Extract
This update is based on the scientific and investigational activities in the specialty of sports medicine from August 2008 to September 2009. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone and Joint Surgery (American Volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery.
This update is based on the scientific and investigational activities in the specialty of sports medicine from August 2008 to September 2009. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone and Joint Surgery (American Volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery.
Anterior cruciate ligament reconstruction is perhaps the most investigated topic in sports medicine. Recent enthusiasm for double-bundle techniques and more horizontal femoral tunnel placement has sparked research focusing on the biomechanical evaluation of rotational control and its corresponding clinical importance. Graft choice and the method of fixation continue to be debated, with patellar tendon and hamstring autografts dominating the graft selection for most surgeons. Additionally, the role of anterior cruciate ligament reconstruction and osteoarthritis has yet to be stratified, with meniscal injury, graft choice, surgical technique, and chondral impact injuries confounding valid correlations.
Single-bundle reconstruction traditionally has been associated with good results and is thought to function biomechanically as the anteromedial bundle and less like the posterolateral bundle. Placement of a more vertical femoral tunnel is believed to create anterior-to-posterior stability with insufficient rotational control. Recent changes to proposed tunnel placement include a more horizontal femoral tunnel (the ten o'clock/two o'clock position), which has improved resistance to pivot-shifting. To obtain this position, many surgeons are either utilizing an accessory portal for femoral tunnel placement or changing the angle of the tibial tunnel to a more medial position for transtibial femoral tunnel reaming.
Proponents of the double-bundle technique suggest that their technique provides better rotational control as well as decreased anterior-to-posterior laxity when compared with single-bundle reconstruction, most markedly from 0° to 30°; however, this suggestion has been refuted by others1. One cadaver biomechanical study compared anterior-to-posterior laxity and rotational control of single and double-bundle techniques with use of allograft patellar tendon and a load-cell measurement to determine the corresponding ligament tension2. The results of the study showed excessive tension in the posterolateral bundle when compared with the native graft at 0°, and three of fourteen specimens had an isolated posterolateral bundle failure. It should be noted that the anteromedial bundle was tensioned at 30° of flexion and the posterolateral bundle was tensioned at 10° to 30° of flexion. The authors of that study concluded that single-bundle reconstruction produced graft forces, knee laxity, and tibial rotation that were closest to the values for the native anterior cruciate ligament. However, another biomechanical study from the University of Pittsburgh compared tibiofemoral contact pressures between knees with intact anterior cruciate ligaments, single-bundle reconstructions, and double-bundle reconstructions3. The single-bundle reconstruction showed a significant decrease in contact area and higher contact pressures in both the medial and lateral joint spaces at 15° of flexion when compared with the double-bundle reconstruction. It should be noted that the double-bundle graft was tensioned at 60° (anteromedial bundle) and 0° (posterolateral bundle) of flexion, respectively, proving the importance and dynamic implications of appropriate graft tensioning.
Tunnel enlargement after anterior cruciate ligament reconstruction is a known complication and may result in increased anterior-to-posterior and rotational laxity. A Level-I study from Finland compared tunnel enlargement between single-bundle and double-bundle reconstructions at two years postoperatively with use of magnetic resonance imaging measurements4. The results showed no significant differences on the femoral side but demonstrated enlargement of the tibial tunnel when the single-bundle reconstructions were compared with the double-bundle grafts.
The ultimate goal of the debate between the use of the single-bundle as opposed to the double-bundle technique is improvement in patient outcomes. To date, neither technique has proved to be clinically superior to the other. The overall success rates of single-bundle reconstructions have ranged from 83% to 95%. Two separate studies from Japan (Level-II)5 and South Korea (Level-III)6 compared the two techniques and their corresponding results. While there was a significant decrease in anterior laxity and pivot-shift in association with the double-bundle technique, there was no difference between the two techniques in terms of mean Lysholm scores, International Knee Documentation Committee (IKDC) scores, or complications5,6.
Many injuries to the anterior cruciate ligament are intrasubstance or partial-thickness tears. Patients also may present with an isolated anteromedial or posterolateral bundle injury. There has been some thought that proprioception and vascularity may be preserved by selectively maintaining the uninjured bundle and reconstructing only the deficient bundle. Ochi et al. investigated the two-year clinical and biomechanical outcomes for forty-five patients who had an injury of only one bundle of the anterior cruciate ligament and who underwent a selective anteromedial or posterolateral bundle reconstruction7. Side-to-side differences on KT-2000 (MEDmetric) testing improved from 3.4 mm preoperatively to 0.5 mm postoperatively. Joint position sense and Lysholm knee scores also improved significantly. However, there was no direct comparison between fully reconstructed anterior cruciate ligaments and selective bundle reconstruction in that Level-IV study.
Graft selection continues to prompt debate. Bone-patellar tendon-bone and quadrupled hamstring autografts remain the top choices for most orthopaedic surgeons. Quadriceps tendon autograft with or without a bone block, contralateral grafts, and a variety of allografts are also being used with increasing frequency. The long-term results of allograft reconstruction have been mixed, with some studies demonstrating alarmingly high rates of failure and revision in active patients. Graft choice is certainly multifactorial, with donor-site morbidity, patient demands, and tissue availability influencing the choice of one graft over another. This year, few published studies directly compared primary reconstruction with use of one graft as opposed to another.
Revision anterior cruciate ligament reconstruction is becoming more frequent as the population ages and physical demands increase. A recent Level-III study compared the outcomes of three separate revision anterior cruciate ligament grafts as well as the outcomes between primary and revision anterior cruciate ligament reconstructions8. Revision grafts were ipsilateral unharvested hamstrings, bone-patellar tendon-bone allografts, or Achilles tendon allograft. IKDC, Lysholm, and KT-2000 scores were assessed at an average of forty-eight months of follow-up. There were no significant differences between graft materials and, as anticipated, patients with primary reconstructions had significantly improved clinical scores in comparison with those in the revision group, despite similar KT-2000 results.
Historically, one concern associated with the use of hamstring autograft is the fixation strength in the bone tunnels. Despite the apparently decreased morbidity in comparison with bone-patellar tendon-bone grafts, fixation options for a quadrupled hamstring graft have been limited. However, the recent development of biomechanically strong hamstring fixation options has alleviated many of these concerns. A recent Level-I study comparing hamstring fixation devices evaluated outcomes at two years postoperatively9. Fixation devices included the femoral RIGIDFIX cross pins (DePuy Mitek, Raynham, Massachusetts), the BioScrew (ConMed Linvatec, Largo, Florida) on the femur or the tibia, and the tibial INTRAFIX device, which is an expandable sheath over a tapered screw, both made of a bioabsorbable tricalcium phosphate/poly-L-lactide acid composite (DePuy Mitek). Although no fixation device had significantly better outcomes on the basis of the Lachman or pivot-shift test, range of motion, or clinical measures at two years postoperatively, two of twenty-eight patients in the RIGIDFIX/INTRAFIX group had a reproducible pivot-shift sign and a positive Lachman test.
The correlation between anterior cruciate ligament injury and the subsequent development of osteoarthritis is a current topic of concern. While the main goal of anterior cruciate ligament reconstruction is to improve stability, protection of the meniscus and chondral surfaces is also important. Previous reports have shown that reconstruction of the anterior cruciate ligament helps to protect the meniscus from additional injury when compared with nonoperative treatment. It is well established that meniscal deficiency leads to early arthritic changes. The direct correlation between anterior cruciate ligament reconstruction and the subsequent prevention of early osteoarthritic changes has yet to be documented. One Level-II study from Sweden evaluated the prevalence of tibiofemoral arthritis fifteen years after anterior cruciate ligament and/or meniscal injury10. Weight-bearing anteroposterior radiographs were reviewed along with clinical outcome scores for patients with different combinations of anterior cruciate ligament injuries and meniscal tears. Patients without a meniscal tear who had nonoperative treatment of the anterior cruciate ligament injury had a 0% rate of osteoarthritis (zero of forty-four), whereas patients with a reconstructed anterior cruciate ligament and a meniscal tear had the highest rate of osteoarthritis (46%; six of thirteen). Patients with an isolated meniscal injury fared the same as those with an isolated anterior cruciate ligament injury that was reconstructed (with rates of 37% and 35%, respectively). A separate historical study involved a thirty-year evaluation of patients with isolated anterior cruciate ligament tears, diagnosed at the time of open arthrotomy, who underwent primary repair or débridement11. As expected, at thirty years, the patients who had primary repair presented with scores similar to those managed with débridement alone. In a systematic review, seven prospective and twenty-four retrospective studies were evaluated with regard to the prevalence of osteoarthritis in the tibiofemoral joint more than ten years after anterior cruciate ligament injury12. No differences in the prevalence of knee arthritis were reported between operatively treated subjects (range, 29% to 51%) and nonoperatively treated subjects (range, 31% to 48%) with anterior cruciate ligament injury. The authors of that review further concluded that an anterior cruciate ligament reconstruction alone did not prevent the development of osteoarthritis and that anterior cruciate ligament injury without meniscal pathology has a low rate of progression to arthritis radiographically (range, 0% to 13%) at more than ten years after injury. Certainly, the most frequently reported risk factor for early-onset osteoarthritis is meniscal injury, not anterior cruciate ligament injury.
