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What's New in Sports Medicine

Marc Tompkins, Richard Ma, MaCalus V. Hogan and Mark D. Miller J Bone Joint Surg Am. 2011;93:789-797. doi:10.2106/JBJS.J.01723

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Specialty Update

Whats New in Sports Medicine

By Marc Tompkins, MD, Richard Ma, MD, MaCalus V. Hogan, MD, and Mark D. Miller, MD This update is based on the scientic and investigational activities in the specialty of sports medicine from September 2009 to August 2010. It includes a review of pertinent research and articles published in the three premier journals of our specialty, namely, The Journal of Bone and Joint Surgery (American Volume), The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery. Knee Anterior Cruciate Ligament Anterior cruciate ligament (ACL) reconstruction continues to be the most studied area in sports medicine. The debate continues between the use of double-bundle or single-bundle reconstructions. A recent Level-I clinical study comparing the two techniques demonstrated that the double-bundle technique was associated with better visual analog scale pain scores and less instrumented anterior knee laxity1. There were no signicant differences in terms of rotational control and subjective KOOS (Knee Injury and Osteoarthritis Outcome Score) and IKDC (International Knee Documentation Committee) scores, but the study was limited to a two-year follow-up. A Level-II comparative study demonstrated no signicant difference in terms of anterior and rotational stability or clinical outcomes at the time of the two-year follow-up, despite a signicant difference in anterior and rotational stability intraoperatively2. Controlled laboratory studies comparing knee kinematics associated with each surgical technique have suggested that there may be some improvement in terms of anterior and rotational knee laxity in association with doublebundle reconstruction as compared with single-bundle reconstruction, but the evidence is inconclusive3-5. Much of the focus on tunnel placement, during both double-bundle and single-bundle reconstructions, has been on achieving more anatomic placement of the graft, with a goal of simultaneously controlling knee rotation and anterior-toposterior stability. Most controlled laboratory studies have
Specialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.

focused on the placement of the femoral tunnel. Studies in which the traditional transtibial technique has been compared with independent drilling of the femoral tunnel have favored independent drilling as being better able to produce an anatomic graft orientation6-8. The result of independent drilling has been more horizontal placement of the graft, accomplished with use of exible reamers, precisely placed anteromedial portals, and the use of accessory medial portals9,10. Some studies, however, also have shown that a more horizontal tunnel can produce a shorter tunnel and an increased risk of posterior wall blowout11,12. Good long-term studies evaluating ACL reconstruction with hamstring autograft as compared with patellar tendon autograft have been published. Three Level-I studies demonstrated no signicant difference in terms of subjective outcome scores, osteoarthritis outcome scores, and instrumented laxity at two, eight, and ten years of follow-up13-15. The only difference was greater anterior knee pain in the patellar tendon group. There remain many options for appropriate xation of the graft, but this topic continues to be investigated. Long-term studies that have compared biodegradable screws with other forms of xation have suggested greater tunnel enlargement in association with biodegradable screws but no clinical differences16,17. Researchers are still seeking to elucidate the causes of development of osteoarthritis following ACL reconstruction18. New studies are also evaluating emerging areas, such as ACL primary repair and the use of platelet-rich plasma for ACL reconstruction19,20. 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 procedures21. 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

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benets or a commitment or agreement to provide such benets from a commercial entity.

J Bone Joint Surg Am. 2011;93:789-97

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scores. In an effort to elucidate the causes of cartilage degeneration following PCL reconstruction, another study was performed to evaluate the kinematics of single-bundle reconstruction22. The investigators found that anteroposterior translation of the tibia and patellar exion and shift were restored, whereas mediolateral translation and patellar rotation and tilt were not. Posterolateral Corner, Posteromedial Corner, and Multiligamentous Injury Recreating normal knee kinematics is the goal in the treatment of posterolateral corner injuries. Two recent studies with intermediate-term follow-up suggested that anatomically based posterolateral corner reconstructions resulted in improved stability and clinical outcomes23,24. Another study suggested that reconstruction is more reliable than repair25. A Level-I study also suggested an improved diagnostic method involving the use of ultrasound to determine which patients would benet from reconstruction26. Valgus stress radiographs to conrm the diagnosis are favored, whereas anatomic reconstruction of the medial collateral ligament and posteromedial corner injuries, including reconstruction of the posterior oblique ligament, is recommended27,28. A retrospective study of knee dislocation in elite athletes with resulting multiligamentous injury involving both cruciate ligaments and at least one collateral ligament suggested that early, single-stage procedures provide the best outcomes, although only one-third of patients returned to preinjury levels of play29. Meniscus The understanding of the role of the meniscus in knee stability and contact forces across the joint continues to improve30,31. The meniscus plays a vital role in both of these areas, and retaining as much meniscus as possible is critical. Meniscal repair, when possible, has been shown to improve outcomes in terms of return to play as well as to minimize osteoarthritis progression in comparison with partial meniscectomy32. Studies continue to demonstrate that meniscal repair with a concomitant ACL reconstruction can provide good results, although more complex tears still have lower likelihood of success33,34. Inside-out meniscal repairs have been the gold standard, but one study suggested that, with concomitant ACL reconstruction, an all-inside technique might achieve similar results35. 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 time36,37. Patellofemoral Articulation A systematic review, although it acknowledged potential confounding variables in the studies reviewed, suggested that there are good outcomes for the appropriate patients undergoing medial patellofemoral ligament reconstructions38. A large Level-IV case series also demonstrated good outcomes in patients undergoing the Fulkerson procedure with a lateral release39. Anterior knee pain can be a vexing problem for clinicians. A recent Level-I study showed that the extent of chondromalacia patellae does not correlate with anterior knee pain and that current physical examination techniques for anterior knee pain do not reliably diagnose chondromalacia patellae40. Magnetic resonance imaging (MRI) may be useful in this setting but can only dependably diagnose more advanced chondromalacia patellae lesions. Osteotomies The effect that high tibial osteotomy has on patellar height and tibial slope is an important clinical consideration. Studies have shown that medial opening-wedge osteotomy tends to decrease patellar height and to increase tibial slope, with the opposite being true for lateral closing-wedge osteotomies41,42. The longterm benet of high tibial osteotomy continues to be documented, with a recent study of patients undergoing medial opening-wedge osteotomy and microfracture for the treatment of arthritic malalignment demonstrating a seven-year survival rate of 91%43. Shoulder Rotator Cuff Multiple systematic reviews of single-row as compared with double-row repairs were conducted during the past year44-47. These studies showed no difference in terms of clinical outcomes, but a double-row repair may provide improved tendon healing and lower retear rates in cases of large and massive tears. One type of double-row repair, the suture bridge technique, has been gaining popularity for the appropriate size and type of tear. Clinical studies involving the use of MRI have demonstrated comparable retear rates and clinical outcomes with this suture technique and other repair techniques48,49. Regardless of repair technique, a recent biomechanical study demonstrated decreased rotator cuff footprint contact area and pressure over time50. Knotless anchors have been increasingly incorporated into repairs. One recent study evaluated suture anchor types and suggested that screw type and subcortical wedging anchors provided better stability than other anchors; this is a particularly important consideration for patients with osteopenia or poor bone quality51. The size and type of the tear, the chronicity of the injury, and patient-related factors such as age affect rotator cuff healing and clinical outcomes. Large and massive tears that involve the supraspinatus and infraspinatus are at risk for fatty degeneration, so early repair may be recommended, depending on other patient-related factors52. The larger the tear, the less likely the tendon is to heal; however, any repair attempt, even without complete coverage of the tendon footprint, may provide clinical improvement53. Even in older patients, repair can yield tendon healing and can result in functional improvement54. For patients who have unsuccessful rotator cuff repair,

