Extract
This is an important year for the subspecialty of sports medicine. The
sports medicine subspecialty certification process officially kicks off this
summer with the first-ever Review Course for Subspecialty Certification in
Orthopaedic Sports Medicine. This course, jointly sponsored by the American
Orthopaedic Society for Sports Medicine (AOSSM) and the American Academy of
Orthopaedic Surgeons (AAOS), will be held on August 3 through 5, 2007, at the
Fairmont Hotel in Chicago. The preliminary program will be mailed to all AOSSM
members in mid-February. One can find more details on the AOSSM website
(www.sportsmed.org).
The examination will be administered at Prometric Technology Centers beginning
in the Fall of 2007. Applications to take the examination are available online
(www.abos.org).
The completed application must be submitted with a $500 application and
credentialing fee, letters of reference, and a complete list of all operative
cases from a consecutive twelve-month period between February 1, 2005 and
January 31, 2007. All applications are due on February 1, 2007. Late
applications can be received by February 28, 2007 for an additional $500 fee.
A $1000 examination fee (in addition to the application and credentialing fee)
will be due in May 2007. We hope that this update, in conjunction with
previous updates and AAOS/AOSSM resources that are available, can be used to
further prepare for this examination.
This is an important year for the subspecialty of sports medicine. The
sports medicine subspecialty certification process officially kicks off this
summer with the first-ever Review Course for Subspecialty Certification in
Orthopaedic Sports Medicine. This course, jointly sponsored by the American
Orthopaedic Society for Sports Medicine (AOSSM) and the American Academy of
Orthopaedic Surgeons (AAOS), will be held on August 3 through 5, 2007, at the
Fairmont Hotel in Chicago. The preliminary program will be mailed to all AOSSM
members in mid-February. One can find more details on the AOSSM website
().
The examination will be administered at Prometric Technology Centers beginning
in the Fall of 2007. Applications to take the examination are available online
().
The completed application must be submitted with a $500 application and
credentialing fee, letters of reference, and a complete list of all operative
cases from a consecutive twelve-month period between February 1, 2005 and
January 31, 2007. All applications are due on February 1, 2007. Late
applications can be received by February 28, 2007 for an additional $500 fee.
A $1000 examination fee (in addition to the application and credentialing fee)
will be due in May 2007. We hope that this update, in conjunction with
previous updates and AAOS/AOSSM resources that are available, can be used to
further prepare for this examination.
This update is based on scientific and organizational activities in sports
medicine that took place from September 2005 to August 2006. It includes a
summary of the Annual and Specialty Day meetings of the AOSSM, the Arthroscopy
Association of North America (AANA) and the AAOS. These meetings featured more
than 200 scientific presentations focusing on sports medicine. In addition, as
in past years, important articles from three journals in our field,
specifically, The Journal of Bone and Joint Surgery (American Volume), The
American Journal of Sports Medicine, and Arthroscopy, will be
reviewed.
Anterior Cruciate Ligament
Reconstruction of the anterior cruciate ligament is one of the most common
procedures performed by orthopaedic surgeons and remains a focal point for new
research in sports medicine. Published studies abound on this topic, with
particular attention being paid to graft choice, fixation options, prevention
programs, the advent of double-bundle reconstruction, and the outcomes of
revision procedures. The ability of the reconstructed anterior cruciate
ligament to both control and prevent recurrent pivoting episodes predictably
and durably over time is the goal driving this research.
Three main graft choices are commonly used for anterior cruciate ligament
reconstruction. Autograft bone-patellar tendon-bone, hamstring, and various
allograft options are the most commonly used grafts. Quadriceps tendon
autograft, although less commonly used, is also effective. The benefits and
detriments of each of these graft choices persist and have been outlined
extensively in the literature. The quality of anterior tibialis allograft has
been recently questioned if the tissue is cryopreserved, and this will likely
lead to more study of the use of allograft for anterior cruciate ligament
reconstruction. In a thirteen-year follow-up trial of anterior cruciate
ligament reconstructions involving the use of bone-patellar tendon-bone
autograft, good outcomes were achieved with respect to knee stability and
functional scores1.
However, half of the patients had loss of extension, likely signaling early
degenerative joint disease. Furthermore, there was increased laxity and
rerupture in those who had undergone partial medial menisectomy at the time of
the index procedure. These findings underscore the importance of the meniscus
as a secondary knee stabilizer. Proponents of bone-patellar tendon-bone
autograft cite improved initial fixation strength as an advantage of this
graft choice. Recent advances in hamstring fixation, however, rival
interference screw fixation for the bone-patellar tendon-bone graft and have
led to increased use of hamstrings as a graft choice. Hamstring proponents
also note decreased postoperative morbidity with this option. Transfemoral
cross-pin fixation has produced good outcomes clinically, and the
biomechanical fixation strength approaches or exceeds interference screw
fixation. Cross-pin fixation also decreases tunnel widening in comparison with
other hamstring fixation methods because the point of fixation is closer to
the aperture of the femoral tunnel. Patients who were evaluated sixteen months
after undergoing a hamstring autograft procedure with cross-pin fixation
showed no clinical differences compared with a similar group of patients who
had undergone a bone-patellar tendon-bone autograft
reconstruction2. In
another study, bioabsorbable cross-pins had a 16% deformation or fracture rate
occurring around the time of graft incorporation, although no clinical
importance was noted with respect to knee stability and overall
outcome3. In a
meta-analysis of thirty-two hamstring and thirty-two bone-patellar tendon-bone
graft studies, four-bundle hamstring grafts had higher stability rates than
did patellar tendon autografts and demonstrated fixation-dependent
stability4. Several
studies showed no difference between the outcomes associated with hamstring
autograft and those associated with bone-patellar tendon-bone graft, with
decreased joint degeneration in knees that were reconstructed with hamstring
tendons.
As the use of hamstring tendons increases, so does the investigation of
postoperative knee flexion deficits secondary to their harvest. While the
regeneration of the tendons has been well established, the function of the
regenerated musculotendinous unit has been questioned. The gracilis and
semitendinosus muscles retain their contractile capabilities after harvest,
but deficits appear to persist in deep flexion. One study showed decreased
flexion strength, torque, and flexor work at two years of
follow-up5. The
clinical implications of these findings are not fully defined and will
continue to be a focus of additional investigation. The use of patellar tendon
autograft has been linked to recurrent anterior knee pain and patellar tendon
shortening secondary to healing of the graft site. However, no change in
patellofemoral biomechanics was shown with tendon shortening of 10% after
harvest.
A survey of sports medicine surgeons was conducted to determine the current
recommendation for dealing with a contaminated autograft at the time of
anterior cruciate ligament
reconstruction6. Of
the 196 surgeons responding to the survey, 25% reported at least one
contaminated graft in their surgical experience. In the cases of these
contaminated grafts, 75% were cleansed and implanted and 25% were discarded
and a second graft option was used. Of note, no cleansed graft resulted in an
infection postoperatively. Sixty-five of the surgeons who had not had this
experience gave a hypothetical management response, with 58% stating that they
would cleanse the graft and then implant it, 34% stating they would choose a
second autograft harvest, and 8% choosing to resort to allograft tissue.
The control of recurrent pivoting episodes following anterior cruciate
ligament reconstruction has continued to be a focus of reconstruction efforts.
