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Specialty Update

What’s New in Sports MedicineJames S. Starman, MD, Justin W. Griffin, MD, Abdurrahman Kandil, MD, Richard Ma, MD,

MaCalus V. Hogan, MD, and Mark D. Miller, MD

This update is based on the scientific and investigational ac-tivities in the specialty of sports medicine from September 2012to August 2013. It includes a review of pertinent researchand articles published in the three premier journals of ourspecialty, namely, The Journal of Bone & Joint Surgery(American volume), The American Journal of Sports Medi-cine, and Arthroscopy: The Journal of Arthroscopic & RelatedSurgery.

ShoulderThe Natural History of Rotator Cuff DiseaseA large body of research continues to focus on maximization ofoutcomes in rotator cuff disease. Moosmayer et al. assessed theclinical and morphological changes that occur in asymptom-atic full-thickness rotator cuff tears. Their study demonstratedthe potential negative consequences of nonsurgical care: a sig-nificant number of initially asymptomatic rotator cuff tearsbecame symptomatic, and the tears that became symptomaticdemonstrated increased fatty atrophy and larger tear patterns1.This raises questions about the role of surveillance and howbest to counsel patients regarding the risks associated withnonsurgical care.

Rotator Cuff RepairDisappointing structural healing rates continue to be associ-ated with rotator cuff repair surgery, particularly with ‘‘mas-sive’’ sized tears2-4. Chung et al. reported a 39% failure rateof massive rotator cuff tear repair, with fatty infiltration beingthe main predictor of healing failure. However, regardless ofhealing, most patients were clinically improved2. Similar con-clusions were demonstrated by Paxton et al. at a follow-up timeof ten-years3.

Research investigating rotator cuff repair techniquesremains active. Outcomes with margin convergence repairtechniques were evaluated in a well-designed study byKim et al.5 This study evaluated twenty-four patients fol-lowed for two years postoperatively, and the authors re-ported that a 47% retear rate occurred when marginconvergence was employed5. Surgical augmentation tech-niques in rotator cuff repair represent an emerging areaof interest. In a recent Level-I study, Weber et al. evaluatedhow platelet-rich fibrin matrix (PRFM) would influencehealing rates; they found no difference in clinical outcomeor structural integrity at one year6. In their systematic re-view, Chahal et al. evaluated the potential of platelet-richplasma to improve rotator cuff healing and found nooverall effect on retear rate or shoulder-specific outcomemeasures7. Finally, a recent prospective randomized con-trolled trial demonstrated that massive rotator cuff repairaugmented with a cellular human dermal allograft resultedin higher rates of intact repair (85% versus 40%) as deter-mined by magnetic resonance imaging (MRI) follow-upat two years8.

Superior Labrum Anterior and Posterior (SLAP) RepairVersus Biceps TenotomyThere is an increasing trend toward surgical management ofSLAP lesions with biceps tenodesis rather than repair. In aprospective analysis of type-II SLAP tears, Provencher et al.evaluated 179 patients who were managed with surgical repair,and the authors reported a 37% clinical failure rate and a 28%surgical revision rate at four years9. Kim et al. examinedfunctional outcomes with type-II SLAP repair versus bicepstenotomy in patients with rotator cuff repair, and they foundthat biceps tenotomy with rotator cuff repair may be a morereliable option than SLAP repair for patients with concomitantbiceps pathology10.

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

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support ofany aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submissionof this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Noauthor has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence whatis written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version ofthe article.

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Shoulder InstabilityThe optimal treatment for instability of the shoulder remainsanother area of controversy. A recent cost-analysis study con-cluded that primary arthroscopic stabilization is clinicallyeffective and cost-effective for first-time glenohumeral dis-location11. Another study examined the natural history ofosseous Bankart lesions, suggesting that this bone fragmentundergoes rapid absorption within one year after the primarydislocation event12. Glenoid reconstruction techniques withautograft or allograft remain a viable option for refractoryinstability, especially when bone loss of the glenoid articularsurface nears 20% to 25%. The stabilizing mechanism of theLatarjet procedure was examined this year in a cadavericmodel, with results indicating that the sling effect is the mostimportant contributor to observed increases in stability13.Another study assessed the biomechanics of allograft tech-niques for glenoid reconstruction with use of the distal tibialarticular surface14.

