What’s New in Sports Medicine

The innovative use of existing biomaterials, optimization of biologics, and improvements in surgical techniques by revisiting prior concepts continues to advance the subspecialty of sports medicine. In this Guest Editorial, we present the best evidence published mainly between October 2022 and September 2023 including the management of the rotator cuff disease spectrum, shoulder instability, joint preservation of the hip and knee, and anterior cruciate ligament (ACL) repair and augmentation. The selected topics are summarized to support adjustments in clinical and surgical decision treatment algorithms. Shoulder Rotator Cuff Rotator cuff disorders can be a common cause of pain and decreased function, which may result in a substantial amount of time away from work for patients. A comprehensive clinical practice guideline was developed from systematic reviews, resulting in 73 recommendations and 3 clinical decision algorithms to help to diagnose and manage rotator cuff disorders and support return of adults to work1. Guidelines for appropriate use of advanced imaging such as diagnostic ultrasound and magnetic resonance imaging (MRI) or magnetic resonance arthrography (MRA) are recommended if there is suspicion for a full-thickness rotator cuff tear, if there has been a traumatic event, or after failure of nonoperative management. An active rehabilitation program combined with oral nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of nonoperative treatment, instead of corticosteroid injections and opioids. Indications for surgical intervention and available techniques are described in the guideline. Lastly, risk factors for prolonged disability are reviewed, emphasizing the importance of a well-developed return-to-work plan. Shoulder impingement describes a broad spectrum of pathologic causes of shoulder pain, with disease processes ranging from subacromial bursitis to rotator cuff tendinopathy to biceps and acromioclavicular joint pathology. Patients confirmed to have chronic subacromial bursitis by ultrasound-guided subacromial injection of lidocaine were enrolled in a randomized controlled trial (RCT) comparing 2 corticosteroid injections (n = 36), physiotherapy for 8 weeks (n = 40), or combined treatment (n = 35)2. After 8 weeks, patients in the corticosteroid and combined treatment groups had significantly better range of motion (flexion [p < 0.003] and external rotation [p < 0.044]), pain reduction (p < 0.024), and patient evaluation of the treatment effect (p < 0.001). However, symptomatic recurrence was less in the physiotherapy group. Orthobiologics, either as a treatment in isolation or combined with surgical techniques, continue to be investigated to improve patient outcomes. A recent, prospective, double-blinded RCT with 1-year follow-up investigated intratendinous injections of plasma rich in growth factors (PRGF) compared with corticosteroid for the management of chronic rotator cuff tendinopathy3. Patients with image-confirmed tendinosis or partial rotator cuff tears who were 40 to 70 years of age were randomized to the PRGF group (39 patients) or the corticosteroid group (40 patients). Platelet-rich plasma (PRP) was prepared utilizing the PRGF-Endoret method, taking the plasma fraction above the buffy coat without leukocytes and activating it prior to injection. Each group received 3 weekly infiltrations and was evaluated at 3, 6, and 12 months. The authors found that both groups had marked clinical improvement in patient-reported outcomes at all time points compared with baseline. However, the PRGF group had higher scores for the University of California Los Angeles (UCLA), abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Constant-Murley outcome instruments at 6 and 12 months, indicating that an intratendinous PRGF injection for chronic rotator cuff tendinopathy was superior and provided better sustained pain relief and functional improvements compared with a corticosteroid. One of the newer advances in orthopaedics is the subacromial balloon spacer for irreparable rotator cuff tears. Kunze et al. performed a systematic review and meta-analysis of 10 studies that met inclusion and exclusion criteria to examine clinically meaningful improvements in outcomes after subacromial balloon spacer implantation4. For the Constant-Murley score, the pooled minimal clinically important difference (MCID) was 83% (95% confidence interval [CI], 71% to 93%; range, 40% to 98%), with 6 of 8 studies showing rates of ≥85%. One study showed a 98% rate of achieving a patient acceptable symptom state (PASS) Constant-Murley score at the 3-year follow-up. The rate of achieving the MCID for the American Shoulder and Elbow Surgeons (ASES) score