whats new in sports medicine 2009

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2009;91:241-256. doi:10.2106/JBJS.H.01627 J Bone Joint Surg Am.Andrew C. Gerdeman, MaCalus V. Hogan and Mark D. Miller

What's New in Sports Medicine

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www.jbjs.org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint Surgery

Specialty Update

Whats New in Sports MedicineBy Andrew C. Gerdeman, MD, MaCalus V. Hogan, MD, and Mark D. Miller, MD

This sports medicine specialty update is based on scientificpublications and organizational proceedings from September2007 to August 2008. It includes a brief review of importantresearch from the three premier sports medicine journals,namely, The Journal of Bone and Joint Surgery (AmericanVolume), The American Journal of Sports Medicine, andArthroscopy. In addition, the scientific presentations from theannual and Specialty Day meetings of the American Academyof Orthopaedic Surgeons (AAOS), the American OrthopaedicSociety for Sports Medicine (AOSSM), and the ArthroscopyAssociation of North America (AANA) were reviewed, withany pertinent material included in this update.

KneeAnterior Cruciate LigamentThe anterior cruciate ligament is perhaps the most extensivelyresearched and frequently reconstructed ligament, and itcontinues to be a major focus of research in sports medicine.Clinical outcomes, biomechanics, and surgical techniques havereceived the majority of recent attention related to anteriorcruciate ligament reconstruction. Along with immediaterestoration of stability, the long-term outcomes of anteriorcruciate ligament reconstruction are of the utmost importance,yet many questions remain unanswered. The restoration ofnormal knee kinematics is thought by many to be the mostcritical aspect of obtaining good long-term results, and this hasfueled an explosion of studies on double-bundle anteriorcruciate ligament reconstruction. The prevention of abnormalrotation is the proposed advantage of this reconstructionmethod. In addition to functional outcomes, the impact ofimproved kinematics on the development of osteoarthritisremains to be seen.

Multiple graft options are available for anterior cruciateligament reconstruction. The most commonly used grafts are

bone-patellar tendon-bone and hamstring autografts. Theimprovements in fixation devices for soft-tissue grafts havepopularized the use of hamstring autografts in recent years,and prospective studies have shown equivalent functionaloutcomes in association with bone-patellar tendon-bone andhamstring autografts. Many surgeons base their graft selectionon minimizing harvest-site complications. The literature hasshown substantial complications in association with the use ofbone-patellar tendon-bone autograft, including anterior kneepain, pain with kneeling, loss of extension, and poorer re-covery of quadriceps strength. The use of hamstring autograftavoids these complications but has been reported to result inweakness of knee flexion and internal rotation, which may becrucial for certain athletes who rely on these important ham-string functions for optimum performance. Sensory deficitsresulting from injury to branches of the saphenous nerveduring hamstring harvest have been reported. It has been welldocumented that the hamstring tendons regenerate, but thefunction of regenerated tendons has been called into questionas the tendon often heals in a non-anatomic position moreproximally on the medial tibial plateau. A thorough under-standing of donor-site morbidity is essential to prevent per-formance deficits in the athletic population.

To completely eliminate harvest-site morbidity, the useof allograft for primary reconstruction is becoming increas-ingly popular. The use of allograft in revision settings andmultiple-ligament reconstructions will continue to be neces-sary as autologous tissue may not be available in these situa-tions. The outcomes of allograft reconstructions have beenmixed, with some studies showing equivalent outcomes com-pared with autograft and others showing increased laxityand more frequent graft failure with long-term follow-up.Although allografts provide tensile strength similar to auto-graft tissue, there are biological differences in revasculariza-tion, cell viability, and healing of allografts to host bone. Thesefactors are also dependent on sterilization methods. A basicscience study recently showed delayed revascularization andrecellularization as well as decreased mechanical properties of

Specialty Update has been developed in collaboration with the Council ofMusculoskeletal Specialty Societies (COMSS) of the American Academy ofOrthopaedic Surgeons.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor amember of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercialentity.

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J Bone Joint Surg Am. 2009;91:241-56 d doi:10.2106/JBJS.H.01627

fresh-frozen allograft in the sheep model1. A meta-analysis ofpatellar tendon autograft as compared with allograft revealedsignificantly better results in terms of the rate of graft ruptureand the performance of a hop test in association with the use ofautograft2. However, none of the studies included were ran-domized studies, and conclusions drawn from the analysiswere limited by possible bias. The potential benefits of de-creased surgical time, smaller incisions, and elimination ofharvest-site morbidity must be weighed against the possibilityof disease transmission, slower graft incorporation, and in-creased cost associated with allograft use.

Tunnel placement is a critical technical aspect of anteriorcruciate ligament reconstruction. Previous research has shownthat range of motion, stability, and early failure rates are alldirectly related to tunnel placement. More recent literature hasfocused on the number of tunnels and the effect of tunnelplacement on knee kinematics, specifically, the control of ro-tation with a double-bundle reconstruction or with a morehorizontal femoral insertion in a single-bundle reconstruction.Numerous biomechanical investigations have continued toshow better rotational stability in association with double-bundle reconstructions as compared with single-bundle re-constructions, and clinical studies have also demonstrated thisadvantage, with significant reductions in pivot shift beingobserved in association with double-bundle reconstruction3-5.Other studies have demonstrated that single-bundle recon-struction is sufficient to restore intact knee kinematics duringpivot-shift maneuvers and that overtensioning of the graft indouble-bundle reconstructions can reduce the rotation to lessthan that of the intact knee6. A recent randomized studycompared outcomes and laxity following vertical as opposed tomore horizontal femoral tunnel placement during single-bundle reconstructions7. There were no significant differencesin laxity, but the subjective stability score was significantlybetter for the more horizontal position, suggesting that low-ering the femoral tunnel in single-bundle reconstructions canimprove clinical outcomes. A meta-analysis of four random-ized controlled trials and five lower-level studies showed thatdouble-bundle reconstruction resulted in standardized laxitymeasurements that were an average of 0.52 mm closer to thosefor the normal knee and demonstrated no significant differ-ence in the odds of having a normal or nearly normal pivotshift when compared with single-bundle reconstruction8. Theauthors concluded that there is no clinically important dif-ference between the two techniques. Part of the difficulty inanalyzing these studies is the use of the pivot shift, which is asubjective clinical test, to assess rotational stability. An accurateobjective measurement method is needed to standardize thisimportant component of the assessment of post-reconstructionkinematics.

The placement of the tibial tunnel is also important forclinical outcome. Studies of current techniques have suggestedthat placement of the tibial tunnel in the posterior portion ofthe anterior cruciate ligament footprint is important in order

to avoid notch impingement. Many surgeons use the posteriorcruciate ligament, the medial tibial eminence, and the free edgeof the anterior horn of the lateral meniscus to guide tunnelplacement, but there continue to be large variations in theorientation of the tibial tunnel. Computer navigation has beenproposed as a way to optimize accurate tunnel placement inanterior cruciate ligament reconstruction. A randomizedcontrolled trial comparing manual and computer-guidedplacement of the tibial tunnel showed no significant differ-ences between the two groups9. This finding is consistent withprevious findings related to tibial tunnel placement guided bycomputer navigation, which is associated with increased sur-gical time and cost. Improvement in clinical outcomes must beweighed against these factors, and further investigation isnecessary to validate the routine use of computer navigationfor anterior cruciate ligament reconstruction.

Revision surgery after failed anterior cruciate ligamentreconstruction remains a substantial challenge in the field ofsports medicine. Failures occurring in the early postoperativeperiod (within six months) are most often due to impropersurgical technique, whereas late failures are commonly asso-ciated with trauma. Errors in tunnel placement, failure of graftincorporation, and failure to recognize associated injuriesare well-documented causes of failure. Graft tensioning is acontroversial technical aspect of anterior cruciate ligamentreconstruction, with no consensus among surgeons with re-gard to the ideal tension. Inadequate tension results in anonfunctional graft and an unstable knee. Recent studies haveinvestigated overtensioning of anterior cruciate ligamentgrafts, which can lead to decreased motion and poor graftvascularization. An overtensioned graft also may lead toincreased femorotibial contact pressures with hypothesizedlong-term damage to cartilage. When revision surgery is nec-essary, meticulous preoperative planning is essential to avoidintraoperative complications. In a recent case series, sixty-three revisions were evaluated after a mean duration of follow-up of seventy-two months10. Restoration of knee stability withgood or excellent results was achieved in most patients, but25% required a repeat revision, a rate much higher than thatfor primary reconstructions. Return to sports activity was alsomuch less predictable after revision surgery. Patients should beproperly advised regarding outcomes and expectations whendiscussing revision anterior cruciate ligament reconstruction.

