Issue FIVE

SPORTS Medicine/Surgery In this issue >>>

Autumn 2014 NewsLetter…... BOSTAA Established 1993

Contact us: deiary.kader@gmail.com www.bostaa.ac.uk

Re-discovery of repair, the role of reconstructon, “new” ligaments, spin & data interpretation.

As my time as BOSTAA President comes to an end I have become increasingly aware of the cycle

of sports surgery together with the twists and turns of publication, presentation and science. The opening addresses at ESSKA featured key speakers from the UK. Andy Williams described

himself as being a bad old-fashioned surgeon by not adopting an “anatomical” ACL reconstruction technique. There was a considerably reduced emphasis of the anatomical technique (Carmont et al. 2011) and to my surprise rather than addressing graft tension, surgeons were turned their focus to the side of the knee to address persistent rotational instability.

Claes’ Antero-Lateral ligament (Claes et al. 2013) injury had already caused consternation in the

British press. The ALL had been known about for some time and may well be associated with a Segond bone fracture avulsion (Claes et al 2014). I was surprised that surgeons were already turning towards reconstruction of this ligament.

Another cycle is the use of synthetic structures to augment or facilitate ligament healing. The use

of internal supports to re-tension the peeled off ACL was also topical. Akin to micro-fracture of a chondral lesion, the healing response of the ligament insertion has been talked about for some time although the literature has only recently focused on this area (Steadman et al 2012, Wasmaier et al 2013). An experienced Scottish surgeon told me of the advantages of this treatment with a shortened period of recovery due to the lack of sizable bone tunnel drilling or autograft harvest. Physiotherapists who had seen his patients had independently told me of the impressive results of patients treated using this technique, effectively an unpublished case series to date. I have been on the look out of a recently injured knee with a peel off avulsion, a good range of movement and muscle function but have yet to find one. Another wise soul in British Sports surgery had also reminded me about ACL healing. The distinction here being one of brace protection with controlled activity and then rehabilitation as opposed to proceeding directly to rehabilitation. This is level 5 evidence based upon lifelong qualitative observation.

We must be careful how to interpret results from studies of outcome data. Should the ACL be

reconstructed at all? Prospective randomized studies of non-operative treatment versus reconstruction following ACL injury show good function for those completing rehabilitation (Frobell et al 2010). Scientists however cannot state that this is an acceptable option given the significant cross over to the operative arm (Lubowitz & Poehling 2011). One step to determine the optimal treatment following injury is to change research from the comparison of samples to populations of patients. In a Danish population the use of hamstring graft was associated with increased risk of revision within the first year compared to bone-patellar tendon-bone autograft (Rahr-Wagner et al 2014). Fares Haddad and his team with the National Ligament Registry have been working hard to establish a database to determine practice and outcome within the United Kingdom.

ACL augmented repair could well be analogous to that of minimally invasive or percutaneous Achilles tendon repairs (Carmont et al 2011). In minimally invasive and arthroscopically/ultrasound assisted percutaneous Achilles repair the ends of the ruptured tendon are apposed and sutured together (Wang et al, Chiu et al 2013). Single suture failure and tendon pull out has been noted with initial tendon loads comparable to those sustained during early weight bearing (Ortiz et al 2012, Longo et al 2012). Tendon elongation, with variations in stiffness, occurs in the first 3 months following surgery, potentially providing biomechanical disadvantage following rehabilitation (Silbernagel et al 2013, Schepull et al 2014). The deficits of strength, power and endurance occur in the presence of increased muscular EMG activity (Suydam et al 2013).

Treatment should focus on optimization of outcome rather than reducing complications. From the patients perspective things may be different. One of my patients told me this week, that he was happy his surgical repair had lead to a relatively quick recovery compared to other patients he had read about on the internet. However he felt it had still taken a considerable period of time and he wanted to avoid re-tearing his Achilles at all costs due to the recovery time.