Traditionally, arthroscopic techniques for addressingsubstantial glenoid osseous insufficiency have been associatedwith high rates of failure; however, new techniques for arthro-scopic stabilization continue to emerge15. Millett et al. followed aseries of fifteen patients who were treated with an arthroscopicosseous Bankart repair technique16. When a reducible bonefragment was present, patients were successfully treated ar-throscopically with anchor placement medial to the fracture siteand sutures shuttled around the osseous piece. Surgical optionsfor addressing humeral-sided defects, such as the remplissagetechnique, have shown increased popularity as well17.

Acromioclavicular JointFree tendon graft reconstruction techniques for high-gradeacromioclavicular separations continue to develop, and ar-throscopic assistance is becoming more commonplace18. In arecent study of tunnel position as it relates to graft failure,the authors noted a 29% failure rate by approximately sevenweeks postoperatively and reported that excessively medializedbone tunnels were a significant predictor of failure19. Anotherstudy demonstrated that bone mineral density was optimalin the anatomic insertion of the coracoclavicular ligamentsbetween 20 and 60 mm from the lateral end of the clavicle andthat placement outside this range may be associated withhigher failure rates20.

KneeAnterior Cruciate Ligament (ACL)ACL Footprint and Tunnel CreationAmong all knee-based topics, articles related to the ACL havebeen the most frequently published over the past year. Con-siderable interest remains regarding anatomic tunnel place-ment in ACL reconstruction surgery, although debate persistson optimal tunnel positions. McConkey et al. investigated ar-throscopic agreement on femoral tunnel positioning amongtwelve surgeons and found that there was no uniform agree-

ment among surgeons on the ideal tunnel position; however,there was general agreement that a transtibial technique mayyield more poorly placed tunnels compared with accessorymedial portal or outside-in techniques21. Several studies havespecifically studied the benefits and drawbacks of differentfemoral tunnel creation techniques22-25. One potential draw-back of the accessory medial portal technique is shorter tunnellength22,23. In a study of 106 consecutive patients who underwentreconstruction with an accessory medial portal technique,Tompkins et al. demonstrated that a tunnel length of >30 mmwithout posterior wall fracture can consistently be achieved22.Rahr-Wagner et al. investigated surgical revision rates in 9239patients on the basis of the femoral tunnel creation technique andfound a higher revision rate (5.16%) in patients who underwentsurgery with use of an accessory medial portal technique ascompared with a transtibial technique (3.20%)24.

Tibial tunnel placement has also been an area of activeresearch, with some authors advocating for a more anterior tibialtunnel. In a recent Level-IV study of sixty patients, Hatayama et al.concluded that a more anterior tibial tunnel improves anteriorstability without resulting in loss of extension26.

ACL Preservation and AugmentationSurgeons continue to debate the usefulness of preserving theremaining ACL fibers during reconstruction procedures whenonly one bundle appears damaged. In a recent study by Parket al., the authors compared the single-bundle augmentationprocedure with the double-bundle technique, finding similaroutcomes in anterior and rotatory stability as well as in theclinical scores of fifty-five patients (thirty-eight cases of pos-terolateral augmentation, seventeen anteromedial bundle aug-mentations)27. Caution must be exercised in defining a trueone-bundle tear, however, and this technique remains techni-cally demanding. Others have studied the preservation of thefootprint of the ACL to promote improved revascularizationand proprioception. Hong et al., in their prospective randomizedstudy of ninety patients, compared ACL remnant preservationwith removal and at two years found equivalent results in stability,synovial coverage, and proprioceptive recovery28.

