695 C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Sports Medicine James S. Starman, MD, Justin W. Griffin, MD, Abdurrahman Kandil, MD, Richard Ma, MD, MaCalus V. Hogan, MD, and Mark D. Miller, MD
This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2012 to August 2013. 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 (American volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic & Related Surgery. Shoulder The Natural History of Rotator Cuff Disease A large body of research continues to focus on maximization of outcomes in rotator cuff disease. Moosmayer et al. assessed the clinical and morphological changes that occur in asymptomatic full-thickness rotator cuff tears. Their study demonstrated the potential negative consequences of nonsurgical care: a significant number of initially asymptomatic rotator cuff tears became symptomatic, and the tears that became symptomatic demonstrated increased fatty atrophy and larger tear patterns1. This raises questions about the role of surveillance and how best to counsel patients regarding the risks associated with nonsurgical care. Rotator Cuff Repair Disappointing structural healing rates continue to be associated with rotator cuff repair surgery, particularly with ‘‘massive’’ sized tears2-4. Chung et al. reported a 39% failure rate of massive rotator cuff tear repair, with fatty infiltration being the main predictor of healing failure. However, regardless of healing, most patients were clinically improved2. Similar conclusions were demonstrated by Paxton et al. at a follow-up time of ten-years3. Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
Research investigating rotator cuff repair techniques remains active. Outcomes with margin convergence repair techniques were evaluated in a well-designed study by Kim et al.5 This study evaluated twenty-four patients followed for two years postoperatively, and the authors reported that a 47% retear rate occurred when margin convergence was employed5. Surgical augmentation techniques in rotator cuff repair represent an emerging area of interest. In a recent Level-I study, Weber et al. evaluated how platelet-rich fibrin matrix (PRFM) would influence healing rates; they found no difference in clinical outcome or structural integrity at one year6. In their systematic review, Chahal et al. evaluated the potential of platelet-rich plasma to improve rotator cuff healing and found no overall effect on retear rate or shoulder-specific outcome measures7. Finally, a recent prospective randomized controlled trial demonstrated that massive rotator cuff repair augmented with a cellular human dermal allograft resulted in higher rates of intact repair (85% versus 40%) as determined by magnetic resonance imaging (MRI) follow-up at two years8. Superior Labrum Anterior and Posterior (SLAP) Repair Versus Biceps Tenotomy There is an increasing trend toward surgical management of SLAP lesions with biceps tenodesis rather than repair. In a prospective 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. examined functional outcomes with type-II SLAP repair versus biceps tenotomy in patients with rotator cuff repair, and they found that biceps tenotomy with rotator cuff repair may be a more reliable option than SLAP repair for patients with concomitant biceps pathology 10.
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.
J Bone Joint Surg Am. 2014;96:695-702
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What’s New in Sports Medicine Shoulder Instability The optimal treatment for instability of the shoulder remains another area of controversy. A recent cost-analysis study concluded that primary arthroscopic stabilization is clinically effective and cost-effective for first-time glenohumeral dislocation11. Another study examined the natural history of osseous Bankart lesions, suggesting that this bone fragment undergoes rapid absorption within one year after the primary dislocation event12. Glenoid reconstruction techniques with autograft or allograft remain a viable option for refractory instability, especially when bone loss of the glenoid articular surface nears 20% to 25%. The stabilizing mechanism of the Latarjet procedure was examined this year in a cadaveric model, with results indicating that the sling effect is the most important contributor to observed increases in stability13. Another study assessed the biomechanics of allograft techniques for glenoid reconstruction with use of the distal tibial articular surface14. Traditionally, arthroscopic techniques for addressing substantial glenoid osseous insufficiency have been associated with high rates of failure; however, new techniques for arthroscopic stabilization continue to emerge15. Millett et al. followed a series of fifteen patients who were treated with an arthroscopic osseous Bankart repair technique16. When a reducible bone fragment was present, patients were successfully treated arthroscopically with anchor placement medial to the fracture site and sutures shuttled around the osseous piece. Surgical options for addressing humeral-sided defects, such as the remplissage technique, have shown increased popularity as well17. Acromioclavicular Joint Free tendon graft reconstruction techniques for high-grade acromioclavicular separations continue to develop, and arthroscopic assistance is becoming more commonplace18. In a recent study of tunnel position as it relates to graft failure, the authors noted a 29% failure rate by approximately seven weeks postoperatively and reported that excessively medialized bone tunnels were a significant predictor of failure19. Another study demonstrated that bone mineral density was optimal in the anatomic insertion of the coracoclavicular ligaments between 20 and 60 mm from the lateral end of the clavicle and that placement outside this range may be associated with higher failure rates20. Knee Anterior Cruciate Ligament (ACL) ACL Footprint and Tunnel Creation