Controversy continues in the management of degenerative meniscal tears. Randomized controlled studies consider the presence of pre-existing degeneration of the articular surfaces (Katz et al 2014). In the absence of trauma there is little doubt that both pathologies are associated (Englund et al 2009). Recent editorials extol the improvements in patients receiving physiotherapy programmes (Risberg 2014). A 12 weeks individualized progressive physiotherapy programme with biweekly sessions, and modality treatment provided for the study is unlikely to be sustainable in the public sector. In the FIDELITY study, patients receiving partial meniscectomy and sham meniscectomy in symptomatic knees with degenerate tears and no osteoarthritis had good improvements (Sihvonen et al 2013). Both groups of patients improved following arthroscopy although there was no significant difference in outcome. Whilst this study was a well-performed RCT, the conclusions that meniscectomy offers no advantage over physiotherapy cannot be made from this work. Considerable comment has been made regarding these conclusions (McDonald 2013, Brophy 2014, Elattrache et al 2014, Hwang et al. 2014, Latterman et al 2014).

The spin on platelet rich plasma appears to be declining. RCTs are increasingly showing no convincing

evidence of improved outcome. The latest being for hamstring injury (Reurink et al 2014, de Vos 2014, Hamilton 2014), in addition to that for Achilles tendinopathy (de Jonge et al 2011). Comparison of PRP with dry needling for the treatment of patellar tendinopathy showed early significant improvement at 3 months but there was no difference at 26 weeks or later (Dragoo et al 2014). Proponents for PRP cite differences in preparation techniques as a cause for the lack of difference. Also the argument that surgeons do not wish to include patients in RCTs is frequently made. The ethical argument that they do not want to reduce their patients outcome by them being randomized to a control arm is valid. There is no potential risk to the use of PRP other than cost. This cost, in the absence of significantly proven benefit, may preclude the use of PRP in the public sector. RCTs showing no benefit may discourage insurance companies from paying for these treatments and if patients are self funded where do surgeons stand morally.

My final observation over the past few months relates to the pattern of publication. New developments are

usually heralded in the lay press, frequently relating to the successful return to play of sports stars. This also confers X factor to the highlighted surgeons. These methods of treatment are then embellished, with the assistance of industry, before case series are published in the orthopaedic literature. Appropriate conclusions from RCTs with positive results are then published in the orthopaedic literature. Recently high impact factor general medical journals have published papers with inaccurate conclusions made from apparently negative results. All surgeons have a duty to follow up our patients, learn from our experiences and share them with others through publication. For the benefit of our patients we need to question our treatments, through randomized studies, where possible. The process of peer review should enable our conclusions to be questioned before publication. British Sports Surgery is well respected at international meetings and we need to be critical of ourselves and our peer to optimize treatment for our patients.

Mike Carmont Past President

BOSTAA&Board&Mr&Simon&Roberts!President)Mr&Panos&Thomas!Vice)President)Mr&Mike&Carmont!Past)President))Prof&Deiary&Kader!Honorary)Secretary!!Prof&Fares&Haddad!Honorary)Treasurer!!Mr&Mike&Dobson!Academic)Secretary)Mr&Neil&Patel!Web)Master!!

The objectives of the association are to provide a forum for the presentation of basic research, advances in clinical practice and the results of surgical procedures pertaining to orthopaedic sports trauma and to improve the care offered by orthopaedic surgeons to sportsman/women

Thoughts of the outgoing President

Arthrex Traveling Fellowship

Board activities

Future events

New members

Research news

PAST&&Presidents&David&Dandy&&&& 1993,1995&&&&&Frank&Horan& 1995,1996&Jonathan&Noble&&& 1996,1997&&&Angus&Wallace&& 1997,1999&&John&Fairclough&&&& 1999,2001&&&&&&&&&Nicola&Maffulli& 2001,2004&&Steve&Bollen&&& 2004,2008&&&&&&&&&&&&&Roger&Hackney& 2008,2012&

Issue FIVE

SPORTS Medicine/Surgery In this issue >>>

Autumn 2014 NewsLetter…... BOSTAA Established 1993

BOSTAA session 1/10/2014 (14-17.30)

Contact us: deiary.kader@gmail.com www.bostaa.ac.uk

Interesting Sports Medicine publications

! The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction. K. Sri-Ram, L. J. Salmon, L. A. Pinczewski, J. P. Roe. Bone Joint J January 2013 95-B:59-64.

