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A study of the group of Andy Williams, about 200 players across the world broad levels of English football, found out that as low as 30% actually returned to performance if you consider just returned to the league level and the playing minutes.
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The thing when you see, for instance, a 16-year-old with an ACL injury football player or whatever sport, the first thing I tell them is: listen, most probably your joint is now 10 years elder than yourself, so you have to take care of it.
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Welcome everyone to another episode of Frontiers in Orthopedic Surgery, the official podcast of SK and Kesta Journal.
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I'm your host, Joaquin Moya Angiler.
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Today we will explore a topic that sits at the intersection of sports medicine rehabilitation and joint preservation.
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Return to performance after knee injury.
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In recent years, our goals have evolved.
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It is no longer just about returning athletes to sport, but about returning them to their previous level of performance while protecting long-term joint health.
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Balancing these objectives remain one of the biggest challenges in modern knee surgery and sports medicine.
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To help us navigate this important topic, I'm delighted to welcome two exceptional experts, Professor Roman Sale from Luxembourg, a leading authority in knee surgery and joint preservation, with longstanding interest in long-term outcomes following sports injuries, and Francesco Della Villa from the Isokinetic Medical Group in Bologna, Italy, a world-renowned specialist in sports medicine.
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Romaine, Francesco, thank you both for joining us today.
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Thank you, Joakin.
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All right, so before we start our discussion, we're gonna begin with our lighting round section.
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It's gonna be 10 questions.
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You just have to answer yes or no.
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We will return to some of these topics later in the episode.
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So Romain will answer first and then Francesco.
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First, is return to sport after knee injury still being rushed too often?
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Yes.
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Yes.
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Second, should return to sport decisions rely more on objected functional testing?
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Yes, yes.
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Three, is psychological readiness as important as physical recovery?
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If I would say no, my wife would kill me.
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She's a psychiatrist, so definitely yes.
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Of course.
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Okay.
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Fourth, are current return to sport criteria too simplistic?
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Yes.
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No.
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Depends on which setting you're working in.
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Okay, we have a disagreement.
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Five, can rehabilitation alone sometimes be as important as surgery for the long-term outcomes?
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I think so, yes.
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Can be.
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Six.
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Should joint preservation strategies be considered earlier in young athletes?
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Absolutely.
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Yes.
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Seven, are we underestimating the risk of early osteoarthritis after sports injuries?
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Oh yes.
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Yes.
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Eight, should data from wearable technology become part of return to performance decisions?
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That would be nice.
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Yes.
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Nine, will personalized rehabilitation protocols become the new standard?
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Yes, I think so.
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It's already.
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Again, depends on which setting you're working in.
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Absolutely.
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And then finally, can we realistically protect the knee joint while allowing athletes to return to elite level performance?
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Joker.
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So I would say to some extent.
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No.
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Okay, well, we have some almost total consensus.
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So let's uh explore these ideas in more detail.
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Francesco, historically, our goal after injury or surgery was simply return to sport.
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But increasingly we talk about return to performance.
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How would you define the difference between these two concepts?
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Well, Joaquin, this is a very interesting question.
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And we just navigated this through a conference.
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So the last conference of the Zucchini Medical Group was solely dedicated to return to performance.
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And there is a big difference.
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So return to sport, it's returned to sport participation.
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So we have uh, for example, a football player that gets back to training with the team, return to training, and then get back to match play, this return to competition.
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And we can define this as return to sport.
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Generally, historically, in sports orthopedics, if you return to the previous sport before the injury and to the previous level, we consider it a success.
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Return to performance is completely different.
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Return to performance can happen or not following ACR reconstruction, for example, in professional players.
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A study of the group of Andy Williams, about 200 players across the world broad levels of English football, found out that as low as 30% actually return to performance if you consider just return to the league level and the playing minutes.
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If we had on top of that all the performance factors that are related, of course, to passes completed, goal scored, saves for the goalkeeper, etc.
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etc.
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And at the end win loses, winning trophies, then that percent is really, really low.
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So return to performance means rising the bar of sports medicine outcomes.
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Alright, interesting concepts and numbers.
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Rome, from a surgical perspective, how important is it to think about the long-term joint preservation when treating young athletes with knee injuries?
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Well, I think it's uh very important.
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Um it defines also how you define young athletes.
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Um I'm 60 now, so uh everybody who is below is young for me.
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Still a young athlete.
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So if we consider the legal perspective, I think the under 18 are the ones where we really need to make efforts and where the legal situation is not really clear.
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So who is responsible for these uh athletes?
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Is it uh the patient himself or herself?
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Is it the club?
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Is it the federation?
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There are a lot of um adults that uh deal with uh these young athletes, they start to make money with them and so on.
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So that goes really beyond surgery, so that's an ethical question that is not being solved in high-level sports yet.
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So the importance on the long-term aspect is is really big.
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So in these athletes, the thing when you see, for instance, a 16-year-old with an ACL injury football player or whatever sport, the first thing I tell them is listen, most probably your joint is now ten years older than yourself, so you have to take care of it.
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And uh irrespective of the surgery I do, and irrespective of what we will do and then what the outcome will be, uh that's how things are, and I think in most of the cases that is reality.
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And uh if they are under 18, you also have to talk to their parents and they have to understand that.
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And uh if you're in an elite level environment and it's difficult, the pill that is difficult to swallow, but uh if you're in an amateur environment, that's still I would say the majority of our patients, the parents understand that, the kids understand it.
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Sometimes you succeed in making them change the sport and so on.
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So I mean we have the responsibility as surgeons to tell our patients that this is um the thing, or even at the level above, if we deal with young professional athletes.
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Then uh depending again on the sport, if you tell them, for instance, triathlon athlete who comes with a severe meniscus injury that we treat, that we repair, then you can say, well, the most important is the longevity of your career and it's not how fast you will be back.
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So plan one year out of competition and then we will see thereafter.
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That's one example.
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Or if you have an another, I don't know, high-level tennis player that comes with again a career-threatening injury.
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I think that's something we have to tell them somehow, and keep these patients informed.
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I think that's the most difficult part in our job.
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So it relates not only to surgery but also much more to an ethical perspective.
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Absolutely.
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A lot of counseling and shared decision making with the patient.
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Yeah, definitely return to sport decisions are among the most difficult moments in sports medicine.
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There is pressure from athletes, teams, and sometimes even surgeons.
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Francesco, what do you think are the most important criteria when deciding whether an athlete is ready to return to competition?
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Uh that's a very broad question, of course.
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First of all, there is not a single time point.
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This is very important.
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It's more a continuum of evaluation of the patient, and Retunto Sport is a continuum also.
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In terms of the criteria, the domains that we need to consider, there are we think uh six main different domains.
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The first one is joint homeostasis.
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You want, of course, for example, in a setting of a ligament reconstruction, a stable joint, quite joint, of course, uh not swollen, and you want a full range of motion.
