Back to the Drawing Board

If you have been watching this space recently, you probably are aware that the American Journal of Sports Medicine is celebrating its 40th year of publication in 2012. In January and February, I put my feet up while Jack Hughston and Bob Leach recounted the early history of AJSM. When I began to brainstorm for this month’s editorial, I asked myself what I might do to continue the anniversary theme. In preparation of the 2-part history, I had reviewed the contents of the early issues of the Journal. Despite the demurrals of my predecessors, I was impressed with the quality and continued relevance of many of those initial studies, which introduced or developed topics that are still very timely. From the beginning, AJSM featured an eclectic mixture of surgery, nonsurgical treatment methods, epidemiology and injury prevention, and translational laboratory research. Although many articles from AJSM’s first years of publication were remarkably prescient of contemporary thinking, it’s not surprising that some of them reported theories or techniques that have since been discarded. It’s human nature to want to forget our missteps and move on; unsuccessful ideas usually fade into oblivion as time passes. In medicine, however, remembering what didn’t work can often be as valuable as remembering what did. Awareness of earlier practices may point out methods that should be avoided in the future or furnish inspiration for approaches that might be fruitful in a different context. One idea from the ’70s that may surprise younger readers was the concept of using a patient’s meniscus to reconstruct a torn anterior or posterior cruciate ligament. While this notion may seem puzzling today, it becomes more understandable when one recalls the state of cruciate ligament care in that era. Because MRI was not available and even diagnostic arthroscopy was limited in its distribution, most ACL tears were not identified until they had led to chronic instability. Even when a correct diagnosis was made at the time of the initial injury, many practitioners did not feel that reconstruction was justified unless a patient had experienced recurrent episodes of givingway. As a result, patients who came to ACL reconstruction often had concomitant bucket-handle meniscus tears. Preserving one attachment of the unstable meniscus and transplanting the other to the femur seemed like a logical and anatomically economical inspiration to enthusiasts of this technique. The meniscus had a proven ability to survive in an intra-articular environment, and its predominant circumferential collagen fibers would be aligned along the longitudinal axis of the neo-ligament. Supporters of meniscal substitution did not just proceed without thoughtful reflection and research. AJSM authors of the era tested the method in an animal model and compared its clinical results with patellar tendon reconstruction, urging caution before widespread adoption of the technique. Although reported outcomes seemed comparable to other methods of the era, enthusiasm for it eventually waned as the importance of preserving the meniscus was better appreciated and other, more effective alternatives were perfected. In this issue of AJSM, several groups of conscientious authors report results that suggest a need to return to the drawing board to develop more effectual methods. In one of the most noteworthy, Smith et al investigated the ability of the Landing Error Scoring System (LESS) to serve as a screening tool for risk of injury to the anterior cruciate ligament. In recent years, extensive research has been undertaken in an attempt to understand the factors that might predispose to noncontact ACL tears in order to facilitate the recognition of athletes at increased risk of injury and the development of effective, targeted prevention programs. Studies utilizing sophisticated laboratory equipment have identified movement parameters that may place the ACL in greater jeopardy and have even correlated some of these parameters with subsequent ACL tears. The LESS is the result of one group’s efforts to develop a relatively simple tool for identifying athletes with an increased risk of ACL injury. Prior studies by the developers of the LESS have shown that the scores correlated with the results of sophisticated kinetic and kinematic laboratory analysis. The current effort, from a different research group, attempted to demonstrate correlations between performance on the LESS and subsequent noncontact ACL rupture. This was an ambitious project that received funding from the National Institutes of Health. Over a 3-year period, the investigators screened 5047 high school and college athletes with the LESS during a drop-jump landing. Twenty-eight of these individuals, who subsequently sustained noncontact ACL ruptures, were each matched with 2 or 3 uninjured teammates. Unfortunately, whether the LESS scores were analyzed as a continuous or a categorical variable, the authors were not able to demonstrate a significant correlation with the risk of noncontact ACL injury. This held true both when the injured cohort was considered as a whole and when it was broken down by sex or level of educational enrollment. Needless to say, this outcome is disappointing. It is important to remember, however, that one study rarely provides the definitive assessment of a technique, even Editorial