It is indeed an honor to be asked to present this update for the
subspecialty of sports medicine. I would be remiss if I did not recognize the
previous author of this section, Dr. Christopher Harner. When I embarked on
this academic project, I did not have a good appreciation for the work that
would be involved or how large the shoes were that I was being asked to fill.
Sports medicine continues to grow as a subspecialty, and, as has been pointed
out in previous updates, it crosses many boundaries. Therefore, before
embarking upon a year-inreview article for orthopaedic sports medicine, it may
be useful first to define what sports medicine really means. The
central focus for the practice of sports medicine is the care of the athlete.
Athletes come in a variety of shapes and sizes and represent a variety of
sports, competitive levels, and nationalities, and we have dedicated our
professional careers to their care. The American Board of Orthopaedic Surgery
(ABOS) and the American Board of Medical Specialties (ABMS) have defined
orthopaedic sports medicine to include expertise in the areas
summarized in Table I. As
orthopaedic sports medicine subspecialists, we have a variety of operative
tools and techniques available to help us in this mission. The arthroscope is
one such tool, but being an accomplished arthroscopist does not make one an
orthopaedic sports medicine subspecialist.
As we embark upon difficult decisions regarding subspecialty certification,
it is important for us to focus on these critical concepts. The ABMS formally
approved subspecialty certification in orthopaedic sports medicine on March
20, 2003. Subspecialty certification is intended to be an extension of the
current academic and scientific environment and will be built by the
contributions of the orthopaedic sports medicine community. The ABOS will
administer the new certification in a one-day written examination that is
expected to be initiated as soon as the spring of 2006. What this means, and
how this is accomplished, will in large part be decided by us as
subspecialists; all are encouraged to get involved!
This update is based on scientific and organizational activities in sports
medicine that took place from September 2002 to August 2003. It includes a
summary of the Annual and Specialty Day Meetings of the American Orthopaedic
Society for Sports Medicine (AOSSM), the Arthroscopy Association of North
America (AANA), the American Academy of Orthopaedic Surgeons (AAOS), and the
International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports
Medicine (ISAKOS). These meetings featured more than 250 scientific
presentations, including both clinical and basic-science studies, that focused
primarily on sports medicine.
The three most influential journals in our field will be reviewed again
this year, specifically, The Journal of Bone and Joint Surgery, The
American Journal of Sports Medicine, and Arthroscopy.
Herbert RD, Gabriel M. Effects of stretching before and after
exercising on muscle soreness and risk of injury: systematic review.
BMJ. 2002;325:468.
This was a pooled analysis of five studies that demonstrated that
stretching did not significantly reduce muscle soreness or the risk of injury.
No conclusion could be reached about the effect of stretching on athletic
performance because of the paucity of papers on this subject. This study was a
good review of the literature and summarized what many of us have believed
clinically.
Hess T, Duchow J, Roland S, Kohn D. Single-versus two-incision
technique in anterior cruciate ligament replacement: influence on
postoperative muscle function. Am J Sports Med. 2002;30:27-31.
This randomized, prospective study compared the results of one and
two-incision techniques for anterior cruciate ligament reconstruction at one
year. The authors found that the single-incision group had improved quadriceps
and hamstring strength on isokinetic testing at three and six months
postoperatively. The authors suggested that the single-incision group improved
faster than the double-incision group did. They attributed these findings to
vastus lateralis dissection. Other clinical parameters were essentially equal.
This was a well-designed study, but it is of limited clinical utility because
most surgeons currently use single-incision anterior cruciate ligament
reconstructions and rarely use double-incision techniques.
Stein DT, Ricciardi CA, Viehe T. The effectiveness of the use of
electrocautery with chondroplasty in treating chondromalacic lesions: a
randomized prospective study. Arthroscopy. 2002;18:190-3.
This was a randomized, prospective study of 146 patients who had either
chondroplasty or chondroplasty and electrocautery. The authors found that
electrocautery offered little benefit in the treatment of chondral lesions and
in fact may limit the chance of a successful outcome. This was an important
study because the ideal treatment of chondral injuries remains controversial.