Among all knee-based topics, articles related to the ACL have been the most frequently published over the past year. Considerable interest remains regarding anatomic tunnel placement in ACL reconstruction surgery, although debate persists on optimal tunnel positions. McConkey et al. investigated arthroscopic agreement on femoral tunnel positioning among twelve surgeons and found that there was no uniform agree-
ment among surgeons on the ideal tunnel position; however, there was general agreement that a transtibial technique may yield more poorly placed tunnels compared with accessory medial portal or outside-in techniques21. Several studies have specifically studied the benefits and drawbacks of different femoral tunnel creation techniques22-25. One potential drawback of the accessory medial portal technique is shorter tunnel length22,23. In a study of 106 consecutive patients who underwent reconstruction with an accessory medial portal technique, Tompkins et al. demonstrated that a tunnel length of >30 mm without posterior wall fracture can consistently be achieved22. Rahr-Wagner et al. investigated surgical revision rates in 9239 patients on the basis of the femoral tunnel creation technique and found a higher revision rate (5.16%) in patients who underwent surgery with use of an accessory medial portal technique as compared with a transtibial technique (3.20%)24. Tibial tunnel placement has also been an area of active research, with some authors advocating for a more anterior tibial tunnel. In a recent Level-IV study of sixty patients, Hatayama et al. concluded that a more anterior tibial tunnel improves anterior stability without resulting in loss of extension26. ACL Preservation and Augmentation
Surgeons continue to debate the usefulness of preserving the remaining ACL fibers during reconstruction procedures when only one bundle appears damaged. In a recent study by Park et al., the authors compared the single-bundle augmentation procedure with the double-bundle technique, finding similar outcomes in anterior and rotatory stability as well as in the clinical scores of fifty-five patients (thirty-eight cases of posterolateral augmentation, seventeen anteromedial bundle augmentations)27. Caution must be exercised in defining a true one-bundle tear, however, and this technique remains technically demanding. Others have studied the preservation of the footprint of the ACL to promote improved revascularization and proprioception. Hong et al., in their prospective randomized study of ninety patients, compared ACL remnant preservation with removal and at two years found equivalent results in stability, synovial coverage, and proprioceptive recovery 28. Pediatric ACL Considerations
Pediatric ACL reconstruction has become more frequent in recent years, leading to renewed interest in outcomes for surgical techniques in skeletally immature patients29,30. Kumar et al. reported positive outcomes of a transphyseal ACL reconstruction technique that made use of autograft hamstring in thirty-two skeletally immature patients with minimum follow-up to age sixteen years. No patients had a limb-length discrepancy, although one developed mild valgus deformity29. The timing of surgery for pediatric ACL reconstruction has also been debated. Dumont et al. found that patients treated more than 150 days after ACL injury had a higher rate of medial meniscal tear. Increased age and weight were also associated with higher overall risk of medial meniscal tears31.
697 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d
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What’s New in Sports Medicine Osteoarthritis After ACL Injury
A major goal of ACL reconstruction is to reduce the possibility of the development of long-term osteoarthritis in the knee following injury. Despite additional studies, it remains unclear whether ACL reconstruction accomplishes this goal as compared with the results obtained with nonoperative treatment protocols32,33. Frobell et al. reported the five-year results of a blinded randomized cohort of patients who underwent either rehabilitation and ACL reconstruction or rehabilitation plus optional delayed ACL reconstruction. Patient-reported and radiographic outcomes were equivalent for both groups, thus challenging the hypothesis that ACL reconstruction contributes to a lower risk of the development of osteoarthritis. Potential bias of the results due to a high crossover rate raises questions about the results, however32. Other factors, such as meniscal and chondral injury, are also important in influencing the development of osteoarthritis, thereby complicating the attempts to understand the specific effects of ACL reconstruction on the progression of arthritis.
allograft group as compared with 3% in the autograft group38. However, other studies have reported more comparable results with allograft tissue39. Graft diameter is also an important consideration, and a recent article investigated the ability of MRI or ultrasound measurements to predict hamstring graft diameter preoperatively40. ACL Rehabilitation and Return to Play
Attempts have been made to identify factors that may allow a faster return to play in select patients. A systematic review of ACL rehabilitation by Kruse et al. concluded that bracing following ACL reconstruction is neither necessary nor beneficial and that home-based rehabilitation can be successful. Neuromuscular interventions were safe but unlikely to have appreciable benefit to patients41. Flanigan et al. found that a majority of patients who do not return to sports after ACL reconstruction cite pain as a contributing factor. Fear of reinjury was cited by half of the patients, while only a minority cited job and family demands42.
