Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Seven, we are delighted to speak to Mr Michael Kelleher Consultant Neurosurgeon and Mr Eoin Fenton Consultant Neurosurgeon at UPMC Sports Surgery Clinic.

This episode focuses on the topic of back pain and the management of radiculopathy and leg referral of pain and what to watch out for in cauda equina.

Shownotes:

04:14
Back pain is an incredibly common condition with huge morbidity caused with both time off in from work, lack of activity and pain, can you talk us through some of the epidemiology?
05:35
Can you talk us through some of the anatomical features in the back which can be associated with injury and pain?
08:15
How important is imaging of the spine in helping the patient and making the diagnosis?
12:20
Hesitancy and asymptomatic prevalence in MRI, how does use the scan to support the understanding rather than head to surgery?
14:40
The importance of strength and conditioning in back pain?
15:30
How long can rehabilitation of the back take?
16:16
If the patient cannot tolerate a strength intervention due to radiculopathy, what next?
18:50
What types of guided injection can be of help in a patient with pain and what are the differences between transiting and exiting nerve roots?
22:00
When is the indication to progress to consider microdisc surgery?
23:13
What actually happens in a microdiscetomy, and what differs when you have bony overgrowth from the facet joint?
24:30
What does the post-operative management look like?
27:00
If there was a recurrence of symptoms after surgery what options remain? And what are the risks of surgery?
29:04
What is Cauda equina syndrome, and what do we do?
32:00
How important is patient understanding in terminology?
33:00
Is digital rectal examination still important for rectal tone?

Neurospine Contact Details

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Eight, we are delighted to speak to Mr Ray Moran, Consultant Orthopaedic Surgeon and Medical Director at UPMC Sports Surgery Clinic.

This episode focuses on the topic of decision making around the Anterior Cruciate Ligament (ACL), the evolving techniques into ACL graft selection and the rehabilitation and post-operative management and Ray’s latest paper on ACL outcomes.

Shownotes:

O4:15
What is an ACL ligament?

06:28
Can you talk me through the decision making regarding surgical repair with the patient?

08:29
What about the debate on conservative non-operative management of ACL rupture?

10:20
How important is a timeline for the patient?

12:24
The outcome of your recent paper in AJSM shows a very low re-injury rate in a big series?

14:20
What are the critical time points postoperatively in management?

16:53
The paper showed that bone patellar bone was prefered for a lower re-injury rate, but the Hamstring graft did ok, too, what makes that decision?

21:01
There is always a new version of the operation, the Australians suggested using Kangaroo tail, we went through a phase of LARS repair, and the follow up suggested these really were not that good, but they are reappearing and now the Quad tendon repair – why the continual quest to change?

24.40
Bertrand Sonnery-Cottet from Lyon has published some work on assisted ligament repair of proximal ACL’s is this something that might come to SSC in the future?

27:40
How important is graft tension to a successful outcome?

29:22
Biomechanical analysis has led to a low re-injury rate, how important is this and if re-injury does occur what then?

Papers mentioned in the podcast

Factors Influencing Return to Play and Second Anterior Cruciate LigamentInjury Rates in Level 1 Athletes After Primary Anterior Cruciate LigamentReconstruction: 2-Year Follow-up on 1432 Reconstructions at a Single Center.
King E, Richter C, Jackson M, Franklyn-Miller A, Falvey E, Myer GD, Strike S, Withers D, Moran R.Am J Sports Med. 2020 Mar;48(4):812-824.

ACL or ACL.
Reider B.Am J Sports Med. 2020 Feb;48(2):281-284.

ACL rupture in the immediate build-up to the Olympic Games: return to elite alpine ski competition 5 months after injury and ACL repair.
Praz C, Kandhari VK, Saithna A, Sonnery-Cottet B.BMJ Case Rep. 2019 Mar 15;12(3):e227735.

About Mr Moran

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC. The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Six, we are delighted to speak to Ms Ann-Maria Byrne, Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic and specialist in elbow, hand and wrist surgery.

This episode focuses on the topic of decision making around the biceps and common extensor origin injuries and surgical indications.

Shownotes:

5:09
Distal biceps ruptures certainly seem to be increasingly common, anecdotally one always thinks anabolic steroid use, but the mechanism is more varied?

8:10
Is there commonly tendinopathy or avulsion?

11:38
What is the mechanism of injury in rupture?

13:04
How do you go about the clinical assessment is this something you use to differentiate between partial and complete tears? What are the decision making steps in deciding to operate?

16:58
Does MRI help or hinder decision making?

18:38
What does biceps surgery involve?

23:12
And what does the post-operative period look like?

27:17
When can they lift heavy again?

29:09
What are the complications of surgery

32:02
When does contact sport come back?

