This update reflects recently published evidence in the field of sports medicine surgery mostly from October 2018 through September 2019. Although this review is not exhaustive of all research that might be pertinent to sports medicine, it highlights many key articles that contribute to the existing evidence base in the field of the subspecialty. The most impactful clinical and basic science studies, primarily from The Journal of Bone & Joint Surgery, The American Journal of Sports Medicine, and Arthroscopy: The Journal of Arthroscopic and Related Surgery, with specific emphasis on Level-I and II studies, have been included in this review.
Anterior Cruciate Ligament (ACL)
There is still debate among surgeons caring for the highest level of competitive athlete with regard to the best-performing graft choice. A well-performed, single-surgeon, randomized controlled trial (RCT) comparing patellar tendon (bone-tendon-bone [BTB]) autograft, quadrupled hamstring tendon autograft, and double-bundle reconstruction using hamstring autograft illustrates this debate1. The study included 110 patients in each group with reported 5-year outcomes and 95% final follow-up data. The mean age for all patients was 28.5 years at the time of the surgical procedure. There was no significant difference in patient-reported quality-of-life (Anterior Cruciate Ligament-Quality of Life [ACL-QOL]) score at 5 years between any of the reconstruction groups. However, there was a significantly (nearly 4 times) higher rate of traumatic graft reinjuries in both the hamstring tendon group (15%) and the double-bundle group (16%) compared with the BTB group (4%). As expected, patients in the BTB group had significantly more kneeling pain or anterior knee pain (10%) compared with the hamstring tendon group (4%) and the double-bundle group (2%). The overall return to preinjury level of activity was fairly low at 37% for the entire population, with no significant difference between groups.
A meta-analysis of previously performed RCTs was performed to assess whether early ACL reconstruction leads to more complications compared with delayed surgery, especially with regard to stiffness and arthrofibrosis2. Early surgery was defined as <3 weeks after the original injury, and >10 weeks after the injury was considered delayed reconstruction. The investigators included 8 previous studies that included 505 patients with a mean age of 28 years and included a 2.4:1 male-to-female ratio with approximately equal numbers in each group (270 patients in the early reconstruction cohort compared with 235 patients in the delayed surgery cohort). There was no significant difference in patient-reported outcome measures, complications (including motion loss or arthrofibrosis), risk of retear, or instrumented laxity, although the Level of Evidence grade for most of the included studies was low. Furthermore, there was a high degree of heterogeneity among the 8 included studies with regard to rehabilitation protocols, preoperative range of motion, graft choice, and allocation into early or delayed surgical groups.
Surgeons using hamstring autografts to perform ACL reconstruction will encounter small-diameter grafts after harvest on occasion. A systematic review of 10 studies (1 Level-II study and 9 Level-III studies) compared ACL reconstructions using hamstring tendon autografts with those using hybrid grafts consisting of hamstring autografts augmented with allograft when the patients’ native hamstring tendons were deemed to be small in diameter3. All studies had a minimum follow-up of 24 months. The pooled data included patient-reported outcomes, ACL physical examination tests, KT-1000 arthrometer (MEDmetric) results, and graft failure rates. No significant difference was identified between groups on any of the outcome parameters noted above. There was heterogeneity within the studies in terms of indications or size cutoffs for allograft augmentation. Further study is required to determine what size graft constitutes “too small” for the wide range of patients undergoing ACL reconstruction with hamstring autograft.
Despite the increasing numbers of ACL reconstructions being performed, relatively few data have been published with regard to optimal injury prevention programs or return-to-play criteria. A recently published, well-performed systematic review and meta-analysis of Level-II and Level-III studies investigated whether patients who had undergone successful ACL reconstruction and had passed impartial and criteria-based return-to-sport testing had a reduction in risk of a second ACL injury4. The authors extracted data from each included study (4 total studies met the inclusion criteria) and pooled data for similar return-to-sport tests (i.e., isokinetic testing and hop testing). The data were dichotomized into treatments that “passed” or “failed” on the basis of whether the patient met the return-to-sport criteria and returned to sport or did not meet return-to-sport criteria and returned to sport. Return to sport was defined as the clearance of a patient for full participation in a sport or activity without restriction. Importantly, the investigators performed an analysis of the quality of studies that they included using the modified Downs and Black checklist and also the GRADE (Grading of Recommendations Assessment, Development and Evaluation) scale showing the overall certainty of the evidence for the outcome being evaluated. There was no significant association between passing objective return-to-sport criteria and risk of a second ACL injury for both graft retear and contralateral ACL tear scenarios. Although not significant, the authors reported an increased incidence of ACL graft reinjury in patients who “failed” return-to-sport criteria (12%) compared with those who passed (6%) and concluded that there may be a protective association present that was not detectable with available data. Return-to-play and rehabilitation guidelines after ACL reconstruction remains unclear in the sports medicine community, and more research is required to help surgeons to better guide patients to a safe return to sport activity.
Huang et al. performed a meta-analysis of all previously published RCTs and cluster RCTs of injury prevention programs for ACL injuries5. The study included 8 previous RCTs in this area of study, and their meta-analysis demonstrated a significant reduction (53%) in ACL injury rate. Although there have been a number of systematic reviews performed on this topic, this study is one of the cleanest analyses to date by including only prior RCTs and addressing the clustering effect bias of the included studies, which often randomized whole (clustered) sports teams. One limitation of the study was that the analysis was largely limited to soccer and may have been less generalizable to other sports. Additionally, the investigators found variability in the specific exercises and the manner of delivery of the injury prevention program across studies. They concluded and advocated for flexibility in the development and implementation of injury prevention programs as a means to achieve more widespread adoption of these programs as the data overwhelmingly support their ability to reduce the rate of ACL injuries. ACL injury prevention is a neglected area of study, and there is an opportunity for substantial improvement in the care of active patients engaging in sports.
