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Specialty Update

What’s New in Sports Medicine John A. Tanksley, MD, Brian C. Werner, MD, Richard Ma, MD, MaCalus V. Hogan, MD, and Mark D. Miller, MD

This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2013 to August 2014. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery. Shoulder Rotator Cuff Disease and Surgery Literature related to rotator cuff disease and surgery continues to be the most common shoulder research published within the timeframe of our review. The societal and individual impact and cost of rotator cuff disease can be substantial, which is reflective of the prevalence of the disease. A recent Markov analysis demonstrated that surgical repair of symptomatic tears may result in not only substantial societal savings, but also improved individual quality-adjusted life-years relative to nonoperative treatment1. Predictors of outcome following either operative or nonoperative treatment of rotator cuff disease remain a topic of great interest. A recent cross-sectional study of 393 patients from the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group demonstrated that objective tear characteristics (i.e., tear size, muscle atrophy, and retraction) did not correlate with patient pain symptoms. Rather, patient demographic characteristics (i.e., lower educational level, greater number of comorbidities, and race) appeared to be associated with greater pain symptoms at initial presentation2. Recognition of these painassociated risk factors may allow a clinician greater insight into the etiology of shoulder pain in the setting of a rotator cuff tear. Retears after rotator cuff repair do occur with frequency and can be a challenging clinical scenario to treat3-5. Research Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

on methods to improve structural healing rates after rotator cuff repairs remains active. The efficacy of platelet-rich plasma as an augment in rotator cuff repair is still unclear6,7. One clinical study suggested that microfracture of the rotator cuff footprint prior to repair may permit egress of bone marrow elements and mesenchymal stem cells, which may aid rotator cuff healing in medium-sized tears (2 to 3 cm) and may reduce retear rates8. The debate continues whether structural healing after repair is critical to a successful patient outcome. A recent systematic review of available Level-I and II studies suggests that structural integrity of the repair (or lack thereof) does not seem to correlate with validated patient subjective outcome measures. Treatment of irreparable rotator cuff tears in the young population is challenging. Latissimus dorsi transfers have been an option with good short-term to intermediate-term results. Gerber et al. reported their long-term results with the technique9. The authors reported maintained patient subjective and objective outcomes to ten years following surgery for both primary and revision scenarios9. Factors that were associated with poorer outcomes included subscapularis and teres minor insufficiency as well as large critical shoulder angles. Shoulder Instability Outcomes after arthroscopic anterior stabilization are approaching those after traditional open techniques. Although the current trend is toward arthroscopic repairs, the literature continues to demonstrate the superiority of open repairs in high-risk individuals. Mohtadi et al.10 demonstrated a recurrent dislocation rate of 23% (twenty of eighty-seven patients) in their arthroscopic repair group compared with 11% (nine of eighty patients) in their open repair group. The authors concluded that young male patients with visible Hill-Sachs lesions on radiographs may be better treated with open repairs than arthroscopic repairs. Their findings also perhaps highlight

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 of any 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 submission of 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. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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What’s New in Sports Medicine whether suture anchor repair of the labrum alone is adequate in high-risk male patients. Additional indicated adjuncts to Bankart repairs, such as remplissage, may be able to reduce the redislocation rate following surgery11,12. Posterior instability episodes are relatively rare in the young athletic population12. In a prospective cohort of 714 young athletes, posterior instability accounted for only 10% of shoulder instability events13. The most significant risk factor for posterior instability in that cohort was increased glenoid retroversion13. Posterior capsulolabral repair is successful in athletes with unidirectional posterior instability. Improvement in pain, stability, and function can be expected following surgery14. Return to play was 90% in a cohort of 183 athletes; however, only 64% returned to the same level of play postoperatively14. The authors also reported better outcome with suture anchor-based repairs than anchorless capsulolabral plication. Acromioclavicular Joint Concomitant Acromioclavicular Arthritis During Rotator Cuff Surgery

Clinically asymptomatic, radiographically evident acromioclavicular arthritis often coexists with rotator cuff disease. Although it may be tempting to prophylactically treat the acromioclavicular arthritis with a distal clavicle excision at the time of the rotator cuff surgery, Oh et al.15 suggested that not only is this unnecessary, but it may also result in postoperative morbidity. In a randomized trial of seventy-eight patients, the authors found that prophylactic distal clavicle excision for asymptomatic acromioclavicular joint arthrosis provided no additional improvement when compared with just addressing the rotator cuff tear alone. Furthermore, they noted a 5% complication rate (two of thirty-nine patients) related to postoperative acromioclavicular joint pain or protuberance with prophylactic distal clavicle excision15. Knee Anterior Cruciate Ligament (ACL) ACL Outcomes

Outcomes after ACL reconstruction continue to garner substantial research interest. In a prospective randomized trial comparing single and double-bundle reconstruction with use of hamstring autograft, Ahld´en et al. found no differences in pivot shift or clinical scores at two years16. Studies on graft failure showed variable rerupture rates17-21. One study from the Swedish registry of approximately 13,000 patients found only a 1.6% revision rate at two years, irrespective of autograft type, associated meniscal injury, or femoral fixation17. In contrast, Paterno et al. reported that young patients involved in pivoting or cutting sports had a substantially higher rate (9%) of ACL retear following ACL reconstruction at twenty-four months in a prospective study. The youngest cohort within the study (mean age of 17.1 years) had an even higher rate (20.5%) of contralateral ACL tear, six times higher than the age-matched

controls18. Shelbourne et al. investigated return to play after revision ACL reconstruction with a bone-patellar tendon-bone autograft. High school and collegiate athletes returned to their preoperative performance level 74% of the time, and the fiveyear retear rate was 2.3% for high school athletes and 5.1% for collegiate athletes 19. Risk Factors for ACL Outcomes