! The impact of platelet-rich plasma on the prevention of tunnel widening in anterior

cruciate ligament reconstruction using quadrupled autologous hamstring tendon: A randomised clinical trial. F. Mirzatolooei, M. T. Alamdari, H. R. Khalkhali. Bone Joint J January 2013 95-B:65-69.

! Proprioceptive changes in the contralateral knee joint following anterior cruciate

injury. J. Arockiaraj, R. J. Korula, A. T. Oommen, S. Devasahayam, S. Wankhar, S. Velkumar, P. M. Poonnoose. Bone Joint J February 2013 95-B:188-191.

! Pathology of the tendo Achillis: Do our genes contribute? W. J. Ribbans; M. Collins.

Bone Joint J March 2013 95-B:305-313.

! Non-invasive imaging of cartilage in early osteoarthritis. A. J. R. Palmer, C. P. Brown, E. G. McNally, A. J. Price, I. Tracey, P. Jezzard, A. J. Carr, S. Glyn-Jones. Bone Joint J June 2013 95-B:738-746.

! The role of osteoblasts in peri-prosthetic osteolysis. S. C. O'Neill, J. M. Queally, B. M.

Devitt, P. P. Doran, J. M. O'Byrne. Bone Joint J August 2013 95-B:1022-1026.

! Do intervertebral discs degenerate before they herniate, or after? P. Lama, C. L. Le Maitre, P. Dolan, J. F. Tarlton, I. J. Harding, M. A. Adams. Bone Joint J August 2013 95-B:1127-1133.

! Femoral head deformity and severity of acetabular dysplasia of the hip. K. Okano, K.

Yamaguchi, Y. Ninomiya, S. Matsubayashi, M. Osaki, K. Takahashi. Bone Joint J September 2013 95-B:1192-1196.

! The viability of cells obtained using the Reamer-Irrigator-Aspirator system and in

bone graft from the iliac crest. H. S. Uppal, B. E. Peterson, M. L. Misfeldt, G. J. Della Rocca, D. A. Volgas, Y. M. Murtha, J. P. Stannard, T. J. Choma, B. D. Crist. Bone Joint J September 2013 95-B:1269-1274

! Differences in the locations and modes of labral tearing between dysplastic hips and

those with femoroacetabular impingement. S. Tamura, T. Nishii, M. Takao, T. Sakai, H. Yoshikawa, N. Sugano. Bone Joint J October 2013 95-B:1320-1325.

! Radial extracorporeal shock-wave therapy in patients with chronic rotator cuff

tendinitis: A prospective randomised double-blind placebo-controlled multicentre trial. A. Kolk, K. G. Auw Yang, R. Tamminga, H. van der Hoeven. Bone Joint J November 2013 95-B:1521-1526.

New Members Neda Farbod, Jonathan Bird, Samer Kakish, Ziali Sivardeen, Sabur Malek, Peter Gallacher and Mahbub Alam.

" You can advertise any sport surgery course for free on BOSTAA website www.bostaa.ac.uk

View the minute of our AGM 2014 on the website !

BOSTAA assists to win the bid to stage the ESSKA 2018 Conference in Glasgow! In the beginning of February 2014, our president Mike Carmont was invited by BASK, BOA and VisitScotland to take part in a meeting with the visiting ESSKA Executive to Glasgow in a bid to secure staging the ESSKA Conference in 2018. The ESSKA Executive had already visited Istanbul, the other bidding city. I was selected to represent BOSTAA in this meeting, which took place on the 20th of February 2014. VisitScotland had arranged a reception at the Blythswood Hotel. Simon Donell, President of BASK, gave a welcome speech and highlighted the links between ESSKA and the British Orthopaedic Community.