Techniques to improve healing after meniscal repair are an area of great interest. A double-blinded RCT with good methodology was performed in Poland, in which 20 patients (21 menisci) underwent isolated meniscal repair and 20 patients (23 menisci) underwent meniscal repair with a bone marrow venting procedure (BMVP)6. All tears were unstable, complete, vertical tears in the red-white zone (majority bucket-handle tears), and repair was performed with either an all-inside or all-inside plus outside-in vertical mattress technique. A chondral pick device was used to created 6 to 7 awl holes in the lateral aspect of the intercondylar notch for the BMVP group. The 2 groups had similar baseline characteristics and underwent the same postoperative rehabilitation protocol. Meniscal healing was assessed via second-look arthroscopy at a mean time (and standard deviation) of 35 ± 4 weeks by a blinded assessor, demonstrating BMVP-augmented repair healing rates to be superior (100%) to the control group (76%) (p = 0.0035). Follow-up at 32 to 51 months found that secondary pain and functional measures were improved in the BMVP group compared with the control group, and both were better than baseline. Surgeons should consider this simple, quick, and low-cost adjunct in patients undergoing isolated meniscal repairs.
The ESCAPE (Early Surgery Versus Conservative Therapy for Meniscal Injuries in Older Patients) Research Group performed a noninferiority, multicenter, non-blinded RCT in patients who were 45 to 70 years of age and had a non-knee-locking meniscal tear and varying degrees of radiographic arthritis (Kellgren-Lawrence grade, 0 to 3); the authors compared physical therapy with arthroscopic partial meniscectomy7. In this study, 162 patients randomized to physical therapy participated in 16 sessions (30 minutes each) conducted over 8 weeks, whereas 159 patients undergoing arthroscopic partial meniscectomy had the surgical procedure within 4 weeks of randomization and were given a postoperative home exercise protocol. A total of 47 patients in the physical therapy group (29%) crossed over to the surgical procedure group because of persistence of symptoms; 75% of these were within 6 months of randomization. The International Knee Documentation Committee (IKDC) function improved 26.2 points in the arthroscopic partial meniscectomy group and 20.4 points in the physical therapy group. The primary mixed model analysis of overall effects up to 24 months found a between-group difference of 3.6 points (97.5% confidence interval [CI], −∞ to 6.5 points) in favor of arthroscopic partial meniscectomy, which indicated noninferiority of physical therapy to arthroscopic partial meniscectomy (p = 0.001). However, the effects at the 12-month period (5.7 points [97.5% CI, −∞ to 9.4 points]) and the 24-month period (4.8 points [97.5% CI, −∞ to 8.5 points]) did not demonstrate noninferiority. The as-treated analysis had similar results. Furthermore, knee pain during weight-bearing favored arthroscopic partial meniscectomy over physical therapy. There was no difference between groups in radiographic osteoarthritis progression. Post hoc exploratory analyses found that patients with increased baseline pain or obesity did better with arthroscopic partial meniscectomy relative to physical therapy. The ESCAPE Research Group thus supported recommendations that physical therapy may be considered an appropriate alternative to arthroscopic partial meniscectomy as first-line therapy.
The optimal approach in treating patients with first-time traumatic patellar dislocations is still an active area of research. A recent systematic review and meta-analysis of RCTs comparing operative and nonoperative treatments of first-time lateral patellar dislocations found that operative treatment is associated with more complications but with better short-term patient-reported outcomes and lower rates of redislocation compared with nonoperative treatment8. No difference in outcomes was found between the groups at a longer-term follow-up. A different systematic review and meta-analysis looking at varying treatments of the medial patellofemoral ligament demonstrated no difference in outcomes or recurrence between operative and nonoperative treatments for patients sustaining a first-time patellar dislocation9. However, for patients with recurrent patellar instability, reconstruction of the medial patellofemoral ligament demonstrated superior results compared with medial soft-tissue realignment techniques such as medial capsule reefing.
With numerous fixation techniques on the patella for medial patellofemoral ligament reconstruction being described and performed, a number of recent studies have been published investigating the outcomes comparing patella-sided fixation techniques. A recent systematic review found that there may be fewer complications and fractures with cortical fixation devices on the patella in comparison with techniques creating a patellar bone socket10. A prospective trial performed in China11 comparing single-bundle transpatellar tunnel and double-anchor anatomic techniques showed that the double-anchor technique may lead to more congruent patellofemoral contact pressures and less recurrent dislocations.