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This is joint homeostasis domain.
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Then you have the strength domain.
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The strength testing started as a functional testing in probably late or early 80s in the United States.
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So they are out there from a lot of years.
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However, they are not really adopted everywhere.
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So as low as 45% of the ACL patients, according to a survey that we have done across 60 or 70 different countries, perform at least one isocinitic test during rebilitation.
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So this is a second domain.
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Strength is always important and come first.
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Then the third domain is biomechanics.
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So you can check how the adlet move, doing jumping, landing, cutting task, deceleration task.
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And it depends from injury to injury.
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If you have an acceleration injury like an hamstring injury or a chillesthenol rupture, maybe you want to check acceleration.
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Whereas knee injuries are generally deceleration injuries.
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So biomechanics can be, of course, explored in 2D fashion or complex, 3D fashion.
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I suggest to keep it simple and stupid, keep it easy in clinical practice.
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Then you have the domain of cardiovascular fitness.
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Cardiovascular fitness is an important health domain in general for longevity as human beings and for athletic longevity, of course.
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And we need to explore also this.
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You can do threshold tests, VO2 max test.
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We have the possibility to do that.
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Then the fifth domain is neurocondia and psychological.
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Psychological readiness, the fear of injuries, kinesophobia, these are all domains that you want to explore.
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And it's very important that you don't find a mismatch between the psychological domain and the physical domains.
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I explain a little bit more.
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The patient at higher risk, in our opinion, and backed up from some preliminary data, are the ones that are very confident, but they score very bad at the physical test.
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So they are not prepared at all, but they are risk takers, and so they they rate themselves more than what they can do.
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The last bit of information that is about the wearables, for example, are GPS sport-specific metrics that you can find on the field.
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This is the ultimate metric that we need to consider in Return to Sport and can be applied also to recreation related, we do in our group, not just professional.
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So to recap a lot of different domains that evolve through time.
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So from joint homestasis, past strengths, biomechanics, cardiovascular affinity, psychological factors, and then GPS, sport specific on the field.
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Well, so these are a lot of domains that we have to balance with the desire of the patient to uh early return to sport.
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So, Romain, how do you balance the desire of the patient?
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Sometimes they want to return to sports uh earlier when maybe they're not ready to do so, and we have to stop them to uh so what uh you just depicted is the ideal world scenario, right?
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So that's that's really this is from theory, the the ideal world where you can add uh or work on these five, six factors just to make them ready, as ready as they can be.
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That's something that is very often not present in in the real world.
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So you need really criteria.
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The way that we are doing it right, or that I'm doing it as a surgeon is um and it's pretty easy.
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I see patients up to three months and then said, okay, so from now you don't need a surgeon anymore, and I transfer them to the sports medicine department if the knee is quiet and if everything is okay.
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Then they take over and they try to apply uh these principles that um Stefano just uh depicted.
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And then later on I may see them again.
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Or what I try to discuss with our sports medicine talks is uh to have the patients evaluated on a regular basis.
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They see them at three, four months, they see them at six months, they see them at nine months doing functional testing, and there we can see if they're ready to get back.
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Very often in the very in very young patients, and that's a program we have right now running in our service, is that at nine months they get really extensive biomechanical testing.
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That's what Francesco just said.
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Sorry Francesco That's probably something really easy and that can be easily performed in in every setting, that you need some objective criteria at six months or nine months, showing the patient that he's not as good as he thinks.
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Even though he has got clearance from his physiotherapist, there are still you find in 90% of the cases, you find still some big biomechanical deficits, and that you can show them.
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You show them here you're still in the red zone or in the orange zone, and you cannot make it safely back yet without uh jeopardizing the future health of your need.
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Yeah, absolutely.
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Uh rehabilitation is often the longest and most demanding part of recovery.
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Francesco, in your perspective, how has rehabilitation evolved in recent years for high-level athletes?
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This is really interesting because um we have been working on that, we have been trying to influence people on uh a couple of uh aspects.
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So I think that there are uh two main aspects in which uh rehabilitation domains to which rehabilitation has evolved a lot.
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The first one is uh uh biomechanical.
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So now, probably in the Zociniti test was a new thing in the 80s, about in 2000-2010, the new thing says uh application, wide application of biomechanical evaluation of single-leg high load tasks.
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Some groups started even before, but now is running out in an important way.
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So, comprehension of biomechanics on one side.
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We test and then basically what we see.
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The suggestion is to apply a targeted neuromaster training in order to correct the altered, say um non-optimal movement pattern, and then you test again.
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So the domains have to be objectively identified, and we need to be precise on that biomechanics.
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So on the other side, which is more something for the present but also for the future, is uh all the word of neurocognition and neurophysiology.
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So biomechanics on one side, neurophysiology on the other side.
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We have seen and we have depicted the neurological neuroconditive errors during, for example, ACL injuries in professional football players, male, female, it doesn't change, especially in football.
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Vast majority, three-quarter of the non-contact injury has this neuroconditive error.
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So we can work on that in order to optimize the recovery.
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And what is really interesting is a concept of neural efficiency.
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So neural efficiency refers to the concept that you don't have to think about your knee while you are executing movements.
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And so if you are performing, for example, a functional brain manori to understand the activation of the brain, if you are neurally efficient in order to do a simple kicking task, you don't need a lot of brain activation.
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But if you are not neurocharely efficient, and this is what exactly what happened after construction, you need more activation than normal.
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So this is not normal, and we are studying how to reduce actually this uh compensatory pattern at the central nervous system.
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So these are two big points of evolution of rehabilitation for the present and for the future.
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The other big aspect, so point number three, there is a number three, is being very sport-specific, adopting unfair rehabilitation.
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We have been done this for the past 35 years, but with the aid of technology now, with the GPS technology, with accelerometers, you can track loading in a very nice way.
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So these are the three evolution.
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Romain, from your perspective, do surgeons sometimes underestimate the importance of rehabilitation in determining the final outcomes?
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Oh, of course.
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I mean uh that's common practice.
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First of all, as you have heard now, rehabilitation and the whole return to sports workup that an athlete and a patient needs to do before being ready has become a specialty in itself.
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And uh that's why we as orthopaedic surgeons our part is getting increasingly smaller.
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So we may have a word to say when it comes to return to sports, but we do not really understand what is going on there to be honest.
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It's so specialized, and uh of course there is all these neurocognitive tasks and so on.
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So if you want to specialize in this also as orthopedic surgeon, you will not be operate uh able to operate anymore.
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That's really something we need to recognize, and we need to put ways in place to work with uh doctors who are as qualified as Francesco to work on our healthcare systems to get more than I would say 16 prescriptions for after an ACL surgery, like it's the case in Germany, for instance.
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These are our real problems we have to deal with.
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So and that's so individually different in in uh in every country in Europe.
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But again, yes, we underestimate it, probably because we do not really know it.
