It is once again an honor and a privilege to be asked to present this
update for the subspecialty of sports medicine. Sports medicine continues to
be an expanding subspecialty field that crosses many boundaries. As mentioned
in previous updates, however, our central mission remains the same—the
care of the athlete.
This update is based on scientific and organizational activities in sports
medicine that took place from September 2003 to August 2004. It includes a
summary of the Annual and Specialty Day Meetings of the American Orthopaedic
Society for Sports Medicine (AOSSM), the Arthroscopy Association of North
America (AANA), and the American Academy of Orthopaedic Surgeons (AAOS). These
meetings featured more than 200 scientific presentations, including both
clinical and basic-science studies, that focused primarily on sports
medicine.
The three most influential journals in our field will be reviewed again
this year, specifically, The Journal of Bone and Joint Surgery, The
American Journal of Sports Medicine, and Arthroscopy.
Anterior Cruciate Ligament
The optimum graft choice for anterior cruciate ligament reconstruction
remains controversial. Several recent randomized, controlled studies showed
equivalent results in association with both bone-patellar tendon-bone and
quadrupled hamstring grafts, effectively endorsing a "double gold
standard." An additional randomized, prospective trial from Australia
showed satisfactory functional outcomes in association with both types of
grafts after three years of
follow-up1. As in
other studies, however, the authors noted increased kneeling pain in the
bone-patellar tendon-bone group and slightly increased laxity and femoral
tunnel widening in the hamstring group. Recent histological studies have shown
that neither type of graft regenerates to a normal functional tendon. In two
independent studies involving the use of magnetic resonance imaging and
ultrasound examination following bone-patellar tendon-bone graft harvest, the
patellar tendon had not normalized by six to ten years
postoperatively2,3.
Both groups of authors concluded that reharvesting the graft was not
recommended. In a separate animal study, the hamstring tendons were noted to
regenerate by nine to twelve months, but with inferior biomechanical and
histological
characteristics4.
A number of recent cadaveric studies critically examined steps in the
surgical technique for anterior cruciate ligament reconstruction in an attempt
to draw conclusions regarding clinical outcomes. Methods for the fixation of
both soft-tissue and bone-patellar tendon-bone grafts were critically
examined. A high-stiffness graft construct (resulting in better fixation) was
noted to be important for postoperative stability because it allowed for less
graft tension5. The
authors of two separate cadaveric studies concluded that both twisting and
braiding reduced the initial strength and stiffness of quadrupled hamstring
grafts6,7.
In contrast, in the same issue of The American Journal of Sports
Medicine, the authors of a third study concluded that graft rotation of
as much as 540° did not result in the loss of initial strength of
bone-patellar tendon-bone grafts and may be a solution for graft-tunnel
mismatch8. The
authors of a two-part study concluded that the initial fixation strength of a
doubled tibialis anterior tendon graft was not increased in association with
the use of serial dilators over extraction-drilled bone tunnels, and thus they
did not recommend the use of dilation. Also, that same group of investigators
concluded that preconditioning of soft-tissue anterior cruciate ligament
grafts could not eliminate the intrinsic viscoelasticity, and thus they
challenged the necessity of preconditioning.
A great deal of research has focused on risk factors and gender issues
related to noncontact anterior cruciate ligament injuries. The findings of a
prospective cohort study of cadets entering the United States Military Academy
agreed with the findings of previous studies supporting the multifactorial
nature of noncontact anterior cruciate ligament injuries, including small
femoral notch width, generalized ligamentous laxity, higher body-mass index,
and female gender9.
Female athletes traditionally have landed from a jump with the knee in
extension and valgus angulation as compared with their male counterparts.
Neuromuscular training has resulted in lower injury rates as reported in
several papers and podium presentations. One study involving three-dimensional
kinematic testing showed that female athletes change the way that they land
from a jump following the onset of the pubertal growth spurt, possibly
contributing to the increased susceptibility to anterior cruciate ligament
tears10. Another
study suggested that quadriceps loading was the key intrinsic force associated
with these noncontact injuries. Prophylactic knee bracing following anterior
cruciate ligament reconstruction has not previously been found to be
effective. One recent study that was presented at the 2004 Annual Meeting of
the AAOS, however, suggested that postoperative bracing may reduce the rate of
reinjury in skiers.
