What’s New in Sports Medicine

Abstract

This update reflects recently published evidence in the field of sports medicine surgery mostly from October 2018 through September 2019. Although this review is not exhaustive of all research that might be pertinent to sports medicine, it highlights many key articles that contribute to the existing evidence base in the field of the subspecialty. The most impactful clinical and basic science studies, primarily from The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery, with specific emphasis on Level-I and II studies, have been included in this review. Knee Anterior Cruciate Ligament (ACL) There is still debate among surgeons caring for the highest level of competitive athlete with regard to the best-performing graft choice. A well-performed, single-surgeon, randomized controlled trial (RCT) comparing patellar tendon (bone-tendon-bone [BTB]) autograft, quadrupled hamstring tendon autograft, and double-bundle reconstruction using hamstring autograft illustrates this debate1. The study included 110 patients in each group with reported 5-year outcomes and 95% final follow-up data. The mean age for all patients was 28.5 years at the time of the surgical procedure. There was no significant difference in patient-reported quality-of-life (Anterior Cruciate Ligament-Quality of Life [ACL-QOL]) score at 5 years between any of the reconstruction groups. However, there was a significantly (nearly 4 times) higher rate of traumatic graft reinjuries in both the hamstring tendon group (15%) and the double-bundle group (16%) compared with the BTB group (4%). As expected, patients in the BTB group had significantly more kneeling pain or anterior knee pain (10%) compared with the hamstring tendon group (4%) and the double-bundle group (2%). The overall return to preinjury level of activity was fairly low at 37% for the entire population, with no significant difference between groups. A meta-analysis of previously performed RCTs was performed to assess whether early ACL reconstruction leads to more complications compared with delayed surgery, especially with regard to stiffness and arthrofibrosis2. Early surgery was defined as <3 weeks after the original injury, and >10 weeks after the injury was considered delayed reconstruction. The investigators included 8 previous studies that included 505 patients with a mean age of 28 years and included a 2.4:1 male-to-female ratio with approximately equal numbers in each group (270 patients in the early reconstruction cohort compared with 235 patients in the delayed surgery cohort). There was no significant difference in patient-reported outcome measures, complications (including motion loss or arthrofibrosis), risk of retear, or instrumented laxity, although the Level of Evidence grade for most of the included studies was low. Furthermore, there was a high degree of heterogeneity among the 8 included studies with regard to rehabilitation protocols, preoperative range of motion, graft choice, and allocation into early or delayed surgical groups. Surgeons using hamstring autografts to perform ACL reconstruction will encounter small-diameter grafts after harvest on occasion. A systematic review of 10 studies (1 Level-II study and 9 Level-III studies) compared ACL reconstructions using hamstring tendon autografts with those using hybrid grafts consisting of hamstring autografts augmented with allograft when the patients’ native hamstring tendons were deemed to be small in diameter3. All studies had a minimum follow-up of 24 months. The pooled data included patient-reported outcomes, ACL physical examination tests, KT-1000 arthrometer (MEDmetric) results, and graft failure rates. No significant difference was identified between groups on any of the outcome parameters noted above. There was heterogeneity within the studies in terms of indications or size cutoffs for allograft augmentation. Further study is required to determine what size graft constitutes “too small” for the wide range of patients undergoing ACL reconstruction with hamstring autograft. Despite the increasing numbers of ACL reconstructions being performed, relatively few data have been published with regard to optimal injury prevention programs or return-to-play criteria. A recently published, well-performed systematic review and meta-analysis of Level-II and Level-III studies investigated whether patients who had undergone successful ACL reconstruction and had passed impartial and criteria-based return-to-sport testing had a reduction in risk of a second ACL injury4. The authors extracted data from each included study (4 total studies met the inclusion criteria) and pooled data for similar return-to-sport tests (i.e., isokinetic testing and hop testing). The data were dichotomized into treatments that “passed” or “failed” on the basis of whether the patient met the return-to-sport criteria and returned to sport or did not meet return-to-sport criteria and returned to sport. Return to sport was defined as the clearance of a patient for full participation in a sport or activity without restriction. Importantly, the investigators performed an analysis of the quality of studies that they included using the modified Downs and Black checklist and also the GRADE (Grading of Recommendations Assessment, Development and Evaluation) scale showing the overall certainty of the evidence for the outcome being evaluated. There was no significant association between passing objective return-to-sport criteria and risk of a second ACL injury for both graft retear and contralateral ACL tear scenarios. Although not significant, the authors reported an increased incidence of ACL graft reinjury in patients who “failed” return-to-sport criteria (12%) compared with those who passed (6%) and concluded that there may be a protective association present that was not detectable with available data. Return-to-play and rehabilitation guidelines after ACL reconstruction remains unclear in the sports medicine community, and more research is required to help surgeons to better guide patients to a safe return to sport activity. Huang et al. performed a meta-analysis of all previously published RCTs and cluster RCTs of injury prevention programs for ACL injuries5. The study included 8 previous RCTs in this area of study, and their meta-analysis demonstrated a significant reduction (53%) in ACL injury rate. Although there have been a