There has been a substantial increase in our efforts to understand the posterior cruciate ligament, especially its biomechanical role, and to pursue improvements in surgical technique. Certainly, the astute orthopaedic surgeon now recognizes that patient history, physical examination findings, and radiographic findings all contribute to the diagnosis of a rare isolated posterior cruciate ligament injury as opposed to a combined ligamentous injury. It is generally accepted that acute isolated grade-I and II injuries should be treated nonoperatively, but debate persists regarding the treatment of grade-III injuries.
As our understanding of posterior cruciate ligament pathology has progressed, additional questions regarding the most anatomic techniques for reconstruction have developed. The anterolateral and posteromedial bundles are differentiated on the basis of their tension patterns during knee motion, with the anterolateral bundle tightening in flexion and the posteromedial bundle resisting posterior translation in extension. A recent well-done cadaver study detailed the separate tibial insertion planes of the two posterior cruciate ligament bundles on the posterior intercondylar fossa to assist with proper anatomic identification during double-bundle reconstruction13. Reconstruction of the posterior cruciate ligament with use of a single-bundle technique has shown control of posterior translation to be similar to the double-bundle technique with an intact posterolateral corner14, suggesting the importance of properly diagnosing isolated as opposed to combined ligamentous injuries. Previous biomechanical work has shown that the posteromedial bundle adds little to overall knee kinematics and that selective reconstruction of the anterolateral bundle provides similar stability. However, these tests were performed in knees with isolated posterior cruciate ligament sectioning. It is now well recognized that a knee with a grade-III posterior cruciate ligament injury is also likely to have a deficiency of the posterolateral corner or other additional ligamentous injury. Consequently, the authors of a recent cadaver study concluded that double-bundle reconstruction offers measurable benefits in comparison with single-bundle reconstruction with regard to rotational stability and posterior translation when an untreated posterolateral corner injury is present15. To our knowledge, no clinical study has shown improved patient outcomes following double-bundle posterior cruciate ligament reconstruction in comparison with single-bundle posterior cruciate ligament reconstruction, and the premier concern for the clinician when managing a patient who has a posterior cruciate ligament-deficient knee is proper diagnosis of an isolated as opposed to a multiligamentous injury.
The goal of reconstruction of a posterior cruciate ligament-deficient knee is to restore normal knee kinematics and to prevent long-term sequelae. The association between posterior knee instability and the development of osteoarthritis has been described previously. A study from Massachusetts General Hospital investigated cartilage degeneration patterns in posterior cruciate ligament-deficient knees16. In that study of fourteen patients, the investigators evaluated magnetic resonance imaging sequences of the posterior cruciate ligament-deficient knees and compared them with those for the contralateral, posterior cruciate ligament-intact knees. The results demonstrated that the posterior cruciate ligament-deficient knees had a more medial and anterior tibiofemoral contact location and increased cartilage deformation in the medial compartment beyond 75° of knee flexion.
Progress continues to be made with regard to the diagnosis and treatment of posterolateral corner injuries. These structures are rarely injured in isolation and are usually diagnosed as part of a multiligamentous knee injury. The deep and most important structures of the posterolateral corner are the lateral collateral ligament, the popliteus tendon, and the popliteofibular ligament. The more superficial layer of the posterolateral corner contains the biceps femoris and the iliotibial band. Appropriate treatment of these complex injuries is crucial for preventing postoperative morbidity, maximizing knee stability, and achieving functional range of motion.
The accurate and timely diagnosis of corner injuries is the first step to maximizing the postoperative outcome. When these injuries are not properly diagnosed, there is an increased risk of failure of cruciate graft reconstruction. Early diagnosis of a posterolateral corner injury also allows for primary repair with or without anterior cruciate ligament reconstruction. Concomitant cruciate injuries can be reconstructed at the same time, or reconstruction can be deferred until the patient has regained adequate knee motion. The most common and accurate physical examination test for diagnosing posterolateral corner injuries is the dial test. Jung et al.17 performed a Level-I study that evaluated the side-to-side differences in external rotation of knees with a combined posterolateral corner-posterior cruciate ligament injury using the dial test at 30° and 90°. They discovered that posterior subluxation of the tibia decreased the side-to-side differences both at 30° and 90°. This finding suggests that the diagnostic accuracy of the dial test will be improved if the tibia is held in a reduced position (anterior) while the dial test is performed.
Radiographic evaluation of multiligamentous injuries of the knee has also improved. The use of magnetic resonance imaging to diagnose posterolateral corner injuries has become highly credible, and coronal oblique views are being used by some radiologists when there is concern about a posterolateral corner injury. This is especially true in the acute setting. A biomechanical study evaluated varus stress radiographs for the diagnosis of posterolateral corner injuries18. The examiners sequentially sectioned the structures of the posterolateral corner and the cruciate ligaments while plain radiographs were made to evaluate the degree of lateral joint-space widening. That in vitro study showed an increased lateral opening of 2.7 mm in association with an isolated lateral collateral ligament injury, and an increased opening of >4.0 mm in association with a grade-III posterolateral corner injury, in comparison with the intact knee. A separate cadaver study compared posterior tibial displacement as seen on stress radiographs that were made after selective posterior cruciate ligament and posterolateral corner ligament sectioning19. The investigators found an average side-to-side difference of 9.8 mm of posterior tibial translation after posterior cruciate ligament resection and an average side-to-side difference of 19.4 mm of translation after posterior cruciate ligament and posterolateral corner resection; they concluded that any patient with a posterior drawer test of >10 to 12 mm (a grade-III posterior cruciate ligament) should be thoroughly examined for a combined posterolateral corner injury.
Injuries to the medial structures are often treated nonoperatively when diagnosed as isolated injuries. However, combined injuries to the anterior cruciate ligament and medial collateral ligament are often addressed surgically. One Level-II study by Halinen et al. evaluated patients who had a combined anterior cruciate ligament and grade-III medial collateral ligament injury pattern20. One group had reconstruction of the anterior cruciate ligament with bone-patellar tendon-bone autograft and repair of the medial collateral ligament; the other group had reconstruction of the anterior cruciate ligament and nonoperative treatment of the medial collateral ligament injury. Both the restoration of knee flexion and quadriceps power were decreased in the combined-repair group, demonstrating that reconstruction of the anterior cruciate ligament without medial collateral ligament repair resulted in better outcome scores at the time of the two-year follow-up.
Stability of the patellofemoral articulation continues to be a multifactorial challenge. A thorough understanding of lower extremity alignment and soft-tissue restraints is required for effective treatment of the often underappreciated pathology. It is well known that the medial patellofemoral ligament is the primary restraint to lateral patellar translation, while patella alta, trochlear dysplasia, systemic hyperlaxity, and malalignment also contribute to an unstable articulation.
For patients with an acute patellar dislocation, three studies from the Central Military Hospital in Finland were published this past year21-23. In a Level-I study, nonoperative treatment was compared with open medial stabilization in younger, mostly male patients21. At the time of the seven-year follow-up, repeat dislocation had not occurred in any of the seventeen patients in the operative treatment group, compared with six of the twenty-one in the nonoperative treatment group; however, there were no clear differences in the clinical outcome scores between the two groups. Conversely, in another study examining primary traumatic patellar dislocations, arthroscopic repair of the medial soft tissues combined with a lateral release resulted in no significant improvement in terms of the redislocation rate or functional outcome score in comparison with nonoperative treatment alone at seven years, although the authors did not stratify the location of the medial patellofemoral ligament injury22.
Important technical considerations for surgical correction include appropriate tensioning of the medial soft-tissue restraints and repair as opposed to reconstruction of the medial patellofemoral ligament. We are not aware of any additional studies that have been published over the past year to clarify the decision between primary repair of the medial patellofemoral ligament as opposed to reconstruction with a free graft. Attention to the location and chronicity of the medial patellofemoral ligament injury may influence this decision. In a seven-year follow-up study of patients with a primary traumatic patellar dislocation that was treated nonoperatively, those with a femoral avulsion of the medial patellofemoral ligament were at significantly greater risk for the development of patellar instability than those with a midsubstance tear or disruption of the ligament at the patellar insertion23.
There is still debate over the appropriate surgical intervention for patients with chronic patellar instability or malalignment. One Level-III study24 compared a novel derotational high tibial osteotomy with an Elmslie-Trillat-Fulkerson proximal-distal realignment in patients with a thigh-foot angle of at least 30° and an increased tubercle-sulcus angle of >10°. The results of that study showed superior outcomes in the group managed with the derotational tibial osteotomy as compared with the group managed with the proximal-distal realignment, with significant improvement in gait patterns and functional scores, suggesting that correction of tibial torsion may reduce the valgus vector through more phases of the gait cycle than a proximal-distal realignment does.
The important role of the meniscus in joint mechanics and cartilage protection continues to be appreciated. The biomechanical function of the meniscus in stability, load distribution, and shock absorption is well known. The meniscus also contributes to articular cartilage nutrition, joint lubrication, and proprioception. Consequently, repairing amenable meniscal tears and preserving meniscal tissue are of utmost importance. The orthopaedic surgeon should understand the biomechanical implications of the various types of tears as well as the current techniques and options for meniscal repair.