A number of recent studies have been published evaluating the outcomes and cost-effectiveness of surgery for high-grade acromioclavicular joint injuries using contemporary techniques and implants. A meta-analysis comparing a suture button construct and hook plate fixation for acute unstable acromioclavicular joint dislocations was performed demonstrating improved outcomes and pain scores in patients treated with suture button constructs12. No differences in complications, postoperative coracoclavicular distance, loss of reduction, or operative time was found between the 2 fixation techniques. An RCT with good methodology was performed in the United Kingdom comparing suspension button fixation with nonoperative treatment of patients with acute type-III or IV acromioclavicular joint injuries13. Operative treatment did not result in better outcomes, return to sport, or cost-effectiveness compared with nonoperative treatment at 1 year. There was a relatively high number (16%) of patients who crossed over from nonoperative treatment to operative treatment. No specific patient factors were identified that were associated with risk of failure of nonoperative treatment, and the authors thus recommended that treatment should be individualized on the basis of age, activity level, and preferences. Lastly, a group from Abu Dhabi performed an RCT comparing arthroscopic treatment and open treatment for acute acromioclavicular joint dislocations14. The authors demonstrated that arthroscopic surgery costs more money and is associated with longer operative times with similar outcomes compared with open treatment.
The efficacy of shoulder arthroscopy for rotator cuff disease continues to be evaluated. A Cochrane Systematic Review of published RCTs comparing subacromial decompression surgery with placebo or nonoperative treatment for shoulder impingement was recently published15. Although 8 RCTs with a total of 1,062 patients were included in the analysis, 2 trials (506 participants) were deemed to have a low risk of bias as they were double-blinded studies and utilized a true placebo group that underwent only an arthroscopy. The other 6 trials were determined to have a high risk of bias because they were not appropriately blinded (as the comparison group was treated nonoperatively, participant blinding was not possible in these studies). All included studies were performed in Europe. Outcomes included mean pain scores, shoulder function, quality of life, patient satisfaction, and adverse events. The review concluded that high-quality evidence demonstrates that subacromial decompression surgery provides no improvement in pain, shoulder function, or health-related quality of life up to 1 year. Across all studies, the adverse event rate for subacromial decompression surgery was determined to be low (≤3%) and likely did not differ from that for placebo surgery. The main limitation in this study (as is the case with all trials involving arthroscopic sham surgery) was the unknown benefit of arthroscopy itself and the lavage portion of the procedure.
Moosmayer et al. published a longer-term follow-up of their prior RCT looking at small to medium-sized rotator cuff tears (≤3 cm) comparing patients randomized to operative repair with those randomized to physiotherapy16. A total of 91 of 103 patients who were initially randomized for the study had 10-year follow-up data (48 patients in the repair group and 43 patients in the physiotherapy group). The Constant score still showed a significant difference of 9.6 points in favor of the surgical repair group, and there was a significantly higher proportion of patients in the repair group (71%) who achieved a good-to-excellent result (Constant score ≥81 points) compared with patients in the physiotherapy group (42%). The patient-reported portion of the American Shoulder and Elbow Surgeons (ASES) score and the 10-cm visual analog scale (VAS) score for pain were also significantly better in the repair group. There was no significant difference in shoulder strength. At 10 years, there were 14 patients who had crossed over from the physiotherapy group and underwent surgery. This represented 27% of the patients in the nonoperative group. The authors found inferior clinical outcomes with a 10-point lower Constant score when comparing this secondary surgery group with the primary repair group. Imaging studies were performed to determine tear progression. In the nonoperative group, tear size progressed in both planes of measurement, with a mean tear size of 10.1 mm in the anterior-posterior plane and 6.3 mm in the medial-lateral plane. The patients with ≥10 mm of tear widening had a lower Constant score by a mean of 14 points compared with patients with <10 mm of tear widening. In the 47 patients who underwent evaluation, magnetic resonance imaging (MRI) scans of surgically repaired tendons revealed a retear rate of 21% (10 patients) at 1 year, followed by 28% (13 patients) at 5 years and 34% (16 patients) at 10 years (the 5 and 10-year assessments were performed by ultrasound). A comparison of the patients sustaining a retear and those with intact repairs showed a mean difference of 6 points in the Constant score. The authors concluded that outcome differences exist between patients treated with surgical repair and those treated with physiotherapy for small to medium-sized rotator cuff tears that become more clinically relevant with time and thus advocated for the surgical repair of these types of rotator cuff tears in the young and active individual.
There are still varying protocols with regard to postoperative rehabilitation after rotator cuff repair. A multisite RCT investigated the effect of early mobilization compared with standard rehabilitation after arthroscopic rotator cuff repair17. In that study, 206 patients who met inclusion criteria of a full-thickness rotator cuff tear that could be repaired arthroscopically and had undergone 3 months of failed nonoperative therapies were enrolled, with various surgical techniques utilized on the basis of surgeon preference. All study participants were instructed to wear a sling and to begin self-assisted range-of-motion exercises that were demonstrated by a physical therapist. The patients who underwent standard rehabilitation were told to wear the sling at all times except when performing their exercises. The patients in the early mobilization group were told that the sling was only needed for comfort and could be taken off and discontinued at the patient’s discretion and were advised to perform pain-free activities as tolerated but were restricted from lifting objects weighing more than 1 to 2 pounds (0.5 to 1 kg). The early mobilization group showed significantly better forward flexion and abduction at 6 weeks postoperatively, but no subjective or objective differences were found at all other time points, including retear rate as evaluated by ultrasound (30% in the early mobilization group and 33% in the standard rehabilitation group). A similar investigation was performed comparing sling immobilization with no sling postoperatively for patients undergoing rotator cuff repair18. A total of 80 patients who had small to medium-sized, full-thickness superior rotator cuff tears (<3 cm) underwent arthroscopic repair and were randomized to sling immobilization for 4 weeks after surgery compared with no sling at all. The results showed that the patients who were not immobilized had better early range of motion at 6 and 12 weeks but the 2 groups had similar results at 6 months. There was no difference in repair integrity between groups as determined by ultrasound.
