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, 14% of the BEAR group had had a reinjury and undergone a conversion to ACL reconstruction, whereas a revision ACL reconstruction was required in 6% of the ACL reconstruction group. In both groups, 50% of retears occurred in the first year. Of those BEAR procedures converted to ACL reconstruction, the IKDC subjective score and knee laxity values were similar to those for patients who had a single, primary ACL reconstruction. At the 2-year follow-up, the ACL reconstruction group had a mean hamstring strength of 63% compared with the contralateral side, whereas the BEAR cohort attained 98% of the contralateral hamstring strength. Lateral augmentation in combination with ACL reconstruction can increase rotational stability. Lateral extra-articular tenodesis (LET), first described by Lemaire, and anterolateral ligament (ALL) reconstruction are 2 viable options that have been shown to increase rotational stability and share the load distribution, which can decrease tension on the ACL graft and prevent graft failure13–15. The Stability 1 study demonstrated that the addition of an LET augment to an ACL reconstruction with a hamstring autograft led to a 60% relative reduction in the risk of graft failure compared with ACL reconstruction alone16. Patients in this study were required to have at least 2 of the following criteria: participation in a competitive pivoting sport, ligamentous laxity as defined by a Beighton score of ≥4, and/or a pivot score grade of ≥2. Controversy remains regarding whether augmentation by LET or by ALL reconstruction is superior. In order to determine the more effective technique, Park et al. performed a meta-analysis of 11 studies comparing a combined single-bundle ACL reconstruction and LET with a combined single-bundle ACL reconstruction and ALL reconstruction. With a minimum follow-up of 12 months, ACL reconstruction with ALL reconstruction appeared to have a significant advantage in rotational stability compared with an isolated ACL reconstruction or ACL reconstruction with LET17. There were no differences in knee pain, Lysholm scores for knee function, or graft failure between the lateral procedure options. Additionally, the ACL reconstruction with LET yielded higher Tegner scores indicating the activity level; however, the ACL reconstruction with ALL reconstruction yielded a higher IKDC score indicating knee function. Despite current investigations, there are no clear indications for lateral augmentation procedures. To determine the key risk factors for graft failure in high-risk patients, Firth et al. retrospectively determined the predictors of graft failure with or without an LET18. Based on data obtained in the Stability 1 study, the OR for graft rupture was 3.27 for preoperative high-grade knee laxity (grade-3 Lachman or pivot shift) and 2 for a >9.5° posterior tibial slope. Increased exposure time, such as earlier return to sport, also increased the odds (specifically, each additional month of exposure time increased the odds of graft rupture by 18%). Each 1.0-mm increase in graft diameter was associated with 38% lower odds of an asymmetric pivot shift. Hamstring ACL reconstruction with LET was significantly associated with 60% lower odds of graft rupture, whereas higher odds of rupture were associated with increased tibial slope, younger age, high-grade preoperative knee laxity, and early return to sport. Each year increase in age was associated with 17% lower odds of rupture. Final recommendations included addition of an LET and increased graft diameter to reduce asymmetric pivot shift. Revision ACL has a risk of failure that is 4 times greater than that after primary reconstruction19. Although the success rate ranges from 75% to 95%, several technical factors including tunnel placement, graft, and aperture fixation choices have been shown to improve revision failure rates20–24. Saithna et al. performed a systematic analysis to determine the advantages, if any, to using an LET with a revision ACL19. Eight studies with a minimum follow-up of 24 months were identified, with 716 patients undergoing revision ACL reconstruction with or without augmentation with a lateral extra-articular procedure including ALL reconstruction, a modified Lemaire procedure, or a modified MacIntosh procedure25. Failure rates ranged from 0% to 13% in patients who underwent lateral augmentation and from 4.4% to 21.4% in patients who underwent isolated ACL reconstruction, in the 6 studies that measured this value. There were only significant differences in high-grade pivot shift, high-grade Lachman, and anteroposterior laxity between cohorts in 1 study. There were no consistent differences between isolated procedures and combined procedures with regard to patient-reported outcomes or return to sport. Boksh et al. showed similar results with revision ACL reconstruction26. In a systematic review and meta-analysis with 10 studies and 793 patients, there were no differences in Lysholm and Tegner scores between either LET or ALL reconstruction and isolated revision ACL reconstruction. However, patients with lateral augmentation had a higher IKDC score, representing a higher level of function and fewer symptoms. Two of 3 studies showed that LET or ALL reconstruction led to a significantly higher proportion of athletes returning to the same level of sports. Overall, LET or ALL reconstruction yielded increased rotational stability and a lower side-to-side difference, resulting in a lower likelihood of failure. Posterior Cruciate Ligament Posterior cruciate ligament reconstruction typically is done with a single-bundle reconstruction of the anterolateral bundle27. However, there have been reports of persistent