Concomitant meniscal and chondral injuries are frequently encountered at the time of ACL reconstruction, but their longterm effect on outcomes is unclear22-24. As part of the MOON consortium, Cox et al. found that Outerbridge grade-III and IV articular cartilage injuries and medial meniscal repair were associated with lower clinical scores, and knees with small, untreated lateral meniscal tears fared better at six years25. Kim et al. investigated the degree of anterior laxity in the uninjured knee in patients scheduled for unilateral ACL reconstruction. The group with anterior laxity of >7.5 mm in the uninjured knee had poorer functional scores and higher sideto-side laxity measurements compared with patients with £7.5 mm of laxity26. Two insightful studies documented the detrimental effects of smoking on outcomes after ACL reconstruction27,28. Side-to-side arthrometer differences and clinical outcome scores were negatively impacted by smoking, but patients who quit at least one month prior to surgery showed equivalency to nonsmokers. The authors recommended bone-patellar tendon-bone autograft for smokers who are unable or unwilling to quit. ACL Nonoperative Treatment

Nonoperative treatment of an ACL injury is a well-established treatment option for less active patients without gross instability, but its application in an active population is less studied. Grindem et al. found no significant differences in International Knee Documentation Committee (IKDC) scores or strength at two years in 143 active patients in an intention-to-treat model comparing operative and nonoperative treatments. Notably, the nonoperative group was significantly older and less likely to have played level-I sports pre-injury. In addition, twenty-one (33%) of the sixty-four patients who initially chose nonoperative treatment later decided to undergo ACL reconstruction because of dynamic instability during sport or daily activities29. ACL Injury Prevention or Rehabilitation

Continued efforts sought to characterize risk factors for noncontact ACL injury to augment prevention via targeted neuromuscular training30,31. Bracing after ACL reconstruction remains controversial. Giotis et al. found in a kinematic analysis that both prophylactic braces and patellofemoral sleeves limited some of the residual increased tibial rotation that remains despite ACL reconstruction, but the clinical impact of this remains unknown32. The role of “prehabilitation” in the setting of subacute ACL injury was the subject of a rigorous

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What’s New in Sports Medicine randomized controlled trial of twenty patients at a mean time of 6.7 months after their injury33. At twelve weeks postoperatively, the treatment group showed sustained improvements in single-leg hop and Cincinnati scores, but peak torque and muscle mass gains had regressed to levels similar to those of control patients. ACL Tunnels

ACL surgeons continue to debate transtibial and anteromedial transportal techniques for femoral tunnel placement. In a large prospective multicenter study, the patients undergoing transtibial techniques had a 2.5 times higher risk of undergoing repeat ipsilateral knee surgery at six years, but clinical outcomes were not different at the time of the latest follow-up34. The technical aspects of anatomic femoral tunnel placement were the subject of multiple studies35-37. Kim et al. compared anteromedial transportal with outside-in drilling for doublebundle ACL reconstruction and concluded that transportal tunnel architecture was superior in terms of aperture shape and entry angle36. Despite evidence that transtibial femoral tunnels are consistently more anterior than transportal tunnels35, Lee et al. demonstrated no significant radiographic differences via application of anterior drawer, varus, and external rotation forces on the tibia at 90° of flexion during transtibial drilling37. ACL Graft

Graft selection in ACL reconstruction is multifactorial, but subtle differences emerged in two large registry studies in favor of bone-patellar tendon-bone autografts over hamstring tendon38,39. Overall revision rates at five years were higher for hamstring tendon autografts (4.45%) compared with bonepatellar tendon-bone autografts (3.03%), especially in the youngest subset of patients who had received a hamstring autograft39. Further studies are needed to elucidate these findings. The often-overlooked third autograft option is becoming increasingly popular. Lund et al. investigated quadriceps tendonbone and bone-patellar tendon-bone grafts and reported fewer positive pivot shifts (14% compared with 38%) and fewer occurrences of anterior knee pain (7% compared with 34%) for the quadriceps tendon-bone cohort40. Contralateral autograft harvest remains a viable option, and a recent Level-I study identified no benefits or drawbacks with contralateral hamstring autograft tendon harvest41.

struction achieved similar clinical outcomes45,47 and rates of osteoarthritis (10%) at four years45. Kim et al. explored the implications of a torn discoid lateral meniscus left untreated until adulthood and contrasted that cohort with a cohort who had symptomatic tears of a non-discoid meniscus. Varuspattern osteoarthritis and more chondral damage occurred in patients with a discoid lateral meniscus, leading the authors to recommend careful monitoring for loss of valgus in this patient population48. Meniscus Operative treatment of degenerative meniscal tears in the setting of osteoarthritis provided discouraging results in two randomized trials totaling nearly 500 patients49,50. Partial meniscectomy was not more effective than physical therapy and showed no mean differences in the Western Ontario Meniscal Evaluation Tool (WOMET) or Lysholm scores compared with a sham procedure50. In the setting of isolated meniscal repair, a Level-I study by Lind et al. challenged conventional wisdom regarding optimal postoperative rehabilitation51. Sixty patients were randomized into either a traditional protocol with toe-touch weight-bearing and hinged brace use for six weeks or free rehabilitation with no restrictions after two weeks. Magnetic resonance imaging (MRI) was used to assess healing, and second-look arthroscopy was performed when symptoms lingered. Partial healing or a lack of healing occurred in 28% in the free rehabilitation group and in 36% in the traditional group; all other outcomes were similar. Posterior Cruciate Ligament (PCL) The development of tunnel volume enlargement following arthroscopic ACL reconstruction is a disconcerting finding with many proposed mechanisms, but the prevalence and clinical effects of widening after PCL reconstruction are not well studied. Kwon et al. reported an overall low prevalence (3.6%) at one year and no significant differences between an Achilles allograft and a hybrid autograft or allograft when using a remnant bundle preservation technique52. Debate continues with regard to single-bundle compared with double-bundle PCL reconstruction. Li et al. found similar satisfaction and activity scores but superior side-to-side posterior translation in favor of double-bundle reconstruction after two years53. Cartilage

Osteoarthritis After ACL or Meniscal Injury

Outcomes

Evidence regarding the relationship between ACL injury and the development of osteoarthritis continues to evolve42-46. Barenius et al. reported a 57% prevalence of radiographic medial compartment osteoarthritis at fourteen years, with no observed differences between hamstring grafts and bonepatellar tendon-bone grafts42. An age-matched population study found a 1.4% prevalence of total knee arthroplasty in the case cohort compared with a 0.2% prevalence in the general population44. Double-bundle and single-bundle ACL recon-