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all of the above factors affect the likelihood of further healing; however, revision surgery can result in healing and clinical improvement, but with a decreased likelihood of success55,56. Novel methods of augmenting rotator cuff healing following repair are also being studied, such as modulating matrix metalloproteinase pathways and using bone marrow-derived stem cells57-59. Concomitant pathology makes the treatment of rotator cuff tears can more difcult. A longitudinal study comparing biceps tenodesis with tenotomy during rotator cuff repairs demonstrated only a cosmetic difference but no functional difference60. There continues to be controversy over the treatment of SLAP (superior labral anterior-posterior) tears during rotator cuff repair because of the concern about stiffness; however, one recent study suggested that in the appropriate middle-aged population, the results for concomitant SLAP and rotator cuff repair can be the same as for rotator cuff repair alone61. Instability Instability may be more prevalent than previously appreciated. In patients under anesthesia, the ability to subluxate the humeral head over the glenoid rim is common; the evaluation of young patients after traumatic subluxation events without frank dislocation suggests that the level of labral and chondral damage is high; and glenohumeral instability is common in young athletes, including collegiate athletes62-64. The treatment of these conditions continues to be debated, particularly in terms of the timing of surgery. A recent systematic review suggested that there were no differences in terms of recurrence or complication rates between patients undergoing surgery following a primary dislocation as compared with those undergoing surgery following recurrent dislocations; however, the nature of the study did not allow for differentiating the cause of the dislocation65. Arthroscopic repair provides adequate treatment for the majority of unstable shoulders66-68. The most important risk factor for recurrent instability following repair is age (less than twenty to twenty-ve years), although male sex, time to surgery, degree of laxity, and Hill-Sachs lesions are also important69,70. SLAP Lesions A recent study suggested that some patients will have improvement in functional outcomes and pain control with nonoperative treatment of type-II SLAP tears71. However, half of the study participants ultimately underwent surgery, and overhead throwing athletes were particularly likely to have a failure of nonoperative management. We are not aware of any Level-I studies evaluating arthroscopic repair of type-II SLAP lesions. A recent systematic review of Level-III and IV studies demonstrated that arthroscopic repair is benecial; however, outcomes in overhead throwing athletes were not as consistent72. Techniques for arthroscopic repair continue to evolve, with a recent study suggesting that knotless suture anchors restore glenohumeral motion with similar strength as simple suture anchor repairs73. Acromioclavicular Joint Multiple techniques for the reconstruction of coracoclavicular ligaments have shown success after short and intermediateterm follow-up74-76. Recently, more emphasis has been placed on reconstructing the acromioclavicular joint, with good results being demonstrated in the laboratory setting77,78. The treatment of acromioclavicular separation, however, also is associated with a high rate of complications, so care must be taken when performing any of the repair techniques79,80. Cartilage Articular Cartilage Defects Much of the recent work in this area has focused on autologous chondrocyte implantation or autologous chondrocyte implantation as compared with microfracture, with fewer studies on osteochondral autograft or allograft treatment. Other areas of cartilage repair are also being investigated, such as the use of juvenile chondrocytes81. Long-term case series have demonstrated the sustained benet in terms of patient satisfaction and outcome measurements following rst-generation autologous chondrocyte implantation82,83. First-generation autologous chondrocyte implantation, however, has been associated with several challenges and a high complication rate related to the technical demands of the procedure, periosteal patch harvest site morbidity, and patch hypertrophy. A recent study demonstrated that the use of a collagen membrane as a patch substitute reduced the reoperation rate84. Currently, no collagen membrane is ofcially approved by the Food and Drug Administration for use in the United States. Second-generation, or matrix-assisted, autologous chondrocyte implantation involves delivering autologous chondrocytes on a bioabsorbable scaffold. A prospective randomized study in which matrix-assisted autologous chondrocyte implantation was compared with autologous chondrocyte implantation demonstrated improved outcomes at twenty-four months in association with both techniques, but the outcomes were comparable between the two techniques85. Similar to synthetic scaffolds, other biologic scaffolds also have yielded good early results, such as porcine type I/III collagen membrane86. Second-generation autologous chondrocyte implantation currently is not available for use in the United States. An accelerated weight-bearing program and intensive rehabilitation after second-generation autologous chondrocyte implantation leads to good outcomes without jeopardizing the autologous chondrocyte implantation graft87,88. There is a lack of evidence-based consensus favoring autologous chondrocyte implantation or microfracture; however, a recent study in which characterized chondrocyte implantation was compared with microfracture demonstrated signicant clinical improvement at thirty-six months, particularly in patients who received autologous chondrocyte

