I gave a talk a couple of weeks ago to the Warrnambool Sports Practitioner Group and the Warrnambool Trainers Group, talking about management of ACL injuries. There are lots of points of argument in this area, but I think that the focus has to be on two main questions: does everyone who ruptures their ACL need a reconstruction (no, only patients who have functional instability after a period of rehab, about 60% of cases), and what is the best graft (something biological such as hamstring tendons rather than something artificial like goretex or carbon fibre).

There was a lot of general discussion, and of particular interest is the question is prevention of injury.  Surely better than surgery! Below are a couple of resources that link to neuromuscular coordination training programmes that have been shown to reduce the risk of ACL injury, and which have the secondary benefits of improving balance strength and speed, which are surely of benefit to athletes?

If you are interested in reading further, I have attached the links to the original sites.  The world expert in the area is Lars Engebretsen, from Norway, who is the senior author of the International Olympic Committee statement linked below.

Hopefully our trainers will be able to incorporate these training methods into player preparation, particularly young athletes, and we can stem the tide of ACL injuries and reduce the need for surgery in the longer term.  Meantime, those with ACL injuries should not be bullied into having surgery or into having "the latest thing" in artificial grafts, but should sit down with a knowledgable and experienced surgeon who can discuss the balance of what is truly important to them.

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https://www.physio-network.com/acl-injury-prevention-better-cure/
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www.thelancet.com Published online November 20, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32457-1

​In summary:  3 study groups; physiotherapy only, shoulder arthroscopy, shoulder arthroscopy + acromioplasty.  Decent numbers, robust follow up.  Both surgical groups did better than physio alone, but no difference between arthroscopy and arthroscopy with acromioplasty. 
 
Just before Christmas, I was at the Geelong Orthopaedic Society annual meeting, and the guest speaker was Prof Andy Carr, from Oxford UK.  He was the lead researcher in this really important study, and my old boss in Aberdeen was on the steering committee.  We had the chance to discuss the process of the study as well as the results and the response to it.  He told us that in less than a week from publication, he had over 700 emails relating to the study, many of them pretty negative, some frankly abusive.
 
Nobody likes to be told that they are wrong, but the defence of acromioplasty has been predictably vigorous, and  largely predictable in its form – everything from “it works in my hands”, to post hoc justifications of why it must work and why this research must be wrong.
 
This is not entirely new. There was a paper comparing acromioplasty with subacromial bursectomy, from Finland nearly 10 years ago, that showed similar outcomes.  The response also mirrors that to the 2002 Moseley study that showed that knee arthroscopy was of no benefit in treatment of OA (see my previous post).
 
Ultimately, the treatment of shoulder impingement symptoms should focus upon a combination of subacromial steroid injections and good quality physiotherapy to get the cuff muscles working more normally.  If that fails, patients do seem to benefit from shoulder arthroscopy and bursectomy, but there is no additional benefit of acromioplasty.

Something a little more philosophical, but very relevant to patient safety.
 
I was very taken by this excellent, thoughtful article, published recently in the Journal of Bone and Joint Surgery, and have been discussing it with our surgical trainees at our weekly teaching session.  http://dx.doi.org/10.2106/JBJS.16.01287
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Briefly, the story is of an experienced surgeon who is operating in a new hospital doing a spinal case.  Prior to the start of surgery, after setup, the surgeon begins to inject what he thinks is local anaesthetic and dilute adrenaline into the area of the planned incision.  Due to a series of system errors, compounded by unfamiliarity of the team, he has been given concentrated adrenaline and the injection causes a crisis of high blood pressure that could have killed the patient.
 
Fortunately, high quality ICU care saved the patient, without any long term problems.
 
More importantly high quality personal skills, including honesty and humility on the part of the surgeon also saved the doctor-patient relationship, and the patient subsequently had the planned operation by the same surgeon some weeks later. 
 
The surgeon felt that he had learnt:

1. When giving medications, always check the original bottle, trust no-one else
2. When operating out of normal hospital, assume nothing and prepare thoroughly
3. Trust your instincts – if something does not feel right, question it until it does.
4. Honesty and humility in the face of complications are difficult but vital.

 
To which I would add that we should never be to old, too clever or too confident to realize that such incidents could happen to any of us and that patient safety is always our prime objective.
 