Pediatric ACL ConsiderationsPediatric ACL reconstruction has become more frequent inrecent years, leading to renewed interest in outcomes for sur-gical techniques in skeletally immature patients29,30. Kumaret al. reported positive outcomes of a transphyseal ACL re-construction technique that made use of autograft hamstringin thirty-two skeletally immature patients with minimumfollow-up to age sixteen years. No patients had a limb-lengthdiscrepancy, although one developed mild valgus deformity29.The timing of surgery for pediatric ACL reconstruction hasalso been debated. Dumont et al. found that patients treatedmore than 150 days after ACL injury had a higher rate of medialmeniscal tear. Increased age and weight were also associatedwith higher overall risk of medial meniscal tears31.

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What’s New in Sports Medicine

Osteoarthritis After ACL InjuryA major goal of ACL reconstruction is to reduce the possibilityof the development of long-term osteoarthritis in the kneefollowing injury. Despite additional studies, it remains unclearwhether ACL reconstruction accomplishes this goal as com-pared with the results obtained with nonoperative treatmentprotocols32,33. Frobell et al. reported the five-year results of ablinded randomized cohort of patients who underwent eitherrehabilitation and ACL reconstruction or rehabilitation plusoptional delayed ACL reconstruction. Patient-reported andradiographic outcomes were equivalent for both groups, thuschallenging the hypothesis that ACL reconstruction contrib-utes to a lower risk of the development of osteoarthritis. Po-tential bias of the results due to a high crossover rate raisesquestions about the results, however32. Other factors, such asmeniscal and chondral injury, are also important in influencingthe development of osteoarthritis, thereby complicating theattempts to understand the specific effects of ACL recon-struction on the progression of arthritis.

ACL OutcomesAuthors from the Multicenter Orthopaedic Outcomes Network(MOON) ACL study group reported on the six-year outcomesof single-bundle ACL reconstruction, establishing rates ofand predictive factors for additional surgical procedures afterprimary ACL reconstruction. At a follow-up time of six years,18.9% of patients had undergone an additional procedure onthe ipsilateral leg, and 10.2% of patients had undergone anadditional procedure on the contralateral leg. On the ipsilateralleg, 7.7% had ACL revision procedures, and 13.3% had cartilage-based procedures. Younger age and the use of ACL allograftswere risk factors for additional surgery34.

Numerous authors have continued to report outcomescomparing single-bundle and double-bundle ACL recon-struction techniques; however, to date, no study has demon-strated convincing evidence to conclude that one techniqueis superior to the other35-37. A meta-analysis of nineteenrandomized controlled trials comparing single-bundle anddouble-bundle ACL reconstruction techniques in 1667 patientsshowed significantly better anterior and rotational stability andhigher International Knee Documentation Committee (IKDC)objective scores in association with double-bundle recon-struction as compared with single-bundle reconstruction,without differences in subjective clinical outcomes36.

ACL Graft SelectionThe use of autograft or allograft in ACL reconstruction con-tinues to be debated. Ellis et al. have recently advocated forthe preferred use of autograft tissue, especially in youngerpatients undergoing ACL reconstruction38. Those authorscompared the revision rates obtained with autograft and allo-graft bone-patellar tendon-bone in skeletally mature patientswho were eighteen years of age or younger, and those authorsnoted a failure rate in the first year after surgery of 35% in the

allograft group as compared with 3% in the autograft group38.However, other studies have reported more comparable resultswith allograft tissue39. Graft diameter is also an importantconsideration, and a recent article investigated the ability ofMRI or ultrasound measurements to predict hamstring graftdiameter preoperatively40.

ACL Rehabilitation and Return to PlayAttempts have been made to identify factors that may allowa faster return to play in select patients. A systematic reviewof ACL rehabilitation by Kruse et al. concluded that bracingfollowing ACL reconstruction is neither necessary nor benefi-cial and that home-based rehabilitation can be successful.Neuromuscular interventions were safe but unlikely to haveappreciable benefit to patients41. Flanigan et al. found that amajority of patients who do not return to sports after ACLreconstruction cite pain as a contributing factor. Fear of re-injury was cited by half of the patients, while only a minoritycited job and family demands42.