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implantation with higher gene proles89. Other patient-specic factors, such as age, the location of the defect, and the size of the lesion, likely also inuence patient outcomes. In a cohort study involving the use of a prospective database, patient age, defect size, and defect location were evaluated three years after microfracture and autologous chondrocyte implantation. Patients who were younger than thirty years and those with medial femoral condylar lesions fared better, whereas defect size did not reliably correlate with clinical outcome90. Both of those studies indicated that early treatment may result in better outcomes. A systematic analysis evaluating factors affecting the rate of return to sports after articular cartilage repair also demonstrated a correlative relationship between earlier repair and return to sports91. 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 chondrotoxicity92-94. In addition to anesthetic toxicity, the deleterious effects on chondrocytes resulting from high temperature related to radiofrequency probe use and arthroscopic uid ow have also been highlighted. Irrigation uid ow rate was found to be the most signicant predictor of intra-articular temperature proles95. Hip The authors of recent case reports have documented abdominal compartment syndrome following hip arthroscopy and have recommend intraoperative vigilance, careful uid management, and the performance of capsulotomy and psoas tenotomy at the end of the central compartment arthroscopy to minimize uid extravasation96,97. Hip labral tears can be effectively addressed with hip arthroscopy98. In a retrospective review, patient-related factors that negatively inuenced recovery after hip labral surgery included Workers Compensation status, female sex, the use of pain medications, the presence of a limp, and the presence of lateral labral tears99. In the setting of impingement, short-term follow-up suggests better Harris hip scores with repair than with labral debridement100. For advanced labral tears, reconstruction with use of iliotibial band autograft is a viable option for hips without substantial osteoarthrosis101. Femoroacetabular impingement is now a well-recognized clinical entity that predisposes an individual to acetabular labral tears, chondral damage, and arthritis. In a computerized tomography study of 100 asymptomatic hip joints, 39% of the hips had at least one morphologic characteristic, such as acetabular retroversion and an aspherical femoral head, that predisposes to femoroacetabular impingement102. Osteoplasty of the femur and acetabulum along with labral pathology can be treated with either an open, an arthroscopic, or a combined approach. In one study, a combined arthroscopic and limited open procedure for femoroacetabular impingement demonstrated improved Harris hip scores, reduced radiographic alpha angles, and symptomatic relief with enhanced overall hip function103. Currently, the evidence is lacking to support one technique over another for the treatment of femoroacetabular impingement. Foot and Ankle In an effort to identify a chondral defect size threshold at which poor clinical outcomes become more likely, 120 ankles were evaluated after arthroscopic marrow stimulation for the treatment of talar dome lesions104. Patients with defects measuring >150 mm2 on MRI had a signicantly higher failure rate, dened by the need for osteochondral transplantation or an American Orthopaedic Foot & Ankle Society (AOFAS) score of <80. No correlation was found between outcome and patient age, the duration of symptoms, trauma, associated lesions, or the location of lesions. This information will aid in patient education and treatment planning. A ten-year follow-up study in which autologous chondrocyte implantation for the treatment of talar osteochondritis dissecans lesions was compared with the long-term results of autologous chondrocyte implantation in the knee was recently reported105. The AOFAS score, radiographic assessment, preoperative MRI ndings, and MRI with T2 mapping at the time of the latest follow-up were used to evaluate clinical outcomes. The authors concluded that the results of autologous chondrocyte implantation in the ankle are comparable with those in the knee. One study on lateral ankle instability sought to identify the effects of anterior talobular ligament injury on in vivo ankle kinematics. Nine patients with chronic lateral ankle instability were evaluated as they stepped on a level surface with kinematic measurements that were made as a function of load. Anterior talobular ligament deciency increased anterior translation, internal rotation, and superior translation of the talus106. Lateral ankle instability associated with osteochondritis dissecans lesions of the talus is a common clinical presentation. In a case series, signicant improvement in ankle scores at a mean of 7.3 years of follow-up was reported for patients who underwent simultaneous arthroscopic treatment of osteochondritis dissecans lesions and open lateral ankle stabilization107. However, the presence of an osteochondritis dissecans lesion had an overall negative impact on outcomes as compared with isolated lateral ankle stabilization. Elbow There has been continued focus on the use of platelet-rich plasma to treat lateral humeral epicondylitis. In a recent Level-I study, platelet-rich plasma was compared with corticosteroid injection for the treatment of chronic lateral humeral epicondylitis108. The platelet-rich plasma group had signicantly better visual analog pain scale and DASH (Disabilities of the Arm, Shoulder and Hand) scores at one year. Of note, the platelet-rich plasma group also showed progressive improvement after treatment in comparison with the corticosteroid