Labrum and Instability
Arthroscopic surgery is generally considered a safe and effective treatment for anterior shoulder instability. However, recurrent instability can persist despite well-performed surgery, and complications other than recurrent dislocation exist. A systematic review of long-term (10-year) follow-up after arthroscopic Bankart repair demonstrated a 78% rate of return to sport, 31% rate of recurrent instability, and 17% overall revision rate19. Most alarmingly, evidence of instability arthropathy was found in 59% of patients in the studies that reported looking for it. It is unknown whether the primary trauma, the surgical procedure, or the subsequent instability episodes are the main cause. A systematic review of complications (other than redislocation) after anterior shoulder stabilization procedures demonstrated a much higher rate of complications in surgical procedures involving bone block transfer compared with procedures involving only soft tissue20.
A systematic review of clinical and biomechanical studies of arthroscopic remplissage found that it is a safe and effective procedure21. Three of 4 studies comparing arthroscopic Bankart repair with or without remplissage found significantly higher recurrence rates in the isolated Bankart repair cohorts (20% to 28%) in contrast to shoulders additionally stabilized with remplissage (0% to 5%). Although cadaveric studies have shown significant decreases in external rotation range of motion after remplissage, clinical studies show small decreases (5° to 12°)22. Overall, it appears that the addition of a remplissage procedure is associated with decreased rates of recurrent instability and better patient-reported shoulder function scores compared with isolated Bankart repair alone.
Similar to the U.K. FASHIoN (Full randomised controlled trial of Arthroscopic Surgery for Hip Impingement versus best CoNventional) trial published in The Lancet in 201823, an RCT aimed at comparing arthroscopic hip surgery with formal physical therapy and activity modification in patients with femoroacetabular impingement syndrome was performed24. The authors reported the follow-up data at 8 months after randomization. Seven sites recruited a total of 222 patients (112 who under a surgical procedure and 110 who underwent physical therapy). The cohorts had similar baseline demographic and morphologic data, and all patients had radiographic Kellgren-Lawrence grades of 0 or 1. Complete data for the primary analysis were available for 188 patients (85%); 13 patients in the surgery group did not undergo the surgical procedure during the time period of interest, and 4 patients from the physical therapy group crossed over to the surgery group. At 8 months after randomization, the mean Hip Outcome Score Activities of Daily Living (HOS ADL) scores in the surgery group was 10.0 points higher than the physical therapy group (p = 0.001). The HOS ADL scores were higher than baseline scores in 70% of surgical patients compared with 50% of the physical therapy patients. The patient acceptable symptomatic state (HOS ADL score, >87 points) was achieved in 48% of patients in the surgery group and 19% of patients in the physical therapy group. Other secondary patient-reported outcome measures were all significantly better in the surgery group than in the physical therapy group, with the surgery group having greater improvement in hip flexion (4.8°; p = 0.03) and less pain with hip flexion (p = 0.01) than the physical therapy group.
Ochen et al. performed a systematic review and meta-analysis on both RCTs and observational studies to compare rerupture rate, complications, and functional outcomes for operative and nonoperative treatments of acute Achilles tendon ruptures25. They performed sensitivity analyses to evaluate rerupture rate as related to early or late full weight-bearing, as well as with or without functional rehabilitation with early range of motion. They included 10 RCTs and 19 observational studies, for a total of 15,862 patients (9,375 operatively treated and 6,487 nonoperatively treated). Both open and minimally invasive surgical procedures were included. The rerupture rate was reported in all 29 studies, with an overall pooled effect demonstrating significant reduction in rerupture rate with operative compared with nonoperative treatment. Although a similar reduction in rerupture rate in favor of operative treatment was seen after both early and late full weight-bearing, no significant differences in rerupture rate were seen between operative and nonoperative treatments in studies that used accelerated functional rehabilitation with early range of motion. The overall pooled complication rate showed an as-expected risk ratio in favor of nonoperative treatment over operative treatment. The overall complication rate was 4.9% after operative treatment (infection as the main complication) compared with 1.6% after nonoperative treatment (deep vein thrombosis as the main complication).
A Level-I meta-analysis of 7 RCTs comparing dynamic fixation (suture button) and static fixation (metal screw) of acute syndesmotic injuries was published representing the highest Level of Evidence and sample size on this topic to date26. Functional outcomes, complications, and reoperations were evaluated (planned implant removal was not classified as a reoperation). A total of 168 patients were treated with dynamic fixation and 167 patients were treated with static fixation, and they were followed for 1 to 2 years. The random effects meta-analysis for overall complications revealed a significantly reduced risk (relative risk, 0.55; p = 0.003) among the dynamic fixation group compared with the static fixation group. This was particularly evident for inadequate reduction at the time of final follow-up as well as the clinical diagnosis of recurrent diastasis or instability. Implant breakage or loosening was significantly reduced with the dynamic fixation devices. The overall reoperation rate was similar in the 2 groups (relative risk, 0.64; p = 0.07) but reduced when comparing dynamic fixation with permanent screw static fixation (relative risk, 0.24; p = 0.007). The American Orthopaedic Foot & Ankle Society (AOFAS) score was higher for dynamic fixation compared with static fixation at 3, 12, and 24 months, and the VAS was lower for dynamic fixation compared with static fixation at 6 and 12 months. The authors acknowledged limitations of patient and personnel blinding, treatment heterogeneity, small samples, and short follow-up in this analysis.
