Hurray for Sports Medicine

Abstract

It’s a cause for celebration! Sports medicine is no longer the deprived and despised orphaned child of the orthopaedic community. From its humble beginnings in the late sixties and early seventies, sports medicine and its practitioners have been viewed as being on the fringe of academic orthopaedics. Those of you in your fifth decade and better may remember when university orthopaedic departments openly ridiculed sports medicine practitioners and referred to the arthroscope as an evil instrument. As a resident, I was once laughed out of grand rounds for saying that I could see the knee joint more completely with the arthroscope than with an open incision. It wasn’t cool to be a sports person back then. Much of the early development of sports medicine occurred in private practice, away from the hallowed halls of academic medicine. Traditional orthopaedics was slow to recognize the value and impact of a more aggressive approach to the treatment of athletes and active individuals. Accordingly, some of the highest profile sports medicine centers are not in university settings. Many of the centers that take care of collegiate athletic teams are not located on campus but are nearby in the community. In large part, this estrangement stemmed from major differences between academicians and sports practitioners. Many academic chairs were slow to recognize the role that sports medicine would eventually assume in modern-day orthopaedics. those departments that did embrace sports medicine benefited handsomely in clinical care, research, and financial support, while those that didn’t soon paid for their shortsightedness. I doubt anyone could have predicted 30 years ago that nearly one-third of all orthopaedic residents completing their training would pursue sports medicine fellowships, even as many traditional orthopaedic fellowship slots went unfilled. What a turnaround! How did this all transpire? When did sports medicine gain not only legitimacy but, indeed, preeminence in orthopaedics? In reality, our success is based on our research. Sports medicine’s founders were true innovators—solving common orthopaedic problems in ways that challenged and, in many cases, eventually overturned traditional orthopaedic thinking. For example, everything didn’t heal in casts; joint motion was an important factor in rehabilitation after injuries or operations. Menisci were not useless structures but, in fact, deserved attempts at preservation and repair. Not only was the knee joint seen better with the arthroscope, but in many cases, so were the shoulder, hip, ankle, and elbow. True, many of the above insights, while important, came from poorly designed, imperfect studies: retrospective reviews, case reports, and small laboratory investigations. Fast-forward to 2010 and the article published in this issue of Sports Health by Kaeding et al: “Allographs Versus Autographs Anterior Cruciate Ligament Reconstruction: Predictors of Failure From a Multicenter Prospective Longitudinal Cohort.” This work—in which a multicenter research consortium examined patient- and surgeon-driven confounders using predictive models, multivariate logistic regression calculated with STATA, odds ratios, and confidence intervals on 645 anterior cruciate ligament reconstructions—is a great example of the development and maturation of orthopaedic sports medicine as a scientific discipline. The consortium and its founder, Dr Kurt Spindler, marshal formidable research and analytic resources to create the most valuable type of clinical research: research that has a direct beneficial impact on the lives of patients. To date, their research provides the best information available to help surgeons and patients choose between an autograft and an allograft. Indeed, their Figure 3 (“Probability of Retear for Autograft vs Allograft by Age”) should hang on the wall of examining rooms where physicians and patients are faced with these issues. Like any study, this one is not perfect. It doesn’t include all the facts and details that we’d like to see: arthrometer measurements of anterior tibial translation; imaging of failures and successes; more details on how and why the reconstructions that failed did so; and, especially, more information on the preparation of allografts. And there is little doubt that the reported percentages of failures are optimistic. These are the known failures that went on to revision surgery. Certainly, there are an untold number of patients with failed grafts that have not been revised and, quite possibly, a larger group whose knees are loose and whose members have either changed their lifestyles or chosen to continue activities with the associated risks. The true number of failures could actually be double those reported for both allografts and autografts. Despite these limitations, this is an outstanding study that is a landmark in sports medicine. I hope everyone that reads this issue of Sports Health will realize how far clinical research in our field has come and will commit himself or herself to continuing this development. Research is no doubt the key to our discipline’s future. Make no mistake about it: Supporting well-designed scientific laboratory and clinical investigations can take sports medicine to even greater heights.