33:51
Common Extensor Origin tendinopathy, what does the evidence suggest?

37:41
What are the differential diagnosis before surgery?

44:52
When can surgery assist?

45:22
Matache published a protocol for a sham RCT of arthroscopic release using DASH (Disability of Shoulder and Hand) and Mayo Elbow Performance Score (MEPS) not all our listeners will be familiar with DASH and MEPS are these well accepted PROMS that can use to track improvement?

Papers mentioned in the podcast

Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence.
Murray DJ, Javed S, Jain N, Kemp S, Watts AC.
J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8. Review.

Matache BA, Berdusco R, Momoli F, Lapner PL, Pollock JW. A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis. BMC Musculoskelet Disord. 2016;17:239. Published 2016 Jun 1. doi:10.1186/s12891-016-1093-9

About Ms Byrne

Ms Ann-Maria Byrne’s clinic is based in UPMC Sports Surgery Clinic’s Northwood Suite in Santry.
Her secretary is Niamh Kennedy
Phone: +353 1 5262345
Email:ambyrneadmin@sportssurgeryclinic.com

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Five, we are delighted to speak to Diarmuid Molony, Consultant Orthopaedic Surgeon specialising in shoulder and elbow surgery at UPMC Sports Surgery Clinic.

This episode focuses on the topic of decision making around subacromial surgery which is often controversial.

Shownotes:

01:47
What are the causes of subacromial pain in an athlete? And what are the 1st steps in managing this before referral?

04:56
What does the clinical examination allow you to differentiate?

05:57
Does Plain X-Ray help in decision making?

06:53
What additional help does MRI imaging provide?

08:50
What role does the injection of steroid have in these patients?

10:16
Can rotator cuff tears also mimic subacromial impingement

12:06
We often hear “failure of rehabilitation” – what does rehabilitation mean to you?

14:46
Underdosing and over-prescription of exercise rehabilitation, is it a problem?

16:59
Differences between Athletic and less athletic populations in management?

18:17
What decision-making steps are there when considering surgery?

19:45
Does adhesive capsulitis commonly co-exist?

22:43
What surgical options exist?

23:20
The Finnish Shoulder Impingement Arthroscopy Controlled Trial (FIMPACT) compared the surgical treatment of shoulder impingement syndrome to placebo surgery and found some surprising results – has that changed your practice?

27:45
What is decompression surgery?

29:50
What is the post-operative period dictated by?

33:00
What are the differences in subacromial surgery and capsulitis surgery?

Papers mentioned in the podcast

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial.
Paavola M, Malmivaara A, Taimela S, Kanto K, Inkinen J, Kalske J, Sinisaari I, Savolainen V, Ranstam J, Järvinen TLN; Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators.
BMJ. 2018 Jul 19;362:k2860

Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources.
Jones T, Carr AJ, Beard D, Linton MJ, Rooshenas L, Donovan J, Hollingworth W.
BMJ Open. 2019 Aug 28;9(8):e030229.
Trials. 2015 May 9;16:210. doi: 10.1186/s13063-015-0725-y.

The CSAW Study (Can Shoulder Arthroscopy Work?) – a placebo-controlled surgical intervention trial assessing the clinical and cost-effectiveness of arthroscopic subacromial decompression for shoulder pain: study protocol for a randomised controlled trial.

Beard D1, Rees J2, Rombach I3, Cooper C4, Cook J5, Merritt N6, Gray A7, Gwilym S8, Judge A9, Savulescu J10, Moser J11, Donovan J12, Jepson M13, Wilson C13, Tracey I14, Wartolowska K15, Dean B16, Carr A17; CSAW Study Group.

About Mr Molony

Mr Diarmuid Moloney has a personal website www.dmorthopaedics.ie

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Four, we are delighted to speak to Mr Gavin McHugh, Consultant Orthopaedic Surgeon at the UPMC Sports Surgery Clinic.

This episode focuses on the topic of decision making around knee replacement surgery-both unicompartmental knee surgery and total knee replacement.

Shownotes:

02:22
Most people have heard of a total knee replacement, indeed many will know someone personally who had one done, how many do you do a year at SSC?

03:11
We often hear of patients being told to wait till their symptoms get worse or they are ‘too good’ for a replacement – what guides that decision making?

07:22
What role is there for imaging in decision making for joint replacement?

09:23
What is a unicompartmental or partial knee replacement?

14:30
David Beard published in the Lancet, an impressive paper comparing the outcomes of (PKR) and (TKR) for treatment of isolated medial compartment osteoarthritis of the knee in 528 patients (42% female, mean age 65·0 years). Interestingly the TOPKAT’s within-trial cost-effectiveness analysis, PKR was found to be more effective (0·240 additional quality-adjusted life-years, 95% CI 0·046 to 0·434) and less expensive (−£910, −1503 to −317) than TKR during the 5 years of follow-up.