The care of skeletally immature athletes who have anterior cruciate
ligament injuries continues to be a source of considerable controversy. While
previous studies have demonstrated that a delay in surgical treatment is
associated with a higher prevalence of medial meniscal tears, a more recent
study showed encouraging results when reconstruction was delayed until within
one month before physeal closure. Although the numbers in the study were
small, the authors found no increase in the rate of additional knee injuries
and concluded that absolute activity restriction was the key. Other authors
have advocated a more aggressive approach. Several studies have challenged the
traditional recommendation of using a soft-tissue graft and avoiding drilling
across the femoral physis. Two recent studies by the same authors showed good
results in association with the use of hamstring autograft with a partial
physeal sparing technique for the management of Tanner stage-2 and 3 children
and with a complete physeal sparing technique for the management of Tanner
stage-1 preadolescent children. No angular deformity or limb-length
discrepancy was noted at the time of skeletal maturity in either group. The
authors of one recent study concluded that good results could be obtained in
association with transphyseal reconstruction of the anterior cruciate ligament
with use of a bone-patellar tendon-bone autograft in Tanner stage-3 and 4
children11.
Particular care was taken to ensure that the bone plug was not within the
physis. No angular deformity or limb-length discrepancy was noted at the time
of skeletal maturity, although hip-to-ankle standing radiographs were not
examined in that study.
Several recent studies have improved our understanding of the natural
history of the anterior cruciate ligament-deficient knee. Two dynamic magnetic
resonance imaging studies confirmed that there is greater anterior subluxation
of the lateral tibial plateau than of the medial tibial plateau in the
anterior cruciate ligament-deficient knee, which could lead to future
degenerative changes. One gait-analysis study showed that a valgus shoe wedge
could prevent the lateral-thrust gait associated with the anterior cruciate
ligament-deficient knee.
Assessing the success of anterior cruciate ligament reconstruction surgery
postoperatively continues to be an important focus of research. The authors of
one recent study examined the correlation between objective and subjective
measurements and concluded that the pivot-shift examination was a better
measure of "functional instability" than the Lachman and
instrumented knee laxity examinations following reconstructive
surgery12. In a
recent study published in The Journal of Bone and Joint Surgery,
four-strand hamstring reconstruction was associated with good functional
results at two years despite an 11% failure rate as determined on the basis of
objective
measurements13. The
authors concluded that the findings of instrumented knee examinations do not
correlate with functional knee scores postoperatively. The authors of two
separate studies concluded that anterior cruciate ligament reconstruction
failed to restore normal tibiofemoral knee kinematics. In one study, dynamic
magnetic resonance imaging demonstrated that the lateral side of the tibia was
5 mm more anterior than the medial side at all flexion angles. In the other
study, stereoradiographs demonstrated that the reconstructed knees of downhill
runners were externally rotated and adducted more than those of controls at
all time-points. In both studies, anterior-posterior laxity was reduced to
within normal limits but rotation was not. The long-term consequences of these
findings are unknown.
Several new trends have appeared in the recent literature. Two studies
showed that growth factors positively influenced the healing and structural
properties of both soft-tissue and bone-patellar tendon-bone grafts.
Additionally, bone-marrow stromal cells were shown to improve tendon-to-bone
healing in an animal model. A retrospective study of a small number of
patients managed with bilateral anterior cruciate ligament reconstruction
showed no difference with regard to return to functional and objective
measurements as compared with the findings for patients managed with
unilateral
reconstruction14.
The authors concluded that bilateral reconstruction was a safe and
cost-effective approach. Other studies have demonstrated that thermal
shrinkage of "partial" cruciate ligament tears or loose grafts can
have catastrophic results.