laxity and instability with the single-bundle technique. Dasari et al. compared double-bundle and single-bundle reconstructions in a meta-analysis of 28 studies27. There was wide variation among the graft choice, size, tunnel placement, and fixation devices used for reconstruction. The double-bundle technique yielded much lower posterior tibial translational laxity in both 30° and 90° of flexion, external rotation laxity in 90° of knee flexion, and side-to-side differences measured by stress radiographs. There were no differences in varus laxity, external rotation laxity in 30°of flexion, and Tegner and Lysholm scores. Overall, double-bundle reconstruction appeared to be biomechanically superior to single-bundle reconstruction and resulted in better IKDC scores. Posterolateral Corner Reconstruction There has been no consensus on a gold standard for posterolateral corner reconstruction of the knee that recreates the lateral collateral ligament, popliteal tendon, and popliteofibular ligament. Neglecting to restore these ligaments can result in posterolateral instability and a varus thrust gait28. Boksh et al. completed a systematic review and meta-analysis to examine the difference between fibular-based (Larson and Arciero) and tibiofibular-based (LaPrade) techniques28. There was no difference in postoperative varus and rotational stability or in patient-reported outcomes after a mean follow-up of 20 months. There were equivalent varus and rotational stability outcomes in all but 1 study29, which favored the Larson technique. The Arciero technique demonstrated a shorter operative time in 1 study30. Finally, the tibiofibular-based technique was more likely to cause the development of arthrofibrosis and stiffness. However, given the small number of studies, we conclude that more evidence is needed to determine the most effective technique. Medial Patellofemoral Ligament (MPFL) The incidence of recurrent dislocation after a first-time patellar dislocation can be up to 61%31, leading some surgeons to advocate for an MPFL reconstruction after the first dislocation. Gurusamy et al. conducted a retrospective analysis of MPFL reconstruction after a first-time dislocation, finding that adolescents treated with MPFL reconstruction were 5 times less likely to have recurrent instability, 2 times more likely to return to sport, and 8 times less likely to require an additional procedure31. Cartilage and Joint Preservation Articular cartilage lesions can be severely debilitating, greatly affecting a patient's physical ability and overall quality of life. Untreated osteochondral lesions can serve as a precursor to osteoarthritis. Current orthopaedic treatments are based on the size and chronicity of lesions. Altschuler et al. conducted an RCT to determine the efficacy of an aragonite (inorganic calcium carbonate)-based osteochondral implant compared with a microfracture control cohort32. Lesions included in the study were 1 to 7 cm2 in size and on the femoral condyles or trochlea. The results showed that the patients in the scaffold group had higher IKDC scores at 6, 12, 18, and 24 months and a larger percentage of defect filling at 2 years (75% compared with 30.9% in the control cohort), verified with MRI. When further stratified, the scaffold outperformed microfracture in all age groups who had mild and moderate arthritis and larger lesions. Osteoarthritis of the Knee Osteoarthritis, one of the most debilitating joint conditions, is initially treated with nonoperative management that includes physical therapy, NSAIDs, and injectable macromolecules such as hyaluronic acid, PRP, or "stem cells." There continues to be a debate between the efficacy of hyaluronic acid and that of PRP. Belk et al. conducted a systematic review and meta-analysis consisting of 18 studies comparing the 2 treatments33. With a mean follow-up of 11.1 months, PRP emerged as the dominant treatment. Of the 9 studies that utilized the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, 6 had significantly better scores at the last follow-up in the PRP cohort, indicating less pain and higher function. Six of 11 studies that recorded pain on a visual analog scale (VAS) showed that patients had less pain with PRP compared with hyaluronic acid. Of the 6 studies assessing IKDC scores, 4 resulted in significantly higher scores in the PRP cohort compared with the hyaluronic acid cohort. Additionally, patients who received leukocyte-poor PRP had better IKDC scores than patients who received leukocyte-rich PRP. Of note, the system for creating PRP, the number of hyaluronic acid injections (3 to 5), the timing of hyaluronic acid injections (1 to 3-week intervals), and the reporting of platelet concentrations all had large variability between studies. Ankle Osteoarthritis The best nonoperative treatment for ankle osteoarthritis has yet to be determined. Prior studies examining PRP injections have shown no benefit up to 26 weeks. Paget et al. conducted a double-blinded RCT of 100 patients to determine the efficacy of PRP compared with a saline solution placebo34. Patients were given 2 talocrural injections: at inclusion in the study and at 6 weeks. No differences were found between the American Orthopaedic Foot & Ankle Society (AOFAS) score or the Foot and Ankle Outcome Score (FAOS) between the placebo and PRP cohorts over the course of 52 weeks. Evidence-Based Orthopaedics 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 the articles cited already in this update, 5 other articles relevant to sports medicine 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. Evidence-Based Orthopaedics Costa GG, Grassi A, Zocco G, Graceffa A, Lauria M, Fanzone G, Zaffagnini S, Russo A. What is the failure rate after arthroscopic