The development of osteoarthritis in anterior cruciateligament-deficient and reconstructed knees has long been asubject of debate. While the short-term goal of anterior cru-ciate ligament reconstruction is to provide a stable, functionalknee and to allow a return to sports activity, the long-term goalis to protect other knee structures, namely, the meniscus andcartilage, from further damage. The protection of the meniscuswith anterior cruciate ligament reconstruction is well estab-lished, but long-term studies on the development of arthritishave yet to provide definitive answers. The previously refer-enced study on revision anterior cruciate ligament surgery

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Whats New in Sports Medicine

emphasized the important relationship between the chronicityof instability and the development of arthritis. On the average,patients without arthritic changes had an unstable knee fortwenty-two months whereas patients with arthritic changeshad an unstable knee for fifty-six months. These late arthriticchanges were independent of cartilage injury at the time ofsurgery. This finding may indicate that there is cumulativedamage to cartilage with prolonged instability and that timelyrestoration of stability may prevent or delay the onset ofarthritis. The presence of a bone bruise also has been impli-cated as a possible factor contributing to the development ofarthritis. A long-term, prospective cohort was evaluated for thedevelopment of arthritis at a minimum of twelve years aftersustaining a bone bruise at the time of the initial injury 11. Allbone bruises had resolved at the time of follow-up, and nocorrelation between the presence of an initial bone bruise andthe development of cartilage lesions or arthritis was found. Therelationship between arthritis and anterior cruciate ligament-injured knees remains unknown, and long-term, prospective,controlled studies are needed to clarify the issue.

Rehabilitation of the knee after anterior cruciate liga-ment reconstruction is paramount to successful outcomes,especially the return to the pre-injury level of athletic com-petition. The use of functional knee braces after reconstructionis controversial, and studies have shown mixed results. In arandomized controlled trial of 127 reconstructed knees, theuse of a functional knee brace was compared with a simpleneoprene sleeve12. There were no significant differences be-tween the brace and sleeve groups in terms of outcome mea-sures, laxity measurements, or functional tests at one and twoyears of follow-up. Graft rerupture rates were equal betweenthe two groups as well. Accelerated rehabilitation programscan allow return to sports activity in as little as four months,although most surgeons prefer six months. An acceleratedprogram should only be considered for highly motivatedathletes with access to skilled, monitored physical therapy.Surgeons also may want to consider backup graft fixationmethods to avoid early fixation failure with aggressive, earlyrehabilitation. The concept of neuromuscular rehabilitationis important to protect the reconstruction as well as the healthof the knee joint as a whole. Joint forces and kinematics aredependent on proprioception, balance, and compensationpatterns, requiring a program that incorporates all of thecomponents of neuromuscular control. Rather than a pre-determined time to return to activity, monitored progressionof functional tests allows safer return to sports.

Posterior Cruciate LigamentDespite the recent increase in research, our understanding ofinjury and treatment of the posterior cruciate ligament isconsiderably less than that of the anterior cruciate ligament.The majority of research is biomechanical, and good clinicaloutcomes and comparative studies are lacking. There is stillconsiderable debate regarding the natural history of posterior

cruciate ligament injuries, the surgical indications, and the bestmethods for reconstruction. The diagnosis of these injuriesrequires a careful history and physical examination as wellas proper radiographic assessment. A recent cadaver studyinvestigated the accuracy of stress radiographic techniquesfor the grading of isolated and combined posterior cruciateligament injury, with the 30 and 80 Telos tests (Telos GmbHLaubscher, Holstein, Switzerland) being most accurate fordistinguishing between the different grades of posterior kneelaxity13. This is an important tool for helping to determinetreatment strategy for these injuries. It is generally acceptedthat acute, isolated grade-I and II injuries should be treatednonoperatively, but debate regarding isolated grade-III injuriespersists. Reconstruction of the posterior cruciate ligament incases of combined ligament injuries is necessary, and thetiming of these reconstructions is crucial, emphasizing theneed for timely and accurate diagnosis of multiple-ligamentinjuries of the knee.

Surgical treatment for posterior cruciate ligament defi-ciency remains controversial. As is the case for the anteriorcruciate ligament, the posterior cruciate ligament consists oftwo anatomic bundles, and the need to reconstruct one or bothof the bundles has been the topic of considerable research. Theadded complexity of the double-bundle procedure has yet tobe justified by the documentation of any clinical advantageas compared with single-bundle reconstruction, and high-powered comparison studies are needed to provide answers.The tibial fixation technique remains a matter of surgeonpreference. Proponents of the inlay method have cited a moreanatomic tibial insertion site and avoidance of the so-calledkiller turn, a sharp angle at the proximal margin of the tibialtunnel associated with the transtibial technique that is theo-rized to contribute to graft elongation or failure. These pro-posed advantages have not been substantiated by clinicaloutcomes. Regardless of the technique used, the restoration ofposterior knee stability can be unreliable, with altered kneejoint biomechanics and contact stresses. The association be-tween posterior knee instability and the development of medialcompartment osteoarthritis has been observed in previousstudies. An investigation of the effect of increased tibial slopeon posterior tibial translation in posterior cruciate ligament-deficient knees was performed in a cadaver model14. Increasingthe slope by an average of 4.6 with an osteotomy caused theresting position of the knee to shift anteriorly, and posteriorsag was reduced when the knee was subjected to axial loads.This biomechanical evidence supports the use of osteotomiesfor the treatment of chronic posterior cruciate ligament defi-ciency, but clinical data to support this technique have notbeen published.

The role of the posterior cruciate ligament in knees withmultiple ligamentous injuries has generated much interest asthe failure to recognize concomitant ligamentous injurieshas been implicated in the failure of posterior cruciate liga-ment reconstructions. Previous research has demonstrated

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that residual laxity following posterior cruciate ligament re-construction is commonly related to missed and untreatedinjuries of posterolateral structures. These complex patterns ofinjury are notoriously difficult to diagnose, and correlatingphysical examination findings with indications for treatmentin cases of multiple-ligament injuries is extremely challengingto the sports medicine physician. A study was recently per-formed to better define the physical examination characteris-tics of isolated posterior cruciate ligament and combinedligamentous injuries15. In a cadaver model with sequentialresection of the posterior cruciate ligament and posterolateralstructures, a finding of grade-III posterior laxity on physicalexamination, or >10 mm of posterior translation on stressradiographs, correlated with posterolateral corner injury inaddition to posterior cruciate ligament disruption. Thesefindings suggest that isolated posterior cruciate ligament re-construction may be insufficient to restore stability when thesefindings are present.

Posterolateral CornerThe posterolateral corner of the knee continues to receivesubstantial attention as unrecognized injuries to these struc-tures have dire clinical consequences. The incidence of theseinjuries is likely underreported, and these injuries often are theresult of high-energy mechanisms. Consequently, thesestructures are rarely injured in isolation and are usuallydiagnosed as part of a multiple-ligament knee injury. Theimportance of recognizing an associated neurovascular injuryor compartment syndrome cannot be overstated. A prospectivemagnetic resonance imaging study was recently performed inan attempt to define the prevalence of posterolateral cornerinjuries in patients with an acute knee injury and a hemar-throsis16. A total of 331 consecutive patients were evaluatedover a ninety-day period. The prevalence of posterolateralcorner tears was 9.1%, and 87% of those with posterolateraltears had multiple ligamentous injuries. Surgical treatment ofthese injuries is accomplished with use of multiple techniques.Primary repair is only possible if attempted very early (two tothree weeks) after the injury, and reconstruction is oftenneeded to restore stability. Commonly, the lateral collateralligament, popliteus tendon, and popliteofibular ligament arereconstructed with use of various methods. Tunnel conver-gence in patients undergoing multiple-ligament reconstruc-tions remains a substantial concern. Some surgeons favor atwo-stage approach to multiple-ligament reconstructions, withacute repair of the posterolateral corner being followed bycruciate reconstruction after motion is restored. In patientswith chronic posterolateral corner injuries, varus malalign-ment can predispose to the failure of ligament reconstruction.A prospective clinical trial assessed functional outcomes forpatients with posterolateral corner deficiency and genu varuswho were managed initially with a medial opening-wedgeosteotomy 17. Eight of twenty-one patients had substantialimprovement after the osteotomy and did not require subse-

quent ligament reconstruction, and the final outcome scoresfor patients requiring reconstruction were significantly worsethan those for patients managed with osteotomy alone. Thatstudy emphasizes the need to address all pathoanatomic factorsin this complex injury pattern in order to avoid the failure ofmajor reconstructive efforts.

MeniscusAlthough our understanding of the function of the meniscuscontinues to improve, the treatment of meniscal injuries re-mains a substantial challenge. Research efforts have elucidatedthe biomechanical role of the meniscus in stability, loaddistribution, and shock absorption as well as its contributionsto the nutrition of articular cartilage, joint lubrication, andproprioception. Because of these diverse functions, preserva-tion of the meniscus is important in order to optimize thelong-term health of the knee. Methods of repair, replacement,and substitution of meniscal tissue continue to evolve, but theindications for these procedures often are not met, and partialmeniscectomy remains among the most common proceduresperformed in orthopaedic surgery. The predictors of short-term recovery after arthroscopic partial meniscectomy wererecently investigated18. Age, body mass index, the depth ofmeniscal excision, and involvement of one or both menisciwere not associated with patient recovery over time, but femalesex and the extent of osteoarthritis were associated with asignificantly slower rate of recovery throughout the first yearpostoperatively. This information can help to plan the practicalaspects of short-term recovery after this very commonprocedure.