Other Knee Ligaments
Posterior cruciate ligament and posterolateral corner injuries continue to
be sources of research interest, perhaps because of their unique clinical
presentations. Isolated posterior cruciate ligament injuries are still best
treated nonoperatively. Combined ligament injuries involving either cruciate
ligament and the posterolateral corner are a strong indication for surgery as
late instability and poor results have been reported following nonoperative
treatment. One study that was presented at the 2004 Annual Meeting of the AAOS
demonstrated superior results in association with the use of posterolateral
corner reconstruction rather than primary repair for the treatment of acute
injuries15. While
the ideal reconstruction technique for posterior cruciate ligament injuries
remains controversial, clinical and biomechanical support for both the
transtibial and tibial inlay methods continues to appear in the literature.
Although the results of earlier studies suggested that the tibial inlay method
was superior to the transtibial technique, the authors of a recent
biomechanical study found no difference, with both methods restoring posterior
tibial translation to within 1.5 to 2
mm16. Another
biomechanical study suggested that the "effective graft length"
played a role, with shorter grafts being stiffer, thus supporting the use of
inlay-type grafts. One recent clinical study involving the use of a tibial
inlay technique with a single-bundle femoral tunnel showed good results after
two to ten years of
follow-up17.
Long-term results are not yet known. Posterior cruciate ligament deficiency
significantly increases patellofemoral contact pressures as shown in a study
that was published in The American Journal of Sports
Medicine18.
The authors found that contact pressures did not significantly change after
posterior cruciate reconstruction, suggesting that long-term degenerative
disease would likely result despite reconstruction.
Knee dislocations are devastating injuries that usually result from
high-energy trauma. The recommended treatment for these injuries continues to
be early operative management. A recent cadaveric study emphasized the
difficulty of properly tensioning the cruciate ligaments during a
multiple-ligament reconstruction. The authors of an intermediate-term
follow-up study concluded that patients who had been managed within three
weeks after a dislocation had higher subjective scores and better objective
restoration of knee stability than did those who had had delayed treatment.
The return to high-demand activities is much more variable following
multiple-ligament reconstruction than it is following other types of knee
reconstructions19.
Meniscal Tears
Meniscal tears can be grouped into two types—acute tears in young
patients and degenerative tears in older patients. The first type of tear is
often associated with other intra-articular knee abnormalities and is more
amenable to repair. Degenerative tears, on the other hand, are better treated
with observation and partial meniscectomy if mechanical symptoms are present.
The results of a recent randomized study showed increased accuracy in the
detection of recurrent meniscal tears with use of either intravenous or
intra-articular contrast-enhanced magnetic resonance imaging as compared with
plain magnetic resonance
imaging20.
Meniscal repair is strongly recommended for patients undergoing a
concurrent anterior cruciate ligament reconstruction. Recently, however, a
nonrandomized nine-year follow-up study showed no improvement in the outcomes
for young, active patients managed with anterior cruciate ligament
reconstruction along with a meniscal repair as compared with those for
patients managed with partial
meniscectomy21. The
authors still recommended repair if possible. They suggested, however, that
some menisci will not function normally despite healing. The authors of
another recent study concluded that repeat meniscal repair was successful in
72% of patients after seven years of
follow-up22.
Although many new repair devices are available, the gold standard remains the
vertical mattress suture. Recent studies have suggested that the newer-design,
flexible, all-inside anchors (FastT-Fix [Smith and Nephew Endoscopy, Andover,
Massachusetts] and Rapid Loc [DePuy Mitek, Norwood, Massachusetts]) allowed
tensioning and were comparable with conventional vertical suture techniques. A
recent prospective study showed that Meniscal Arrows (formerly manufactured by
Bionix, Blue Bell, Pennsylvania, and now manufactured by Linvatec, Largo,
Florida) were as effective as horizontal mattress sutures during concurrent
anterior cruciate ligament reconstruction; however, the protocol called for
five weeks of non-weight-bearing. Despite good early results in association
with the all-inside devices, there is still concern with regard to long-term
chondral damage, especially in patients with smaller or tighter
knees23. The use of
a fibrin clot for meniscal repairs is still recommended, and recent data have
shown improvement in the healing of tears in even the avascular zone with the
addition of autologous chondrocytes or growth factors.
Meniscal transplantation is a salvage operation that is indicated for young
patients with substantial compromise of the existing meniscus or those who
have had a total meniscectomy. Two recent studies demonstrated that this
procedure was associated with encouraging intermediate-term results in terms
of the reduction of knee pain and the improvement of
function24,25.