Studies with rigorous methodology have demonstrated no clear benefit of using platelet-rich plasma in the treatment of tendinopathy. With regard to rotator cuff tendinopathy, a recent double-blinded RCT found that platelet-rich plasma injections within interstitial supraspinatus tears did not improve tendon healing (as seen on magnetic resonance arthrography [MRA]) or patient-reported outcome measures compared with saline solution injections and that platelet-rich plasma injections were associated with more complications27. Eighty-four patients with >6 months of shoulder pain, a positive Jobe test, and MRA showing an isolated interstitial supraspinatus tear were randomized to receive either 2 leukocyte-poor platelet-rich plasma infiltrations or 2 infiltrations of saline solution, with no formal physical therapy to avoid potential bias. The primary outcome of change in lesion volume on MRA at 6 months after the second infiltration showed no significant difference, despite adequate power. There were no differences in any patient-reported outcome measure at any time point. The platelet-rich plasma group had a higher incidence of adverse effects, which included pain for >48 hours, frozen shoulder, and extension of the lesion to the bursal or articular surface (54% compared with 26%; p = 0.020). Seven patients in the platelet-rich plasma group went on to surgery compared with 2 patients in the control group (p = 0.182).
Similarly, a single-blinded trial of platelet-rich plasma compared with saline solution injection for patellar tendinopathy demonstrated no difference in any outcome measure at the 1-year follow-up28. Scott et al. randomized 57 patients into 3 single-injection arms: leukocyte-rich platelet-rich plasma, leukocyte-poor platelet-rich plasma, and saline solution, all followed by 6 weeks of supervised rehabilitation. The primary analysis at 12 weeks after intervention (93% follow-up) showed that the majority of patients (58%) experienced improvement in the Victorian Institute of Sport Assessment Questionnaire, Patellar Tendon (VISA-P) score, with no significant difference among treatments. At a 1-year follow-up of 79% of patients, all outcome measures were the same. There was a trend toward more recipients of platelet-rich plasma experiencing worsening of the condition at 6 weeks compared with recipients of saline solution, and a trend toward fewer patients in the leukocyte-rich platelet-rich plasma group experiencing significant improvement at 12 weeks. There was higher-than-expected variability in treatment responses, which may indicate that the study was underpowered for its primary outcome.
There have been several RCTs comparing platelet-rich plasma with hyaluronic acid for knee osteoarthritis in prior years, but Lin et al. performed a double-blinded RCT also including a saline solution control group29. They randomized 87 knees (53 patients) to 3 weekly injections of leukocyte-poor platelet-rich plasma, hyaluronic acid, or saline solution. They had minimal loss to follow-up. All groups had a significantly improved patient-reported outcome measures from baseline to 1 month, but only the platelet-rich plasma group sustained this improvement at 2, 6, and 12 months, and only the platelet-rich plasma group reached the minimal clinically important difference for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at every time point. Between-group analysis demonstrated significant differences between the platelet-rich plasma group and the saline solution group at 2, 6, and 12 months, but no differences between the hyaluronic acid group and the saline solution group at any time point. Di Martino et al. reported on their 5-year results for leukocyte-rich platelet-rich plasma compared with hyaluronic acid injection for knee osteoarthritis30; the short-term results of their RCT were previously published31. They maintained >80% follow-up by the final analysis. Both platelet-rich plasma and hyaluronic acid treatment groups had significantly improved IKDC scores up to 24 months. At 5 years, the platelet-rich plasma group maintained significantly higher values at 60.5 ± 19.0 points compared with baseline at 53.3 ± 14.3 (p < 0.001), and the hyaluronic acid group did not. Platelet-rich plasma also had a lower reintervention rate at 24 months compared with hyaluronic acid. However, when comparing platelet-rich plasma directly with hyaluronic acid, there were no significant differences between the groups at any time point, including final follow-up.
The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 9 other articles with a higher Level of Evidence grade relevant to sports medicine surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area.
Brochin RL, Zastrow R, Hussey-Andersen L, Parsons BO, Cagle PJ. Revision rotator cuff repair: a systematic review. J Shoulder Elbow Surg. 2019 Aug 28. [Epub ahead of print].
Brochin et al. compared open and arthroscopic revision repair results to identify preoperative prognostic factors associated with postoperative outcomes. This review included 22 studies with considerably varied patients in terms of comorbidities, number of prior surgical procedures, cuff tear size, surgical technique, and concomitant procedures. Study quality was rated using the Methodological Index for NOn-Randomized Studies (MINORS), and the mean score was 10 (of 16), indicating a fair quality of evidence. The mean ASES scores showed significant improvement from 46 to 76 points, the mean VAS decreased from 6 to 3, and these improvements were seen in both the open and arthroscopic groups. The overall complication rate was 12%, and the most frequent complications were repair failure (88%), shoulder stiffness (5%), and infection (4%). The prognostic factor most correlated with a higher postoperative ASES score was preoperative forward flexion. This study suggests that revision rotator cuff repair can be performed safely using arthroscopic and open techniques with good improvements in patient-reported outcomes but higher rates of retear compared with primary repair.
Chaudhry ZS, Salem HS, Hammoud S, Salvo JP. Does prior hip arthroscopy affect outcomes of subsequent hip arthroplasty? A systematic review. Arthroscopy. 2019 Feb;35(2):631-43. Epub 2019 Jan 4.