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group, which initially showed improvement but then showed worsening. The results of nonoperative treatment of biceps tendon ruptures were recently compared with the results for operatively treated historical controls109. Functional outcomes scores and elbow exion strength were comparable, but supination strength was superior in the operative treatment group. The optimal rehabilitation program following ulnar collateral ligament reconstruction is a point of controversy. A recent controlled laboratory study evaluated passive range of motion, isometric muscle contraction, and varus-valgus torque in cadaveric elbows in which the ulnar collateral ligament had been reconstructed with use of a docking technique and gracilis tendon graft110. The results demonstrated that full extension was safe in the immediate postoperative period, whereas passive exion beyond 50, isometric exercises at >90, and valgus exercises increased strain on the reconstruction. A study of nineteen patients with osteochondritis dissecans of the elbow who were managed with autologous osteochondral mosaicplasty showed that all but one of the patients were pain-free, had a good or excellent result, and had improved total elbow motion after an average of forty-ve months of follow-up111. All but two returned to competitive play. A follow-up MRI study showed that graft incorporation following mosaicplasty occurred around six months postoperatively, and it was suggested that rehabilitation programs begin after this time112. Wrist and Hand Chronic loading of the ulnocarpal joint of the wrist can result in degenerative articular disc perforations of the triangular brocartilage complex. A recent study investigated the role of apoptotic pathways and ulnar length on the development of these degenerative lesions113. Seventeen patients with degenerative tears underwent arthroscopic debridement of the triangular brocartilage complex, with histological and immunohistochemical analysis. Both extrinsic and intrinsic apoptotic pathways were involved in the development of degenerative disc lesions, with brocartilage cell loss occurring through the intrinsic pathway in most cases. This information may be useful in the development of treatment options focused on limiting triangular brocartilage complex cell loss and degeneration. Head and Spinal Cord-Related Sports Injuries Concussion injuries to high-prole athletes have raised awareness for in-game vigilance for and recognition of this injury. Changes in sideline management at all levels of competition include withholding athletes with any concussive symptoms, regardless of severity. The natural history of concussion among Australian football players was described in a prospective cohort study114. Most of the concussed athletes presented with fewer than four clinical symptoms that lasted for less than forty-eight hours; however, nearly 20% of patients had symptoms that lasted for more than seven days. More importantly, the cognitive decits resulting from the concussion resolved independent of reported symptoms. Clinical features that were associated with prolonged time to return to sports included having more profound initial symptoms, a headache lasting for more than sixty hours, and self-reported fatigue or fogginess. In addition, the use of computerized performance tests was highlighted as a more sensitive instrument for the detection of cognitive decits following a concussive event than pencil-and-paper tests. In an evaluation of one such test, ImPACT, the test-retest reliability in collegiate athletes remained stable over a twoyear period115. Evidence-Based Orthopaedics Over the past year, 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. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to the articles already cited in this Update, six Level-I articles were identied that were relevant to sports medicine. A list of these titles is appended to this review following the standard bibliography. We have provided a brief commentary about each of these articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area. Subspecialty Certication in Sports Medicine Subspecialty certication in sports medicine is under the direction of the American Board of Orthopaedic Surgery (ABOS). The ve-year grandfather period for any surgeon seeking this certication will expire in 2012. Therefore, applicants are now required to have completed an Accreditation Council for Graduate Medical Education (ACGME)-accredited and/or Arthroscopy Association of North America (AANA)recognized sports medicine fellowship to sit for the examination. A complete list of requirements, including eligible sports medicine cases, is available online at the ABOS web site (http:// www.abos.org). The application deadline for the 2012 examination is March 15, 2012. It must include case lists, required documents, and fees. Eligible candidates will be mailed their scheduling/ admission permits in August 2012, and the examination will be administered on November 1, 2012, at Prometric Technology Centers nationwide. The application materials will be available at the ABOS web site. The American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeons (AAOS) review course for subspecialty certication in orthopaedic sports medicine will be held in August 2012, in Chicago, Illinois, and information on this course can be found at the AOSSM web site (http://www.sportsmed.org). Applications for the 2012 examination are available online beginning in August 2011.

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Sports Medicine Fellowships Sports medicine remains the most popular orthopaedic surgery fellowship. The match process continues to receive positive reviews from fellowship applicants and program directors alike. STOP Program The STOP (Sports Trauma and Overuse Prevention) Sports Injuries Program was conceived by the AOSSM in 2007. The initiative is aimed at reducing trauma and overuse injuries in young athletes and is supported by many national not-forprot organizations. As described on the STOP web site, it is an outreach program to raise awareness and to provide education on injury reduction in young athletes. Multimedia educational materials for distribution to athletes, parents, coaches, or other health-care providers can be ordered from the STOP web site at http://www.stopsportsinjuries.org/ resources.aspx, via email at info@stopsportsinjuries.org, or via telephone at 1-847-655-8660. Upcoming Meetings The seventy-ninth Annual Meeting of the American Academy of Orthopaedic Surgeons will be held on February 7 through 11, 2012, in San Francisco, California, with Specialty Day being held on February 11, 2012. The Annual Meeting of the AANA will be held on May 17 through 20, 2012, in Orlando, Florida. The Annual Meeting of the AOSSM will be held on July 7 through 11, 2011, in San Diego, California.

Marc Tompkins, MD Richard Ma, MD MaCalus V. Hogan, MD Mark D. Miller, MD Department of Orthopaedics, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22908. E-mail address for M.D. Miller: MDM3P@virginia.edu