The gold standard for meniscus repair remains theinside-out technique with vertical mattress sutures. It is wellknown that anterior cruciate ligament reconstruction at thetime of meniscus repair improves healing rates, and this factormust be taken into consideration when evaluating the litera-ture on meniscal repair. While the development of all-insidemeniscus-repair devices has made this procedure technicallyeasier, the indications for repair based on tear pattern andlocation must be followed to avoid high failure rates and ad-ditional surgery. Numerous all-inside devices are currentlyavailable, and the clinical efficacy and complications of thesedevices have been well documented in recent years. A clinicaltrial of 280 meniscal repairs in patients undergoing concom-itant anterior cruciate ligament reconstruction demonstratedsimilar outcomes in association with three commonly used all-inside devices after an average duration of follow-up of twoyears19. The success rates, based on clinical examination andsymptoms, were 92.4% for the FAST-FIX device (Smith andNephew Endoscopy, Andover, Massachusetts), 87% for theT-Fix device (Acufex Microsurgical, Mansfield, Massachusetts),and 86.5% for the RAPIDLOC device (DePuy Mitek, Raynham,Massachusetts). Chronicity, the length or location of the tear, andpatient age did not affect clinical outcomes. Of note, grooving ofthe medial condyle by the top hat of the RAPIDLOC device was

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observed in two of six patients undergoing repeat arthroscopybecause of failure. Further investigation is needed to determineany clinical consequences of this finding. While many studieshave evaluated the healing of repair on the basis of clinicalsymptoms, the question of clinically silent failures remains.When imaging studies are used to evaluate healing, a wide rangeof results, including partial healing of the meniscus, are dem-onstrated. The functional implications of these findings remainunknown. A recent study evaluated fifty-three meniscal repairs(including thirty-one repairs in knees undergoing concomitantanterior cruciate ligament reconstruction) with computedtomographic arthrograms at six months postoperatively20.Following the repairs, which were performed with use of all-inside, outside-in, or hybrid techniques, 58% of the meniscicompletely healed, 24% partially healed, and 18% failed, with asignificant reduction in the width of the repaired tissue. Theauthors emphasized the importance of removal of fibrous tissueand tear-site abrasion along with stable fixation with nonab-sorbable suture to optimize meniscal repair.

Despite advances in meniscal repair, many injuries resultin irreparable tears. The long-term outcomes of total menis-cectomy are notoriously poor. Meniscal replacement can beindicated for young patients with persistent pain, normalalignment, stable ligaments, and healthy cartilage who havehad a failure of conservative management. Allograft trans-plantation is an established option, but it is a technically de-manding procedure that recent research has shown to beheavily dependent on proper sizing and insertion technique.Tissue-engineered implants have been developed and studiedin the laboratory for years, and a clinical trial of the collagenmeniscus implant was recently published21. That prospective,randomized, multicenter, controlled trial, in which the colla-gen meniscus implant was compared with partial meniscec-tomy, was conducted as part of a Phase-II feasibility study toconfirm the safety and to establish the efficacy of the implant.This implant is a tissue-engineered scaffold that enableshost-tissue ingrowth and requires a meniscal rim for attach-ment. Second-look arthroscopy, which was performed for 141patients who had received the implant, revealed that the newtissue was well integrated and stable, with no failures due tolack of healing to the host meniscal rim. Both the acute group(no previous surgery) and the chronic group (previous me-niscal surgery) were studied at a mean of fifty-nine months offollow-up. In the chronic group, patients who had received theimplant regained significantly more of their lost activity andunderwent significantly fewer reoperations as compared withthose who had undergone partial meniscectomy only. In theacute group, there were no significant differences between thepatients who had received the implant and those who hadundergone partial meniscectomy, and the rate of seriouscomplications was equal for the implant and partial menis-cectomy groups. This implant appears to be safe and biome-chanically competent to replace meniscal tissue and to improveknee function.

PatellaDisorders of the patellofemoral joint are very common amongyoung athletes. Acute trauma, overuse injuries, and malalign-ment problems cause alterations in the delicate balance of thiscomplex articulation. A careful physical and radiographicevaluation is imperative to determine any biomechanical fac-tors to which the instability or pain can be attributed. Becauseof the wide array of surgical treatments for these disorders, anaccurate diagnosis is essential to define the correct indicationsfor these diverse problems.

While the treatment of patellar instability remains con-troversial, the medial patellofemoral ligament is now generallyaccepted as the primary soft-tissue restraint to lateral dis-placement of the patella, leading to an increase in proximalrealignment procedures in recent years. Although nonopera-tive treatment of initial patellar dislocations is recommended,persistent instability is a common complaint. A randomizedtrial compared the operative and nonoperative treatment ofprimary acute patellar dislocation in patients younger thansixteen years of age22. Operative treatment consisted of a lateralrelease, either alone or in combination with direct medial re-pair. This method of initial operative repair did not improvethe long-term outcome, and the recurrent dislocation rateswere nearly identical. The authors identified a positive familyhistory and contralateral patellofemoral instability as riskfactors for recurrence. Another study, in which nonoperativetreatment of primary dislocation of the patella was comparedwith operative treatment with use of anchor-based reattach-ment of the medial patellofemoral ligament to the adductortubercle, showed that this procedure was of no benefit forreducing the rate of recurrent dislocation or improving func-tional outcome in patients thirteen to thirty years of age23.Some surgeons advocate medial patellofemoral ligament re-construction instead of direct repair because the pattern of in-jury to the medial ligamentous structures appears to be variableand intraoperative isolation of these structures is difficult.Recent research has focused on the alteration of patellofemoralcontact pressures with overtensioning of the reconstruction andthe possible development of patellofemoral arthritis. In a recentcase series with a mean duration of follow-up of 11.9 years, onlytwo of twenty-four knees had definite progression to moderatearthritis, 88% of the knees had a good or excellent clinicaloutcome, and two knees had recurrent instability24. Furtherresearch is needed to determine the best method for restoringstability and improving clinical outcomes.

ShoulderRotator CuffThe treatment of rotator cuff disorders continues to improve,and these injuries are among the most common reasons forevaluation by a sports medicine physician. The rotator cuffremains the topic of intense research, and our understandingof cuff tears and their treatment has grown enormously as aresult of these efforts. An evaluation of the recent literature

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reveals that the outcomes of arthroscopic rotator cuff repairhave become equivalent to those of open and mini-opentechniques. This is likely due to improved familiarity and skillwith arthroscopic methods as well as to continued advancesin implant materials and surgical devices that facilitatearthroscopic repair. Many surgeons prefer to perform an ar-throscopic subacromial decompression combined with a mini-open rotator cuff repair. In a randomized controlled trial ofsixty-three patients, the results of open acromioplasty androtator cuff repair were compared with arthroscopic acro-mioplasty and mini-open rotator cuff repair after an averageduration of follow-up of twenty-eight months25. No differencesin outcome scores were found at one and two years aftersurgery, but a significant difference was demonstrated at thethree-month follow-up in favor of the arthroscopic mini-openrepair group. This finding is representative of the less-invasivenature of arthroscopic procedures and is consistent with pre-vious findings that good results are obtained with both openand arthroscopic methods.

The method of fixation for rotator cuff repair has re-ceived much attention in recent years. The goal of repair at thetime of surgery is to provide maximum initial strength and toprovide a large tendon-bone contact area. The strength of therepair must withstand displacement and gap formation untilhealing of the tendon to bone is complete. A large contact areais necessary to restore the normal anatomic rotator cuff foot-print, which covers a large portion of the tuberosity. Theseconcepts led to double-row and transosseous-equivalent su-ture methods. Numerous biomechanical studies have shownsuperior initial strength in association with the double-rowrepair. Recently, two studies demonstrated the importance ofincluding humeral rotation when assessing the biomechanicalstrength of repair methods. One study demonstrated thatdouble-row repairs performed significantly better than single-row repairs, particularly when cyclic loading was measuredwith humeral internal and external rotation26. Another studyrevealed that dynamic external rotation resulted in greater gapformation anteriorly than posteriorly following suture tendon-bridging repair, but overall, no difference was found in termsof gap formation, stiffness, or ultimate load to failure betweenthe suture tendon-bridge and double-row methods27. Despitethe advantages of double-row techniques seen in the labora-tory, significant advantages in clinical outcomes have not beenconsistently demonstrated. It appears that the greatest advan-tage of double-row repairs is seen in association with largetears. A recent study with a two-year follow-up demonstratedimproved outcomes for tears of >3 cm that were repaired witha double-row method and demonstrated no difference be-tween single and double-row repairs for tears of

strained nature of the joint allows an extraordinary range ofmotion but can result in excessive laxity, causing damage to thelabrum and the capsuloligamentous restraints. The treatmentof a primary dislocation of the shoulder has been a topic ofcontinuous debate as the etiologic factors, pathology, andprognosis are highly variable among various patient groups.Research in previous years suggested that younger male pa-tients may experience an unacceptably high rate of recurrentdislocation and poorer functional scores in association withnonoperative management, whereas the rate of recurrent in-stability decreases among older patients participating in less-high-risk activities. Among studies evaluating nonoperativemanagement, the necessity for immobilization and the methodof immobilization have been questioned. A recent long-termstudy (duration of follow-up, twenty-five years) investigatedthe natural history and prognostic factors for patients fortyyears of age and younger who received conservative manage-ment with and without immobilization for the treatment of aprimary anterior dislocation35. Overall, 43% of the patients hadno additional episodes of dislocation, with a nonrecurrencerate of 28% in the twelve to twenty-two-year age group, a 44%rate in the twenty-three to twenty-nine-year age group, and a73% rate in the thirty to forty-year age group. The authors alsoreported that half of the shoulders in the youngest age groupbecame stable over time, providing a basis for initial nonop-erative management. They found no difference in prognosiswhen immobilization for three to four weeks was comparedwith immediate mobilization, and they found no associationbetween athletic activity and the risk of recurrence.