repair of bucket-handle meniscal tears? A systematic review and meta-analysis. Am J Sports Med. 2022 May;50(6):1742-52. Failure rates for meniscal tears vary widely in the historic literature because of the outdated techniques reported. In this systematic review and meta-analysis with 38 studies, contemporary failure rates ranged from 0% to 75%. Bucket-handle repairs failed 1.5 times more often than simple tears, and isolated repairs more often than those with concomitant ACL reconstruction; the overall failure rate was estimated at 14.8% in a range from 2 to 126 months. There was no difference in failure rates between red-red and red-white zone repairs. Meniscal repairs are thus generally successful, with an overall expected failure rate of approximately 1 in 7. Heyworth BE, Ganley TJ, Liotta ES, Hergott KA, Miller PE, Wall EJ, Myer GD, Nissen CW, Edmonds EW, Lyon RM, Chambers HG, Milewski MD, Green DW, Weiss JM, Wright RW, Polousky JD, Nepple JJ, Carey JL, Kocher MS, Shea KG; ROCK Group. Transarticular versus retroarticular drilling of stable osteochondritis dissecans of the knee: a prospective multicenter randomized controlled trial by the ROCK Group. Am J Sports Med. 2023 May;51(6):1392-402. The ROCK group compared the relative effectiveness of transarticular drilling with that of retrograde drilling for the surgical treatment of unstable osteochondritis dissecans. Transarticular drilling is a percutaneous technique in which retrograde drilling through articular cartilage is performed intra-articularly. Retrograde drilling is an antegrade extra-articular technique in which drilling down to the subchondral bone is performed without perforating the articular cartilage. No differences in patient-reported outcomes at 6, 12, or 24 months or in secondary surgical procedures were found between the 2 cohorts. The transarticular drilling cohort also had greater median ossification and boundary healing at 6 and 12 months, which allowed the transarticular drilling cohort to return to sport earlier (median, 4.1 compared with 5.8 months), but there was no longer a difference by 24 months. Thus, this study demonstrated that the transarticular drilling technique results in better outcomes and faster return to sports than retrograde drilling. Lemmens L, De Houwer H, van Beek N, De Schrijver F. Functional recovery in the surgical treatment of tennis elbow: side-to-side vs. tendon-to-bone attachment using a knotless suture anchor: a randomized controlled trial. J Shoulder Elbow Surg. 2023 Apr;32(4):751-9. Lateral epicondylitis is usually a self-limiting disease, resolving in 90% of patients within 1 year. For patients who undergo failed nonoperative treatment, surgical treatment has been described. Lemmens et al. compared a side-to-side tendon repair with a bone-tendon interface restoration and found no difference in the QuickDASH, Mayo Elbow Performance Index, or Numeric Pain Rating scale score or in the time to return to work. The cohort who underwent the suture anchor repair had better functional outcomes, grip strength, and wrist extension at 6 weeks, suggesting that the bone-tendon interface should be restored. Neal BS, Bartholomew C, Barton CJ, Morrissey D, Lack SD. Six treatments have positive effects at 3 months for people with patellofemoral pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022 Nov;52(11):750-68. Patellofemoral syndrome can be an extremely debilitating condition. To determine which treatments resulted in the best patient-reported outcomes, Neal et al. performed a systematic review and meta-analysis of various modalities including exercise therapy, electrotherapy, manual therapy, foot orthoses, dry needling, injection therapies, taping techniques, gait retraining, blood flow restriction therapy, and psychological therapy. Knee-targeted exercise therapy, foot orthoses, combined intervention, and lower-quadrant manual therapy each provided more pain relief at short-term follow-up (≤3 months) than no treatment. Combined treatments involved hip and knee exercise therapy, vastus medialis oblique biofeedback, soft-tissue stretching, and patellar taping. Hip and knee-targeted exercise therapy and knee-targeted exercise therapy with perineural dextrose injection were each more efficacious at short-term follow-up compared with knee-targeted therapy alone. Thus, when prescribing therapy for patellofemoral pain, 6 modalities (knee-targeted exercises, foot orthoses, manual therapy, combination therapies, hip and knee-targeted exercises, and perineural dextrose injections) have shown clinical improvement in the short term. However, no intervention has been adequately tested for longer than 3 months. van der Graaff SJA, Meuffels DE, Bierma-Zeinstra SMA, van Es EM, Verhaar JAN, Eggerding V, Reijman M. Why, when, and in which patients nonoperative treatment of anterior cruciate ligament injury fails: an exploratory analysis of the COMPARE Trial. Am J Sports Med. 2022 Mar;50(3):645-51. To determine why nonoperative treatment for ACL reconstruction fails, van der Graff et al. investigated patients in the COMPARE (conservative versus operative methods for patients with ACL rupture evaluation) trial. Fifty percent of patients did not need ACL reconstruction within a 2-year follow-up period because of satisfactory clinical outcomes, whereas the other 50% underwent delayed reconstruction after a median time of 6.4 months because of knee instability (90.2%). Thus, patients with ACL tears can initially be treated nonoperatively, but whether surgical intervention is necessary will be decided within 3 to 6 months of physical therapy. Patients who are younger (20 to 39 years of age) and were active before the injury will more likely require a reconstructive surgical procedure.