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Tsai AG, Wijdicks CA, Walsh MP, Laprade RF. Comparative kinematic evaluation of all-inside single-bundle and double-bundle anterior cruciate ligament reconstruction: a biomechanical study. Am J Sports Med. 2010;38:263-72. 6. 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. 7. 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. 8. 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. 9. 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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. 14. 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. 15. 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 xation methods. Am J Sports Med. 2009;37: 1946-57. 16. Jagodzinski M, Geiges B, von Falck C, Knobloch K, Haasper C, Brand J, Hankemeier S, Krettek C, Meller R. Biodegradable screw versus a press-t bone plug xation for hamstring anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 2010;38:501-8. 17. Stener S, Ejerhed L, Sernert N, Laxdal G, Rostgrd-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. 18. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med. 2010;38:455-63. 19. 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. 20. 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. 21. 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. 22. Gill TJ, Van de Velde SK, Wing DW, Oh LS, Hosseini A, Li G. Tibiofemoral and patellofemoral kinematics after reconstruction of an isolated posterior cruciate ligament injury: in vivo analysis during lunge. Am J Sports Med. 2009;37:2377-85. 23. LaPrade RF, Johansen S, Agel J, Risberg MA, Moksnes H, Engebretsen L. Outcomes of an anatomic posterolateral knee reconstruction. J Bone Joint Surg Am. 2010;92:16-22. 24. Rios CG, Leger RR, Cote MP, Yang C, Arciero RA. Posterolateral corner reconstruction of the knee: evaluation of a technique with clinical outcomes and stress radiography. Am J Sports Med. 2010;38:1564-74. 25. Levy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ. Repair versus reconstruction of the bular collateral ligament and posterolateral corner in the multiligament-injured knee. Am J Sports Med. 2010;38:804-9. 26. Sekiya JK, Swaringen JC, Wojtys EM, Jacobson JA. Diagnostic ultrasound evaluation of posterolateral corner knee injuries. Arthroscopy. 2010;26:494-9.

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27. Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, Laprade RF. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38:339-47. 28. Laprade RF, Bernhardson AS, Grifth CJ, Macalena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. 2010;38:330-8. 29. Hirschmann MT, Iranpour F, Muller W, Friederich NF. Surgical treatment of complex bicruciate knee ligament injuries in elite athletes: what long-term outcome can we expect? Am J Sports Med. 2010;38:1103-9. 30. Bedi A, Kelly NH, Baad M, Fox AJ, Brophy RH, Warren RF, Maher SA. Dynamic contact mechanics of the medial meniscus as a function of radial tear, repair, and partial meniscectomy. J Bone Joint Surg Am. 2010;92:1398-408. 31. Musahl V, Citak M, OLoughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on the stability of the anterior cruciate ligamentdecient knee. Am J Sports Med. 2010;38:1591-7. 32. Stein T, Mehling AP, Welsch F, von Eisenhart-Rothe R, J ger A. Long-term a outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med. 2010;38:1542-8. 33. 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. 34. Tachibana Y, Sakaguchi K, Goto T, Oda H, Yamazaki K, Iida S. Repair integrity evaluated by second-look arthroscopy after arthroscopic meniscal repair with the FasT-Fix during anterior cruciate ligament reconstruction. Am J Sports Med. 2010; 38:965-71. 35. Choi NH, Kim TH, Victoroff BN. Comparison of arthroscopic medial meniscal suture repair techniques: inside-out versus all-inside repair. Am J Sports Med. 2009;37:2144-50. 36. 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. 37. van der Wal RJ, Thomassen BJ, van Arkel ER. Long-term clinical outcome of open meniscal allograft transplantation. Am J Sports Med. 2009;37:2134-9. 38. Buckens CF, Saris DB. Reconstruction of the medial patellofemoral ligament for treatment of patellofemoral instability: a systematic review. Am J Sports Med. 2010;38:181-8. 39. Tjoumakaris FP, Forsythe B, Bradley JP. Patellofemoral instability in athletes: treatment via modied Fulkerson osteotomy and lateral release. Am J Sports Med. 2010;38:992-9. 40. Pihlajam ki HK, Kuikka PI, Lepp nen VV, Kiuru MJ, Mattila VM. Reliability of a a clinical ndings and magnetic resonance imaging for the diagnosis of chondromalacia patellae. J Bone Joint Surg Am. 2010;92:927-34. 41. 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. 42. 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. 43. Sterett WI, Steadman JR, Huang MJ, Matheny LM, Briggs KK. Chondral resurfacing and high tibial osteotomy in the varus knee: survivorship analysis. Am J Sports Med. 2010;38:1420-4. 44. Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med. 2010; 38:835-41. 45. Nho SJ, Slabaugh MA, Seroyer ST, Grumet RC, Wilson JB, Verma NN, Romeo AA, Bach BR Jr. Does the literature support double-row suture anchor xation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor conguration. Arthroscopy. 2009; 25:1319-28. 46. Saridakis P, Jones G. Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review. J Bone Joint Surg Am. 2010;92: 732-42. 