ACL Outcomes
Posterior Cruciate Ligament (PCL)
Authors from the Multicenter Orthopaedic Outcomes Network (MOON) ACL study group reported on the six-year outcomes of single-bundle ACL reconstruction, establishing rates of and predictive factors for additional surgical procedures after primary ACL reconstruction. At a follow-up time of six years, 18.9% of patients had undergone an additional procedure on the ipsilateral leg, and 10.2% of patients had undergone an additional procedure on the contralateral leg. On the ipsilateral leg, 7.7% had ACL revision procedures, and 13.3% had cartilagebased procedures. Younger age and the use of ACL allografts were risk factors for additional surgery 34. Numerous authors have continued to report outcomes comparing single-bundle and double-bundle ACL reconstruction techniques; however, to date, no study has demonstrated convincing evidence to conclude that one technique is superior to the other35-37. A meta-analysis of nineteen randomized controlled trials comparing single-bundle and double-bundle ACL reconstruction techniques in 1667 patients showed significantly better anterior and rotational stability and higher International Knee Documentation Committee (IKDC) objective scores in association with double-bundle reconstruction as compared with single-bundle reconstruction, without differences in subjective clinical outcomes36.
Isolated PCL Treatment
ACL Graft Selection
The use of autograft or allograft in ACL reconstruction continues to be debated. Ellis et al. have recently advocated for the preferred use of autograft tissue, especially in younger patients undergoing ACL reconstruction38. Those authors compared the revision rates obtained with autograft and allograft bone-patellar tendon-bone in skeletally mature patients who were eighteen years of age or younger, and those authors noted a failure rate in the first year after surgery of 35% in the
Historically, an isolated PCL injury has commonly been managed nonsurgically. Shelbourne et al., in reporting the tenyear minimum outcomes with nonoperative treatment of acute, isolated PCL injuries in sixty-eight patients who were followed prospectively, revealed evidence to support this treatment. The cohort of patients remained active and had good strength and range of motion and good subjective scores. The results were not affected by the grade of PCL laxity. The prevalence of moderate-to-severe osteoarthritis was 11%43. A subset of patients with isolated PCL injuries or those with a combined ligamentous injury may require surgical reconstruction of the PCL, and several recent studies have attempted to better define surgical and radiographic landmarks for recreation of the normal anatomy44-46. Anderson et al. investigated the anatomic landmarks associated with arthroscopic PCL reconstruction in twenty nonpaired cadavers, concluding that the femoral attachments of the anterolateral and posteromedial bundles are an average of 12.1 mm apart compared with the tibial attachment points, which are only 8.9 mm apart. They advocated placing a femoral anterolateral tunnel adjacent to the articular cartilage and a posteromedial tunnel 8.6 mm proximal to the cartilage margin, just distal to the medial intercondylar ridge. If a single-bundle technique is preferred, the tunnel should approximate the midpoint between the anterolateral and posteromedial insertion points44. Combined PCL and Posterolateral Corner Injury
Posterolateral corner injury combined with posterior cruciate ligament injury remains a difficult problem and represents a spectrum of injury, making it a challenge to standardize treatment. Kim et al. investigated the effects of physiological posterolateral rotatory laxity on the outcomes of combined
698 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d
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What’s New in Sports Medicine PCL and posterolateral corner injury reconstruction. They retrospectively reviewed sixty-five patients, grouped according to the degree of laxity of the uninjured limb, and evaluated clinical outcomes and posterior stability. Using stress radiography with use of a Telos device (Telos, Marburg, Germany), they found no differences between the groups with regard to posterior translation or varus opening and no differences in clinical outcomes or in the grades on the dial test47. Another study assessed the utility of combined PCL and posterolateral corner reconstruction in patients with a posterolateral corner injury but only mild (
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Sports Medicine James S. Starman, MD, Justin W. Griffin, MD, Abdurrahman Kandil, MD, Richard Ma, MD, MaCalus V. Hogan, MD, and Mark D. Miller, MD
This update is based on the scientific and investigational activities in the specialty of sports medicine from September 2012 to August 2013. 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 (American volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic & Related Surgery. Shoulder The Natural History of Rotator Cuff Disease A large body of research continues to focus on maximization of outcomes in rotator cuff disease. Moosmayer et al. assessed the clinical and morphological changes that occur in asymptomatic full-thickness rotator cuff tears. Their study demonstrated the potential negative consequences of nonsurgical care: a significant number of initially asymptomatic rotator cuff tears became symptomatic, and the tears that became symptomatic demonstrated increased fatty atrophy and larger tear patterns1. This raises questions about the role of surveillance and how best to counsel patients regarding the risks associated with nonsurgical care. Rotator Cuff Repair Disappointing structural healing rates continue to be associated with rotator cuff repair surgery, particularly with ‘‘massive’’ sized tears2-4. Chung et al. reported a 39% failure rate of massive rotator cuff tear repair, with fatty infiltration being the main predictor of healing failure. However, regardless of healing, most patients were clinically improved2. Similar conclusions were demonstrated by Paxton et al. at a follow-up time of ten-years3. Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