There are multiple variables that influence the meniscal healing potential. It is well known that anterior cruciate ligament reconstruction at the time of meniscal repair improves healing rates, and this confounding factor must be realized when evaluating previous reports on meniscal repair. The blood supply and location of the tear, the pattern and shape of the tear, the age of the patient, and the choice of repair technique all influence the healing potential of the meniscus and operative decisions. Recently, it has been suggested that biological factors may be of greater importance than surgical technique. Rasping, trephination, and the use of interposed fibrin clots or mesenchymal stem cells all show promise for improving the rates of healing of meniscal tears, but additional clinical research in this area is needed.
The gold standard for meniscal repair continues to be the inside-out technique with vertical mattress sutures; however, clinical success rates do not correspond closely to the magnitude of mechanical strength found in association with the different repair techniques. A variety of all-inside options are often used for meniscal repair as these products are easier to use and have provided similar clinical outcomes in short-term studies. Newer devices allow tensioning of the repair and utilize ultra-high molecular weight suture material. These products are being continually tested to determine a superior technique, and their associated complications have been described, but long-term follow-up is lacking. One Level-IV study investigated clinical results at an average of 30.7 months postoperatively in patients with longitudinal meniscal tears in the red-red or red-white zone that were treated with the FAST-FIX (Smith and Nephew Endoscopy, Andover, Massachusetts) all-inside repair device25. The authors reported an 83% clinical success rate at the time of the review. This rate is comparable with the success rates associated with most meniscal repair techniques and devices, which have ranged from 56% to 100%, with the majority of the worse results correlating with longer-term follow-up26.
Recent studies have suggested that meniscal root tears may be underappreciated in comparison with meniscal body tears or meniscocapsular tears, which are relatively well understood. Advances in magnetic resonance imaging have improved our ability to diagnose meniscal root tears, and the posterior root is often visible on coronal images as a band of low-signal fibrocartilage. There has been a growing consensus that meniscal root tears completely disrupt the circumferential fibers of the meniscus, which prohibits hoop stress formation, leading to meniscal extrusion and possibly the development of spontaneous osteonecrosis of the knee. A cadaveric biomechanical study compared loading patterns in knees with intact menisci, those with posterior root tears, those with repaired posterior root tears, and those with a complete meniscectomy27. Axial loading with 1000 N was applied at 0°, 30°, 60°, and 90°. The study showed that a posterior root tear and a complete meniscectomy had biomechanical similarities. Increases in peak medial compartment pressures, external rotation, and lateral tibial translation were seen in both groups. Also, the knees with repaired posterior root tears behaved similarly to those with intact menisci, confirming the importance of meniscal root repair. Lee et al. recently reported their two-year follow-up data on twenty-seven posterior root tears that were repaired with use of a pullout suture technique28. With their technique, vertical mattress sutures are placed in the posterior root and are passed through a bone tunnel to the anterior cortex of the tibia, where they are tied over a button. That Level-IV study showed significant improvement in clinical scores, with little or no radiographic changes. Second-look arthroscopy, performed for ten knees, demonstrated healing of all repairs, without additional chondral injury.
Articular Cartilage Defects
Currently, one of the most exciting and hotly investigated areas of orthopaedics is the use of biological products for articular cartilage replacement. The orthopaedic industry continues to make substantial financial investments in the investigation of therapeutic options for cartilage regeneration. Marketing of these products will continue to be aggressive in the years to come, and reviewing the literature from a scientific perspective will be most beneficial to the surgeon and the patient, who should not succumb to the latest trend. Several techniques are available to address full-thickness focal chondral defects; most of these techniques have been investigated for use in the knee. These options range from marrow-stimulation techniques, such as microfracture, to cartilage restorative procedures, such as osteochondral transfer, autologous chondrocyte implantation, and articular cartilage allograft options.
Microfracture has shown good early to intermediate-term clinical results, and the procedure is inexpensive and relatively easy to perform. The major drawback of this procedure is the resulting fibrocartilage, which tends to dissociate from its base over time and is less durable than native hyaline cartilage is. The development of regenerative techniques to restore hyaline cartilage, such as autologous chondrocyte implantation, has been the subject of extensive research in recent years. This technique requires two operations, is technically demanding, has a difficult postoperative routine, and is expensive. The regenerated cartilage is often described as "hyaline-like." An increased benefit in comparison with microfracture has yet to be proved in clinical trials, calling into question its long-term validity. Currently, only the first-generation technique, which involves the use of a watertight periosteal patch that is placed over the implanted chondrocytes, is available for use in the United States. Second-generation techniques involve the use of biodegradable polymers as temporary scaffolds with viable chondrocytes, which are placed directly into the cartilage defect. This technique eliminates the periosteal patch and the need to pass sutures through the surrounding cartilage. Also, with the elimination of the periosteal flap portion of the technique, previous problems with chondrocyte overgrowth and periosteal flap hypertrophy may be avoided. One European nonrandomized Level-II study compared second-generation autologous chondrocyte implantation with microfracture over a five-year period29. The study demonstrated that both groups had significant improvement in terms of the IKDC scores at two and five years of follow-up, confirming good intermediate-term results for both surgical options, but showed no effective clinical superiority of autologous chondrocyte implantation in comparison with microfracture.
Osteochondral autograft transfer is another commonly utilized option for focal chondral defects. The osteochondral plugs are transferred to fill the defect with normal hyaline cartilage, which may be more durable over the long term, but the creation of a congruent surface contour is often difficult and there can be donor-site morbidity. Nevertheless, this is a popular technique for defects that are <2.5 to 3 cm2 in size. Larger defects can be repaired with osteochondral allografts. Fresh allografts do not appear to induce an immune reaction and are thought to incorporate into host bone, but additional long-term investigation is needed to determine the structural durability of such grafts.
Osteochondritis dissecans is an osteochondral disorder that is commonly seen in the knee. The lesions are defined by their size, depth, and stability and are best assessed with magnetic resonance imaging. When an articular cartilage or bone fragment is displaced in the adult population, it often can be repaired with an open technique and bioabsorbable fixation after the fibrous tissue is removed from both the fragment and its native bed. In the skeletally immature patient, nonoperative treatment of stable osteochondritis dissecans lesions is the preferred method of treatment. A recent study from the Cincinnati Children's Hospital evaluated the effect of patient age, lesion size, location, knee symptoms, and patient sex on the rates of stable osteochondritis dissecans lesions in the pediatric population30. The only significant predictor of healing was lesion size, with a greater than fivefold increase in healing potential for every 5% decrease in lesion surface area (relative to the femoral condyle).
Chondrocyte Preservation
Another crucial concern in the treatment of articular pathology is attention to the preservation of the remaining chondrocytes. Intra-articular injections have long been a treatment of choice to control pain and inflammation. Reinvestigation of chondrocyte morbidity associated with steroid and analgesic agents that are used intra-articularly has changed long-held standards. Indwelling pain pumps, mostly used postoperatively, are no longer recommended because of the substantial chondrocyte toxicity of the medications infused. The authors of previous in vitro studies have favored ropivacaine over other analgesics for intra-articular use, citing increased chondrocyte viability. Seshadri et al. evaluated chondrocyte viability in vitro with use of bovine cartilage that was exposed to saline solution, methylprednisolone, methylprednisolone and lidocaine, or methylprednisolone with saline solution31. Their results showed a direct correlation between increased steroid concentration and increased chondrocyte apoptosis as well as increased chondrocyte toxicity with increasing time of exposure to methylprednisolone. The addition of lidocaine to methylprednisolone significantly increased the rate of chondrocyte cell death. Clinical use of injectable corticosteroids and analgesic agents should be approached with caution, and additional investigation will help to stratify the potential morbidity with in vivo use.
The effect of temperature on chondrocyte cell viability has also been investigated extensively in the past, with a consensus that radiofrequency devices should not be used on articular cartilage. One recent study investigated the increasing temperature of intra-articular arthroscopy fluid when radiofrequency devices are used in the glenohumeral joint32. Temperature was measured at four locations, and the radiofrequency device was applied for varying lengths of time with irrigation flow rates of 0%, 50%, and 100%. Temperatures exceeding 45°C (the critical temperature for cell death) were measured in all tests, and an increased rate of flow decreased the maximum temperature and the necessary time to cool. The authors concluded that care should be taken to ensure maximum fluid-pump flow rates for chondrocyte protection.
New thoughts on post-impact chondrocyte preservation have sparked the investigation of antioxidants, apoptosis inhibitors, and cell-membrane stabilizers to increase chondrocyte viability. A well-performed in vitro microbiological study from the University of Iowa demonstrated a significant increase in bovine chondrocyte viability after impact when specimens were treated with the antioxidant N-acetylcysteine33. Cell viability was time-dependent and improved when treatment occurred in the first four hours after the injury. Additional investigation is needed to delineate the clinical effect of antioxidant use after impaction injuries.
