Lateral ankle ligament surgeryMr Ioan Tudur Jones

In this issue:

ACL Reconstruction in Footballers Mr Andy Williams

What footballers teach you!

Mr Simon Ball

The Fortius Clinic Lecture Series - September 2015 Issue

To keep up to date with Fortius news, follow us on twitter @FortiusClinicUK or like us on Facebook.Alternatively, check our news & events page on the website www.fortiusclinic.com.

Football Crazy

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We had another full room for September’s lecture on the theme of Football, which was a popular subject and was also

likely to be the last chance for football talk before the Rugby World Cup kicked off and took over the conversation.

Our speakers for the evening were Mr Andy Williams and Mr Simon Ball, Consultant Knee surgeons and Mr Ioan Tudur-Jones, Consultant foot and ankle surgeon.

Mr Williams spoke on ACL Reconstruction in Footballers – starting with the explanation that an ACL rupture is a rare injury in a first team player, compared to academy level, as a predisposition to ACL rupture is identified when the players are relatively young and tear the ligament. He also spoke about the emotional impact that an ACL tear has on a professional footballer

Mr Ball spoke on the topic “What Footballers Teach You” and how the team at Fortius applies the knowledge and experience gained while treating professional footballers and other elite athletes, to provide a better standard of care for all our patients. Elite footballers are under constant pressure to perform consistently at the peak of their ability, and if injured, they need a solution that enables an optimal return to play with low risk of re-injury. A well thought out individualised treatment program is key.

Mr Tudur Jones spoke about the difference in how we manage elite athletes compared to the general population. He looked at challenging Grade 3 ATFL and

CFL injuries, where there has been a complete rupture, to see what we learn from the treatment of athletes such as professional footballers, and when to consider Lateral ankle ligament surgery.

In their talks, the team all touched on the pressures an injury places on a professional footballer and how much an injury affects the individual. They emphasised how crucial it is that the surgery and post-surgical procedures are done carefully and properly, keeping the patient in as long as possible and then the importance of an aggressive rehab process.

The topic of our November lecture is the MSK Cocktail, with lectures from Mr Andy Roche, Consultant Orthopaedic Foot and Ankle Surgeon, Mr Jason Harvey , Consultant Spinal Surgeon and Professor Cathy Speed

, Consultant in Rheumatology, Sport & Exercise Medicine.

Please send any enquiries through to me, details above as I’ll now be taking on responsibility for the lecture series. Thank you to everyone for their feedback to date, which we really appreciate, please

do keep those comments coming through about what does or doesn’t work for you and what topics you’d like covered. You’ll be seeing some changes coming through as we continue to evolve the programme.

We look forward to seeing you at the next lecture.

For more information please visit the FISIC website: www.fisic.co.uk or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists and Sports & Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.

Sophie Whitby, Marketing Assistant e: Sophie.Whitby@fortiusclinic.com t: 0203 195 3043.

SEPTEMBER TOPIC: Football Crazy

Don’t forget to follow us on Twitter @FortiusClinicUK. You will also find us on Facebook and LinkedIn.

More than 650 delegates and speakers attended FISIC ’15, gathering to review the latest thinking and best practice in performance sports injury treatment and management of return to play for athletes.

The programme attracted a multi disciplinary audience of orthopaedic surgeons, sports physicians, physiotherapists and other sports and exercise professionals. It offered a unique opportunity to hear leading experts with international reputations, who presented and debated as cross-disciplinary panels.

Amongst the delegates were 70 members of World Rugby’s top medical teams who came to debate and learn more on the current medical issues and hot topics within their sport from concussion, to management of return to play.

The event was timed to coincide with a brief interlude in play before the Quarter Finals, and gave team medical personnel a unique opportunity to participate in a world-class, multidisciplinary congress. As well as rugby relevant subjects, the varied programme covered a wide range of topics, including joint specific sessions with more technical content, overviews of more specialist areas such as disability sport or the adolescent athlete, presentations of the latest science on muscle injuries & repair, bone health and cell therapies, and debates on the merits of PRP injections. Running alongside the main sports injury conference, was a specific GP programme covering MSK conditions and injuries commonly seen in a regular GP practice, by recreational athletes as well as inactive individuals.

Videos and Newsletters available online! www.fortiusclinic.com

> news-events > lecture-series

THANK YOU TO EVERYONE WHO ATTENDED THE FORTIUS INTERNATIONAL SPORTS INJURY CONFERENCE AT THE QEII CENTRE ON 13TH AND 14TH OCTOBER, WHICH WAS OUR FIRST MAJOR CONFERENCE AND SEEMED TO BE A GREAT SUCCESS.