ranged from 83% to 87.5%, with a PASS achievement rate of 56%, at the 2-year follow-up. The rate of achieving the MCID was 74% for the Numeric Rating Scale and 78% for the Oxford Shoulder Score at the 1-year follow-up, and 69% for the Numeric Rating Scale and 87% for the Oxford Shoulder Score at the 3-year follow-up. The authors concluded that subacromial balloon spacer implantation for massive irreparable rotator cuff tears demonstrated a high rate of clinically important improvement in outcomes at short-term to intermediate-term follow-up, but that more data were needed to define and evaluate the rates of achieving the PASS and substantial clinical benefit after implantation. Glenohumeral Instability There continues to be debate over the most appropriate treatment, and timing of surgical intervention, for patients with shoulder instability. In a recent systematic review and meta-analysis of RCTs, Alkhatib et al. examined short-term and long-term outcomes of Bankart repair compared with conservative treatment for first-time anterior shoulder dislocation5. From 6 RCTs, the authors identified 348 patients with a mean age of 23.7 years. A surgical procedure lowered recurrent instability in both the short term (2 to 3 years), with a relative risk of 0.15 (95% CI, 0.08 to 0.27; p < 0.0001), and the long term (5 to 12 years), with a relative risk of 0.23 (95% CI, 0.14 to 0.39; p < 0.0001). There was no difference in return to sport between the surgical treatment and conservative treatment groups. A surgical procedure after a first-time dislocation decreased the subsequent need for a stabilization surgical procedure in the short term and the long term and resulted in higher patient satisfaction (relative risk, 1.75 [95% CI, 1.4 to 2.2]; p < 0.0001). The Western Ontario Shoulder Instability Index (WOSI) scores were not different in the short term, but were higher in the surgical group in the long-term follow-up. Recurrent shoulder instability is most commonly treated with an arthroscopic Bankart repair, but the Latarjet procedure is performed for patients with high-risk factors such as glenoid bone loss. Overall, there has been a lack of comparative studies to determine the superiority of either procedure in terms of return-to-play outcomes in the athletic population. In a systematic review of 9 studies with 1,242 patients who were 15 to 30 years of age, Hurley et al.6 found that the rate of return to play ranged from 61% to 94.1% in the arthroscopic Bankart repair group compared with 72% to 96.8% in the Latarjet group. Two studies found a significant difference in favor of the Latarjet procedure (p < 0.05), but, overall, there were no differences in the mean time for return to play (which ranged from 5 to 7 months). Thus, Hurley et al. concluded that there was no difference in the rate of return to play or time to return to play following arthroscopic Bankart repair compared with an open Latarjet procedure. Arthroscopic remplissage has been added as an augment to arthroscopic Bankart procedures to reduce the recurrence of anterior shoulder instability in patients with off-track Hill-Sachs lesions. However, indications have been expanding to include on-track lesions with subcritical glenoid bone loss. Davis et al. looked at the return-to-sport rates, functional outcomes, and adverse events in athletes who underwent arthroscopic Bankart repair with remplissage compared with those who underwent Bankart repair alone or the Latarjet procedure7. In this study, 538 athletes underwent remplissage, with 86% (395 of 457) returning to sport at any level. The systematic review and meta-analysis found that return to sport was significantly higher in the group treated with remplissage compared with the other surgical alternatives (odds ratio [OR], 2.71 [95% CI, 1.14 to 6.43]; p = 0.02). Return to sport at the previous or a higher level was also significantly higher in the remplissage group (OR, 2.07 [95% CI, 1.29 to 3.31]; p = 0.002). The mean Rowe score improved significantly from the preoperative score but was not different compared with the other surgical techniques (p = 0.54). Recurrence (OR, 0.18 [95% CI, 0.08 to 0.39]; p < 0.001) and reoperation (OR, 0.17 [95% CI, 0.06 to 0.50]; p = 0.001) were significantly less likely after remplissage compared with other surgical procedures. Although Bankart repair alone or the Latarjet procedure had a high likelihood of returning athletes to sports, the addition of an arthroscopic remplissage to an arthroscopic Bankart repair significantly decreased the risk of recurrence or reoperation. Hip Chondral Lesions As the field of hip arthroscopy continues to grow, the most common reason for hip arthroscopy remains femoroacetabular impingement, which