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And the third is uh yeah, we have to to find ways then to get around the legal framework that these are that are existing in in every country to bring this message back to sports.
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Our American colleagues have a several big advantages, especially when it comes to young athletes there, because many athletes are in the schools, in high schools, and sports has a much, much bigger value there than it has in Europe.
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So they are putting programs in place which can reach the athletes on the field.
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It's also very important for these young kids, for instance, to get their scholarships to go to university and so on and so on.
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So that's a totally different world.
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Uh and we are far from that in Europe.
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Yeah, absolutely.
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It's a it's a difficult balance as a surgeon to specialize also in the in this part that's growing so much rehabilitation.
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So another critical issue is the risk of early osteoarthritis following knee injuries.
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Even when athletes uh successfully return to sporn, the long-term health of the joint might still be compromised.
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Romain, what strategies can help protect the joint in the long term after injuries such as ACLTRS or meniscal damage?
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Well, I would say first before it comes to an injury prevention.
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An important thing I had a very interesting experience some weeks ago at the University of Sports in Cologne in Germany, where they made an uh survey among uh coaches uh in their area, and they got several hundreds of uh responses, and the questions was which are your priorities in sports with your athletes?
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And on the the ten first points, there was not a single point that was touching health injuries.
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It doesn't exist in in the sports world, especially in the youth sports world.
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And that's uh one thing we have to to deal with and to protect the joints with prevention.
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And we've heard Tom Pat this morning that uh we we are working on it.
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Well I hope that uh in the future also organizations, big organizations are taking their responsibility to work on that.
00:20:44.000 --> 00:20:52.559
Now after injury, after surgery, of course, I gave a whole lecture this morning on on what you can do to improve the outcome of surgery of joint preservation.
00:20:52.720 --> 00:20:55.680
It's not only about ACL reconstruction anymore.
00:20:55.759 --> 00:21:08.319
If we talk about ACL injuries, it's also about taking the whole environment into consideration, uh looking at uh the mini sky which play a much bigger role than uh we have um expected in the past.
00:21:08.559 --> 00:21:20.559
So extensive meniscal repair, good ACL reconstruction, adding or not a lateral extra tidinodesis when it comes to rerupture, consider slope changing procedures and so on and so on.
00:21:20.799 --> 00:21:26.319
In the end, we will never be able to fully protect athletes' knee, be they injured or not.
00:21:26.480 --> 00:21:32.960
So um we know that if you have a 10-year high-level sports practice that you will have some degree of ostearthritis.
00:21:33.119 --> 00:21:43.519
But again, there we need them to learn and to bring the principles to the sports world that they need to do load management and so on, which is not the case in many many sports yet.
00:21:43.759 --> 00:21:45.200
So, yeah, there are different ways.
00:21:45.279 --> 00:21:51.039
So both prevention and then prevention of secondary injuries and do better surgery, better job that we do.
00:21:51.119 --> 00:21:54.880
And then finally, what Francesco just said is uh making good reaction.
00:21:55.279 --> 00:21:56.799
Prevention with capitals.
00:21:57.039 --> 00:21:59.599
Looking ahead, Francesco, new technologies might.
00:22:00.480 --> 00:22:06.960
How we monitor recovery and performance, wearables, motion analysis, digital tracking tools.
00:22:07.279 --> 00:22:10.400
These are already entering sports medicine.
00:22:10.559 --> 00:22:16.079
How do you see technology influencing return to performance decisions in coming years?
00:22:16.400 --> 00:22:17.279
A nice point.
00:22:17.440 --> 00:22:19.920
This is one of my favorite ones in general.
00:22:20.160 --> 00:22:24.160
I don't think that technology will influence any decision.
00:22:24.319 --> 00:22:30.400
I think that we, as human beings, will influence decisions based on information.
00:22:30.480 --> 00:22:32.640
So I explain a little bit better.
00:22:32.880 --> 00:22:43.279
Of course, we need to embrace technology and we will as a community progressively embrace also complex software, artificial intelligence software.
00:22:43.599 --> 00:22:48.559
But human intelligence is different because human intelligence is based on the process.
00:22:48.799 --> 00:22:51.920
So we are better because we do something.
00:22:52.160 --> 00:23:00.640
In order, for example, to do a systematic review, you need to read maybe 500 papers or 1000 papers in the wider ones.
00:23:00.799 --> 00:23:02.960
In this process, you get better.
00:23:03.119 --> 00:23:05.759
It's not the end result that is important.
00:23:06.000 --> 00:23:09.839
Whereas in terms of artificial intelligence, it's exactly the opposite.
00:23:10.079 --> 00:23:12.480
Artificial intelligence is about the end result.
00:23:12.720 --> 00:23:14.960
So you put something and you have the end result.
00:23:15.119 --> 00:23:21.920
Maybe something that you had in before in one month, in two months, in three months, you add in 30 seconds.
00:23:22.160 --> 00:23:24.319
So we need to embrace this aspect.
00:23:24.720 --> 00:23:26.480
Human intelligence is different.
00:23:26.640 --> 00:23:34.079
And so we as human beings, we will take probably better decisions because we'll have these sides, but we need to interpret in this way.
00:23:34.400 --> 00:23:46.640
So the six domains of physical function that we discussed before can be even integrated and probably will arrive to a sort of digital twinning of our patients.
00:23:47.039 --> 00:23:49.599
We are not very far from this point.
00:23:49.759 --> 00:23:57.440
It can be automatic because of the aid of technology, but decisions need to be taken on a few factors.
00:23:57.759 --> 00:24:01.039
Six are the very maximum, maybe five is even better.
00:24:01.200 --> 00:24:02.640
We need to keep it simple.
00:24:02.880 --> 00:24:09.039
So technology without us, at a certain extent, yes, but our approach, our evolving approach, will do it more.
00:24:09.279 --> 00:24:20.160
Romain, you already mentioned preservation, but if you had to predict the next big breakthrough in joint preservation and not leap recovery, what would it be?
00:24:20.559 --> 00:24:25.759
I would like to have an injury or re-injury risk predictor, an individual one.
00:24:25.839 --> 00:24:27.599
I know that some people are working on that.
00:24:27.680 --> 00:24:38.640
That would be really interesting, and that this should be based on the uh findings of the structural damage that has occurred in the knee on one side and on the other side on the knee morphology.
00:24:38.880 --> 00:24:45.279
Including and also analysis uh of MRIs, which are still poor today, we're very poor at that.
00:24:45.359 --> 00:24:50.400
So AI could really help us uh getting a big step forward in this direction.
00:24:50.640 --> 00:24:53.200
You mentioned digital twins, I I agree on that.
00:24:53.359 --> 00:25:09.759
Um if you have your digital twin and you follow up a knee, uh for instance with follow-up MRIs, I would say on an annual or biannual basis, that uh could be super interesting to see in which direction any evolves, if there is something you need to improve on that, so it will be much more individualized and personalized.