Posterior Cruciate Ligament (PCL)Isolated PCL TreatmentHistorically, an isolated PCL injury has commonly beenmanaged nonsurgically. Shelbourne et al., in reporting the ten-year minimum outcomes with nonoperative treatment ofacute, isolated PCL injuries in sixty-eight patients who werefollowed prospectively, revealed evidence to support thistreatment. The cohort of patients remained active and hadgood strength and range of motion and good subjective scores.The results were not affected by the grade of PCL laxity. Theprevalence of moderate-to-severe osteoarthritis was 11%43.

A subset of patients with isolated PCL injuries or thosewith a combined ligamentous injury may require surgical re-construction of the PCL, and several recent studies have at-tempted to better define surgical and radiographic landmarksfor recreation of the normal anatomy44-46. Anderson et al. in-vestigated the anatomic landmarks associated with arthro-scopic PCL reconstruction in twenty nonpaired cadavers,concluding that the femoral attachments of the anterolateraland posteromedial bundles are an average of 12.1 mm apartcompared with the tibial attachment points, which are only8.9 mm apart. They advocated placing a femoral anterolateraltunnel adjacent to the articular cartilage and a posteromedialtunnel 8.6 mm proximal to the cartilage margin, just distalto the medial intercondylar ridge. If a single-bundle technique ispreferred, the tunnel should approximate the midpoint betweenthe anterolateral and posteromedial insertion points44.

Combined PCL and Posterolateral Corner InjuryPosterolateral corner injury combined with posterior cruciateligament injury remains a difficult problem and representsa spectrum of injury, making it a challenge to standardizetreatment. Kim et al. investigated the effects of physiologicalposterolateral rotatory laxity on the outcomes of combined

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PCL and posterolateral corner injury reconstruction. Theyretrospectively reviewed sixty-five patients, grouped accordingto the degree of laxity of the uninjured limb, and evaluatedclinical outcomes and posterior stability. Using stress radiogra-phy with use of a Telos device (Telos, Marburg, Germany), theyfound no differences between the groups with regard to poste-rior translation or varus opening and no differences in clinicaloutcomes or in the grades on the dial test47. Another study as-sessed the utility of combined PCL and posterolateral cornerreconstruction in patients with a posterolateral corner injurybut only mild (<7 mm) posterior translation. This Level-III co-hort study of forty-six patients revealed that patients with com-bined PCL and posterolateral corner injury reconstruction hadsuperior stress radiographic, clinical, and functional results48.

MeniscusSurgeons continue to seek confirmation of the biomechanicaleffects of the meniscus and the effects of surgical interventionfor different types of meniscal tears. Schillhammer et al. eval-uated the biomechanics of posterior horn detachment lesionsof the lateral meniscus in eight cadavers and found that peaktibiofemoral pressures can be reduced to a normal level fol-lowing repair; however, the maximum contact area was notfully restored to normal49.

Clinical outcomes in meniscal repairs have also beeninvestigated, particularly with regard to intermediate andlonger-term outcomes. Nepple et al. reported a systematic re-view and meta-analysis on meniscal repair outcomes in studieswith follow-up times of more than five years. They includedthirteen studies and reported similar failure rates across studiesregardless of the technique used (failure rates of 22.3% to24.3%) at a minimum of five years postoperatively. Questionsremain regarding the long-term failure rates of modern all-inside ‘‘tensionable’’ devices, which have yet to be reported50.

Meniscal Allograft TransplantationMeniscal allograft transplantation continues to be a reasonableoption for carefully selected patients, and recent reports suggestsatisfactory short-term and intermediate-term outcomes inan athletic population following the procedure. Outcomesfollowing meniscal allograft transplantation in thirteen high-level athletes were reported by Chalmers et al. in a Level-IVstudy51: 77% were able to return to the previous level of playin sports with a mean follow-up of 3.3 years after surgery, while23% underwent additional meniscal procedures. Others haverecently reported on outcomes with meniscal scaffold devices;however, these devices remain relatively new and long-termoutcomes are unknown52.

