which awards $20,000 for an outcome research project or pilot study. Finally, the NCAA (National Collegiate Athletic Association) award will be given to the best paper at the AOSSM meeting that pertains to collegiate athletics. The award consists of a plaque and a $500 honorarium.

	Evidence-Based Articles Related to Sports Medicine

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