The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 8

Specialty Update | April 18, 2012

What's New in Sports Medicine

Joshua C. Hamann, MD¹; Richard Ma, MD²; Stephen R. Thompson, MD, MEd, FRCSC³; MaCalus V. Hogan, MD¹; Mark D. Miller, MD¹

¹ Department of Orthopaedics, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, PO Box 800159, Charlottesville, VA 22908-0159
² Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
³ Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada N6A 3K7

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Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Apr 18;94(8):757-765. doi: 10.2106/JBJS.K.01689

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Extract

This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2010 to August 2011. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone and Joint Surgery (American Volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery.

Figures in this Article

Introduction

Knee

Anterior Cruciate Ligament

Single-Bundle Versus Double-Bundle Reconstruction

Anterior cruciate ligament (ACL) reconstruction remains the most studied area in sports medicine. One aspect of ACL reconstruction that continues to be heavily debated is single-tunnel versus double-tunnel ACL reconstruction. Controlled laboratory studies have shown the superiority of double-bundle ACL reconstructions in resisting knee rotational stress relative to single-bundle reconstructions^1,2. A recent cadaveric study further demonstrated that the advantages of double-bundle ACL reconstruction in restoring knee rotational and tibial translation control are more apparent in meniscus-deficient states².

While differences in controlled laboratory conditions have been demonstrated, a clear clinical advantage of double-bundle ACL reconstruction remains unproven^3,4. A recent Level-I randomized controlled study evaluated 153 patients who were randomized into single-bundle or double-bundle ACL reconstruction with use of hamstring autografts⁴. At two years of follow-up, no significant differences were noted in terms of International Knee Documentation Committee (IKDC) scores, KT-1000 measurements, and pivot-shift examinations. However, the authors reported a higher rate of revision ACL reconstruction in the single-bundle group (n = 7) relative to the double-bundle group (n = 1).

Tunnel Position and ACL Reconstruction

Another research focus of ACL reconstruction surgery is on graft tunnel placement and achieving more “anatomic” positioning of the graft with the goal of achieving better rotational and anteroposterior stability. Several controlled laboratory studies have documented the difficulty of achieving, or the inability to achieve, an anatomically positioned ACL femoral tunnel with use of the transtibial drilling technique^5-7. Advocates of a separate anteromedial portal for femoral tunnel drilling have cited more accurate positioning of the guidewire and femoral tunnel in the center of the femoral ACL footprint. While the focus has been more on the femoral tunnel, the position of the tibial tunnel also has an effect on the ability of the reconstructed ACL to resist anterior translation and pivot-shift maneuver⁸.

Allograft Reconstruction

Graft selection for ACL reconstruction is dependent on both surgeon and patient preferences as well as availability. The outcomes following allograft ACL reconstruction have been under recent scrutiny, particularly in the young and active patient population. Recent outcomes of allograft reconstruction in this patient group have been mixed, with some studies showing results comparable with those in patients managed with autograft^9,10 and others showing inferior Tegner activity levels and greater instability episodes following allograft ACL reconstruction¹¹. The Multicenter Orthopaedic Outcomes Network (MOON) consortium recently reported lower IKDC and Knee Injury and Osteoarthritis Outcome Score (KOOS) indices in its allograft reconstruction group at six years of follow-up after ACL reconstruction¹².

Return to Sports After ACL Surgery

Favorable long-term outcomes following ACL reconstruction continue to be reported for both hamstring and patellar tendon autografts^13,14. Both techniques demonstrated similar long-term success at nine and fifteen years of follow-up¹⁴. Patellar tendon reconstruction has been associated with greater anterior knee pain and problems with kneeling¹⁴. The rate of return to sports at the preinjury level following ACL reconstruction may be lower than previously perceived for both the competitive athletic and general populations^15-18. The MOON consortium reported a 45% rate of return to activity in its cohort at two years¹⁷. A Level-IV study of 504 competitive athletes demonstrated that only 33% of the study population attempted to return to sports at one year following surgery¹⁶. A Level-IV study evaluating a series of National Football League (NFL) players demonstrated a similar lower-than-expected rate of return to play¹⁸.

Posterior Cruciate Ligament

Similar to ACL reconstruction, one of the objectives of posterior cruciate ligament (PCL) surgery is to achieve an anatomic reconstruction and graft isometry. In a controlled laboratory study with computer modeling, the position of the femoral graft attachment site was shown to be most important for achieving graft isometry¹⁹. As with the ACL, debate exists about whether an anatomic PCL reconstruction can be achieved with a single-bundle reconstruction as compared with a double-bundle reconstruction. A recent Level-II prospective randomized trial compared arthroscopic-assisted transtibial single-bundle PCL reconstruction with double-bundle reconstruction with use of Achilles tendon allograft after a minimum of two years of follow-up²⁰. The authors found significant differences in Telos stress radiography and IKDC knee examination scores in favor of double-bundle reconstruction, although there were no significant differences in terms of patient-assessed subjective outcome measures. Another Level-III study also showed no difference between single-bundle and double-bundle PCL reconstruction in patients with combined PCL and posterolateral corner repairs²¹. Several factors, including sex-based differences, may have a role in clinical outcomes following PCL reconstruction²².

Posterolateral Corner, Posteromedial Corner, and Multiligamentous Injury

Restoration of knee stability and kinematics is one of the main goals in the treatment of posterolateral corner injuries. Success with both femorofibular as well as anatomic posterolateral reconstructions has been reported^23,24. A recent controlled laboratory study in which the modified Larson two-strand (single femoral tunnel) technique was compared with the four-strand (double femoral tunnel) posterolateral reconstruction demonstrated that the four-strand reconstruction was better able to resist posterior and external rotational loads than was the two-strand technique²⁵. A cadaveric study utilizing computer navigation for measurements similarly demonstrated that the four-strand technique was superior for resisting rotational stress²⁶. Whether these laboratory findings will be replicated in clinical situations remains to be determined.