Rotator Cuff
Rotator cuff pathology continues to be a common reason for visits to the orthopaedic surgeon. As the population ages, the demands for improved functional outcomes will continue to rise, opening the doors for funded investigation and market-driven product promotion. The astute surgeon must assist the patient with realistic expectations after rotator cuff repair. The prolonged and often painful postoperative course should influence the offering of this procedure to only those individuals who understand the risks and benefits associated with rotator cuff repair. Attritional changes to the rotator cuff occur with aging and substantially alter the normal healing potential. Familial predisposition to rotator cuff disease also may help to direct therapeutic options and to provide insight into the patient's prognosis. One recent study confirmed this inheritable predisposition to rotator cuff disease through an evaluation with use of the Utah population database34. It is well known that rotator cuff tears are often asymptomatic and increase in severity and frequency with age. Investigators at Washington University recently used ultrasound imaging to confirm that tear size is the strongest predictor of humeral head migration in asymptomatic patients35 and that an abrupt loss of abduction strength in the asymptomatic elderly patient is likely to be associated with a massive cuff tear36.
Our ability to increase the healing potential of the diseased rotator cuff through biological augmentation is an area of substantial research. Mechanical scaffolds have yet to prove their clinical effectiveness, and a variety of growth factors are under investigation. Recombinant human bone morphogenetic protein-12 (rhBMP-12) has been studied as a biological modulator that accelerates the healing response following rotator cuff repair37. In a sheep model, a sponge soaked with rhBMP-12 was applied to the surface of a cuff repair. Ultrasonography, biomechanical testing, and histological evaluation were performed to detect an altered healing response. In that industry-sponsored study, increases in biomechanical strength, cross-sectional area, and stiffness were reported. Histological evaluation showed a fibrocartilaginous tendon-to-bone attachment with an increased alignment of collagen fibers, suggesting an advanced stage of healing when compared with those treated without rhBMP-12.
Arthroscopic repair of rotator cuff tears has progressed to yield outcomes similar to those of open repair in most situations. Intermediate-term and long-term clinical follow-up comparing open and arthroscopic repairs is still pending for certain cohorts. A Level-IV review of Swiss patients detailed the results of open repair after ten years of follow-up38. The rate of repeat tears was 57%, and more fatty infiltration was found in cuffs with larger initial tears, despite maintenance of the integrity of the repair. Also, a wide lateral acromial extension was identified as a risk factor for a repeat tear; despite a repeat-tear rate of 57%, twenty-two of twenty-three patients were very satisfied with the results.
The treatment of partial-thickness tears is often controversial. Frequently, the orthopaedic surgeon will débride the tear back to healthy tissue, often creating a full-thickness tear, and then will appropriately repair the tendon. This very concept was evaluated in a Level-IV study, in which shoulder function scores improved from 46.1 to 82.1 at eleven months and 88% of the subjects had intact cuff repairs on ultrasound imaging39. Once again, patient age was a significant risk factor for lack of healing, and older patients were more likely to have a persistent rotator cuff defect.
Repair of a subscapularis tendon tear with arthroscopic techniques is challenging, and these techniques are continually improving. Adams et al. reported the five-year results of arthroscopic subscapularis repairs. Of the 217 patients who had an arthroscopic subscapularis repair, only forty were available for follow-up40. Thirty-two (80%) of the forty patients had a good or excellent outcome according to clinical evaluation scores alone. Of note, 63% of the forty patients had biceps abnormality, confirming the anatomic relationship between the biceps tendon and the subscapularis. Certainly, when subluxation of the biceps is seen on imaging or during arthroscopy, potential subscapularis involvement should be suspected.
The choice between single-row as opposed to double-row fixation continues to be discussed among those who favor one technique over another for rotator cuff repair. Biomechanical models have shown that double-row fixation is associated with superior pullout strength, but few clinical data support one technique over the other. The goal of rotator cuff repair is to obtain a large tendon-to-bone contact surface at the footprint, with limited gap formation in abduction, rotation, and forward flexion. Fortunately, two Level-I studies that were published this year compared the two techniques. Both of these studies involved the use of suture anchors and a simple antegrade suture technique for the single-row repairs. The double-row repairs consisted of the same simple lateral suture configuration and an independent horizontal mattress medial row. Grasso et al. prospectively evaluated seventy-two patients with use of the Disabilities of the Arm, Shoulder and Hand (DASH) self-reported questionnaire, Constant scores, and muscle strength at the time of the two-year follow-up after single-row or double-row repair41. Risk factors and independent variables were also considered. These comparisons showed no significant differences between the two groups. Increasing age was independently associated with a lower Constant score, and female sex was associated with lower DASH and strength scores. No imaging evaluation was performed in that study. Another Level-I study was a collaborative effort of the University of Utah and the Australian Institute of Sport42. That prospective study evaluated forty patients on the basis of multiple clinical measures, range of motion, strength, and magnetic resonance imaging findings at six weeks, three months, and one year after either single-row or double-row repair. Early evaluation at one year showed no significant differences between the two groups in terms of clinical scores, strength, or magnetic resonance imaging results. We look forward to additional follow-up of the intermediate and long-term results from these two study groups.
Most surgeons still prefer to perform a limited acromioplasty to assist with visualization and to increase the subacromial space. A Level-III study evaluated clinical outcomes twelve years after arthroscopic acromioplasty43. In that series, 77% of thirty-one patients had a good or excellent outcome according to the clinical scoring techniques utilized. Previous Level-I data had shown no clinical difference in rotator cuff repair procedures performed with or without a corresponding acromioplasty44. The coracoacromial ligament must be preserved (especially in patients with large cuff tears) to avoid the disastrous anterior escape phenomenon as the rotator cuff disease continues to progress over time.
Evaluating patients preoperatively with regard to their ability to adhere to a regimented postoperative rehabilitation course will improve outcomes and will limit postoperative stiffness. In one retrospective review of 489 arthroscopic rotator cuff repairs, twenty-four patients (4.9%) had development of postoperative stiffness45. Independent risk factors included Workers' Compensation insurance, an age of less than fifty years, coexisting calcific tendinitis or adhesive capsulitis, a partial articular-sided cuff tear, and a concomitant labral repair. All patients improved with arthroscopic capsular release, performed at an average of nine months postoperatively.
Labrum and Instability
Traumatic shoulder dislocations are thought to occur at a rate of around eleven per 100,000 per year in the general population. This number is significantly higher in the younger and physically active population. A recent United States Military study documented a dislocation rate of 1.69 per 1000 per year46. Anterior dislocations are by far the most common, and the recurrence rate correlates inversely with patient age at the time of the primary dislocation. Debate exists regarding the initial treatment for first-time dislocations, with the traditional protocol being closed reduction, immobilization, and physical therapy. However, neither physical therapy nor immobilization has proved to decrease the redislocation rate. Immobilization in external rotation recently was recommended, on the basis of the work of Itoi, for better coaptation of the "essential lesion" or Bankart injury to the anterior glenoid rim. One Level-II study from Germany compared immobilization in either traditional internal rotation or 30° of external rotation47. All patients had a magnetic resonance imaging scan within three days after reduction, at three weeks after the injury, and at five weeks after the injury. A significant decrease in the anterior joint effusion and distance from the Bankart lesion to the glenoid was found in association with either external rotation at 30° or maximum external rotation in comparison with a neutral or internally rotated position. The difference between groups diminished with time as the effusion subsided, and, after five weeks, a significant difference in the labrum-to-glenoid distance was only found between the internal rotation and extreme external rotation groups.
Clinical diagnosis of shoulder labrum and biceps pathology on the basis of physical examination is often difficult, and much interobserver variation exists in testing techniques. A meta-analysis of clinical examination tests for the diagnosis of SLAP (superior labrum, anterior and posterior) lesions was published recently48. Of the 198 identified studies, only six had verification of true pathology on the basis of arthroscopy, arthrotomy, or magnetic resonance imaging and were reported in the analysis. The major finding was that the anterior slide test should not be used because it was found to be inferior to the active compression, crank, and Speed tests. However, examination techniques vary among examiners, and the variable success of specific techniques in multiple studies cannot necessarily be validated through a meta-analysis. Recently, a well-done Level-II study addressed this issue when the results of eight different clinical examination techniques (Yergason, Speed, bear hug, belly press, O'Brien, anterior slide, upper cut, and modified dynamic labral shear) were documented for 101 patients prior to shoulder arthroscopy49. For the diagnosis of biceps disease, including midsubstance tendinopathy, the combination of the upper cut test (reproducing a boxing "upper cut" punch against resistance) and the Speed test was superior to other tests alone. Interestingly, the belly press and Speed tests were the most specific (0.85 and 0.81, respectively). For the diagnosis of labral injury, the modified dynamic labral shear test proved superior, with a sensitivity of 0.72, a specificity of 0.98, and a positive likelihood ratio of 31.57. This test involves bringing the arm of the patient to 90° of flexion at the elbow and to 120° of shoulder abduction and then to maximum external rotation. The hand or finger of the examiner is placed on the posterior glenohumeral joint as the arm of the patient is lowered from 120° of abduction to 60° of abduction. The test is positive if pain is reproduced or clicking or catching occurs at the posterior joint line. The combination of the dynamic labral shear test and the O'Brien test was found to be the best for the diagnosis of labral lesions.