47. Wall LB, Keener JD, Brophy RH. Clinical outcomes of double-row versus singlerow rotator cuff repairs. Arthroscopy. 2009;25:1312-8. 48. Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010; 38:664-71. 49. Voigt C, Bosse C, Vosshenrich R, Schulz AP, Lill H. Arthroscopic supraspinatus tendon repair with suture-bridging technique: functional outcome and magnetic resonance imaging. Am J Sports Med. 2010;38:983-91. 50. Mazzocca AD, Bollier MJ, Ciminiello AM, Obopilwe E, DeAngelis JP, Burkhart SS, Warren RF, Arciero RA. Biomechanical evaluation of arthroscopic rotator cuff repairs over time. Arthroscopy. 2010;26:592-9. 51. Pietschmann MF, G lecy z MF, Fieseler S, Hentschel M, Rossbach B, Jansson u u V, M ller PE. Biomechanical stability of knotless suture anchors used in rotator cuff u repair in healthy and osteopenic bone. Arthroscopy. 2010;26:1035-44. 52. Kim HM, Dahiya N, Teefey SA, Keener JD, Galatz LM, Yamaguchi K. Relationship of tear size and location to fatty degeneration of the rotator cuff. J Bone Joint Surg Am. 2010;92:829-39. 53. Yoo JC, Ahn JH, Koh KH, Lim KS. Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage. Arthroscopy. 2009;25:1093-100. 54. Charousset C, Bellache L, Kalra K, Petrover D. Arthroscopic repair of fulli thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older? Arthroscopy. 2010;26:302-9. 55. Keener JD, Wei AS, Kim HM, Paxton ES, Teefey SA, Galatz LM, Yamaguchi K. Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome. J Bone Joint Surg Am. 2010;92:590-8. 56. Piasecki DP, Verma NN, Nho SJ, Bhatia S, Boniquit N, Cole BJ, Nicholson GP, Romeo AA. Outcomes after arthroscopic revision rotator cuff repair. Am J Sports Med. 2010;38:40-6. 57. Mazzocca AD, McCarthy MB, Chowaniec DM, Cote MP, Arciero RA, Drissi H. Rapid isolation of human stem cells (connective tissue progenitor cells) from the proximal humerus during arthroscopic rotator cuff surgery. Am J Sports Med. 2010;38:1438-47. 58. Gulotta LV, Kovacevic D, Montgomery S, Ehteshami JR, Packer JD, Rodeo SA. Stem cells genetically modied with the developmental gene MT1-MMP improve regeneration of the supraspinatus tendon-to-bone insertion site. Am J Sports Med. 2010;38:1429-37. 59. Bedi A, Fox AJ, Kovacevic D, Deng XH, Warren RF, Rodeo SA. Doxycyclinemediated inhibition of matrix metalloproteinases improves healing after rotator cuff repair. Am J Sports Med. 2010;38:308-17. 60. Koh KH, Ahn JH, Kim SM, Yoo JC. Treatment of biceps tendon lesions in the setting of rotator cuff tears: prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. 2010;38:1584-90. 61. Forsythe B, Guss D, Anthony SG, Martin SD. Concomitant arthroscopic SLAP and rotator cuff repair. J Bone Joint Surg Am. 2010;92:1362-9. 62. Jia X, Ji JH, Petersen SA, Freehill MT, McFarland EG. An analysis of shoulder laxity in patients undergoing shoulder surgery. J Bone Joint Surg Am. 2009;91:2144-50. 63. Owens BD, Agel J, Mountcastle SB, Cameron KL, Nelson BJ. Incidence of glenohumeral instability in collegiate athletics. Am J Sports Med. 2009;37:1750-4. 64. Owens CB, Nelson BJ, Duffey ML, Mountcastle SB, Taylor DC, Cameron KL, Campbell S, DeBerardino TM. Pathoanatomy of rst-time, traumatic, anterior glenohumeral subluxation events. J Bone Joint Surg Am. 2010;92:1605-11. 65. Grumet RC, Bach BR Jr, Provencher MT. Arthroscopic stabilization for rst-time versus recurrent shoulder instability. Arthroscopy. 2010;26:239-48. 66. Baker CL 3rd, Mascarenhas R, Kline AJ, Chhabra A, Pombo MW, Bradley JP. Arthroscopic treatment of multidirectional shoulder instability in athletes: a retrospective analysis of 2-to 5-year clinical outcomes. Am J Sports Med. 2009;37:1712-20. 67. Boileau P, Richou J, Lisai A, Chuinard C, Bicknell RT. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy. 2009;25: 1075-84. 68. Tokish JM, McBratney CM, Solomon DJ, Leclere L, Dewing CB, Provencher MT. Arthroscopic repair of circumferential lesions of the glenoid labrum. J Bone Joint Surg Am. 2009;91:2795-802. 69. Porcellini G, Campi F, Pegref F, Castagna A, Paladini P. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint Surg Am. 2009;91:2537-42. 70. Voos JE, Livermore RW, Feeley BT, Altchek DW, Williams RJ, Warren RF, Cordasco FA, Allen AA. Prospective evaluation of arthroscopic Bankart repairs for anterior instability. Am J Sports Med. 2010;38:302-7. 71. Edwards SL, Lee JA, Bell JE, Packer JD, Ahmad CS, Levine WN, Bigliani LU, Blaine TA. Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. Am J Sports Med. 2010;38:1456-61. 72. Gorantla K, Gill C, Wright RW. The outcome of type II SLAP repair: a systematic review. Arthroscopy. 2010;26:537-45. 73. Uggen C, Wei A, Glousman RE, ElAttrache N, Tibone JE, McGarry MH, Lee TQ. Biomechanical comparison of knotless anchor repair versus simple suture repair for type II SLAP lesions. Arthroscopy. 2009;25:1085-92. 74. Boileau P, Old J, Gastaud O, Brassart N, Roussanne Y. All-arthroscopic WeaverDunn-Chuinard procedure with double-button xation for chronic acromioclavicular joint dislocation. Arthroscopy. 2010;26:149-60. 75. Salzmann GM, Walz L, Buchmann S, Glabgly P, Venjakob A, Imhoff AB. Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med. 2010;38:1179-87. 76. Yoo JC, Ahn JH, Yoon JR, Yang JH. Clinical results of single-tunnel coracoclavicular ligament reconstruction using autogenous semitendinosus tendon. Am J Sports Med. 2010;38:950-7.

