What’s New in Sports Medicine

The field of sports medicine advances at an ever-increasing pace with developments in improvements in outcomes for surgical techniques including procedures involving the anterior cruciate ligament (ACL), meniscus, rotator cuff, and shoulder labrum and hip arthroscopy. In addition, there have been improvements in utilizing orthobiologics and rehabilitation and in decreasing the use of opioids for postoperative pain management. We have included selected studies to update the most relevant recent findings and outcomes to help in adjusting treatment algorithms. Knee ACL Despite improvements in ACL reconstruction, persistent anterolateral rotational instability remains problematic in some patients. In a recent systematic review and meta-analysis of randomized controlled trials (RCTs) of 7 studies and 517 patients, Onggo et al.1 compared ACL reconstruction alone (hamstring or bone-patellar tendon-bone [BPTB]) with ACL reconstruction plus lateral extra-articular tenodesis (LEAT). LEAT is used to decrease anterolateral rotational instability and act as a check rein to instability and includes a heterogenous group of procedures including the modified Lemaire technique2,3, the Marcacci technique4, the Losee tenodesis5, the modified iliotibial band tenodesis6, and the MacIntosh-modified Coker-Arnold procedure7. Although the LEAT group had significantly better Lysholm scores (p = 0.009) and International Knee Documentation Committee (IKDC) scores (p = 0.01), the pooled mean differences were not clinically important. The LEAT group also had significantly less residual positive pivot shift (p = 0.01), but no difference in the positive residual Lachman test. Most importantly, rerupture in the LEAT group was 3 times less likely than in the non-LEAT group overall (relative risk [RR], 0.31; p < 0.001) and for patients treated with hamstring ACL reconstruction alone (RR, 0.31; p < 0.001). Among the 2 studies showing revision rates, a lower rate of revision was found in the LEAT group (1.4%) compared with the non-LEAT group (5.4%)1. To determine the optimal knee flexion angle for graft fixation among patients treated with anatomic single-bundle BPTB ACL reconstruction, Chahal et al.8 performed an RCT with 169 patients comparing graft tibial fixation at 0° and 30° of knee flexion. A significantly greater percentage of the patients with 0° fixation achieved the minimal clinically important difference (MCID) for the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale (p = 0.04) and had higher Marx Activity Scores (p = 0.04). Otherwise, there were no differences in outcomes, KT-1000 (MEDmetric) findings, or rates of graft rupture8. Lin et al.9 recently completed an RCT comparing all-inside (24 patients) and anatomic standard (26 patients) ACL reconstruction using quadruple-bundle hamstring tendon autograft. There were no significant differences in the IKDC, Tegner, or Lysholm scores, although there was greater anterior tibial translation in the all-inside reconstruction group (p = 0.048). The all-inside reconstruction group also had significantly lower graft maturity at 6 months, determined by a higher magnetic resonance imaging (MRI) signal/noise quotient (p < 0.05)9. Meniscus The ideal surgical technique for securing meniscal allografts remains controversial. In a meta-analysis of 36 studies, Ow et al.10 assessed the outcomes of meniscal allograft transplantation in 2,604 patients by comparing sutures only (24.7%), bone plugs (43.5%), or bone blocks (31.6%) for fixation. Graft failure, defined as requiring revision meniscal allograft transplantation, conversion to joint arthroplasty, or allograft removal, was the lowest in the bone plug group (6.2%), followed by the suture-only group (6.9%), and was the greatest in the bone bridge group (9.3%). Similarly, the rates of reoperation were the lowest in the bone plug group (5.2%), followed by the suture-only group (13.4%) and the bone bridge group (32.6%). There were no significant differences in MRI-assessed graft extrusion between groups10. To assess the progression of knee function and knee osteoarthritis in patients with degenerative meniscal tears, Noorduyn et al.11 randomized 321 patients into partial meniscectomy or physical therapy and 2 of these patients withdrew from participation directly after the randomization; of the 319 patients remaining, 278 (87.1%) completed the trial, with a mean follow-up of 61.8 months. The initial radiographic assessments and progression of knee osteoarthritis were comparable in both groups, with no significant differences in IKDC knee function, pain, or quality-of-life scores, suggesting that physical therapy is not inferior to partial meniscectomy for patients with degenerative meniscal tears11. Eseonu et al.12 compared the different management options for acute meniscal root tears identifying 11 studies that compared repair (158 patients who underwent pull-out repair and 13 patients who underwent all-inside repair), partial meniscectomy (176 patients), and nonoperative management (157 patients). The mean ages ranged from 46.1 to 62 years and follow-up ranged from 7.1 to 77 months. All treatment options significantly improved functional outcomes at 12 