00:25:09.920 --> 00:25:13.680
So these are some path that I just see now popping up.
00:25:13.920 --> 00:25:19.680
So before we finish, I would like to ask each of you for one uh take-home message.
00:25:20.000 --> 00:25:32.000
For surgeons, physiotherapists, and sports uh medicine physicians working with athletes today, what is the most important principle when managing return to performance?
00:25:32.319 --> 00:25:35.039
The most important principle is work as a team.
00:25:35.200 --> 00:25:36.559
We need to work together.
00:25:36.720 --> 00:25:46.559
So, in order to take care of an athlete with a complex knee injury, we need a sports medicine team, a sports orthopedics team.
00:25:46.640 --> 00:25:51.680
So I need Romaine as Romain needs me for the for the subsequent part.
00:25:51.839 --> 00:25:54.559
So we need to cross-talk more and work as a team.
00:25:54.720 --> 00:25:56.559
This is my final message.
00:25:56.880 --> 00:26:00.559
I do agree, but this teamwork is not supported.
00:26:00.720 --> 00:26:05.599
I do not know any healthcare system in the world that supports teamwork, right?
00:26:05.759 --> 00:26:12.640
So that's a game changer, then if you would get into this direction, but I do totally agree with Francesco that this is the most important thing.
00:26:12.880 --> 00:26:17.759
Well, Romain, Francesco, thank you both for sharing your insights and experience.
00:26:18.240 --> 00:26:19.119
Thank you, Joaquin.
00:26:19.279 --> 00:26:19.680
Thank you very much for it.
00:26:21.200 --> 00:26:35.920
Balancing performance, recovery, and long-term joint health remains one of the central challenges in sports medicine, and discussions like this help us better understand how to guide athletes safely back to their highest level.
00:26:36.160 --> 00:26:45.519
To our listeners, thank you for joining us on another episode of Frontiers in Orthopedic Surgery, the Eska Kesta Official Podcast.
00:26:45.839 --> 00:26:54.880
Stay tuned for our next episode about optimizing ACL revision surgery with Martin Lind and Alberto Grassi.
00:26:54.960 --> 00:26:58.960
And until then, keep advancing orthopedic science.
00:00:00.320 --> 00:00:17.120
A study of the group of Andy Williams, about 200 players across the world broad levels of English football, found out that as low as 30% actually returned to performance if you consider just returned to the league level and the playing minutes.
00:00:17.679 --> 00:00:31.440
The thing when you see, for instance, a 16-year-old with an ACL injury football player or whatever sport, the first thing I tell them is: listen, most probably your joint is now 10 years elder than yourself, so you have to take care of it.
00:00:32.000 --> 00:00:39.520
Welcome everyone to another episode of Frontiers in Orthopedic Surgery, the official podcast of SK and Kesta Journal.
00:00:39.600 --> 00:00:42.159
I'm your host, Joaquin Moya Angiler.
00:00:42.240 --> 00:00:49.840
Today we will explore a topic that sits at the intersection of sports medicine rehabilitation and joint preservation.
00:00:50.159 --> 00:00:53.119
Return to performance after knee injury.
00:00:53.359 --> 00:00:55.920
In recent years, our goals have evolved.
00:00:56.079 --> 00:01:06.799
It is no longer just about returning athletes to sport, but about returning them to their previous level of performance while protecting long-term joint health.
00:01:07.120 --> 00:01:14.959
Balancing these objectives remain one of the biggest challenges in modern knee surgery and sports medicine.
00:01:15.200 --> 00:01:43.040
To help us navigate this important topic, I'm delighted to welcome two exceptional experts, Professor Roman Sale from Luxembourg, a leading authority in knee surgery and joint preservation, with longstanding interest in long-term outcomes following sports injuries, and Francesco Della Villa from the Isokinetic Medical Group in Bologna, Italy, a world-renowned specialist in sports medicine.
00:01:43.280 --> 00:01:46.799
Romaine, Francesco, thank you both for joining us today.
00:01:47.200 --> 00:01:48.159
Thank you, Joakin.
00:01:48.480 --> 00:01:54.239
All right, so before we start our discussion, we're gonna begin with our lighting round section.
00:01:54.400 --> 00:01:56.000
It's gonna be 10 questions.
00:01:56.239 --> 00:01:58.400
You just have to answer yes or no.
00:01:58.719 --> 00:02:02.480
We will return to some of these topics later in the episode.
00:02:02.640 --> 00:02:05.760
So Romain will answer first and then Francesco.
00:02:06.319 --> 00:02:12.479
First, is return to sport after knee injury still being rushed too often?
00:02:12.879 --> 00:02:13.199
Yes.
00:02:14.080 --> 00:02:14.400
Yes.
00:02:15.280 --> 00:02:22.159
Second, should return to sport decisions rely more on objected functional testing?
00:02:22.479 --> 00:02:23.360
Yes, yes.
00:02:23.599 --> 00:02:28.479
Three, is psychological readiness as important as physical recovery?
00:02:28.800 --> 00:02:30.719
If I would say no, my wife would kill me.
00:02:30.800 --> 00:02:32.879
She's a psychiatrist, so definitely yes.
00:02:33.120 --> 00:02:33.599
Of course.
00:02:33.919 --> 00:02:34.159
Okay.
00:02:34.319 --> 00:02:39.120
Fourth, are current return to sport criteria too simplistic?
00:02:39.680 --> 00:02:40.159
Yes.
00:02:40.800 --> 00:02:41.120
No.
00:02:42.159 --> 00:02:44.400
Depends on which setting you're working in.
00:02:44.879 --> 00:02:46.479
Okay, we have a disagreement.
00:02:46.719 --> 00:02:54.240
Five, can rehabilitation alone sometimes be as important as surgery for the long-term outcomes?
00:02:54.719 --> 00:02:55.599
I think so, yes.
00:02:56.080 --> 00:02:56.479
Can be.
00:02:56.879 --> 00:02:57.360
Six.
00:02:57.840 --> 00:03:03.439
Should joint preservation strategies be considered earlier in young athletes?
00:03:03.919 --> 00:03:04.560
Absolutely.
00:03:04.800 --> 00:03:05.199
Yes.
00:03:05.520 --> 00:03:11.919
Seven, are we underestimating the risk of early osteoarthritis after sports injuries?
00:03:12.159 --> 00:03:12.639
Oh yes.
00:03:12.800 --> 00:03:13.199
Yes.
00:03:13.680 --> 00:03:19.840
Eight, should data from wearable technology become part of return to performance decisions?
00:03:20.159 --> 00:03:21.039
That would be nice.
00:03:21.199 --> 00:03:21.599
Yes.
00:03:21.840 --> 00:03:26.319
Nine, will personalized rehabilitation protocols become the new standard?
00:03:26.639 --> 00:03:27.439
Yes, I think so.
00:03:27.680 --> 00:03:28.639
It's already.
00:03:29.120 --> 00:03:31.520
Again, depends on which setting you're working in.