Repair techniques for SLAP lesions continue to draw the attention of orthopaedic surgeons and, correspondingly, industry. Multiple anchors and knotless systems for SLAP repair are currently on the market. In a biomechanical cadaver study that was published this year, the gap formation and failure rates following SLAP repair performed with use of a "knotted" lupine Mitek anchor preloaded with number-2 ORTHOCORD suture (Mitek, Norwood, Massachusetts) and a horizontal mattress technique were compared with those following repair performed with the BIOKNOTLESS Mitek suture anchor (DePuy Mitek)50. Type-II SLAP lesions were created, repaired, and tested by means of cyclic loading of the biceps tendon at 90° to the face of the glenoid. A 2-mm gap occurred sooner in the knotless system (70 compared with 104 N); however, ultimate failure and the number of cycles to failure were similar between the two groups. These observations confirmed previous reports of rotator cuff and labral repair failures occurring most often at the suture-soft tissue interface and less commonly at the anchor-bone interface. Brockmeier et al. confirmed the use of modern techniques for SLAP repair in their prospective evaluation of forty-seven patients at the Hospital for Special Surgery in New York51. Patients who had a type-II SLAP lesion that was repaired with standard anchor placement and a simple suture configuration were evaluated after more than twenty-four months on the basis of clinical shoulder scores and physical examination. The clinical shoulder scores improved, twenty-five (74%) of the thirty-four athletes were able to return to their previous level of competition, and forty-one patients (87%) rated their outcome as good or excellent.
Acromioclavicular Joint
Injuries to the acromioclavicular joint are common, especially among athletes involved in contact sports. The type-III separation is a severe injury pattern and often requires a full three months of decreased activity for symptoms to resolve. Chronic type-III through type-VI injuries are often repaired surgically with use of a variety of techniques. The coracoclavicular ligaments are important stabilizers of the acromioclavicular joint, especially in the anterior-to-posterior plane. Multiple techniques and devices are available for reconstruction of the acromioclavicular joint, and a single superior procedure has not been determined. Recently, the modified Weaver-Dunn procedure was compared with an anatomic coracoclavicular ligament reconstruction with use of an autogenous semitendinosus graft52. With the latter technique, the tendon is routed from superior to inferior through bone tunnels in the lateral part of the clavicle, is looped under the coracoid process and back up to the clavicle in a figure-of-eight fashion, and is secured to the clavicle. The clinical results of this procedure were encouraging, with significant improvement in Constant scores and less displacement of the coracoclavicular distance with loading than were seen in association with the Weaver-Dunn technique. Again, the goals of acromioclavicular reconstruction are stabilization in the coronal and sagittal planes with freedom for limited rotation during shoulder motion. Prospective randomized studies are needed to determine if a superior technique exists.
Surgical intervention for hip pathology has gained momentum over the past few years, and hip arthroscopy has subsequently improved in terms of both technique and technology. Labral tears, femoroacetabular impingement, and chondral injuries or loose-body removal are the main indications for arthroscopic intervention. Labral tears have been thought to produce mechanical symptoms of the hip, such as catching, popping, groin pain, and pinching pain with sitting. One recent Level-III study demonstrated that these symptoms alone did not lead to an accurate diagnosis of intra-articular labral injury53. Furthermore, the study showed that an intra-articular injection with an anesthetic-steroid solution decreased symptoms only in two-thirds of individuals with a known labral tear. The authors concluded that extra-articular sources for mechanical symptoms should be considered and that labral tears on magnetic resonance imaging arthrography may not necessarily be the major contributor to the patient's complaints.
Treatment of hip labral tears has progressed in a fashion similar to glenoid labral tears in the shoulder or meniscal tears in the knee; it consists of repairing amenable labral tears or débridement. Byrd and Jones recently reported the ten-year outcomes for twenty-nine patients who had been managed with hip arthroscopy and labral débridement54. The Harris hip score improved significantly from preoperatively to postoperatively, and the mean improvement did not deteriorate at the time of the ten-year follow-up. Not surprisingly, patients with preoperative radiographic evidence of osteoarthritis did poorly, and seven of eight had undergone total hip arthroplasty at the time of the latest follow-up.
Femoroacetabular impingement is recognized as a frequent cause of hip pain and a precursor to osteoarthritis. Cam-type impingement results from a pistol-grip deformity of the femoral neck with a decreased head-neck offset ratio, whereas pincer-type impingement results from acetabular retroversion and subsequent overcoverage with anterior abutment. Clinical evidence suggests that intra-articular chondral damage and labral pathology correlate with the extent of altered femoral and acetabular morphology, which is often a combination of these two major types. However, one Level-III study addressed this concern in a retrospective assessment of sixty-four hips that were treated with open techniques55. In the study population, 44% of the hips had acetabular cartilage delamination, which was strongly correlated with cam-type femoroacetabular impingement and male sex, whereas there was no correlation with pincer-type femoroacetabular impingement (coxa profunda). Larson and Giveans evaluated a cohort of patients with repairable labral tears and femoroacetabular impingement (either pincer or combined) who were managed with either labral débridement (prior to the development of current techniques) or repair56. On short-term follow-up, the clinical hip scores were significantly improved postoperatively in both groups. Also, the Harris hip score was significantly better for the repair group than for the débridement group, but the SF-12 scores were not significantly different. Finally, treatment of femoroacetabular impingement with osteoplasty of the femur and/or acetabular rim can be done with either open or arthroscopic techniques. The goal is to create an anatomically shaped hip joint with an improved range of motion by contouring an appropriate femoral head-neck offset and restoring normal hip biomechanics. Clinical results are promising, but long-term follow-up is sparse for the endorsement of either arthroscopic or open treatment for the prevention of hip osteoarthritis.
Suchak et al. recently reported the results of a Level-I study in which a postoperative protocol of early weight-bearing was compared with a protocol of non-weight-bearing following acute Achilles tendon repair57. All patients were non-weight-bearing for two weeks, and then they were randomized into weight-bearing or non-weight-bearing groups for an additional four weeks. Patients were followed at six weeks, three months, and six months. Early weight-bearing was found to lead to improved health-related quality of life in the early postoperative period, with no adverse effects on outcomes.
Recurrent lateral ankle instability is common among athletes. Of concern to both surgeons and patients is the resulting injury to the chondral surface over time. Sugimoto et al. arthroscopically evaluated the articular cartilage of ninety-nine ankles in patients with prolonged lateral instability58. The average time from the diagnosis of instability to arthroscopic evaluation was seventy-four months. The authors concluded that patient age, talar tilt angle, and varus inclination of the ankle plafond were risk factors for severe chondral injury in these patients.
Athletes who participate in sports requiring excessive plantar flexion or twisting are particularly prone to posterior ankle impingement. Ballet dancers and soccer players represent a considerable portion of this patient population. Posterior impingement is usually classified as either an overuse injury or a result of a traumatically induced event with impingement of an os trigonum or the surrounding scar tissue. Open surgical excision of the offending bone fragments or scar tissue is usually performed through a posterolateral incision. One Level-IV study evaluated a two-portal endoscopic technique for the surgical treatment of posterior ankle impingement59. After an average duration of follow-up of thirty-six months, patients with overuse and traumatic etiologies had increased American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, with the overuse group having significantly more improvement than the post-traumatic group. The authors suspected that their endoscopic technique was associated with less morbidity than open surgical techniques, although no direct comparison was performed.
Injury to the head or spine is of paramount concern for the physician who manages athletes during sporting events. Various algorithms have been developed for return to play after a concussive event, with no one treatment protocol being routinely advocated. Certainly, the risk for catastrophic neurologic sequelae increases significantly when an athlete is allowed to return to play without complete resolution of symptoms. All athletes with concussive symptoms should be closely managed with nonoperative care.
Recent literature has suggested that both the shoulder pads and the helmet should be left on football and hockey athletes to maintain spinal alignment during transport following a suspected cervical spine injury and that cervical kyphosis will ensue with selective removal of the shoulder pads. Fortunately, educating the athlete and coach proved to be effective in one French epidemiological study that demonstrated that the incidence of catastrophic cervical spine injuries has significantly decreased in rugby players since 199660. Continued vigilance and attention to training and tackling techniques are of primary importance for the prevention of these injuries, which are often permanently disabling.
Lateral epicondylitis, medial collateral ligament pathology, and elbow instability are some of the more common elbow injuries seen in the athlete. Recent use of the docking technique for ulnar collateral ligament reconstruction has simplified the procedure and has substantially decreased the rate of associated complications. Richard et al. reported success with the repair of acute traumatic medial collateral ligament avulsions from the humeral origin61. The implementation of pitch counts in Little League baseball has decreased the associated morbidity, and protective rules should continue to be explored and used when proved to be beneficial.
An additional concern related to the young athlete is osteochondritis dissecans of the capitellum. Traditionally, nonoperative treatment with activity modification for stable low-grade lesions in children has yielded excellent results. This was confirmed again in a Level-IV study from Japan62. The authors found that twenty-five of thirty early-stage lesions healed during the follow-up period, compared with only one of nine advanced-stage lesions; surgical intervention was recommended for the lesions that did not heal. Healing was also associated with open growth plates as sixteen of seventeen patients with open growth plates had healing of the lesions, compared with only eleven of twenty-two patients with closed growth plates.