The authors showed acceptable results even in patients managed with
concomitant osteochondral autograft transfer and knee ligament reconstruction,
but they stressed proper selection in this difficult population. Graft
shrinkage, displacement, and tearing continue to be a clinical challenge at
the time of intermediate-term follow-up.
Articular Cartilage Injuries
The treatment of focal articular cartilage defects remains a hot topic in
sports medicine. Options include microfracture, osteochondral autograft
cylinder (plug) transfer, autologous cartilage implantation, and the use of
allografts. A recent randomized, multicenter study from Europe showed no
difference with regard to clinical, macroscopic, or histological results,
after two years of follow-up, between patients managed with microfracture and
those managed with autologous chondrocyte
implantation26. One
study of autologous chondrocyte implantation demonstrated good healing despite
a sequential decrease in the number of chondrocytes in the
defect27. The
authors questioned the role of chondrocytes in the formation of repair tissue.
No consensus exists with regard to the best treatment of these injuries, and
factors such as cost, resource utilization, and disease transmission all play
a role in the discussion of treatment options.
Allograft tissue has abundant uses in orthopaedics and sports medicine,
including ligament reconstruction, bone-grafting, and, more recently,
osteoarticular replacement. Recent studies have examined the viability and
safety of this tissue. Three recent studies examined chondrocyte viability in
fresh osteoarticular allografts and showed that chondrocyte viability
decreased significantly within as few as fourteen days, with structural
properties declining more slowly over a period of sixty days. Another study
showed a 26% decrease in chondrocyte viability after seventeen days and a 48%
decrease after forty-two days. The authors of a study on the safety of
allograft tissue concluded that freeze-drying of retroviral-infected cortical
bone and tendon did not inactivate
retrovirus28.
Instability and Labral Tears
The diagnosis and treatment of the unstable shoulder has evolved with
recent advances in imaging methods, implants, and arthroscopic techniques. A
study assessing the validity of various physical examination tests
demonstrated that anterior instability is most accurately diagnosed on the
basis of a combination of positive results on the apprehension test, the
relocation test, and the surprise test (apprehension after releasing the
posterior force from a relocation
test)38. The
pitfalls associated with the use of magnetic resonance imaging for the
evaluation of elite overhead athletes were recently explored in a study of
individuals with asymptomatic
shoulders39. In
that study, 40% of dominant shoulders had evidence of a partial or
full-thickness rotator cuff tear and 25% had a posterior-superior ossification
(a Bennett lesion) but no shoulder-related problems developed in any of the
patients during the subsequent five-year period. The authors concluded that
magnetic resonance imaging alone should not be used to diagnose shoulder
abnormalities in this asymptomatic population.
The treatment of a first-time traumatic anterior dislocation remains
controversial. A recent four-year follow-up study showed a recurrence rate of
as high as 75% in the eleven to eighteen-year-old age-group. Although it has
been noted that the rate of recurrence increases with younger age at the time
of presentation, the current trend is still toward nonoperative treatment
unless recurrent instability is experienced. Recent studies from Japan have
suggested that early immobilization of the shoulder in external rotation may
reduce the prevalence of recurrent instability. One recent five-year follow-up
study compared open capsulolabral repairs with arthroscopic repairs involving
transglenoid
sutures40. Among
athletes involved in contact sports, a higher rate of redislocation was noted
in shoulders that had been treated with arthroscopic repair whereas decreased
external rotation was noted in shoulders that had been treated with open
repair. The decrease in external rotation in the open-treatment group was
echoed by the findings of a prospective, randomized study that was published
in
Arthroscopy41.
In that study, the arthroscopically treated group did not have a higher
redislocation rate; however, suture anchors were used, the patients were not
athletes involved in contact sports, and the duration of follow-up was only
two years. Accelerated rehabilitation following Bankart repair was described
in a recent study of nonathletes, with the investigators reporting an
increased return to activities and no change in intermediate-term
outcomes.