number of systematic reviews performed on this topic, this study is one of the cleanest analyses to date by including only prior RCTs and addressing the clustering effect bias of the included studies, which often randomized whole (clustered) sports teams. One limitation of the study was that the analysis was largely limited to soccer and may have been less generalizable to other sports. Additionally, the investigators found variability in the specific exercises and the manner of delivery of the injury prevention program across studies. They concluded and advocated for flexibility in the development and implementation of injury prevention programs as a means to achieve more widespread adoption of these programs as the data overwhelmingly support their ability to reduce the rate of ACL injuries. ACL injury prevention is a neglected area of study, and there is an opportunity for substantial improvement in the care of active patients engaging in sports. Meniscus Techniques to improve healing after meniscal repair are an area of great interest. A double-blinded RCT with good methodology was performed in Poland, in which 20 patients (21 menisci) underwent isolated meniscal repair and 20 patients (23 menisci) underwent meniscal repair with a bone marrow venting procedure (BMVP)6. All tears were unstable, complete, vertical tears in the red-white zone (majority bucket-handle tears), and repair was performed with either an all-inside or all-inside plus outside-in vertical mattress technique. A chondral pick device was used to created 6 to 7 awl holes in the lateral aspect of the intercondylar notch for the BMVP group. The 2 groups had similar baseline characteristics and underwent the same postoperative rehabilitation protocol. Meniscal healing was assessed via second-look arthroscopy at a mean time (and standard deviation) of 35 ± 4 weeks by a blinded assessor, demonstrating BMVP-augmented repair healing rates to be superior (100%) to the control group (76%) (p = 0.0035). Follow-up at 32 to 51 months found that secondary pain and functional measures were improved in the BMVP group compared with the control group, and both were better than baseline. Surgeons should consider this simple, quick, and low-cost adjunct in patients undergoing isolated meniscal repairs. The ESCAPE (Early Surgery Versus Conservative Therapy for Meniscal Injuries in Older Patients) Research Group performed a noninferiority, multicenter, non-blinded RCT in patients who were 45 to 70 years of age and had a non-knee-locking meniscal tear and varying degrees of radiographic to the authors compared physical with this study, patients randomized to physical in 8 patients undergoing had the surgical procedure within 4 weeks of and were a postoperative protocol. A total of patients in the physical group to the surgical procedure group of of of these were within 6 months of The Knee improved in the group and in the physical group. The analysis of overall to 24 months found a difference of to in of which of physical to (p = However, the at the to and the to did not The analysis had similar Furthermore, knee pain physical There was no difference between groups in radiographic analyses found that patients with increased baseline pain or did better with to physical The ESCAPE Research Group that physical may be considered an to as The optimal in patients with traumatic patellar is still an active area of A systematic review and meta-analysis of RCTs comparing and treatments of lateral patellar found that is with more complications with better patient-reported outcomes and rates of compared with No difference in outcomes was found between the groups at a A systematic review and meta-analysis at varying treatments of the demonstrated no difference in outcomes or between and treatments for patients a patellar However, for patients with patellar reconstruction of the demonstrated superior compared with as on the for reconstruction being and performed, a number of studies have been published the outcomes comparing A systematic review found that there may be complications and with on the in with a patellar bone A trial performed in comparing and that the may to more and less Joint A number of studies have been published the outcomes and of surgery for using and A meta-analysis comparing a and for was performed demonstrating improved outcomes and pain in patients with No in postoperative loss of or time was found between the 2 RCT with good methodology was performed in the comparing with of patients with or did not in better outcomes, return to or compared with at There was a relatively high number (16%) of patients who from to No specific patient were identified that were with risk of failure of and the authors that should be on the basis of activity and a group from performed an RCT comparing and for The authors demonstrated that surgery more and is with with similar outcomes compared with The of arthroscopy for to be evaluated. A of published RCTs comparing surgery with or for was recently Although 8 RCTs with a total of patients were included in the 2 were deemed to have a low risk of bias as they were double-blinded studies and a group that underwent only an The other 6 were to have a high risk of bias they were not blinded the group was was not in these All included studies were performed in included mean pain quality of patient and The review concluded that evidence that surgery no improvement in or quality of to all studies, the rate for surgery was to be low and did not from that for The limitation in this study is the with all was the of arthroscopy and the of the procedure. et al. published a follow-up of their prior RCT at small to tears comparing patients randomized to repair with those randomized to A total of of patients who were randomized for the study had follow-up data patients in the repair group and patients in the The score still a significant difference of in of the surgical repair group, and there was a significantly higher of patients in the repair group who a score compared with patients in the group The patient-reported of the American and Surgeons score and the scale score for pain were also significantly better in the repair group. There was no significant difference in 10 there were patients who had from the group and underwent This of the patients in the group. The authors found clinical outcomes with a score when comparing this secondary surgery group