Research investigating rotator cuff repair techniques remains active. Outcomes with margin convergence repair techniques were evaluated in a well-designed study by Kim et al.5 This study evaluated twenty-four patients followed for two years postoperatively, and the authors reported that a 47% retear rate occurred when margin convergence was employed5. Surgical augmentation techniques in rotator cuff repair represent an emerging area of interest. In a recent Level-I study, Weber et al. evaluated how platelet-rich fibrin matrix (PRFM) would influence healing rates; they found no difference in clinical outcome or structural integrity at one year6. In their systematic review, Chahal et al. evaluated the potential of platelet-rich plasma to improve rotator cuff healing and found no overall effect on retear rate or shoulder-specific outcome measures7. Finally, a recent prospective randomized controlled trial demonstrated that massive rotator cuff repair augmented with a cellular human dermal allograft resulted in higher rates of intact repair (85% versus 40%) as determined by magnetic resonance imaging (MRI) follow-up at two years8. Superior Labrum Anterior and Posterior (SLAP) Repair Versus Biceps Tenotomy There is an increasing trend toward surgical management of SLAP lesions with biceps tenodesis rather than repair. In a prospective 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. examined functional outcomes with type-II SLAP repair versus biceps tenotomy in patients with rotator cuff repair, and they found that biceps tenotomy with rotator cuff repair may be a more reliable option than SLAP repair for patients with concomitant biceps pathology 10.
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.
J Bone Joint Surg Am. 2014;96:695-702
d
http://dx.doi.org/10.2106/JBJS.M.01569
696 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d
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W H AT ’ S N E W
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SPORTS MEDICINE
d
What’s New in Sports Medicine Shoulder Instability The optimal treatment for instability of the shoulder remains another area of controversy. A recent cost-analysis study concluded that primary arthroscopic stabilization is clinically effective and cost-effective for first-time glenohumeral dislocation11. Another study examined the natural history of osseous Bankart lesions, suggesting that this bone fragment undergoes rapid absorption within one year after the primary dislocation event12. Glenoid reconstruction techniques with autograft or allograft remain a viable option for refractory instability, especially when bone loss of the glenoid articular surface nears 20% to 25%. The stabilizing mechanism of the Latarjet procedure was examined this year in a cadaveric model, with results indicating that the sling effect is the most important contributor to observed increases in stability13. Another study assessed the biomechanics of allograft techniques for glenoid reconstruction with use of the distal tibial articular surface14. Traditionally, arthroscopic techniques for addressing substantial glenoid osseous insufficiency have been associated with high rates of failure; however, new techniques for arthroscopic stabilization continue to emerge15. Millett et al. followed a series of fifteen patients who were treated with an arthroscopic osseous Bankart repair technique16. When a reducible bone fragment was present, patients were successfully treated arthroscopically with anchor placement medial to the fracture site and sutures shuttled around the osseous piece. Surgical options for addressing humeral-sided defects, such as the remplissage technique, have shown increased popularity as well17. Acromioclavicular Joint Free tendon graft reconstruction techniques for high-grade acromioclavicular separations continue to develop, and arthroscopic assistance is becoming more commonplace18. In a recent study of tunnel position as it relates to graft failure, the authors noted a 29% failure rate by approximately seven weeks postoperatively and reported that excessively medialized bone tunnels were a significant predictor of failure19. Another study demonstrated that bone mineral density was optimal in the anatomic insertion of the coracoclavicular ligaments between 20 and 60 mm from the lateral end of the clavicle and that placement outside this range may be associated with higher failure rates20. Knee Anterior Cruciate Ligament (ACL) ACL Footprint and Tunnel Creation
Among all knee-based topics, articles related to the ACL have been the most frequently published over the past year. Considerable interest remains regarding anatomic tunnel placement in ACL reconstruction surgery, although debate persists on optimal tunnel positions. McConkey et al. investigated arthroscopic agreement on femoral tunnel positioning among twelve surgeons and found that there was no uniform agree-