The diagnosis and treatment of atraumatic multidirectional instability
remains a challenge. Recent research has demonstrated that the criteria used
for the diagnosis of multidirectional instability and the use of laxity
testing vary greatly from study to study, making uniform treatment
recommendations difficult and comparisons between outcomes less
valid42. According
to one study, the surgical repair of instability can significantly improve the
proprioception of the affected and contralateral
shoulders43.
Numerous studies have highlighted the unacceptably high failure rate
associated with the use of thermal capsulorrhaphy alone for the surgical
treatment of this instability. One recent follow-up study demonstrated a 17%
rate of recurrence and a 50% rate of inability to return to previous levels of
overhead activity following thermal
capsulorrhaphy44.
Reports of capsular necrosis and severe chondrolysis following thermal
capsulorrhaphy are even more concerning. The current trend is away from the
use of thermal capsulorrhaphy in patients with atraumatic instability. The use
of arthroscopic suture plication for the treatment of atraumatic instability
has been associated with good early results. There has been a renewed interest
in the role of the rotator interval in instability. While many authors have
recommended routine arthroscopic closure for all cases of instability, there
is still concern about restricted motion in patients managed with selective
capsulorrhaphy. Just as instability exists along a spectrum ranging from
asymptomatic to clinically debilitating, no absolute values can be given for
how much capsular volume should be reduced. Avoiding both overtightening and
undertightening of the capsule remains a critical challenge for the
surgeon.
Internal impingement in the throwing athlete generally is believed to be
related to either posterior capsular contraction or anterior capsular laxity.
Initial treatment should include posterior capsular stretching, particularly
in patients with limited internal rotation (glenohumeral internal rotation
deficit [GIRD]). Operative treatment remains controversial, with one group
recommending posterior capsular release and the other recommending anterior
plication or thermal capsulorrhaphy.
The diagnosis of SLAP tears (tears of the superior portion of the labrum
from anterior to posterior) with use of current imaging and physical
examination techniques continues to be a challenge. One recent study described
an anatomic variation that is characterized by articular cartilage over the
superior glenoid tubercle and a mobile labrum overlying intact
cartilage45. The
authors noted that this variation is not an indication for surgical
repair.
A recent cadaveric study demonstrated that the initial fixation strength of
bioabsorbable tacks was comparable with that of metal suture
anchors46.
According to another study, the angle of suture anchor placement in the
glenoid rim should be within 20° of orthogonal to the rim and at 30°
to the articular surface in order to maximize pull-out
strength46.
According to that same study, the anterior-inferior quadrant (the area of
Bankart repair) is the most critical area for anchor stability because it has
the weakest bone. Another study presented at the 2004 Annual Meeting of the
AAOS suggested that better results can be achieved in association with
fixation that avoids placing portals through the rotator cuff and involves the
rotator interval instead. Finally, arthroscopic decompression of spinoglenoid
ganglion cysts was reported to be successful in a paper that was presented at
the 2004 AOSSM Specialty Day.
Rotator Cuff Injuries
Impingement and rotator cuff pathology comprise a substantial percentage of
the lesions associated with shoulder pain that are seen by sports medicine
physicians. Arthroscopic subacromial decompression continues to be a safe and
reliable method for reducing impingement and for allowing sufficient space for
the irritated or torn rotator cuff tendons to function. However, there is
still debate about whether routine subacromial decompression is needed for
every patient who is managed with rotator cuff repair.
Rotator cuff tears can be diagnosed both clinically and with use of
imaging. A recent study showed that magnetic resonance imaging and ultrasound
were associated with similar efficacy for the diagnosis of partial and
full-thickness cuff tears by experienced
technicians47.
Ultrasound was found to be as effective as magnetic resonance imaging for
determining tear size and thus can be useful if contraindications to magnetic
resonance imaging are present. The use of ultrasound continues to be more
popular in Europe.
There continues to be a strong push to transition from open to mini-open to
arthroscopic rotator cuff repair. The advantages of the mini-open approach
include less trauma to the anterior part of the deltoid, which can result in
less atrophy and a quicker recovery but at the expense of visualization. The
advantages of the all-arthroscopic approach include better visualization and
mobilization of retracted cuff tendons, decreased trauma to the deltoid,
decreased postoperative pain, and quicker rehabilitation. An increasing number
of large and massive rotator cuff tears associated with retraction and atrophy
are being mobilized and repaired with margin convergence and interval slide
techniques. Arthroscopic repairs involve the use of suture anchors and require
proficiency in suture management and arthroscopic knot-tying. Arthroscopic
repairs continue to be technically challenging, although implants and
techniques are improving. In a recent two-year follow-up study of large and
massive rotator cuff tears that were repaired arthroscopically, >90% of the
patients had a re-tear as demonstrated with
ultrasound48.
