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AAOS Now

Published 8/1/2015
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Mary Ann Porucznik

AOSSM Studies Focus on Getting Athletes Back on the Field

Presentations range from knees to elbows, shoulders to ankles

Temperatures in the 90s outside kept attendees at the 2015 annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) focused on the research being presented inside the Hilton Orlando Bonnet Creek in Orlando, Fla., last month. The meeting included more scientific posters and research presentations than ever before, including the following studies.

ACL studies
Surgeons making reconstruction choices for an injured anterior cruciate ligament (ACL) can consider both bone-tendon-bone (BTB) and hamstring autografts as equally viable options with regard to healing, according to the results of one study, funded by the Orthopaedic Research and Education Foundation. Researchers hypothesized that the BTB autograft would heal more quickly than the hamstring autograft and with less motion under functional, dynamic loads. The reality, however, was quite different.

“We compared the graft-tunnel motion of 12 patients, 6 of whom received a BTB autograft and 6 of whom received a hamstring autograft. Both groups had similar graft motion (ranging between 1 mm and 2 mm) at 6 weeks and 1 year from surgery,” commented Justin W. Arner, MD, from the University of Pittsburgh Medical Center.

“Often surgeons will recommend earlier return to play in patients receiving a BTB graft, but with these findings we cannot support the commonly perceived assumption of earlier healing with BTB,” he continued.

The 12 patients (average age: 24 years) underwent anatomic single-bundle ACL reconstruction; tiny tantalum beads were embedded into the grafts at the bone tunnel and mid-substance regions. Patients participated in a standard physical therapist-supervised rehab program after surgery. Motion was measured during treadmill walking using dynamic stereo radiographic images to determine the maximum range of motion of the most proximal femoral tunnel and most distal tibial tunnel beads along the direction of the bone tunnels during the stance phase of gait.

Across all time points, femoral graft-tunnel motion was significantly greater for BTB than for hamstring grafts. “This study brings into question if there is any real difference in rates of healing of BTB versus hamstring autografts,” said Dr. Arner. “This may have ramifications on physical therapy protocols and timing of return to sport following ACL reconstruction.”

An award-winning study from the Multicenter Orthopaedic Outcomes Network (MOON) ACL group focused on the need to treat stable meniscus tears during ACL surgery. It found positive results for meniscal tears that were deemed stable and left alone at the time of ACL reconstruction.

“We examined 194 patients with meniscus tears who did not receive treatment at the time of ACL surgery (between 2002 and 2004),” noted lead author Kyle R. Duchman, MD, from the University of Iowa Hospitals and Clinics. “Among patients with untreated meniscus tears, 97.8 percent of those with lateral tears and 94.4 percent of those with medial tears required no reoperation at least 6 years after initial surgery.” The study noted that overall, only 16 tears (7.7 percent) required reoperation, primarily in younger patients and in tears larger than 10 mm.

“As surgeons, we want to avoid too much intervention on a patient’s knee when good outcomes can be expected,” noted Dr. Duchman. “Although large, unstable meniscus tears may need treatment at time of ACL surgery, this study confirms that smaller, stable tears can be left alone.”

Finally, an award-winning prospective cohort, double-blind, randomized controlled trial examined the effectiveness of neuromuscular training in reducing the risk of female athletes sustaining an ACL injury. The study involved 624 female athletes from 52 different teams (basketball, soccer, and volleyball) who performed various biomechanical tests before the playing season. The results of the tests were used to identify distinct at-risk profiles.

“Neuromuscular training significantly increased hip external rotation movements and moment impulse, increased peak trunk flexion, and decreased trunk extension,” wrote the authors. “Higher risk groups had a more significant treatment effect of neuromuscular training than low-risk groups.”

Elbow
The results of a retrospective review of a large private-payer database found that surgeries related to overuse elbow injuries (Tommy John surgery) are more common among youth athletes than previously believed.