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77. Freedman JA, Adamson GJ, Bui C, Lee TQ. Biomechanical evaluation of the acromioclavicular capsular ligaments and reconstruction with an intramedullary free tissue graft. Am J Sports Med. 2010;38:958-64. 78. Michlitsch MG, Adamson GJ, Pink M, Estess A, Shankwiler JA, Lee TQ. Biomechanical comparison of a modied Weaver-Dunn and a free-tissue graft reconstruction of the acromioclavicular joint complex. Am J Sports Med. 2010;38: 1196-203. 79. Kippe MA, Demetropoulos CK, Baker KC, Jurist KA, Guettler JH. Failure of coracoclavicular articial graft reconstructions from repetitive rotation. Arthroscopy. 2009;25:975-82. 80. Turman KA, Miller CD, Miller MD. Clavicular fractures following coracoclavicular ligament reconstruction with tendon graft: a report of three cases. J Bone Joint Surg Am. 2010;92:1526-32. 81. Adkisson HD 4th, Martin JA, Amendola RL, Milliman C, Mauch KA, Katwal AB, Seyedin M, Amendola A, Streeter PR, Buckwalter JA. The potential of human allogeneic juvenile chondrocytes for restoration of articular cartilage. Am J Sports Med. 2010;38:1324-33. 82. Moseley JB Jr, Anderson AF, Browne JE, Mandelbaum BR, Micheli LJ, Fu F, Erggelet C. Long-term durability of autologous chondrocyte implantation: a multicenter, observational study in US patients. Am J Sports Med. 2010;38:238-46. 83. Peterson L, Vasiliadis HS, Brittberg M, Lindahl A. Autologous chondrocyte implantation: a long-term follow-up. Am J Sports Med. 2010;38:1117-24. 84. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use of a type I/III bilayer collagen membrane decreases reoperation rates for symptomatic hypertrophy after autologous chondrocyte implantation. Am J Sports Med. 2009;37:20S-3S. 85. 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. 86. Niemeyer P, Lenz P, Kreuz PC, Salzmann GM, S dkamp NP, Schmal H, u Steinwachs M. Chondrocyte-seeded type I/III collagen membrane for autologous chondrocyte transplantation: prospective 2-year results in patients with cartilage defects of the knee joint. Arthroscopy. 2010;26:1074-82. 87. Della Villa S, Kon E, Filardo G, Ricci M, Vincentelli F, Delcogliano M, Marcacci M. Does intensive rehabilitation permit early return to sport without compromising the clinical outcome after arthroscopic autologous chondrocyte implantation in highly competitive athletes? Am J Sports Med. 2010;38:68-77. 88. Wondrasch B, Zak L, Welsch GH, Marlovits S. Effect of accelerated weightbearing after matrix-associated autologous chondrocyte implantation on the femoral condyle on radiographic and clinical outcome after 2 years: a prospective, randomized controlled pilot study. Am J Sports Med. 2009;37:88S-96S. 89. Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared with microfracture. Am J Sports Med. 2009;37:10S-9S. 90. de Windt TS, Bekkers JE, Creemers LB, Dhert WJ, Saris DB. Patient proling in cartilage regeneration: prognostic factors determining success of treatment for cartilage defects. Am J Sports Med. 2009;37:58S-62S. 91. Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. Return to sports participation after articular cartilage repair in the knee: scientic evidence. Am J Sports Med. 2009;37:167S-76S. 92. 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. 93. Dragoo JL, Korotkova T, Kim HJ, Jagadish A. Chondrotoxicity of low pH, epinephrine, and preservatives found in local anesthetics containing epinephrine. Am J Sports Med. 2010;38:1154-9. 94. Grishko V, Xu M, Wilson G, Pearsall AW 4th. Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine. J Bone Joint Surg Am. 2010;92:609-18. 95. Zoric BB, Horn N, Braun S, Millett PJ. Factors inuencing intra-articular uid temperature proles with radiofrequency ablation. J Bone Joint Surg Am. 2009;91: 2448-54. 96. Fowler J, Owens BD. Abdominal compartment syndrome after hip arthroscopy. Arthroscopy. 2010;26:128-30. 97. Ladner B, Nester K, Cascio B. Abdominal uid extravasation during hip arthroscopy. Arthroscopy. 2010;26:131-5. 98. Byrd JW, Jones KS. Hip arthroscopy in athletes: 10-year follow-up. Am J Sports Med. 2009;37:2140-3. 99. Lee HH, Klika AK, Bershadsky B, Krebs VE, Barsoum WK. Factors affecting recovery after arthroscopic labral debridement of the hip. Arthroscopy. 2010;26:328-34. 100. Larson CM, Giveans MR. Arthroscopic debridement versus rexation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25:369-76. 101. Philippon MJ, Briggs KK, Hay CJ, Kuppersmith DA, Dewing CB, Huang MJ. Arthroscopic labral reconstruction in the hip using iliotibial band autograft: technique and early outcomes. Arthroscopy. 2010;26:750-6. 102. Kang AC, Gooding AJ, Coates MH, Goh TD, Armour P, Rietveld J. Computed tomography assessment of hip joints in asymptomatic individuals in relation to femoroacetabular impingement. Am J Sports Med. 2010;38:1160-5. 103. Clohisy JC, Zebala LP, Nepple JJ, Pashos G. Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement. J Bone Joint Surg Am. 2010;92:1697-706. 104. Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral lesion of the talus: is there a critical defect size for poor outcome? Am J Sports Med. 2009;37:1974-80. 105. Giannini S, Battaglia M, Buda R, Cavallo M, Ruflli A, Vannini F. Surgical treatment of osteochondral lesions of the talus by open-eld autologous chondrocyte implantation: a 10-year follow-up clinical and magnetic resonance imaging T2-mapping evaluation. Am J Sports Med. 2009;37:112S-8S. 106. Caputo AM, Lee JY, Spritzer CE, Easley ME, DeOrio JK, Nunley JA 2nd, DeFrate LE. In vivo kinematics of the tibiotalar joint after lateral ankle instability. Am J Sports Med. 2009;37:2241-8. 107. Gregush RV, Ferkel RD. Treatment of the unstable ankle with an osteochondral lesion: results and long-term follow-up. Am J Sports Med. 2010; 38:782-90. 108. 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. 109. 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. 110. Bernas GA, Ruberte Thiele RA, Kinnaman KA, Hughes RE, Miller BS, Carpenter JE. Dening safe rehabilitation for ulnar collateral ligament reconstruction of the elbow: a biomechanical study. Am J Sports Med. 2009;37:2392-400. 111. Iwasaki N, Kato H, Ishikawa J, Masuko T, Funakoshi T, Minami A. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes. J Bone Joint Surg Am. 2009;91:2359-66. 112. Iwasaki N, Kato H, Kamishima T, Minami A. Sequential alterations in magnetic resonance imaging ndings after autologous osteochondral mosaicplasty for young athletes with osteochondritis dissecans of the humeral capitellum. Am J Sports Med. 2009;37:2349-54. 113. Unglaub F, Thomas SB, Kroeber MW, Dragu A, Fellenberg J, Wolf MB, Horch RE. Apoptotic pathways in degenerative disk lesions in the wrist. Arthroscopy. 2009;25:1380-6. 114. Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: markers of severity and implications for management. Am J Sports Med. 2010;38:464-71. 115. Schatz P. Long-term test-retest reliability of baseline cognitive assessments using ImPACT. Am J Sports Med. 2010;38:47-53.

