Despite the best attempts of the freezing weather, the fifth 'Sports & Exercise Medicine for London 2012 meeting in association with DJO Education went ahead at the Royal Society of Medicine in London on December 10th. Organised by Professor Nicola Maffulli, (Centre Lead and Professor of Sports and Exercise Medicine at Queen Mary University of London Centre for Sports and Exercise Medicine), the December meeting ran two parallel sessions: Anti Doping, chaired by Dr Tom Crisp, Sports and Orthopaedic Physician at the London Independent Hospital, and Knee Injuries co-chaired by Prof Nicola Maffulli and Mr Mike Carmont, Consultant Orthopaedic Surgeon at Princess Royal Hospital, Telford.
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| Knee Injuries: L to R: Rhidian Thomas, Mike Carmont, Panos Thomas, Nicola Maffulli, Petri Sillanpaa, Massimo Barcellona |
Both sessions were well attended, and the input of experts from different SEM backgrounds added to the educational value of the day. The 'Knee Injuries' session was an excellent session of advances in complex knee problems, while the focus of the Anti-Doping session was on banned substances, the use of PRP therapy, biological passports and anti-doping rules, and how they are likely to evolve in the future.
Mr Steve Bollen, Consultant Knee Surgeon, and Clinical Director at the Bradford Royal Infirmary, Yorkshire (and former BOSTAA President) and Mr Rhidian Thomas, Consultant Knee Surgeon at Imperial College, London and ACL study group member, explained the current state-of-the-art management for ACL knee injuries. Steve's presentation reflected his 20 years of knee reconstruction experience, emphasising the importance of careful history taking, observant examination and directed referral. He explained the diagnosis of subtle multi-directional instabilities and the importance of PCL graft placement to re-establish a baseline for the reconstruction of other knee ligaments. Rhidian gave an update on current thinking in ACL Injuries. As well as reminding the delegates of the importance of ACL reconstruction in preventing meniscal injuries together with the restoration of normal knee kinematics and activities for the patient, he focused on the historical progression of ACL reconstruction from bone-patella tendon bone, to hamstring, single and double bundle. He also considered the exciting future progression of knee reconstruction with ACL scaffolds and tissue engineered ligaments.
Advancements in meniscal imaging and surgery were presented by Dr David Elias, Radiologist at King's College, London and Mr Panos Thomas, Consultant Knee Surgeon at Whittington Hospital, London. With Sports Clinicians finding MRI reports useful in their work, the opening guest speaker, Dr Elias, focused on recent advances in MRI images of the knee, and explained the interpretation of meniscal changes and occult ligamentous injuries. He also highlighted the new dGEMRIC cartilage imaging technologies and stressed the importance of sports clinicians giving the radiologist clear accurate clinical information. Panos explained the transition from the removal of “vestigial remnants” to the preservation of normal kinematics, with repair meniscal reconstruction, using synthetic scaffolds and transplantation.
The subject of Rehabilitation was addressed by Dr Massimo Barcellona, Research Physiotherapist, Kings College, who took delegates through the basis behind current ACL rehabilitation distinguishing between myth and scientific rehabilitation, the quadriceps co-contraction being a key component. This prompted technical questions from an enquiring audience.
Patellar instability is a complicated area which surgeons and sports physicians are beginning to understand thanks to the research work being done. Mike Carmont said: “We were therefore fortunate to have Prof Maffulli and to welcome Dr Petri Sillanpaa, Consultant Orthopaedic Surgeon from Tampere University Hospital in Finland, both leaders in the field of patellar instability, to report on the latest findings of scientific research and opinions, which form the current evidence-based best practice. Prof Maffulli was recently the Godfather of the Patellofemoral Study Group Travelling Fellowship, and presented the basic sciences thoughts behind the multiple complex factors involved in the management of patellar instability. Petri presented his interpretation of the current published evidence on patellar dislocation together with the findings of his own prospective randomised studies into the benefits of surgical repair. He advised that there is no good single option for every patient, but that those with large osteochondral fragments or bony avulsions may benefit from internal fixation.”