Maximal efforts continued as researchers tackled the challenging issues regarding articular cartilage injury. Cell-based regenerative techniques such as autologous chondrocyte implantation received considerable attention. Nawaz et al. performed either autologous chondrocyte implantation or matrix-induced autologous chondrocyte implantation, finding similar overall postoperative survival rates of 78% at five years and 51% at ten years, but the failure rate was five times higher for the patients who had undergone a prior regenerative

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What’s New in Sports Medicine procedure54. Matrix-induced autologous chondrocyte implantation provided a superior short-term Knee Injury and Osteoarthritis Outcome Score (KOOS) when prospectively compared with microfracture for lesions of ‡3 cm2, although similar repair tissue quality was seen histologically55. Treatment algorithms for cartilage repair in the patellofemoral compartment are less established and published results are less consistent than those for lesions involving the femoral condyles. Despite the higher degree of complexity, good results were achieved with either matrix-induced autologous chondrocyte implantation or autologous osteochondral transplantation for trochlear or patellar lesions in two studies56,57. Biologics and Cartilage Regeneration

The biologic frontier of cartilage restoration has remarkable promise, but much work remains before long-term clinical outcomes are available58-62. Injectable autologous mesenchymal stem cells improved the two-year outcomes of high tibial osteotomy with or without microfracture for chondral injury with varus malalignment58,59. Stanish et al. reported short-term outcomes on BST-CarGel (Piramal Life Sciences), a novel chitosan-based device designed to be mixed with whole blood and applied to a microfractured defect. The treated lesions demonstrated greater filling and superior repair tissue compared with the control group (conventional microfracture); clinical benefit and safety were not different at twelve months60. Rehabilitation Following Cartilage Repair

The safe return to activity after cartilage repair remains an open question, but evidence continues to support early weight-bearing63,64. Edwards et al. conducted a randomized controlled trial comparing accelerated with conventional rehabilitation. The accelerated group reached full weight-bearing by six weeks, two weeks earlier than the conventional cohort, and reported higher quality-of-life scores with no adverse effects at the repair site63. Following osteochondral autograft transplantation of small lesions (with a mean size of 0.72 cm2), early weight-bearing was associated with fewer deep vein thrombosis and arthrofibrosis complications in a retrospective study of 567 patients64. Patellofemoral Instability Reconstruction of the medial patellofemoral ligament has become a well-accepted treatment for patellofemoral instability, but concomitant procedures should be carefully considered on the basis of pathological conditions and alignment57,65. Following isolated medial patellofemoral ligament reconstruction, 100% of young patients returned to sport, with 53% at an equal or higher level and 47% at lower levels66. Multiligament Knee Injury Multiligament knee injuries are well known as serious injuries that pose a high level of morbidity for patients and severe challenges for surgeons67-70. These concerns were compounded by obesity in a retrospective study by Ridley et al., who noted the

odds ratio of complication increased by 9.2% for every 1 unit of body mass index (BMI)68. A large case series by Werner et al. found an 11% prevalence of the unusual ultra-low velocity mechanism of multiligament knee injury that occurs in morbidly obese individuals. The cohort had a mean BMI of 49 kg/m2 and had a five times higher rate of peroneal nerve injury and vascular injury67. Effective rehabilitation following multiligament knee injury is problematic because of the paradoxical nature of two of the most common postoperative complications, arthrofibrosis and recurrent instability. Stannard et al. reported that hinged external fixation (Compass Knee Hinge; Smith & Nephew, Memphis, Tennessee) used for six weeks to supplement ligament reconstruction led to fewer ligament failures and equivalent motion when compared with hinged bracing70. Hip Femoroacetabular Impingement Substantial interest continues regarding hip arthroscopy as the understanding of femoroacetabular impingement continues to evolve. Cam deformities, considered to be major risk factors for hip osteoarthritis, were recently demonstrated to gradually develop during skeletal maturation in youth soccer players71. The authors suggested that the adjustment of athletic activities during a small period of skeletal growth may limit the development of femoroacetabular impingement and subsequent hip osteoarthritis. A trial of conservative management, including rest, physical therapy, and potentially intra-articular injections, is indicated for nearly all patients who have femoroacetabular impingement. Byrd et al. compared in-office ultrasoundguided injections with fluoroscopically guided injections. In patients who underwent both types of injections, office-based ultrasound-guided injections were found to be more convenient and less painful than hospital-based fluoroscopically guided injections72. Pathological Extra-Articular Hip Conditions Although less studied than intra-articular hip problems, extraarticular disorders of the hip can cause overlapping clinical symptoms that require diligence to diagnose and manage. Proximal hamstring tears typically occur in more active populations and create treatment dilemmas. A Level-IV study evaluated the outcomes of nineteen patients (mean age, fiftynine years) with complete proximal hamstring avulsions treated conservatively73. The authors determined that nonsurgical treatment yielded notable subjective outcome and strength deficits at a mean of thirty-one months postoperatively. In an athletic population with acute hamstring injuries, platelet-rich plasma injections combined with rehabilitation were compared with rehabilitation alone in a Level-II study74. The authors found a significantly decreased return-to-play time in the group that received a single autologous platelet-rich plasma injection combined with a rehabilitation program (twenty-seven days) compared with the group that received rehabilitation alone (forty-three days).