What are the decisions that lead you to a PKR?

17:50
Can you adjust knee alignment with a partial knee replacement?

21:30
How do you manage the contralateral limb during rehabilitation?

23:18
What options in the manufacturer of the joint are there available?

30:22
How often do you need to convert to a total knee replacement?

31:05
What limitations are there in a replaced joint?

33:19
What does the future hold in joint replacement?

Link to the study mentioned in the podcast

Lancet. 2019 Aug 31;394(10200):746-756. doi: 10.1016/S0140-6736(19)31281-4. Epub 2019 Jul 17.
The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial.
Beard DJ1, Davies LJ2, Cook JA3, MacLennan G4, Price A2, Kent S5, Hudson J4, Carr A2, Leal J5, Campbell H5, Fitzpatrick R5, Arden N2, Murray D2, Campbell MK4; TOPKAT Study Group.

About Mr McHugh

Mr Gavin McHugh has personal website www.gavinmchughorthopaedics.com

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind making a decision to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Three, we are delighted to speak to Professor Cathal Moran, Consultant Orthopaedic Surgeon and Professor of Sports Medicine and Orthopaedics, Trinity College Dublin.

This episode focuses on the topic of orthobiologics in their role in cartilage injury.

Shownotes:

04:20
What does orthobiologics refer to?

06:05
What is cartilage in the joint, and how is it injured?

07:23
What treatment options currently exist for chondral lesions, and what guidelines are there on size and grading?

08:11
Osteoarthritis and links to chondral damage?

09:19
What is the decision-making process on operative choice between microfracture, and autograft and allografting?

11:25
How do you decide with the patient what works?

14:24
Why does chondral surface not regrow?

15:48
We hear of patients flying to specialist centres around the world for treatment… what are they offering?

20:48
What is a stem cell? We can obtain the from fat and bone marrow – which is the favoured approach in the trials right now?

24:01
Platelet-rich plasma trials on osteoarthritis in the knee, what does the evidence show? Where does stem cell research take us?

28:40
There is some promising work from Stanford on magnetised mesenchymal stem cells being pulled into lesions.

30:30
What is the latest work from Trinity and the Bioengineering department trials into stem cell plugs and inclusion criteria?

33:19
There a plethora of stem cell clinics springing up – is this something that can benefit me right now or is it smoke and mirrors.

Link to the metanalysis mentioned in the podcast

Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Meta-analysis of Randomized Controlled Trials.
Dai WL, Zhou AG, Zhang H, Zhang J. Arthroscopy. 2017 Mar;33(3):659-670.e1.
Xia T, Yu F, Zhang K, et al. The effectiveness of allogeneic mesenchymal stem cells therapy for knee osteoarthritis in pigs. Ann Transl Med. 2018;6(20):404. doi:10.21037/atm.2018.09.55

Selected papers from Professor Moran

Anterior Cruciate Ligament Reconstruction with Platelet-Rich Plasma: A Systematic Review of Randomized Control Trials. Davey MS, Hurley ET, Withers D, Moran R, Moran CJ. Arthroscopy. 2020 Apr;36(4):1204-1210.

Mechanisms of ACL injury in professional rugby union: a systematic video analysis of 36 cases. Montgomery C, Blackburn J, Withers D, Tierney G, Moran C, Simms C.Br J Sports Med. 2018 Aug;52(15):994-1001. doi: 10.1136/bjsports-2016-096425. Epub 2016 Dec 30.

Translation of science to surgery: linking emerging concepts in biological cartilage repair to surgical intervention.Moran CJ, Shannon FJ, Barry FP, O’Byrne JM, O’Brien T, Curtin W. J Bone Joint Surg Br. 2010 Sep;92(9):1195-202. doi: 10.1302/0301-620X.92B9.23651. Review.

Gene-modified mesenchymal stem cells express functionally active nerve growth factor on an engineered poly lactic glycolic acid (PLGA) substrate.
Rooney GE, Moran C, McMahon SS, Ritter T, Maenz M, Flügel A, Dockery P, O’Brien T, Howard L, Windebank AJ, Barry FP.
Tissue Eng Part A. 2008 May;14(5):681-90.

About Professor Moran

Professor Moran has personal website www.cathaljmoran.com, and you can follow Cathal on twitter @CMoransurgeon

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s first orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician at SSC.

The purpose of the podcast is to explore the reasons behind deciding to operate in common orthopaedic conditions and explore the latest evidence and post-operative strategies.

