Chester Knee Clinic News 2008

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Introduction

We have been very busy fixing knees and have taken some time to put this page together. We felt that a dynamic space for news and updates on our clinical, research and other activities was needed. We have added a few Sport Knee Injuries pages, starting with Cycling and will continue to add more content, pages and space for updates on management of sports knee injuries, rehabilitation and injury prevention. The Skiing and Snowboarding Knee Injury page is online now, from 16 October 2008, although we are still working on a few sections.

We are also updating our Articular Cartilage Repair page, which has grown into a textbook-type website of its own (www.cartilage.org.uk). We hope that it will be completed early next year. Watch this space.

This year was exceptionally good for skiing and snowboarding, and we enjoyed plenty of new snow in Sun Valley in February and Engelberg in March. We are still in one piece and quite happy with our knees (some more than others ... and not to mention a few stiff shoulders!).

Latest News

updated on 12 December 2008

AAOS Adopts Clinical Practice Guideline on Treatment of Knee Osteoarthritis (OA)

12 December 2008, AAOS Headline News Now

American Academy of Orthopaedic Surgeons (AAOS) has released an evidence-based clinical practice guideline regarding treatment of osteoarthritis (OA) of the knee. The guideline, which was adopted by the AAOS Board of Directors at its December meeting, specifically focuses on treatments that are less invasive than arthroplasty. The guideline includes the following recommendations:

• Not performing an arthroscopic lavage if a patient displays only symptoms of osteoarthritis with no other problems
• Encouraging patients with symptomatic OA of the knee, who are overweight (as defined by a Body Mass Index > 25), to lose a minimum of 5 percent of body weight and maintain their weight at a lower level with an appropriate program of dietary modification and exercis
• Providing intra-articular corticosteroids for short-term pain relief for patients with symptomatic OA of the knee

Furthermore, the guideline recommends against the following treatments:

• Glucosamine and/or chondroitin sulfate or hydrochloride
• Needle lavage
• Custom-made foot orthotics

Read the complete guideline (pdf download) ...

ACL Reconstruction in Patients over 50

3 November 2008, AAOS Headline News Now

According to the results of a study published in the November issue of the Journal of Bone and Joint Surgery (British volume), reconstruction of the anterior cruciate ligament (ACL) in carefully selected patients aged 50 years or over can achieve results similar to those in younger patients, with no increased risk of complications. The research team reviewed the records of 34 patients aged 50 years or over who underwent primary ACL reconstruction (35 knees) between 1990 and 2002. Overall, 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The authors noted postsurgery improvements in mean knee extension and flexion, Lachman grade, International Knee Documentation Committee (IKDC) scores, and Lysholm scores. Three graft failures (8.6 percent) required revision. Source: D. L. Dahm, MD, et al.: Reconstruction of the anterior cruciate ligament in patients over 50 years. Journal of Bone and Joint Surgery - British Volume, November 2008, Vol 90-B, Issue 11, 1446-1450.

Complications After ACI Knee Surgery

1 November 2008, AJSM

Dr Philipp Niemeyer and collaborators analysed a total of 309 consecutive patients with 349 ACI procedures of the knee joint. Three different ACI techniques were used: Periosteum-covered ACI in 52 cases (14.9%), ChondroGide (Geistlich Biomaterials, Wolhusen, Switzerland) membrane-covered ACI in 215 cases (61.6%), and a 3-dimensional matrix-associated ACI (BioSeed-C, Biotissue Technologies, Freiburg, Germany) in 82 cases (23.5%). In 52 patients, revision surgery was performed for persistent clinical problems. These patients were analyzed for defect size and location, technique of ACI, and intraoperative findings during revision surgery. The mean time of follow-up for patients after ACI was 4.5 years.