Advances in surgical stabilization procedures reflectthe increased understanding of the pathoanatomy of shoul-der instability, specifically, the detached anteroinferior aspectof the glenoid labrum and capsuloligamentous structures(Bankart lesion). The decision to perform open as opposed toarthroscopic stabilization depends on surgeon experience, witharthroscopic procedures showing equivalent success rates inrecent years. A randomized trial comparing arthroscopic ex-amination and lavage with arthroscopic Bankart repair for thetreatment of primary dislocation demonstrated a 76% reduc-tion in risk of further dislocation for the repair group36. Thefunctional scores, patient satisfaction, and return to contactsports were also significantly higher for the repair group ascompared with the group managed with lavage alone. Theauthors concluded that there is a treatment benefit in associ-ation with repair of a primary dislocation, but they did notrecommend routine prophylactic repair for all primary dislo-cations because patients managed without repair in whom theshoulder remained stable over time had no functional disad-vantage. A thorough discussion with patients regarding prog-nosis, the risk of complications, and the expectations forreturn to sports is essential to tailor the correct treatment planfor each individual. As materials and implants evolve, theclinical outcomes associated with their use must be followed. Arecent trial comparing nonabsorbable and absorbable sutures

for the treatment of shoulder instability demonstrated nodifference in outcomes at two years of follow-up37. Laboratoryinvestigations of various stabilization techniques are a con-tinued focus of published research. Reduction of shouldervolume with an arthroscopic method recently demonstratedeffects comparable with those of open methods, with possibleimplications for the arthroscopic treatment of multidirectionalshoulder instability 38. A study on the effect of rotator intervalclosure on anterior and posterior instability in a cadaver modelshowed no improvement in terms of posterior or inferiorinstability after interval closure, with the expected loss ofexternal rotation associated with this technique39. This findingis contrary to those of previous published reports, and furtherinvestigation is necessary to elucidate the role of interval clo-sure in reducing instability.

Multiple factors must be addressed to provide the opti-mal treatment of an unstable shoulder. Recent literature hasreflected an emphasis on the evaluation of bone deficiency inpatients with shoulder instability. Clinically relevant bonedefects include the engaging Hill-Sachs lesion and the in-verted pear glenoid, both of which result in unacceptably highrates of recurrent instability when treated arthroscopically. If adeficiency of >25% of the inferior part of the glenoid exists, abone augmentation procedure is indicated. This has led to theresurgence of the Latarjet procedure and the development ofother open procedures to address the osseous deficiency oftenassociated with recurrent dislocations. A study in which theglenoid index as determined with three-dimensional com-puted tomography was used to evaluate glenoid defects showedthat 96% of the cases needing an osseous procedure werepredicted with three-dimensional computed tomography40.This represents an important diagnostic tool for preoperativeplanning, although it requires computed tomography scans ofboth shoulders to calculate the glenoid index. A recent caseseries evaluating the results of a modified Latarjet procedurefor recurrent instability reported a 4.9% rate of recurrenceafter a mean duration of follow-up of fifty-nine months41.Another series investigated the outcomes associated with theuse of an anatomically modeled bicortical iliac crest graft forglenoid reconstruction after recurrent dislocation42. The au-thors reported no recurrent instability and good functionalscores after a mean duration of follow-up of 106 months.These studies validate the use of open bone-restoring pro-cedures in cases in which soft-tissue reconstruction alone isinsufficient to provide stability.

The diagnosis and treatment of lesions involving thesuperior labrum and biceps anchor are subjects of continuedinterest to the sports medicine specialist. Accurate diagnosis ofsuperior labrum anterior and posterior (SLAP) tears is a dif-ficult problem as multiple physical examination tests exist,with only modest sensitivity and specificity for any single testwhen used in isolation. A suspicion for these lesions shouldbe high in young patients with pain and/or clicking duringoverhead activities. Current recommendations favor the use of

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multiple physical examination tests along with patient history,demographic data, and magnetic resonance arthrography todefine these subtle lesions. A randomized controlled trial eval-uated outcomes in patients over the age of fifty years who hadtype-II SLAP lesions and rotator cuff tears43. A comparisonbetween patients who underwent SLAP lesion repair and rotatorcuff repair and patients who underwent rotator cuff repair andbiceps tenotomy revealed no advantages to including the SLAPlesion repair in this patient population. The relationship be-tween rotator cuff and biceps tendon pathology continues to bea gray area, and the indications for tenotomy as opposed totenodesis in this setting have yet to be definitively determined.

Acromioclavicular JointTraumatic disruption of the acromioclavicular joint is acommon injury in the athletic population. The coracoclavic-ular ligaments are key stabilizing structures of the acromio-clavicular joint, and a multitude of techniques to reconstructthese ligaments have been described. Controversy over treat-ment of the acute type-III acromioclavicular separation con-tinues, but current recommendations support nonoperativetreatment of these injuries, with surgical treatment being re-served for chronic injuries for which conservative treatmenthas failed. The classic Weaver-Dunn reconstruction with use ofthe coracoacromial ligament is still commonly performed, butweak initial suture fixation to the clavicle in some cases hasled to techniques involving suture anchors and allograft orautograft tendon reconstructions. These methods have shownsuperior biomechanical strength in the laboratory. A numberof recently published case series involving suture anchors andtendon reconstructions have shown good recovery of strengthand motion, with no loss of reduction. Prospective, random-ized comparison studies are lacking, and no consensus on thepreferred technique exists.

CartilageThe treatment of articular cartilage defects is controversial.These injuries have a poor capacity to heal spontaneously andoften lead to early osteoarthritis. There are many treatmentoptions that attempt to restore pain-free function over the longterm, but no single method has consistently proved to be su-perior. The major anatomic foci of these techniques are theknee and ankle, where substantial disability can result fromarticular cartilage injuries. Treatment options include marrowstimulation techniques (microfracture), osteochondral auto-graft plug transfer, osteochondral allograft, and autologouschondrocyte implantation. While each of these methods canlead to good results, they are also associated with drawbacks.Autograft plug transfer replaces the defect with normal hyalinecartilage, but restoring a congruent articular contour isdifficult and the harvest site can produce persistent pain.Osteochondral allografts are generally indicated for largerdefects and those associated with substantial subchondral boneloss, but matching the normal contour is difficult and ques-

tions regarding chondrocyte viability with various preservationtechniques persist. Recent studies have suggested that freshallografts, which maintain viable chondrocytes, incorporatewell into host bone and do not cause immune rejection.Further research is needed to elucidate the role of allograftrestoration of cartilage defects.

Microfracture has provided good clinical results, and theprocedure is inexpensive and easy to perform. The majordrawback of this procedure is healing of the defect withfibrocartilage, which is far less durable than the native hyalinecartilage. The development of regenerative techniques torestore hyaline cartilage, such as autologous chondrocyte im-plantation, has been the subject of extensive research in recentyears. This technique requires two operations, requires com-pliance with an extensive postoperative rehabilitation pro-gram, and is very expensive. Moreover, the regeneratedcartilage is described as hyaline-like, calling into question itslong-term durability. A randomized study in which autologouschondrocyte implantation was compared with microfractureof the femoral condyle showed no significant clinical orradiographic differences between the two groups after fiveyears of follow-up44. At the time of the two-year follow-up,histological specimens were collected and graded, and nocorrelation was found between histological quality and clinicaloutcome, although no patient with predominantly hyalinecartilage had clinical failure at the five-year mark. This resultsuggests that microfracture may be a better first-line procedurethan autologous chondrocyte implantation is because of thelow cost and simplicity of the procedure. In another ran-domized controlled trial, characterized chondrocyte implan-tation (ChondroCelect; TiGenix, Leuven, Belgium) was comparedwith microfracture. Characterized chondrocytes are an expandedpopulation of cells that express a marker that is predictive ofthe capacity to form hyaline-like cartilage, with greater homoge-neity and optimal potency of each cell batch45. At one year aftertreatment, clinical outcome was similar for both treatments,but characterized chondrocyte implantation was associated withregenerated tissue that was histologically superior to that ofmicrofracture. Long-term follow-up is necessary to determineif the structural advantages of this tissue result in improvedclinical outcomes.