Meniscus

The understanding of the role of the meniscus in knee stability and resisting contact forces continues to improve. Retaining as much meniscal function as possible is critical^27,28. Controlled laboratory studies have demonstrated that a meniscal repair restores tibiofemoral contact forces and area compared with intact meniscal states²⁹. Successful repair is dependent on several factors, including the need to address ligament deficiency at time of meniscal repair³⁰. Outcomes following meniscal root repairs generally have been favorable, although reported healing rates have varied^27,31,32. Meniscal substitution, including allograft or collagen meniscal transplantation, remains an option for carefully selected patients^33,34. One Level-II prospective study evaluated a cohort of thirty-six patients who either received a medial collagen meniscal implant or underwent partial medial meniscectomy³⁴. After a minimum of ten years of follow-up, the meniscal implant group had lower pain scores, higher patient-assigned subjective and objective outcome scores, and less radiographic narrowing of the medial knee compartment. Finally, a recent Level-I study evaluating the use of a novel arthroscopic fluid (OMS103HP) for knee arthroscopy demonstrated improved mean visual analog scores for pain, improved knee motion, and postoperative functional outcomes relative to controls³⁵.

Patellofemoral Articulation

Anterior knee pain can be difficult to treat. Vastus medialis muscle dysfunction, including both muscle activation delay and atrophy, has been implicated in patellofemoral pain syndrome and patellar maltracking^36,37. A rehabilitation program focused on proximal strengthening and improving neuromuscular control of the hip and core musculature has produced improved patient outcomes and reduced knee pain³⁸.

Patellar dislocation is another commonly studied entity. The risk of dislocation may be attributable to several factors. Females are at greater risk for patellar dislocation, which may be attributed to a higher incidence of trochlear dysplasia, including a greater tibial tubercle-trochlear groove (TT-TG) distance³⁹. Surgical treatment for recurrent dislocations includes medial patellofemoral ligament repair as well as reconstruction^40-42. Relatively high failure rates were reported in a recent case series of medial patellofemoral ligament repair (28%; eight of twenty-nine knees)⁴⁰. Risk factors for medial patellofemoral ligament repair failures include nonanatomic repair and unrecognized underlying trochlear dysplasia. Medial patellofemoral ligament reconstruction with a free tendon graft remains a good option for the treatment of recurrent patellar dislocations. As is the case for medial patellofemoral ligament repairs, care should be taken to restore the anatomy of the medial patellofemoral ligament with the graft reconstruction⁴².

Osteotomy

A medial opening-wedge high tibial osteotomy can affect both the tibial slope and the patellar height. Meticulous surgical techniques can minimize these unwanted changes during the performance of a high tibial osteotomy⁴³. Cartilage-specific magnetic resonance imaging (MRI) sequences have been developed and have shown potential cartilage recovery in the medial knee compartment following high tibial osteotomy⁴⁴. In a recent large case series, the five, ten, and fifteen-year survival rates following high tibial osteotomy were 95%, 79%, and 56%, respectively⁴⁵.

Shoulder

Rotator Cuff

Rotator cuff disease remains a highly studied field in sports medicine. In a study that focused on the progression of rotator cuff tears, the authors evaluated characteristics that led to painful rotator cuff tears as compared with asymptomatic tears⁴⁶. The authors found that as the size of the rotator cuff tear increases, the tear becomes symptomatic. They also concluded that larger asymptomatic cuff tears are more likely to increase in size. In a natural history study of rotator cuff tears that were treated nonoperatively, patients who were sixty years of age or older were followed for an average of twenty-nine months⁴⁷. The authors noted an increase in size for thirty of the sixty-one tears, whereas only five of the sixty-one tears had a decrease in size when monitored with ultrasound. The only characteristic that was correlated with rotator cuff tear progression was increased pain at the time of follow-up.

The technique of repair of rotator cuff tears continues to be a hot topic in the orthopaedic literature. In a prospective randomized trial of single-row versus double-row repair by a single surgeon, there was no difference in outcome scores at two years and no significant difference in the rate of retears⁴⁸. In the meta-analysis by Prasathaporn et al., double-row repair was associated with a higher rate of healing but no significant difference was found between single and double-row repairs in terms of patient outcomes⁴⁹. Finally, in a Level-III retrospective analysis of 132 tears, there was no significant difference between single and double-row repairs in terms of outcomes, but the authors noted that a subgroup of larger tears (2.5 to 3.5 cm) had better healing rates following double-row repair⁵⁰.

Various methods of augmentation of rotator cuff repairs have been explored over the past year. Barber et al. studied platelet-rich plasma fibrin matrix in a Level-III case-control study⁵¹. The authors found that healing rates were higher in the platelet-rich plasma group but that, aside from Rowe scores, clinical outcome scores were not changed significantly. Castricini et al., in a prospective randomized study, found no difference in the incidence or retears among patients with smaller (<3-cm) tears with or without the use of platelet-rich fibrin matrix on the basis of repeat MRI and Constant scores at an average of sixteen months of follow-up⁵².

Instability

The position of shoulder immobilization after primary glenohumeral dislocation continues to be debated in the literature. A Level-I study with two-year follow-up showed no difference in the rate of recurrence of first-time shoulder dislocations with sling immobilization or immobilization in external rotation⁵³. In the meta-analysis by Paterson et al., pooled data showed a difference in redislocation rates between external rotation immobilization (25%) and sling immobilization (40%), but the difference was not significant (p = 0.07)⁵⁴. The most predictive factor of recurrent instability was chronological age at time of the initial dislocation.

Arthroscopic repair of anterior glenohumeral instability has been associated with good long-term outcomes, but the results diminish over time, as shown by Castagna et al.⁵⁵. The most common cause for the failure of repair is the failure to recognize capsular laxity and glenohumeral bone loss. Castagna et al. also concluded that participation in contact sports and overhead activities also are risk factors for recurrent instability, but this finding did not reach statistical significance⁵⁵. One study that was published during the past year indicated that college football players who have undergone surgery for the treatment of glenohumeral instability will have shorter NFL careers than matched controls⁵⁶.

SLAP (Superior Labrum, Anterior to Posterior) Lesions

The literature supports arthroscopic repair of Type-II SLAP tears, but Level-I evidence is still lacking. The outcomes of revision SLAP repair were recently reported by Park and Glousman⁵⁷. The authors found that revision SLAP repairs tend to have worse results than primary repairs, with patients receiving Workers’ Compensation and overhead athletes faring the worst. Type-II SLAP repair in patients older than forty years of age has been controversial, but in the study by Alpert et al., such patients did just as well as those who were younger than forty years of age⁵⁸.