Four typical major complications were identified: hypertrophy of the transplant, disturbed fusion of the regenerative cartilage and the healthy surrounding cartilage, insufficient regenerative cartilage, and delamination. These diagnoses covered a total of 88.5% of the patients who underwent revision surgery. The overall complication rate was highest in the group of patients treated with periosteum-covered ACI. The incidence of symptomatic hypertrophy was 5.2% for all techniques and defect locations; the highest incidence was in patients treated with periosteum-covered ACI (15.4%). The incidence of disturbed fusion was highest in the ChondroGide-covered ACI (3.7%) and the matrix-associated ACI group (4.8%). Concerning the incidence of complications by defect location, there was a tendency for increased complications in patellar defects. Within the patellar defects group, no correlation was found for the occurrence of delamination, insufficient regeneration, and disturbed fusion. As a statistical trend, an increased rate of hypertrophy was found for patellar defects. Source: Philipp Niemeyer, MD, et al.: Characteristic Complications After Autologous Chondrocyte Implantation for Cartilage Defects of the Knee Joint. The American Journal of Sports Medicine 36:2091-2099 (2008).

CKC Seminar on Skiing & Snowboarding Injuries

Chester, 23 October 2008. Programme

We held our second Educational Seminar this year at the Grosvenor Hospital in Chester on 23 October. Places on the seminar were fully booked: it was attended by 40 enthusiastic GPs and Physiotherapists. This was the first seminar on Skiing and Snowboarding Injuries ever held at the Grosvenor Hospital in Chester and following its success, we are looking forward to holding more Educational Seminars in the future.

The Skiing and Snowboarding Injuries seminar was focused on injury prevention, as well as early diagnosis and treatment, in preparation for the upcoming skiing and snowboarding season. Following each talk, which was given by an experienced sub-specialist, there was plenty of time to discuss the subject of the talk and ask questions. The speakers were:

• Mr Vladimir Bobic, Consultant Orthopaedic Knee Surgeon, The Grosvenor Hospital Chester
• Mr Nick Geary, Consultant Orthopaedic Foot and Ankle Surgeon, The Grosvenor Hospital Chester
• Mr Ian Harvey, Consultant Orthopaedic and Hand Surgeon, The Grosvenor Hospital Chester
• Adam Jowett, Manager, Snow + Rock Wirral (www.snowandrock.com)
• Dr Mike Langran, GP, Aviemore Medical Practice (www.ski-injury.com)
• Dr David Ritchie, Consultant Musculoskeletal Radiologist, Glasgow

During the evening, we demonstrated and discussed new ski equipment and discussed how to choose and fit individual components. All speakers emphasised the importance of wearing a helmet while skiing and snowboarding. A team from Ossur UK also exhibited a range of knee braces and supports.

We would like to thank everyone who attended the seminar, as well as our speakers for sharing their wealth of knowledge with us and for their excellent presentations. We are particularly grateful to our guest speakers from Scotland, Dr Mike Langran from Aviemore and Dr David Ritchie from Glasgow, who travelled such a long way to Chester and back, all in one day.

Study Casts Doubt on Glucosamine and Chondroitin for Knee Osteoarthritis.

1 October 2008, AAOS Headline News Now.

A study published in the October issue of the journal Arthritis and Rheumatism finds that glucosamine and chondroitin sulfate (OA) may have little effect in slowing loss of cartilage in osteoarthritis of the knee. Researchers conducted a 24-month, double-blind, placebo-controlled study across 9 sites and covering 572 patients with knee OA who satisfied radiographic criteria. Patients were randomized to one of five groups: glucosamine 500 mg 3 times daily, CS 400 mg 3 times daily, the combination of glucosamine and CS, celecoxib 200 mg daily, or placebo. At two-year follow-up, no statistically significant difference in mean joint space width (JSW) loss was observed in any treatment group compared with the placebo group. Treatment effects on Kellgren/Lawrence (K/L) grade 2 knees, but not on K/L grade 3 knees, showed a trend toward improvement relative to the placebo group. The authors state that the power of the study was diminished by a limited sample size, variance of JSW measurement, and a smaller than expected loss in JSW in the placebo group. Read more...