The intra-articular administration of local anesthetic hasreceived much attention in the recent literature. Because of thepopularity of outpatient surgery for many sports medicineprocedures, alternative methods of pain control have beendeveloped, including the pain pump, which continuously in-fuses local anesthetic to the operative site. Reports of chon-drolysis associated with use of the pain pump have called intoquestion the safety of this modality. Although bupivacaine hasbeen implicated in most investigations, a report on lidocainetoxicity was recently published46. Cultured bovine chondro-cytes and osteochondral cores were treated with 1% or2% lidocaine for fifteen, thirty, or sixty minutes and werecompared with buffered saline solution treatment with regard

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to chondrocyte viability. Results showed dose and time-dependent effects of lidocaine exposure for both the culturedchondrocytes and the osteochondral plugs. To determine ifropivacaine may be a safer alternative to bupivacaine, a studycomparing their effects on human chondrocytes was con-ducted47. Full-thickness cartilage explants and cultured chon-drocytes were treated with saline solution, 0.5% ropivacaine,or 0.5% bupivacaine for thirty minutes. Chondrocyte viabilitywas significantly greater after treatment with ropivacaine ascompared with bupivacaine in both the cartilage explants andthe cultured chondrocytes. These laboratory results suggestthat ropivacaine is a safe alternative, but clinical correlation isnecessary. Moreover, multiple studies have questioned the ef-ficacy of pain relief with use of the pain pump, and some haveconcluded that interscalene block is equally effective for painrelief following arthroscopic shoulder surgery, without theconcerns for cartilage damage. More research is necessary, buton the basis of the current literature, the use of bupivacaine forintra-articular analgesia should be avoided.

Hand and WristDisorders of the hand and wrist are common among athletes,but few studies pertaining to the treatment of these injuries arefound in the sports medicine literature. The current focusremains on arthroscopic treatment for injuries of the wrist,including dorsal wrist impingement syndrome, ulnar-sidedwrist pain, and tears of the triangular fibrocartilage complex.Techniques for arthroscopic repair of the triangular fibrocar-tilage complex continue to evolve, and most of these injuriesare still treated by hand surgeons. It has been demonstratedrecently that an ulnar positive variance is associated with in-creased cell death in degenerative triangular fibrocartilagecomplex lesions, which may explain why this anatomic varianthas been associated with poorer outcomes after arthroscopicrepair. Techniques to normalize ulnar variance are likelynecessary to avoid failed repair in this patient population.

Injuries to the ulnar collateral ligament of the thumb arevery common among athletes, especially football players.However, no recent studies on the treatment of these injurieshave been published in the sports medicine literature. Researchon operative and nonoperative treatment, the timing of sur-gery, and the impact of this injury on sport and position-specific performance is needed to guide the team physicianthrough this difficult decision-making process.

ElbowLateral epicondylitis is a very common diagnosis amongcompetitive and recreational athletes. Overuse, especiallyrepetitive forearm activity and wrist extension, leads to thedevelopment of tendinosis and the formation of granulationtissue in an attempt to repair the damaged extensor tendonorigin. While initial nonoperative management is the mainstayof treatment, refractory cases often require surgical interven-tion. Debate over the method of surgical treatment persists.

Recent published long-term follow-up studies of both thearthroscopic and open methods have demonstrated remark-ably similar outcomes. It appears that either surgical techniqueis acceptable, as long as the pathologic tissue is accuratelyidentified and adequately resected.

The treatment of acute distal biceps ruptures continuesto evolve. Operative repair has been associated with superioroutcomes in comparison with nonoperative treatment, espe-cially with regard to the restoration of supination strength.Multiple repair methods utilizing one or two incisions andvarious fixation devices have been described. The anteriorincision has been associated with various nerve injuries,whereas the two-incision transosseous suture approach canresult in radioulnar synostosis. A biomechanical comparisonof multiple fixation devices and the transosseous suturemethod showed initial failure loads sufficient to withstandrehabilitation techniques for all methods tested, but theENDOBUTTON (Smith and Nephew Endoscopy, Andover,Massachusetts) had a significantly higher load to failure thanall other techniques did48. This finding is consistent with thoseof previous biomechanical reports, and further clinical corre-lation is needed to compare the results and complicationsassociated with these various techniques.

Injury to the ulnar collateral ligament of the elbow re-sults in markedly decreased performance in throwing athletes.The anterior band of the ulnar collateral ligament experi-ences tremendous stresses during the late-cocking and early-acceleration phases of throwing, resulting in stretching,attenuation, or rupture of the ligament. Numerous previousreports have documented the efficacy of reconstruction of theulnar collateral ligament for return to throwing sports. Theresults of a new hybrid reconstruction technique, combiningthe advantages of the docking technique for proximal fixationwith the improved biomechanical characteristics of distal in-terference screw fixation, were published this year49. This methodlessens the risk of fracture of the medial epicondyle, while re-storing the native, narrow insertion of the ligament through asingle distal tunnel. After a mean duration of follow-up of thirty-six months, nineteen of twenty-two patients had an excellentresult, with two cases of ulnar neuritis. These results are similarto those associated with other published techniques, and theauthors concluded that this technique is especially useful forrevisions and cases of sublime tubercle insufficiency.

HipThe arthroscopic treatment of structural abnormalities of thehip has increased dramatically in recent years. Hip arthroscopyhas been an effective treatment for labral pathology, and theosseous abnormalities leading to labral damage are now beingaddressed arthroscopically. Femoroacetabular impingementresults from a decreased anterior head-neck offset of theproximal part of the femur (cam-type impingement) or ace-tabular overcoverage (pincer-type impingement), and theseareas can be treated with arthroscopic osteoplasty. The diagnosis

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of cam-type femoroacetabular impingement has been shown tocorrelate with an increased offset angle, and the larger camlesions are associated with larger areas of cartilage damage andlabral detachment. Both open and arthroscopic treatmentmethods have been described, and case series investigating theclinical outcomes of arthroscopic treatment have shown goodoutcomes in the short term. Cadaver studies have confirmedthat adequate osseous resection can be achieved arthroscopic-ally, and avoiding the extensive open approach and its associatedrisk to the femoral head blood supply is a decided advantage ofthe arthroscopic technique. However, as this is a new method oftreatment, no long-term results are available and direct com-parison studies of the open and arthroscopic techniques havenot been performed, to our knowledge.

Foot and AnkleInjuries to the foot and ankle are common in our increasinglyactive population. Acute trauma or overuse can result in bone,ligament, tendon, or cartilage injuries. As mentioned previ-ously, cartilage lesions of the ankle represent a difficult treat-ment challenge, and, similar to the knee, there is no consensuson the best treatment for these troublesome lesions. Recentstudies have shown microfracture to be effective, but well-designed comparison studies are lacking. A number of recentstudies have investigated the effects of different nonoperativetreatments on chronic Achilles tendinopathy. In a randomizedcontrolled trial, the probability for recovery was found to besignificantly lower after eccentric loading than after low-energyshock wave therapy 50. Another randomized controlled trialevaluated three different nonoperative treatment regimens51.No significant differences were found between groups treatedwith eccentric loading, a specifically designed heel brace, or acombination of the two methods at six, twelve, or fifty-fourweeks of follow-up. These studies challenge the effectiveness ofeccentric calf-loading and provide less painful alternatives thatcan be effective for treating these chronic injuries.

The treatment of acute Achilles tendon ruptures is alsocontroversial. It is well established that the rerupture rate islower in association with operative treatment, and there is alsoevidence that nonoperative treatment is associated with stiff-ness and decreased strength. Surgical treatment along withearly, restricted motion has demonstrated outcomes superiorto those of nonoperative treatment. A recent randomizedcontrolled study investigated the importance of early motionafter the operative or nonoperative treatment of an Achillestendon rupture52. Patients in both the operative and nonoper-ative treatment groups were managed with the same controlledearly motion, and the authors found no significant differencesbetween the groups in terms of plantar flexion, dorsiflexion, orcalf circumference at multiple time intervals during the first yearafter treatment. There was also no difference between the twogroups with regard to the rerupture rate, providing strong evi-dence that controlled early motion may be the most importantpart of treatment for a ruptured Achilles tendon.

SpineThe on-field treatment of spine and other neurologic injuriescontinues to be a focus of sports medicine physicians. Theimportance of recognizing concussions, and the devastatingconsequences of repeat episodes, continues to receive in-creasing attention. In particular, the second-impact syndrome,which is a minor second injury after incomplete recovery froma previous head injury, must be avoided. There are still nouniversally accepted guidelines for diagnosis and criteria forreturn to play, but a conservative approach with these seriousinjuries is warranted. A close working relationship with theathletic trainer is crucial to provide the safest treatment on thesidelines, and for follow-up in the training room.