Additionally, medial translation of the tibia on the femur in anterior
cruciate ligament-deficient knees emphasizes the multidirectional deficits
that exist with this injury. The placement of single-bundle grafts lower in
the intercondylar notch has been shown to better control this motion and to
reestablish the relationship of the anterior cruciate ligament to the
posterior cruciate ligament. This is the same principle driving the
investigation of double-bundle grafts for anterior cruciate ligament
reconstruction. Advocates propose a reconstruction that more accurately
replicates the native biomechanics of the anterior cruciate ligament. Ideal
tunnel position and the correct knee flexion for graft tensioning continue to
be debated. Proper tunnel placement and bundle tension are critical for
preventing graft overload during knee motion. Two studies comparing double and
single-bundle anterior cruciate ligament reconstructions demonstrated
decreased laxity and pivot measurements in association with the double-bundle
method, but no change in the clinical outcome was noted. Additional
biomechanical and clinical trials are needed to fully define the clinical
usefulness and technical recommendations for this developing technique.
Current reconstructive techniques have proven to be durable, with similar
rates of reinjury compared with native anterior cruciate ligament tears in the
contralateral knee. In the event of graft failure, revision anterior cruciate
ligament reconstruction can be a challenge, with patients showing similar
postoperative laxity measurements but decreased overall outcomes compared with
those following primary reconstruction. These poorer outcomes are thought to
be secondary to an increased number of cartilage and meniscal lesions at the
time of revision surgery. Bone-grafting of tunnel defects in either a one or
two-stage procedure is encouraged to improve fixation of the revision graft.
The search for bioabsorbable fixation devices that can provide good initial
fixation, degrade in a timely fashion, and be replaced with bone ingrowth
continues. In a computed tomography follow-up study performed seven years
after anterior cruciate ligament reconstruction with polylactic acid
interference screws, all screws were absorbed but no bone ingrowth was noted
at the screw
site7.
The use of computer guidance, a resource that is gaining interest in the
total joint literature, has been shown to increase the accuracy of femoral and
tibial tunnel placement with a trend toward decreased laxity. Whether this
trend leads to improved patient outcomes and validates the cost of such
guidance systems has yet to be determined.
Home-based therapy programs following anterior cruciate ligament
reconstruction have been shown to be more effective than formal therapy
sessions for achieving postoperative range-of-motion goals, a finding that
could decrease the overall cost of this procedure. Finally, the treatment of
the skeletally immature patient who has an anterior cruciate
ligament-deficient knee remains controversial. One follow-up study of
forty-four patients who were evaluated five years after physeal-sparing
anterior cruciate ligament reconstruction showed no growth disturbance or
angular deformity, excellent functional outcomes, and a low revision
rate8.
Posterior Cruciate Ligament
While nonoperative treatment of grade-I and II posterior cruciate ligament
injuries remains the treatment of choice, the investigation of several issues
related to the operative treatment of grade-III injuries persists. Debate
continues over the use of single or double-bundle reconstruction, the use of a
transtibial as opposed to an inlay technique for tibial fixation (the killer
turn question), and the timing of ligament reconstruction. Similar to anterior
cruciate ligament reconstruction, double-bundle posterior cruciate ligament
reconstruction has enjoyed increased interest in the literature, with the
underlying premise being that patients have a kinematically more normal knee
with independent reconstruction of the anterolateral and posteromedial bundles
of the posterior cruciate ligament. Little has been shown in the way of
improved clinical outcomes in this area, however, and most patients still
receive a single-bundle reconstruction. Regardless of whether a one or
two-bundle reconstruction is performed, tunnel placement is critical to the
success of this operation. Anterior femoral tunnel placement is superior to
posterior positioning for the restoration of normal knee kinematics. In a
cadaver model, a single anterolateral graft best reproduced normal posterior
cruciate ligament force but resulted in increased laxity at 0° to 30°
of flexion9. One
recent study, presented at the meeting of the AOSSM, demonstrated that
grade-III injuries with displacement of the tibia well posterior to the medial
femoral condyle on posterior drawer testing were associated with combined
posterior cruciate ligament and posterolateral corner disruption. In a
laboratory study, double-bundle reconstruction restored better rotational
control, with equivalent findings on stress radiographs, compared with
single-bundle reconstruction. Of note, however, neither single nor
double-bundle reconstruction controlled rotational or varus laxity with a
combined posterior cruciate ligament-posterolateral corner injury, emphasizing
the importance of recognition and proper reconstruction of this injury
combination.
Another point of contention continues to be the choice of tibial fixation.
Advocates of the tibial inlay technique cite elimination of the killer turn
caused by graft abrasion at the proximal tibial tunnel aperture. Preservation
of posterior cruciate ligament fibers at the tibial insertion may decrease
this abrasion at the turn with the arthroscopic tibial tunnel technique. In
addition, combined tibial fixation of the graft with a fixation point both
distal and proximal in the tunnel provides better initial fixation and
restores more normal kinematics than does distal tibial tunnel fixation alone.
A recent two-year follow-up study showed no difference in outcome between the
two techniques and showed that patients did not necessarily return to normal
function with respect to the injured knee, regardless of the tibial fixation
used10. In patients
who have operative treatment of posterior cruciate ligament injuries, early
reconstruction appears to maximize clinical results, as demonstrated in a
recent follow-up
study11.
Posterolateral Corner
Recognition and appropriate treatment of injuries to the lateral side of
the knee prevent long-term disability secondary to abnormal varus and
rotational laxity and are important for preventing the failure of concomitant
reconstruction of the cruciate ligaments. Reconstruction of the posterolateral
corner requires an understanding of the critical structures in this region,
from both an anatomical and a biomechanical standpoint, as well as of the
surgical techniques that reproduce the stabilizing force of the native
complex. The lateral collateral ligament, popliteofibular ligament, and
popliteus tendon are the three critical structures in this region. The tensile
strengths of these structures have been defined as 295, 298, and 700 N,
respectively12.
These values establish a goal for reconstruction and graft choice strength. In
a cadaver model, reconstruction of the lateral collateral ligament with
fibular interference screw fixation consistently failed at the fibular
fixation site and was associated with stiffness measurements that were
significantly lower than those for the intact ligament. Lateral collateral
ligament reconstruction should be protected to prevent postoperative loosening
until graft incorporation at the fibular head. Tunnel convergence when the
posterolateral corner is reconstructed in the case of a multiligamentous knee
injury remains a concern. A cadaver study yielded recommendations for the
placement of these tunnels to prevent encroachment with the anterior cruciate
ligament tunnel13.
The recommended femoral tunnel orientation was 0° in the coronal plane,
<40° anterior in the axial plane, and <25 mm in depth. Current
reconstruction techniques are effective, with patients in a recent two-year
follow-up study demonstrating excellent functional
results14. Patients
who underwent an isolated reconstruction had better range of motion and
decreased failure rates than those who had multiple ligamentous injuries.