Numerous recent articles have suggested that thermal devices have a negative
effect on articular cartilage. This study suggested that electrocautery, like
radiofrequency, should be used sparingly in the treatment of chondral
injuries.
Owens BD, Stickles BJ, Balikian P, Busconi BD. Prospective analysis
of radiofrequency versus mechanical débridement of isolated patellar
chondral lesions. Arthroscopy. 2002;18:151-5.
This was a prospective, randomized study in which radiofrequency was
compared with mechanical débridement for the treatment of patellar
chondral lesions. The groups were studied at one and two years
postoperatively. The authors suggested that the radiofrequency group had
superior results following the treatment of grade-2 and 3 chondral lesions.
These results are clearly better than those of other studies on the use of
radiofrequency. Concerns about chondrocyte death extending well beyond the
area treated with radiofrequency devices raise questions about the findings of
the study itself. The best treatment for these injuries is unclear, and the
long-term recommendations regarding the use of radiofrequency for the
treatment of articular cartilage lesions remain extremely controversial.
Hoenecke HR Jr, Pulido PA, Morris BA, Fronek J. The efficacy of
continuous bupivacaine infiltration following anterior cruciate ligament
reconstruction. Arthroscopy. 2002;18:854-8.
This was a prospective, randomized, double-blind study in which continuous
bupivacaine infiltration was compared with saline infiltration following
anterior cruciate ligament reconstruction. In both groups, a disposable pump
with an infusion rate of 2 mm/hour was used for forty-eight hours. The authors
found significant differences between the groups with regard to visual analog
scores for pain. The bupivacaine group used 37% less narcotics compared with
the placebo group. There were no other differences between the groups, and no
complications were noted in association with this technique. This was a
well-done study, and it had further credibility because it was not funded by
the pump manufacturer. This study suggests that the use of pain pumps may have
some clinical utility.
Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk
CN. Immobilisation and functional treatment for acute lateral ankle
ligament injuries in adults. Cochrane Database Syst Rev.
2002;3:CD003762.
This was a pooled analysis of several studies concerning the treatment of
lateral ankle sprains. The findings included a shorter time to return to work
for patients who had been treated with a semi-rigid cast compared with those
who had been treated with a short-leg cast. Similarly, patients who had
received functional treatment had better outcomes in terms of return to
sports, return to work, short-term ankle swelling, objective instability, and
satisfaction. There were no differences in terms of pain, long-term swelling,
subjective instability, recurrent sprains, or range of motion. Although this
study does provide some useful information to the clinician, most sports
medicine specialists do not utilize casts for the treatment of lateral ankle
sprains and therefore the usefulness of this study is somewhat limited.
Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand
hamstring tendon autograft compared with patellar tendon-bone autograft for
anterior cruciate ligament reconstruction. A randomized study with two-year
follow-up. Am J Sports Med. 2001;29:722-8.
This was a randomized study from Norway in which anterior cruciate ligament
reconstructions that had been performed with hamstring grafts were compared
with those that had been performed with patellar ligament grafts. The patients
were evaluated at six, twelve, and twenty-four months. The two groups were
comparable with regard to most study parameters. The subjective results and
the results of single-leg hop tests were better for the hamstring group after
six and twelve months, but no differences were found after twenty-four months.
The hamstring group had better isokinetic knee extension strength at six
months, but not at twelve and twenty-four months. The authors also found that
there was significant weakness in isokinetic knee-flexion strength in the
hamstring tendon group. Finally, anterior knee pain was not significantly
different between the two groups, but kneeling pain was significantly less
common in the hamstring group after twenty-four months. Numerous other studies
have compared hamstring and patellar ligament grafts. Most of those studies,
like the one described here, demonstrated small differences. Overall, both
grafts are considered to be effective.
Jacobson E, Forssblad M, Weidenhielm L, Renstrom P. Knee arthroscopy
with the use of local anesthesia—an increased risk for repeat
arthroscopy? A prospective, randomized study with a six-month follow-up.