This was a systematic review of studies directly comparing outcomes of total or resurfacing hip arthroplasty between patients with and without a history of hip arthroscopy. Case series were excluded. Seven studies (all retrospective case-control, Level-III evidence) met inclusion criteria, with a mean follow-up period of 3.2 years. There were 235 patients with a history of hip arthroscopy with a mean age of 47.2 years and 374 matched controls with a mean age of 49.1 years. The time between arthroscopy and arthroplasty was inconsistently reported but was a mean of 1.8 years. There were no significant differences between the groups for postoperative complications including superficial or deep joint infection, revision, heterotopic ossification, postoperative hip dislocation, aseptic implant loosening, and periprosthetic fracture. Patient-reported outcome measures were comparable between groups, with 1 study demonstrating a better postoperative Harris hip score in the control group than the arthroscopy group. The review was limited by the small sample sizes and retrospective nature of the included studies as well as the lack of homogeneity in surgical indications, technique, and postoperative outcome measures. Based on these results, patients can be counseled that hip arthroscopy is unlikely to negatively affect the success of future hip replacement.
de Sa D, Arakgi ME, Lian J, Crum RJ, Lin A, Lesniak BP. Labral repair versus biceps tenodesis for primary surgical management of type II superior labrum anterior to posterior tears: a systematic review. Arthroscopy. 2019 Jun;35(6):1927-38. Epub 2019 Apr 30.
A systematic review of mostly Level-III and IV studies comparing superior labrum anterior to posterior (SLAP) repair with biceps tenodesis in patients with type-II SLAP tears demonstrated reasonable outcomes with either surgical treatment. On closer inspection of the included studies, patients who underwent SLAP repair had more variance in their rates of return to sport and need for subsequent reoperation compared with patients treated with biceps tenodesis. These results imply that, despite similar patient-reported outcomes between SLAP repair and biceps tenodesis, the risk of having a poorer outcome may be greater after SLAP repair.
Funchal LFZ, Astur DC, Ortiz R, Cohen M. The presence of the arthroscopic “floating meniscus” sign as an indicator for surgical intervention in patients with combined anterior cruciate ligament and grade II medial collateral ligament injury. Arthroscopy. 2019 Mar;35(3):930-7. Epub 2019 Feb 4.
This study was a single-surgeon RCT of patients who were identified as having a floating meniscus at the time of arthroscopy for ACL reconstruction. This floating meniscus sign is the phenomenon identified at the time of arthroscopy when the meniscus appears to float proximally with the femur when a valgus force is placed across the knee, indicating injury to the meniscotibial coronary ligaments of the deep medial collateral ligament (MCL). There were 123 patients who were found to have this floating meniscus sign at the time of arthroscopy; these patients were randomized into 2 treatment groups. The first group had both ACL and MCL reconstruction, and the second group had ACL reconstruction alone. Although appropriate randomization was performed, patients undergoing the combined reconstructions were younger in general. The results showed significantly greater improvement in the Tegner and Lysholm scores at the 2-year follow-up and a lower ACL graft failure rate in the group that had the combined reconstruction. This sign may be a helpful adjunct in addition to examination under anesthesia and the classic drive-through sign to assess MCL injury at the time of ACL reconstruction.
Kim YS, Jin HK, Lee HJ, Cho HL, Lee WS, Jang HJ. Is it safe to inject corticosteroids into the glenohumeral joint after arthroscopic rotator cuff repair? Am J Sports Med. 2019 Jun;47(7):1694-700. Epub 2019 May 14.
This is a small, randomized, double-blinded clinical trial comparing 2 groups undergoing arthroscopic rotator cuff repair, 1 group that received a glenohumeral joint cortisone injection at 8 weeks after the repair and another group that was given placebo. There were 40 patients in each group, and the investigators examined range of motion, the ASES score, the Constant score, the VAS pain score, and the Simple Shoulder Test score at 3, 6, and 12 months and at the time of final follow-up. All patients had small to medium-sized cuff tears, and the repairs were all performed by a single surgeon who used a single-row technique for small tears and a double-row technique for medium-sized tears. At 8 weeks postoperatively, all patients underwent an ultrasound-guided glenohumeral injection of either cortisone (triamcinolone 40 mg) or normal saline solution placebo. The results showed that the group that received cortisone had significantly more range of motion in forward flexion and external rotation and correspondingly higher ASES scores and lower VAS scores at the 3-month time point than the control group. However, after 6 months postoperatively, there were no longer any significant differences between groups in any of the subjective or objective outcome measures including retear. The authors concluded that 1 cortisone injection after cuff repair surgery is safe and does not increase the risk of retear and may help patients to improve pain and range of motion early in the postoperative course. Because the benefits to patients appear to be transient, it is not recommended to perform routine postoperative injections.
Novaretti JV, Patel NK, Lian J, Vaswani R, de Sa D, Getgood A, Musahl V. Long-term survival analysis and outcomes of meniscal allograft transplantation with minimum 10-year follow-up: a systematic review. Arthroscopy. 2019 Feb;35(2):659-67.