Cervical spine injury is a major concern in collisionsports. On-field immobilization recommendations for adultfootball players are well described. Recently, an investigation ofthe most effective cervical immobilization for youth footballplayers was conducted53. To determine if the increased head-to-torso ratio in developing children leads to increased ky-phosis when placed on a spine board, the effects of helmets andpads on cervical alignment were evaluated. Thirty-one footballplayers who were eight to fourteen years of age were evaluatedradiographically while wearing both shoulder pads and helmet,no equipment, or shoulder pads and no helmet. The radio-graphs showed that the proper alignment was maintainedwhen the helmet and shoulder pads were left on. Therefore,the current recommendation for youth football players isimmobilization and transport with the helmet and shoulderpads left in place. Additionally, continued education on propertackling technique is a very important part of the prevention ofthese potentially catastrophic injuries.

Injury PreventionThe prevention of sports injuries continues to be a major focusin our field. An increased understanding of injury risk factors,including neuromuscular factors, has led to the developmentof effective prevention strategies. The higher risk of anteriorcruciate ligament tears in females is well documented, and therelationship of kinematic factors to anterior cruciate ligamentinjuries in this population has been investigated extensively. Arandomized controlled study of noncontact anterior cruciateligament injury prevention in female collegiate soccer playersshowed a 41% decrease in the overall rate of anterior cruciateligament injury with use of a neuromuscular and proprio-ceptive training program54. The PEP program (Prevent injuryand Enhance Performance) consists of stretching, strength-ening, plyometrics, and agility exercises to address potentialdeficits in strength and neuromuscular coordination of thestabilizing muscles around the knee. This program was im-plemented during normal practice time and without the needfor special equipment, making it more feasible than manypreviously reported programs, and provides promising resultsin the reduction of noncontact anterior cruciate ligament in-juries. The incidence of other injuries may not be influenced

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by prevention programs. For instance, the risk of developingoveruse knee injuries and medial tibial stress syndrome wasnot influenced by an exercise program in a study of >1000army recruits55. The concurrent increase in activity levelcombined with the exercise program likely resulted in excessiveincreased load, which is the underlying cause of these partic-ular injuries. Further investigation is necessary to establish theoptimal role of prevention programs for specific activities.

The increasing rate of injuries in youth baseball pitchersis another area of concern. The incidence of elbow and shoulderpain in these athletes is alarmingly high, and the number ofsurgical procedures used to address these injuries has increaseddramatically in recent years. An increased risk of injury has beenassociated with the number of pitches thrown and the type ofpitch thrown, specifically, the curveball. A biomechanical com-parison of different types of pitches showed that in general,elbow and shoulder loads were greatest for the fastball, whichsuggests that the curveball may not be more harmful than thefastball for youth pitchers56. That study supports the recent focuson limiting the number of pitches rather than the type of pitch.Regardless of what type of pitches are thrown, a strict pitchcount limit that includes games and practices is essential toinjury prevention in youth baseball players.

Evidence-Based OrthopaedicsThe editorial staff of The Journal reviewed a large number ofrecently published research studies related to the musculo-skeletal system that received a Level of Evidence grade of I. Over100 medical journals were reviewed to identify these articles, all ofwhich have high-quality study design. In addition to articles al-ready cited in this update, twenty-one additional level-I articleswere identified that were relevant to orthopaedic sports medi-cine. A list of those articles is appended to this review followingthe standard bibliography. We have provided a brief commentaryabout each of the articles to help to guide your further reading,in an evidence-based fashion, in this subspecialty area.

Subspecialty Certification in Sports MedicineSubspecialty certification in sports medicine is under thedirection of the American Board of Orthopaedic Surgery(ABOS). The subspecialty certification examination has beenheld twice, in 2007 and 2008, and the five-year grandfatherperiod for any surgeon seeking this certification will expire in2012. After this date, applicants will be required to havecompleted an Accreditation Council for Graduate MedicalEducation (ACGME)-accredited and/or Arthroscopy Associa-tion of North America (AANA)-recognized sports medicinefellowship to sit for the examination. Current requirements toapply for the examination include ABOS certification and anactive sports medicine practice with at least 115 sports medi-cine cases (seventy-five of which must include arthroscopy)within the previous year. A complete list of requirements, in-cluding eligible sports medicine cases, is available online at theABOS web site (www.abos.org).

The application deadline for the 2009 examination isMarch 15, 2009. It must include case lists, required documents,and fees. Eligible candidates will be mailed their scheduling/admission permits in August 2009, and the examination will beadministered in November 2009 at Prometric TechnologyCenters nationwide. The application materials are available atthe ABOS web site. The AOSSM and AAOS review course forsubspecialty certification in orthopaedic sports medicine willbe held August 14 through 16, 2009, in Chicago, Illinois, andinformation on this course can be found at the AOSSM website (www.sportsmed.org). Applications for the 2010 exami-nation will be available online beginning in August.

Sports Medicine FellowshipsSports medicine remains the most popular fellowship choice inorthopaedic surgery. This year, important changes in sportsmedicine fellowships are taking place. The 2008-2009 fellow-ship class represents the first class that requires completion ofan ACGME-accredited program to be eligible for the ABOSsubspecialty certification examination. Currently, eighty-fivefellowships are accredited, and applicants may wish to considerthis factor when choosing a fellowship given the subspecialtycertification requirements discussed above. As many unac-credited fellowship programs continue to seek accreditation,applicants should contact individual programs or the ACGMEto determine changes in accreditation status.

Another important change in the fellowship process thisyear is the establishment of a formal match for appointmentyear 2010. The previous match system dissolved in 2005, and agentlemans agreement among participating programs wasin place last year. The formal match process combined theefforts of the AOSSM, AANA, and ABOS, and is necessary toallow applicants the opportunity to complete all offered in-terviews before making a final decision. At this time, ninety-four programs representing 225 positions will participate inthe match, and it is hoped that participating programs andfellowship directors will honor this system to standardize theprocess and provide a fair system for applicants. The matchwill be administered by the San Francisco Match Servicesand utilizes the Central Application Service (CAS). Both ac-credited and unaccredited programs are participating, and thisdesignation is available online at the San Francisco Match website (www.sfmatch.org). Applicants must register directlywith the San Francisco Match to participate. The deadlinefor submission of rank lists by programs and applicants isMarch 20, 2009, and match day is April 15, 2009. More in-formation, including the match agreement, fees, and deadlines,is available at both the AOSSM and the San Francisco Matchweb sites.

Upcoming MeetingsThe Seventy-sixth Annual Meeting of the American Academyof Orthopaedic Surgeons will be held February 25 through 28,2009, in Las Vegas, Nevada, with specialty day being held on

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February 28, 2009. The annual meeting of the ArthroscopyAssociation of North America will be held April 30 throughMay 3, 2009, in San Diego, California. The annual meeting ofthe American Orthopaedic Society for Sports Medicine will beheld July 9 through 12, 2009, in Keystone, Colorado.

Andrew C. Gerdeman, MDMaCalus V. Hogan, MDMark D. Miller, MDDepartment of Orthopaedic Surgery, University of Virginia,400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22908-0159.E-mail address for M.D. Miller: [email protected]

References

1. Scheffler SU, Schmidt T, Gangey I, Dustmann M, Unterhauser F, Weiler A.Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligamentreconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep. Arthroscopy. 2008;24:448-58.

2. Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendonautograft versus patellar tendon allograft in anterior cruciate ligament reconstruc-tion. Arthroscopy. 2008;24:292-8.

3. Siebold R, Dehler C, Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy.2008;24:137-45.

4. Fu FH, Shen W, Starman JS, Okeke N, Irrgang JJ. Primary anatomic double-bundle anterior cruciate ligament reconstruction: a preliminary 2-year prospectivestudy. Am J Sports Med. 2008;36:1263-74.

5. Jarvela T, Moisala AS, Sihvonen R, Jarvela S, Kannus P, Jarvinen M. Double-bundle anterior cruciate ligament reconstruction using hamstring autografts andbioabsorbable interference screw fixation: prospective, randomized, clinical studywith 2-year results. Am J Sports Med. 2008;36:290-7.

6. Markolf KL, Park S, Jackson SR, McAllister DR. Simulated pivot-shift testing withsingle and double-bundle anterior cruciate ligament reconstructions. J Bone JointSurg Am. 2008;90:1681-9.

7. Jepsen CF, Lundberg-Jensen AK, Faunoe P. Does the position of the femoraltunnel affect the laxity or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized, double-blind study.Arthroscopy. 2007;23:1326-33.

8. Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundleversus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med. 2008;36:1414-21.

9. Mauch F, Apic G, Becker U, Bauer G. Differences in the placement of the tibialtunnel during reconstruction of the anterior cruciate ligament with and withoutcomputer-assisted navigation. Am J Sports Med. 2007;35:1824-32.

10. Battaglia MJ 2nd, Cordasco FA, Hannafin JA, Rodeo SA, OBrien SJ, AltchekDW, Cavanaugh J, Wickiewicz TL, Warren RF. Results of revision anterior cruciateligament surgery. Am J Sports Med. 2007;35:2057-66.

11. Hanypsiak BT, Spindler KP, Rothrock CR, Calabrese GJ, Richmond B,Herrenbruck TM, Parker RD. Twelve-year follow-up on anterior cruciate ligamentreconstruction: long-term outcomes of prospectively studied osseous and articularinjuries. Am J Sports Med. 2008;36:671-7.