Other CKC News

10 Bridge Clinic

Chester Knee Clinic has established a working relationship with the newly founded physiotherapy and rehabilitation clinic at 10 Bridge Health and Wellness Centre in Bridge Trafford. The team is led by Mark Browes, Chartered Physiotherapist, whose main interest is the sporting knee. He worked as the physiotherapist for Queens Park Rangers football club, followed by a long period with the first team at Liverpool FC. He set up 10 Bridge Health and Wellness Centre with Newcastle and England player Michael Owen and Chester City player Reggie Partridge.

This new relationship will provide Chester Knee Clinic patients with sub-specialised physiotherapy and sport-specific rehabilitation programmes, with a focus on good three-way communication throughout the process. The clinic features a state of the art Technogym rehabilitation suite for pre- and post-operative rehabilitation work, following Chester Knee Clinic's postoperative protocols. Mark Browes and Vladimir Bobic will continue to work closely and provide individually tailored physiotherapy programmes for Chester Knee Clinic patients.

News From the Nuffield Health: The Grosvenor Hospital Chester

Major refurbishment completed

The Grosvenor Hospital Chester has undergone a major exterior and interior refurbishment. The reception area, most rooms, physiotherapy department and theatres have been improved and upgraded, and a new dedicated meeting and conference room added. Simon Shepherd, Hospital Manager, and his team have done an excellent job, under rather difficult circumstances. We managed to maintain all of our normal activities through a long period of renovating the hospital.

A new MRI Scanner

We have a new service for MR imaging at The Grosvenor Hospital Chester, provided by Nuffield Diagnostics , and a brand new mobile GE 1,5T scanner. The unit is available for MR imaging on Mondays, Tuesdays and Fridays. We have maintained the same quality of knee MR imaging, and sub-specialist expertise with an emphasis on articular cartilage and subchondral imaging. We store all MR images on a dedicated secure server and continue to provide CKC patients with an MRI CD with a complete set of DICOM images. We no longer print MRI films. Our web-based Kodak MRI teleradiology system, now 4 years old, will be replaced soon with a PACS system which is already in place. A fixed MRI unit is expected on site in the not too distant future.

To download a brochure on MR imaging click on: About Your Scan

Dr David Ritchie

Dave continues to work with us from his base in Glasgow as our principal Consultant Musculoskeletal Radiologist thanks to a web link to our MRI teleradiology system.

Joanna Rosedale

Jo, our wonderful Secretary since 1999, left Chester Knee Clinic last year. She now works as a Secretary for a Paediatric Consultant at The The Grosvenor Hospital Chester. We are very grateful for all her help over the years and wish her all the best.

New CKC Staff Members

We would like to introduce two new members of the CKC team, since September 2007. Bojana is our indispensable and efficient Medical Director and Practice Manager, and Marta works part-time remotely from London as our typist, proof reader and web content editor.

SOCRATES Software

SOCRATES is a standardised automated data collection system to allow Orthopaedic Surgeons to monitor and assess the outcomes for patients undergoing surgical joint reconstruction procedures. It stands for Standardised Orthopaedic Cartilage Repair And Treatment Evaluation Software.

The Socrates program, developed in conjunction with and exclusively distributed by the ICRS. It is primarily focused on cartilage repair procedures to the knee but information on other joints can also be included. Surgeons with even small numbers of patients can use Socrates to contribute to a combined and potentially global dataset. Its widespread use will result in more empirically founded publications on new procedures, early detection of complications, and allow all surgeons to participate in studies. Ultimately, this will lead to verifiably improved outcomes for patients undergoing joint surgery.

In 2007 we were trained by Robyn Kildey, Socrates Project Coordinator, who visited us here in Chester. Earlier this year we updated the software to Version 2.10 and have started to use it for data collection in all cartilage repair procedures.

We are grateful to TiGenix for providing us with a copy of this valuable and expensive software, used to record and analyse data for our ChondroCelect patients.