Articular Cartilage LesionsArticular cartilage lesions continue to pose major problems.Many new and promising treatment options have been devel-oped over time, making this an area of both immense debateand promise.

An important criterion in determining which cartilagerepair technique to use is the size of the cartilage defect. Sistonet al. looked at the different measurement techniques to esti-mate the size of cartilage defects in knees and found thatthe four commonly used techniques yielded highly variableresults53. Only 57% of the measurements in this study wouldhave accurately led to the appropriate surgical procedure, givencurrent treatment algorithms. Campbell et al. comparedthe size of articular cartilage defects on MRI with that onarthroscopy (gold standard)54. They found that actual defectsize was underestimated in 74% of patients.

Determining how quickly to permit progression toweight-bearing in patients undergoing cartilage repair hasalso been debated55-57. Ebert et al. studied the outcomes of atraditional versus an accelerated postoperative weight-bearingregimen after matrix-induced autologous chondrocyteimplantation in a Level-I randomized controlled trial55. Theyconcluded that accelerated rehab protocols are safe and effec-tive with equivalent clinical outcomes. Similarly, Lee et al.found that early weight-bearing (at two weeks) in patientswith talar osteochondral lesion microfracture was safe56.

Cartilage Repair OutcomesGudas et al. reported the ten-year follow-up results regardingmosaic-type osteochondral autologous plug transfer versusmicrofracture in the treatment of osteochondral defects of theknee58. In their Level-I trial, significantly better results weredetected in patients in the osteochondral autologous plugtransfer group as compared with those in the microfracturegroup at ten years. Quantitative MRI of articular cartilage asan outcomes assessment technique is increasing in popularity.Bekkers et al. looked at the quality of cartilage one year after TruFitimplantation with use of the delayed gadolinium-enhanced MRIof cartilage (dGEMRIC) technique59. They found that the im-plantation of the TruFit plug (Smith & Nephew, Andover,Massachusetts) in osteochondral lesions does not cause damage tosurrounding cartilage and that the newly formed tissue inside theplug has cartilage-like dGEMRIC characteristics twelve monthsafter implantation. Tompkins et al. evaluated outcomes and MRIfindings after the use of particulated juvenile cartilage for thetreatment of Outerbridge grade-4 articular defects of the patella60.Seventy-three percent of patients had normal or near-normalcartilage repair on MRI, and the clinical results suggested thatparticulated juvenile articular cartilage allograft offers a viableoption for this subset of patients.

HipImaging in Femoroacetabular Impingement and LabralPathologyMany recent studies emphasize the importance of correlatingimaging studies with clinical history and examination whenevaluating femoroacetabular impingement61,62. Register et al.studied the prevalence of abnormal MRI findings in an asymp-tomatic population62. They found labral tears in 69% of hips

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and chondral defects in 24%. Similarly, Schmitz et al. foundlabral tears and acetabular paralabral cysts in 80% and 20% ofasymptomatic patients, respectively63. In another study of ra-diographic femoroacetabular impingement parameters, Neppleet al. found that coxa profunda, which was evident in 76% ofasymptomatic hips as compared with 64% of the hips withfemoroacetabular impingement, may represent a normal radio-graphic finding, at least in women64. Finally, Schmitz et al. studiedthe prevalence of radiographic impingement morphology inasymptomatic adolescents65. Of 180 hips, 92.8% demonstrated atleast one parameter suggesting impingement morphology, and52.2% showed at least two signs.

Femoroacetabular Impingement and Osteoarthritis: The Roleof Hip ArthroscopyThe issue of timing of hip arthroscopy in the treatment offemoroacetabular impingement is an area of contention. Huntet al. performed a prospective observational study examiningthe outcomes of initial nonsurgical treatment in patients pre-senting with a prearthritic, intra-articular hip disorder66. Allpatients, ultimately treated with or without surgery, demon-strated significant reduction in pain and improvement infunction from baseline to one year. These data suggest that atrial of conservative management for persons with prearthritic,intra-articular hip disorders should be considered before pro-ceeding with surgical intervention.