Arthroscopic tenodesis of the long head of the biceps was extensively researched over the review period. Scheibel et al., in a clinical study, showed that osseous fixation was favored over soft-tissue tenodesis when the results were assessed with use of a new long head of the biceps tendon outcome scale⁵⁹. Slabaugh et al., in a biomechanical study, reported that smaller, shorter interference screws were favored to reduce surgical complications⁶⁰, and Patzer et al. reported similar ultimate failure loads for interference screw and suture techniques⁶¹.

Acromioclavicular Joint

Biomechanical analysis of the coracoclavicular ligaments showed that the conoid provides better superior restraint and that the trapezoid is better for posterior restraint⁶². Biomechanical analyses of coracoclavicular ligament reconstructions showed that superior strength was observed following anatomic reconstruction with use of allograft as compared with other techniques⁶³ and that coracoacromial ligament transfer does not add significant strength to constructs⁶⁴.

Cartilage

Articular Cartilage Defects

The optimal therapy for the treatment of cartilage lesions remains a topic of debate and extensive research. Surgeons and scientists continue to evaluate the outcomes of accepted techniques and continue to explore novel future options⁶⁵. A recent controlled laboratory study involving rabbits compared microfracture and drilling in terms of their effects on cartilage remodeling and repair⁶⁶. Histological analysis and three-dimensional microcomputed tomographic analysis demonstrated incomplete reconstitution of the subchondral bone structure in association with both techniques but showed that deeper drilling led to a larger volume of repair and remodeling, which led to improved chondral repair. Marquass et al. compared the use of matrix-associated implantation of predifferentiated mesenchymal stem cells (pre-MSC) with that of articular chondrocytes in osteochondral lesions created on the medial femoral condyles of sheep hindlegs⁶⁷. At one year of follow-up, they demonstrated immunohistochemical collagen type-II staining as well as improved bonding of pre-MSC gels to native cartilage with no degradation. They concluded that the delivery of pre-MSCs with collagen hydrogels may play a future role in the treatment of osteochondral defects.

There have been several recent clinical studies comparing articular cartilage lesion treatment options. Kon et al. performed a prospective study in which arthroscopic second-generation autologous chondrocyte implantation with Hyalograft C was compared with microfracture in high-level male soccer players⁶⁸. The rate of return to competition and the IKDC subjective scores were similar in both groups at the time of the two-year follow-up. The patients in the Hyalograft C group took an average of 4.5 months longer to return to an official soccer game but also had significantly better results at the time of the final evaluation, whereas the results in the microfracture group decreased over time. Cole et al. reported the results of a randomized controlled prospective clinical safety trial in which single-stage Cartilage Autograft Implantation System (CAIS) treatment was compared with microfracture⁶⁹. General outcome scores were improved overall for both groups, and no difference was found between the groups in terms of the number of adverse effects. The CAIS group had significantly higher IKDC and KOOS scores that were maintained over a two-year period. Qualitative imaging analysis showed no significant differences, except for increased intralesional osteophyte formation for the microfracture group. The authors concluded that CAIS is safe, feasible, and effective for the treatment of focal chondral defects and may provide improved long-term outcomes.

Vanlauwe et al. performed a randomized controlled trial in which the five-year results of characterized chondrocyte implantation were compared with those of microfracture⁷⁰. One hundred and eleven patients with International Cartilage Repair Society (ICRS) grade-III or IV femoral condyle articular cartilage lesions were randomized and followed for five years with use of KOOS scores. The outcomes of both treatments were comparable at five years, with characterized chondrocyte implantation showing significantly better outcomes in patients who had been treated within three years after the onset of symptoms. In addition to supporting treatment with characterized chondrocyte implantation, this study highlighted the time to the onset of symptoms as a variable in decision-making for the treatment of these injuries.

Hip

Research into hip arthroscopy continues at a rapid pace, better defining the indications and improving outcomes. Originally, hip arthroscopy was used to treat labral and cartilage disorders. Indications have expanded to include osteochondroplasty for the treatment of femoroacetabular impingement, debridement of tears of the ligamentum teres, and iliopsoas tenotomy for the treatment of snapping hip. Hip arthroscopy remains a technically difficult procedure, with a learning curve of approximately thirty cases⁷¹. Case reports of intrathoracic fluid extravasation⁷², severing of the inferior gluteal artery⁷³, and femoral neck fracture⁷⁴ following hip arthroscopy recently have been reported.

Femoroacetabular impingement is being increasingly recognized. In a study of 200 healthy volunteers without hip pain, the prevalence of cam morphology on MRI was 14%, with a relatively higher prevalence in men (24%) than women (5%)⁷⁵. This cam-type impingement may result in cartilage damage to the anterosuperior region of the acetabulum. The dGEMRIC (delayed gadolinium-enhanced MRI of cartilage) technique of MRI is capable of detecting this cartilage damage in patients with cam deformities before changes are visible on radiographs and eventually may be useful for early diagnosis and for evaluating the effectiveness of surgical treatment⁷⁶. Femoroacetabular impingement can be treated with open, mini-open, and arthroscopic approaches. In a systematic review, Matsuda et al.⁷⁷ demonstrated a comparatively high rate of major complications in association with open techniques, primarily due to difficulties with the trochanteric osteotomy. The arthroscopic technique had outcomes similar to open or mini-open approaches and a lower rate of complications. In a second systematic review, Ng et al.⁷⁸ found that surgical treatment reliably decreased symptoms in patients without advanced osteoarthritis, but there is not yet sufficient evidence to determine whether treatment delays the progression of osteoarthritis. Naal et al., in a case series of twenty-two male high-level athletes who were managed with surgical dislocation, reported that 86% of the patients were able to return to the same level of professional sports after a mean duration of follow-up of forty-five months⁷⁹.

The acetabular labrum is an important structure that should be reattached if torn. In a cadaveric study, Kalhor et al. demonstrated that the labrum receives its blood supply from a periacetabular periosteal vascular ring located on the capsular side⁸⁰. In patients without osseous abnormalities, Haviv and O'Donnell⁸¹ demonstrated improved modified Harris hip scores and nonarthritic hip scores following arthroscopic debridement or repair.

Foot and Ankle

Waterman et al., in an effort to estimate the rate of syndesmotic and medial ankle sprain injuries and identify risk factors for such injuries in United States Military Academy (USMA) cadets, searched the Cadet Illness and Injury Tracking System database at the USMA for all ankle injuries that had occurred over a period of four years⁸². The authors found that men were three times more likely to have medial ankle sprains and that athletics accounted for 81% of syndesmotic injuries and 64% of medial ankle sprains across sexes. Higher-level athletic competition increased the risk of syndesmotic injury. Franklyn-Miller et al. reported on the preventive role of customized total foot orthoses in military officer trainees, with results of their randomized controlled trial showing an absolute risk reduction of 0.49 (p < 0.0001)⁸³.