00:03:31.919 --> 00:03:32.639
Absolutely.
00:03:32.960 --> 00:03:42.319
And then finally, can we realistically protect the knee joint while allowing athletes to return to elite level performance?
00:03:42.800 --> 00:03:43.280
Joker.
00:03:43.360 --> 00:03:45.280
So I would say to some extent.
00:03:46.080 --> 00:03:46.319
No.
00:03:46.639 --> 00:03:50.000
Okay, well, we have some almost total consensus.
00:03:50.159 --> 00:03:53.599
So let's uh explore these ideas in more detail.
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Francesco, historically, our goal after injury or surgery was simply return to sport.
00:04:00.240 --> 00:04:03.680
But increasingly we talk about return to performance.
00:04:03.840 --> 00:04:06.960
How would you define the difference between these two concepts?
00:04:07.199 --> 00:04:09.599
Well, Joaquin, this is a very interesting question.
00:04:09.680 --> 00:04:12.800
And we just navigated this through a conference.
00:04:12.960 --> 00:04:18.720
So the last conference of the Zucchini Medical Group was solely dedicated to return to performance.
00:04:18.959 --> 00:04:20.399
And there is a big difference.
00:04:20.560 --> 00:04:23.920
So return to sport, it's returned to sport participation.
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So we have uh, for example, a football player that gets back to training with the team, return to training, and then get back to match play, this return to competition.
00:04:32.560 --> 00:04:35.600
And we can define this as return to sport.
00:04:36.079 --> 00:04:46.399
Generally, historically, in sports orthopedics, if you return to the previous sport before the injury and to the previous level, we consider it a success.
00:04:46.720 --> 00:04:48.959
Return to performance is completely different.
00:04:49.199 --> 00:04:56.319
Return to performance can happen or not following ACR reconstruction, for example, in professional players.
00:04:56.560 --> 00:05:13.040
A study of the group of Andy Williams, about 200 players across the world broad levels of English football, found out that as low as 30% actually return to performance if you consider just return to the league level and the playing minutes.
00:05:13.199 --> 00:05:24.079
If we had on top of that all the performance factors that are related, of course, to passes completed, goal scored, saves for the goalkeeper, etc.
00:05:24.240 --> 00:05:24.560
etc.
00:05:24.720 --> 00:05:30.240
And at the end win loses, winning trophies, then that percent is really, really low.
00:05:30.399 --> 00:05:36.639
So return to performance means rising the bar of sports medicine outcomes.
00:05:36.879 --> 00:05:39.040
Alright, interesting concepts and numbers.
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Rome, from a surgical perspective, how important is it to think about the long-term joint preservation when treating young athletes with knee injuries?
00:05:49.839 --> 00:05:51.680
Well, I think it's uh very important.
00:05:52.000 --> 00:05:55.680
Um it defines also how you define young athletes.
00:05:55.839 --> 00:05:59.759
Um I'm 60 now, so uh everybody who is below is young for me.
00:06:00.079 --> 00:06:01.199
Still a young athlete.
00:06:01.600 --> 00:06:12.160
So if we consider the legal perspective, I think the under 18 are the ones where we really need to make efforts and where the legal situation is not really clear.
00:06:12.240 --> 00:06:15.600
So who is responsible for these uh athletes?
00:06:15.839 --> 00:06:18.480
Is it uh the patient himself or herself?
00:06:18.639 --> 00:06:19.360
Is it the club?
00:06:19.439 --> 00:06:20.720
Is it the federation?
00:06:20.959 --> 00:06:27.839
There are a lot of um adults that uh deal with uh these young athletes, they start to make money with them and so on.
00:06:27.920 --> 00:06:34.000
So that goes really beyond surgery, so that's an ethical question that is not being solved in high-level sports yet.
00:06:34.319 --> 00:06:38.560
So the importance on the long-term aspect is is really big.
00:06:38.639 --> 00:06:53.600
So in these athletes, the thing when you see, for instance, a 16-year-old with an ACL injury football player or whatever sport, the first thing I tell them is listen, most probably your joint is now ten years older than yourself, so you have to take care of it.
00:06:53.839 --> 00:07:04.959
And uh irrespective of the surgery I do, and irrespective of what we will do and then what the outcome will be, uh that's how things are, and I think in most of the cases that is reality.
00:07:05.199 --> 00:07:10.079
And uh if they are under 18, you also have to talk to their parents and they have to understand that.
00:07:10.160 --> 00:07:24.399
And uh if you're in an elite level environment and it's difficult, the pill that is difficult to swallow, but uh if you're in an amateur environment, that's still I would say the majority of our patients, the parents understand that, the kids understand it.
00:07:24.560 --> 00:07:28.399
Sometimes you succeed in making them change the sport and so on.
00:07:28.639 --> 00:07:39.279
So I mean we have the responsibility as surgeons to tell our patients that this is um the thing, or even at the level above, if we deal with young professional athletes.
00:07:39.519 --> 00:07:54.879
Then uh depending again on the sport, if you tell them, for instance, triathlon athlete who comes with a severe meniscus injury that we treat, that we repair, then you can say, well, the most important is the longevity of your career and it's not how fast you will be back.
00:07:55.199 --> 00:08:00.079
So plan one year out of competition and then we will see thereafter.
00:08:00.240 --> 00:08:01.120
That's one example.
00:08:01.279 --> 00:08:07.839
Or if you have an another, I don't know, high-level tennis player that comes with again a career-threatening injury.
00:08:07.920 --> 00:08:12.079
I think that's something we have to tell them somehow, and keep these patients informed.
00:08:12.319 --> 00:08:15.600
I think that's the most difficult part in our job.
00:08:15.680 --> 00:08:20.319
So it relates not only to surgery but also much more to an ethical perspective.
00:08:20.639 --> 00:08:21.120
Absolutely.
00:08:21.279 --> 00:08:24.639
A lot of counseling and shared decision making with the patient.
00:08:24.879 --> 00:08:30.959
Yeah, definitely return to sport decisions are among the most difficult moments in sports medicine.
00:08:31.120 --> 00:08:35.600
There is pressure from athletes, teams, and sometimes even surgeons.
00:08:35.840 --> 00:08:43.679
Francesco, what do you think are the most important criteria when deciding whether an athlete is ready to return to competition?
00:08:43.919 --> 00:08:46.720
Uh that's a very broad question, of course.
00:08:47.039 --> 00:08:51.279
First of all, there is not a single time point.
00:08:51.440 --> 00:08:52.480
This is very important.
00:08:52.799 --> 00:08:58.799
It's more a continuum of evaluation of the patient, and Retunto Sport is a continuum also.
00:08:59.200 --> 00:09:07.360
In terms of the criteria, the domains that we need to consider, there are we think uh six main different domains.
00:09:07.600 --> 00:09:10.080
The first one is joint homeostasis.