I strongly endorse the World Health Organisation Peri-Operative  Surgical Patient Check List in all surgical environments, and have been working with Mr Toma (plastic surgeon) and theatre management at South West Healthcare to improve our current procedures.  If you want to read more about the development of this key safety innovation, I would recommend the Checklist Manifesto by Atul Gawande (or his TED talk)  www.ted.com/talks/atul_gawande_how_do_we_heal_medicine

The recent newspaper and television publicity about PPS (Pentosan Polysulfate Sodium) is inevitably raising the discussion about treatment of arthritis.  But what is it? 

PPS has been shown, in a few papers, to be of some benefit in a specific form of virus-related arthritis, and is used by veterinary surgeons in treating horses and dogs with osteoarthritis (though by subcutaneous or intramuscular injection rather than into the joints).  There is no clear indication of how a drug previously used for treating blood clots and bladder complaints might help in osteoarthritis pain, but we have been introduced to patients who have had dramatic symptom improvements with PPS treatment.
 
Is it the end of joint replacements for osteoarthritis?
 
Best we look at the evidence to date.  All we have from the recent news is a so-far-unpublished case study, reported primarily by NewsCorp Health Reporter Sue Dunlevy  (http://www.heraldsun.com.au/lifestyle/health/a-breakthrough-treatment-for-osteoarthritis-could-delay-the-need-for-hip-and-knee-replacements/news-story/07b6142b4440b1d1316fcac066183c82 ).  Apparently there were 30 patients involved, getting 6 injections over 3 weeks, and 70% of the patients had significant reduction in arthritis pain.  The Herald Sun article continues “there has been no double-blind placebo controlled trial of the medicine”.   Which seems to ignore a 1996 abstract publication (Footnote 1), but does at least note that evidence is incomplete.
 
There is, according to the same newspaper article, a planned Phase 2 (Footnote 2) trial shortly to start.  
 
What about the individual patient that we saw on the news, walking with her horse? 

We know nothing about the lady’s xrays and the severity of her OA; we know nothing about whether the decision to offer a knee replacement, which she apparently now no longer needs, was reasonable.  But she says that the injections cured her, so there must be something in it?
 
Here, we need to go back in time a little to the famous Moseley trial, published in NEJM in 2002 (http://www.nejm.org/doi/full/10.1056/NEJMoa013259#t=article).  In this study, patients with knee OA were randomized to arthroscopic surgery (washout or active debridement) or placebo surgery, and to cut it short there was no difference between the groups.  There is a very good full hour documentary “Placebo: cracking the code” (https://www.youtube.com/watch?v=QvbQnMvhQFw  and a shorter clip from a BBC documentary on placebos https://www.youtube.com/watch?v=HqGSeFOUsLI ).  In both of these films patients from the Moseley study were interviewed, describing the improvement in their knee pain.  Would you be surprised to hear that these patients were in the placebo arm, and had no surgery beyond having minor cuts in the skin to mimic the arthroscopic surgery? 
 
The Moseley study, and subsequent studies, have led to a marked reduction in the number of arthroscopic knee operations across the world.
 
What does this mean for patients now?

Of course this is all complex, and it is not easy to deal with the individual  with knee pain who wants to try PPS, because it "helped a person on the TV news".  And of course the placebo effect is still an effect.  Nevertheless, we need to be both scientific and honest with patients:  PPS might work, but there is as yet no real proof that it does, and we should await proper randomized, placebo-controlled trials before promising them relief from their pain by a miracle injection.  There is still much else that we can do to help without rushing to surgery, which is the last resort.


But I won’t be giving up joint replacement surgery just yet.
 
 
 

 
Footnote 1: 
The earliest human use of PPS that I could find was an abstract published in 1996 by the same Dr Ghosh who was in the news this week ( Rasaratnam, I; Ryan, P; Bowman, L; Smith, M; Ghosh, P (1996). "A double-blind placebo-controlled study of intra-articular pentosan polysulphate (Cartrophen) in patients with gonarthritis: laboratory and clinical findings". Osteoarthritis Cartilage. 4: vi-vii. doi:10.1016/s1063-4584(96)80025-2. ).  Abstracts published in this form represent summaries of papers presented at conferences, and are not subject to the same peer review scrutiny as full papers.  When studies presented as abstracts don’t subsequently appear as full papers, you do wonder if that was because they did not withstand the peer review process.
 
Footnote 2:
We are told that there will be a Phase 2 study about the start, which sounds impressive.  It suggests that the process had passed the first hurdle and is moving on to more important testing.  In fact, Phase 2 studies are for formal testing of efficacy - does it have an effect?  For Phase 2 studies, the drug is not yet presumed to have any therapeutic effect https://en.wikipedia.org/wiki/Phases_of_clinical_research ).