Nearly all patients had an excellent early clinical result that deteriorated
somewhat by two years. The long-term results of arthroscopic rotator cuff
repair are still not known and must be compared with the gold standard of open
repair with a double row of suture anchors or a combination of anchors and
trough fixation.
Ongoing research will result in additional improvements in both suture and
anchor fixation and will eliminate the weakest links in the system. A recently
described arthroscopic stitch combines simple horizontal and vertical stitches
and provides strength comparable with that of a modified Mason-Allen locking
stitch49. According
to another study, suture anchor pull-out strength can be maximized by placing
anchors in the proximal anterior and middle regions of the tuberosities, which
are the areas with the highest bone mineral
density50. Current
knotless fixation systems are in their infancy and need long-term clinical
follow-up. They are part of a wave of new technology in arthroscopic surgery
that needs critical evaluation before it can replace the current gold
standard.
The results of rotator cuff surgery can be affected by many factors.
Obesity and body-mass index are directly related to rotator cuff disease and
rotator cuff surgery. Medical comorbidities have a negative impact on
preoperative shoulder function and likely affect postoperative results of
rotator cuff repair. Surgeon-related factors are responsible for increased
readmission rates, increased operative times, and increased durations of
hospitalization. One animal model showed that the timing of rotator cuff
surgery could be important, with the results of earlier repairs being better
than those of late
repairs51.
Lateral Epicondylitis
In two separate randomized, double-blind, placebo-controlled trials, both
topical nitric oxide and low-energy shock-wave treatment were judged to be
more effective than placebo for the treatment of chronic, refractory lateral
epicondylitis52,53.
The findings of the latter study, which involved low-energy shock-wave
treatment, were in direct contrast to those of previously published studies
that have shown no effect in randomized trials. This treatment modality,
although safe, remains controversial.
Medial Collateral Ligament Injuries
Ulnar collateral ligament injuries in overhead athletes continue to receive
tremendous attention in the literature and the news. Reconstruction techniques
include the "Tommy John" technique described by Jobe, the docking
technique proposed by Altcheck, and a newer interference screw technique
described by Ahmad et al. Good success rates and a high level of return to
play have been reported in association with the earlier techniques. A recent
report on ulnar collateral ligament injuries and subsequent reconstructions in
high-school pitchers demonstrated a high percentage of risk factors for
overuse in this adolescent
population54. Of
the patients undergoing reconstruction, 75% returned to the sport and nearly
half were still playing baseball three years later.
Other Areas
Nutritional supplements and the safety issues surrounding them continue to
be major issues for sports physicians and athletes alike. Supplements are
still not under governmental control and yet, despite warnings and case
reports of serious adverse health effects and even death, athletes continue to
take ergonomic aids for their perceived performance enhancement. The authors
of a recent randomized, double-blind, placebo-controlled trial concluded that
patients did not benefit from creatine supplementation during the first twelve
weeks of rehabilitation following anterior cruciate ligament
reconstruction55.
Due to the various ways in which athletes spend their time and the inherent
differences in each sport, there has been a recent increase in the number of
sports-specific studies in the literature. While too numerous to detail here,
articles on specific injuries, risk profiles, and/or injury rates associated
with various sports (including high-school, college, and professional
football; amateur and professional baseball; cheerleading; golf; marathon
running; ice hockey; rugby; swimming; soccer; women's lacrosse; skiing;
snowboarding; skiboarding; pommel horse gymnastics; wakeboarding; team
handball; and kitesurfing) were published in major sports-related orthopaedic
journals in the past year. This follows a current trend in sport-specific
training accompanied by injury prevention, recognition, treatment, and
rehabilitation that is likely to continue.