Although the Level of Evidence of the included studies was low (mostly case series), this systematic review is one of the few studies to show long-term results of meniscal allograft transplantation. Both bone fixation and suture-only fixation were included. The mean graft survivorship rates were 73.5% at the 10-year follow-up and 60.3% at the 15-year follow-up. There was some heterogeneity within the patients included in the review and the definition of failure varied but was most commonly defined as graft removal or conversion to total knee arthroplasty. Functional outcomes were overall improved compared with preoperative scores. Such data can help to counsel patients considering meniscal transplantation, although long-term studies of meniscal allograft with better methodology are required to better understand the true durability of this procedure.
Qvist AH, Væsel MT, Jensen CM, Jensen SL. Plate fixation compared with nonoperative treatment of displaced midshaft clavicular fractures: a randomized clinical trial. Bone Joint J. 2018 Oct;100-B(10):1385-91.
In this multicenter RCT performed in Denmark comparing the outcomes and healing of displaced midshaft clavicle fractures, fractures treated with open reduction and internal fixation with locked plating were shown to have better short-term (3 months) function and lower nonunion rates compared with nonoperative treatment. The 6-month and 1-year outcomes were the same, suggesting that the surgical procedure should be selectively performed in patients requiring better early function.
Shumborski S, Heath E, Salmon LJ, Roe JP, Linklater JP, Facek M, Pinczewski LA. A randomized controlled trial of PEEK versus titanium interference screws for anterior cruciate ligament reconstruction with 2-year follow-up. Am J Sports Med. 2019 Aug;47(10):2386-93. Epub 2019 Jul 15.
This was a blinded RCT evaluating the use of polyetheretherketone (PEEK) screws compared with titanium metal screws for ACL fixation in 133 patients who underwent 4-stranded hamstring autograft reconstructions. Patient demographic characteristics, surgery technique, presence of concomitant meniscal tears, tunnel size, and bone quality were similar between the 2 groups. MRI evaluations at 12 months were performed, with 2-year outcome data available for >90% of patients. The results showed no differences in patient-reported outcomes, graft rerupture rate, and objective IKDC ligament grading. MRI evaluation of the graft integration as well as tunnel diameter at 1 year postoperatively did not show any clinically meaningful difference between groups. The less expensive implant is likely to be more cost-effective, but further study evaluating the effect of implant choice on subsequent revision ACL surgery would be beneficial.
Zastrow RK, London DA, Parsons BO, Cagle PJ. Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review. Arthroscopy. 2019 Aug;35(8):2525-2534.e1.
The investigators in this study systematically reviewed 5 clinical studies (all case series without a comparison group) that had minimum 12-month follow-up data. All studies showed a significant improvement in range of motion and ASES scores from the preoperative state. The complication rate was 17.2% across all studies, and the overall graft failure rate was 11.7%. Graft failure accounted for 68% of complications, and other complications included suture anchor loosening, infraspinatus tear, infection, shoulder contracture, persistent pain, and fascia lata donor site morbidity. The Level of Evidence is low and the potential for bias exists as these were all studies that lacked a control group and there was much heterogeneity in the surgical technique, graft source, and reported outcome data. More future research is required, including RCTs with longer-term follow-up, to better understand the indications for superior capsule reconstruction, its efficacy, and its cost-effectiveness.
1. Mohtadi NG, Chan DS. A randomized clinical trial comparing patellar tendon, hamstring tendon, and double-bundle ACL reconstructions: patient-reported and clinical outcomes at 5-year follow-up. J Bone Joint Surg Am. 2019 Jun 5;101(11):949-60.
2. Deabate L, Previtali D, Grassi A, Filardo G, Candrian C, Delcogliano M. Anterior cruciate ligament reconstruction within 3 weeks does not increase stiffness and complications compared with delayed reconstruction: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019 Aug 5. [Epub ahead of print].
3. Wang HD, Gao SJ, Zhang YZ. Hamstring autograft versus hybrid graft for anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2019 Jun 5. [Epub ahead of print].
4. Losciale JM, Zdeb RM, Ledbetter L, Reiman MP, Sell TC. The association between passing return-to-sport criteria and second anterior cruciate ligament injury risk: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2019 Feb;49(2):43-54. Epub 2018 Nov 30.
5. Huang YL, Jung J, Mulligan CMS, Oh J, Norcross MF. A majority of anterior cruciate ligament injuries can be prevented by injury prevention programs: a systematic review of randomized controlled trials and cluster-randomized controlled trials with meta-analysis. Am J Sports Med. 2019 Aug 30. [Epub ahead of print].
6. Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy. 2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
7. van de Graaf VA, Noorduyn JCA, Willigenburg NW, Butter IK, de Gast A, Mol BW, Saris DBF, Twisk JWR, Poolman RW; ESCAPE Research Group. Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA. 2018 Oct 2;320(13):1328-37.
8. Pagliazzi G, Napoli F, Previtali D, Filardo G, Zaffagnini S, Candrian C. A meta-analysis of surgical versus nonsurgical treatment of primary patella dislocation. Arthroscopy. 2019 Aug;35(8):2469-81.
9. Lee DY, Park YJ, Song SY, Hwang SC, Park JS, Kang DG. Which technique is better for treating patellar dislocation? A systematic review and meta-analysis. Arthroscopy. 2018 Nov;34(11):3082-3093.e1. Epub 2018 Oct 6.
10. Desai VS, Tagliero AJ, Parkes CW, Camp CL, Cummings NM, Stuart MJ, Dahm DL, Krych AJ. Systematic review of medial patellofemoral ligament reconstruction techniques: comparison of patellar bone socket and cortical surface fixation techniques. Arthroscopy. 2019 May;35(5):1618-28. Epub 2019 Apr 15.
