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ISAKOS NEWSLETTER 2013 • VOLUME II Current Concepts on Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine
ISAKOS newsletter redesign
ISAKOS, an international society of surgeons, engaged us to have their Newsletter redesigned so that it has a fresher feel + reflects the more broader appeal that they were looking for.
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INSIDE 6 ISAKOS & FIFA–A GOLD TEAM
Femoral head
as seen during hip Arthroscopy in a
15 year old boy
with Perthes. Impingement mechanism was addressed prior
to subsequent PAO.
ISAKOS would like to thank
all who attended the 9th Biennial ISAKOS Congress in Toronto, Canada! The city of Toronto played host to more than 3,300 ISAKOS Congress participants, exhibitors and their guests during the week of May 12–16, 2013.
ISAKOS Congress Program Chairman, Marc Safran, MD, USA and the ISAKOS Program Committee developed a diverse and exceptional educational program including more than 280 international experts on a variety of topics ranging from general arthroscopy, to the use of biologics, to the pearls and pitfalls of surgical techniques. All major specialty areas were covered from concussion to the foot and ankle!
The 9th Biennial ISAKOS Congress offered course participants a packed schedule of Instructional Course Lectures, symposia, debates, lectures, surgical demonstrations and scientific paper presentations. More than 250 scientific papers were presented at the podium, in addition to more than 500 electronic posters. Presentations on topics such as hip arthroscopy, ACL reconstruction and rotator cuff repair were especially well attended. Special thanks are due to all ISAKOS Congress presenters – your vitality and variety help to make the ISAKOS Congress the outstanding educational event that it has become!
ISAKOS participants also had the option to expand their educational opportunities with the ISAKOS Congress Pre-Courses and Sports Rehabilitation Concurrent Course. Special thanks to the chairs of these courses! More information on these events can be found on page 16 of this Newsletter.
The ISAKOS Executive Committee and Board of Directors wish to thank all who attended the 2013 ISAKOS Congress. It is your participation and diverse perspectives that make the ISAKOS Congress the extraordinary educational event that it is!
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01 Marc Safran, ISAKOS Program Chair 2013 and Moises Cohen, ISAKOS President 2011–2013
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Differences in muscle development between males and females are well known, with females having less muscle mass, different muscle fiber composition and differences in muscle stiffness about the knee. Testosterone increases muscle fiber mass, fiber recruitment and type 2 fiber development. Muscle stability also shows variances between the sexes; joint load is influenced by muscle strength and fatigue. These neuromuscular differences between males and females, particularly manifest after puberty, may explain discrepancies in the rates of PF pain and injury. Males may have an advantage in regard to knee stability, strengthening of knee musculature, and by association, may be less prone to AKP. Another consideration is pain perception; females are more sensitive to pain and have different physical responses to pain than males. In experimental settings, females are more sensitive to pain stimuli, less tolerant of pain, and more able to discriminate between different pain pathways. Several studies suggest a sex difference in pain perception. Males tolerate more pain than females in experimental settings. High ‘male- identifying’ men tolerate more pain than high and low ‘female- identifying’ women. However, low male identifying men are equal to women. This highlights the roles of sex and gender norms in pain-reporting behaviors.
EDITOR’S MESSAGE
As summer continues in the northern hemisphere, and winter cools the south, we are still digesting our recent memories from the long-awaited ISAKOS Congress in Toronto.
As with previous Congresses, the meeting in Toronto was a huge success, bringing together surgeons from all over the globe to interact scientifically and socially, to share experiences and thoughts, differences and similarities.
In my opinion, this is what ISAKOS is all about...
Big world, small (but rapidly growing!) community.
Interaction without boundaries, resulting in a fruitful experience for us all.
New friends, new places to visit, new techniques to adopt, and constant evolution.
With our eyes on the future ISAKOS Congress in Lyon in 2015, we have decided to broaden the ISAKOS voice to many more aspects of life that are important and relevant to us. This is in keeping with our society’s spirit and our ever expanding interests far beyond simply orthopaedics.
ISAKOS members are well read and up to date with the scientific literature, and as your global voice we are aware that the ISAKOS Newsletter is not meant to be a substitute for high impact orthopaedic journals. However, we would like to generate a global discussion and common language, to provide the community with cutting edge information that is not usually available in the purely scientific forums. We aspire to share life experiences and to let our role models pass on their wisdom, in order to eliminate the need to reinvent the wheel all over again, or fight battles which have already been won.