The role of platelet-rich plasma in the treatment of acute and chronic tendon injury continues to be a frequently discussed topic in both orthopaedic and media forums. Schepull et al. randomized thirty patients undergoing acute Achilles tendon rupture repair into treatment with or without injection of platelet-rich plasma⁸⁴. There was no significant difference in elastic modulus at seven weeks and heel raise index at one year. The authors concluded that platelet-rich plasma was not a useful treatment for Achilles tendon ruptures. de Jonge et al., in a recent double-blind randomized placebo-controlled trial, evaluated the effects of platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy after one year of follow-up⁸⁵. Fifty-four patients with chronic tendinopathy were randomized to treatment with injection of platelet-rich plasma injection or saline solution (placebo) combined with eccentric strengthening exercises. The Victorian Institute of Sports Assessment-Achilles score improved in both groups after one year, with no significant difference between the groups. There also was no significant difference between the groups in terms of structural appearance with ultrasound imaging.

Operative versus nonoperative treatment of acute Achilles tendon rupture has continued to be a topic of debate. Willits et al. randomized 144 patients into operative and nonoperative treatment arms⁸⁶. All patients were enrolled in an accelerated rehabilitation protocol program with early weight-bearing and ankle motion. There was no significant clinical difference between the groups. The authors concluded that an accelerated-rehabilitation program provided results comparable with those of operative treatment without the complications of surgery. Nilsson-Helander et al. reported similar results after randomizing ninety-seven patients into operative and nonoperative treatment groups⁸⁷. Although the rerupture rate was higher for the nonoperative treatment group (12%) than for the operative treatment group (2%), the authors found no significant difference in function at the time of the one-year follow-up except for the heel-rise work test being improved in the operative treatment group. The authors concluded that early mobilization was beneficial regardless of treatment chosen, although the increased rerupture rate may be seen as clinically important.

Elbow

The use of platelet-rich plasma for the treatment of lateral elbow epicondylitis continues to be a hot topic. Gosens et al., in a Level-I study with two years of follow-up, reported continued benefits in the platelet-rich plasma group as compared with the corticosteroid treatment group at the time of the latest follow-up⁸⁸. The platelet-rich plasma group maintained better Disabilities of the Arm, Shoulder and Hand (DASH) scores at two years, whereas the corticosteroid group had a return to baseline DASH scores at two years. Schipper et al. reported on the long-term results of open treatment of concomitant lateral and medial tendinosis⁸⁹. In a case series of forty-eight patients with a minimum of five years of follow-up, good to excellent results were seen in 85% of the patients. Hurd et al. performed MRI studies of asymptomatic high school baseball pitchers in order to compare radiographic abnormalities^90,91. They found a high rate of thickening of the anterior band of the ulnar collateral ligament and correlated this with increased peak internal elbow adduction moments. Forty-three percent of asymptomatic high school throwing elbows had radiographic abnormalities in the throwing elbow as compared with the nonthrowing elbow.

Treatment of osteochondritis dissecans lesions of the capitellum remains controversial, with long-term prospective studies needed. A case series of capitellar osteochondritis dissecans lesions that were treated with arthroscopic debridement showed good outcomes at an average of 3.6 years⁹². However, the return to sports in this group was poor after surgical treatment.

Head and Spinal Cord-Related Sports Injuries

Sports-related concussion continues to predominate in this area. In a large, prospective epidemiological study investigating the rates of concussion in high school boys’ and girls’ sports, boys’ sports accounted for 75% of all concussions. Football and girls’ soccer had the highest injury rates. Neurocognitive testing is becoming increasingly important in return-to-play criteria and predicting protracted recovery from concussion⁹³. Lau et al. investigated 108 male high school football athletes immediately after concussion with use of the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) test battery and found that patients with migraine-like symptoms (headache, dizziness, nausea, light sensitivity) may be at increased risk for delayed recovery⁹⁴.

Subspecialty Certification in Sports Medicine

Subspecialty certification in sports medicine is under the direction of the American Board of Orthopaedic Surgery (ABOS). The five-year “grandfather period” for any surgeon seeking this certification will expire in 2012. Therefore, applicants are now required to have completed an Accreditation Council for Graduate Medical Education (ACGME)-accredited and/or Arthroscopy Association of North America (AANA)-recognized sports medicine fellowship to sit for the examination. A complete list of requirements, including eligible sports medicine cases, is available online at the ABOS web site (www.abos.org).

The application deadline for the 2012 examination is March 15, 2012. It must include case lists, required documents, and fees. Eligible candidates will be mailed their scheduling/admission permits in August 2012, and the examination will be administered on November 1, 2012, at Prometric Technology Centers nationwide. The application materials will be available at the ABOS web site. The American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeons (AAOS) review course for subspecialty certification in orthopaedic sports medicine will be held in August 2012 in Chicago, Illinois, and information on this course can be found at the AOSSM web site (www.sportsmed.org). Applications for the 2012 examination are available online.

Sports Medicine Fellowships

Sports medicine continues to be the most popular fellowship among orthopaedic residents who apply for a subspecialty fellowship, with 28% of a recent survey of orthopaedic residents seeking a sports medicine fellowship⁹⁵. Reviews of the match process continue to be positive, making selection of fellows better for both program directors and applicants.

Upcoming Meetings

The Annual Meeting of the American Academy of Orthopaedic Surgeons will be held on March 19-23, 2013, in Chicago, Illinois, with Specialty Day being held on March 23, 2012. The annual meeting of the AANA will be held on May 17 through 19, 2012, in Orlando, Florida. The annual meeting of the AOSSM will be held on July 12 through 15, 2012, in Baltimore, Maryland.

Evidence-Based Orthopaedics

Over the past year, 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 those cited previously in this Update, six Level-I studies were identified that were relevant to sports medicine. We have provided a brief commentary about these articles after the standard bibliography to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.

Musahl V; Bedi A; Citak M; O'Loughlin P; Choi D; Pearle AD. Effect of single-bundle and double-bundle anterior cruciate ligament reconstructions on pivot-shift kinematics in anterior cruciate ligament- and meniscus-deficient knees. Am J Sports Med. 2011;39:289-95.