results in abnormal contact between the femoral head-neck junction and can lead to focal chondral defects and early arthritis. As such, there continues to be interest in and debate on how best to manage these chondral defects. A recent systematic review compared microfracture of full-thickness acetabular chondral lesions with other cartilage repair techniques in patients with femoroacetabular impingement8. Six studies met the inclusion criteria for the systematic review, with 202 patients who underwent microfracture and 327 patients who underwent other cartilage procedures (bone marrow aspirate concentrate, microfragmented adipose tissue concentrate, autologous matrix-induced chondrogenesis, or a combination of autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate). In all studies, better patient-reported outcomes were found in patients who underwent other cartilage procedures compared with microfracture. Three of 5 studies found a greater reoperation rate in the group treated with microfracture compared with other cartilage procedures. The authors concluded that microfracture for acetabular chondral lesions results in a greater or equivalent reoperation rate and equivalent or inferior patient-reported outcomes compared with other cartilage repair procedures. Capsular Repair Hip arthroscopy can be performed by either using a periportal technique or performing a capsulotomy. The periportal approach causes less damage to the capsule, which contains strong ligaments that play an important role in hip stability, but a capsulotomy results in increased intra-articular visualization and working room. There were 2 systematic reviews that looked at the outcomes of those patients who had a capsulotomy and capsular repair compared with those who did not have a capsular repair. The first systematic review, which had a minimum 2-year follow-up, identified 3 articles with 249 hips that underwent capsular repair and 157 hips that had no repair9. This study found improved patient-reported outcomes in the capsular repair group compared with the no-repair group. The authors also found lower hip survivorship in the non-repair group compared with the repair group but no difference in the rate of revision between the 2 groups. The second systematic review had somewhat different results. In this review, Kaplan et al. examined patient-reported outcomes, rates of clinically important outcomes, and rates of revision or conversion to total hip arthroplasty with a minimum 5-year follow-up10. There were a total of 8 studies, with 4 studies of 387 patients (mean ages, 33.1 to 38 years) who did not undergo capsular repair and 5 studies of 835 patients (mean ages, 33.6 to 43.1 years) who underwent capsular repair. There were no differences in patient-reported outcomes between patients who underwent a capsular repair and those who did not. There were also similar rates of achieving the MCID and PASS for the modified Harris hip score and similar rates of conversion to total hip arthroplasty in both groups. However, there was a lower rate of revision hip arthroscopy in the capsular repair group. Knee ACL Reconstruction ACL reconstruction continues to be a main topic of sports medicine research, with current debate centering on various techniques to improve postoperative stability and returning patients to their pre-injury baseline function. Although hamstring autograft has been established as a reliable option for ACL reconstruction, the best technique for the use of hamstring autograft has yet to be determined. In a double-blinded RCT, Kuliński et al.11 compared a 4-strand semitendinosus tendon graft with a doubled semitendinosus and gracilis graft. All techniques were performed by the same senior surgeon, and patients were prescribed the same rehabilitation protocol. After a mean follow-up of 67 months, there were no differences in patient-reported outcomes. In male patients, there was no difference in anterior tibial translation between the grafts. However, a subset analysis revealed that semitendinosus grafts were inferior in the female cohort, yielding significantly larger (p = 0.004) anterior tibial translation (3.44 ± 0.62 mm [95% CI, 2.23 to 4.65] compared with the semitendinosus and gracilis group (0.83 ± 0.58 mm [95% CI, −0.32 to 1.99]). In the semitendinosus cohort, 68.75% of the female patients had translation of >3 mm with the KT-1000 arthrometer (MEDmetric), compared with 8.33% of female patients in the semitendinosus and gracilis cohort. Patient-reported outcomes were also inferior in the female cohort in the quadrupled semitendinosus group. Since U.S. Food and Drug Administration (FDA) approval in 2020, bridge-enhanced ACL repair (BEAR) has been a major topic of discussion. Indicated