WHAT’S NEW IN SPORTS MEDICINE

Saseendar Sundaram, MS

Knee

Anterior Cruciate Ligament

Double-bundle technique was associated with better visual analog scale pain scores and less instrumented anterior knee laxity based on a recent Level-I clinical study. There were no significant differences in terms of rotational control and subjective KOOS (Knee Injury and Osteoarthritis Outcome Score) and IKDC (International Knee Documentation Committee) scores¹.
On comparing traditional transtibial technique with independent drilling of the femoral tunnel, independent drilling has been shown to better reproduce an anatomic graft orientation^2-4. However, more horizontal tunnel can produce a shorter tunnel and an increased risk of posterior wall blowout^5,6.
Comparisons of ACL reconstruction with hamstring autograft as compared with patellar tendon autograft have demonstrated no significant difference in terms of subjective outcome scores, osteoarthritis outcome scores, and instrumented laxity at two, eight, and ten years of follow-up. The only difference was greater anterior knee pain in the patellar tendon group^7-9.
Biodegradable screws have been associated with greater tunnel enlargement when compared with other forms of fixation^10,11.
Current studies also evaluate ACL primary repair and the use of platelet-rich plasma for ACL reconstruction^12,13.

Posterior Cruciate Ligament

Common topics of debate related to posterior cruciate ligament (PCL) reconstruction are the superiority of double as compared with single-bundle reconstruction and tibial inlay as compared with transtibial graft placement.

In one recent study, transtibial single-bundle arthroscopic tibial inlay procedures were compared with double-bundle arthroscopic tibial inlay procedures¹⁴. The results suggested that the double-bundle arthroscopic tibial inlay procedure produced better posterior stability but no difference in terms of knee motion or Lysholm scores.

Meniscus

Meniscal repair has shown better outcomes in terms of return to play as well as minimising osteoarthritis progression in comparison with partial meniscectomy¹⁵. Meniscal repair with a concomitant ACL reconstruction also have shown good results¹⁶.
Laboratory and clinical studies have demonstrated that meniscal transplantation improves knee biomechanics as well as long-term clinical outcomes as compared with those in knees with no meniscus, although some deterioration in clinical outcome has been noted over time¹⁷.

Patellofemoral articulation

The extent of chondromalacia patellae does not correlate with anterior knee pain and current physical examination techniques for anterior knee pain do not reliably diagnose chondromalacia patellae¹⁸.

Osteotomies

Medial opening-wedge osteotomy tends to decrease patellar height and to increase tibial slope, with the opposite being true for lateral closing-wedge osteotomies^19,20.

Cartilage

Articular Cartilage Defects

There have been lot of recent work on autologous chondrocyte implantation and its comparison with microfracture and also on osteochondral autograft or allograft treatment. Another field of investigation is the use of juvenile chondrocytes.
Second-generation, or matrix-assisted, autologous chondrocyte implantation (MACI) involves delivering autologous chondrocytes on a bioabsorbable scaffold. A comparison of MACI with autologous chondrocyte implantation demonstrated improved but comparable outcomes with both techniques at twenty-four months²¹.

Cartilage Preservation

Investigations pertaining to chondrocyte cell death following exposure to local anesthetic continue. Various anesthetic formulations, including those that contain epinephrine, lidocaine, bupivacaine, and ropivacaine, have been linked to chondrotoxicity²².

Hip

Hip arthroscopy has been associated with abdominal compartment syndrome and intraoperative vigilance, careful fluid management, and performance of capsulotomy and psoas tenotomy at the end of the central compartment arthroscopy have been recommended to minimize fluid extravasation²³.

Foot and Ankle

A long-term follow-up study comparing autologous chondrocyte implantation of talus with that of the knee has shown comparable results²⁴.

Elbow

Platelet-rich plasma has demonstrated significantly better visual analog pain scale and DASH (Disabilities of the Arm, Shoulder and Hand) scores at one year as compared to corticosteroid injection for the treatment of chronic lateral humeral epicondylitis²⁵. The platelet-rich plasma group also showed progressive improvement after treatment while the corticosteroid group showed initial improvement but then showed worsening.

Comparison of results of non-operative treatment of biceps tendon ruptures with operative treatment has shown superior functional outcome scores and elbow flexion strength with operative treatment.