Fujita N; Kuroda R; Matsumoto T; Yamaguchi M; Yagi M; Matsumoto A; Kubo S; Matsushita T; Hoshino Y; Nishimoto K; Araki D; Kurosaka M. Comparison of the clinical outcome of double-bundle, anteromedial single-bundle, and posterolateral single-bundle anterior cruciate ligament reconstruction using hamstring tendon graft with minimum 2-year follow-up. Arthroscopy. 2011;27:906-13.

Suomalainen P; Moisala AS; Paakkala A; Kannus P; Järvelä T. Double-bundle versus single-bundle anterior cruciate ligament reconstruction: randomized clinical and magnetic resonance imaging study with 2-year follow-up. Am J Sports Med. 2011;39:1615-22.

Bedi A; Musahl V; Steuber V; Kendoff D; Choi D; Allen AA; Pearle AD; Altchek DW. Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy. 2011;27:380-90.

Piasecki DP; Bach BR Jr; Espinoza Orias AA; Verma NN. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique?Am J Sports Med. 2011;39:1306-15.

Strauss EJ; Barker JU; McGill K; Cole BJ; Bach BR Jr; Verma NN. Can anatomic femoral tunnel placement be achieved using a transtibial technique for hamstring anterior cruciate ligament reconstruction?Am J Sports Med. 2011;39:1263-9.

Bedi A; Maak T; Musahl V; Citak M; O'Loughlin PF; Choi D; Pearle AD. Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction: is the tibial tunnel position most important?Am J Sports Med. 2011;39:366-73.

Mascarenhas R; Tranovich M; Karpie JC; Irrgang JJ; Fu FH; Harner CD. Patellar tendon anterior cruciate ligament reconstruction in the high-demand patient: evaluation of autograft versus allograft reconstruction. Arthroscopy. 2010;26( 9 Suppl):S58-66.

Sun K; Zhang J; Wang Y; Xia C; Zhang C; Yu T; Tian S. Arthroscopic anterior cruciate ligament reconstruction with at least 2.5 years’ follow-up comparing hamstring tendon autograft and irradiated allograft. Arthroscopy. 2011;27:1195-202.

Barrett AM; Craft JA; Replogle WH; Hydrick JM; Barrett GR. Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level. Am J Sports Med. 2011;39:2194-8.

Spindler KP; Huston LJ; Wright RW; Kaeding CC; Marx RG; Amendola A; Parker RD; Andrish JT; Reinke EK; Harrell FE Jr; MOON Group; Dunn WR. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med. 2011;39:348-59.

Hui C; Salmon LJ; Kok A; Maeno S; Linklater J; Pinczewski LA. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for “isolated” anterior cruciate ligament tear. Am J Sports Med. 2011;39:89-98.

Wipfler B; Donner S; Zechmann CM; Springer J; Siebold R; Paessler HH. Anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon: a prospective comparative study with 9-year follow-up. Arthroscopy. 2011;27:653-65.

Ardern CL; Taylor NF; Feller JA; Webster KE. Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2012;40:41-8.

Ardern CL; Webster KE; Taylor NF; Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med. 2011;39:538-43.

Dunn WR; Spindler KP; MOON Consortium. Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med. 2010;38:2040-50.

Shah VM; Andrews JR; Fleisig GS; McMichael CS; Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. Am J Sports Med. 2010;38:2233-9.

Jeong WS; Yoo YS; Kim DY; Shetty NS; Smolinski P; Logishetty K; Ranawat A. An analysis of the posterior cruciate ligament isometric position using an in vivo 3-dimensional computed tomography-based knee joint model. Arthroscopy. 2010;26:1333-9.

Kim SJ; Jung M; Moon HK; Kim SG; Chun YM. Anterolateral transtibial posterior cruciate ligament reconstruction combined with anatomical reconstruction of posterolateral corner insufficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction over a 2- to 6-year follow-up. Am J Sports Med. 2011;39:481-9.

Jung TM; Lubowicki A; Wienand A; Wagner M; Weiler A. Knee stability after posterior cruciate ligament reconstruction in female versus male patients: a prospective matched-group analysis. Arthroscopy. 2011;27:399-403.

LaPrade RF; Spiridonov SI; Coobs BR; Ruckert PR; Griffith CJ. Fibular collateral ligament anatomical reconstructions: a prospective outcomes study. Am J Sports Med. 2010;38:2005-11.

Noyes FR; Barber-Westin SD. Long-term assessment of posterolateral ligament femoral-fibular reconstruction in chronic multiligament unstable knees. Am J Sports Med. 2011;39:497-505.

Miyatake S; Kondo E; Tsai TY; Hirschmann M; Halewood C; Jakobsen BW; Yasuda K; Amis AA. Biomechanical comparisons between 4-strand and modified Larson 2-strand procedures for reconstruction of the posterolateral corner of the knee. Am J Sports Med. 2011;39:1462-9.

Ho EP; Lam MH; Chung MM; Fong DT; Law BK; Yung PS; Chan WY; Chan KM. Comparison of 2 surgical techniques for reconstructing posterolateral corner of the knee: a cadaveric study evaluated by navigation system. Arthroscopy. 2011;27:89-96.

Kim SB; Ha JK; Lee SW; Kim DW; Shim JC; Kim JG; Lee MY. Medial meniscus root tear refixation: comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011;27:346-54.

Han SB; Shetty GM; Lee DH; Chae DJ; Seo SS; Wang KH; Yoo SH; Nha KW. Unfavorable results of partial meniscectomy for complete posterior medial meniscus root tear with early osteoarthritis: a 5- to 8-year follow-up study. Arthroscopy. 2010;26:1326-32.

Muriuki MG; Tuason DA; Tucker BG; Harner CD. Changes in tibiofemoral contact mechanics following radial split and vertical tears of the medial meniscus an in vitro investigation of the efficacy of arthroscopic repair. J Bone Joint Surg Am. 2011;93:1089-95.

Dürselen L; Vögele S; Seitz AM; Ignatius A; Friederich NF; Bauer G; Majewski M. Anterior knee laxity increases gapping of posterior horn medial meniscal tears. Am J Sports Med. 2011;39:1749-55.