In Episode Two, we are delighted to speak to Ms Ruth Delaney, Consultant Orthopaedic Surgeon and Assistant Clinical Professor, University College Dublin.

This episode focuses on the topic of acromioclavicular joint injury and clavicular fractures.

Shownotes:

3:42
The epidemiology of AC joint disruption, the anatomy of the joint, and how it is injured.

5:08
Talk us through imaging and how radiologists like to give these a graded score and referrers often get confused both about what the grading means and the imaging to make that grading, can you explain it and is it useful?

10:51
What do write on the X-Ray referral form to make an appropriate assessment?

12:02
What does conservative management mean to you?

13:35
When does an AC joint need stabilisation surgery and what does that entail?

14: 47
What complications of surgery exist?

18:37
How do you manage pain in the ACJ further down the line, When does excision of the distal clavicle play a part?

21:26
Clavicular fractures, management is tricky; how do you approach it? What re the risks of NSAIDS? What are the surgical options for repair?

25:30
The post-operative surgical timeline is predictable, talking through the return to sport protocols

29:00
Different approaches to clavicular management

Selected papers from Ms Delaney

Complications of the Latarjet procedure. Gupta A, Delaney R, Petkin K, Lafosse L.
Curr Rev Musculoskelet Med. 2015 Mar;8(1):59-66.

Neer Award Paper: neuromonitoring the Latarjet procedure. Delaney RA, Freehill MT, Janfaza DR, Vlassakov KV, Higgins LD, Warner JJ. J Shoulder Elbow Surg. 2014 Oct;23(10):1473-80.

Immobilisation in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation. Vavken P, Sadoghi P, Quidde J, Lucas R, Delaney R, Mueller AM, Rosso C, Valderrabano V. J Shoulder Elbow Surg. 2014 Jan;23(1):13-9.

Durability of partial humeral head resurfacing. Delaney RA, Freehill MT, Higgins LD, Warner JJ. J Shoulder Elbow Surg. 2014 Jan;23(1):e14-22.
Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies.Müller AM, Sadoghi P, Lucas R, Audige L, Delaney R, Klein M, Valderrabano V, Vavken P. J Shoulder Elbow Surg. 2013 Aug;22(8):1146-52.. Review.

Utilisation of the safe surgical dislocation approach of the hip to retrieve a bullet from the femoral head. Delaney R, Albright M, Rebello G. Case Rep Orthop. 2011;2011:160591.

About Ms Delaney

Ms Ruth Delaney has personal website www.dublinshoulderinstitutecom, and you can follow Ruth on twitter @RDShoulder

Welcome to ‘On the Table’ – UPMC Sports Surgery Clinic’s first orthopaedic advances podcast hosted by Dr Andy Franklyn-Miller.

In Episode One, we are delighted to speak to Mr Hannan Mullet, Consultant Orthopaedic Surgeon and Honorary Senior Lecturer at The Royal College of Surgeons Ireland.

This episode focuses on the topic of shoulder dislocation and the best practice evidence in its management.

Shownotes:

1:30
Shoulder dislocation is pretty common in contact sports, can you tell us about the epidemiology of it?

2:18
What factors do you take into account when making the clinical assessment?

10:30
What does an MRI add to the assessment?

12:01
Good et all in 2005 “Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment.” Highlights a poor outcome in adolescents who dislocate in terms of stability, is that what you find? Is the evidence convincing?

16:45
What is the surgical stabilisation procedure? What are the risks of the surgery afterwards?

22:26
Postoperatively can you talk us through the stages of what happens?

24:20
Sling position, post-surgery, has generated some controversy originally from the Japanese group recommending external rotation to improve post-surgical mobility, is that debate still ongoing?

26:24
Contact sport athletes often re-injury the shoulder–what options do you have at that point, is a repeat operation an option?

28:24
What advances might we see in the future?

Papers mentioned in this podcast

Video Analysis of Shoulder Dislocations in Rugby: Insights Into the Dislocating Mechanisms.
Montgomery C, O’Briain DE, Hurley ET, Pauzenberger L, Mullett H, Moran CJ.
Am J Sports Med. 2019 Dec;47(14):3469-3475. DOI: 10.1177/0363546519882412. Epub 2019 Nov 11.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up.
Murphy AI, Hurley ET, Hurley DJ, Pauzenberger L, Mullett H.
J Shoulder Elbow Surg. 2019 Nov;28(11):2084-2089. doi: 10.1016/j.jse.2019.04.057. Epub 2019 Jul 13.

Return to Play After the Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review.
Hurley ET, Montgomery C, Jamal MS, Shimozono Y, Ali Z, Pauzenberger L, Mullett H.
Am J Sports Med. 2019 Oct;47(12):3002-3008