Injuries to the hand and wrist are common in competitive athletes, but there have been few additional publications in the sports medicine literature over the past year. Triangular fibrocartilage complex injuries are often the cause of ulnar-sided wrist symptoms and can be disabling for certain athletes. The authors of one Level-IV study reviewed the arthroscopic treatment of sixteen competitive athletes with triangular fibrocartilage complex injuries63. Fourteen of the sixteen patients were able to return to play at three months after either an arthroscopic débridement or inside-out repair of the triangular fibrocartilage complex, and all patients had significant improvement in opportunity function scores.
Although most orthopaedic literature is appropriately focused on surgical intervention, the investigation of injury prevention programs continues to move toward a unifying protocol. The majority of anterior cruciate ligament ruptures are noncontact injuries that occur during planting, cutting, or jumping with a valgus-directed force vector and excessive tibial rotation. Understanding this mechanism provokes a prevention protocol that would decrease the frequency of this scenario. However, no consensus injury-prevention protocol exists, and the success of any program has been difficult to reproduce because of multiple confounding variables. One physical therapy-focused study investigated individualized therapy for athletes with at-risk movement patterns64. A variety of at-risk movements were targeted in patient-specific protocols that addressed the different needs of each athlete. Not surprisingly, the success of these protocols in correcting the offending behaviors was superior to a generic, all-inclusive program. Zebis et al. confirmed their hypothesis that female athletes with lower electromyographic hamstrings activity, when compared with quadriceps activity during side-cutting maneuvers, were at an increased risk for anterior cruciate ligament injury65. Of the fifty-five athletes who were screened, ten had a significant vastus lateralis-to-semitendinosus mismatch, and five of these ten sustained an anterior cruciate ligament injury within two match seasons of the screening.
The overhead throwing athlete also has been targeted for injury prevention. Recent attention to the associated injury patterns of athletes with glenohumeral internal rotation deficit has prompted the encouragement of posterior capsular stretching and additional investigation. Trakis et al. studied adolescent pitchers with throwing-related shoulder pain and found that portions of the trapezius and supraspinatus were weaker in throwers with pain as compared with overhead throwers without pain66. Certainly, attention to appropriate biomechanics, the development of a full and uniform range of motion, and strength balancing across the joint are necessary goals for any program focused on injury prevention.
Over the past year, the editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, all of which have high-quality study design. Seven Level-I articles were identified that were relevant to orthopaedic sports medicine. A list of those articles is appended to this review following the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.
Subspecialty certification in sports medicine is under the direction of the American Board of Orthopaedic Surgery (ABOS). The five-year "grandfather period" for any surgeon seeking this certification will expire in 2012. After this date, applicants will be required to have completed an Accreditation Council for Graduate Medical Education (ACGME)-accredited and/or Arthroscopy Association of North America (AANA)-recognized sports medicine fellowship to sit for the examination. Current requirements to apply for the examination include ABOS certification and an active sports medicine practice with at least 115 sports medicine cases (seventy-five of which must include arthroscopy) within the previous year. A complete list of requirements, including eligible sports medicine cases, is available online at the ABOS web site (http://www.abos.org). In the future, only subspecialty-certified orthopaedic surgeons will be eligible to take a sports-specific examination for ABOS recertification.
The application deadline for the 2010 examination is March 15, 2010. It must include case lists, required documents, and fees. Eligible candidates will be mailed their scheduling/admission permits in July 2010, and the examination will be administered on November 4, 2010, at Prometric Technology Centers nationwide. The application materials will be available at the ABOS web site. The American Orthopaedic Society for Sports Medicine (AOSSM) and AAOS review course for subspecialty certification in orthopaedic sports medicine will be held in August 2010, in Chicago, Illinois, and information on this course can be found at the AOSSM web site (http://www.sportsmed.org). Applications for the 2010 examination will be available online beginning August 1, 2010.
Sports medicine remains the most popular orthopaedic surgery fellowship. The return of the match was lauded by fellowship applicants and program directors alike. Although there is room for improvement, the first year of the sports medicine fellowship match was largely successful.
The Seventy-seventh Annual Meeting of the American Academy of Orthopaedic Surgeons will be held on March 9 through 13, 2010, in New Orleans, Louisiana, with Specialty Day being held on March 13, 2010. The Annual Meeting of the AANA will be held on May 20 through 23, 2010, in Hollywood, Florida. The Annual Meeting of the AOSSM will be held on July 15 through 18, 2010, in Providence, Rhode Island.
Ferretti
A;
Monaco
E;
Labianca
L;
De Carli
A;
Maestri
B;
Conteduca
F. Double-bundle anterior cruciate ligament reconstruction: a comprehensive kinematic study using navigation. Am J Sports Med.
2009;37:1548-53.
[PubMed][CrossRef]
Markolf
KL;
Park
S;
Jackson
SR;
McAllister
DR. Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions. J Bone Joint Surg Am.
2009;91:107-18.
[PubMed][CrossRef]
Morimoto
Y;
Ferretti
M;
Ekdahl
M;
Smolinski
P;
Fu
FH. Tibiofemoral joint contact area and pressure after single- and double-bundle anterior cruciate ligament reconstruction. Arthroscopy.
2009;25:62-9.
[PubMed][CrossRef]
Järvelä
T;
Moisala
AS;
Paakkala
T;
Paakkala
A. Tunnel enlargement after double-bundle anterior cruciate ligament reconstruction: a prospective, randomized study. Arthroscopy.
2008;24:1349-57.
[PubMed][CrossRef]
Kondo
E;
Yasuda
K;
Azuma
H;
Tanabe
Y;
Yagi
T. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med.
2008;36:1675-87.
[PubMed][CrossRef]
Kim
SJ;
Chang
JH;
Kim
TW;
Jo
SB;
Oh
KS. Anterior cruciate ligament reconstruction with use of a single or double-bundle technique in patients with generalized ligamentous laxity. J Bone Joint Surg Am.
2009;91:257-62.
[PubMed][CrossRef]
Ochi
M;
Adachi
N;
Uchio
Y;
Deie
M;
Kumahashi
N;
Ishikawa
M;
Sera
S. A minimum 2-year follow-up after selective anteromedial or posterolateral bundle anterior cruciate ligament reconstruction. Arthroscopy.
2009;25:117-22.
[PubMed][CrossRef]
Ahn
JH;
Lee
YS;
Ha
HC. Comparison of revision surgery with primary anterior cruciate ligament reconstruction and outcome of revision surgery between different graft materials. Am J Sports Med.
2008;36:1889-95.
[PubMed][CrossRef]
Harilainen
A;
Sandelin
J. A prospective comparison of 3 hamstring ACL fixation devices—Rigidfix, BioScrew, and Intrafix—randomized into 4 groups with 2 years of follow-up. Am J Sports Med.
2009;37:699-706.
[PubMed][CrossRef]
Neuman
P;
Englund
M;
Kostogiannis
I;
Fridén
T;
Roos
H;
Dahlberg
LE. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study. Am J Sports Med.
2008;36:1717-25.
[PubMed][CrossRef]
Taylor
DC;
Posner
M;
Curl
WW;
Feagin
JA. Isolated tears of the anterior cruciate ligament: over 30-year follow-up of patients treated with arthrotomy and primary repair. Am J Sports Med.
2009;37:65-71.
[PubMed][CrossRef]
Øiestad
BE;
Engebretsen
L;
Storheim
K;
Risberg
MA. Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. Am J Sports Med.
2009;37:1434-43.
[PubMed][CrossRef]
Tajima
G;
Nozaki
M;
Iriuchishima
T;
Ingham
SJ;
Shen
W;
Smolinski
P;
Fu
FH. Morphology of the tibial insertion of the posterior cruciate ligament. J Bone Joint Surg Am.
2009;91:859-66.
[PubMed][CrossRef]
Bergfeld
JA;
Graham
SM;
Parker
RD;
Valdevit
AD;
Kambic
HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med.
2005;33:976-81.
[PubMed][CrossRef]
Whiddon
DR;
Zehms
CT;
Miller
MD;
Quinby
JS;
Montgomery
SL;
Sekiya
JK. Double compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model. J Bone Joint Surg Am.
2008;90:1820-9.
[PubMed][CrossRef]
Van de Velde
SK;
Bingham
JT;
Gill
TJ;
Li
G. Analysis of tibiofemoral cartilage deformation in the posterior cruciate ligament-deficient knee. J Bone Joint Surg Am.
2009;91:167-75.
[PubMed][CrossRef]
Jung
YB;
Lee
YS;
Jung
HJ;
Nam
CH. Evaluation of posterolateral rotatory knee instability using the dial test according to tibial positioning. Arthroscopy.
2009;25:257-61.
[PubMed][CrossRef]
LaPrade
RF;
Heikes
C;
Bakker
AJ;
Jakobsen
RB. The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg Am.
2008;90:2069-76.
[PubMed][CrossRef]
Sekiya
JK;
Whiddon
DR;
Zehms
CT;
Miller
MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am.
2008;90:1621-7.
[PubMed][CrossRef]
Halinen
J;
Lindahl
J;
Hirvensalo
E. Range of motion and quadriceps muscle power after early surgical treatment of acute combined anterior cruciate and grade-III medial collateral ligament injuries. A prospective randomized study. J Bone Joint Surg Am.