Anderson L; Watts M; Shapter O; Logan M; Risebury M; Duffy D; Myers P. Repair of radial tears and posterior horn detachments of the lateral meniscus: minimum 2-year follow-up. Arthroscopy. 2010;26:1625-32.

Seo HS; Lee SC; Jung KA. Second-look arthroscopic findings after repairs of posterior root tears of the medial meniscus. Am J Sports Med. 2011;39:99-107.

Vundelinckx B; Bellemans J; Vanlauwe J. Arthroscopically assisted meniscal allograft transplantation in the knee: a medium-term subjective, clinical, and radiographical outcome evaluation. Am J Sports Med. 2010;38:2240-7.

Zaffagnini S; Marcheggiani Muccioli GM; Lopomo N; Bruni D; Giordano G; Ravazzolo G; Molinari M; Marcacci M. Prospective long-term outcomes of the medial collagen meniscus implant versus partial medial meniscectomy: a minimum 10-year follow-up study. Am J Sports Med. 2011;39:977-85.

Garrett WE; Kaeding CC; ElAttrache NS; Xerogeanes JW; Hewitt MS; Skrepnik NV; Papilion JD; O'Donnell JB; Fox DL; Ruvuna F; Whitaker JS; Demopulos GA. Novel drug OMS103HP reduces pain and improves joint motion and function for 90 days after arthroscopic meniscectomy. Arthroscopy. 2011;27:1060-70.

Pal S; Draper CE; Fredericson M; Gold GE; Delp SL; Beaupre GS; Besier TF. Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. Am J Sports Med. 2011;39:590-8.

Pattyn E; Verdonk P; Steyaert A; Vanden Bossche L; Van den Broecke W; Thijs Y; Witvrouw E. Vastus medialis obliquus atrophy: does it exist in patellofemoral pain syndrome?Am J Sports Med. 2011;39:1450-5.

Earl JE; Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011;39:154-63.

Balcarek P; Jung K; Ammon J; Walde TA; Frosch S; Schüttrumpf JP; Stürmer KM; Frosch KH. Anatomy of lateral patellar instability: trochlear dysplasia and tibial tubercle-trochlear groove distance is more pronounced in women who dislocate the patella. Am J Sports Med. 2010;38:2320-7.

Camp CL; Krych AJ; Dahm DL; Levy BA; Stuart MJ. Medial patellofemoral ligament repair for recurrent patellar dislocation. Am J Sports Med. 2010;38:2248-54.

Deie M; Ochi M; Adachi N; Shibuya H; Nakamae A. Medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation. Am J Sports Med. 2011;39:140-5.

Servien E; Fritsch B; Lustig S; Demey G; Debarge R; Lapra C; Neyret P. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med. 2011;39:134-9.

Hinterwimmer S; Beitzel K; Paul J; Kirchhoff C; Sauerschnig M; von Eisenhart-Rothe R; Imhoff AB. Control of posterior tibial slope and patellar height in open-wedge valgus high tibial osteotomy. Am J Sports Med. 2011;39:851-6.

Parker DA; Beatty KT; Giuffre B; Scholes CJ; Coolican MR. Articular cartilage changes in patients with osteoarthritis after osteotomy. Am J Sports Med. 2011;39:1039-45.

Hui C; Salmon LJ; Kok A; Williams HA; Hockers N; van der Tempel WM; Chana R; Pinczewski LA. Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med. 2011;39:64-70.

Mall NA; Kim HM; Keener JD; Steger-May K; Teefey SA; Middleton WD; Stobbs G; Yamaguchi K. Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. J Bone Joint Surg Am. 2010;92:2623-33.

Safran O; Schroeder J; Bloom R; Weil Y; Milgrom C. Natural history of nonoperatively treated symptomatic rotator cuff tears in patients 60 years old or younger. Am J Sports Med. 2011;39:710-4.

Koh KH; Kang KC; Lim TK; Shon MS; Yoo JC. Prospective randomized clinical trial of single- versus double-row suture anchor repair in 2- to 4-cm rotator cuff tears: clinical and magnetic resonance imaging results. Arthroscopy. 2011;27:453-62.

Prasathaporn N; Kuptniratsaikul S; Kongrukgreatiyos K. Single-row repair versus double-row repair of full-thickness rotator cuff tears. Arthroscopy. 2011;27:978-85.

Pennington WT; Gibbons DJ; Bartz BA; Dodd M; Daun J; Klinger J; Popovich M; Butler B. Comparative analysis of single-row versus double-row repair of rotator cuff tears. Arthroscopy. 2010;26:1419-26.

Barber FA; Hrnack SA; Snyder SJ; Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation. Arthroscopy. 2011;27:1029-35.

Castricini R; Longo UG; De Benedetto M; Panfoli N; Pirani P; Zini R; Maffulli N; Denaro V. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med. 2011;39:258-65.

Liavaag S; Brox JI; Pripp AH; Enger M; Soldal LA; Svenningsen S. Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2011;93:897-904.

Paterson WH; Throckmorton TW; Koester M; Azar FM; Kuhn JE. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2010;92:2924-33.

Castagna A; Markopoulos N; Conti M; Rose GD; Papadakou E; Garofalo R. Arthroscopic Bankart suture-anchor repair: radiological and clinical outcome at minimum 10 years of follow-up. Am J Sports Med. 2010;38:2012-6.

Brophy RH; Gill CS; Lyman S; Barnes RP; Rodeo SA; Warren RF. Effect of shoulder stabilization on career length in National Football League athletes. Am J Sports Med. 2011;39:704-9.

Park S; Glousman RE. Outcomes of revision arthroscopic type II superior labral anterior posterior repairs. Am J Sports Med. 2011;39:1290-4.

Alpert JM; Wuerz TH; O'Donnell TF; Carroll KM; Brucker NN; Gill TJ. The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions. Am J Sports Med. 2010;38:2299-303.

Scheibel M; Schröder RJ; Chen J; Bartsch M. Arthroscopic soft tissue tenodesis versus bony fixation anchor tenodesis of the long head of the biceps tendon. Am J Sports Med. 2011;39:1046-52.

Slabaugh MA; Frank RM; Van Thiel GS; Bell RM; Wang VM; Trenhaile S; Provencher MT; Romeo AA; Verma NN. Biceps tenodesis with interference screw fixation: a biomechanical comparison of screw length and diameter. Arthroscopy. 2011;27:161-6.