References:

Aglietti P, Giron F, Losco M, Cuomo P, Ciardullo A, Mondanelli N. Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial. Am J Sports Med. 2010;38:25-34.
Kopf S, Forsythe B, Wong AK, Tashman S, Anderst W, Irrgang JJ, Fu FH. Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am. 2010;92:1427-31.
Miller MD, Gerdeman AC, Miller CD, Hart JM, Gaskin CM, Golish SR, Clancy WG Jr. The effects of extra-articular starting point and transtibial femoral drilling on the intra-articular aperture of the tibial tunnel in ACL reconstruction. Am J Sports Med. 2010;38:707-12.
Steiner ME, Battaglia TC, Heming JF, Rand JD, Festa A, Baria M. Independent drilling outperforms conventional transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med. 2009;37:1912-9.
Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ 3rd. Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy. 2010;26:342-50.
Chang CB, Yoo JH, Chung BJ, Seong SC, Kim TK. Oblique femoral tunnel placement can increase risks of short femoral tunnel and cross-pin protrusion in anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38:1237-45.
Barenius B, Nordlander M, Ponzer S, Tidermark J, Eriksson K. Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial. Am J Sports Med. 2010;38:1533-41.
Holm I, Oiestad BE, Risberg MA, Aune AK. No difference in knee function or prevalence of osteoarthritis after reconstruction of the anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon-bone autograft: a randomized study with 10-year follow-up. Am J Sports Med. 2010;38:448-54.
Taylor DC, DeBerardino TM, Nelson BJ, Duffey M, Tenuta J, Stoneman PD, Sturdivant RX, Mountcastle S. Patellar tendon versus hamstring tendon autografts for anterior cruciate ligament reconstruction: a randomized controlled trial using similar femoral and tibial fixation methods. Am J Sports Med. 2009;37:1946-57.
Jagodzinski M, Geiges B, von Falck C, Knobloch K, Haasper C, Brand J, Hankemeier S, Krettek C, Meller R. Biodegradable screw versus a press-fit bone plug fixation for hamstring anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2010;38:501-8.
Stener S, Ejerhed L, Sernert N, Laxdal G, Rostgård-Christensen L, Kartus J. A long-term, prospective, randomized study comparing biodegradable and metal interference screws in anterior cruciate ligament reconstruction surgery: radiographic results and clinical outcome. Am J Sports Med. 2010;38:1598-605.
Joshi SM, Mastrangelo AN, Magarian EM, Fleming BC, Murray MM. Collagenplatelet composite enhances biomechanical and histologic healing of the porcine anterior cruciate ligament. Am J Sports Med. 2009;37:2401-10.
Nin JR, Gasque GM, Azcarate AV, Beola JD, Gonzalez MH. Has platelet-rich plasma any role in anterior cruciate ligament allograft healing? Arthroscopy. 2009; 25:1206-13.
Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009; 91:2543-9.
Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, J¨ager A. Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med. 2010;38:1542-8.
Krych AJ, Pitts RT, Dajani KA, Stuart MJ, Levy BA, Dahm DL. Surgical repair of meniscal tears with concomitant anterior cruciate ligament reconstruction in patients 18 years and younger. Am J Sports Med. 2010;38:976-82.
Spang JT, Dang AB, Mazzocca A, Rincon L, Obopilwe E, Beynnon B, Arciero RA. The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligament biomechanics. Arthroscopy. 2010;26: 192-201.
Pihlajam¨aki HK, Kuikka PI, Lepp¨anen VV, Kiuru MJ, Mattila VM. Reliability of clinical findings and magnetic resonance imaging for the diagnosis of chondromalacia patellae. J Bone Joint Surg Am. 2010;92:927-34.
LaPrade RF, Oro FB, Ziegler CG, Wijdicks CA, Walsh MP. Patellar height and tibial slope after opening-wedge proximal tibial osteotomy: a prospective study. Am J Sports Med. 2010;38:160-70.
El-Azab H, Glabgly P, Paul J, Imhoff AB, Hinterwimmer S. Patellar height and posterior tibial slope after open- and closed-wedge high tibial osteotomy: a radiological study on 100 patients. Am J Sports Med. 2010;38:323-9.
Zeifang F, Oberle D, Nierhoff C, Richter W, Moradi B, Schmitt H. Autologous chondrocyte implantation using the original periosteum-cover technique versus matrix-associated autologous chondrocyte implantation: a randomized clinical trial. Am J Sports Med. 2010;38:924-33.
Chu CR, Coyle CH, Chu CT, Szczodry M, Seshadri V, Karpie JC, Cieslak KM, Pringle EK. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92:599-608.
Fowler J, Owens BD. Abdominal compartment syndrome after hip arthroscopy. Arthroscopy. 2010;26:128-30.
Giannini S, Battaglia M, Buda R, Cavallo M, Ruffilli A, Vannini F. Surgical treatment of osteochondral lesions of the talus by open-field autologous chondrocyte implantation: a 10-year follow-up clinical and magnetic resonance imaging T2-mapping evaluation. Am J Sports Med. 2009;37:112S-8S.
Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38:255-62.
Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am. 2009;91:2329-34.