Am J Sports Med. 2002;30:61-5.
This was a prospective, randomized study of 400 patients undergoing knee
arthroscopy. The patients were allocated into three groups, with one-half
being assigned to local anesthesia, one-quarter being assigned to spinal
anesthesia, and one-quarter being assigned to general anesthesia. The patients
were evaluated six months after surgery. The only parameter studied was repeat
arthroscopy. Three of the 200 patients who underwent arthroscopy with local
anesthesia required repeat surgery, but none of the patients in the other
groups required repeat arthroscopy. The authors concluded there was no
difference among the three groups with regard to the rate of satisfaction.
This was an interesting paper, but it did not include a power analysis;
therefore, the conclusions are difficult to endorse. Furthermore, parameters
other than just repeat arthroscopy should be studied and a follow-up period of
greater than six months may be more appropriate.
Lam RY, Ng GY, Chien EP. Does wearing a functional knee brace affect
hamstring reflex time in subjects with anterior cruciate ligament deficiency
during muscle fatigue? Arch Phys Med Rehabil. 2002;83:1009-12.
The authors of this study attempted to determine if a functional knee brace
affects muscle fatigue and hamstring reflex time in subjects with anterior
cruciate ligament deficiency. In a repeated-measures clinical trial, the
authors found that a functional brace facilitated hamstring muscle reflex time
but that muscle fatigue lengthened the hamstring reflex latency. Therefore,
they suggested that the use of a knee brace was not protective during sporting
activities for patients with anterior cruciate ligament-deficient knees. This
article is another addition to the already large body of literature that
suggests that anterior cruciate ligament functional braces provide no benefit.
In fact, anterior cruciate ligament functional braces have been shown to be
beneficial only for skiers. I believe that the authors' conclusion is correct
and that functional braces should not be relied on for the protection of
anterior cruciate ligament-deficient knees.
Nau T, Lavoie P, Duval N. A new generation of artificial ligaments
in reconstruction of the anterior cruciate ligament. Two-year follow-up of a
randomised trial. J Bone Joint Surg Br. 2002;84:356-60.
This was a randomized clinical trial in which reconstructions of the
anterior cruciate ligament that had been performed with a patellar ligament
autograft were compared with those that had been performed with a synthetic
anterior cruciate ligament (ligament advancement reinforcement system; LARS,
Arc sur Tille, France). After two years of follow-up, the authors found no
difference between the two groups with regard to the failure rate. A close
review of the results suggests that there was more laxity in the LARS group at
six months but that the difference was not significant at twelve and
twenty-four months. Nevertheless, the difference appeared to approach
significance, and the small size of the samples makes this finding a cause for
concern. The authors suggested that the LARS device may allow for an earlier
return to activities, although they offered no supporting evidence. This
article should cause concern, especially among surgeons in the United States,
who have had extremely poor experiences in association with the use of
synthetic ligaments for anterior cruciate ligament reconstruction. A longer
follow-up study with additional subjects and an appropriate power analysis
should be accomplished. Synthetic ligaments are not even available in the
United States, a fact that should certainly raise our index of suspicion about
the use of these devices.
Stetson WB, Templin K. Two-versus three-portal technique for routine
knee arthroscopy. Am J Sports Med. 2002;30:108-11.
This was a prospective, randomized, double-blind study of only sixteen
patients undergoing knee arthroscopy. The authors compared a two-incision
technique with a three-incision technique. They found that the use of the
third superomedial portal adversely affected quadriceps muscle strength, total
strength, and Lysholm scores. Additionally, patients in whom the procedure was
performed through a superomedial portal required more time before returning to
work and normal activities. The authors recommended that the two-portal
technique be used. This paper is somewhat useful, although most surgeons no
longer use a superomedial portal. In fact, most arthroscopic pump equipment
now allows the surgeon to perform arthroscopy with use of two standard
portals. If a third portal is required, most surgeons prefer to use a
superolateral rather than a superomedial portal for these very reasons.
Nevertheless, concerns with the superomedial portal need to be expressed, and
we discourage the use of this portal.