In the era of Facebook, Twitter and streamlined communication, where information is available in small digestible bites, the ISAKOS Newsletter is moving to quick, take-away messages, so you can consume it, sip by sip, with your morning espresso or in between cases.
As the new Editor of the ISAKOS Newsletter, my vision is for the ISAKOS Newsletter to be something you can pick up and read for a few minutes at a time, and still be provided with interesting, relevant information. We hope it will provoke thought perhaps on topics slightly broader than typical journals.
There are the things that surround us or we use everyday, but we do not always stop to think what are they made of or how they work (see ‘In a Nutshell’, Page 45).
• As we progress and develop in our careers, we are all curious to know how our mentors deal with both family and professional life decision making (jump to ‘Life Style’, Page 42).
• We have also included advice from the more organized or experienced physicians among us, that we hope you find helpful to learn how they keep five balls in the air, stay productive, on schedule, safe and happy! (see Robert Marx’s OR checklist on Page 39).
• Everyone could use tips on how to get through a busy professional day without stumbling or fading, an issue which many of us have been dealing with (without too much success) for years (Visit our Nutritionist on Page 44).
I’d like to take this opportunity to thank James Lubowitz, USA, the legendary Editor in Chief of this Newsletter, for six outstanding years of excellence. Jim has turned this Newsletter into an established and respected global forum, making it hard for anyone to fill these large shoes.
Finally, we would like congratulate our incoming new President, Masahiro Kurosaka, and send a round of applause to ISAKOS’ Executive Director, Michele Johnson, and her amazing team, Donna Festo, Katie Anderson, Hilary Matthews, Kathleen Reyes, April Warden and Beverlee Galstan, who will take us with great vision and expertise into this new and exciting 2013–2015 term.
in this issue
Editor’s Message ..........................................1 Presidential Message....................................2 ISAKOS Office Update ...................................3 ISAKOS & OREF Grant
Winner Announcement.............................4 ISAKOS and FIFA ..........................................6 2013 ISAKOS Congress Wrap Up ..................7 Case Corner................................................24 Current Concept Article...............................26 Worst Case Scenario ..................................34 Pearls & Pitfalls – Surgical Technique ........37 Lifestyle......................................................42 Tip of the “Day” .........................................44 In A Nutshell...............................................45 Approved ISAKOS Courses..........................46 ISAKOS Asks...............................................47 Upcoming ISAKOS Collaborative Courses....47 Upcoming Approved Courses......................48
EDITOR
Omer Mei-Dan, MD, USA
EDITORIAL BOARD
Nadim Aslam, FRCS Orth, UNITED KINGDOM Mandeep S. Dhillon, Prof., MS, FAMS, INDIA Lucio S. R. Ernlund, MD, MSc, BRAZIL Norimasa Nakamura, MD, PhD, JAPAN David Sadigursky, MD, BRAZIL
Gonzalo Samitier, MD, PhD, USA
Daniel A. Slullitel, MD, Prof., ARGENTINA Luis Alberto Vargas, MD, USA
James H. Lubowitz, MD, USA, Past Editor
International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
2678 Bishop Drive, Suite 250 San Ramon, CA 94583 USA Telephone: (925) 807 – 1197 Fax: (925) 807 – 1199
Email: [email protected]
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CURRENT CONCEPTS
Patellofemoral Disorders: Are They a Female Issue?
Elizabeth A. Arendt, MD
Minneapolis, MN, USA
Patellofemoral (PF) injury and disease are commonly thought to be more prevalent in females. Literature to support this conclusion is sparse. This article investigates possible sex differences in three categories of PF disorders: PF pain, patella dislocations, and (isolated) PF arthritis. Patellofemoral Pain/Anterior Knee Pain
Is anterior knee pain (AKP) more common in females? One study investigated constitutional features such as sex, age, body composition, athletic activity and duration of symptoms as possible predictive factors in the outcome of non- operative management of AKP. Results did not show sex as a determinant for AKP. Younger age was the only predictive factor for favorable outcomes.
A two-year prospective study evaluated motor performance, joint laxity, limb alignment and muscle flexibility of physical education students with no prior history of knee problems. Of the 282 students assessed (151 M/131F; average age, 18.6 years), AKP developed in 7% of the males and 10% of the females. DeHaven and Litner reported on college-age athletes presenting to the training room over a 7-year period; PF pain was reported in 18.1% of males and 33.2% of females.