00:09:10.159 --> 00:09:20.960
You want, of course, for example, in a setting of a ligament reconstruction, a stable joint, quite joint, of course, uh not swollen, and you want a full range of motion.
00:09:21.039 --> 00:09:23.039
This is joint homeostasis domain.
00:09:23.279 --> 00:09:25.279
Then you have the strength domain.
00:09:25.519 --> 00:09:33.919
The strength testing started as a functional testing in probably late or early 80s in the United States.
00:09:34.159 --> 00:09:37.759
So they are out there from a lot of years.
00:09:37.919 --> 00:09:41.200
However, they are not really adopted everywhere.
00:09:41.279 --> 00:09:54.080
So as low as 45% of the ACL patients, according to a survey that we have done across 60 or 70 different countries, perform at least one isocinitic test during rebilitation.
00:09:54.240 --> 00:09:55.440
So this is a second domain.
00:09:55.679 --> 00:09:58.639
Strength is always important and come first.
00:09:59.360 --> 00:10:01.279
Then the third domain is biomechanics.
00:10:01.360 --> 00:10:07.200
So you can check how the adlet move, doing jumping, landing, cutting task, deceleration task.
00:10:07.279 --> 00:10:09.679
And it depends from injury to injury.
00:10:09.840 --> 00:10:15.679
If you have an acceleration injury like an hamstring injury or a chillesthenol rupture, maybe you want to check acceleration.
00:10:15.840 --> 00:10:19.120
Whereas knee injuries are generally deceleration injuries.
00:10:19.279 --> 00:10:24.559
So biomechanics can be, of course, explored in 2D fashion or complex, 3D fashion.
00:10:24.720 --> 00:10:28.799
I suggest to keep it simple and stupid, keep it easy in clinical practice.
00:10:29.039 --> 00:10:32.080
Then you have the domain of cardiovascular fitness.
00:10:32.159 --> 00:10:40.639
Cardiovascular fitness is an important health domain in general for longevity as human beings and for athletic longevity, of course.
00:10:40.799 --> 00:10:42.639
And we need to explore also this.
00:10:42.879 --> 00:10:45.840
You can do threshold tests, VO2 max test.
00:10:46.399 --> 00:10:48.320
We have the possibility to do that.
00:10:48.559 --> 00:10:52.320
Then the fifth domain is neurocondia and psychological.
00:10:52.480 --> 00:10:59.440
Psychological readiness, the fear of injuries, kinesophobia, these are all domains that you want to explore.
00:10:59.600 --> 00:11:06.879
And it's very important that you don't find a mismatch between the psychological domain and the physical domains.
00:11:07.039 --> 00:11:08.480
I explain a little bit more.
00:11:08.720 --> 00:11:18.159
The patient at higher risk, in our opinion, and backed up from some preliminary data, are the ones that are very confident, but they score very bad at the physical test.
00:11:18.399 --> 00:11:25.519
So they are not prepared at all, but they are risk takers, and so they they rate themselves more than what they can do.
00:11:25.919 --> 00:11:34.960
The last bit of information that is about the wearables, for example, are GPS sport-specific metrics that you can find on the field.
00:11:35.200 --> 00:11:46.879
This is the ultimate metric that we need to consider in Return to Sport and can be applied also to recreation related, we do in our group, not just professional.
00:11:47.039 --> 00:11:52.320
So to recap a lot of different domains that evolve through time.
00:11:52.480 --> 00:12:02.159
So from joint homestasis, past strengths, biomechanics, cardiovascular affinity, psychological factors, and then GPS, sport specific on the field.
00:12:02.399 --> 00:12:10.000
Well, so these are a lot of domains that we have to balance with the desire of the patient to uh early return to sport.
00:12:10.159 --> 00:12:14.159
So, Romain, how do you balance the desire of the patient?
00:12:14.399 --> 00:12:27.120
Sometimes they want to return to sports uh earlier when maybe they're not ready to do so, and we have to stop them to uh so what uh you just depicted is the ideal world scenario, right?
00:12:27.279 --> 00:12:38.240
So that's that's really this is from theory, the the ideal world where you can add uh or work on these five, six factors just to make them ready, as ready as they can be.
00:12:38.399 --> 00:12:42.639
That's something that is very often not present in in the real world.
00:12:42.720 --> 00:12:45.279
So you need really criteria.
00:12:45.519 --> 00:12:51.519
The way that we are doing it right, or that I'm doing it as a surgeon is um and it's pretty easy.
00:12:51.679 --> 00:13:02.879
I see patients up to three months and then said, okay, so from now you don't need a surgeon anymore, and I transfer them to the sports medicine department if the knee is quiet and if everything is okay.
00:13:03.120 --> 00:13:10.399
Then they take over and they try to apply uh these principles that um Stefano just uh depicted.
00:13:10.639 --> 00:13:13.519
And then later on I may see them again.
00:13:13.600 --> 00:13:22.320
Or what I try to discuss with our sports medicine talks is uh to have the patients evaluated on a regular basis.
00:13:22.559 --> 00:13:32.960
They see them at three, four months, they see them at six months, they see them at nine months doing functional testing, and there we can see if they're ready to get back.
00:13:33.200 --> 00:13:43.919
Very often in the very in very young patients, and that's a program we have right now running in our service, is that at nine months they get really extensive biomechanical testing.
00:13:44.000 --> 00:13:45.840
That's what Francesco just said.
00:13:46.000 --> 00:14:02.000
Sorry Francesco That's probably something really easy and that can be easily performed in in every setting, that you need some objective criteria at six months or nine months, showing the patient that he's not as good as he thinks.
00:14:02.159 --> 00:14:12.159
Even though he has got clearance from his physiotherapist, there are still you find in 90% of the cases, you find still some big biomechanical deficits, and that you can show them.
00:14:12.320 --> 00:14:20.879
You show them here you're still in the red zone or in the orange zone, and you cannot make it safely back yet without uh jeopardizing the future health of your need.
00:14:21.200 --> 00:14:22.080
Yeah, absolutely.
00:14:22.240 --> 00:14:26.720
Uh rehabilitation is often the longest and most demanding part of recovery.
00:14:26.879 --> 00:14:33.200
Francesco, in your perspective, how has rehabilitation evolved in recent years for high-level athletes?
00:14:33.519 --> 00:14:42.399
This is really interesting because um we have been working on that, we have been trying to influence people on uh a couple of uh aspects.
00:14:42.639 --> 00:14:49.600
So I think that there are uh two main aspects in which uh rehabilitation domains to which rehabilitation has evolved a lot.
00:14:49.840 --> 00:14:52.879
The first one is uh uh biomechanical.
00:14:53.120 --> 00:15:10.080
So now, probably in the Zociniti test was a new thing in the 80s, about in 2000-2010, the new thing says uh application, wide application of biomechanical evaluation of single-leg high load tasks.
00:15:10.240 --> 00:15:15.919
Some groups started even before, but now is running out in an important way.