Patient selection and understanding of risk factorsare important considerations for patients and surgeons.McCormick et al., using the modified Harris hip score, soughtto determine whether arthritis or age is predictive of outcomesafter hip arthroscopy for labral pathology67. The presence ofarthritic changes at the time of arthroscopy was predictiveof worse outcome scores. Patients who were younger thanforty years did better than older patients.

There is substantial interest in hip labral reconstruction,but high-level evidence to support its use is sparse68,69. Boykinet al. looked at the clinical outcomes and the rate of returnto play of high-level athletes undergoing arthroscopic labralreconstruction68. The rate of return to play was 85.7%, with81% returning to a similar level. Matsuda and Burchette like-wise reported favorable clinical outcomes after arthroscopichip labral reconstruction with use of gracilis autograft69.

Complications of Hip ArthroscopyRadiographic heterotopic ossification is one important com-plication that has been reported following hip arthroscopy and ispresent in as much as 44% of patients according to some studies70.Bedi et al. determined that the addition of indomethacin waseffective in reducing the incidence of heterotopic ossification afterhip arthroscopy, reducing the rate from 8.3% to 1.8% in theirseries of 616 hips71. Labral penetration is another potential com-plication of hip arthroscopy. In previous studies, the rate of labralpenetration has been reported to be as much as 20%; however,a newer series by Domb et al. revealed a rate of less than 1%72.

Finally, neurologic injury has been reported following hip ar-throscopy. Telleria et al., using intraoperative nerve monitoring,examined the prevalence, pattern, and predisposing factors forsciatic nerve traction injury during hip arthroscopy and found thatthe maximum traction weight, not the total traction time, is thegreatest risk factor for sciatic nerve dysfunction73.

Measuring OutcomesWith the increasing popularity of hip arthroscopy, validatedoutcome measures need to be studied. The modified Harris hipscore is currently the most common outcome tool reported in thehip arthroscopy literature74. However, the Hip Outcome Scoremay now be considered the optimal validated outcome assess-ment tool for patients who are undergoing hip arthroscopy75.Aprato et al. looked at the relationship between commonly re-ported clinical outcomes and patient satisfaction after hip ar-throscopy by comparing modified Harris hip scores with patientsatisfaction scores76. They found that, although there is a corre-lation between patient satisfaction and modified Harris hipscores, limitations persist, as some patients with good-to-excellentmodified Harris hip scores were dissatisfied with their outcome.

Foot and AnkleTalar Chondral LesionsThe treatment of osteochondral lesions of the talus continuesto be debated. Arthroscopic bone-marrow stimulation tech-niques, such as microfracture or retrograde drilling, remain themainstay of first-line surgical treatments; however, the long-termability of such fibrocartilaginous infill to withstand the biome-chanical loads across the tibiotalar joint continues to be a subjectof research inquiry77. In a large retrospective therapeutic studywith a follow-up of eight to twenty years, van Bergen et al.evaluated fifty patients who underwent arthroscopic debride-ment and bone-marrow stimulation for the treatment of a pri-mary osteochondral defect of the talus. Ninety-four percent ofpatients resumed work and 88% returned to sports, and theauthors concluded that this surgical approach for talar os-teochondral lesions was both successful and durable78.

Achilles TendonNonsurgical management with functional rehabilitation versussurgical treatment for acute Achilles tendon rupture remainscontroversial. A recent meta-analysis of randomized trialsfound that when a functional rehabilitation protocol with earlyrange of motion was initiated, rerupture rates were equal forboth surgical and nonsurgical patients. Surgery was associatedwith an absolute risk increase of 15.8% for complications otherthan rerupture. However, there was no significant differencein calf circumference, strength, or functional outcome acrosssurgical and nonsurgical treatment groups. The authors con-cluded that, at centers where a functional rehabilitation pro-gram is available, conservative treatment should be consideredas this resulted in rerupture rates similar to those associatedwith surgical treatment. Surgical treatment was recommended

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in areas that did not employ early range-of-motion functionalrehabilitation protocols79.