with the repair group. studies were performed to determine tear the group, tear size in both of with a mean tear size of in the and in the The patients with of tear had a score by a mean of compared with patients with of tear the patients who underwent of tendons a retear rate of at by at 5 years and at 10 years 5 and were performed by A of the patients a retear and those with a mean difference of 6 in the The authors concluded that outcome between patients with surgical repair and those with for small to tears that more with time and advocated for the surgical repair of these of tears in the and active There are still varying with regard to postoperative rehabilitation after A RCT investigated the effect of early compared with standard rehabilitation after that study, patients who met inclusion criteria of a tear that be and had undergone months of were with surgical on the basis of All study were to a and to exercises that were demonstrated by a physical The patients who underwent standard rehabilitation were to the at all when their The patients in the early group were that the was only for and be and at the and were to perform as were from more than to 2 to The early group significantly better and at 6 weeks no or objective were found at all other time including retear rate as by in the early group and in the standard rehabilitation A similar was performed comparing with no for patients undergoing A total of patients who had small to superior tears underwent repair and were randomized to for 4 weeks after surgery compared with no at The that the patients who were not had better early range of motion at 6 and weeks the 2 groups had similar at 6 months. There was no difference in repair between groups as by and Arthroscopic surgery is considered a safe and for anterior However, well-performed surgery, and complications other than A systematic review of follow-up after repair demonstrated a rate of return to rate of and overall evidence of was found in of patients in the studies that reported for is whether the the surgical or the are the A systematic review of complications than after anterior demonstrated a higher rate of complications in surgical bone compared with only A systematic review of clinical and studies of found that it is a safe and of 4 studies comparing repair with or without found significantly higher rates in the isolated repair to in to with to Although studies have significant in range of motion after clinical studies small to it that the of a procedure is with rates of and better patient-reported compared with isolated repair to the controlled trial of Arthroscopic Surgery for trial published in The in an RCT at comparing surgery with physical and activity in patients with was The authors reported the follow-up data at 8 months after a total of patients who a surgical procedure and 110 who underwent physical The had similar baseline and and all patients had radiographic of or data for the analysis were available for patients patients in the surgery group did not the surgical procedure the time of and 4 patients from the physical group to the surgery group. 8 months after the mean of in the surgery group was higher than the physical group (p = The were higher than baseline in of surgical patients compared with of the physical The patient was in of patients in the surgery group and of patients in the physical group. secondary patient-reported outcome measures were all significantly better in the surgery group than in the physical group, with the surgery group improvement in = and less pain with (p = than the physical group. et al. performed a systematic review and meta-analysis on both RCTs and studies to and functional outcomes for and treatments of tendon They performed analyses to rate as to early or full as as with or without functional rehabilitation with early range of They included 10 RCTs and studies, for a total of patients and and surgical were The rate was reported in all studies, with an overall pooled effect demonstrating significant reduction in rate with compared with Although a similar reduction in rate in of was after both early and full no significant in rate were between and treatments in studies that used functional rehabilitation with early range of The overall pooled rate an risk ratio in of The overall rate was after as the compared with after as the A Level-I meta-analysis of 7 RCTs comparing and of was published the highest Level of Evidence and size on this to outcomes, and were was not as a A total of patients were with and patients were with and they were for to 2 The meta-analysis for overall complications a significantly risk = among the group compared with the group. This was for reduction at the time of final follow-up as as the clinical of or or was significantly with the The overall rate was similar in the 2 groups = when comparing with = The American & score was higher for compared with at and 24 and the was for compared with at 6 and months. The authors of patient and small and follow-up in this with methodology have demonstrated no of using in the of regard to a double-blinded RCT found that within tears did not improve tendon healing on or patient-reported outcome measures compared with and that were with more patients with months of a and showing an isolated tear were randomized to either 2 or 2 of with no physical to The outcome of in on at 6 months after the second no significant There were no in any patient-reported outcome at any time The group had a higher incidence of which included pain for and of the to the or compared with = patients in the group on to surgery compared with 2 patients in the control group (p = a trial of compared with for patellar demonstrated no difference in any outcome at the et al. randomized patients into and all by 6 weeks of The analysis at weeks after that the of patients improvement in the of with no significant difference among a follow-up of of all outcome measures were the There was a more of of the at 6 weeks compared with of and a patients in the group significant improvement at There was variability in which may that the study was for There have been RCTs comparing with for knee in prior et al. performed a double-blinded RCT also including a control They randomized to of or They had loss to All groups had a significantly improved patient-reported outcome measures from baseline to only the group this improvement at and and only the group the difference for the and score at time analysis demonstrated significant between the group and the group at and no between the group and the group at any time et al. reported on their 5-year for compared with for knee the of their RCT were previously They follow-up by the final and groups had significantly improved to 24 months. 