Mike Carmont presented the key principles in the recognition and management of extensor mechanism ruptures, and how injured tendon should be protected but allowed to bare weight and to move.
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| Antidoping: L to R: Michele Verroken, Fabio Pigozzi, Nicola Maffulli, Filippo Spiezia, Andrea Petroczi, Tom Crisp |
The anti-doping session was thought-provoking, and generated heated discussion in the plenary sessions especially on ethical issues which raised more questions than answers.
Dr Tom Crisp, who chaired the session and spoke on 'What the future holds', reminded delegates that testing was introduced in the 1960's and has come a long way since then with WADA taking over from the IOC in 1999. Nevertheless, he said, the cheats are always one or two steps ahead of the testers. He added: “More education is needed not just on banned substances but also on supplementation and its dangers.”
Former UK Sport Director of Ethics and Anti-Doping, Michele Verroken, who was responsible for setting up the UK's Drug Information Database, gave an insightful presentation entitled 'Intelligent Anti-Doping' which covered the main issues involved in anti-doping from changes in athletes' doping practices to the Doctor's role, biological passports and therapeutic use exemption and the new anti-doping procedures and rules for 2011. Above all, it highlighted the ever-increasing complexities - and costs - associated with testing procedures and analysis in the world's battle against doping. She also explained the impact of WADA's new 2011 List of Prohibited Substances and Methods which came into force on 1st January this year.
One of the most notable removals from WADA's Prohibited List is Platelet-rich Plasma therapy which has sparked major debate over the last 10 years and Prof Maffulli took the opportunity to report the IOC's position on the use of the therapy in sports injuries. He also referred to his systematic review published in early 2010 in which he found that the studies showed that injections with autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact in improving pain and/or function over time. However, only three studies using autologous blood products had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. He used the meeting to call for more research and higher quality studies using proper control groups.
Prof Maffulli's sentiments were echoed in part by Professor Fabio Pigozzi, a member of the Health Medical and Research Committee of WADA whose recent research project 'Platelet-Rich Plasma in Muscle Healing' was conducted at the Department of Health Sciences at the University of Rome “Foro Italico”, where he is Deputy Rector, in association with Italy's Federation of Sport Medicine.
His keynote presentation examined the role of platelet-derived growth factors and PRP, and their potential orthopaedic applications in the management of sports injuries and issues with anti-doping. He believes that the inflammatory process response appears to be a crucial component in the increased healing process and recommended that local anaesthetics are avoided so as not to modify the local pH. Until there is standardisation in PRP preparations and the long-term side-effects (such as the potential of fibrosis) have been properly researched, PRP therapy is still a matter of debate and personal choice.
The second part of the session heard Dr Filippo Spiezia from Rome discussing the 'Gladiators' diet' and Prof Andrea Petroczi, Professor of Public Health at Kingston University who discussed popular drugs in sport. Drawing from her work and other published studies, she discussed a wide range of substances commonly used by athletes, including dietary supplements, over-the-counter medications and prohibited performance enhancing drugs and methods. She advocated adopting a holistic view to anti-doping, which recognises that doping behaviour is likely to grow out of habitual (and often encouraged) engagement in acceptable performance enhancing practices, including daily intake of supplements. Andrea concluded her presentation with a discussion on regulatory issues of the dietary supplement market and their potential consequences to athletes.
Dr Lucienne Attart, Specialist in Sports and Exercise Medicine from Mater Dei Hospital, University of Malta, enjoyed the meeting: “I found the content of the day's seminar to be very informative and interesting. The knee session was full of information and gave a very good overview of the treatment of the most common knee injuries in sport. I was impressed at how many world-leading experts attended and contributed to the meeting: I congratulate the organisers on their ability to bring together such a world class programme and I regret not attending previous meetings. I will certainly consider attending future events - what better reason to visit London again?!”
This series of high level interactive meetings provides a unique forum for leading UK and overseas sport and exercise medicine (SEM) professionals to discuss current developments in a range of topics. The next meeting is at the RSM on Friday 18th March 2011. For further details and 2011's dates, visit www.DJOglobal.co.uk/DJOeducation or email
barryghill@hotmail.com.