An established link exists between PF pain and clinical overload. Dye and associates4 have advanced a pain theory centering on biological load acceptance, i.e. PF pain reflects the loss of tissue homeostasis, i.e., biological tissue exceeding load acceptance capacity. With this model, the role of motor control and strengthening in reducing pain is better understood.
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28 ISAKOS NEWSLETTER 2013: Volume II
We redesigned the entire 48 page stylish newsletter at the same time keeping it clean + informative for the orthopaedists.
Enjoy!
Omer Mei-Dan, MD, USA
Patella Dislocations
Historically, PF instability was felt to be primarily a disorder of females. (Figure 1) However, a systematic review of primary traumatic patella dislocations reveals a nearly equal female to male distribution. Of 22 articles reviewed, the total number of first-time PF dislocators was 1765, with a male / female ratio of 46% / 54%, average age 21.5 years. A second study looking at the epidemiology and natural history of acute patella dislocations suggests a similar incidence of males and females in primary patella dislocations, with a preponderance of recurrent dislocations occurring in females. In this study, risk was highest among females age 10 – 17 years.
A report of 127 patients with primary dislocations at two Finnish trauma centers followed for 7 years revealed a slight female preponderance (64%). In analyzing risk factors, the authors found two risk factors for recurrent instability were initial contralateral instability and young age. Females with open tibial epiphysis at the time of the initial dislocation had the worst prognosis for recurrent instability.
A seminal study from Lyon, France analyzed factors of patella instability using standardized imaging to identify factors related to patella instability. In their review of 110 patients, 83 were female (75%). In reviewing risk factors for patella instability, the authors found that trochlear dysplasia, as defined by the crossing sign, was present in 96% of patients with objective patella instability. (Figure 2)
A recent study analyzed imaging of patella instability patients compared to a control group. The goal was to identify sex-related differences in the anatomy of lateral patellar dislocations. The authors found that trochlear dysplasia and the TT-TG distance is more pronounced in women who experience patellar dislocation.
A cautious assumption of the current literature suggests that females are more likely to suffer recurrent patella dislocations than their male counterparts. Reasons for this are likely multi- factorial; including anatomic and neuromuscular factors. We know that compared with males, females display lower knee flexion angles with activities, with greater knee valgus angles and quadriceps activation. There is a higher prevalence of dysplastic distal femora among females.
Understanding sexual dimorphism in neuromuscular and anatomic risk factors is key. The clinician should be especially vigilant with their female patients when discussing re-injury risk, inclusive of known anatomic factors of instability, and be aware of potential neuromuscular factors during rehabilitation back to sporting activities after a patella dislocation.
ISAKOS NEWSLETTER 2013: Volume II 1
CURRENT CONCEPTS
(Isolated) Patellofemoral Arthritis
PF arthritis has been a relatively undiagnosed as a cause of knee pain. (Figure 3) Though studies looking at sex as a risk for isolate PF arthritis are sparse, the available clinical studies show an overwhelmingly female preponderance. McAlindon et al. reviewed radiographs of 273 subjects with complaints of knee pain; isolated PF arthritis was present more than twice as often in females (24%) vs. males (11%). The incidence of combined medial and PF compartment arthritis showed equal incidence between males (7%) and females (6%). Iwano et al. and colleagues reviewed a series of 108 knees in 69 patients with PF arthritis; 93% were female. In a large French multi- center review of 578 patients with isolated PF arthritis, 72% of the patients were female.
Conclusion
Review of the clinical literature to date suggests sexual dimorphism in the presentation of PF disorders, with an overrepresentation of these disorders in females. However, to date there has not been shown a reason to alter our treatments of these disorders based on the patient’s sex. Continued study of PF disorders and their treatments should include sex as a variable, in hope of providing better prevention, treatment and care of these disorders.
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Fig 1 Axial MR image of an acute patella dislocation depicting classic bone bruising, torn MPFL, and large effusion
Fig 2 True lateral Radiograph depicting Type B Trochlea Dysplasia with Crossing sign and supratrochlear bump
Fig 3 An axial radiograph showing loss of lateral patallofemoral joint space indicative of patellofemoral arthritis
ISAKOS NEWSLETTER 2013: Volume II 29
in us...
10TH Biennial
isAkos congress
2015
E 7–11, 2015 N, FRANCE