5 the group significantly higher at ± compared with baseline at ± (p and the group did also had a rate at 24 months compared with However, when comparing with there were no significant between the groups at any time including final The of a number of recently published studies to the that a higher Level of Evidence to articles in this 9 other articles with a higher Level of Evidence grade to sports medicine surgery are to this review after the standard with a each to help guide in an in this a systematic review. of et al. compared and repair to preoperative with postoperative This review included studies with patients in terms of number of prior surgical tear surgical and quality was using the for and the mean score was 10 a quality of The mean significant improvement from to the mean from 6 to and these were in both the and groups. The overall rate was and the most complications were repair failure stiffness and (4%). The most with a higher postoperative score was preoperative This study that repair be performed using and with good in patient-reported outcomes higher rates of retear compared with prior arthroscopy outcomes of A systematic review. This was a systematic review of studies comparing outcomes of total or between patients with and without a of were studies Level-III met inclusion with a mean follow-up of There were 235 patients with a of arthroscopy with a mean age of years and with a mean age of The time between arthroscopy and was reported was a mean of There were no significant between the groups for postoperative complications including or postoperative and outcome measures were between with study demonstrating a better postoperative score in the control group than the arthroscopy group. The review was limited by the small and of the included studies as as the of in surgical and postoperative outcome on these results, patients be that arthroscopy is to the of repair for surgical of II superior anterior to a systematic review. A systematic review of mostly Level-III and studies comparing superior anterior to repair with in patients with tears demonstrated outcomes with either surgical of the included studies, patients who underwent repair had more in their rates of return to sport and for compared with patients with similar patient-reported outcomes between repair and the risk of a outcome may be after The of the as an for surgical in patients with anterior and grade II This study was a RCT of patients who were identified as a at the time of arthroscopy for ACL reconstruction. This is the identified at the time of arthroscopy when the to with the when a is across the injury to the of the There were patients who were found to have this at the time of these patients were randomized into 2 groups. The group had both ACL and and the second group had ACL reconstruction Although was performed, patients undergoing the reconstructions were in The significantly improvement in the and at the follow-up and a ACL graft failure rate in the group that had the reconstruction. This may be a adjunct in to examination and the to assess injury at the time of ACL reconstruction. it safe to into the after Sports This is a double-blinded clinical trial comparing 2 groups undergoing group that a at 8 weeks after the repair and group that was There were patients in each group, and the investigators range of motion, the the the pain and the score at and months and at the time of final All patients had small to and the were all performed by a who used a for small tears and a for 8 weeks all patients underwent an of either or The that the group that had significantly more range of motion in and and higher and at the time than the control group. However, after 6 months there were no any significant between groups in any of the or objective outcome measures including The authors concluded that after repair surgery is safe and not the risk of retear and may help patients to improve pain and range of motion early in the postoperative the to patients to be it is not to perform postoperative analysis and outcomes of meniscal allograft with minimum a systematic review. Although the Level of Evidence of the included studies was low this systematic review is one of the few studies to of meniscal allograft bone and were The mean graft rates were at the follow-up and at the There was heterogeneity within the patients included in the review and the of failure was most defined as graft or to total knee outcomes were overall improved compared with preoperative data help to patients meniscal although studies of meniscal allograft with better methodology are required to better the of this procedure. compared with of a randomized clinical Bone Joint 2018 this RCT performed in comparing the outcomes and healing of with reduction and with were to have better and rates compared with The and outcomes were the that the surgical procedure should be performed in patients better early A randomized controlled trial of for anterior reconstruction with Sports This was a blinded RCT the of compared with for ACL in patients who underwent hamstring autograft surgery of meniscal and bone quality were similar between the 2 groups. at months were performed, with outcome data available for of The no in patient-reported outcomes, graft and objective of the graft as as at did not any difference between groups. The less is to be more study the effect of on ACL surgery be reconstruction for a systematic review. The investigators in this study 5 clinical studies without a that had minimum follow-up data. All studies a significant improvement in range of motion and from the preoperative The rate was across all studies, and the overall graft failure rate was failure for of and other complications included and The Level of Evidence is low and the for bias as these were all studies that a control group and there was heterogeneity in the surgical graft and reported outcome data. research is including RCTs with to better the indications for superior and

The authors' abstract, as published at the source. Journal of Bone and Joint Surgery, 2020 · DOI ↗