ment among surgeons on the ideal tunnel position; however, there was general agreement that a transtibial technique may yield more poorly placed tunnels compared with accessory medial portal or outside-in techniques21. Several studies have specifically studied the benefits and drawbacks of different femoral tunnel creation techniques22-25. One potential drawback of the accessory medial portal technique is shorter tunnel length22,23. In a study of 106 consecutive patients who underwent reconstruction with an accessory medial portal technique, Tompkins et al. demonstrated that a tunnel length of >30 mm without posterior wall fracture can consistently be achieved22. Rahr-Wagner et al. investigated surgical revision rates in 9239 patients on the basis of the femoral tunnel creation technique and found a higher revision rate (5.16%) in patients who underwent surgery with use of an accessory medial portal technique as compared with a transtibial technique (3.20%)24. Tibial tunnel placement has also been an area of active research, with some authors advocating for a more anterior tibial tunnel. In a recent Level-IV study of sixty patients, Hatayama et al. concluded that a more anterior tibial tunnel improves anterior stability without resulting in loss of extension26. ACL Preservation and Augmentation
Surgeons continue to debate the usefulness of preserving the remaining ACL fibers during reconstruction procedures when only one bundle appears damaged. In a recent study by Park et al., the authors compared the single-bundle augmentation procedure with the double-bundle technique, finding similar outcomes in anterior and rotatory stability as well as in the clinical scores of fifty-five patients (thirty-eight cases of posterolateral augmentation, seventeen anteromedial bundle augmentations)27. Caution must be exercised in defining a true one-bundle tear, however, and this technique remains technically demanding. Others have studied the preservation of the footprint of the ACL to promote improved revascularization and proprioception. Hong et al., in their prospective randomized study of ninety patients, compared ACL remnant preservation with removal and at two years found equivalent results in stability, synovial coverage, and proprioceptive recovery 28. Pediatric ACL Considerations
Pediatric ACL reconstruction has become more frequent in recent years, leading to renewed interest in outcomes for surgical techniques in skeletally immature patients29,30. Kumar et al. reported positive outcomes of a transphyseal ACL reconstruction technique that made use of autograft hamstring in thirty-two skeletally immature patients with minimum follow-up to age sixteen years. No patients had a limb-length discrepancy, although one developed mild valgus deformity29. The timing of surgery for pediatric ACL reconstruction has also been debated. Dumont et al. found that patients treated more than 150 days after ACL injury had a higher rate of medial meniscal tear. Increased age and weight were also associated with higher overall risk of medial meniscal tears31.
697 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d
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W H AT ’ S N E W
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SPORTS MEDICINE
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What’s New in Sports Medicine Osteoarthritis After ACL Injury
A major goal of ACL reconstruction is to reduce the possibility of the development of long-term osteoarthritis in the knee following injury. Despite additional studies, it remains unclear whether ACL reconstruction accomplishes this goal as compared with the results obtained with nonoperative treatment protocols32,33. Frobell et al. reported the five-year results of a blinded randomized cohort of patients who underwent either rehabilitation and ACL reconstruction or rehabilitation plus optional delayed ACL reconstruction. Patient-reported and radiographic outcomes were equivalent for both groups, thus challenging the hypothesis that ACL reconstruction contributes to a lower risk of the development of osteoarthritis. Potential bias of the results due to a high crossover rate raises questions about the results, however32. Other factors, such as meniscal and chondral injury, are also important in influencing the development of osteoarthritis, thereby complicating the attempts to understand the specific effects of ACL reconstruction on the progression of arthritis.
allograft group as compared with 3% in the autograft group38. However, other studies have reported more comparable results with allograft tissue39. Graft diameter is also an important consideration, and a recent article investigated the ability of MRI or ultrasound measurements to predict hamstring graft diameter preoperatively40. ACL Rehabilitation and Return to Play
Attempts have been made to identify factors that may allow a faster return to play in select patients. A systematic review of ACL rehabilitation by Kruse et al. concluded that bracing following ACL reconstruction is neither necessary nor beneficial and that home-based rehabilitation can be successful. Neuromuscular interventions were safe but unlikely to have appreciable benefit to patients41. Flanigan et al. found that a majority of patients who do not return to sports after ACL reconstruction cite pain as a contributing factor. Fear of reinjury was cited by half of the patients, while only a minority cited job and family demands42.