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What’s New in Sports Medicine Hip Arthroscopy Hip arthroscopy remains an important surgical option for patients who fail conservative management of pathological structural hip conditions. There continues to be a lack of Level-I and II studies on outcomes after hip arthroscopy. Wilkin et al. found retrospectively that arthroscopic labral debridement in patients forty-five years of age or older was associated with a relatively high reoperation rate and minimal overall improvement in outcome measures75. Elbow Overuse Syndromes The efficacy of platelet-rich plasma in the treatment of chronic elbow overuse syndromes continues to be a topic of interest. A double-blinded, prospective, multicenter Level-II study evaluated the efficacy of a platelet-rich plasma injection for chronic lateral epicondylitis76. A total of 230 patients at twelve centers over five years who had at least three months of symptoms and had failed conservative therapy were randomized to a platelet-rich plasma group (n = 116) and an active control group (n = 114). At twenty-four weeks, clinically meaningful improvement was found in patients treated with leukocyte-enriched platelet-rich plasma compared with an active control group as measured by a visual analog pain score76. In contrast, another recent Level-I study compared platelet-rich plasma for lateral epicondylitis with a glucocorticoid or saline solution injection and found no significant differences between the groups at three months77. The authors reported that platelet-rich plasma did not reduce pain or disability at three months any more than placebo. However, the results of that study have been recently questioned78. Traumatic Injuries to the Elbow Elbow trauma can lead to high morbidity and is associated with arthrofibrosis and chondral injury despite appropriate treatment. A Level-II study evaluated the efficacy and reliability of combining three validated clinical tests for identifying complete distal biceps tendon ruptures79. In this prospective cohort study, the hook test, the passive forearm pronation test, and the biceps crease interval test were applied in sequence with standard history and physical examination in forty-eight patients with suspected distal biceps ruptures. When all three tests were in agreement, the result had 100% sensitivity and specificity for a rupture79. In equivocal cases, soft-tissue imaging was utilized to evaluate the injury further. Foot and Ankle Achilles Tendon The treatment of Achilles tendon injuries continues to be a widely researched area in the orthopaedic literature. Surgical compared with nonsurgical treatment of acute Achilles tendon ruptures remains an often debated issue. The ideal weightbearing status recommendation in the setting of nonsurgical treatment is unclear. In their randomized controlled trial,

Young et al. followed eighty-four patients over a two-year period; patients were randomized into a weight-bearing cast with a B¨ohler iron or a non-weight-bearing cast for eight weeks. The rerupture rate was low for both groups and showed no significant difference. Furthermore, return to work was equivalent for both groups80. A blinded, randomized controlled trial looked at the role of dynamic rehabilitation in the nonoperative treatment of Achilles tendon injuries. Patients were randomized to either a day-one weight-bearing group or a six-week non-weight-bearing group. The Achilles tendon Total Rupture Score (ATRS) at one year was the primary outcome, with heelrise work, rerupture rate, and health-related quality of life evaluated as secondary outcomes. There was no significant difference in heel-rise work or the ATRS. The overall rerupture rate in that study was 9%81. In another randomized controlled trial, Olsson et al. evaluated stable surgical repair and accelerated rehabilitation compared with nonoperative management. One hundred patients were randomized into each group. The ATRS at one year was the primary outcome. The surgically treated group showed superiority in both the drop countermovement jump and the hopping domains. There were no reruptures in the surgical group but five reruptures in the nonsurgical group. There were six superficial infections in the surgical treatment group, but they did not affect the final outcome. Functional deficits were still present for both groups at twelve months. The authors concluded that surgical repair can result in optimal outcome without rerupture or major wound complications; however, surgical repair was not found to be superior to nonoperative treatment in terms of functional results, physical activity, or quality of life82. Ankle Ligament Injuries Ankle sprains continue to represent the most commonly occurring sports-related injury. Bracing and physical therapy with neuromuscular training represent essential elements of the treatment and prevention protocols for these injuries. A cost-effectiveness analysis was done to compare one group that received neuromuscular training, a second group that received brace therapy with all sports activities for twelve months, and a third group that received combined neuromuscular training and ankle bracing for eight weeks with all sports activities. A total of 340 athletes were randomized into each group. Cost analysis on the recurrence of ankle sprains was performed over a one-year follow-up period. Incremental cost-effectiveness ratio results showed that bracing was the single dominant secondary preventive intervention83. Miscellaneous Concussion Head injuries and concussions sustained during athletic contests have garnered heightened public awareness and media attention. Prolific research is emerging regarding the understanding, prevention, and treatment of these frequently perplexing and sometimes devastating injuries. The risk of

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What’s New in Sports Medicine sports-related concussion appears to be independent of the helmet brand worn by high school football players. McGuine et al. reported that the most significant risk factor for concussion in this population is a previous concussion within the prior twelve months84. Furthermore, young athletes with a history of three concussions or more were still impaired eight days after a concussion and took significantly longer to recover than athletes with one or no prior concussions85. Recent evidence also demonstrates that some sex disparities exist after sport-related concussions, as female athletes exhibit lower performance on visual memory and higher scores on total symptoms than male athletes after concussions86. Reporting of concussions is improving in all levels of athletics from high school to the professional level, but much work remains. Although an increasing onus has been placed on athletes to report any potential symptoms, a recent study evaluated the effect of coach education on reporting of concussions87. The authors of this Level-II study found that 69% of concussed athletes reported playing with symptoms and 40% reported that their coach was not aware of their concussion. The fact that these claims occurred despite recent outreaches to improve concussion awareness calls for renewed vigor in the task of creating a culture change among athletes and coaches, as legislative action alone will likely fall short87. Female Athletes Female athletes have unique biomechanical characteristics that predispose them to specific injuries. Numerous studies have demonstrated that neuromuscular control deficits increase the risk of ACL tears in female athletes. In addition, a recent study found an alarming overall incidence of injuries in adolescent female soccer athletes, including many severe injuries88. Although playing level was not associated with the risk of severe injury, lower participation frequency was associated with a significantly higher injury risk compared with more frequent participation. The playing surface for female soccer athletes

may have some effect on injuries, as a recent prospective investigation found a significantly lower total injury incidence rate and lower rate of substantial injuries on FieldTurf compared with natural grass during game play89. Evidence-Based Orthopaedics The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I or II. In addition to articles published previously in this journal or cited already in the Update, six additional Level-I and/or LevelII articles were identified that were relevant to sports medicine. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

John A. Tanksley, MD Brian C. Werner, MD Mark D. Miller, MD Department of Orthopaedic Surgery, University of Virginia, PO Box 800159, Charlottesville, VA 22908 Richard Ma, MD Missouri Orthopaedic Institute, 1100 Virginia Avenue, Columbia, MO 65212 MaCalus V. Hogan, MD Department of Orthopaedic Surgery, Kaufmann Medical Building, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213