TiGenix ChondroCelect CCI (ACI)

On 9th January 2008, we were informed that following the GMP inspection of TiGenix Cell Expansion Facility the company was requested to strictly adhere to the product specifications on the regulatory file, which includes the European Compassionate Use program. Dr Micheline Wille, TiGenix Medical Affairs Manager, stated that the implication of this for CKC ACI patients is that the indications for TiGenix ChondroCelect cartilage repair are limited to femoral condyles only (we can no longer treat patella and tibial chondral and osteochondral defects), and to the age limit from 18 to 50 years. In addition, in the case of a negative ChodroCelect score the product will not be released for implantation. We will continue with femoral ACI surgery but patellar and tibial chondral lesions will have to wait for the commercial release of this product, planned for February 2009.

For more information on TiGenix ChondroCelect CCI (Characterized Chondrocyte Implantation) cartilage repair technology visit TiGenix website.

• For more information on short-term outcomes of ChondroCelect CCI surgery read the following article: Saris DBF, et al.: Characterized Chondrocyte Implantation Results in Better Structural Repair When Treating Symptomatic Cartilage Defects of the Knee in a Randomized Controlled Trial Versus Microfracture. Am. J. Sports Med., Feb 2008; 36: 235 - 246. Article summary: one year after treatment, characterized chondrocyte implantation (CCI) was associated with a tissue regenerate that was superior to that after microfracture. Short-term clinical outcome was similar for both treatments. The superior structural outcome may result in improved long-term clinical benefit with characterized chondrocyte implantation. Long-term follow-up is needed to confirm these findings.

New Hospital Name: Spire Cheshire Hospital (SCH)

Spire Healthcare has acquired BUPA North Cheshire Hospital, now renamed to Spire Cheshire Hospital. The private group of Spire hospitals is owned by leading private equity firm Cinven. The hospital is set in secluded grounds and located on the A49, in Stretton, just off junction 10 of the M56 motorway. It remains under the successful management of Alison da Silva and her team. Chester Knee Clinic will continue to run clinics from 9 to 12 on Thursday mornings.

2008 Orthopaedic News

New Meniscal Repair Device

Meniscal tears are difficult to repair successfully. Most of the adult meniscus is avascular, meaning that it does not have a good blood supply and therefore does not heal well. Because two-thirds of the meniscus is avascular, a tear in that region will not repair itself. Surgeons call this portion of the meniscus the "white zone." The "red zone" of the meniscus is well vascularized tissue which can be repaired in certain situations.

However, the new meniscal repair device, called the BioDuct, will transport blood and cells from the vascular portion of the knee to the avascular portion of the meniscus. Supplied with blood and cells for healing, the previously untreatable meniscal tear now has the potential to heal and protect the joint over a sustained period of time. Currently, there is no other device on the market that can provide improved fixation over time. The use of BioDuct has been approved by the FDA for human use. For more information click on University of Missouri News Bureau Press Release. This exciting new product was developed by Schwartz Biomedical LLC and it will be marketed internationally by Stryker Corporation. Mr Bobic participated in designing the clinical concept and the surgical technique with a number of US researchers and clinicians, as a member of the clinical advisory board. This device is not yet available in the UK.

• James L. Cook and Derek B. Fox, from the Comparative Orthopaedic Laboratory, University of Missouri, Columbia, Missouri, USA, published an article A Novel Bioabsorbable Conduit Augments Healing of Avascular Meniscal Tears in a Dog Model in the November 2007 issue of the American Journal of Sports Medicine. They conclude: "conduit treatment resulted in functional healing with bridging tissue and biomechanical integrity in 71% of avascular meniscal defects for up to 6 months after surgery. No functional healing was noted in avascular meniscal tears treated by trephination and suture repair."