Sports Medicine continues to be the most popular fellowship in orthopaedic
surgery, with over one-third of all graduating residents completing a
fellowship in our field. There are currently ninety-five programs with 205
fellows per year across the country along with several international
fellowships. There are several controversies that inevitably arise in any
discussion about fellowship selection and experience. The first major issue is
accreditation through the Accreditation Council for Graduate Medical Education
(ACGME), the same governing body that accredits residency programs. Most
subspecialties within orthopaedics (including spine, foot and ankle, trauma,
oncology, and pediatric orthopaedics) do not offer accredited fellowship
positions, whereas most hand fellowships are currently accredited. Currently,
just over one-half of sports medicine fellowships are accredited.
Accreditation will become more of a factor in subsequent years as orthopaedic
sports subspecialty certification is implemented. In the future, following a
certain grandfather period, candidates will have to have completed an
accredited fellowship in order to sit for the subspecialty examination. The
first examination (administered by the American Board of Orthopaedic Surgery)
may be scheduled as early as the fall of 2006; however, it more likely will be
delayed until the following year. The AOSSM, with the assistance of an
educational grant from Arthrex, is actively developing educational material
for candidates to prepare for this examination.
The second area of controversy involves the fellowship match program. In
previous years, the match has been coordinated by the National Residency
Matching Program (NRMP). The NRMP has been widely successful for residency
placement and other fellowship fields, but it has not been as successful in
sports medicine. This year, the fellowship match in sports medicine has been
terminated because the majority of the programs were not participating. The
AOSSM is aware of the difficulties that occurred this year and in previous
years and will continue to work closely with the NRMP to rectify them.
Subspecialty certification will inevitably lead to changes in the match
process as well. Hopefully, in future years, a single unified selection
process for fellows will exist.
Harvey GP, Chelly JE, AlSamsam T, Coupe K. Patient-controlled
ropivacaine analgesia after arthroscopic subacromial decompression.
Arthroscopy. 2004;20:451-5.
This was a prospective, randomized, double-blind study of a consecutive
group of twenty-four patients undergoing arthroscopic subacromial
decompression. Some patients underwent concurrent rotator cuff repair or
distal clavicular excision. Ropivacaine was used for its long active effect
and reduced cardiac toxicity as compared with bupivacaine. The use of a
patient-controlled anesthesia (PCA) ropivacaine infusion (Group I) resulted in
a significant (34%) reduction of postoperative pain in the first forty-eight
hours postoperatively as measured with a visual analog scale (p <
0.05) but had no effect on hydrocodone consumption. The authors concluded that
patient-controlled anesthesia with use of subacromial infusions of 0.2%
ropivacaine provided effective postoperative pain control.
Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous
chondrocyte implantation and osteochondral cylinder transplantation in
cartilage repair of the knee joint. A prospective, comparative trial. J
Bone Joint Surg Am. 2003;85:185-92.
This prospective clinical study from Germany investigated the two-year
results for forty patients with an articular cartilage lesion of the femoral
condyle who had been randomized to treatment with either autologous
osteochondral cylinder transplantation or autologous chondrocyte implantation.
Forty patients were split evenly between the two groups and were examined
after a minimum duration of follow-up of two years. Biopsy specimens from
representative patients from both groups were evaluated with histological
staining, immunohistochemistry, and scanning electron microscopy. Both
treatments resulted in a decrease in symptoms. However, the improvement
provided by the autologous chondrocyte implantation lagged behind that
provided by the osteochondral cylinder transplantation. Histologically, the
defects treated with autologous chondrocyte implantation were primarily filled
with fibrocartilage, whereas the osteochondral cylinder transplants retained
their hyaline character, although there was a persistent interface between the
transplant and the surrounding original cartilage. Although the study was
limited by the small numbers of patients and the short duration of follow-up,
the authors concluded that osteochondral cylinder transplantation is
appropriate for the treatment of these defects.
Airaksinen OV, Kyrklund N, Latvala K, Kouri JP, Gronblad M, Kolari
P.Efficacy of cold gel for soft tissue injuries: a prospective randomized
double-blinded trial. Am J Sports Med. 2003;31:680-4.