References 1. Mather RC 3rd, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, Bach BR Jr, Spindler KP; MOON Knee Group. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013 Oct 2;95(19):1751-9. 2. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Holloway GB, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic fullthickness rotator cuff tear. J Bone Joint Surg Am. 2014 May 21;96(10):793-800. 3. Russell RD, Knight JR, Mulligan E, Khazzam MS. Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis. J Bone Joint Surg Am. 2014 Feb 19;96(4):265-71. 4. Namdari S, Donegan RP, Chamberlain AM, Galatz LM, Yamaguchi K, Keener JD. Factors affecting outcome after structural failure of repaired rotator cuff tears. J Bone Joint Surg Am. 2014 Jan 15;96(2):99-105. 5. Kim HM, Caldwell JM, Buza JA, Fink LA, Ahmad CS, Bigliani LU, Levine WN. Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear. J Bone Joint Surg Am. 2014 Jan 15;96(2):106-12. 6. Li X, Xu CP, Hou YL, Song JQ, Cui Z, Yu B. Are platelet concentrates an ideal biomaterial for arthroscopic rotator cuff repair? A meta-analysis of randomized controlled trials. Arthroscopy. 2014 Nov;30(11):1483-90. Epub 2014 Jun 6.

7. Jo CH, Shin JS, Lee YG, Shin WH, Kim H, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med. 2013 Oct;41(10):2240-8. Epub 2013 Aug 6. 8. Jo CH, Shin JS, Park IW, Kim H, Lee SY. Multiple channeling improves the structural integrity of rotator cuff repair. Am J Sports Med. 2013 Nov;41(11):2650-7. Epub 2013 Aug 13. 9. Gerber C, Rahm SA, Catanzaro S, Farshad M, Moor BK. Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years. J Bone Joint Surg Am. 2013 Nov 6; 95(21):1920-6. 10. Mohtadi NG, Chan DS, Hollinshead RM, Boorman RS, Hiemstra LA, Lo IK, Hannaford HN, Fredine J, Sasyniuk TM, Paolucci EO. A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes. J Bone Joint Surg Am. 2014 Mar 5;96(5):353-60. 11. Leroux T, Bhatti A, Khoshbin A, Wasserstein D, Henry P, Marks P, Takhar K, Veillette C, Theodoropolous J, Chahal J. Combined arthroscopic Bankart repair and remplissage for recurrent shoulder instability. Arthroscopy. 2013 Oct;29(10):1693701. Epub 2013 Aug 6.

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What’s New in Sports Medicine 12. Buza JA 3rd, Iyengar JJ, Anakwenze OA, Ahmad CS, Levine WN. Arthroscopic HillSachs remplissage: a systematic review. J Bone Joint Surg Am. 2014 Apr 2;96 (7):549-55. 13. Owens BD, Campbell SE, Cameron KL. Risk factors for posterior shoulder instability in young athletes. Am J Sports Med. 2013 Nov;41(11):2645-9. Epub 2013 Aug 27. 14. Bradley JP, McClincy MP, Arner JW, Tejwani SG. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 200 shoulders. Am J Sports Med. 2013 Sep;41(9):2005-14. Epub 2013 Jun 26. 15. Oh JH, Kim JY, Choi JH, Park SM. Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study. Am J Sports Med. 2014 Nov; 42(11):2567-73. Epub 2014 Sep 5. 16. Ahld´en M, Sernert N, Karlsson J, Kartus J. A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med. 2013 Nov;41(11):2484-91. Epub 2013 Aug 6. 17. Andernord D, Bj¨ornsson H, Petzold M, Eriksson BI, Forssblad M, Karlsson J, Samuelsson K. Surgical predictors of early revision surgery after anterior cruciate ligament reconstruction: results from the Swedish National Knee Ligament Register on 13,102 patients. Am J Sports Med. 2014 Apr 28;42(7):1574-82. 18. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014 Apr 21;42(7):1567-73. 19. Shelbourne KD, Benner RW, Gray T. Return to sports and subsequent injury rates after revision anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2014 Mar 13;42(6):1395-400. 20. Ryan J, Magnussen RA, Cox CL, Hurbanek JG, Flanigan DC, Kaeding CC. ACL reconstruction: do outcomes differ by sex? A systematic review. J Bone Joint Surg Am. 2014 Mar 19;96(6):507-12. 21. Maletis GB, Inacio MC, Funahashi TT. Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med. 2013 Sep;41(9):2090-8. Epub 2013 Jun 28. 22. Bogunovic L, Kruse LM, Haas AK, Huston LJ, Wright RW. Outcome of all-inside second-generation meniscal repair: minimum five-year follow-up. J Bone Joint Surg Am. 2014 Aug 6;96(15):1303-7. 23. Pula DA, Femia RE, Marzo JM, Bisson LJ. Are root avulsions of the lateral meniscus associated with extrusion at the time of acute anterior cruciate ligament injury?: a case control study. Am J Sports Med. 2014 Jan;42(1):173-6. Epub 2013 Oct 10. 24. Chu CR, Williams AA, West RV, Qian Y, Fu FH, Do BH, Bruno S. Quantitative magnetic resonance imaging UTE-T2* mapping of cartilage and meniscus healing after anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2014 May 8;42(8):1847-56. 25. Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty EC, Spindler KP. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med. 2014 May;42(5):1058-67. Epub 2014 Mar 19. 26. Kim SJ, Lee SK, Kim SH, Kim SH, Kim JS, Jung M. Does anterior laxity of the uninjured knee influence clinical outcomes of ACL reconstruction? J Bone Joint Surg Am. 2014 Apr 2;96(7):543-8. 27. Kim SJ, Lee SK, Choi CH, Kim SH, Kim SH, Jung M. Graft selection in anterior cruciate ligament reconstruction for smoking patients. Am J Sports Med. 2014 Jan;42(1):166-72. Epub 2013 Oct 10. 28. Kim SJ, Lee SK, Kim SH, Kim SH, Ryu SW, Jung M. Effect of cigarette smoking on the clinical outcomes of ACL reconstruction. J Bone Joint Surg Am. 2014 Jun 18;96(12):1007-13. 29. Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA. Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL Cohort Study. J Bone Joint Surg Am. 2014 Aug 6; 96(15):1233-41. 30. Beynnon BD, Vacek PM, Newell MK, Tourville TW, Smith HC, Shultz SJ, Slauterbeck JR, Johnson RJ. The effects of level of competition, sport, and sex on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med. 2014 Jul 11;42(8):1806-12. 31. Swart E, Redler L, Fabricant PD, Mandelbaum BR, Ahmad CS, Wang YC. Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis. J Bone Joint Surg Am. 2014 May 7;96(9):705-11. 32. Giotis D, Zampeli F, Pappas E, Mitsionis G, Papadopoulos P, Georgoulis AD. Effects of knee bracing on tibial rotation during high loading activities in anterior cruciate ligament-reconstructed knees. Arthroscopy. 2013 Oct;29(10):1644-52. Epub 2013 Aug 29. 33. Shaarani SR, O’Hare C, Quinn A, Moyna N, Moran R, O’Byrne JM. Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. Am J Sports Med. 2013 Sep;41(9):2117-27. Epub 2013 Jul 11.