“Our results showed that 15- to 19-year-olds accounted for 56.7 percent of the ulnar collateral ligament reconstruction (UCLR) or Tommy John surgeries performed in the United States between 2007 and 2011. This is a significant increase over time, with an average increase of 9.12 percent per year,” said lead author, Brandon J. Erickson, MD, of Chicago’s Rush University Medical Center.

The researchers identified a total of 790 patients (65 males and 95 females) who underwent UCLR procedures across the country. The overall average annual incidence of the procedure was 3.96 per 100,000 patients with an annual overall growth rate of 4.2 percent. Although more than half of the surgeries were performed on patients in the 15–19-year-old age group, those aged 20–24 years accounted for the second highest incident rate.

Following are other interesting details from the study:

  • More UCLR procedures were performed in the South (53 percent) than in any other region.
  • Most UCLR surgeries were performed between April and June.
  • The most common surgery setting was outpatient hospital (58 percent), followed by surgical centers (40 percent). Just 3 percent of UCLR procedures were performed in an inpatient hospital setting.

Shoulder
Among studies on shoulder conditions were three that focused on arthroscopic treatments. An award-winning study on return to play after arthroscopic stabilization for anterior shoulder instability found that 90 percent of intercollegiate contact athletes were able to return to play after surgery, compared to just 40 percent of athletes who opted for nonsurgical treatment.

“Our research highlights that collegiate collision athletes with in-season shoulder instability injuries are more likely to return to sport successfully the following season if they undergo arthroscopic stabilization compared to nonsurgical treatment,” said Jon Dickens, MD, from Walter Reed National Military Medical Center, Bethesda, Md.

The prospective, multicenter, observational study followed 39 contact intercollegiate athletes who were treated nonsurgically or with arthroscopic stabilization and evaluated recurrent instability issues following an initial in-season shoulder injury. Data analyzed included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (arthroscopic or nonsurgical). All nonsurgical patients underwent an accelerated, standardized rehabilitation program without shoulder immobilization. Successful return to play was evaluated the following competitive season.

A second study on the treatment of multidirectional shoulder instability (MDI) also found higher rates of return to play among athletes who were treated with arthroscopic surgery. “We examined 41 athletes who received arthroscopic surgery for MDI, and noted that 73 percent returned to play approximately the same level of performance as before the injury,” commented M. Brett Raynor, MD, from the Steadman Philippon Research Institute Program. “Our study group included patients at an average 3 years out from surgery.”

Prior to surgery, the 22 men and 19 women (mean age: 23.7 years) had undergone a conservative treatment approach (supervised exercise program), which was unsuccessful in reducing instability. “Prior research has shown that nonsurgical approaches to this type of injury have less-than-optimal results,” noted Peter J. Millett, MD, MSc, who performed the surgeries. “More research is needed, but the results of this study certainly support arthroscopic surgery for the treatment of MDI.”

Another study by Dr. Millett focused on the treatment of rotator cuff tears (RCT) sustained by older (70 years or older) recreational athletes. Based on the results of this study, arthroscopic RCT repair in high-demand elderly individuals may be highly effective in reducing pain, improving function, and enabling patients to return to sport.

“More than three-quarters (77 percent) of patients who had an arthroscopic repair of a full thickness RCT were able to return to their sport at a similar level of intensity,” said Dr. Millett.

The 44 patients (33 men and 11 women) had a mean age of 73 years. Five patients had bilateral tears. All postoperative measures to evaluate progress demonstrated a significant amount of improvement than before surgery. Patients who simply modified their activities due to postoperative weakness were significantly less satisfied.

“Although patients older than age 70 typically are not treated surgically for rotator cuff issues, these results highlight that there might be significant reason to assess and treat a tear arthroscopically,” said Dr. Millett.

Foot & ankle
According to the results of a motion analysis study, an athlete’s use of silicone ankle sleeves (SAS) and lace-up ankle braces (LAB) during sports participation can improve neuromuscular control.