Present at the meeting were: ESSKA Executive: Prof Joao Mendes (President), Prof Matteo Denti (current President) Prof Romain Seil (2nd Vice President), Prof Jacques Menetrey (Secretary) and Prof Niek Van Dijk (Past President). Local Representatives: Mr William Leach (Clinical Director T&O NHS Glasgow), Dr John McLean (CMO, The National Stadium and Commonwealth Games) and Mr Mark Blyth (Consultant T&O NHS Glasgow). BOA: Mr Mike Kimmons (CEO). BASK: Simon Donell (President). BOSTAA: Panos Thomas (Academic Secretary). VisitScotland: Aileen Crawford and team.

Later on, we were taken to the Glasgow City Chambers. The Lord Provost, Sadie Docherty, received us to a dinner. In her speech, she welcomed the party and provided information on the history of the Chambers and Glasgow in general. Prof Joao Mendes expressed the Executive gratitude for the hospitality and went on to highlight the Academic objectives of ESSKA. The evening was closed following a visit to the majestic Banqueting Suite, where Staff from the Chambers gaveus a tour in the history of the building and the wealth of the art paintings.

VisitScotland notified BOSTAA in May, that following the AGM, the ESSKA Executive took the decision to select Glasgow as the venue for the 2018 Conference. Aileen Crawford has thanked BOSTAA for its contribution. Panos Thomas!!

BOSTAA Scientific Presentations at EFORT and BASEM 2014

June 2014- Joint Instability: Rehabilitate, Repair Or Reconstruct Type: Speciality Society Session Auditorium: Berlin Society: EFOST/BOSTAA Date/Time: Wednesday - June 4, 2014 | 15:00 - 16:30 Moderator N Maffulli, M Carmont Rehabilitation In Return To Play Nigel Jones ATFL & CFL Acute Repair In The Athlete: Is There Role To Prevent Joint Instability? Gian Luigi Canata MPFL & Patella Instability Deiary Kader ACL Repair Is There A Role? Gernot Felmet Glenohumeral Instability Mike Dobson Treatment Of The Ankle Syndesmotic Injury: Bas Pijnenberg Labral Tears And Hip Instability Vikas Khanduja

BOSTAA/BASEM October 2014 Spine Session Chair: Mr Mike Carmont and Mr Panos Thomas Low back pain in the athlete Dr Eleanor Tillett MRI investigation of the spine Prof Frank Smith Rib and Chest Wall injuries Dr Ian Hunt Hip Arthroscopy: Lessons learned from the meniscus Professor Damian Griffin Elbow Session Chair: Dr Mike Carmont Medial tension injuries Mr Carlos Cobiella Posterolateral injuries Dr Rob Turner Elbow Epicondylitis Dr Kevin Baird Questions and Answers All Speakers

BOSTAA&Board&Mr&Simon&Roberts!President)Mr&Panos&Thomas!Vice)President)Mr&Mike&Carmont!Past)President))Prof&Deiary&Kader!Honorary)Secretary!!Prof&Fares&Haddad!Honorary)Treasurer!!Mr&Mike&Dobson!Academic)Secretary)Mr&Neil&Patel!Web)Master!!

The objectives of the association are to provide a forum for the presentation of basic research, advances in clinical practice and the results of surgical procedures pertaining to orthopaedic sports trauma and to improve the care offered by orthopaedic surgeons to sportsman/women

Thoughts of the outgoing President

Arthrex Traveling Fellowship

Board activities

Future events

New members

Research news

PAST&&Presidents&David!Dandy!!!! 1993,1995!!!!!Frank!Horan! 1995,1996!Jonathan!Noble!!! 1996,1997!!!Angus!Wallace!! 1997,1999!!John!Fairclough!!!! 1999,2001!!!!!!!!!Nicola!Maffulli! 2001,2004!!Steve!Bollen!!! 2004,2008!!!!!!!!!!!!!Roger!Hackney! 2008,2012!