Patzer T; Rundic JM; Bobrowitsch E; Olender GD; Hurschler C; Schofer MD. Biomechanical comparison of arthroscopically performable techniques for suprapectoral biceps tenodesis. Arthroscopy. 2011;27:1036-47.

Yoo YS; Tsai AG; Ranawat AS; Bansal M; Fu FH; Rodosky MW; Smolinski P. A biomechanical analysis of the native coracoclavicular ligaments and their influence on a new reconstruction using a coracoid tunnel and free tendon graft. Arthroscopy. 2010;26:1153-61.

Thomas K; Litsky A; Jones G; Bishop JY. Biomechanical comparison of coracoclavicular reconstructive techniques. Am J Sports Med. 2011;39:804-10.

Clevenger T; Vance RE; Bachus KN; Burks RT; Tashjian RZ. Biomechanical comparison of acromioclavicular joint reconstructions using coracoclavicular tendon grafts with and without coracoacromial ligament transfer. Arthroscopy. 2011;27:24-30.

Chu CR; Beynnon BD; Buckwalter JA; Garrett WE Jr; Katz JN; Rodeo SA; Spindler KP; Stanton RA. Closing the gap between bench and bedside research for early arthritis therapies (EARTH): report from the AOSSM/NIH U-13 Post-Joint Injury Osteoarthritis Conference II. Am J Sports Med. 2011;39:1569-78.

Chen H; Chevrier A; Hoemann CD; Sun J; Ouyang W; Buschmann MD. Characterization of subchondral bone repair for marrow-stimulated chondral defects and its relationship to articular cartilage resurfacing. Am J Sports Med. 2011;39:1731-40.

Marquass B; Schulz R; Hepp P; Zscharnack M; Aigner T; Schmidt S; Stein F; Richter R; Osterhoff G; Aust G; Josten C; Bader A. Matrix-associated implantation of predifferentiated mesenchymal stem cells versus articular chondrocytes: in vivo results of cartilage repair after 1 year. Am J Sports Med. 2011;39:1401-12.

Kon E; Filardo G; Berruto M; Benazzo F; Zanon G; Della Villa S; Marcacci M. Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture. Am J Sports Med. 2011;39:2549-57.

Cole BJ; Farr J; Winalski CS; Hosea T; Richmond J; Mandelbaum B; De Deyne PG. Outcomes after a single-stage procedure for cell-based cartilage repair: a prospective clinical safety trial with 2-year follow-up. Am J Sports Med. 2011;39:1170-9.

Vanlauwe J; Saris DB; Victor J; Almqvist KF; Bellemans J; Luyten FP; TIG/ACT/01/2000&EXT Study Group. Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. Am J Sports Med. 2011;39:2566-74.

Konan S; Rhee SJ; Haddad FS. Hip arthroscopy: analysis of a single surgeon's learning experience. J Bone Joint Surg Am. 2011;93 Suppl 2:52-6.

Verma M; Sekiya JK. Intrathoracic fluid extravasation after hip arthroscopy. Arthroscopy. 2010;26( 9 Suppl):S90-4.

Bruno M; Longhino V; Sansone V. A catastrophic complication of hip arthroscopy. Arthroscopy. 2011;27:1150-2.

Ayeni OR; Bedi A; Lorich DG; Kelly BT. Femoral neck fracture after arthroscopic management of femoroacetabular impingement. A case report. J Bone Joint Surg Am. 2011;93: e47.

Hack K; Di Primio G; Rakhra K; Beaulé PE. Prevalence of cam-type femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am. 2010;92:2436-44.

Pollard TC; McNally EG; Wilson DC; Wilson DR; Mädler B; Watson M; Gill HS; Carr AJ. Localized cartilage assessment with three-dimensional dGEMRIC in asymptomatic hips with normal morphology and cam deformity. J Bone Joint Surg Am. 2010;92:2557-69.

Matsuda DK; Carlisle JC; Arthurs SC; Wierks CH; Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 2011;27:252-69.

Ng VY; Arora N; Best TM; Pan X; Ellis TJ. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med. 2010;38:2337-45.

Naal FD; Miozzari HH; Wyss TF; Nötzli HP. Surgical hip dislocation for the treatment of femoroacetabular impingement in high-level athletes. Am J Sports Med. 2011;39:544-50.

Kalhor M; Horowitz K; Beck M; Nazparvar B; Ganz R. Vascular supply to the acetabular labrum. J Bone Joint Surg Am. 201; 92:2570-5.

Haviv B; O'Donnell J. Arthroscopic treatment for acetabular labral tears of the hip without bony dysmorphism. Am J Sports Med. 2011;39 Suppl:79S-84S.

Waterman BR; Belmont PJ Jr; Cameron KL; Svoboda SJ; Alitz CJ; Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39:992-8.

Franklyn-Miller A; Wilson C; Bilzon J; McCrory P. Foot orthoses in the prevention of injury in initial military training: a randomized controlled trial. Am J Sports Med. 2011;39:30-7.

Schepull T; Kvist J; Norrman H; Trinks M; Berlin G; Aspenberg P. Autologous platelets have no effect on the healing of human Achilles tendon ruptures: a randomized single-blind study. Am J Sports Med. 2011;39:38-47.

de Jonge S; de Vos RJ; Weir A; van Schie HT; Bierma-Zeinstra SM; Verhaar JA; Weinans H; Tol JL. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011;39:1623-9.

Willits K; Amendola A; Bryant D; Mohtadi NG; Giffin JR; Fowler P; Kean CO; Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92:2767-75.

Nilsson-Helander K; Silbernagel KG; Thomeé R; Faxén E; Olsson N; Eriksson BI; Karlsson J. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38:2186-93.

Gosens T; Peerbooms JC; van Laar W; den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39:1200-8.

Schipper ON; Dunn JH; Ochiai DH; Donovan JS; Nirschl RP. Nirschl surgical technique for concomitant lateral and medial elbow tendinosis: a retrospective review of 53 elbows with a mean follow-up of 11.7 years. Am J Sports Med. 2011;39:972-6.

Hurd WJ; Eby S; Kaufman KR; Murthy NS. Magnetic resonance imaging of the throwing elbow in the uninjured, high school-aged baseball pitcher. Am J Sports Med. 2011;39:722-8.

Hurd WJ; Kaufman KR; Murthy NS. Relationship between the medial elbow adduction moment during pitching and ulnar collateral ligament appearance during magnetic resonance imaging evaluation. Am J Sports Med. 2011;39:1233-7.