Medial Collateral Ligament
Nonoperative treatment of medial collateral ligament injuries remains the
standard of care. Debate continues, however, with regard to the proper
treatment of combined medial collateral ligament and anterior cruciate
ligament injuries. Some surgeons routinely repair or reconstruct grade-III
medial collateral ligament injuries, whereas others treat them nonoperatively
following anterior cruciate ligament reconstruction. A recent randomized,
controlled, Level-I trial of concomitant anterior cruciate ligament and
grade-III medial collateral ligament injuries addressed this
issue15. One arm of
the trial consisted of patients who underwent operative treatment of both
injuries, whereas the second arm consisted of patients who underwent anterior
cruciate ligament reconstruction and brace treatment of the medial collateral
ligament injury. All anterior cruciate ligament reconstructions were performed
with bone-patellar tendon-bone autograft secured with interference screw
fixation. At the time of the final (two-year) follow-up, the two groups showed
no differences in terms of functional outcome or laxity measurements and the
investigators concluded that nonoperative treatment of medial collateral
ligament injuries with simultaneous reconstruction of the anterior cruciate
ligament should be the preferred method of treating this injury pattern. In
the case of medial collateral ligament reconstruction, the use of
semitendinosus autograft secured over a medial epicondylar post (the modified
Bosworth technique) remains an excellent option, with attention being given to
isometric placement of the post to prevent postoperative knee stiffness.
Meniscus
The role of the meniscus and the effects and treatment of meniscal
pathology continue to be defined. The preservation of meniscal tissue when
possible, and replacement if indicated, is the goal of meniscal surgery in the
knee. The repair of tears with use of a variety of all-inside devices attempts
to replicate the results achieved with inside-out techniques. A recent study
of meniscal repair demonstrated good functional results after five to
seventeen years of
follow-up16.
However, the prevention of degenerative changes in the joint was unclear.
Meniscal transplantation remains a viable but controversial treatment option
with evolving but still narrow indications. Finally, the creation of an
artificial meniscal substitute has shown some promise but clearly remains in
the early developmental stages.
Although inside-out meniscal repair remains the gold standard for the
treatment of repairable meniscal lesions, multiple all-inside meniscal repair
devices are currently available, and many have achieved good results in short
to intermediate-term clinical follow-up studies. The advantages that have been
cited for these devices include decreased operative time, the elimination of
additional incisions, and a greatly reduced risk to neurovascular structures.
Detractors of all-inside devices, particularly arrows and screws, question the
potential chondral damage that can be caused by these devices over time. A new
generation of flexible and tensionable all-inside devices has shown good
results in short-term follow-up studies. The RapidLoc (Mitek, Raynham,
Massachusetts), FasT-Fix (Smith and Nephew, Andover, Massachusetts) and
BioStinger (CONMED Linvatec, Largo, Florida) devices all demonstrated 90%
success rates in early follow-up
studies17-19.
A vertically placed FasT-Fix was shown to have increased strength, stiffness,
and load to failure as compared with horizontal inside-out and RapidLoc
all-inside repairs. Although vertically placed inside-out repairs have been
shown to be the strongest constructs, one study demonstrated increased
resistance to shear stress in association with horizontal repair and
demonstrated no significant difference between the two techniques with regard
to resistance to distraction across the repair
site20. Another
study showed compression rather than distraction across tear sites with knee
range of motion. These findings may lead to hybrid repair configurations
maximizing the benefit of both suture orientations. Predictors of meniscal
repair failure were found to be bucket handle tears, complex tears, large
tears (>2 cm in length), and chronic tears (more than three months
old).
The treatment of a failed meniscal repair or an irreparable tear resulting
in total or subtotal menisectomy in a young, active patient remains a
challenging dilemma. The role of meniscal tissue in increasing conformity of
the knee joint and serving as a secondary stabilizer is well understood. The
lateral meniscus is especially important because of the convexity of the
tibial plateau on that side. Lack of functional lateral meniscal tissue leads
to point loading on the lateral femoral condyle and can lead to rapid
articular cartilage wear. Prior to the development of advanced chondrosis,
these patients may benefit from allograft meniscal transplantation. Several
studies have demonstrated good short-term clinical results, with an allograft
survival rate of 89% in arthritic knees in one series. An improvement in pain
scores was seen in 96% of the patients, with the results of bone fixation
exceeding those of suture-only fixation and with better results being seen
when transplantion was performed prior to the radiographic detection of
joint-space narrowing. Unfortunately, these good early results appear to
decrease with longer follow-up, warranting continued investigation to improve
these outcomes. Another option that remains in the developmental stage is
meniscal replacement with a collagen scaffold. This scaffold would allow for
the ingrowth of meniscal tissue and would avoid the risks associated with
allograft transplantation. One canine model demonstrated
"meniscus-like" tissue ingrowth into a collagen scaffold and
provided better chondral protection than partial meniscectomy
alone21. Another
canine study showed tissue infiltration into a porous polymer meniscal implant
but continued progression of
osteoarthritis22.
The search continues for a meniscal prosthesis that encourages tissue ingrowth
with reproduction of meniscal biomechanics that will protect the overlying
articular cartilage from degeneration over time. Proximal tibial osteotomy
remains an option for the young active patient who has chondrosis and axial
malalignment. It should be noted, however, that increased failure rates have
been noted in association with the use of allograft bone, and attention should
be paid to alteration of the tibial slope with this procedure.
Patella
Treatment options for several pathologic conditions of the knee extensor
mechanism continue to be explored. Multiple modalities and techniques are
available for the treatment of recurrent patellar dislocation and instability,
patellofemoral pain, and recalcitrant patellar tendinosus, with no one method
established as the standard of care.
Patellar dislocation and recurrent instability following unsuccessful
nonoperative treatment may be addressed in several ways. Release of the
lateral retinaculum and vastus lateralis was shown to decrease dislocation
rates, to improve knee function, and to increase quadriceps strength in these
patients. Concomitant or isolated medial patellofemoral ligament repair or
reconstruction also has been shown to decrease instability episodes and to
improve functional knee scores in several studies. Medial patellofemoral
ligament reconstruction was more effective for medializing patellofemoral
tracking mechanics than a tibial tubercle osteotomy in a cadaver
model23.
The treatment of patellofemoral pain has long been a challenge for
orthopaedic surgeons. Multiple physical therapy modalities have been proposed
with the goal of stabilizing patellar tracking and strengthening the dynamic
stabilizers about the knee. In addition to knee-based programs for
rehabilitation, a focus on hip strengthening in a therapy regimen has been
shown to decrease symptoms associated with this problem. Nonoperative
treatment of patellar tendinosis remains the standard of care, with surgical
treatment showing no difference compared with a twelve-week training program
of eccentric
strengthening24. In
cases of failed nonoperative treatment, open débridement of the
pathologic tissue has shown improvement in high-level athletes.
Glenoid Labrum
Numerous arthroscopic shoulder techniques, including Bankart repair,
rotator cuff repair, and biceps tenodesis, have increased in popularity
recently. In addition to these procedures, more novel approaches such as
scapulothoracic bursoscopy and suprascapular nerve decompression have been
pioneered. The results of both anterior and posterior arthroscopic labral
repair continue to improve and have steadily approached the 90% to 95% success
rates associated with traditional open procedures. Factors leading to an
increased risk for repair failure are large glenoid bone defects, generalized
hyperlaxity, and the use of three or fewer anchors. The proposed advantages of
the arthroscopic technique include decreased or no hospital stay, fewer
postoperative subscapularis complications, decreased pain, and less loss of
motion. Two studies showed that the results associated with knotless suture
anchor constructs rivaled those associated with standard anchors and open
procedures, at least at the time of early follow-up. Recommendations for the
treatment of traumatic anterior shoulder instability in collision athletes are
less clear, with some authorities on the subject recommending arthroscopic
Bankart repair and others performing open repairs for this unique subset of
patients. Subscapularis function and integrity have been shown to be paramount
for ultimate function, and their protection remains a definite advantage of
arthroscopic techniques. In a cost analysis comparing arthroscopic and open
techniques, arthroscopic treatment was shown to be less
expensive25.