months. Repair yielded a slower rate of knee osteoarthritis progression when compared with nonoperative treatment and partial meniscectomy, suggesting that meniscal root repair can be considered in the treatment armamentarium in older individuals12. Longer follow-up will be required to further illuminate the functional outcomes for these treatment options. Cartilage and Joint Preservation A focal chondral defect within the knee remains a challenging problem with many surgical treatment options. Fortier et al.13 completed a systematic review and meta-analysis comparing microfracture treatment with and without augmentation for focal chondral defects in the knee, including 14 studies of 744 patients with a mean age of 46.8 years, a mean follow-up of 26.7 months, and a mean chondral lesion size ranging from 1.3 to 4.8 cm2. Microfracture augmentation with orthobiologics (platelet-rich plasma, hyaluronic acid, mesenchymal stem cells) was used in 57% of studies and scaffolds (biomembranes, fibrin-based) were used in 43% of studies. The control groups included isolated microfracture, microfracture with high tibial osteotomy, microfracture with high tibial osteotomy and hyaluronic acid, and microfracture with hyaluronic acid. Microfracture with augmentation resulted in greater improvement by a clinically important margin in Lysholm and MOCART (magnetic resonance observation of cartilage repair tissue) scores; however, there were no differences in the mean improvement in the visual analog scale (VAS) pain, IKDC, or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. A subgroup analysis in which cases with concomitant high tibial osteotomy were excluded demonstrated the same clinical findings13. In a systematic review and meta-analysis of 6 RCTs, Dhillon et al.14 compared 274 patients undergoing third-generation autologous chondrocyte implantation, defined as implantation of cells cultured within a collagen membrane, with 238 patients undergoing microfracture for the management of focal chondral defects. Patients were randomized regardless of lesion size, which ranged from 1.8 to 5.0 cm2. Treatment failures included any reoperation due to symptoms, detachment, or <50% of the repair tissue filling the defect and/or minimal to no improvement in patient-reported outcomes. Treatment failure was higher in the microfracture group, ranging from 2.5% to 8.3%, compared with 0% to 1.8% in the autologous chondrocyte implantation group. Postoperative improvements in Lysholm, Tegner, and subjective IKDC scores were all significantly greater in the autologous chondrocyte implantation group. Although cost-effectiveness was not addressed, third-generation autologous chondrocyte implantation showed promising improvements in patient-reported outcomes and low rates of failure, particularly when compared with microfracture14. In a systematic review and meta-analysis of 33 studies with 876 patients, Ow et al.15 assessed short-term outcomes to compare the efficacy of different acellular scaffolds, with and without bone marrow aspirate concentrate for cartilage repair. Scaffolds were classified as single-layered (Hyalofast; Anika Therapeutics), multilayered (collagen I/III bilayer, Chondro-Gide; Geistlich Pharma), and gel-based, which included acellular collagen (Cartifill; Sewon Cellontech) and acellular chitosan (CarGel; Smith & Nephew). The patients in all scaffold groups had significant improvements between preoperative and postoperative patient-reported outcome measures. VAS pain scores had significantly greater improvement in patients receiving multilayered scaffolds compared with other scaffolds (p = 0.03). Gel-based scaffolds had significantly lower risks of incomplete defect filling when compared with single-layer scaffolds (p = 0.001) and multilayered scaffolds (p < 0.001). Subgroup analysis demonstrated significantly greater Tegner scores (p = 0.02) and lower rates of incomplete defect filling in patients receiving bone marrow aspirate concentrate augmentation compared with those not receiving it. However, for all analyses, improvements were below their respective MCIDs15. Shoulder Rotator Cuff Tears Delay between rotator cuff injury and surgical repair is thought to increase the risk of tendon decompensation and tear size progression, but optimal timing is unclear. In a systematic review and meta-analysis by van der List et al. of 33 studies and 8,118 patients, the surgical repair had an ideal window of 3 to 6 months, but could be delayed up to 1 year, without a significant difference in the retear rate, American Shoulder and Elbow Surgeons (ASES) score, and Constant-Murley score, compared with a surgical procedure performed more acutely16. With no clear evidence demonstrating superiority of various rotator cuff repair techniques, Lavoie-Gagne et al. performed a meta-analysis of 2,046 shoulders with small to medium complete rotor cuff tears treated with arthroscopic or open repair using double-row or single-row technique, with or without the addition of acromioplasty, platelet-rich plasma, and/or footprint microfracture. No clearly superior technique emerged: arthroscopic, double-row repair with acromioplasty and platelet-rich plasma ranked the highest for minimizing the retear