2009;91:1305-12.
[PubMed][CrossRef]
Sillanpää
PJ;
Mattila
VM;
Mäenpää
H;
Kiuru
M;
Visuri
T;
Pihlajamäki
H. Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am.
2009;91:263-73.
[PubMed][CrossRef]
Sillanpää
PJ;
Mäenpää
HM;
Mattila
VM;
Visuri
T;
Pihlajamäki
H. Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up. Am J Sports Med.
2008;36:2301-9.
[PubMed][CrossRef]
Sillanpää
PJ;
Peltola
E;
Mattila
VM;
Kiuru
M;
Visuri
T;
Pihlajamäki
H. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study. Am J Sports Med.
2009;37:1513-21.
[PubMed][CrossRef]
Paulos
L;
Swanson
SC;
Stoddard
GJ;
Barber-Westin
S. Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med.
2009;37:1288-300.
[PubMed][CrossRef]
Barber
FA;
Schroeder
FA;
Oro
FB;
Beavis
RC. FasT-Fix meniscal repair: mid-term results. Arthroscopy.
2008;24:1342-8.
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Stärke
C;
Kopf
S;
Petersen
W;
Becker
R. Meniscal repair. Arthroscopy.
2009;25:1033-44.
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Allaire
R;
Muriuki
M;
Gilbertson
L;
Harner
CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am.
2008;90:1922-31.
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Lee
JH;
Lim
YJ;
Kim
KB;
Kim
KH;
Song
JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: radiographic and clinical results with a 2-year follow-up. Arthroscopy.
2009;25:951-8.
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Kon
E;
Gobbi
A;
Filardo
G;
Delcogliano
M;
Zaffagnini
S;
Marcacci
M. Arthroscopic second-generation autologous chondrocyte implantation compared with microfracture for chondral lesions of the knee: prospective nonrandomized study at 5 years. Am J Sports Med.
2009;37:33-41.
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Wall
EJ;
Vourazeris
J;
Myer
GD;
Emery
KH;
Divine
JG;
Nick
TG;
Hewett
TE. The healing potential of stable juvenile osteochondritis dissecans knee lesions. J Bone Joint Surg Am.
2008;90:2655-64.
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Seshadri
V;
Coyle
CH;
Chu
CR. Lidocaine potentiates the chondrotoxicity of methylprednisolone. Arthroscopy.
2009;25:337-47.
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Good
CR;
Shindle
MK;
Griffith
MH;
Wanich
T;
Warren
RF. Effect of radiofrequency energy on glenohumeral fluid temperature during shoulder arthroscopy. J Bone Joint Surg Am.
2009;91:429-34.
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Martin
JA;
McCabe
D;
Walter
M;
Buckwalter
JA;
McKinley
TO. N-acetylcysteine inhibits post-impact chondrocyte death in osteochondral explants. J Bone Joint Surg Am.
2009;91:1890-7.
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Tashjian
RZ;
Farnham
JM;
Albright
FS;
Teerlink
CC;
Cannon-Albright
LA. Evidence for an inherited predisposition contributing to the risk for rotator cuff disease. J Bone Joint Surg Am.
2009;91:1136-42.
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Keener
JD;
Wei
AS;
Kim
HM;
Steger-May
K;
Yamaguchi
K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am.
2009;91:1405-13.
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Kim
HM;
Teefey
SA;
Zelig
A;
Galatz
LM;
Keener
JD;
Yamaguchi
K. Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs. J Bone Joint Surg Am.
2009;91:289-96.
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Seeherman
HJ;
Archambault
JM;
Rodeo
SA;
Turner
AS;
Zekas
L;
D'Augusta
D;
Li
XJ;
Smith
E;
Wozney
JM. rhBMP-12 accelerates healing of rotator cuff repairs in a sheep model. J Bone Joint Surg Am.
2008;90:2206-19.
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Zumstein
MA;
Jost
B;
Hempel
J;
Hodler
J;
Gerber
C. The clinical and structural long-term results of open repair of massive tears of the rotator cuff. J Bone Joint Surg Am.
2008;90:2423-31.
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Kamath
G;
Galatz
LM;
Keener
JD;
Teefey
S;
Middleton
W;
Yamaguchi
K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am.
2009;91:1055-62. .
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Adams
CR;
Schoolfield
JD;
Burkhart
SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy.
2008;24:1381-9.
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Grasso
A;
Milano
G;
Salvatore
M;
Falcone
G;
Deriu
L;
Fabbriciani
C. Single-row versus double-row arthroscopic rotator cuff repair: a prospective randomized clinical study. Arthroscopy.
2009;25:4-12.
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Burks
RT;
Crim
J;
Brown
N;
Fink
B;
Greis
PE. A prospective randomized clinical trial comparing arthroscopic single- and double-row rotator cuff repair: magnetic resonance imaging and early clinical evaluation. Am J Sports Med.
2009;37:674-82.
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Odenbring
S;
Wagner
P;
Atroshi
I. Long-term outcomes of arthroscopic acromioplasty for chronic shoulder impingement syndrome: a prospective cohort study with a minimum of 12 years' follow-up. Arthroscopy.
2008;24:1092-8.
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Milano
G;
Grasso
A;
Salvatore
M;
Zarelli
D;
Deriu
L;
Fabbriciani
C. Arthroscopic rotator cuff repair with and without subacromial decompression: a prospective randomized study. Arthroscopy.
2007;23:81-8.
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Huberty
DP;
Schoolfield
JD;
Brady
PC;
Vadala
AP;
Arrigoni
P;
Burkhart
SS. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy.
2009;25:880-90.
[PubMed][CrossRef]
Owens
BD;
Dawson
L;
Burks
R;
Cameron
KL. Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population. J Bone Joint Surg Am.
2009;91:791-6.
[PubMed][CrossRef]
Scheibel
M;
Kuke
A;
Nikulka
C;
Magosch
P;
Ziesler
O;
Schroeder
RJ. How long should acute anterior dislocations of the shoulder be immobilized in external rotation?Am J Sports Med.
2009;37:1309-16.
[PubMed][CrossRef]
Meserve
BB;
Cleland
JA;
Boucher
TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Am J Sports Med.
2009;37:2252-8.
[PubMed][CrossRef]
Ben Kibler
W;
Sciascia
AD;
Hester
P;
Dome
D;
Jacobs
C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med.
2009;37:1840-7.
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Sileo
MJ;
Lee
SJ;
Kremenic
IJ;
Orishimo
K;
Ben-Avi
S;
McHugh
M;
Nicholas
SJ. Biomechanical comparison of a knotless suture anchor with standard suture anchor in the repair of type II SLAP tears. Arthroscopy.
2009;25:348-54.
[PubMed][CrossRef]
Brockmeier
SF;
Voos
JE;
Williams
RJ
3rd;
Altchek
DW;
Cordasco
FA;
Allen
AA; Hospital for Special Surgery Sports Medicine and Shoulder Service. Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am.
2009;91:1595-603.
[PubMed][CrossRef]
Tauber
M;
Gordon
K;
Koller
H;
Fox
M;
Resch
H. Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study. Am J Sports Med.
2009;37:181-90.
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Martin
RL;
Irrgang
JJ;
Sekiya
JK. The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates. Arthroscopy.
2008;24:1013-8.
[PubMed][CrossRef]
Byrd
JW;
Jones
KS. Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up. Arthroscopy.
2009;25:365-8.
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Anderson
LA;
Peters
CL;
Park
BB;
Stoddard
GJ;
Erickson
JA;
Crim
JR. Acetabular cartilage delamination in femoroacetabular impingement. Risk factors and magnetic resonance imaging diagnosis. J Bone Joint Surg Am.
2009;91:305-13.
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Larson
CM;
Giveans
MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy.
2009;25:369-76.
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Suchak
AA;
Bostick
GP;
Beaupré
LA;
Durand
DC;
Jomha
NM. The influence of early weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am.
2008;90:1876-83.
[PubMed][CrossRef]
Sugimoto
K;
Takakura
Y;
Okahashi
K;
Samoto
N;
Kawate
K;
Iwai
M. Chondral injuries of the ankle with recurrent lateral instability: an arthroscopic study. J Bone Joint Surg Am.
2009;91:99-106.
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Scholten
PE;
Sierevelt
IN;
van Dijk
CN. Hindfoot endoscopy for posterior ankle impingement. J Bone Joint Surg Am.
2008;90:2665-72.
[PubMed][CrossRef]
Bohu
Y;
Julia
M;
Bagate
C;
Peyrin
JC;
Colonna
JP;
Thoreux
P;
Pascal-Moussellard
H. Declining incidence of catastrophic cervical spine injuries in French rugby: 1996-2006. Am J Sports Med.
2009;37:319-23.
[PubMed][CrossRef]
Richard
MJ;
Aldridge
JM
3rd;
Wiesler
ER;
Ruch
DS. Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair. J Bone Joint Surg Am.
2008;90:2416-22.
[PubMed][CrossRef]
Mihara
K;
Tsutsui
H;
Nishinaka
N;
Yamaguchi
K. Nonoperative treatment for osteochondritis dissecans of the capitellum. Am J Sports Med.
2009;37:298-304.
[PubMed][CrossRef]
McAdams
TR;
Swan
J;
Yao
J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med.