However, patients who underwent open repair were admitted overnight, leading
to an increase in cost that would likely be normalized if all patients were
managed on an outpatient basis. We recognize the importance of all shoulder
structures in maintaining stability of the joint and know that anterior labral
injury alone is not sufficient to cause recurrent instability. Injury to the
anteroinferior capsule remains part of the essential lesion in this entity.
Additionally, cadaver studies have shown that a tear of the rotator cuff
decreases the stability of the glenohumeral joint and should be addressed in
the treatment of this condition, particularly in older patients, in whom
rotator cuff tears are more common after shoulder dislocation.
The accurate diagnosis of superior labral anterior posterior (SLAP) tears
remains an elusive goal. The search continues for a more reliable clinical
examination to increase the likelihood of finding correlative pathology at the
time of arthroscopy. While the O'Brien, Speed, and crank tests all continue to
be used for this purpose, the supination-external rotation test and forced
abduction test have been added to the clinician's battery to detect biceps
anchor injuries. The combination of these examinations with the improved
quality of arthrogram-enhanced magnetic resonance imaging will aid in
increasing the accuracy of diagnosis of this problem.
Rotator Cuff
The arthroscopic repair of rotator cuff tears has gained popularity yearly,
with recent studies showing no difference between arthroscopic techniques and
mini-open techniques with regard to clinical outcomes after two, three, and
four years of
follow-up26-28.
Interestingly, these outcomes may not be affected by subacromial
decompression, which has long been thought to be necessary for repair success.
In another study, arthroscopic repair was associated with less fatty atrophy
of the rotator cuff musculature postoperatively as compared with open
techniques. Advances in available instrumentation, implants, and surgical
techniques, including the introduction of a new device that was developed to
measure the thickness of partial tears, have complemented this trend. In
addition, a better understanding of tear morphology and rotator cuff
characteristics such as mobility and tissue quality has more fully defined the
unique properties that may be present with any tear. Chronic tears begin to
show decreased muscle volume, increased fat content, and increased stiffness
as early as twelve weeks after the
injury29. These
changes decrease the mobility of the tissues and can hinder the surgeon's
ability to achieve a dependable repair. The resultant functionally different
musculotendinous unit highlights the need for early diagnosis and treatment of
rotator cuff pathology.
Improving initial fixation and increasing the overall contact area have led
to changes in recommendations regarding suture constructs. Initial load to
failure is increased in association with more anchors, double-row fixation,
and suture patterns that grab more tissue, such as the mattress or
Kessler-type suture. In a comparison of ten knot configurations that are used
for arthroscopic repair, the Dines knot provided superior knot and loop
security with decreased suture material and knot
size30. Double-row
repair concepts designed to increase initial fixation strength and footprint
size have recently increased in popularity and have shown excellent early
clinical results. One study demonstrated increased ultimate tensile load and
initial fixation strength when a double-row technique was compared with
single-row constructs. This finding was demonstrated to be particularly
important in association with rotator cuff repairs under tension. No
difference in clinical outcome was observed when this technique was compared
with single-row fixation in an outcomes study, although structural integrity
was shown to be improved on magnetic resonance images at three years of
follow-up31.
Certainly, continued investigation into this technique is warranted as new
devices are made available with the goal of improving the proficiency of
double-row fixation. While cuff integrity after repair remains the goal of
treatment, many patients will demonstrate functional improvement even in the
presence of a recurrent rotator cuff tear as long as seven years after
surgery.
The treatment of a massive chronic rotator cuff tear continues to be a
challenge. Recent interest in the use of various tissue-augmentation patches
either to span an irreparable defect or to reinforce a repair in the presence
of poor tissue quality has increased. These patches are readily available and
may consist of human, porcine, or bovine skin or porcine intestinal submucosa,
among other materials. All have varying characteristics, depending on their
tissue of origin. Of these, patches of dermal origin have an increased load to
failure compared with submucosa-based grafts. In a dog model, however, patch
supplementation of a rotator cuff that was repaired under tension produced no
increase in strength in comparison with simple
repair32. While
these patches theoretically serve to increase the available collagen framework
for ultimate healing, they have not consistently shown improvement in healing
rates or clinical outcomes, and their ultimate role in the repair of rotator
cuff tears or other tendon defects remains undefined.
A trend in the treatment of shoulder pathology has been the improvement of
the quality and diagnostic accuracy of magnetic resonance imaging, which can
be used to predict rotator cuff tear morphology and configuration through the
assessment of the maximum tear length and width as seen on coronal and
sagittal images. This allows for more accurate preoperative planning and a
more efficient surgical repair. Recognition of the importance of partial and
complete subscapularis tears has grown, and techniques for the repair of these
injuries are being refined. A narrowed coracohumeral distance as measured on
magnetic resonance imaging may indicate subtle subscapularis pathology.
Magnetic resonance imaging also has been used to quantify the accuracy of
subacromial injections, with postinjection imaging confirming the relative
inaccuracy of these injections. Injections from a posterior site reached the
subacromial bursa 76% of the time, whereas injections given anteromedially had
a 69% success
rate33. This
finding questions the clinical usefulness of subacromial injection for the
confirmation of subacromial pathology.
Acromioclavicular Joint and Clavicle
Acromioclavicular joint pathology, whether the result of degenerative
processes or posttraumatic conditions, can cause considerable pain and
dysfunction. Coplaning of the clavicle and the medial edge of the acromion has
long been used to treat impingement of the rotator cuff by inferior
osteophytes. This has raised concerns of destabilization of the joint. In one
study, patients managed with coplaning of the joint had outcomes similar to
those managed with arthroscopic decompression and open distal clavicular
excision at the time of the six-year
follow-up34.
Multiple methods for reconstruction of the displaced and symptomatic
acromioclavicular joint have been described over time. Anatomic and
nonanatomic repairs involving the use of autograft or allograft tissue or
screw fixation have all been successfully attempted. Several studies have
demonstrated that anatomic repair with soft-tissue grafts results in the most
stable reconstruction, with anterior-to-posterior translation being similar to
that in the native joint.
While nonoperative treatment of most clavicular fractures remains the gold
standard, the indications for open reduction and internal fixation continue to
evolve. Decreased strength following nonoperative treatment has been
identified as a possible indication for fixation of these fractures at the
time of the injury, particularly in young, active patients with displaced
midshaft fractures.
Biceps Tendon
Multiple options are available for the treatment of pathology of the long
head of the biceps. Tenodesis remains the mainstay when the tendinopathy
involves =50% of the tendon. The method of proximal fixation varies
greatly, with arthroscopic, arthroscopically assisted, and open methods all
being used commonly. No differences in outcomes have been shown in association
with the use of suture anchors, a soft-tissue sling, or a tenodesis
screw35. Surgeon
comfort with a particular method seems to be the most important factor in
choosing a technique. Additional research is needed to identify the construct
with the best initial fixation.