00:15:16.080 --> 00:15:19.440
So, comprehension of biomechanics on one side.
00:15:19.600 --> 00:15:22.080
We test and then basically what we see.
00:15:22.159 --> 00:15:31.840
The suggestion is to apply a targeted neuromaster training in order to correct the altered, say um non-optimal movement pattern, and then you test again.
00:15:32.000 --> 00:15:38.639
So the domains have to be objectively identified, and we need to be precise on that biomechanics.
00:15:38.720 --> 00:15:48.080
So on the other side, which is more something for the present but also for the future, is uh all the word of neurocognition and neurophysiology.
00:15:48.159 --> 00:15:51.039
So biomechanics on one side, neurophysiology on the other side.
00:15:51.200 --> 00:16:04.799
We have seen and we have depicted the neurological neuroconditive errors during, for example, ACL injuries in professional football players, male, female, it doesn't change, especially in football.
00:16:05.120 --> 00:16:10.639
Vast majority, three-quarter of the non-contact injury has this neuroconditive error.
00:16:10.799 --> 00:16:14.639
So we can work on that in order to optimize the recovery.
00:16:14.879 --> 00:16:19.279
And what is really interesting is a concept of neural efficiency.
00:16:19.440 --> 00:16:27.440
So neural efficiency refers to the concept that you don't have to think about your knee while you are executing movements.
00:16:27.679 --> 00:16:40.639
And so if you are performing, for example, a functional brain manori to understand the activation of the brain, if you are neurally efficient in order to do a simple kicking task, you don't need a lot of brain activation.
00:16:40.799 --> 00:16:48.960
But if you are not neurocharely efficient, and this is what exactly what happened after construction, you need more activation than normal.
00:16:49.200 --> 00:16:58.480
So this is not normal, and we are studying how to reduce actually this uh compensatory pattern at the central nervous system.
00:16:58.639 --> 00:17:04.720
So these are two big points of evolution of rehabilitation for the present and for the future.
00:17:04.960 --> 00:17:12.480
The other big aspect, so point number three, there is a number three, is being very sport-specific, adopting unfair rehabilitation.
00:17:12.640 --> 00:17:23.839
We have been done this for the past 35 years, but with the aid of technology now, with the GPS technology, with accelerometers, you can track loading in a very nice way.
00:17:23.920 --> 00:17:25.599
So these are the three evolution.
00:17:25.839 --> 00:17:33.920
Romain, from your perspective, do surgeons sometimes underestimate the importance of rehabilitation in determining the final outcomes?
00:17:34.319 --> 00:17:35.039
Oh, of course.
00:17:35.119 --> 00:17:37.119
I mean uh that's common practice.
00:17:37.359 --> 00:17:51.440
First of all, as you have heard now, rehabilitation and the whole return to sports workup that an athlete and a patient needs to do before being ready has become a specialty in itself.
00:17:51.759 --> 00:17:57.119
And uh that's why we as orthopaedic surgeons our part is getting increasingly smaller.
00:17:57.359 --> 00:18:04.480
So we may have a word to say when it comes to return to sports, but we do not really understand what is going on there to be honest.
00:18:04.880 --> 00:18:09.839
It's so specialized, and uh of course there is all these neurocognitive tasks and so on.
00:18:09.920 --> 00:18:15.599
So if you want to specialize in this also as orthopedic surgeon, you will not be operate uh able to operate anymore.
00:18:15.839 --> 00:18:33.839
That's really something we need to recognize, and we need to put ways in place to work with uh doctors who are as qualified as Francesco to work on our healthcare systems to get more than I would say 16 prescriptions for after an ACL surgery, like it's the case in Germany, for instance.
00:18:34.079 --> 00:18:36.319
These are our real problems we have to deal with.
00:18:36.400 --> 00:18:40.480
So and that's so individually different in in uh in every country in Europe.
00:18:40.640 --> 00:18:45.680
But again, yes, we underestimate it, probably because we do not really know it.
00:18:45.839 --> 00:18:57.599
And the third is uh yeah, we have to to find ways then to get around the legal framework that these are that are existing in in every country to bring this message back to sports.
00:18:57.680 --> 00:19:10.559
Our American colleagues have a several big advantages, especially when it comes to young athletes there, because many athletes are in the schools, in high schools, and sports has a much, much bigger value there than it has in Europe.
00:19:10.799 --> 00:19:15.759
So they are putting programs in place which can reach the athletes on the field.
00:19:16.000 --> 00:19:21.839
It's also very important for these young kids, for instance, to get their scholarships to go to university and so on and so on.
00:19:21.920 --> 00:19:23.599
So that's a totally different world.
00:19:23.680 --> 00:19:25.440
Uh and we are far from that in Europe.
00:19:25.680 --> 00:19:26.400
Yeah, absolutely.
00:19:26.480 --> 00:19:33.680
It's a it's a difficult balance as a surgeon to specialize also in the in this part that's growing so much rehabilitation.
00:19:33.839 --> 00:19:39.519
So another critical issue is the risk of early osteoarthritis following knee injuries.
00:19:39.759 --> 00:19:47.440
Even when athletes uh successfully return to sporn, the long-term health of the joint might still be compromised.
00:19:47.680 --> 00:19:56.000
Romain, what strategies can help protect the joint in the long term after injuries such as ACLTRS or meniscal damage?
00:19:56.240 --> 00:19:59.359
Well, I would say first before it comes to an injury prevention.
00:19:59.680 --> 00:20:18.000
An important thing I had a very interesting experience some weeks ago at the University of Sports in Cologne in Germany, where they made an uh survey among uh coaches uh in their area, and they got several hundreds of uh responses, and the questions was which are your priorities in sports with your athletes?
00:20:18.160 --> 00:20:24.559
And on the the ten first points, there was not a single point that was touching health injuries.
00:20:24.799 --> 00:20:28.480
It doesn't exist in in the sports world, especially in the youth sports world.
00:20:28.640 --> 00:20:33.440
And that's uh one thing we have to to deal with and to protect the joints with prevention.
00:20:33.519 --> 00:20:37.279
And we've heard Tom Pat this morning that uh we we are working on it.
00:20:37.440 --> 00:20:43.839
Well I hope that uh in the future also organizations, big organizations are taking their responsibility to work on that.
00:20:44.000 --> 00:20:52.559
Now after injury, after surgery, of course, I gave a whole lecture this morning on on what you can do to improve the outcome of surgery of joint preservation.
00:20:52.720 --> 00:20:55.680
It's not only about ACL reconstruction anymore.
00:20:55.759 --> 00:21:08.319
If we talk about ACL injuries, it's also about taking the whole environment into consideration, uh looking at uh the mini sky which play a much bigger role than uh we have um expected in the past.
00:21:08.559 --> 00:21:20.559
So extensive meniscal repair, good ACL reconstruction, adding or not a lateral extra tidinodesis when it comes to rerupture, consider slope changing procedures and so on and so on.