In this prospective, randomized, double-blind study from Norway,
seventy-four sports-related soft-tissue injuries were treated with a cold gel
(Group I) or a placebo gel (Group II) that was applied to the skin four times
daily for fourteen days. Clinical assessments were made after seven, fourteen,
and twenty-eight days. The cold gel treatment was associated with
significantly lower pain scores and higher patient satisfaction at all
time-points. Cold gel therapy provides an effective and safe option for the
treatment of sports-related soft-tissue injuries.
Meighan AA, Keating JF, Will E. Outcome after reconstruction of the
anterior cruciate ligament in athletic patients. A comparison of early versus
delayed surgery. J Bone Joint Surg Br. 2003;85:521-4.
In this prospective, randomized study from Scotland, patients with anterior
cruciate ligament injuries were managed with either early reconstruction
(within two weeks) or delayed reconstruction (within eight to twelve weeks)
with use of a quadrupled hamstring graft in order to determine whether early
reconstruction was associated with any functional advantages. Both groups were
assessed with validated outcome measures at the time of the one-year
follow-up. Although the authors found significant improvement in range of
motion and quadriceps strength in the delayed-treatment group after two and
twelve weeks of follow-up, they found no differences between the two groups at
the time of the one-year follow-up. The authors concluded that no functional
advantages are gained by early reconstruction. Although the duration of
follow-up was short, the study design was good.
Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application
for chronic plantar fasciitis in running athletes. A prospective, randomized,
placebo-controlled trial. Am J Sports Med. 2003;31:268-75.
In this study from Germany, forty-five running athletes who had had
intractable plantar heel pain for more than twelve months were randomized into
two groups. One group received three applications of 2100 impulses of
low-energy shock waves, and the other group received sham treatment. At six
and twelve months of follow-up, there was significantly greater improvement in
the visual analog scores for pain in the group that had received low-energy
shock-wave therapy. The authors concluded that low-energy shock waves are safe
and effective for the management of this population. The findings of this
study add support to the use of shock-wave therapy for runners with chronic
plantar fasciitis.
Otsuka H, Ishibashi Y, Tsuda E, Sasaki K, Toh S. Comparison of three
techniques of anterior cruciate ligament reconstruction with bone-patellar
tendon-bone graft. Differences in anterior tibial translation and tunnel
enlargement with each technique. Am J Sports Med. 2003;31:282-8.
In this prospective cohort study from Japan, sixty patients were randomized
into three groups: a nonanatomic fixation group, an anatomic fixation group
with outside-in fixation (with bone plug grafted into the tibial tunnel), and
an anatomic fixation group with all-inside fixation. At the time of the
two-year follow-up, there were no differences in clinical stability or outcome
among the three groups. There was a decrease in tibial tunnel enlargement on
postoperative radiographs in the anatomic fixation groups. The authors
concluded that although the tibial tunnel was more enlarged in the nonanatomic
fixation group, it had no clinical effect on knee stability at the time of the
two-year follow-up.
Turbeville SD, Cowan LD, Owen WL, Asal NR, Anderson MA. Risk factors
for injury in high school football players. Am J Sports Med.
2003;31:974-80.
In this two-year prospective investigation of risk factors for injury in
717 high-school football players in the Oklahoma City, Oklahoma, School
District, the authors found that physical characteristics such as body-mass
index and strength were not associated with a risk of injury. Both increased
playing experience and a history of injury in the previous season were
significantly associated with increased risk. Notably, linemen were at the
highest risk of injury, especially knee injury and season-ending injury. The
findings of this study can help us to better understand the injury patterns
and prevention strategies for this group of young athletes.
Dhawan A, Doukas WC, Papazis JA, Scoville CR. Effect of drain use in
the early postoperative period after arthroscopically assisted anterior
cruciate ligament reconstruction with bone-patellar tendon-bone graft. Am
J Sports Med. 2003;31:419-24.
In this prospective, randomized clinical trial, twenty-one patients who had
been managed with bone-patellar tendon-bone anterior cruciate ligament
reconstruction were managed either with a drain for twenty-four hours or with
no drain. The authors found that the use of a drain provided no benefits in
terms of range of motion, effusion, or pain-control, and, therefore, they did
not recommend such treatment.