for midsubstance ACL tears, the BEAR procedure involves placing a resorbable bovine collagen implant between the ends of the ACL tear, which acts as a scaffold to assist in healing the tear. In an RCT of patients who were 15 to 23 years of age, Murray et al. compared the BEAR procedure and ACL reconstruction with a hamstring or bone-patellar tendon-bone (BTB) autograft. There were 65 patients in the BEAR cohort and 35 patients in the ACL reconstruction cohort, and no difference in the side-to-side difference in knee laxity or in the International Knee Documentation Committee (IKDC) subjective score between the groups was demonstrated at 2 years12. At 2 years, of the BEAR group had had a and a conversion to ACL reconstruction, a revision ACL reconstruction was in of the ACL reconstruction group. In both of in the first those BEAR procedures to ACL reconstruction, the subjective score and knee laxity were similar to those for patients who had a ACL At the 2-year follow-up, the ACL reconstruction group had a mean hamstring of compared with the the BEAR cohort 98% of the hamstring in combination with ACL reconstruction can first described by and ligament reconstruction are 2 that have been to stability and the which can on the ACL graft and graft The study demonstrated that the addition of an augment to an ACL reconstruction with a hamstring autograft to a relative reduction in the risk of graft failure compared with ACL reconstruction Patients in this study were to have at 2 of the following in a laxity as by a score of a score of remains by or by reconstruction is In to determine the more et al. performed a meta-analysis of studies comparing a combined ACL reconstruction and with a combined ACL reconstruction and a minimum follow-up of 12 months, ACL reconstruction with reconstruction to have a significant in stability compared with an ACL reconstruction or ACL reconstruction with There were no differences in knee pain, scores for knee function, or graft failure between the procedure the ACL reconstruction with higher scores indicating the the ACL reconstruction with reconstruction a higher score indicating knee function. current there are no indications for procedures. determine the risk factors for graft failure in high-risk patients, et al. the of graft failure with or without an on data in the study, the for graft was for preoperative knee laxity or and 2 for a tibial such as return to also increased the of time increased the of graft by Each in graft was with lower of an ACL reconstruction with was significantly with lower of graft higher of were with increased tibial age, preoperative knee and early return to Each in age was with lower of recommendations addition of an and increased graft to reduce ACL has a risk of failure that is 4 greater that after Although the rate from to factors including and have been to improve revision failure et al. performed a systematic analysis to determine the if to using an with a revision studies with a minimum follow-up of were with patients revision ACL reconstruction with or without with a procedure including reconstruction, a modified or a modified rates ranged from to in patients who underwent and from to in patients who underwent ACL reconstruction, in the 6 studies that this There were significant differences in and laxity between in There were no differences between procedures and combined procedures with to patient-reported outcomes or return to et al. showed similar results with revision ACL In a systematic review and meta-analysis with 10 studies and patients, there were no differences in and scores between either or reconstruction and revision ACL However, patients with had a higher score, a higher level of and Two of 3 studies showed that or reconstruction to a significantly higher of athletes returning to the same level of Overall, or reconstruction increased stability and a lower side-to-side resulting in a lower likelihood of cruciate ligament reconstruction is with a reconstruction of the However, there have been of laxity and instability with the et al. compared and in a meta-analysis of There was the graft and for The technique lower tibial laxity in both and of external rotation laxity in of knee and side-to-side differences by There were no differences in external rotation laxity in and and Overall, reconstruction to be superior to reconstruction and resulted in better Reconstruction There has been no on a for reconstruction of the knee that the and to these ligaments can result in instability and a et al. a systematic review and meta-analysis to examine the difference between and and There was no difference in postoperative and stability or in patient-reported outcomes after a mean follow-up of months. There