Schoch B; Wolf BR. Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement. Arthroscopy. 2010;26:1469-73.

Meehan WP 3rd; d'Hemecourt P; Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med. 2010;38:2405-9.

Lau BC; Kontos AP; Collins MW; Mucha A; Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?Am J Sports Med. 2011;39:2311-8.

Hariri S; York SC; O'Connor MI; Parsley BS; McCarthy JC. Career plans of current orthopaedic residents with a focus on sex-based and generational differences. J Bone Joint Surg Am. 2011;93: e16.

Yoon KH; Bae DK; Song SJ; Cho HJ; Lee JH. A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med. 2011;39:474-80.In this prospective randomized controlled trial, the authors compared single-bundle and double-bundle Achilles tendon allograft PCL reconstruction after an average duration of follow-up of two years. They found no difference in knee motion and functional scores. The side-to-side difference in posterior translation improved significantly in both groups. The double-bundle group showed significantly improved IKDC scores as well as significantly improved posterior stability at the time of the latest follow-up. The authors concluded that despite the differences that were found, they could not determine the clinical superiority of double-bundle PCL reconstruction because there were no differences in subjective scores. This study serves as a foundation for further studies evaluating single-bundle versus double-bundle PCL reconstruction and clinical outcomes.

Fukuda TY; Rossetto FM; Magalhães E; Bryk FF; Lucareli PR; de Almeida Aparecida Carvalho N. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther. 2010;40:736-42.This randomized controlled trial investigated the effect of hip abductor and lateral rotator musculature strengthening exercises on pain and function of females with patellofemoral pain syndrome. Seventy females with patellofemoral pain syndrome were randomized into three groups: a conventional knee-focused exercise group, a knee and hip exercise group, and a no-treatment group. Pain scores and functional data were collected. Both exercise groups showed significant improvement in functional and pain scale scores. However, only the knee and hip exercise group showed clinically meaningful differences, specifically, an improved pain rating while descending stairs. This study highlights the benefits of hip strengthening exercises for women with patellofemoral pain syndrome. Surgeons may consider the addition of such a rehabilitation program for their patients presenting with patellofemoral pain syndrome.

Hemmerich A; van der Merwe W; Batterham M; Vaughan CL. Knee rotational laxity in a randomized comparison of single- versus double-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39:48-56.In this controlled laboratory study of thirty-two patients with unilateral anterior cruciate ligament injury, rotational laxity was assessed with the knee at full extension and in 30° of flexion with use of an MRI-compatible torsional loading device. Patients were then randomized to treatment with single or double-bundle ACL reconstruction. ACL rupture led to increased internal rotation laxity in the extended position, with single-bundle reconstruction not affecting rotational restraint. Double-bundle reconstruction decreased internal laxity in the flexed position. Double-bundle reconstruction resulted in superior rotational control. This study provides surgeons with biomechanical data comparing single and double-bundle ACL reconstruction. This information may be useful moving forward as research of the outcomes of single versus double-bundle ACL reconstruction continues.

Hupperets MD; Verhagen EA; Heymans MW; Bosmans JE; van Tulder MW; van Mechelen W. Potential savings of a program to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial. Am J Sports Med. 2010;38:2194-200.Ankle sprains are among the most common, and most costly, of musculoskeletal injuries. In this cohort economic analysis study from the Netherlands, the authors hypothesized that an unsupervised proprioceptive training program could reduce ankle sprain recurrences and could reduce the health-care cost associated with these injuries. The study included 522 athletes who were evenly distributed into either an intervention group or a control group. Both groups underwent the standard therapy following an ankle sprain. The intervention group underwent an additional eight-week proprioceptive training program. Cost and cost-effectiveness analysis was done, including that related to ankle sprain recurrences. The patients were followed for one year. The data analysis showed that the intervention group had significantly lower health-care costs compared with the control group. The final analysis showed that the Netherlands could save an estimated 35.9 million euros annually in medical and lost productivity costs through the implementation of a proprioceptive training program following ankle sprains. This study highlights the potential benefits of injury prevention in the evolving health-care environment.

Barenius B; Nordlander M; Ponzer S; Tidermark J; Eriksson K. Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial. Am J Sports Med. 2010;38:1533-41.One hundred and sixty-four patients were randomized to undergo ACL reconstruction with autologous quadrupled semitendinosus tendon or bone patellar tendon-bone graft. One hundred and fifty-three patients were available for follow-up after an average of eight years. Functional scores were similar for both groups. Patellofemoral pain was similar for both groups, with the bone-patellar tendon-bone graft group having increased donor-site morbidity pain with kneeling and knee walking. Furthermore, the authors found that patients who underwent early reconstructions (less than five months after ACL tear) had a lower risk for meniscal injuries than those who underwent late ACL reconstruction. The authors concluded that semitendinosus graft ACL reconstruction provided similar stability, function, and health-related quality of life with less donor-site morbidity than did bone-patellar tendon-bone graft ACL reconstruction. This study provides surgeons with more information for their patients regarding the outcomes comparison of semitendinosus tendon compared with bone-patellar tendon-bone graft ACL reconstruction.

Stener S; Ejerhed L; Sernert N; Laxdal G; Rostgård-Christensen L; Kartus J. A long-term, prospective, randomized study comparing biodegradable and metal interference screws in anterior cruciate ligament reconstruction surgery: radiographic results and clinical outcome. Am J Sports Med. 2010;38:1598-605.Seventy-seven patients with unilateral ACL ruptures were randomized into use of either a metal interference screw or poly-L-lactide acid (PLLA) interference screw during ACL reconstruction. Each patient underwent hamstring autograft reconstruction. The average duration of follow-up was ninety-six months. The PLLA group had significantly larger bone tunnels on radiographs compared with the metal screw group on the femoral side. No differences were found on the tibial side. No differences were found between groups on knee laxity analysis or functional scores. C-reactive protein values were increased on postoperative Day 1 for the PLLA group. No long-term difference was found. This study provides a comparison of PLLA and metal interference screws. It is paramount that surgeons understand how these fixation options compare and may potentially affect patient outcomes.

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Joshua C. Hamann, Richard Ma, Stephen R. Thompson, MaCalus V. Hogan, Mark D. Miller; What's New in Sports Medicine. The Journal of Bone & Joint Surgery. 2012 Apr;94(8):757-765.

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