11. Li J, Li Z, Wang K, Liu C, Wang Y, Wang H. Medial patellofemoral ligament reconstruction: a comparison of single-bundle transpatellar tunnel and double-anchor anatomic techniques for the treatment of recurrent lateral patellar dislocation in adults. Arthroscopy. 2019 Mar;35(3):845-854.e1. Epub 2019 Jan 29.
12. Wang C, Meng JH, Zhang YW, Shi MM. Suture button versus hook plate for acute unstable acromioclavicular joint dislocation: a meta-analysis. Am J Sports Med. 2019 Jul 17. [Epub ahead of print].
13. Murray IR, Robinson PG, Goudie EB, Duckworth AD, Clark K, Robinson CM. Open reduction and tunneled suspensory device fixation compared with nonoperative treatment for type-III and type-IV acromioclavicular joint dislocations: the ACORN prospective, randomized controlled trial. J Bone Joint Surg Am. 2018 Nov 21;100(22):1912-8.
14. Abdelrahman AA, Ibrahim A, Abdelghaffar K, Ghandour TM, Eldib D. Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness. J Shoulder Elbow Surg. 2019 Nov;28(11):2090-7. Epub 2019 Aug 23.
15. Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019 Jan 17;1:CD005619.
16. Moosmayer S, Lund G, Seljom US, Haldorsen B, Svege IC, Hennig T, Pripp AH, Smith HJ. At a 10-year follow-up, tendon repair is superior to physiotherapy in the treatment of small and medium-sized rotator cuff tears. J Bone Joint Surg Am. 2019 Jun 19;101(12):1050-60.
17. Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy. 2019 Mar;35(3):749-760.e2.
18. Tirefort J, Schwitzguebel AJ, Collin P, Nowak A, Plomb-Holmes C, Lädermann A. Postoperative mobilization after superior rotator cuff repair: sling versus no sling: a randomized prospective study. J Bone Joint Surg Am. 2019 Mar 20;101(6):494-503.
19. Murphy AI, Hurley ET, Hurley DJ, Pauzenberger L, Mullett H. Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up. J Shoulder Elbow Surg. 2019 Nov;28(11):2084-9. Epub 2019 Jul 13.
20. Williams HLM, Evans JP, Furness ND, Smith CD. It’s not all about redislocation: a systematic review of complications after anterior shoulder stabilization surgery. Am J Sports Med. 2019 Nov;47(13):3277-83. Epub 2018 Dec 10.
21. Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy. 2019 Feb;35(2):617-28. Epub 2019 Jan 3.
22. Alkaduhimi H, Verweij LPE, Willigenburg NW, van Deurzen DFP, van den Bekerom MPJ. Remplissage with Bankart repair in anterior shoulder instability: a systematic review of the clinical and cadaveric literature. Arthroscopy. 2019 Apr;35(4):1257-66.
23. Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE; FASHIoN Study Group. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet. 2018 Jun 2;391(10136):2225-35. Epub 2018 Jun 1.
24. Palmer AJR, Ayyar Gupta V, Fernquest S, Rombach I, Dutton SJ, Mansour R, Wood S, Khanduja V, Pollard TCB, McCaskie AW, Barker KL, Andrade TJMD, Carr AJ, Beard DJ, Glyn-Jones S; FAIT Study Group. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial. BMJ. 2019 Feb 7;364:l185.
25. Ochen Y, Beks RB, van Heijl M, Hietbrink F, Leenen LPH, van der Velde D, Heng M, van der Meijden O, Groenwold RHH, Houwert RM. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019 Jan 7;364:k5120.
26. Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019 Jun 12. [Epub ahead of print].
27. Schwitzguebel AJ, Kolo FC, Tirefort J, Kourhani A, Nowak A, Gremeaux V, Saffarini M, Lädermann A. Efficacy of platelet-rich plasma for the treatment of interstitial supraspinatus tears: a double-blinded, randomized controlled trial. Am J Sports Med. 2019 Jul;47(8):1885-92. Epub 2019 Jun 4.
28. Scott A, LaPrade RF, Harmon KG, Filardo G, Kon E, Della Villa S, Bahr R, Moksnes H, Torgalsen T, Lee J, Dragoo JL, Engebretsen L. Platelet-rich plasma for patellar tendinopathy: a randomized controlled trial of leukocyte-rich PRP or leukocyte-poor PRP versus saline. Am J Sports Med. 2019 Jun;47(7):1654-61. Epub 2019 Apr 30.
29. Lin KY, Yang CC, Hsu CJ, Yeh ML, Renn JH. Intra-articular injection of platelet-rich plasma is superior to hyaluronic acid or saline solution in the treatment of mild to moderate knee osteoarthritis: a randomized, double-blind, triple-parallel, placebo-controlled clinical trial. Arthroscopy. 2019 Jan;35(1):106-17.
30. Di Martino A, Di Matteo B, Papio T, Tentoni F, Selleri F, Cenacchi A, Kon E, Filardo G. Platelet-rich plasma versus hyaluronic acid injections for the treatment of knee osteoarthritis: results at 5 years of a double-blind, randomized controlled trial. Am J Sports Med. 2019 Feb;47(2):347-54. Epub 2018 Dec 13.
31. Filardo G, Di Matteo B, Di Martino A, Merli ML, Cenacchi A, Fornasari P, Marcacci M, Kon E. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med. 2015 Jul;43(7):1575-82. Epub 2015 May 7.