2009;37:291-7.
[PubMed][CrossRef]
DiStefano
LJ;
Padua
DA;
DiStefano
MJ;
Marshall
SW. Influence of age, sex, technique, and exercise program on movement patterns after an anterior cruciate ligament injury prevention program in youth soccer players. Am J Sports Med.
2009;37:495-505.
[PubMed][CrossRef]
Zebis
MK;
Andersen
LL;
Bencke
J;
Kjaer
M;
Aagaard
P. Identification of athletes at future risk of anterior cruciate ligament ruptures by neuromuscular screening. Am J Sports Med.
2009;37:1967-73.
[PubMed][CrossRef]
Trakis
JE;
McHugh
MP;
Caracciolo
PA;
Busciacco
L;
Mullaney
M;
Nicholas
SJ. Muscle strength and range of motion in adolescent pitchers with throwing-related pain: implications for injury prevention. Am J Sports Med.
2008;36:2173-8.
[PubMed] [CrossRef]
Arneja
S;
McConkey
MO;
Mulpuri
K;
Chin
P;
Gilbart
MK;
Regan
WD;
Leith
JM. Graft tensioning in anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Arthroscopy.
2009;25:200-7.The purpose of this study was to perform a systematic review to analyze the current literature for randomized controlled trials evaluating the effect of graft tensioning on the outcomes of anterior cruciate ligament reconstruction. Secondarily, the authors sought to determine the scientific quality of the studies that were selected on the basis of their review of the literature. The authors performed a computer-based search and a manual search of widely accepted key orthopaedic journals and sports medicine conference proceedings. Five trials met the inclusion criteria, with only two scoring highly on the Detsky study-quality index. All trials included autogenous grafts. There was vast heterogeneity across the studies in terms of the amount of tension applied to grafts during fixation. The authors concluded that there was a trend suggesting that 80 N of tension is most effective for anterior cruciate ligament reconstruction with use of hamstring-polyester graft sources. However, no conclusions or recommendations could be made regarding the ideal tension to apply for other hamstring graft sources or patellar bone-patellar tendon-bone autografts.[PubMed][CrossRef]
Gerber
JP;
Marcus
RL;
Dibble
LE;
Greis
PE;
Burks
RT;
LaStayo
PC. Effects of early progressive eccentric exercise on muscle size and function after anterior cruciate ligament reconstruction: a 1-year follow-up study of a randomized clinical trial. Phys Ther.
2009;89:51-9.This one-year follow-up of a randomized clinical trial evaluated the effects of early progressive eccentric exercise on muscle volume and function at one year following anterior cruciate ligament reconstruction. Previous work from this group of authors showed greater short-term gains during the first fifteen weeks after anterior cruciate ligament reconstruction with use of this rehabilitation protocol as compared with a standard program. Following anterior cruciate ligament reconstruction, forty patients were randomized into two rehabilitation groups, with one group managed with early progressive eccentric exercise and a second group managed with standard rehabilitation. The eccentric exercise group had significant gains in terms of quadriceps femoris and gluteus maximus muscle volume and strength as well as functional improvement in comparison with the standard rehabilitation group from three weeks to one year following surgery. The authors emphasized the importance of an early progressive eccentric exercise program following anterior cruciate ligament reconstruction and advocated that this program can be performed safely and therefore should be considered as part of a comprehensive rehabilitation program.[PubMed]
Meredick
RB;
Vance
KJ;
Appleby
D;
Lubowitz
JH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med.
2008;36:1414-21.The purpose of this meta-analysis was to review the outcome of single-bundle as compared with double-bundle anterior cruciate ligament reconstruction. The authors performed a systematic review in which they identified four randomized trials, followed by a secondary analysis of nonrandomized trials that yielded five more studies. KT-1000 arthrometer testing and the pivot-shift test were the two outcome measures that were consistently reported. A statistical difference in KT-1000 measurements was found, with double-bundle reconstruction resulting in measurements that were closer to normal. However, this finding was thought to be clinically unimportant as the side-to-side difference was 0.52 mm closer to normal in patients treated with double-bundle reconstruction. This difference (0.52 mm) lies within the International Knee Documentation Committee (IKDC) normal postoperative value of 2 mm. There was also no significant difference between the two techniques in terms of the results of the pivot shift test postoperatively. The authors concluded that current literature does not support the theoretical advantages of better knee control and outcomes attributed to double-bundle reconstruction. The need for more quality randomized controlled trials comparing these two techniques with multiple outcome measures was stressed.[PubMed]
Myers
P;
Logan
M;
Stokes
A;
Boyd
K;
Watts
M. Bioabsorbable versus titanium interference screws with hamstring autograft in anterior cruciate ligament reconstruction: a prospective randomized trial with 2-year follow-up. Arthroscopy.
2008;24:817-23.In this prospective, randomized trial, 100 patients undergoing hamstring autograft anterior cruciate ligament reconstruction were randomized to have either bioresorbable or titanium interference screw graft tunnel fixation. Screws of identical shape were used, regardless of material. Patients were followed for two years. Tunnel width was assessed with radiographs at twelve months postoperatively. Bioresorbable screws led to a mildly increased tunnel width in comparison with titanium screws. However, there was no significant difference between the groups in terms of clinical outcomes at two years. The authors concluded that bioresorbable and titanium fixation screws led to equal outcomes when used for hamstring anterior cruciate ligament reconstruction.[PubMed]
Naranje
S;
Mittal
R;
Nag
H;
Sharma
R. Arthroscopic and magnetic resonance imaging evaluation of meniscus lesions in the chronic anterior cruciate ligament-deficient knee. Arthroscopy.
2008;24:1045-51.The value of magnetic resonance imaging and its correlation with arthroscopic evaluation of meniscal lesions in the setting of acute anterior cruciate ligament injury has been well discussed in the literature. The purpose of this prognostic prospective study was to evaluate the correlation of magnetic resonance imaging with arthroscopy for the evaluation of meniscal pathology in chronic anterior cruciate ligament-deficient knees. Fifty patients who were scheduled to undergo arthroscopic anterior cruciate ligament reconstruction for the treatment of a chronic anterior cruciate ligament tear (more than six weeks after the injury) were evaluated clinically and with magnetic resonance imaging within one month prior to surgery. The sensitivity, specificity, positive predictive value, and negative predictive value of magnetic resonance imaging were calculated and analyzed in comparison with arthroscopy as the gold standard. The posterior horn of the medial meniscus was most commonly injured, often with a complex tear. The negative predictive value of magnetic resonance imaging was found to be very high (93%), and the authors concluded that magnetic resonance imaging correlated well overall with arthroscopy for the diagnosis of meniscal pathology in chronically anterior cruciate ligament-deficient knees.[PubMed]
Rodkey
WG;
DeHaven
KE;
Montgomery
WH
3rd;
Baker
CL
Jr;
Beck
CL
Jr;
Hormel
SE;
Steadman
JR;
Cole
BJ;
Briggs
KK. Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial. J Bone Joint Surg Am.
2008;90:1413-26.In this multicenter, prospective, therapeutic randomized trial, 311 patients with either an irreparable medial meniscus or previous partial medial meniscectomy were enrolled into one of two study arms (acute or chronic). The acute-arm patients had had no previous meniscal surgery, and the chronic-arm patients had undergone previous meniscal surgery (with a range of one to three procedures). Patients from both arms were then randomized to receive an investigational collagen meniscal implant or to serve as a control and be treated with partial meniscectomy only. Patients were followed clinically for two years and with validated outcome questionnaires for seven years. In addition, patients who underwent collagen meniscus implantation underwent a second-look arthroscopy at one year, including biopsy. One hundred and sixty patients (seventy-five from the acute arm, and eighty-five from the chronic arm) received the collagen meniscus implant, and 141 were available for repeat arthroscopy. The collagen meniscal implant resulted in significantly increased meniscal tissue in comparison with that seen after the index meniscectomy, supporting meniscus-like matrix production and integration. Chronic-group patients who were managed with the implant had a significantly higher rate of return to preinjury levels in comparison with controls, and they underwent fewer reoperations. No such differences were detected in the acute group. The early results of this collagen meniscal transplant are promising, with evidence of new tissue ingrowth and the potential for improved meniscal function in chronically meniscus-deficient knees.[PubMed]
Shetty
AA;
Tindall
AJ;
James
KD;
Relwani
J;
Fernando
KW. Accuracy of hand-held ultrasound scanning in detecting meniscal tears. J Bone Joint Surg Br.
2008;90:1045-8.The goal of this prospective study was to evaluate the sensitivity and specificity of ultrasound in comparison with magnetic resonance imaging for the diagnosis of meniscal tears. Arthroscopy was the final outcome comparison measure. Thirty-five patients were included in the study. The sensitivity of ultrasound was the same as that of magnetic resonance imaging (86.4% for both methods). However, the lower specificity for ultrasound (69.2%) in comparison to that of magnetic resonance imaging (100%) led the authors to conclude that ultrasound is a reasonable option for confirming a clinical diagnosis of a meniscal tear but that improvements in technique are needed to achieve better specificity and ultimately to avoid false-positive diagnoses and unnecessary arthroscopic procedures.[PubMed]