Shoulder Biomechanics
The biomechanical profile of the overhand thrower continues to attract
interest. Attempts to more fully understand this complex activity have aimed
to improve the care of athletes who depend on this motion for their vocations
or avocations. Pitchers have been shown to have increased external rotation
and decreased internal rotation with the same or decreased total arc of motion
in the throwing shoulder as in the contralateral, nonthrowing shoulder. This
internal rotation deficit and posterior capsular tightness contribute to the
entity of internal cuff impingement. Capsular contractures, however, do not
appear to be the sole cause of this altered mobility pattern. The safety of
various pitch selections in pitchers is still debated, with a recent study of
collegiate pitchers demonstrating no difference in shoulder kinematics between
throwing curveballs and
fastballs36.
Shoulder joint kinetics and angular velocity were lower for the change-up as
compared with the fastball, curveball, and slider. The protection of the young
pitcher remains paramount. Pitching practices correlate with shoulder and
elbow injury in the adolescent pitcher, with the highest correlation seen in
those pitching with pain and fatigue. Other factors correlating with injury
included the number of games pitched per week and the numbers of pitches and
innings pitched per game. Attention should be given to strict enforcement of
daily and weekly pitch and inning counts, with close monitoring of any
discomfort experienced by these athletes.
Interest in the arthroscopic treatment of wrist injuries, including
triangular fibrocartilage complex tears, dorsoradiocarpal ligament tears, and
posttraumatic radiocarpal contracture, continues to increase. Arthroscopic
repair of the triangular fibrocartilage complex has become more popular over
the past several years. Increased age, decreased grip strength, decreased
wrist motion, and increased ulnar variance are predictors of a less favorable
outcome37.
Additionally, in athletes with refractory ulnar-sided wrist pain, erosion
of the floor of the sixth dorsal compartment should be considered. In a case
series of golfers and tennis players, débridement of the compartment
with interposition of local soft tissue was shown to reduce symptoms
significantly38.
The treatment of lateral epicondylitis remains challenging. Nonoperative
treatment with physical therapy and a tennis elbow brace remains the standard
of care. Patients who have a positive result on the extensor grip test fare
better after this intervention than do those who have a negative result.
Despite extensive nonoperative treatment, some patients with refractory pain
require surgical intervention to address the pain. Suture anchor repair of the
extensor carpi radialis brevis to the lateral epicondyle after
débridement has led to improved postoperative grip strength and
decreased pain after four years of
follow-up39.
As in other locations, osteochondral defects of the elbow present
particular problems with respect to pain, dysfunction, and effective
treatment. Two studies demonstrated good results following the treatment of
these troublesome lesions with osteochondral autograft. In another study, the
interference screw technique was shown to be stronger than the use of two bone
tunnels and similar to the use of native tendon for the repair of distal
biceps ruptures in a cadaver
model40.
Ankle sprains remain one of the most common injuries in all of competitive
sports. A recent study demonstrated the incidence to be one per 1000 athlete
exposures, with the highest incidence being in female basketball players.
Another study demonstrated that an increased body mass index and a history of
previous lateral ankle injury increased the risk of sprain in male athletes.
Balance training decreased the rate of ankle sprains, with a risk reduction to
one-half, in a randomized, controlled, Level-I trial of 765 high school soccer
and basketball
players41. Chronic
lateral ankle ligament injury resulting in insufficient restraint can lead to
varus hindfoot alignment and is the leading cause of posttraumatic
osteoarthritis after soft-tissue injury about the ankle. A Brostrom
reconstruction of the lateral ankle ligaments remains the mainstay of
treatment, with excellent long-term results after twenty-six years of
follow-up.
Treatment of Achilles tendon injuries remains a challenge. A meta-analysis
of twelve clinical trials involving 800 patients confirmed that open treatment
results in a decreased rerupture rate, but at the expense of an increase in
the overall complication
rate42.
Percutaneous repair with functional bracing was associated with decreased
complication rates and improved range of motion in comparison with open
techniques. Another study demonstrated that percutaneous repair was associated
with decreased complication rates but increased rates of rerupture and sural
nerve problems postoperatively. No differences in functional outcomes were
found at the time of the final follow-up. Sural nerve complications may be
minimized with care being taken to expose the nerve during the percutaneous
procedure.
Catastrophic cervical spine injury continues to occur in contact sports. In
American football, recent changes have allowed for the easier enforcement of
rules prohibiting the spear-tackling technique, which remains the most common
mechanism of these injuries. In a recent compilation of thirteen years of data
from the National Center for Catastrophic Sports Injury Research, the
incidence of these injuries in American football was found to be fifteen per
year, with about six of these injuries resulting in
quadriplegia43. The
incidence was 1.1 per 100,000 exposures among high school football players and
4.7 per 100,000 exposures among collegiate players. Forty-three athletes had a
cervical cord neurapraxia (incidence, 3.31 cases per year), with sixteen of
these players returning to football and none suffering a permanent
quadriplegic event. Defensive backs had the highest risk for catastrophic
cervical spine injury. Attention should be given to the continued education of
athletes and coaches, with focus on proper tackling technique to decrease the
incidence of these injuries.
Arthroscopy of the hip has allowed for the treatment of intraarticular
pathology in a joint that had been relatively inaccessible in the past. As
arthroscopic treatment of various hip ailments continues to evolve, diagnosing
pathology and defining operative indications take on increasing importance.
The most effective use of hip arthroplasty continues to be for the treatment
of mechanical symptoms caused by labral pathology. In one study, 80% of
patients who had intra-articular snapping of the hip had labral tears as the
underlying etiology, and all improved with arthroscopic débridement of
the labrum. Patients with Czerny stage-II (intrasubstance tears) and stage-III
(complete avulsions) labral injuries did equally well with arthroscopic
treatment44.
Recently, imaging techniques have evolved to more accurately identify patients
with treatable hip pathology. Magnetic resonance imaging arthrography with
radial reformatting and true sagittal images has increased the sensitivity and
accuracy of diagnosis of arthroscopically confirmed labral pathology. A new
approach also has been described for the treatment of extra-articular snapping
hip, with endoscopic release of the iliotibial band showing good results at
the time of the most recent follow-up.
The search for an effective treatment of cartilage injury continues.
Methods such as microfracture, autograft plug transfer, and chondrocyte cell
culture implantation are the mainstays of treatment, and all have been
associated with good results in properly selected patients. The use of
radiofrequency energy to smooth articular cartilage defects has been
associated with good visual results but with detrimental changes in the
mechanical properties of the treated and surrounding cartilage. Additionally,
a sheep model showed death of surrounding chondrocytes in association with the
use of this
modality45.
Microfracture has demonstrated good clinical results at two years of
follow-up, with filling of the defects being demonstrated with magnetic
resonance imaging. Patients with better results had a lower body mass index
and a shorter duration of symptoms. In a Level-I study of athletes, the
results of osteochondral autograft transfer were superior to those of
microfracture at three years of
follow-up46.