Evidence-Based Articles Related to Sports Medicine

Raviraj A, Anand A, Kodikal G, Chandrashekar M, Pai S. A comparison of early and delayed arthroscopically-assisted reconstruction of the anterior cruciate ligament using hamstring autograft. J Bone Joint Surg Br. 2010;92:521-6. One hundred and ve consecutive patients with ACL injuries associated with grade-1 and 2 chondral and/or low-grade meniscal tears were randomized to early treatment (less than two weeks after the injury) or delayed treatment (more than four to six weeks after the injury) with ACL reconstruction with use of autogenous quadrupled hamstring graft. No competitive athletes were included in the study. No signicant difference was found between the groups in

terms of the Lysholm score, Tegner activity score, or range of motion. Stability and KT-1000 arthrometer testing also showed no signicant difference between the study groups. This study demonstrates that early and late ACL reconstruction can result in similar functional outcomes. Endele D, Jung C, Becker U, Bauer G, Mauch F. Anterior cruciate ligament reconstruction with and without computer navigation: a clinical and magnetic resonance imaging evaluation 2 years after surgery. Arthroscopy. 2009;25:1067-74. This prospective, randomized controlled trial included forty patients, with twenty patients being assigned to a computer navigation group and twenty

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being assigned to a manual navigation group. All patients underwent patellar tendon autograft ACL reconstruction with press-t xation. At the time of the two-year follow-up, radiographs and MRI showed no difference between the groups in terms of tibial or femoral tunnel placement. No signicant difference was identied between the groups in terms of functional outcomes. This study showed that equivalent tunnel placement and clinical results can be achieved with both computer and manual navigation for ACL reconstruction. Biau DJ, Katsahian S, Kartus J, Harilainen A, Feller JA, Sajovic M, Ejerhed L, Zaffagnini S, R pke M, Nizard R. Patellar tendon versus hamstring tendon o autografts for reconstructing the anterior cruciate ligament: a meta-analysis based on individual patient data. Am J Sports Med. 2009;37:2470-8. A meta-analysis of individual patient data from six randomized clinical trials involving 423 patients was performed. In all studies, the patients were randomized to ACL reconstruction with use of either patellar tendon autograft or hamstring tendon autograft. Knee instability, dened as a positive pivotshift, was the primary outcome measure. A positive Lachman test was the secondary outcome. Patellar tendon ACL reconstruction was associated with a decreased risk of a positive pivot-shift test postoperatively (adjusted odds ratio, 0.46; p = 0.016). Positive pivot-shift was more common in female patients and younger patients (p = 0.0170). Functional outcome in relation to knee stability was not a variable in the analysis. This study provides valuable information for surgeons when educating patients about ACL reconstruction technique options and expected stability outcomes. Shen C, Jiang SD, Jiang LS, Dai LY. Bioabsorbable versus metallic interference screw xation in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Arthroscopy. 2010;26:705-13. The authors of this study performed a meta-analysis of randomized controlled clinical trials comparing bioresorbable xation with metallic screw xation for single-bundle ACL reconstruction. Outcomes were analyzed in terms of the infection rate, knee joint effusion, the Lysholm score, the International Knee Documentation Committee nal score, the pivot-shift test, and KT-1000/KT-2000 arthrometer measurements. Graft choice was ignored in this meta-analysis. No signicant differences in knee joint stability or knee joint function were found between bioabsorbable and metallic interference screws. Bioresorbable screws were associated with an increased prevalence of knee joint effusion. This study demonstrates that bioresorbable and metallic screw xation for ACL reconstruction can result in similar acceptable outcomes. Ibrahim SA, Hamido F, Al Misfer AK, Mahgoob A, Ghafar SA, Alhran H. Anterior cruciate ligament reconstruction using autologous hamstring double bundle graft compared with single bundle procedures. J Bone Joint Surg Br. 2009;91:1310-5. Two hundred and eighteen ACL-decient knees were randomized into four groups. Patients either underwent double-bundle ACL reconstruction, single-bundle reconstruction with an EndoButton, single-bundle reconstruction with RigidFix cross pins, or single-bundle reconstruction with bioabsorbable TransFix II for femoral xation. Tibial xation with use of a bioabsorbable Intrax interference screw was used across all four groups. After an average duration of follow-up of twenty-nine months, there were no differences across the four groups in terms of injury and range of movement and Lysholm knee scores. Double-bundle reconstruction demonstrated signicantly better results on pivot-shift testing (p = 0.002). KT-1000 arthrometer measurements were better for the double-bundle technique as compared with the single-bundle technique. Furthermore, the double-bundle technique demonstrated improved Lachman and anterior drawer testing outcomes. The double-bundle technique also demonstrated less laxity in comparison with all single-bundle techniques. Of note, all knees were improved following ACL reconstruction as compared with the preoperative functional status. This article demonstrates superior postoperative examination results for double-bundle as compared with singlebundle ACL reconstruction with use of hamstring autograft but no differences in terms of subjective outcome scores. Goldman EF, Jones DE. Interventions for preventing hamstring injuries. Cochrane Database Syst Rev. 2010;1:CD006782. The authors of this study performed a systematic review of the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2008, Issue 4), MEDLINE and other databases (to December 2008), reference lists, and clinical trials registers to assess the effects of interventions used to prevent hamstring injuries. Seven randomized controlled trials including 1919 patients were included. After review and analysis, the authors concluded that there is insufcient evidence to draw conclusions on the effectiveness of interventions used to prevent hamstring injury.