rate and improving the Disabilities of the Arm, Shoulder and Hand (DASH) score, and arthroscopic repair with single-row repair and acromioplasty ranked the highest for pain single-row repair with footprint microfracture ranked the highest for improving the Constant-Murley score, and acromioplasty with single-row repair ranked the highest for improving the A more meta-analysis of trials including randomized patients comparing single-row fixation with double-row fixation found the of retear with single-row fixation to be to compared with double-row but with no difference in functional or pain scores at the No differences in functional outcomes or retear rates were when comparing arthroscopic repair with open or among reconstruction techniques for rotator also unclear. et al. performed a RCT comparing superior reconstruction with allograft for rotator cuff tears in patients who had patients had significantly improved of patient-reported outcomes, and radiographic outcomes due to the surgical although there were no differences in the or of the between patients with and without an graft at 1 all patients underwent partial repair of the and cuff months, patients with cuff tears, when compared with or cuff tears, had significantly lower scores compared with p = and Western Ontario Rotator Cuff scores compared with p = that the to a partial repair have a greater than the for superior management for instability an in the of patients who at high risk for instability and to the postoperative A systematic review and meta-analysis including studies patients, to years of with a anterior shoulder compared patients who underwent surgical with patients who underwent nonoperative treatment with Patients treated significantly lower rates (p < of instability compared with patients treated patients treated required significantly (p < instability surgical procedures compared with patients treated However, treatment high rates of requiring to the of reconstruction be more and repair outcomes of revision Patients with anterior shoulder instability repair no difference in when revision repair was compared with reconstruction in a systematic review and meta-analysis of The rate after reconstruction, was significantly lower than the rate after (p < but there were no significant differences in to revision surgical or and for reconstruction to to the of bone and surgical procedures as as the of as by a systematic review of open The surgical technique as with to and management and the of the of outcomes was of in was and of subjective or bone graft for defects was more or than or In a analysis of patients, the outcome after bone was not by the mean age at the of the surgical of graft or surgical In the overall group, there were low rates of and and open procedures yielded higher rates of instability and of patients had a surgical revision procedures and instability procedures were with the highest instability rate for for to be controversial. et al. performed a systematic review and meta-analysis comparing labrum anterior to repair with tenodesis in the 6 tenodesis studies had patients with a mean age of years, and the repair studies had patients with a mean age of The not any significant differences in outcomes between the 2 However, there was a better outcomes in the tenodesis group scores, rate of to and to of and tenodesis was to repair for but the size have been small to and Joint In a no differences in scores, Constant-Murley scores, or VAS pain scores were between the and treated at any of the up to 1 However, the treated group greater with shoulder at 6 compared with p = and 3 compared with p = 0.01), which not at and a lower rate of to and at 6 compared with p = The rate was in the treated group, with requiring a surgical The rate was in the treated group, but of treated patients required a procedure for the of the and fixation is for the management of and or joint In a RCT comparing a with a with fixation in patients, all patients achieved by 12 months, with no difference in scores and Constant-Murley scores. improvement from 6 to 12 in the group, but no were in the group after 6 months, suggesting that those patients achieved functional The mean surgical was significantly (p < 0.001) for the and fixation group than the group but all patients in the group required The optimal management of remains after of the Shoulder of patients with pain randomized to arthroscopic with surgical or No difference in to was at 2 and years, the to that arthroscopic no or therapy with to to The of for compared with RCT to compare the clinical and cost-effectiveness of hip with those of the Patients years of age with were randomized to hip with postoperative physical therapy patients) or physical therapy with an physical patients) and had a follow-up of 3 Patients and were not to treatment were by the patient-reported International Outcome at 12 after the Patients who underwent hip improved from to and the physical therapy group improved from to after adjusting for scores, and the the there was a mean greater improvement with hip as the compared with physical increase was than the of hip as a more by a clinically important importantly, of the patients undergoing physical therapy to hip between 