Correct placement of autograft plugs is paramount. Particular attention must
be paid to the harvest and delivery of the plugs perpendicular to the joint
surface. In the event of a less-than-perpendicular plug delivery, depth has
been shown to be important for survival of the graft. In one study, less
contact pressure was noted on the plug when one side was flush with the
surrounding cartilage and the other was resting slightly lower as opposed to
when one side of the plug was
elevated47. In
another study, plugs showed good incorporation at two years of follow-up and
grafts with increased diameter appeared to be more stable
initially48. In a
rabbit model, decreased cartilage stiffness was noted from the time of
osteochondral plug implantation to twelve weeks after surgery. This finding
could have implications for postoperative rehabilitation and the decision to
allow full weight-bearing prior to three months after surgery. For large
defects, allograft plugs have the advantages of decreased donor-site morbidity
and the avoidance of multiple-site harvesting. It should be noted that
decreased chondrocyte viability has been demonstrated in association with
standard storage techniques, a phenomenon that is independent of the
cartilage-to-bone
ratio49.
Implantation of cultured autogenous chondrocytes has produced
"hyaline-like" cartilage in multiple studies and remains an option
for the treatment of cartilage defects. Limitations include cost and the need
for more than one surgical procedure. In a study of young high-level soccer
players, this procedure provided durable and functional results and was
associated with higher knee scores and decreased pain at three years of
follow-up in comparison with débridement
alone50. The three
most common adverse events for this procedure as reported by the United States
Food and Drug Administration were graft failure, delamination, and local
tissue hypertrophy. Finally, tissue-engineered chondral plugs may have a
future in the treatment of articular defects. These plugs healed with 90%
type-II collagen in a rabbit model, although questions persist with regard to
their strength and resistance to shear forces in
situ51.
Intra-articular injections of the shoulder and knee, whether for
postoperative pain control or as a therapeutic or diagnostic modality, are
common in most orthopaedic practices. In addition, some surgeons use
intra-articular pain pumps in an effort to decrease pain after surgery and to
facilitate outpatient surgical treatments. Two studies questioned the safety
of intra-articular bupivacaine and its effect on articular chondrocytes. One
rabbit shoulder infusion model and one bovine in vitro model demonstrated
cytotoxicity of bupivacaine on these cells with only relatively short exposure
to the compound (forty-eight hours and ten to thirty minutes,
respectively)52,53.
Additional study is needed to determine the safety of other types of
intra-articular injections.
While the successful treatment of sports injuries has long been a goal of
sports medicine physicians, emphasis on injury prevention is equally important
in the care of athletes at all levels. Noncontact anterior cruciate ligament
injuries remain a concern, and the prevention of these injuries with
plyometric training with a focus on landing and jumping biomechanics has
increased in popularity over the past several years. Directional and reactive
jumping influence knee biomechanics and affect stresses across the anterior
cruciate ligament. Female athletes are at particular risk with increased knee
valgus moments, decreased knee and hip flexion angles at the time of initial
ground contact, increased landing forces, and an increased
quadriceps-to-hamstrings ratio with drop-jump activities. Adolescents,
regardless of gender, have shown increased valgus moments at the knee with
drop-jump testing, and this group may be a target for prevention of anterior
cruciate ligament injury. A plyometric and dynamic stabilization program was
shown to decrease lower extremity valgus measurements and should be
incorporated into prevention strategies. However, a prospective study of
female high school basketball players who were managed with an in-season
plyometric exercise program for twenty minutes twice a week showed no
significant decrease in noncontact anterior cruciate ligament
injuries54.
Finally, the link between anterior cruciate ligament rupture and the
menstrual cycle remains controversial, with one study showing an increased
risk of anterior cruciate injury in the pre-ovulatory stage of the cycle.
Another study demonstrated no difference in knee or ankle laxity with respect
to serum estrogen or progesterone levels.
Stress fracture risk in the lower extremity continues to be defined. In
female United States Marine Corps recruits, low aerobic fitness was correlated
with an increased risk of stress fracture. Preliminary fitness training may be
of benefit for these recruits prior to the start of formal boot camp
activities. Female professional basketball players were shown to have a higher
injury rate than their male counterparts over six
seasons55. Little
difference was noted, however, when individual injuries were compared between
the two groups over the same time-period.
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 medical journals were
reviewed to identify these articles, which all have high-quality study design.
In addition to articles cited already in this Update, four level-I articles
were identified that were relevant to sports medicine. A list of those titles
is appended to this review after the standard bibliography. We have provided a
brief commentary about each of the articles to help to guide your further
reading, in an evidence-based fashion, in this subspecialty area.
The annual meeting of the Arthroscopy Association of North America (AANA)
will be held on April 26 through 29, 2007, in San Francisco, California. The
annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM)
will be held on July 12 through 15, 2007, in Calgary, Alberta, Canada. The
AOSSM/AAOS first annual review course for Subspecialty Certification in Sports
Medicine will be held on August 3 through 5, 2007, in Chicago, Illinois.
Sports medicine fellowships continue to be the most popular fellowship
choice in orthopaedic surgery. Accreditation has become even more important
because, beginning in 2012, one will be required to have graduated from an
accredited fellowship in order to take the subspecialty certification
examination. Unfortunately, there is still not a formal match for sports
medicine fellowship programs. Several of the more sought-after fellowship
programs have developed a "gentlemen's agreement" to allow
applicants to interview at other programs prior to making a decision regarding
their fellowship location, but there are no written guarantees. Clearly, the
match should be restored or an effective alternative must be developed.
The AOSSM research agenda has expanded considerably over the last few years
with both society-sponsored multicenter clinical trials as well as
topic-oriented calls for proposals. Below is a summary of these new grant
opportunities.
The AOSSM has embarked on a topic-oriented research focus. Every three
years, a research topic is identified that could change the practice of AOSSM
members. Abstracts of research plans are submitted, and the best proposals are
presented at a one-day grant workshop. Full proposals are accepted a few
months later, and $250,000 is awarded to fund the best proposal. The goal of
this program is twofold: (1) to fund research programs that are of interest to
the AOSSM, and (2) to help high-quality research projects to develop enough
pilot data to compete for major grant funding such as through the National
Institutes of Health (NIH). The first topic funded by the AOSSM was noncontact
anterior cruciate ligament injury mechanisms. Although only one investigator
was funded, three individuals who submitted grant proposals went on to obtain
NIH funding. The second topic was articular cartilage, for which final
abstracts have been received and currently are under review. The AOSSM is in
the process of developing the topic for the next round of submissions, and
this information will be made available on the AOSSM web site once it is
finalized. The AOSSM is sponsoring several multicenter trials, including the
Multicenter Anterior Cruciate Ligament Revision Study (MARS), the Multicenter
Evaluation of the Responsiveness of the International Knee Documentation
Committee (MERI), and a study of the treatment of anterior cruciate ligament
injuries in pediatric patients.
Other research opportunities include investigator-initiated proposals such
as the AOSSM Young Investigator Grant, which awards amounts of up to $40,000
for pilot projects, and the Sandy Kirkley Clinical Outcome Research Grant,
which awards $20,000 for an outcome research project or pilot study. Finally,
the NCAA (National Collegiate Athletic Association) award will be given to the
best paper at the AOSSM meeting that pertains to collegiate athletics. The
award consists of a plaque and a $500 honorarium.
Fauno P, Kaalund S. Tunnel widening after hamstring anterior
cruciate ligament reconstruction is influenced by the type of graft fixation
used: a prospective randomized study. Arthroscopy.
2005;21:1337-41.