34. Duffee A, Magnussen RA, Pedroza AD, Flanigan DC, Kaeding CC; MOON Group. Transtibial ACL femoral tunnel preparation increases odds of repeat ipsilateral knee surgery. J Bone Joint Surg Am. 2013 Nov 20;95(22):2035-42. 35. Hensler D, Working ZM, Illingworth KD, Tashman S, Fu FH. Correlation between femoral tunnel length and tunnel position in ACL reconstruction. J Bone Joint Surg Am. 2013 Nov 20;95(22):2029-34. 36. Kim JG, Chang MH, Lim HC, Bae JH, Ahn JH, Wang JH. Computed tomography analysis of the femoral tunnel position and aperture shape of transportal and outsidein ACL reconstruction: do different anatomic reconstruction techniques create similar femoral tunnels? Am J Sports Med. 2013 Nov;41(11):2512-20. Epub 2013 Aug 27. 37. Lee JK, Lee S, Seong SC, Lee MC. Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique. J Bone Joint Surg Am. 2014 Apr 16;96(8):664-72. 38. Persson A, Fjeldsgaard K, Gjertsen JE, Kjellsen AB, Engebretsen L, Hole RM, Fevang JM. Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: a study of 12,643 patients from the Norwegian Cruciate Ligament Registry, 2004-2012. Am J Sports Med. 2014 Feb;42(2):285-91. Epub 2013 Dec 9. 39. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M. Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the Danish registry of knee ligament reconstruction. Am J Sports Med. 2014 Feb;42(2):278-84. Epub 2013 Nov 25. 40. Lund B, Nielsen T, Faunø P, Christiansen SE, Lind M. Is quadriceps tendon a better graft choice than patellar tendon? A prospective randomized study. Arthroscopy. 2014 May;30(5):593-8. Epub 2014 Mar 14. 41. McRae S, Leiter J, McCormack R, Old J, MacDonald P. Ipsilateral versus contralateral hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized trial. Am J Sports Med. 2013 Nov;41(11):2492-9. Epub 2013 Sep 3. 42. Barenius B, Ponzer S, Shalabi A, Bujak R, Norl´en L, Eriksson K. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med. 2014 May;42(5):1049-57. Epub 2014 Mar 18. 43. Chalmers PN, Mall NA, Moric M, Sherman SL, Paletta GP, Cole BJ, Bach BR Jr. Does ACL reconstruction alter natural history?: A systematic literature review of longterm outcomes. J Bone Joint Surg Am. 2014 Feb 19;96(4):292-300. 44. Leroux T, Ogilvie-Harris D, Dwyer T, Chahal J, Gandhi R, Mahomed N, Wasserstein D. The risk of knee arthroplasty following cruciate ligament reconstruction: a populationbased matched cohort study. J Bone Joint Surg Am. 2014 Jan 1;96(1):2-10. 45. Song EK, Seon JK, Yim JH, Woo SH, Seo HY, Lee KB. Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2013 Oct;41(10):2340-6. Epub 2013 Aug 19. 46. Gallagher B, Tjoumakaris FP, Harwood MI, Good RP, Ciccotti MG, Freedman KB. Chondroprotection and the prevention of osteoarthritis progression of the knee: a systematic review of treatment agents. Am J Sports Med. 2014 May 27. 47. Gong X, Jiang D, Wang YJ, Wang J, Ao YF, Yu JK. Second-look arthroscopic evaluation of chondral lesions after isolated anterior cruciate ligament reconstruction: single- versus double-bundle reconstruction. Am J Sports Med. 2013 Oct;41(10): 2362-7. Epub 2013 Jul 18. 48. Kim SJ, Bae JH, Lim HC. Does torn discoid meniscus have effects on limb alignment and arthritic change in middle-aged patients? J Bone Joint Surg Am. 2013 Nov 20;95(22):2008-14. 49. MacDonald PB. Arthroscopic partial meniscectomy was not more effective than physical therapy for meniscal tear and knee osteoarthritis. J Bone Joint Surg Am. 2013 Nov 20;95(22):2058. 50. Sihvonen R, Paavola M, Malmivaara A, It¨al¨a A, Joukainen A, Nurmi H, Kalske J, J¨arvinen TL; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24. 51. Lind M, Nielsen T, Faunø P, Lund B, Christiansen SE. Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens. Am J Sports Med. 2013 Dec;41(12):2753-8. Epub 2013 Oct 10. 52. Kwon JH, Han JH, Jo DY, Park HJ, Lee SY, Bhandare N, Suh DW, Nha KW. Tunnel volume enlargement after posterior cruciate ligament reconstruction: comparison of Achilles allograft with mixed autograft/allograft—a prospective computed tomography study. Arthroscopy. 2014 Mar;30(3):326-34. 53. Li Y, Li J, Wang J, Gao S, Zhang Y. Comparison of single-bundle and double-bundle isolated posterior cruciate ligament reconstruction with allograft: a prospective, randomized study. Arthroscopy. 2014 Jun;30(6):695-700. Epub 2014 Apr 14. 54. Nawaz SZ, Bentley G, Briggs TW, Carrington RW, Skinner JA, Gallagher KR, Dhinsa BS. Autologous chondrocyte implantation in the knee: mid-term to long-term results. J Bone Joint Surg Am. 2014 May 21;96(10):824-30. 55. Saris D, Price A, Widuchowski W, Bertrand-Marchand M, Caron J, Drogset JO, Emans P, Podskubka A, Tsuchida A, Kili S, Levine D, Brittberg M; on behalf of the