ACL Outcomes
Posterior Cruciate Ligament (PCL)
Authors from the Multicenter Orthopaedic Outcomes Network (MOON) ACL study group reported on the six-year outcomes of single-bundle ACL reconstruction, establishing rates of and predictive factors for additional surgical procedures after primary ACL reconstruction. At a follow-up time of six years, 18.9% of patients had undergone an additional procedure on the ipsilateral leg, and 10.2% of patients had undergone an additional procedure on the contralateral leg. On the ipsilateral leg, 7.7% had ACL revision procedures, and 13.3% had cartilagebased procedures. Younger age and the use of ACL allografts were risk factors for additional surgery 34. Numerous authors have continued to report outcomes comparing single-bundle and double-bundle ACL reconstruction techniques; however, to date, no study has demonstrated convincing evidence to conclude that one technique is superior to the other35-37. A meta-analysis of nineteen randomized controlled trials comparing single-bundle and double-bundle ACL reconstruction techniques in 1667 patients showed significantly better anterior and rotational stability and higher International Knee Documentation Committee (IKDC) objective scores in association with double-bundle reconstruction as compared with single-bundle reconstruction, without differences in subjective clinical outcomes36.
Isolated PCL Treatment
ACL Graft Selection
The use of autograft or allograft in ACL reconstruction continues to be debated. Ellis et al. have recently advocated for the preferred use of autograft tissue, especially in younger patients undergoing ACL reconstruction38. Those authors compared the revision rates obtained with autograft and allograft bone-patellar tendon-bone in skeletally mature patients who were eighteen years of age or younger, and those authors noted a failure rate in the first year after surgery of 35% in the
Historically, an isolated PCL injury has commonly been managed nonsurgically. Shelbourne et al., in reporting the tenyear minimum outcomes with nonoperative treatment of acute, isolated PCL injuries in sixty-eight patients who were followed prospectively, revealed evidence to support this treatment. The cohort of patients remained active and had good strength and range of motion and good subjective scores. The results were not affected by the grade of PCL laxity. The prevalence of moderate-to-severe osteoarthritis was 11%43. A subset of patients with isolated PCL injuries or those with a combined ligamentous injury may require surgical reconstruction of the PCL, and several recent studies have attempted to better define surgical and radiographic landmarks for recreation of the normal anatomy44-46. Anderson et al. investigated the anatomic landmarks associated with arthroscopic PCL reconstruction in twenty nonpaired cadavers, concluding that the femoral attachments of the anterolateral and posteromedial bundles are an average of 12.1 mm apart compared with the tibial attachment points, which are only 8.9 mm apart. They advocated placing a femoral anterolateral tunnel adjacent to the articular cartilage and a posteromedial tunnel 8.6 mm proximal to the cartilage margin, just distal to the medial intercondylar ridge. If a single-bundle technique is preferred, the tunnel should approximate the midpoint between the anterolateral and posteromedial insertion points44. Combined PCL and Posterolateral Corner Injury
Posterolateral corner injury combined with posterior cruciate ligament injury remains a difficult problem and represents a spectrum of injury, making it a challenge to standardize treatment. Kim et al. investigated the effects of physiological posterolateral rotatory laxity on the outcomes of combined
698 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014 d
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W H AT ’ S N E W
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SPORTS MEDICINE
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What’s New in Sports Medicine PCL and posterolateral corner injury reconstruction. They retrospectively reviewed sixty-five patients, grouped according to the degree of laxity of the uninjured limb, and evaluated clinical outcomes and posterior stability. Using stress radiography with use of a Telos device (Telos, Marburg, Germany), they found no differences between the groups with regard to posterior translation or varus opening and no differences in clinical outcomes or in the grades on the dial test47. Another study assessed the utility of combined PCL and posterolateral corner reconstruction in patients with a posterolateral corner injury but only mild (