This randomized, prospective study evaluated the relationship of hamstring
autograft fixation distance from the joint line and its effect on tunnel
widening. Eighty-seven patients were randomized into two groups, with one
group (Group A) receiving transfemoral and tibial interference screw fixation
and the other group (Group B) receiving extracortical femoral and tibial screw
and washer fixation. At one year after surgery, Group A had significantly less
tunnel widening on both sides of the joint. No significant differences were
noted with respect to clinical outcome measures or laxity. Tunnel widening
after anterior cruciate ligament reconstruction is affected by fixation
choice. The clinical importance of this effect is unclear, although it could
have an effect on revision anterior cruciate ligament surgery.
Ekman E, Wahba M, Ancona F. Analgesic efficacy of perioperative
celecoxib in ambulatory arthroscopic knee surgery: a double-blind,
placebo-controlled study. Arthroscopy. 2006;22:635-42.
Patients undergoing knee arthroscopy to address meniscal pathology were
randomized to receive celecoxib (Group A) or a placebo (Group B)
perioperatively. Patients in Group A had significantly less opioid usage after
surgery and experienced fewer opioid-related side effects. Celecoxib use
before and immediately after arthroscopic knee surgery can be an effective
adjunct to current pain-control regimens and may reduce harmful side effects
experienced with opioid use.
Drogset J, Grontvedt T, Robak O, Molster A, Viset A, Engebretsen L.
A sixteen-year follow-up of three operative techniques for the treatment of
acute ruptures of the anterior cruciate ligament. J Bone Joint Surg
Am. 2006;88:944-52.
Patients who were randomized to primary anterior cruciate ligament repair,
repair with synthetic ligament augmentation, or repair with bone-patellar
tendon-bone augmentation were evaluated at sixteen years after surgery. The
rate of revision surgery was higher for the primary repair group than for the
bone-patellar tendon-bone augmentation group. In addition, the rate of
osteoarthritis was higher in the knees with an anterior cruciate ligament
injury than in the contralateral knees (11% compared with 3.5%). Primary
repair of anterior cruciate ligament injuries results in increased revision
rates and poorer functional outcomes, while anterior cruciate ligament injury
may predispose patients to the development of osteoarthritis in the involved
knee as compared with the contralateral, uninjured knee.
Grant J, Mohtadi N, Maitland M, Zernicke R. Comparison of home
versus physical therapy-supervised rehabilitation programs after anterior
cruciate ligament reconstruction: a randomized clinical trial. Am J Sports
Med. 2005;33:1288-97.
The effectiveness of a home-based rehabilitation program after anterior
cruciate ligament reconstruction was compared with a traditional physical
therapy protocol. The home-based therapy group had a higher percentage of
patients with acceptable range of motion of the knee, and no differences in
functional outcomes between the two treatment groups were seen. A structured,
minimally supervised home therapy program may be more effective for achieving
postoperative goals and more cost effective than a traditional physical
therapy regimen after anterior cruciate ligament reconstruction.
Salmon LJ, Russell VJ, Refshauge K,
Kader D, Connolly C, Linklater J, Pinczewski LA. Long-term outcome of
endoscopic anterior cruciate ligament reconstruction with patellar tendon
autograft: minimum 13-year review. Am J Sports Med.
2006;34:
721-32.34721
2006
[PubMed][CrossRef]
Wilcox JF, Gross JA, Sibel R, Backs RA,
Kaeding CC. Anterior cruciate ligament reconstruction with hamstring tendons
and cross-pin femoral fixation compared with patellar tendon autografts.
Arthroscopy. 2005;21:
1186-92.211186
2005
[PubMed][CrossRef]
Cossey AJ, Kalairajah Y, Morcom R,
Spriggins AJ. Magnetic resonance imaging evaluation of biodegradable
transfemoral fixation used in anterior cruciate ligament reconstruction.
Arthroscopy. 2006;22:
199-204.22199
2006
[PubMed][CrossRef]
Prodromos CC, Joyce BT, Shi K, Keller
BL. A meta-analysis of stability after anterior cruciate ligament
reconstruction as a function of hamstring versus patellar tendon graft and
fixation type. Arthroscopy.
2005;21:
1202.211202
2005
[PubMed]
Elmlinger BS, Nyland JA, Tillett ED.
Knee flexor function 2 years after anterior cruciate ligament reconstruction
with semitendinosus-gracilis autografts. Arthroscopy.
2006;22:
650-5.22650
2006
[PubMed][CrossRef]
Izquierdo R Jr, Cadet ER, Bauer R,
Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists
investigating the preferred management of contaminated anterior cruciate
ligament grafts. Arthroscopy.
2005;21:
1348-53.211348
2005
[PubMed][CrossRef]
Barber FA, Dockery WD. Long-term
absorption of poly-L-lactic acid interference screws.
Arthroscopy. 2006;22:
820-6.22820
2006
[PubMed][CrossRef]
Kocher MS, Garg S, Micheli LJ. Physeal
sparing reconstruction of the anterior cruciate ligament in skeletally
immature prepubescent children and adolescents. Surgical technique. J
Bone Joint Surg Am. 2006;88Suppl 1 Pt 2: 283-93.88283
2006
[CrossRef]
Markolf KL, Feeley BT, Jackson SR,
McAllister DR. Biomechanical studies of double-bundle posterior cruciate
ligament reconstructions. J Bone Joint Surg Am.
2006;88:
1788-94.881788
2006
[PubMed][CrossRef]
MacGillivray JD, Stein BE, Park M, Allen
AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial
techniques for isolated posterior cruciate ligament reconstruction: minimum
2-year follow-up. Arthroscopy.
2006;22:
320-8.22320
2006
[PubMed][CrossRef]
Sekiya JK, West RV, Ong BC, Irrgang JJ,
Fu FH, Harner CD. Clinical outcomes after isolated arthroscopic single-bundle
posterior cruciate ligament reconstruction. Arthroscopy.
2005;21:
1042-50.211042
2005
[PubMed][CrossRef]
LaPrade RF, Bollom TS, Wentorf FA, Wills
NJ, Meister K. Mechanical properties of the posterolateral structures of the
knee. Am J Sports Med.
2005;33:
1386-91.331386
2005
[PubMed][CrossRef]
Shuler MS, Jasper LE, Rauh PB, Mulligan
ME, Moorman CT 3rd. Tunnel convergence in combined anterior cruciate ligament
and posterolateral corner reconstruction. Arthroscopy.
2006;22:
193-8.22193
2006
[PubMed][CrossRef]
Stannard JP, Brown SL, Robinson JT,
McGwin G Jr, Volgas DA. Reconstruction of the posterolateral corner of the
knee. Arthroscopy. 2005;21:
1051-9.211051
2005
[PubMed][CrossRef]
Halinen J, Lindahl J, Hirvensalo E,
Santavirta S. Operative and nonoperative treatments of medial collateral
ligament rupture with early anterior cruciate ligament reconstruction: a
prospective randomized study. Am J Sports Med.
2006;34:
1134-40.341134
2006
[PubMed][CrossRef]
Majewski M, Stoll R, Widmer H, Muller W,
Friederich NF. Midterm and long-term results after arthroscopic suture repair
of isolated, longitudinal, vertical meniscal tears in stable knees. Am
J Sports Med. 2006;34:
1072-6.341072
2006
[CrossRef]
Quinby JS, Golish SR, Hart JA, Diduch
DR. All-inside meniscal repair using a new flexible, tensionable device.