If you attended, we’d love to have your feedback, receive photos, or hear suggestions for how we could improve. Plans are already underway for the next conference in 2017 – so watch this space!

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FEATURE | ACL RECONSTRUCTION IN FOOTBALLERSLecture by Mr Andy WilliamsConsultant Orthopaedic Knee Surgeon

Half the ACL operations I carry out are on professional athletes and I have learnt a lot from treating them. Professional athletes, footballers in particular, will test your judgement and your surgery to the limit, because of the enormous pressure they are under to return quickly to play, and the amazing things they have to do in play.

ACL rupture is a rare injury in a first team player. Usually a predisposition to ACL rupture is identified when the players are relatively young and tear the ligament. It is really ‘natural selection in action’- their knees can’t cope with the necessary loading. They often re-rupture after ACL reconstruction. And they will not make it to the top level even after successful surgery. If you get a professional footballer with a fresh ACL tear in the clinic, they are deeply affected by the injury. They are often sad, scared and suspicious. Missing their sport to have an operation is like bereavement. They maybe wary of a surgeon they don’t know.At the first consultation, you must be properly prepared, to create an atmosphere of competence and confidence. Research when the patient’s contract ends and what major tournaments are imminent. Know when you can operate. Don’t hide bad news, but present it in an honest, positive way. Don’t exaggerate. Tell them that return to play will probably be between six and nine months, but that the chances of returning to top level sport are high. It is essential that the player believes in you and respects you, and this has to be earned and quickly.With regard to the general population with ACL tears a decision between surgery and non-surgical treatment must be made. Of course a bad operation is generally worse than no operation. But for a professional footballer with an ACL problem, it is essential that they have a stable knee to perform at their peak. There is no place for non-surgical treatment of ACL ruptures in these athletes.Timing is important and here, nature rules. If the knee is angry and inflamed, it may never come straight after surgery, so waiting until the knee has settled, and has full active extension, is crucial.For most ACL reconstructions in the general population I use a hamstring graft. The hamstring is best for patients who are still growing, as they can’t have bone blocks across the growth plate. The hamstring graft is also best for athletes playing sports, which feature lots of jumping, like netball, as harvest of this graft avoids damaging the extensor mechanism. It is preferable for sports, which involve lots of kneeling, like judo. However, I use a patellar tendon graft for footballers. They have half the re-rupture rate with this tendon compared to results using a hamstring graft in my experience.

A footballer with a second rupture, and a second season missed, is looking at the end of their career. But, patellar tendon surgery comes with an increased incidence of anterior knee pain and involves a slightly more technically demanding harvest procedure. But as it’s a more rigid graft than a hamstring, it’s better for footballers, and for other patients with significant MCL laxity, or generally very loose.Patellar tendon ACL surgery has improved enormously in the last twenty years. Nowadays the surgeon effectively lifts the graft off the fat pad and proceeds to an arthroscopic procedure to implant the graft. We don’t use chisels any more, we don’t cut out the fat pad, we don’t wrap them in plaster for weeks. We get the patient and their patella mobile.The post-operative process is hugely important. The patient needs to be able to move the limb as soon as they wake up, and this depends on the skill of the anaesthetist understanding and managing their pain relief,

and use of gentle surgical technique, high quality equipment (especially saws) and infiltration of local anaesthetic. Don’t let the an athlete go home quickly, take your time- gain control of the situation. With correct supervision and pain relief, they can start passive work, stretches, prone hangs, and

most importantly active isometric quads contraction, as soon as possible. After restoration of full active extension as soon as possible, swelling is the biggest concern. Don’t let players return to play too early to minimise the risk of re-rupture.The whole treatment of ACL rupture is a joint project between surgeon, sports physician, and physiotherapist. The surgeon shouldn’t dump the patient on the physio and forget about him. They should be involved, know what’s going on, throughout the treatment. We need to trust each other, to be in complete accord about process and progress, particularly when dealing with pressure from the player, their advisory team and coaching / administration staff at a club. Following rehab, the player must be fit, they must trust their knee completely, there should be no swelling and they have to be strong, before they return to play. The player should feel able to twist and turn equally on both knees, with perfect symmetry. Then they are ready to do their magic once more.

“The whole treatment of ACL rupture is a joint project

between surgeon, sports physician, and physiotherapist.”