“Athletes often use prophylactic sleeves or braces, and this study used markerless motion analysis to determine whether these support aids are beneficial,” said Seth L. Sherman, MD, from the department of orthopaedic surgery at the University of Missouri, Columbia.

The 10 study participants (5 female and 5 male) performed tests including the drop vertical jump (DJV), 45-degree bound, and various timed cutting maneuvers while wearing and not wearing SAS and LAB. Using both SAS and LAB, study participants showed decreased dynamic valgus and hip internal rotation during DJV testing, and decreased knee and ankle torque as compared to controls. The use of SAS or LAB did not negatively influence athletic performance measures.

“Although improvements in neuromuscular control were noted in this study, we cannot assume that the use of SAS or LAB leads to a lower injury risk,” Dr. Sherman said. “Athletes should continue to practice proven injury prevention methods, even when using a support device.”

Mary Ann Porucznik is managing editor of AAOS Now; she can be reached at porucznik@aaos.org

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Abstracts

Paper 8: ACL Reconstruction: Is there a Difference in Graft Motion for Bone-Tendon-Bone and Hamstring Autograft at One Year?
Justin W. Arner, MD; James N. Irvine, MD; Eric Thorhauer, BS; Ermias Shawel Abebe, MD; Jennifer Lynn D’Auria, BS; Verena Schreiber, MD; Scott Tashman, PhD; and Christopher D. Harner, MD

Paper 15: Do Ankle Sleeves and Lace-up Braces Effect Neuromuscular Control and Athletic Performance?
Blake Bodendorfer; Gary Stover; Christopher Ryan James, MD; Nicholas R. Arnold, BS; Ben Summerhays, DPM; Aaron D. Gray, MD; Seth Lawrence Sherman, MD

Paper 23: AOSSM Fellow Research Award in Clinical Science: Improved Return to Play in Intercollegiate Contact Athletes following Arthroscopic Stabilization for Anterior Shoulder Instability: A Prospective Multicenter Study
Jonathan F. Dickens, MD; John Paul H. Rue, MD; Kenneth L. Cameron, PhD, MPH, ATC; Kelly G. Kilcoyne, MD; C. Dain Allred, MD; Steven J. Svoboda, MD; Robert T. Sullivan, MD; John M. Tokish, MD; Karen Y. Peck, MEd, ATC; Brett D. Owens, MD

Paper 25: Outcomes following Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Instability
Martin Brett Raynor, MD; Marilee P. Horan, MPH; Joshua A. Greenspoon, BSc; Peter J. Millett, MD, MSc

Paper 35: Herodicus Award: The Fate of Meniscus Tears Left at the Time of Anterior Cruciate Ligament Reconstruction: A 6-Year Follow-up Study from the MOON Cohort
Kyle R. Duchman, MD; Robert W. Westermann, MD; Kurt P. Spindler, MD; Annunziato Amendola, MD; Brian R. Wolf, MD, MS; Richard D. Parker, MD; Jack T. Andrish, MD; Laura J. Withrow, MS; Emily Reinke, PhD; Christopher C. Kaeding, MD; Rick W. Wright, MD; Robert G. Marx, MD, MSc, FRCSC; Eric C. McCarty, MD; Michelle Lora Wolcott, MD; Warren R. Dunn MD, MPH

Paper 42: Two-Year Outcomes following Arthroscopic Rotator Cuff Repair in Recreational Athletes Over 70 Years of Age
Sanjeev Bhatia, MD; Joshua A. Greenspoon, BSc; Marilee P. Horan, MPH; Ryan J. Warth, MD; Peter J. Millett, MD, MSc

Paper 67: United States Trends in Medial Ulnar Collateral Ligament Reconstruction: A Retrospective Review of a Large Private-Payer Database from 2007 to 2011
Brandon J. Erickson, MD; Benedict U. Nwachukwu, MD, MBA; Sam Rosas, BS; William W. Schairer, MD; Francis McCormick, MD; Bernard R. Bach, MD; Charles A. Bush-Joseph, MD; Anthony A. Romeo, MD