were equivalent and stability outcomes in all but which the The technique demonstrated a time in the technique was more likely to cause the of and However, the of studies, we that more evidence is needed to determine the most The of recurrent dislocation after a first-time dislocation can be to to for an reconstruction after the first et al. a analysis of reconstruction after a first-time that treated with reconstruction were 5 less likely to have recurrent instability, 2 more likely to return to and 8 less likely to an and cartilage lesions can be a and of lesions can as a to are on the and of lesions. et al. an RCT to determine the of an implant compared with a microfracture Lesions in the study were to 7 in and on the femoral or The results showed that the patients in the scaffold group had higher scores at 6, and and a larger of at 2 years compared with in the with the scaffold microfracture in all age groups who had and and larger lesions. of the Knee of the most joint is treated with nonoperative management that and such as or There continues to be a debate between the of and that of et al. a systematic review and meta-analysis of studies comparing the 2 a mean follow-up of months, as the the 9 studies that the Western Ontario and Index score, 6 had significantly better scores at the follow-up in the cohort, indicating less pain and higher function. Six of studies that pain on a showed that patients had less pain with compared with the 6 studies 4 resulted in significantly higher scores in the cohort compared with the cohort. patients who received had better scores patients who received the for the of injections to the timing of injections to and the of all had between The best nonoperative treatment for has yet to be determined. studies injections have no benefit to et al. a double-blinded RCT of patients to determine the of compared with a Patients were 2 at inclusion in the study and at 6 differences were found between the American score or the and Score between the and over the of The of a of published studies to the that received a higher of In addition to the articles in this 5 other articles to sports medicine are to this review after the with a to help in an in this subspecialty is the failure rate after arthroscopic repair of A systematic review and 2022 rates for tears in the of the techniques In this systematic review and meta-analysis with 38 studies, failure rates ranged from to more tears, and more those with ACL the failure rate was at in a range from 2 to months. There was no difference in failure rates between and are with an failure rate of in of of the a randomized controlled trial by the 2023 The group compared the relative of with that of for the surgical treatment of is a technique in which cartilage is performed is an technique in which to the bone is performed without the differences in patient-reported outcomes at 6, or or in surgical procedures were found between the 2 The cohort also had greater and healing at 6 and 12 months, which the cohort to return to sport compared with but there was no a difference by months. Thus, this study demonstrated that the technique results in better outcomes and return to sports in the surgical treatment of side-to-side using a a randomized controlled Shoulder Elbow 2023 is a in of patients For patients who undergo nonoperative treatment, surgical treatment has been et al. compared a side-to-side tendon repair with a and found no difference in the Elbow or Numeric Rating score or in the time to return to The cohort who underwent the repair had better functional outcomes, and at 6 weeks, that the be Six have at 3 for with a systematic review with 2022 can be an determine which resulted in the best patient-reported outcomes, et al. performed a systematic review and meta-analysis of various including injection techniques, and combined intervention, and provided more pain relief at short-term follow-up no hip and knee and Hip and and with injection were more at short-term follow-up compared with Thus, for pain, 6 combination hip and and have clinical improvement in the short However, no intervention has been for 3 months. and in which patients nonoperative treatment of anterior cruciate ligament an analysis of the 2022 determine nonoperative treatment for ACL reconstruction et al. investigated patients in the for patients with ACL of patients did not need ACL reconstruction a 2-year follow-up of clinical outcomes, the other underwent reconstruction after a time of of knee instability Thus, patients with ACL tears can be treated but surgical intervention is be 3 to 6 of Patients who are to years of and were active the more likely a surgical procedure.

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