Am J Sports Med. 2006;34:
1281-6.341281
2006
[PubMed][CrossRef]
Kotsovolos ES, Hantes ME, Mastrokalos
DS, Lorbach O, Paessler HH. Results of all-inside meniscal repair with the
FasT-Fix meniscal repair system. Arthroscopy.
2006;22:
3-9.223
2006
[PubMed][CrossRef]
Barber FA, Coons DA. Midterm results of
meniscal repair using the BioStinger meniscal repair device.
Arthroscopy. 2006;22:
400-5.22400
2006
[PubMed][CrossRef]
Zantop T, Temmig K, Weimann A, Eggers
AK, Raschke MJ, Petersen W. Elongation and structural properties of meniscal
repair using suture techniques in distraction and shear force scenarios:
biomechanical evaluation using a cyclic loading protocol. Am J Sports
Med. 2006;34:
799-805.34799
2006
[CrossRef]
Cook JL, Fox DB, Malaviya P, Tomlinson
JL, Kuroki K, Cook CR, Kladakis S. Long-term outcome for large meniscal
defects treated with small intestinal submucosa in a dog model. Am J
Sports Med. 2006;34:
32-42.3432
2006
[CrossRef]
Tienen TG, Heijkants RG, de Groot JH,
Pennings AJ, Schouten AJ, Veth RP, Buma P. Replacement of the knee meniscus by
a porous polymer implant: a study in dogs. Am J Sports Med.
2006;34:
64-71.3464
2006
[PubMed][CrossRef]
Ostermeier S, Stukenborg-Colsman C,
Hurschler C, Wirth CJ. In vitro investigation of the effect of medial
patellofemoral ligament reconstruction and medial tibial tuberosity transfer
on lateral patellar stability. Arthroscopy.
2006;22:
308-19.22308
2006
[PubMed][CrossRef]
Bahr R, Fossan B, Loken S, Engebretsen
L. Surgical treatment compared with eccentric training for patellar
tendinopathy (Jumper's Knee). A randomized, controlled trial. J Bone
Joint Surg Am. 2006;88:
1689-98.881689
2006
[CrossRef]
Wang C, Ghalambor N, Zarins B, Warner
JJ. Arthroscopic versus open Bankart repair: analysis of patient subjective
outcome and cost. Arthroscopy.
2005;21:
1219-22.211219
2005
[PubMed][CrossRef]
Verma NN, Dunn W, Adler RS, Cordasco FA,
Allen A, MacGillivray J, Craig E, Warren RF, Altchek DW. All-arthroscopic
versus mini-open rotator cuff repair: a retrospective review with minimum
2-year follow-up. Arthroscopy.
2006;22:
587-94.22587
2006
[PubMed][CrossRef]
Sauerbrey AM, Getz CL, Piancastelli M,
Iannotti JP, Ramsey ML, Williams GR Jr. Arthroscopic versus mini-open rotator
cuff repair: a comparison of clinical outcome. Arthroscopy.
2005;21:
1415-20.211415
2005
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Ide J, Maeda S, Takagi K. A comparison
of arthroscopic and open rotator cuff repair. Arthroscopy.
2005;21:
1090-8.211090
2005
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Safran O, Derwin KA, Powell K, Iannotti
JP. Changes in rotator cuff muscle volume, fat content, and passive mechanics
after chronic detachment in a canine model. J Bone Joint Surg
Am. 2005;87:
2662-70.872662
2005
[CrossRef]
Hassinger SM, Wongworawat MD, Hechanova
JW. Biomechanical characteristics of 10 arthroscopic knots.
Arthroscopy. 2006;22:
827-32.22827
2006
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Sugaya H, Maeda K, Matsuki K, Moriishi
J. Functional and structural outcome after arthroscopic full-thickness rotator
cuff repair: single-row versus dual-row fixation. Arthroscopy.
2005;21:
1307-16.211307
2005
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Adams JE, Zobitz ME, Reach JS Jr, An KN,
Steinmann SP. Rotator cuff repair using an acellular dermal matrix graft: an
in vivo study in a canine model. Arthroscopy.
2006;22:
700-9.22700
2006
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Henkus HE, Cobben LP, Coerkamp EG,
Nelissen RG, van Arkel ER. The accuracy of subacromial injections: a
prospective randomized magnetic resonance imaging study.
Arthroscopy. 2006;22:
277-82.22277
2006
[PubMed][CrossRef]
Barber FA. Long-term results of
acromioclavicular joint coplaning. Arthroscopy.
2006;22:
125-9.22125
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Kilicoglu O, Koyuncu O, Demirhan M,
Esenyel CZ, Atalar AC, Ozsoy S, Bozdag E, Sunbuloglu E, Bilgic B.
Time-dependent changes in failure loads of 3 biceps tenodesis techniques: in
vivo study in a sheep model. Am J Sports Med.
2005;33:
1536-44.331536
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Fleisig GS, Kingsley DS, Loftice JW,
Dinnen KP, Ranganathan R, Dun S, Escamilla RF, Andrews JR. Kinetic comparison
among the fastball, curveball, change-up, and slider in collegiate baseball
pitchers. Am J Sports Med.
2006;34:
423-30.34423
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Ruch DS, Papadonikolakis A.
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complex tears: factors affecting outcome. Arthroscopy.
2005;21:
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2005
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Carneiro RS, Fontana R, Mazzer N. Ulnar
wrist pain in athletes caused by erosion of the floor of the sixth dorsal
compartment: a case series. Am J Sports Med.
2005;33:
1910-3.331910
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Thornton SJ, Rogers JR, Prickett WD,
Dunn WR, Allen AA, Hannafin JA. Treatment of recalcitrant lateral
epicondylitis with suture anchor repair. Am J Sports Med.
2005;33:
1558-64.331558
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Idler CS, Montgomery WH 3rd, Lindsey DP,
Badua PA, Wynne GF, Yerby SA. Distal biceps tendon repair: a biomechanical
comparison of intact tendon and 2 repair techniques. Am J Sports
Med. 2006;34:
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[CrossRef]
McGuine TA, Keene JS. The effect of a
balance training program on the risk of ankle sprains in high school athletes.
Am J Sports Med. 2006;34:
1103-11.341103
2006
[PubMed][CrossRef]
Khan RJ, Fick D, Keogh A, Crawford J,
Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A
meta-analysis of randomized, controlled trials. J Bone Joint Surg
Am. 2005;87:
2202-10.872202
2005
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Boden BP, Tacchetti RL, Cantu RC,
Knowles SB, Mueller FO. Catastrophic cervical spine injuries in high school
and college football players. Am J Sports Med.
2006;34:
1223-32.341223
2006
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Freedman BA, Potter BK, Dinauer PA,
Giuliani JR, Kuklo TR, Murphy KP. Prognostic value of magnetic resonance
arthrography for Czerny stage II and III acetabular labral tears.
Arthroscopy. 2006;22:
742-7.22742
2006
[PubMed][CrossRef]
Kaab MJ, Bail HJ, Rotter A,
Mainil-Varlet P, apGwynn I, Weiler A. Monopolar radiofrequency treatment of
partial-thickness cartilage defects in the sheep knee joint leads to extended
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