Genzyme Receives European CE Mark for Synvisc-One

The European Commission granted a CE Mark* for a single-treatment formulation of hylan G-F 20 (Synvisc-One, Genzyme Biosurgery) that provides up to 6 months of pain relief from osteoarthritis of the knee in patients who have failed to respond adequately non-pharmacologic treatment and simple analgesics. In contrast with the current product (www.synvisc.com) that is administered via three 2mL intra-articular injections at one week intervals, the new formulation combines the 3 doses into one 6mL injection. "Delivering the benefits of Synvisc through one treatment rather than three will provide additional options for physicians and their patients to reduce the cost and burden of multiple injections" said Ann Merrifield, president of Genzyme Biosurgery, in a company news release. The approval was based on data from a double-blind study (N = 253) that demonstrated a statistically significant improvement in pain over 26 weeks for patients receiving hylan G-F vs placebo. Patient and physician global assessments likewise showed significant benefit, and safety profiles were no different from that of placebo. The 6mL Synvisc-One formulation has not been approved by the US Food and Drug Administration and Genzyme expects FDA approval to be delayed in the USA until at least the second half of 2008. Source: Medscape

The CE mark

The CE mark is a conformity marking consisting of the letters CE and it is an abbreviation for Conformité Européenne. Initially, CE Mark was the phrase used to indicate this conformity marking. However, CE Mark was officially replaced by the term CE Marking in 1993. The CE Marking applies to products regulated by certain European health, safety and environmental protection legislation. The CE Marking is obligatory for products it applies to: the manufacturer affixes the marking in order to be allowed to sell his product in the European market. The CE Mark indicates that the product it is affixed to conforms to all relevant essential requirements and other applicable provisions that have been imposed upon it by means of European directives, and that the product has been subject to the appropriate conformity assessment procedure(s). The essential requirements refer, among other things, to safety, public health and consumer protection. The CE Marking is not a quality-mark, it refers to safety rather than to the quality of a product.

2008 Conference News

Metcalf Memorial Arthroscopy Meeting

Sun Valley, Idaho, USA, 2 - 5 February 2008. See details

This is a continuation of the largest arthroscopy meeting in the United States, originally founded and run by Dr. Robert Metcalf for many years. After his death, as a tribute to his contributions to the field, the meeting has been continued and includes top physicians from the United States and around the world interested in advances in arthroscopic procedures. Professor Robert Burks tirelessly organised, executed and moderated one more superb Metcalf meeting, with an excellent faculty. Bob Burks has been a friend of the Bobic family for many years. This meeting was also a great chance to catch up with his family (Karen, Rachel and Peter) and other friends like Karon Sorensen and Bob Schenck. We were sad to hear that Karon is retiring this year but we wish her all the best and hope to see her again next year.

This year was Mr Bobic’s fourth time at the Metcalf Memorial Meeting as faculty member and he hopes to continue this tradition for the following years. He was invited to give talks on the following topics: The role of non-operative management in cartilage deficient patients, Articular cartilage repair: European experience and new thoughts on early OA and osteonecrosis and ACL revision surgery.

Sun Valley was fantastic this year and we had more new snow on Baldy than ever before.

ACL Study Group Meeting

Engelberg, Switzerland, 23 - 28 March 2008. See details

The meeting of this prestigious group (membership by invitation only) was organised and run by Steve Howell, John Campbell, Roger Larson, John Bergfeld, John Feagin, local host Peter Burkart and Cheri Baumann. The programme was packed with many interesting talks. Scott Dye's talk about knee joint homeostasis, which was an extension of his previous work and a talk he gave at the ACL SG meeting also in Engelberg 19 years ago, was particularly interesting. Great outside-of-the-box thinking! In this context, George Bernard Shaw's quote springs to mind: "The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man."

We enjoyed many great in-depth discussions but still disagree on some basic terminology (bone marrow bruise and oedema vs. subchondral and osteochondral changes or events, osteoarthrtitis vs. osteoarthrosis, etc.). It is quite obvious that inflammation is not necessarily a major component of joint degeneration in chronic ACL and meniscal deficiency and that chondral and subchondral changes, which may be a consequence of the initial osteochondral trauma of ACL injury and subsequent instability, play a very significant role in this process. This is perhaps like: "All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident." Arthur Schopenhauer (1788 - 1860). Not to mention the epic issue of where to place the femoral and tibial tunnels for ACL grafts, which is best summed up by Andre Gide (1891) : "Everything has been said before, but since nobody listens we have to keep going back and beginning all over again."