1 and 3 years after the The cost-effectiveness of surgical was not demonstrated in a but be with follow-up in the and In a systematic review and meta-analysis of of patients who underwent an open surgical procedure and who underwent a surgical procedure et compared the 2 procedures to tendon and found that there was no significant difference in the postoperative American & score, rate or and mean rerupture However, the group had a significantly higher rate of injury compared with 0% to p = = the open surgical procedure group had a significantly higher rate of compared with to p < = and mean surgical compared with et al. compared therapy and with therapy and to The found that the group that underwent therapy and had an increase of to p < 0.001) in of scores at 6 compared with the group that underwent with The group that underwent therapy and in the management of also had no 2 Elbow tendon that were treated had significantly higher flexion and and than those that were treatment was also with superior scores and Elbow tendon can be treated with a of surgical techniques, with an overall rate of with sutures was the most technique followed by and repair had the lowest rate of followed by sutures and repair sutures had the highest rate of rerupture compared with or repair which with studies demonstrating sutures to have fixation and greater with when compared with postoperative rehabilitation for knee an of et studies patients) that assessed the of for after ACL reconstruction, patients) of which were included in their systematic review and There were no significant differences between the postoperative and control groups for any of the However, the of the was significantly in the patients with compared with the control group (p = suggesting that postoperative not a clear with to The to a in However, a for physical therapy with to increase in therapy and decrease the was The with a that and been to of in the Patients to different RCT comparing the with arthroscopic shoulder surgical procedures found no significant differences in of scores, and scores, suggesting that can be an for postoperative have been to in the management of pain studies have been performed to determine the efficacy of blocks and pain with to the of after procedures involving the and analysis of that patients who underwent a for hip not have postoperative or VAS scores for the when compared with patients who of In an RCT comparing plus for with alone in arthroscopic rotator cuff et al. found that not or VAS pain scores at in the group compared with 3 in the p = 0.02) or at in the group compared with in the p = which was a significant but not the but increase the at (p = Similarly, a systematic review and meta-analysis of 11 of patients comparing with or blocks for shoulder showed no significant difference in VAS pain scores at and of or patients undergoing ACL reconstruction with hamstring or BPTB were randomized to a of by and or a Patients who the had significantly lower VAS pain scores in the postoperative (p < and outcomes comparable with those of the group demonstrating that pain after ACL reconstruction can be without the use of pain also arthroscopic shoulder Patients who and for arthroscopic rotator cuff repair had significantly pain scores (p < compared with patients who Similarly, in patients undergoing arthroscopic shoulder a with the addition of after the of also to pain scores at all postoperative compared with standard (p < have for use in postoperative pain, but there been a of their efficacy and et al. performed a RCT the of in patients undergoing arthroscopic rotator cuff repair and found although there was no significant difference in the group had significantly lower VAS pain scores postoperative 1 and greater with pain control postoperative 1 and The but was no significant at postoperative 7 and No were found to be with the use of The of a of recently studies to the that a higher of In addition to in 13 other with a higher of relevant to sports medicine to review after the standard with a to help further in an in management of in a systematic review and meta-analysis of The use of orthobiologics in fixation of in was recently in a systematic review and meta-analysis of The of augmentation resulted in higher rates, with rates and to findings be further with to for augmentation with The use of orthobiologics rates, but not in to efficacy of rotator for a randomized To assess the efficacy of the rotator compared with the for for the treatment of patients in the rotator group and in the were randomized and assessed by a at and 12 There were no significant differences in pain or functional scores and Shoulder the 12 All patients who significant improvements in pain functional scores, and of compared with their scores the The found the rotator group, compared with the group, to have greater flexion compared with p = and compared with p = at 12 suggesting that anterior a in the of the rotator more in of in a shoulder treated for shoulder than outcomes in anterior cruciate ligament a randomized controlled In a of ACL et al. compared the clinical outcomes of anatomic hamstring ACL reconstruction in patients randomized to the group and patients randomized to the group. There were