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What’s New in Sports Medicine SUMMIT Study Group. Matrix-applied characterized autologous cultured chondrocytes versus microfracture: two-year follow-up of a prospective randomized trial. Am J Sports Med. 2014 Apr 8;42(6):1384-94. 56. Astur DC, Arliani GG, Binz M, Astur N, Kaleka CC, Amaro JT, Pochini A, Cohen M. Autologous osteochondral transplantation for treating patellar chondral injuries: evaluation, treatment, and outcomes of a two-year follow-up study. J Bone Joint Surg Am. 2014 May 21;96(10):816-23. 57. Filardo G, Kon E, Andriolo L, Di Martino A, Zaffagnini S, Marcacci M. Treatment of “patellofemoral” cartilage lesions with matrix-assisted autologous chondrocyte transplantation: a comparison of patellar and trochlear lesions. Am J Sports Med. 2014 Mar;42(3):626-34. Epub 2013 Dec 3. 58. Wong KL, Lee KB, Tai BC, Law P, Lee EH, Hui JH. Injectable cultured bone marrow-derived mesenchymal stem cells in varus knees with cartilage defects undergoing high tibial osteotomy: a prospective, randomized controlled clinical trial with 2 years’ follow-up. Arthroscopy. 2013 Dec;29(12):2020-8. 59. Koh YG, Kwon OR, Kim YS, Choi YJ. Comparative outcomes of open-wedge high tibial osteotomy with platelet-rich plasma alone or in combination with mesenchymal stem cell treatment: a prospective study. Arthroscopy. 2014 Nov;30(11):1453-60. Epub 2014 Aug 6. 60. Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J, Restrepo A, Shive MS. Novel scaffold-based BST-CarGel treatment results in superior cartilage repair compared with microfracture in a randomized controlled trial. J Bone Joint Surg Am. 2013 Sep 18;95(18):1640-50. 61. Smyth NA, Haleem AM, Murawski CD, Do HT, Deland JT, Kennedy JG. The effect of platelet-rich plasma on autologous osteochondral transplantation: an in vivo rabbit model. J Bone Joint Surg Am. 2013 Dec 18;95(24):2185-93. 62. Cavallo C, Filardo G, Mariani E, Kon E, Marcacci M, Pereira Ruiz MT, Facchini A, Grigolo B. Comparison of platelet-rich plasma formulations for cartilage healing: an in vitro study. J Bone Joint Surg Am. 2014 Mar 5;96(5):423-9. 63. Edwards PK, Ackland TR, Ebert JR. Accelerated weightbearing rehabilitation after matrix-induced autologous chondrocyte implantation in the tibiofemoral joint: early clinical and radiological outcomes. Am J Sports Med. 2013 Oct;41(10):231424. Epub 2013 Jul 23. 64. Kosiur JR, Collins RA. Weight-bearing compared with non-weight-bearing following osteochondral autograft transfer for small defects in weight-bearing areas in the femoral articular cartilage of the knee. J Bone Joint Surg Am. 2014 Aug 20;96 (16):e136. 65. Dickens AJ, Morrell NT, Doering A, Tandberg D, Treme G. Tibial tubercle-trochlear groove distance: defining normal in a pediatric population. J Bone Joint Surg Am. 2014 Feb 19;96(4):318-24. 66. Lippacher S, Dreyhaupt J, Williams SR, Reichel H, Nelitz M. Reconstruction of the medial patellofemoral ligament: clinical outcomes and return to sports. Am J Sports Med. 2014 Apr 23;42(7):1661-8. 67. Werner BC, Gwathmey FW Jr, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med. 2014 Feb;42(2):358-63. Epub 2013 Nov 8. 68. Ridley TJ, Cook S, Bollier M, McCarthy M, Gao Y, Wolf B, Amendola A. Effect of body mass index on patients with multiligamentous knee injuries. Arthroscopy. 2014 Nov;30(11):1447-52. Epub 2014 Jul 23. 69. Zhang H, Sun Y, Han X, Wang Y, Wang L, Alquhali A, Bai X. Simultaneous reconstruction of the anterior cruciate ligament and medial collateral ligament in patients with chronic ACL-MCL lesions: a minimum 2-year follow-up study. Am J Sports Med. 2014 Apr 25;42(7):1675-81. 70. Stannard JP, Nuelle CW, McGwin G, Volgas DA. Hinged external fixation in the treatment of knee dislocations: a prospective randomized study. J Bone Joint Surg Am. 2014 Feb 5;96(3):184-91. 71. Agricola R, Heijboer MP, Ginai AZ, Roels P, Zadpoor AA, Verhaar JA, Weinans H, Waarsing JH. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: a prospective study with minimum 2-year follow-up. Am J Sports Med. 2014 Apr;42(4):798-806. Epub 2014 Feb 28.