Mr Bobic focused on The Significance of Subchondral Events which was, judging by the discussion about bone bruising and bone marrow oedema afterwards, less about known knowns but more about known unknowns and perhaps even more about unknown unknowns! Being worried about limited time for his talk Mr Bobic delivered his talk (for the whole seven minutes) in a rapid-fire mode and forgot to thank Don Johnson for inviting and recommending him for the ACL SG membership and Program Chair Roger Larson for accepting his talk. Hopefully, he will be forgiven one day.

Skiing on Mount Titlis was excellent although the weather was less than perfect. Luckily, the last day on Klein Titlis (3020 m) and Stand was brilliant. As far as we are aware there were no (reported) knee injuries amongst the knee surgeons, some of whom were skiing happily with their chronically ACL deficient knees!

CKC 2008 Knee Seminar: Let's Talk About Knees

Chester, 1 May 2008. Programme

Chester Knee Clinic and The Grosvenor Hospital Chester organised and hosted a small meeting for local GPs and Physiotherapists, as a continuation of our annual educational knee seminars. The seminar is generally designed as an update on the treatment of knee injuries. We discussed advances in knee imaging (with an emphasis on articular cartilage and subchondral MR imaging), pain management and numerous advances in knee surgery.

We also talked about running and cycling knee injuries. We are delighted that a team from Chester Specialized Concept Store, led by Mark Runcie, joined us and demonstrated correct bike fit based on BG (Body Geometry) concept, a couple of new road bikes designed for speed and comfort, and a concept of gender-specific bikes which are in tune with the anatomies and physiologies of female riders (Specialized Designs for Women™). The developing relationship between Chester Knee Clinic and Chester Specialized Concept Store is based entirely on a mutual interest in knee injury prevention through the proper fitting of cycles to individual riders, without commitments to the brand or any commercial interests involved.

The seminar was very well attended but the new Jubilee room, built last year as a dedicated meeting and lecture room, was a bit small for all the participants, bicycles and other bike equipment. This time we did not have enough time for the discussion, but we will make sure that each presentation is followed by 10 minutes of discussion time at our next seminar on knee injuries on 23 October 2008, with an emphasis on winter sports (see the top of this page).

This page was launched on 30 April 2008

Site last updated on: 28 March 2014

Disclaimer: This website is a source of information and education resource for health professionals and individuals with knee problems. Neither Chester Knee Clinic nor Vladimir Bobic make any warranties or guarantees that the information contained herein is accurate or complete, and are not responsible for any errors or omissions therein, or for the results obtained from the use of such information. Users of this information are encouraged to confirm the accuracy and applicability thereof with other sources. Not all knee conditions and treatment modalities are described on this website. The opinions and methods of diagnosis and treatment change inevitably and rapidly as new information becomes available, and therefore the information in this website does not necessarily represent the most current thoughts or methods. The content of this website is provided for information only and is not intended to be used for diagnosis or treatment or as a substitute for consultation with your own doctor or a specialist. Email addresses supplied are provided for basic enquiries and should not be used for urgent or emergency requests, treatment of any knee injuries or conditions or to transmit confidential or medical information. If you have sustained a knee injury or have a medical condition, you should promptly seek appropriate medical advice from your local doctor. Any opinions or information, unless otherwise stated, are those of Vladimir Bobic, and in no way claim to represent the views of any other medical professionals or institutions, including Nuffield Health and Spire Hospitals. Chester Knee Clinic will not be liable for any direct, indirect, consequential, special, exemplary, or other damages, loss or injury to persons which may occur by the user's reliance on any statements, information or advice contained in this website. Chester Knee Clinic is not responsible for the content of external websites.

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