What's New in Sports Medicine

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<ul><li><p>Specialty Update</p><p>Whats New in Sports MedicineJames S. Starman, MD, Justin W. Griffin, MD, Abdurrahman Kandil, MD, Richard Ma, MD,</p><p>MaCalus V. Hogan, MD, and Mark D. Miller, MD</p><p>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 &amp; Joint Surgery(American volume), The American Journal of Sports Medi-cine, and Arthroscopy: The Journal of Arthroscopic &amp; RelatedSurgery.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>Specialty Update has been developed in collaboration with the Board ofSpecialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.</p><p>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.</p><p>695</p><p>COPYRIGHT 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED</p><p>J Bone Joint Surg Am. 2014;96:695-702 d http://dx.doi.org/10.2106/JBJS.M.01569</p></li><li><p>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.</p><p>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.</p><p>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.</p><p>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-</p><p>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 &gt;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.</p><p>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.</p><p>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.</p><p>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.</p><p>696</p><p>TH E J O U R N A L O F B O N E &amp; JO I N T SU R G E RY d J B J S . O R GVO LU M E 96-A d NU M B E R 8 d A P R I L 16, 2014</p><p>WH AT S NE W I N SP O R T S ME D I C I N E</p><p>Whats New in Sports Medicine</p></li><li><p>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.</p><p>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.</p><p>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.</p><p>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</p><p>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.</p><p>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.</p><p>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 we...</p></li></ul>


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