12. Birmingham TB, Bryant DM, Giffin JR, Litchfield RB, Kramer JF, Donner A,Fowler PJ. A randomized controlled trial comparing the effectiveness of functionalknee brace and neoprene sleeve use after anterior cruciate ligament reconstruc-tion. Am J Sports Med. 2008;36:648-55.

13. Garavaglia G, Lubbeke A, Dubois-Ferrie`re V, Suva D, Fritschy D, Menetrey J.Accuracy of stress radiography techniques in grading isolated and combined pos-terior knee injuries: a cadaveric study. Am J Sports Med. 2007;35:2051-6.

14. Giffin JR, Stabile KJ, Zantop T, Vogrin TM, Woo SL, Harner CD. Importance oftibial slope for stability of the posterior cruciate ligament deficient knee. Am JSports Med. 2007;35:1443-9.

15. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessmentof posterior cruciate ligament and posterolateral corner injuries. Evaluation ofisolated and combined deficiency. J Bone Joint Surg Am. 2008;90:1621-7.

16. LaPrade RF, Wentorf FA, Fritts H, Gundry C, Hightower CD. A prospectivemagnetic resonance imaging study of the incidence of posterolateral and multipleligament injuries in acute knee injuries presenting with a hemarthrosis.Arthroscopy. 2007;23:1341-7.

17. Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as theinitial treatment for chronic posterolateral corner deficiency in the varus knee: aprospective clinical study. Am J Sports Med. 2007;35:1844-50.

18. Fabricant PD, Rosenberger PH, Jokl P, Ickovics JR. Predictors of short-termrecovery differ from those of long-term outcome after arthroscopic partial menis-cectomy. Arthroscopy. 2008;24:769-78.

19. Kalliakmanis A, Zourntos S, Bousgas D, Nikolaou P. Comparison of arthro-scopic meniscal repair results using 3 different meniscal repair devices in anteriorcruciate ligament reconstruction patients. Arthroscopy. 2008;24:810-6.

20. Pujol N, Panarella L, Selmi TA, Neyret P, Fithian D, Beaufils P. Meniscal healingafter meniscal repair: a CT arthrography assessment. Am J Sports Med.2008;36:1489-95.

21. Rodkey WG, DeHaven KE, Montgomery WH 3rd, Baker CL Jr, Beck CL Jr,Hormel SE, Steadman JR, Cole BJ, Briggs KK. Comparison of the collagenmeniscus implant with partial meniscectomy. A prospective randomized trial.J Bone Joint Surg Am. 2008;90:1413-26.

22. Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dis-location in children and adolescents: a randomized clinical trial. J Bone Joint SurgAm. 2008;90:463-70.

23. Christiansen SE, Jakobsen BW, Lund B, Lind M. Isolated repair of the medialpatellofemoral ligament in primary dislocation of the patella: a prospective ran-domized study. Arthroscopy. 2008;24:881-7.

24. Nomura E, Inoue M, Kobayashi S. Long-term follow-up and knee osteoarthritischange after medial patellofemoral ligament reconstruction for recurrent patellardislocation. Am J Sports Med. 2007;35:1851-8.

25. Mohtadi NG, Hollinshead RM, Sasyniuk TM, Fletcher JA, Chan DS, Li FX. Arandomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: disease-specific qualityof life outcome at an average 2-year follow-up. Am J Sports Med. 2008;36:1043-51.

26. Ahmad CS, Kleweno C, Jacir AM, Bell JE, Gardner TR, Levine WN, Bigliani LU.Biomechanical performance of rotator cuff repairs with humeral rotation: a newrotator cuff repair failure model. Am J Sports Med. 2008;36:888-92.

27. Park MC, Idjadi JA, Elattrache NS, Tibone JE, McGarry MH, Lee TQ. The effectof dynamic external rotation comparing 2 footprint-restoring rotator cuff repairtechniques. Am J Sports Med. 2008;36:893-900.

28. Park JY, Lhee SH, Choi JH, Park HK, Yu JW, Seo JB. Comparison of the clinicaloutcomes of single- and double-row repairs in rotator cuff tears. Am J Sports Med.2008;36:1310-6.

29. Barber FA, Herbert MA, Beavis RC, Barrera Oro F. Suture anchor materials,eyelets, and designs: update 2008. Arthroscopy. 2008;24:859-67.

30. Busfield BT, Glousman RE, McGarry MH, Tibone JE, Lee TQ. A biomechanicalcomparison of 2 technical variations of double-row rotator cuff fixation: theimportance of medial row knots. Am J Sports Med. 2008;36:901-6.

31. Zheng N, Harris HW, Andrews JR. Failure analysis of rotator cuff repair:a comparison of three double-row techniques. J Bone Joint Surg Am. 2008;90:1034-42.

32. Frank JB, ElAttrache NS, Dines JS, Blackburn A, Crues J, Tibone JE. Repair siteintegrity after arthroscopic transosseous-equivalent suture-bridge rotator cuffrepair. Am J Sports Med. 2008;36:1496-503.

33. Sallay PI, Hunker PJ, Lim JK. Frequency of various tear patterns in full-thickness tears of the rotator cuff. Arthroscopy. 2007;23:1052-9.

34. Costouros JG, Porramatikul M, Lie DT, Warner JJ. Reversal of suprascapularneuropathy following arthroscopic repair of massive supraspinatus and infraspi-natus rotator cuff tears. Arthroscopy. 2007;23:1152-61.

35. Hovelius L, Olofsson A, Sandstrom B, Augustini BG, Krantz L, Fredin H,Tillander B, Skoglund U, Salomonsson B, Nowak J, Sennerby U. Nonoperativetreatment of primary anterior shoulder dislocation in patients forty years of age andyounger. A prospective twenty-five-year follow-up. J Bone Joint Surg Am.2008;90:945-52.

252




36. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. Primary arthroscopic sta-bilization for a first-time anterior dislocation of the shoulder. A randomized, double-blind trial. J Bone Joint Surg Am. 2008;90:708-21.

37. Monteiro GC, Ejnisman B, Andreoli CV, Pochini AC, Cohen M. Absorbableversus nonabsorbable sutures for the arthroscopic treatment of anterior shoulderinstability in athletes: a prospective randomized study. Arthroscopy. 2008;24:697-703.

38. Sekiya JK, Willobee JA, Miller MD, Hickman AJ, Willobee A. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reductionof shoulder volume in a cadaveric model. Arthroscopy. 2007;23:1145-51.

39. Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT. The addi-tion of rotator interval closure after arthroscopic repair of either anterior or posteriorshoulder instability: effect on glenohumeral translation and range of motion. Am JSports Med. 2008;36:1123-31.

40. Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensionalcomputed tomography to quantify glenoid bone loss in shoulder instability.Arthroscopy. 2008;24:376-82.

41. Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP.Results of modified Latarjet reconstruction in patients with anteroinferior instabilityand significant bone loss. Arthroscopy. 2007;23:1033-41. Erratum in: Arthroscopy.2007;23:A16.

42. Auffarth A, Schauer J, Matis N, Kofler B, Hitzl W, Resch H. The J-bone graft foranatomical glenoid reconstruction in recurrent posttraumatic anterior shoulderdislocation. Am J Sports Med. 2008;36:638-47.

43. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. No ad-vantages in repairing a type II superior labrum anterior and posterior (SLAP) lesionwhen associated with rotator cuff repair in patients over age 50: a randomizedcontrolled trial. Am J Sports Med. 2008;36:247-53.

44. Knutsen G, Drogset JO, Engebretsen L, Grntvedt T, Isaksen V, Ludvigsen TC,Roberts S, Solheim E, Strand T, Johansen O. A randomized trial comparing autol-ogous chondrocyte implantation with microfracture. Findings at five years. J BoneJoint Surg Am. 2007;89:2105-12.

45. Saris DB, Vanlauwe J, Victor J, Haspl M, Bohnsack M, Fortems Y, VandekerckhoveB, Almqvist KF, Claes T, Handelberg F, Lagae K, van der Bauwhede J, VandenneuckerH, Yang KG, Jelic M, Verdonk R, Veulemans N, Bellemans J, Luyten FP. Characterized

chondrocyte implantation results in better structural repair when treating symptomaticcartilage defects of the knee in a randomized controlled trial versus microfracture. Am JSports Med. 2008;36:235-46.

46. Karpie JC, Chu CR. Lidocaine exhibits dose- and time-dependent cytotoxic ef-fects on bovine articular chondrocytes in vitro. Am J Sports Med. 2007;35:1621-7.

47. Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in hu-man articular chondrocytes. J Bone Joint Surg Am. 2008;90:986-91.

48. Kettler M, Lunger J, Kuhn V, Mutschler W, Tingart MJ. Failure strengths indistal biceps tendon repair. Am J Sports Med. 2007;35:1544-8.

49. Dines JS, ElAttrache NS, Conway JE, Smith W, Ahmad CS. Clinical outcomes ofthe DANE TJ technique to treat ulnar collateral ligament insufficiency of the elbow.Am J Sports Med. 2007;35:2039-44.

50. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wavetreatment for chronic insertional Achilles tendinopathy. A randomized, controlledtrial. J Bone Joint Surg Am. 2008;90:52-61.

51. Petersen W, Welp R, Rosenbaum D. Chronic Achilles tendinopathy: a pro-spective randomized study comparing the therapeutic effect of eccentric training,the AirHeel brace, and a combination of both. Am J Sports Med. 2007;35:1659-67.

52. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgeryimportant? A randomized, prospective study. Am J Sports Med. 2007;35:2033-8.

53. Treme G, Diduch DR, Hart J, Romness MJ, Kwon MS, Hart JM. Cervical spinealignment in the youth football athlete: recommendations for emergency trans-portation. Am J Sports Med. 2008;36:1582-6.

54. Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY,Watanabe DS, Dick RW, Dvorak J. A randomized controlled trial to prevent non-contact anterior cruciate ligament injury in female collegiate soccer players.Am J Sports Med. 2008;36:1476-83.

55. Brushj C, Larsen K, Albrecht-Beste E, Nielsen MB, Lye F, Holmich P. Pre-vention of overuse injuries by a concurrent exercise program in subjects exposed toan increase in training load: a randomized controlled trial of 1020 army recruits.Am J Sports Med. 2008;36:663-70.

56. Dun S, Loftice J, Fleisig GS, Kingsley D, Andrews JR. A biomechanical com-parison of youth baseball pitches: is the curveball potentially harmful? Am J SportsMed. 2008;36:686-92.

Evidence-Based ArticlesRelated to Sports MedicineGohil S, Annear PO, Breidahl W. Anterior cruciate ligament reconstructionusing autologous double hamstrings: a comparison of standard versus minimaldebridement techniques using MRI to assess revascularisation. A randomisedprospective study with a one-year follow-up. J Bone Joint Surg Br.2007;89:1165-71.

Patients were randomized to minimal debridement of the intercon-dylar notch or conventional clearance of the notch for autologous hamstringanterior cruciate ligament reconstruction. All patients underwent magneticresonance imaging postoperatively at two, six, and twelve months to evaluaterevascularization of the implanted autografts. Results showed earlier revas-cularization of the midsubstance of the anterior cruciate ligament graft attwo months in association with the minimal debridement technique. Theclinical importance of this finding, however, is unclear, as no differences inclinical outcomes or examination findings were demonstrated between thegroups.

Hantes ME, Basdekis GK, Varitimidis SE, Giotikas D, Petinaki E, MalizosKN. Autograft contamination during preparation for anterior cruciate liga-ment reconstruction. J Bone Joint Surg Am. 2008;90:760-4.

The contamination rates of bone-patellar tendon-bone and hamstringautografts were evaluated with graft-tissue culture samples at different timeintervals during preparation. The contamination rate before implantation was12% overall, with no difference between the bone-patellar tendon-bone andhamstring groups, and no postoperative infections were reported. Also, nochanges in the postoperative erythrocyte sedimentation rate or C-reactiveprotein level were demonstrated between patients with a contaminated graftand those with an uncontaminated graft. These findings suggest that in a

patient with a contaminated graft, no additional treatment is necessary in theabsence of clinical signs of infection.

Bottoni CR, Liddell TR, Trainor TJ, Freccero DM, Lindell KK. Postoperativerange of motion following anterior cruciate ligament reconstruction usingautograft hamstrings: a prospective, randomized clinical trial of early versusdelayed reconstructions. Am J Sports Med. 2008;36:656-62.

This randomized, prospective controlled trial evaluated the effect ofearly as opposed to delayed anterior cruciate ligament reconstruction withhamstring autograft on postoperative range of motion and stability in young,active patients. Seventy patients were randomized into two groups, with onegroup undergoing surgery within three weeks after the injury and a secondgroup undergoing reconstruction at a minimum of six weeks after the injury.The average duration of follow-up after surgery was one year. No significantdifference in postoperative range of motion was found between the two groups.There also were no differences between the groups in terms of operative time,KT-1000 measurements, or subjective knee outcome measures. This studydemonstrates that anterior cruciate ligament reconstruction does not need tobe delayed to achieve optimal results. The authors advocate the use of a re-habilitation program that emphasizes early mobilization and maintenance ofextension.

Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, HoffmanAR, Marcus R. Do capacitively coupled electric fields accelerate tibial stressfracture healing? A randomized controlled trial.Am J Sports Med. 2008;36:545-53.

Twenty men and twenty-four women with acute posteromedial tibialstress fractures were randomly assigned to treatment with active or placebocapacitively coupled electric field stimulation devices for fifteen hours a dayuntil the fractures healed. Patients also received supplemental calcium and

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were instructed to refrain from provocative training. The active and placebogroups showed no difference in terms of the time to healing. Women healedmore slowly than men did. Noncompliance with rest instructions led to anincreased time to healing, with optimal compliance leading to a reducedhealing time. Severe stress fractures showed shortened healing time in asso-ciation with active capacitively coupled electric field device use. This studyshows that capacitively coupled electric field stimulation may be most effica-cious for patients with a higher incentive to return to play, assuming that thispatient population will be motivated to be more compliant with device use andweight-bearing restrictions during healing.

Henn RF 3rd, Kang L, Tashjian RZ, Green A. Patients preoperative expec-tations predict the outcome of rotator cuff repair. J Bone Joint Surg Am.2007;89:1913-9.

This observational study evaluated the relationship between preoper-ative expectation and postoperative outcome following unilateral primary re-pair of chronic rotator cuff tears for 125 patients. Each patient prospectivelycompleted several limb-specific outcome instruments and SF-36 (Short Form-36) forms preoperatively and again at one year postoperatively. The resultsshowed that greater preoperative expectations were correlated with betterpostoperative performance on self-assessed outcome measures. The authorsnoted that, unlike in previous studies, higher preoperative expectations wereassociated with better postoperative function and pain. This study highlightsthe importance of preoperative expectations on outcomes following rotatorcuff repair, and it also reiterates the importance of preoperative patientcounseling.

Fredberg U, Bolvig L, Andersen NT. Prophylactic training in asymptomaticsoccer players with ultrasonographic abnormalities in Achilles and patellartendons: the Danish Super League Study. Am J Sports Med. 2008;36:451-60.

This randomized controlled trial evaluated the effect of a prophylacticeccentric training and stretching program for professional soccer players withultrasonographic intratendinous changes of the Achilles and patellar tendons.Two hundred and nine Danish professional soccer players from twelve teamswere followed over a twelve-month period. Half of the teams were randomizedto a treatment group and underwent prophylactic eccentric training andstretching of the Achilles and patellar tendons during the season. The trainingand stretching program for patients with normal patellar tendons led to asignificant reduction in the proportion of players with ultrasonographic pa-tellar tendon changes by the end of the season. The program had no effect onnormal Achilles tendons. Preseason intratendinous changes on ultrasoundsignificantly increased the risk of tendon problems during the season. Thus,ultrasound can be used in the preseason to identify players in whom symp-tomatic Achilles or patellar tendon problems may develop during the season.Unfortunately, the preseason eccentric training program aimed at reducingintraseason injuries in patients with ultrasonographic changes actually wasassociated with an increased injury risk.

Hiemstra LA, Sasyniuk TM, Mohtadi NG, Fick GH. Shoulder strength afteropen versus arthroscopic stabilization. Am J Sports Med. 2008;36:861-7.

This piggyback randomized controlled trial assessed shoulder strengthfollowing open as opposed to arthroscopic stabilization for the treatment oftraumatic anterior instability. The hypothesis was that patients undergoingopen stabilization would have internal rotation deficits when compared withthose undergoing arthroscopic repair. Forty-eight patients were randomized toeither open stabilization (with a subscapularis splitting approach) or arthro-scopic stabilization. All patients underwent isokinetic strength testing at oneyear after surgery. No significant difference in internal concentric strength at60/sec (the primary outcome measure) was found between the groups. Bothgroups had strength deficits in the treated limb as compared with the con-tralateral limb. This study demonstrated that internal and external rotationdeficits exist following both open and arthroscopic anterior stabilizationprocedures. Further study is needed to determine if subscapularis tendondetachment procedures for anterior stabilization lead to increased internalrotation deficits.

Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Preventionof injuries among male soccer players: a prospective, randomized interventionstudy targeting players with previous injuries or reduced function. Am J SportsMed. 2008;36:1052-60.

The authors of this randomized controlled trial sought to determinewhether the most common injuries in high-risk soccer players could beidentified and subsequently prevented through the implementation of apreventive training program. Five hundred and eight players completed aquestionnaire evaluating previous injury and/or limited function. From this,high-risk and low-risk groups were created. The high-risk group was ran-domized into an intervention group (managed with a preventive trainingprogram) and a control group. High-risk players were successfully identifiedwith the questionnaire. There was no difference in the risk of injury betweenthe high-risk intervention and control groups. This finding was thought to bedue in large part to poor compliance with the training program by those in theintervention group.

Tagesson S, Oberg B, Good L, Kvist J. A comprehensive

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journal of bone

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use of hamstring autografts

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