72. Byrd JW, Potts EA, Allison RK, Jones KS. Ultrasound-guided hip injections: a comparative study with fluoroscopy-guided injections. Arthroscopy. 2014 Jan;30 (1):42-6. 73. Hofmann KJ, Paggi A, Connors D, Miller SL. Complete avulsion of the proximal hamstring insertion: functional outcomes after nonsurgical treatment. J Bone Joint Surg Am. 2014 Jun 18;96(12):1022-5. 74. A Hamid MS, Mohamed Ali MR, Yusof A, George J, Lee LP. Platelet-rich plasma injections for the treatment of hamstring injuries: a randomized controlled trial. Am J Sports Med. 2014 Oct;42(10):2410-8. Epub 2014 Jul 29. 75. Wilkin G, March G, Beaul´e PE. Arthroscopic acetabular labral debridement in patients forty-five years of age or older has minimal benefit for pain and function. J Bone Joint Surg Am. 2014 Jan 15;96(2):113-8. 76. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, Ramsey ML, Karli DC, Rettig AC. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014 Feb;42(2):463-71. Epub 2013 Jul 3. 77. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013 Mar; 41(3):625-35. Epub 2013 Jan 17. 78. Mandelbaum B. An injection of platelet-rich plasma, glucocorticoid, or saline solution produced similar pain and disability results in lateral epicondylitis. J Bone Joint Surg Am. 2013 Nov 20;95(22):2059. 79. Devereaux MW, ElMaraghy AW. Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med. 2013 Sep;41(9):1998-2004. Epub 2013 Jun 26. 80. Young SW, Patel A, Zhu M, van Dijck S, McNair P, Bevan WP, Tomlinson M. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: a randomized controlled trial. J Bone Joint Surg Am. 2014 Jul 2;96(13):1073-9. 81. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weightbearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014 Sep 17;96(18):1497-503. 82. Olsson N, Silbernagel KG, Eriksson BI, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013 Dec;41(12):2867-76. Epub 2013 Sep 6. 83. Janssen KW, Hendriks MR, van Mechelen W, Verhagen E. The cost-effectiveness of measures to prevent recurrent ankle sprains: results of a 3-arm randomized controlled trial. Am J Sports Med. 2014 Apr 21;42(7):1534-41. 84. McGuine TA, Hetzel S, McCrea M, Brooks MA. Protective equipment and player characteristics associated with the incidence of sport-related concussion in high school football players: a multifactorial prospective study. Am J Sports Med. 2014 Oct;42(10):2470-8. Epub 2014 Jul 24. 85. Covassin T, Moran R, Wilhelm K. Concussion symptoms and neurocognitive performance of high school and college athletes who incur multiple concussions. Am J Sports Med. 2013 Dec;41(12):2885-9. Epub 2013 Aug 19. 86. Covassin T, Elbin RJ, Bleecker A, Lipchik A, Kontos AP. Are there differences in neurocognitive function and symptoms between male and female soccer players after concussions? Am J Sports Med. 2013 Dec;41(12):2890-5. Epub 2013 Nov 6. 87. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203. Epub 2014 Feb 25. 88. Clausen MB, Zebis MK, Møller M, Krustrup P, H¨olmich P, Wedderkopp N, Andersen LL, Christensen KB, Thorborg K. High injury incidence in adolescent female soccer. Am J Sports Med. 2014 Oct;42(10):2487-94. Epub 2014 Jul 2. 89. Meyers MC. Incidence, mechanisms, and severity of match-related collegiate women’s soccer injuries on FieldTurf and natural grass surfaces: a 5-year prospective study. Am J Sports Med. 2013 Oct;41(10):2409-20. Epub 2013 Aug 13.

Evidence-Based Articles Related to Sports Medicine

active young adults who sustain anterior shoulder dislocation, but the authors noted the lack of evidence for patients in other categories.

Longo UG, Loppini M, Rizzello G, Ciuffreda M, Maffulli N, Denaro V. Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy. 2014 Apr;30(4):506-22. The authors synthesized available randomized controlled trials regarding surgical and nonsurgical treatment of first-time anterior shoulder dislocation. Thirty-one studies with 2813 shoulders were included, and the pooled data showed nonoperatively treated shoulders had a significantly higher rate of recurrence (odds ratio, 12.71). This study supports primary surgery for highly

Park SS, Dwyer T, Congiusta F, Whelan DB, Theodoropoulos J. Analysis of irradiation on the clinical effectiveness of allogenic tissue when used for primary anterior cruciate ligament reconstruction. Am J Sports Med. 2015 Jan;41 (1):225-35. Epub 2014 Jan 29. Park et al. conducted a systematic review to evaluate the clinical implications of low-dose irradiation or other tissue-processing methods on an

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What’s New in Sports Medicine ACL allograft. Knees with nonirradiated allografts had higher mean Lysholm scores, less laxity on knee examination, and lower rates of revision surgery when compared with low-dose irradiated grafts. The results were limited by an insufficient amount of data on several of the cryopreservation techniques, but the authors concluded that nonirradiated grafts may be superior. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2013 Dec 23;12:CD010071. This review encompassed the full spectrum of musculoskeletal applications of platelet-rich plasma to assess three primary outcomes: function, pain, and adverse events. Currently, insufficient evidence exists to recommend the use of platelet-rich therapies for treating any musculoskeletal injuries. Lee JJ, Kim DY, Hwang JT, Lee SS, Hwang SM, Kim GH, Jo YG. Effect of ultrasonographically guided axillary nerve block combined with suprascapular nerve block in arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy. 2014 Aug;30(8):906-14. Epub 2014 May 29. The suprascapular nerve supplies 70% of the sensation within the shoulder, especially superior and posterior, but lateral sensation is primarily from the axillary nerve. This Level-I study compared combined axillary and suprascapular nerve blocks with suprascapular nerve block alone after rotator cuff surgery. The primary outcomes were postoperative pain and satisfaction within the first forty-eight hours. The cohort with combined axillary nerve block and suprascapular nerve block had a lower amount of pain and a lower

frequency of rebound pain in the first thirty-six hours. The suprascapular nerve block is a useful block but, when combined with an axillary nerve block, it provides superior early postoperative pain control. Riboh JC, Garrigues GE. Early passive motion versus immobilization after arthroscopic rotator cuff repair. Arthroscopy. 2014 Aug;30(8):997-1005. Epub 2014 May 10. The highest-quality literature pertaining to postoperative mobilization following arthroscopic rotator cuff repair was synthesized in this Level-II metaanalysis and revealed that only a small number of high-level studies are available. The best available evidence shows that early passive motion results in improved forward flexion of 15° at three months and 5° at six and twelve months and in no apparent increased retear rate compared with strict sling immobilization. Surgeons should use best judgment based on tear configuration until more conclusive evidence emerges, but the best available evidence supports early mobilization. Eggerding V, Reijman M, Scholten RJ, Meuffels DE. Computer-assisted surgery for knee ligament reconstruction. Cochrane Database Syst Rev. 2014 Aug 4;8:CD007601. This was a review of five randomized controlled trials comparing conventional ACL or PCL reconstruction with computer-assisted surgery augmentation. In light of low-quality evidence reporting either no difference or clinically inconsequential differences, the authors concluded that available evidence does not support improved outcomes with computer-assisted surgery for ACL or PCL reconstruction.