00:21:20.799 --> 00:21:26.319
In the end, we will never be able to fully protect athletes' knee, be they injured or not.
00:21:26.480 --> 00:21:32.960
So um we know that if you have a 10-year high-level sports practice that you will have some degree of ostearthritis.
00:21:33.119 --> 00:21:43.519
But again, there we need them to learn and to bring the principles to the sports world that they need to do load management and so on, which is not the case in many many sports yet.
00:21:43.759 --> 00:21:45.200
So, yeah, there are different ways.
00:21:45.279 --> 00:21:51.039
So both prevention and then prevention of secondary injuries and do better surgery, better job that we do.
00:21:51.119 --> 00:21:54.880
And then finally, what Francesco just said is uh making good reaction.
00:21:55.279 --> 00:21:56.799
Prevention with capitals.
00:21:57.039 --> 00:21:59.599
Looking ahead, Francesco, new technologies might.
00:22:00.480 --> 00:22:06.960
How we monitor recovery and performance, wearables, motion analysis, digital tracking tools.
00:22:07.279 --> 00:22:10.400
These are already entering sports medicine.
00:22:10.559 --> 00:22:16.079
How do you see technology influencing return to performance decisions in coming years?
00:22:16.400 --> 00:22:17.279
A nice point.
00:22:17.440 --> 00:22:19.920
This is one of my favorite ones in general.
00:22:20.160 --> 00:22:24.160
I don't think that technology will influence any decision.
00:22:24.319 --> 00:22:30.400
I think that we, as human beings, will influence decisions based on information.
00:22:30.480 --> 00:22:32.640
So I explain a little bit better.
00:22:32.880 --> 00:22:43.279
Of course, we need to embrace technology and we will as a community progressively embrace also complex software, artificial intelligence software.
00:22:43.599 --> 00:22:48.559
But human intelligence is different because human intelligence is based on the process.
00:22:48.799 --> 00:22:51.920
So we are better because we do something.
00:22:52.160 --> 00:23:00.640
In order, for example, to do a systematic review, you need to read maybe 500 papers or 1000 papers in the wider ones.
00:23:00.799 --> 00:23:02.960
In this process, you get better.
00:23:03.119 --> 00:23:05.759
It's not the end result that is important.
00:23:06.000 --> 00:23:09.839
Whereas in terms of artificial intelligence, it's exactly the opposite.
00:23:10.079 --> 00:23:12.480
Artificial intelligence is about the end result.
00:23:12.720 --> 00:23:14.960
So you put something and you have the end result.
00:23:15.119 --> 00:23:21.920
Maybe something that you had in before in one month, in two months, in three months, you add in 30 seconds.
00:23:22.160 --> 00:23:24.319
So we need to embrace this aspect.
00:23:24.720 --> 00:23:26.480
Human intelligence is different.
00:23:26.640 --> 00:23:34.079
And so we as human beings, we will take probably better decisions because we'll have these sides, but we need to interpret in this way.
00:23:34.400 --> 00:23:46.640
So the six domains of physical function that we discussed before can be even integrated and probably will arrive to a sort of digital twinning of our patients.
00:23:47.039 --> 00:23:49.599
We are not very far from this point.
00:23:49.759 --> 00:23:57.440
It can be automatic because of the aid of technology, but decisions need to be taken on a few factors.
00:23:57.759 --> 00:24:01.039
Six are the very maximum, maybe five is even better.
00:24:01.200 --> 00:24:02.640
We need to keep it simple.
00:24:02.880 --> 00:24:09.039
So technology without us, at a certain extent, yes, but our approach, our evolving approach, will do it more.
00:24:09.279 --> 00:24:20.160
Romain, you already mentioned preservation, but if you had to predict the next big breakthrough in joint preservation and not leap recovery, what would it be?
00:24:20.559 --> 00:24:25.759
I would like to have an injury or re-injury risk predictor, an individual one.
00:24:25.839 --> 00:24:27.599
I know that some people are working on that.
00:24:27.680 --> 00:24:38.640
That would be really interesting, and that this should be based on the uh findings of the structural damage that has occurred in the knee on one side and on the other side on the knee morphology.
00:24:38.880 --> 00:24:45.279
Including and also analysis uh of MRIs, which are still poor today, we're very poor at that.
00:24:45.359 --> 00:24:50.400
So AI could really help us uh getting a big step forward in this direction.
00:24:50.640 --> 00:24:53.200
You mentioned digital twins, I I agree on that.
00:24:53.359 --> 00:25:09.759
Um if you have your digital twin and you follow up a knee, uh for instance with follow-up MRIs, I would say on an annual or biannual basis, that uh could be super interesting to see in which direction any evolves, if there is something you need to improve on that, so it will be much more individualized and personalized.
00:25:09.920 --> 00:25:13.680
So these are some path that I just see now popping up.
00:25:13.920 --> 00:25:19.680
So before we finish, I would like to ask each of you for one uh take-home message.
00:25:20.000 --> 00:25:32.000
For surgeons, physiotherapists, and sports uh medicine physicians working with athletes today, what is the most important principle when managing return to performance?
00:25:32.319 --> 00:25:35.039
The most important principle is work as a team.
00:25:35.200 --> 00:25:36.559
We need to work together.
00:25:36.720 --> 00:25:46.559
So, in order to take care of an athlete with a complex knee injury, we need a sports medicine team, a sports orthopedics team.
00:25:46.640 --> 00:25:51.680
So I need Romaine as Romain needs me for the for the subsequent part.
00:25:51.839 --> 00:25:54.559
So we need to cross-talk more and work as a team.
00:25:54.720 --> 00:25:56.559
This is my final message.
00:25:56.880 --> 00:26:00.559
I do agree, but this teamwork is not supported.
00:26:00.720 --> 00:26:05.599
I do not know any healthcare system in the world that supports teamwork, right?
00:26:05.759 --> 00:26:12.640
So that's a game changer, then if you would get into this direction, but I do totally agree with Francesco that this is the most important thing.
00:26:12.880 --> 00:26:17.759
Well, Romain, Francesco, thank you both for sharing your insights and experience.
00:26:18.240 --> 00:26:19.119
Thank you, Joaquin.
00:26:19.279 --> 00:26:19.680
Thank you very much for it.
00:26:21.200 --> 00:26:35.920
Balancing performance, recovery, and long-term joint health remains one of the central challenges in sports medicine, and discussions like this help us better understand how to guide athletes safely back to their highest level.
00:26:36.160 --> 00:26:45.519
To our listeners, thank you for joining us on another episode of Frontiers in Orthopedic Surgery, the Eska Kesta Official Podcast.
00:26:45.839 --> 00:26:54.880
Stay tuned for our next episode about optimizing ACL revision surgery with Martin Lind and Alberto Grassi.
00:26:54.960 --> 00:26:58.960
And until then, keep advancing orthopedic science.
