Issue FIVE SPORTS Medicine/Surgery In this issue >>> Autumn 2014 NewsLetter…... BOSTAA Established 1993 Contact us: [email protected] 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patients had independently told me of the impressive results of patients treated using this technique, effectively an unpublished case series to date.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 PASTPresidents 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