no significant differences in postoperative Lysholm, Tegner or IKDC scores or KT-1000 However, there was a significantly better with (p = The of the in ACL reconstruction at a of surgical of at with no difference in patient-reported outcomes. No difference in clinical outcomes for arthroscopic open tenodesis at a randomized et al. an update of their randomized comparing arthroscopic tenodesis and open tenodesis with fixation in patients with of the of the their there were no differences in anterior shoulder pain, or of at the follow-up for patient-reported outcomes and Constant-Murley No patients failures of the tendon or required reoperation of the of the There is no difference in patient-reported outcomes of or open tenodesis in the treatment of patients with tendon Lavoie-Gagne marrow aspirate concentrate augmentation allograft in anterior cruciate ligament a randomized controlled within sports medicine remains a with many recent studies the of platelet-rich plasma, hyaluronic acid, mesenchymal stem and to different or surgical In bone marrow aspirate BPTB allograft improved rates of in ACL reconstruction but not any clinically important differences in the Joint Tegner, or IKDC scores. marrow aspirate to a BPTB allograft at 3 months, but not in any improvement in clinical outcome measures. efficacy of or for of anterior shoulder a systematic review and A systematic review and meta-analysis of with patients for and blocks of anterior shoulder and blocks were with but demonstrated no difference in the of overall of or and blocks patients from In an important in which the use of more and likely to the comparing and for shoulder achieved with the same of and rates as but with times and without the for No clinical or radiographic difference in arthroscopic repair with a randomized controlled at short-term in arthroscopic in shoulder instability to be patients undergoing anterior repair were randomized to or No differences were found in of postoperative or at after the surgical and outcomes the same in anterior repair performed with or standard for degenerative knee including degenerative meniscal The of in knee osteoarthritis is controversial. In a recent systematic review of and studies with et al. assessed the efficacy of arthroscopic knee for the management of degenerative knee studies patients) were that compared knee with hyaluronic and In the treatment group, postoperative pain at 3 was compared with in the group, and the mean quality-of-life was compared with in the group. found and evidence that that knee not knee function, pain, or of at 3 Knee for the treatment of knee osteoarthritis not pain or function in the with the use of high therapy after anterior cruciate ligament a randomized controlled et al. recently completed an RCT the efficacy of therapy after ACL The therapy group had a significantly greater increase in (p < greater (p < greater knee (p < and a better Lysholm (p < compared with undergoing standard after ACL but more to be use of therapy ACL sutures for the repair of acute tendon a randomized controlled Joint A RCT was the of sutures in the surgical treatment of acute tendon patients were and patients completed a clinical The no difference between the groups with to flexion VAS pain score, or the score, suggesting that sutures can be considered for the repair of an acute tendon sutures can be used for tendon repair and no different than sutures in of outcomes. after hip a of A recent RCT was to assess the of an postoperative for patients undergoing hip and the and Osteoarthritis Outcome Score and with rehabilitation and 2 patients were The outcomes assessed were differences in the and scores from to outcomes included differences in and to physical therapy or use from to of after hip to a significant difference in (p = (p = patient-reported with postoperative or with and from the surgical However, of that were to in the The of or follow-up was the and that for a of be after by patients Patients postoperative pain and after hip although there was no clinical improvement patient-reported outcomes for pain and and for of anterior shoulder blocks used for postoperative pain control in patients undergoing shoulder but to be used in the as in procedures of shoulder blocks with were with more pain, and more when compared with the with and However, and were with a and more as and The use of blocks for in of shoulder some with but not pain, or of The efficacy of after arthroscopic partial a randomized controlled The use of the of the within the knee, which can can et al. performed an RCT the of hyaluronic after partial A of patients were in the with patients randomized to the hyaluronic group and patients randomized to the control group. In the hyaluronic group, of were partial compared with in the control group. In the hyaluronic group, there was significantly less pain (p = as by the VAS pain score, and significantly greater of at the follow-up (p = However, there were no differences at the or or any significant differences in patient-reported outcomes. not hyaluronic knee arthroscopy. knee of joint can some in the acute postoperative with pain and of but those improvements not at 6 or 12

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