ElbowUlnar Collateral LigamentReconstruction of the medial ulnar collateral ligament hashistorically been accomplished with use of autograft. How-ever, a recent study by Savoie et al. challenges this concept.Their report showed positive results at a follow-up time oftwo-years in 123 throwing athletes undergoing allograft ham-string reconstruction. With use of an advanced postoperativeprotocol, patients were able to return to play earlier (average,9.5 months) than those in previous series, and 83% attaineda Conway-Jobe rating of excellent80. Surgeons also continueto debate the proper management of partial ulnar collateral lig-ament injuries in athletes. A study by Podesta et al. showedpossible benefit in treating partial ulnar collateral ligamentinjuries with platelet-rich plasma. Thirty-four athletes with MRI-documented partial ulnar collateral ligament tears who hadprevious failure of a nonoperative management trial wereinjected with platelet-rich plasma. Thirty of thirty-four playerswere subsequently able to return to play without complaints,while one underwent later reconstruction81.

Elbow ArthroscopyAdvances in elbow arthroscopy have resulted in expanded in-dications and techniques, although concerns regarding neuro-vascular injury remain high82,83. Arthroscopic release of elbowcontracture presents a particular concern regarding nerve injury.In their large series of 502 patients with a fifteen-year follow-up,Blonna et al. reported that twenty-four of the 502 patientshad transient nerve injury but that no patients had permanentinjuries82. This study suggests that, in expert hands, the risk ofnerve injury is low for arthroscopic contracture release.

Treatment of lateral epicondylitis has been an activearea of research. The number of surgeons treating lateral epi-condylitis with use of arthroscopic techniques is growing, anddebate persists regarding the potential risk-to-benefit ratio84. Therole of platelet-rich plasma in the management of lateral epi-condylitis is also an area of controversy. In their Level-I studyof sixty patients, Krogh et al. examined whether a single injectionof platelet-rich plasma is more effective than placebo or corti-costeroids in reducing pain at three months. No significantdifference in clinical outcomes or ultrasound or Doppler testingresults was observed for patients who were treated with platelet-rich plasma as compared with patients treated with placebo85.

Head and SpineConcussionsIn-game concussions and head injuries remain a focus of notonly the public media but also ongoing efforts to minimizegame-play scenarios that place athletes at risk for these typesof injuries. Research utilizing video analysis has shown head-to-head contact to be the most common mechanism of con-firmed in-game concussive episodes among high-schoollacrosse athletes86. Such findings reinforce the importance ofrecent emphasis on both professional and amateur levels toprevent intentional head-to-head contact.

Posttraumatic headaches are common following concus-sive episodes. Kontos et al. reported that male high-schoolfootball players who had posttraumatic headaches or migraineswere more likely to have protracted recovery than were indi-viduals with no headaches following concussion87. Mihalik et al.reported similar findings in their cohort of student athletes88. Onthe basis of these studies, clinicians should exercise caution inallowing early return to play for players with migraine-typesymptoms following a concussive episode.

Athletic Disc Degeneration and HerniationAthletes that experience repetitive load and contact, suchas football players, are at a higher risk for the developmentof disc disease89. The treatment decision for symptomaticathletes is highly individualized and depends on the level andcharacteristics of the injury, the symptoms being experiencedby the player, as well as the findings from studies of thespinal cord. Watkins et al. reported an 89% (sixty-seven ofseventy-five athletes) return-to-sport rate for various pro-fessional athletes twelve months following microscopiclumbar discectomy 90. No significant differences were seen inthis series when comparing the rate of return between thedifferent sports.

James S. Starman, MDJustin W. Griffin, MDAbdurrahman Kandil, MDRichard Ma, MDMaCalus V. Hogan, MDMark D. Miller, MDDepartment of Orthopaedic Surgery,University of Virginia,Box B00159 HSC,Charlottesville, VA 22908

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