Mr Andy WilliamsConsultant Orthopaedic Knee SurgeonConsultant knee surgeon with particular expertise in soft tissue knee surgery and sports-related knee injuries.

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Whilst footballers stand in varus they exhibit dynamic valgus when playing as the weave from side to side. As a result they overload the lateral compartment, which leads to degeneration of the lateral meniscus, leaving them at risk of a lateral meniscal tear. In essence footballers are “living wear simulators”. They show, in a relatively short period of time, what will happen to the general population over many years following certain injuries.A partial lateral meniscectomy can be the beginning of the end for elite footballers as it often leads to repeated arthroscopies, chondral damage and lateral compartment osteoarthritis. This is one of the commonest reasons for early retirement from professional football.This experience teaches us the importance of the lateral meniscus and how important it is to save the meniscus.

Even when faced with a complete radial tear of the lateral meniscus one should attempt to salvage the meniscus as loss of the meniscus will lead to rapid onset of osteoarthritis.

3. The unusual MCL injuryMCL injury is common and healing is normally reliable and predictable. However, a small subgroup of patients will continue to be symptomatic with persistent pain, especially when “bending the ball” by striking it with the

inside of the foot. This may be due to an unhealed injury to the deep proximal MCL. On examination, tenderness may be felt just superior to the joint line at the femoral attachment of the deep proximal MCL. Valgus stress test is often normal with no pain on stressing and no increased laxity. Pain is re-created with rapid external rotation at 30 degrees of flexion.The first line of treatment should be non-operative with appropriate bracing and injection therapy to enable healing to take place. If non-operative treatment fails surgery may be required. This involves identifying the unhealed deep proximal MCL and re-attaching it using bone anchors. During closure the superficial MCL is re-tensioned.

Post-surgery the patient will be non-weight-bearing for two weeks in a brace 30-60; then partial weight-bearing with a brace 10-90 for two weeks; followed by full weight-bearing in a brace with full range for a further two weeks. They then start strength, balance and conditioning work, with a return to training at 12-16 weeks. Our results demonstrate a 100% return to sport with no on-going symptoms (mean follow up 48 weeks).

FEATURE | WHAT FOOTBALLERS TEACH YOU!

Elite footballers are under constant pressure to perform consistently at the peak of their ability. There is no let-up. If injured, they need a solution that enables an optimal return to play with low risk of re-injury. These athletes, as well as all patients, require a well thought out individualised treatment program.There are many lessons to be learnt but I will touch on 3 topics as follows:

1. ConditioningConditioning is crucial. Elite athletes have excellent trunk and pelvic stability and superb neuromuscular control of the knee. This reduces the risk of injury but also enable them to cope with minor damage to the knee. During a pre-signing medical it is not uncommon for there to be minor changes on the MRI scan of the knee but the payer will often be asymptomatic, playing regularly at the highest level with no pain or swelling.

2. The Lateral MeniscusThe lateral side of the knee is very vulnerable. In layman’s terms it may be thought of as a “ball on ball” joint with the meniscus playing a very important role in load sharing. If the meniscus is removed, the force is concentrated over a smaller surface area, which results in an increased rate of degeneration. The medial side of the knee is less problematic. Our data shows that the average return to play following medial meniscectomy in elite footballers is five weeks. About 13% had some pain or swelling after the operation but no players needed repeat surgery or injections. The lateral side of the knee is much more unpredictable. The average return to play following lateral meniscectomy is 7.8 weeks, with pain and swelling in 70% of cases and 10% requiring a second arthroscopy.

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ALBERT EINSTEIN ONCE SAID: “THE ONLY SOURCE OF KNOWLEDGE

IS EXPERIENCE.”

Mr Simon Ball Consultant Orthopaedic Surgeon Mr Ball specialises in all aspects of knee surgery

Lecture by Mr Simon BallConsultant Orthopaedic Surgeon

AT FORTIUS, THE KNOWLEDGE AND EXPERIENCE WE GAIN TREATING PROFESSIONAL FOOTBALLERS AND OTHER ELITE ATHLETES, ENABLES US TO PROVIDE A BETTER STANDARD OF CARE FOR ALL OUR PATIENTS.

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FEATURE | LATERAL ANKLE LIGAMENT SURGERY – WHEN?

I’m going to look at atfl and cfl injuries, the challenging grade 3 ones, where there has been a complete rupture, to see what we learn from the treatment of athletes such as professional footballers.As the late Spanish anatomist Pau Golano said: “Diagnosis and therapy starts with knowledge of anatomy.” The anatomy is key both to making your diagnosis and to your treatment of these lateral ligament injuries.The ATFL is a small structure – it’s only 1 or 2 mm thick, about 5 mm wide and 2 cm long. The CFL ligament on the other hand is the size of an adult finger, tubular and thick. The ATFL is lax in ankle dorsiflexion but tight in plantar flexion, which is where ATFL tears happen. Conversely, the CFL gets injured in dorsiflexion. The CFL is in charge in the coronal plane, side to side, whereas the ATFL controls the sagittal plane which moves to and fro, it controls the talus moving in and out of the ankle mortise, so that it subluxes out at the front.Ankle sprains can take an athlete out of their sport for quite a while. They’re painful and there is significant joint instability. The biggest risk factor is a previous sprain. So should we be managing sprains in a different way?Two recent surveys of Australian high school athletes and young Japanese men both show that for Grade 3 ankle injuries, surgical patients return to sport more quickly, in an average of 10 weeks, compared to 16 weeks for those who have had functional bracing. Similarly, re-injury rates are far fewer in the surgical group, 7% to 39% in the Australian study and 0% to 10% in the Japanese study, with results in Japan taken at a two year follow-up. However, advice to the general public is that even the most serious ankle sprains are best treated with functional bracing. We need to assess whether this is accurate.

The gains achieved by surgery may seem slight, but when treating elite athletes and their ankle injuries, I think we could take our lead from Sir David Brailsford, general manager of Team Sky and formerly performance director of British Cycling. He pioneered the concept of marginal gains, the little things which make a difference to success, whether it’s bringing a chef on the Tour de France or providing great pillows for the cyclists to ensure a good night’s sleep. So how do I make my diagnosis and how do I decide on treatment?Examination is key. I look for patterns of injury, I feel for subluxation and I compare the injured side with its opposite. The anatomy is central to my diagnosis.History is next. I find out about previous instability. I listen to the patient’s expectations – have other members of the team had successful surgical repair and is this what s/he wants? I consider the timing of the injury within the season. If I operate, will this athlete be able to return to the team for a substantial part of the season?MRI is third on my list because there is often disagreement among radiologists as to what is broken, or partially torn, or completely torn for example. But MRIs are useful, and influential, when there is a multiple ligament injury.I assess each case individually and will operate if the ankle is highly unstable, with a history of instability, if the patient and club want me to operate and if there are at least two ligament injuries on an MRI. Following surgery, strong, functional rehab is crucial. My recommendation would be two weeks in a cast, then two weeks in an Aircast boot working on dorsiflexion and peroneal function, followed by an A60 type brace.

ANKLE SPRAINS ARE COMMONPLACE. TREATMENT IS USUALLY EITHER FUNCTIONAL BRACING OR SURGERY. BUT THERE SEEMS TO BE A DIFFERENCE IN HOW WE MANAGE ELITE ATHLETES COMPARED TO THE GENERAL POPULATION.

Mr Ioan Tudur Jones Orthopaedic Foot and Ankle Surgeon

Consultant Orthopaedic surgeon with a specialist interest in sport and dance injury, ankle replacement and joint sparing deformity correction.

At Fortius we have completed a two year review of 22 Grade 3 ATFL or CFL ruptures treated surgically. The patients returned to play typically at ten weeks. Two years later, we have had no injury recurrence. Fortius has a low complication rate and three months after surgery, with a full rehab programme, the result is a high degree of stability and a return to sport. In conclusion, these results suggest that we should adopt a surgical approach in a greater number of Grade 3 ankle injuries, not only to achieve those marginal gains pioneered by David Brailsford, but also to improve results and reduce re-occurrence in the general population as well.

Lecture by Ioan Tudur Jones Consultant Orthopaedic Foot and Ankle Surgeon

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For further information or to book an appointment, please contact us:

t: +44 (0) 203 195 2442 f: 0203 070 0106 e: appointments@fortiusclinic.comw: www.fortiusclinic.com

How to find us:Fortius Clinic is situated in Central London, close to Selfridges, and just off Manchester Square.

17 Fitzhardinge Street London W1H 6EQ

Don’t forget to follow us on Twitter @FortiusClinicUK. You will also find us on Facebook and LinkedInTo be added to the attendance list please email: marketing@fortiusclinic.com

MSK COCKTAIL

Mr Andy RocheConsultant Orthopaedic Foot and Ankle Surgeon

Mr Jason HarveyConsultant Spinal Surgeon

Professor Cathy SpeedConsultant in Rheumatology, Sport & Exercise Medicine

NOVEMBER LECTURE: