I N S I D E T H I S I S S U E

From the ISAKOS Office . . . . . .2ISAKOS Welcomes New Members .22003 Congress Update . . . . . . . .3ISAKOS Committee Meeting

Schedule . . . . . . . . . . . . . . . . .4ISAKOS Initiative Will Increase

Member Services in Education . .6Spotlight on Teaching Centers . . .6In Memoriam:

Alexandra (Sandy) Kirkley . . . .7Meeting Review: First Annual

Meeting of the Indian Arthroscopy Society . . . . . . . . .8

Meeting Review: 6th Turkish Sports Traumatology, Arthroscopy and Knee Surgery Congress . . . . . . . . . .8

Current Concepts: Viscosupplementation for the Osteoarthritis of the Knee . . . . .9

ISAKOS-Approved Courses . . . .12

W I N T E R 2 0 0 3

Volume 6, Issue 2

E D I T O R

Roland P. Jakob, M.D., Switzerland

A S S O C I A T E E D I T O R

Ronald M. Selby, M.D., USA

E D I T O R I A L B O A R D

Moises Cohen, M.D., BrazilMark Ferguson, M.D., South Africa

Philippe Hardy, M.D., FranceNicola Maffulli, M.D., United Kingdom

Peter Myers, M.D., AustraliaMitsuo Ochi, M.D., Japan

Fernando Radice, M.D., ChileKurt Spindler, M.D., USATerry Whipple, M.D., USA

ISAKOSN E W S L E T T E R

As orthopedic surgeons,we are constantly look-

ing for the best surgicaltreatment option to applyfor a given cartilage lesionbased on the size, locationand etiology of the defectas well as on the age of thepatient. As doctors, however,we must also be cognizantof the nonoperative optionsand alternatives to surgery

that can be used alone, or in combinationwith surgery. We continue to be faced with

patient pressure to look for alternatives tosurgery.

There is, for example, a growing interest inusing nutritional supplements that areadministered orally or injected into the joint.There is a huge market supporting them. Yetmany nutritional supplements are not reim-bursed by insurance, and it is important thatthe money spent by the patient is worthwhile.

When considering the efficacy of vitamins,minerals or antioxidants for preventing ortreating cartilage problems including arthritis,

Today in Auckland thesun is shining and the

sky is clear blue. On thewater, yachts from aroundthe world are competing todetermine who will chal-lenge New Zealand for theAmerica’s Cup in February.We are very fortunate tolive in a beautiful, safecountry.

In September we weredeeply saddened to learn of the tragic deathof Sandy Kirkley in a small plane crash. Sandyhad been an inspirational leader of theISAKOS Scientific Committee. In her flourish-ing career, she had made friends all aroundthe world where everyone was impressed byher commitment to scientific excellence. I washonored that Nicola Maffuli agreed to assumeleadership of the Scientific Committee.Sandy’s legacy will be the ScientificCommittee’s monograph titled Methodology forClinical Trials in Orthopaedic Surgery, which is duefor completion before the ISAKOS Congress inAuckland. At the congress, Peter Fowler willdeliver the Sandy Kirkley Memorial Lecture.

In November I traveled to Florence for theISAKOS Knee Committee Workshop on PCLReconstruction. This is the second workshopled by Paolo Aglietti, Chairman of the ISAKOS

Knee Committee. Once again, the meetingwas an outstanding success with contribu-tions from 21 surgeons and one scientist, rep-resenting 13 countries. The important issueswere intensely debated and consensus wasreached in the congenial spirit of internation-al cooperation that is the hallmark of our soci-ety. A book and CD-ROM will be producedfrom the workshop, containing all the work-shop presentations together with consensusstatements from the chairman of each work-shop session. These books and CDs will bepresented to everyone who attends theISAKOS Congress in Auckland.

The continuing work of the Arthroscopy,Orthopaedic Sports Medicine and UpperExtremity committees will also be presentedin Auckland. All arrangements are in place forthe congress. At that time we will welcome thefirst ISAKOS Exchange Traveling Fellows rep-resenting SLARD, our South American region-al partner. The South American group will bemaking a three-week visit to the Asia Pacificregion to coincide with the ISAKOS Congress.John Bartlett and his program committee haveconstructed an outstanding scientific programfor the congress with a truly international fac-ulty, bringing us the best of current knowledge.

I look forward to seeing you all in Aucklandin March.

President’s MessageBarry R. Tietjens, FRACS, New Zealand, 2001-2003 ISAKOS President

Editor’s NoteRoland P. Jakob, MD, Switzerland, ISAKOS Newsletter Editor

(continued on page 7)

F R O M T H E H O M E O F F I C E

ACTIVE MEMBERSAlcino Affonseca, MD, BrazilUlf Moebius, GreeceMario Orrego, MD, Chile

ASSOCIATE MEMBERSStephen Abelow, MD, USA • Devrim Akseki, MD,Turkey • Marlon Alarcon, MD, Ecuador •Rajkumar Amaravati, MBBS, DNB, MNAMS, India• Emmanuel Antonogiannakis, MD, Greece •Angel Auad, MD, Ecuador • Paulo Barone, MD,Brazil • Jean-Paul Barthelemy, MD, France • KeithBerend, MD, USA • Kevin Black, MD, USA •Benito Caruzo, MD, Venezuela • Sung-Do Cho,MD, PhD, South Korea • Chang-Hyuk Choi, MD,Korea • Nam-Hong Choi, MD, Korea • MichelCollette, MD, Belgium • Glenn Davies, MD,FRACS, Australia • Frank Dawson Garcia, MD,Chile • Alexandre de Almeida, MD, Brazil • MarioDe Araujo, Brazil • Andre Demblon, MBChB, FCS,South Africa • James Dettling, MD, USA • DavidDickison, MD, Australia • Richard Edelson, MD,USA • Irfan Esenkaya, MD, Assoc. Prof., Turkey •James Ferries, MD, USA • Mauricio Finkelstein,MD, Israel • Edson Freitas, Brazil • RandolphGent, MD, Chile • Scott Gillogly, MD, USA • MilanHandl, MD, Czech Republic • Syed Hasan, FRCS,United Kingdom • David Hayes, MB, BS, FRACS,Australia • Laurie Hiemstra, MD, FRCSC, Canada• David Higgins, USA • Regina Hillsman, MD,USA • Erik Hohmann, MD, FRCS, Australia •Jinyoung Jeong, MD, Korea • Ian Jones, MD,Australia • Izumi Kanisawa, MD, Japan • PhillipLobenhoffer, MD, Germany • Tatsuo Mae, MD,PhD, Japan • E. Camilo Martinez, MD, Colombia• Dimitrios Mastrokalos, MD, Germany • NorinaoMatsumoto, MD, PhD, Japan • Brian McCarty,MD, USA • Hiroyuki Miyashita, MD, Japan •Shigeto Nakagawa, MD, Japan • Abhay Narvekar,MS (Orth), India • Yoshikazu Oohashi, MD, Japan• Palanivel Pandiarajan, India • ChristosPapageorgiou, MD, PhD, Greece • Jose Pecora,MD, Brazil • Uwe Pietzner, MD, Germany •Peixoto Pinto, Portugal • Maximiliano Ranalletta,MD, Argentina • Antonio Rivera, MD, Philippines• Paulo Roithmann, MD, Brazil • StevenRosenfeld, BSc, MD, FRCS, Canada • FranciscoSalas, MD, Chile • Juan Sarasquete, MD, Spain •Christopher Servant, FRCS, United Kingdom •Matthew Shapiro, MD, USA • Roger Smith, FRCS,United Kingdom • Christian Sobau, MD,Germany • Rami Sorial, FRACS, Australia •Andrew Swan, FRACS, New Zealand • MasaakiTakahashi, MD, PhD, Japan • Masato Takao, MD,Japan • Tapio Tarvainen, MD, PhD, Finland •Adrian Trivett, FRACS, Australia • Bruce Twaddle,FRACS, New Zealand • George Vandanathil, MS(Ortho), India • George Varghese, MS (Ortho),Australia • Stewart Walsh, FRACS, New Zealand •Christopher Wilson, MBChB, MRCS, UnitedKingdom • Ate Wymenga, MD, PhD, Netherlands• Yasuhiro Yamamoto, MD, PhD, Japan • YujiYamamoto, MD, USA • Chyun-Yu Yang, MD,Taiwan • Masanori Yasumoto, MD, Japan • ShayZayontz, FRACS, Australia

ISAKOS Welcomes New Members

Review the List of PresidentsThe ISAKOS Web site contains a comprehen-sive list of international, regional and nationalsocieties that relate to ISAKOS specialties.Please help us to keep the societies’ contactinformation and presidents listings current.Many people use it as a resource. The officedepends on your help to keep the informa-tion accurate and timely. Simply e-mail theISAKOS office with any changes.

Pay Your Dues Today OnlineISAKOS has a new online dues payment sys-tem that is fast, easy and secure. Visit theISAKOS Web site today to review your mem-ber balance and ensure that you continue toreceive the journal in 2003. Remember, youmust be current with your 2003 ISAKOS duesif you wish to register as an ISAKOS Memberat the congress.

Include Your Educational CD-ROM in the ISAKOS Multimedia CenterISAKOS is establishing an educational libraryof instructional CD-ROMs and DVDs for useby its members. We would like to includeyour CD-ROM or DVD in the ISAKOSMultimedia Center at the ISAKOS Congress inAuckland. Please send your CDs to the ISAKOS

office by February 15 if your would like yourmedia included in the Auckland catalogue.

Review the BylawsThere are several proposed changes to thecurrent ISAKOS bylaws, and they will be votedon at the first business meeting of the 2003congress in Auckland. Visit the ISAKOS Web sitetoday to review the changes prior to your vote.

ISAKOS CommitteesIf you are interested in becoming a memberof an ISAKOS committee for the 2003-2005term, please contact the ISAKOS office by e-mail at isakos@isakos.com or fax +1 (925) 314-7922. Please indicate in which committeesyou are interested. You must be an activemember in good standing to become anISAKOS committee member.

Associate MembersThe Membership Committee will review allassociate member applications for promotionto active status at the 2003 Congress inAuckland. If you are an associate member whowishes to be eligible for active status, you musthave at least one sponsor recommendation on file.Please ensure your sponsor has submittedyour recommendation.

Announcements From the ISAKOS Office

PLATINUM SPONSORS

LinvatecLinvatec Corporation, a leading manufactur-er of arthroscopic instrumentation, medicalimaging, and power surgical equipment,offers a diverse line of products critical to theorthopaedic/arthroscopic surgeon.

Smith & Nephew, Inc., Endoscopy DivisionA global leader within arthroscopy and aninnovator in endoscopic surgery, Smith &Nephew, Endoscopy Division, designs, develops

and manufactures endoscopic surgicalinstrumentation and techniques with the goalof reducing trauma and pain to the patient,reducing cost to the healthcare system, andproviding better outcomes for surgeons.

GOLD SPONSORS

Mitek Worldwide

SILVER SPONSORS

ISAKOS Thanks 2003 Congress SponsorsISAKOS thanks the following companies for their generous donations to the ISAKOSCongress. Their sponsorships have made the congress more accessible and affordable to ourattendees. It would be impossible to have an international congress without their support.

• Arthrex, Inc.• Arthrotek• Centerpulse

• Pharmacia/Pfizer• Stryker Endoscopy

ISAKOS NEWSLETTER • WINTER 2003 • 3

2 0 0 3 C O N G R E S S U P D A T E

Pre-registration Deadline February 10The deadline to pre-register for the congressis February 10, 2003. After February 10, youwill be required to register on-site at themeeting in Auckland.

Simultaneous Interpretation to SpanishRemember, all presentations held in the twoconcurrent general session rooms will beinterpreted to Spanish, free of charge to allattendees.

Knot-Tying Manual Will Be Provided to All Congress AttendeesISAKOS is proud to announce that it will beable to give every congress participant aknot-tying manual at the 2003 ISAKOSCongress in New Zealand. The booklet willbe printed in color. All knots currently usedin arthroscopic surgery will be covered.

We appreciate the cooperation and assis-tance of Mitek Worldwide, which hasenabled us to produce this educational tool.We know how helpful a book like this can befor those just starting to perform arthroscopicprocedures.

Special Congress Events

Welcome Reception at the Town Hall This festive eventwill offer music,hors d’oeuvres andcocktails for allcongress atten-dees. Attendanceis included withthe cost of regis-

tration. Dress is business casual, and guestsare welcome. The Town Hall, built in 1911, isnow home to both the New ZealandSymphony Orchestra and the AucklandPhilharmonia.

Poster, New Member and Exhibit ReceptionJoin congress attendees and exhibitors asISAKOS officially welcomes its newest mem-bers. This relaxed wine and cheese receptionwill be held in the foyers of the conventioncenter, amidst the exhibits and electronicposters.

NEW! Free Lunchtime Workshops WillOffer Hands-on Education at CongressArthroCare, Bionx Implants, Inc.,Centerpulse, Linvatec, Pharmacia/Pfizer,Smith & Nephew Endoscopy and StrykerEndoscopy will be offering lunchtime work-shops and presentations to all ISAKOSattendees. Highlights include:

Arthroscopic Rotator Cuff RepairJames Esch, MDSponsored by Smith & Nephew EndoscopyAttendees will be able to insert sutureanchors arthroscopically into the humeralhead of the shoulder model; pass suturethrough the rotator cuff of the shouldermodel; and tie secure sliding knot arthro-scopically in the shoulder model.

Clinical Experience and Surgical Technique in Rotator Cuff Fixation Using Bionx‚ Bioabsorbable SportsSurgery DevicesJames Tasto, MDSponsored by BionxAttendees will hear a lecture about the clini-cal experience of Dr. Tasto, with the Bio CuffShoulder devices from Bionx Implants Inc.This lecture will include a demonstration ofthe technique as presented by Dr. Tasto.

Collagen Meniscus Implant - An InnovativeApproach for Meniscus RegenerationRene Verdonk, MD; William Rodkey, DVM; J. Richard Steadman, MD; Paolo Bulgheroni, MDSponsored by CenterpulseAttendees will study the treatment possibili-ties of irreparable meniscus injuries, as wellas the concept and philosophy of collegenmeniscus implantation, US clinical results,selected Italian cases, and analysis of tissueregeneration.

Current Concepts in Meniscal RepairJens Buelows MD; Philippe Colombet MDSponsored by Smith & Nephew EndoscopyAttendees will be able to discuss currentoptions for meniscal repair including “all-inside” technique and perform a meniscalrepair on sawbones model using the FasT-Fix® implant.

Last-Minute Congress RemindersREGISTER FOR THE 2003 CONGRESS ONLINE AT WWW.ISAKOS.COM/REGISTER ISAKOS is offering a series of live sur-

gical demonstrations on cadavers, freeto all attendees. All demonstrationswill be interpreted to Spanish.

Monday, March 1013:30 -14:15ACL FixationDon Johnson, MD, CanadaSponsored by Linvatec

Tuesday, March 1111:15-12:00Arthroscopic Rotator Cuff Repair Including Use ofElectroblade James Esch, MD, USASponsored by Smith & Nephew, Inc.,Endoscopy Division

14:00-14:45Shoulder ArthroscopyAnthony Romeo, MD, USASponsored by Arthrex

Wednesday, March 1211:15-12:00ACL Technique for AggressiveRehabilitation Using DLSTG Graftand Patellar Tendon DemonstrationStephen Howell, MD, USA, and Pier Paolo Mariani, MD, ItalySponsored by Arthrotek

13:30 -14:15Tibia & Femur OsteotomyGiancarlo Puddu, MD, ItalySponsored by Arthrex

Thursday, March 1311:15-12:00 Total Knee ReplacementProf. Johan Bellemans, BelgiumSponsored by Smith & NephewOrthopaedics

13:30 -14:15Use of the ExoJet Fluidjet Systemfor Contouring Articular Cartilageand Meniscal Tears. ComprehensiveArthroscopic Technique forOsteochondral Graft TransferMoises Cohen, MD, Brazil, and David Diduch, MD, USASponsored by Mitek Worldwide

Live SurgicalDemonstrations

4 • ISAKOS NEWSLETTER • WINTER 2003

Innovative, Reproducible Approach to ACL Graft TensioningDon Johnson, MDSponsored by LinvatecThis hands-on workshop will allow the par-ticipants to:• Learn this reproducible technique for ACL

hamstring repair using the SE™ GraftTensioning System.

• Gain an understanding of isometry andstress equalization of hamstring grafts.

• Practice tibial and femoral fixation withBioScrew® and XtraLok™ interferencescrews and the SE™ Graft Tensioningsystem.

Innovative Solutions in Shoulder ArthroscopyAlex Castagna, MD; Stephen J. Snyder, MDSponsored by LinvatecThis hands-on workshop will allow the par-ticipants to:• Become more proficient in arthroscopic

knot tying techniques.• Perform arthroscopic Bankart/SLAP repairs

using Mini-Revo® and Ultrafix® KnotlessMinimite® anchors.

• Perform arthroscopic rotator cuff repairusing Super Revo®/UltraSorb™ and theSpectrum® suture passing system.

New Directions in Pain Management for Orthopaedic SurgeryFaculty To Be AnnouncedSponsored by Pharmacia/PfizerThe potential for coxibs to be used in thetreatment of surgical pain will be exploredfully by leading physicians during thePharmacia/Pfizer-sponsored symposium tobe held on Tuesday March 11, 18.00–19.30, atthe Carlton Hotel, Auckland. The symposiumwill enable you to learn more about emerg-ing trends in orthopaedic surgical pain man-agement and provide you with the opportu-nity to engage with other specialists in dis-cussion of this important topic.

A welcome dinner reception will be heldat 17.30 and continue with coffee anddesserts following the symposium.

New Frontiers for ACL FixationLonnie E. Paulos, MDSponsored by Stryker EndoscopyAttendees will be able to describe femoralfixation for hamstring ACL reconstruction,

and discuss the advantages of absorbableACL fixation.

PCL Reconstruction Techniques & Clinical ResultsModerator: David McGuire, MD; Faculty: Pascal SChristel, MD; Pier Paolo Mariani MD, PhDSponsored by Smith & Nephew EndoscopyAttendees will be able to discuss technicalaspects of PCL reconstruction proceduresincluding approach, graft choice, fixationoption and tunnel placement. They will also

be able to identify indications for surgeryand management of PCL injury.

Shoulder Instability Treatment: Use of Thermal Capsulorrhaphy as an Adjunct to Labral RepairModerator: Joe DeBeer, MD; Faculty: AnthonyMiniaci, MD; Andrew Wallace, FRCSSponsored by Smith & Nephew EndoscopyAttendees will be able to identify the correctindications for the use of thermal capsulor-rhaphy in the shoulder. They will discuss the

ISAKOS Committee Meeting Schedule2003 ISAKOS Congress

Carlton Hotel & Aotea Centre, Auckland, New ZealandSaturday, March 8, 2003

13:00 – 14:00 Membership Carlton I Room, Carlton Hotel15:00 – 16:00 Finance Carlton I Room, Carlton Hotel16:00 – 18:00 Executive Board Carlton I Room, Carlton Hotel

Sunday, March 9, 2003 Carlton I Room, Carlton Hotel

08:00 – 09:45 Program Tasman I Room, Carlton Hotel09:30 – 10:00 Bylaws Carlton I Room, Carlton Hotel10:00 – 11:00 Upper Extremity Carlton I Room, Carlton Hotel10:00 – 11:00 Orthopaedic Sports Medicine Carlton II Room, Carlton Hotel10:00 – 11:00 Arthroscopy Tasman I Room, Carlton Hotel11:15 – 12:15 Communications Carlton I Room, Carlton Hotel11:15 – 12:15 Education Carlton II Room, Carlton Hotel11:15 – 12:15 Scientific Tasman I Room, Carlton Hotel12:15 – 13:00 Newsletter Editorial Board Carlton I Room, Carlton Hotel12:30 – 13:30 Knee Carlton II Room, Carlton Hotel13:30 – 15:30 Board of Directors Tasman I Room, Carlton Hotel16:00 – 19:00 ISAKOS Strategic Planning Forum Carlton I Room, Carlton Hotel

(all committee chairs and committee members to attend)

Wednesday, March 12, 2003

14:00 – 15:30 Nominating Durafort Room, Aotea Centre

Thursday, March 13, 2003

14:00 – 15:00 Site Selection (NOTE NEW TIME) Durafort Room, Aotea Centre15:00 – 17:00 Committee on Committees Durafort Room, Aotea Centre

Friday, March 14, 2003

09:00 – 11:30 New Board of Directors and Durafort Room, Aotea CentreCommittee Chairs Meeting (2003-2005)(NOTE NEW TIME)

ISAKOS NEWSLETTER • WINTER 2003 • 5

treatment technique and how to avoidpotential complications, as well as the reha-bilitation protocol required to achieve goodoutcomes.

Techniques of Bionx‚ Bioabsorbable Sportsand Trauma Fixation Devices in KneeGert Kristensen, MDSponsored by BionxAttendees will hear a lecture on the ContourArrow, meniscus repair device and Smart

Nail, trauma and osteochondral fragmentsrepair device from Bionx Implants Inc. Thislecture will include a demonstration of thetechniques as presented by Dr. Kristensen.

TOPAZ: Minimally Invasive RF Treatment of TendinosisJames Tasto, MDSponsored by ArthroCareAre you satisfied with your current treatmentoptions for tendinosis? If not, please come

by our workshop to learn more about TOPAZ,a new, minimally invasive, radiofrequency(RF) treatment for chronic tendinosis. JamesP. Tasto, MD, from the University ofCalifornia San Diego, will present hisresearch and clinical experience with TOPAZ.

Free Instructional Course Lectures in AucklandInstructional Course Lectures (ICLs) will be held Tuesday, March 11, through Friday, March 14, from 07:00-08:30. Instructional courselectures will be free of charge to all attendees. Attendees should register in advance for each course using the congress registrationform located in the Preliminary Program. Please Note: There will be no interpretation to Spanish in any of these sessions.

Tuesday, March 11, 2003, 07:00-08:30

ICL #01: Basic Science and Clinical Use ofCell Therapy in Articular Cartilage RepairChair: Lars Peterson, MDFaculty: Scott Gillogly, MD, Bert Mandelbaum, MD,Anders Lindahl, Wayne Gersoff and Carl Winalski

ICL #02: Computers in Clinical PracticeChair: Don Johnson, MDFaculty: Vladimir Bobic, MD, Nicola Maffulli, MD,MS, PhD, FRCS and Ronald Selby, MD

ICL #03: Issues in ACL Surgery Chair: Peter Fowler, MD, FRCSFaculty: Charles Brown, Jr., MD, Burt Klos andPhilippe Neyret, MD

ICL #04: Current Concepts in PosterolateralInstability of the KneeChair: Robert F. LaPrade, MDFaculty: Lars Engebretsen, MD, PhD, SteinarJohansen, MD and Fred Wentorf, MS

ICL #05: Clavicle Fractures and DislocationsChair: Ulrich Bosch, MDFaculty: Eugene Wolf, MD, Stephen Snyder, MD andReinhard Fremery

Wednesday, March 12, 2003, 07:00-08:30

ICL #06: Sports Specific Outcomes in ACLSurgery Chair: Jose Huylebroek, MDFaculty: Suzanne Werner, Stephen Howell,LarsEngebretsen and Jean-Claude Imbert

ICL #07: Emerging Technologies in KneeSurgery Chair: Masahiro Kurosaka, MD

ICL #08: Arthroscopic Evaluation andTreatment of Rotator Cuff InjuriesChair: Stephen Snyder, MDFaculty: Stephen Burkhart, MD, James Esch, MD andAlessandro Castagna, MD

ICL #09: Arthroscopic Management of Intra Articular Fractures of the Knee Chair: M. Nedim Doral, MDFaculty: W. Jaap Willems, MD, Phillip Lobenhoffer,MD, Freddie Fu, MD and David McAllister, MD

ICL #10: Management of the PostMeniscectomy Knee and Decision MakingChair: Giancarlo Puddu, MDFaculty: Christopher Harner, MD, AnnunziatoAmendola, MD and Philippe Neyret, MD

Thursday, March 13, 2003, 07:00-08:30

ICL #11: Total Knee Arthroplasty – New Perspectives on DesignChair: Paolo Aglietti, MDFaculty: David Barrett, MD, Timothy Wright, PhD,Kelly Vince, MD, Johan Bellemans, William Walsh, MDand Mark Pagnano, MD

ICL #12: Tendon Injuries in Football (Soccer) Chair: Alberto Pienovi, MDFaculty: Ramon Cugat, MD and Sergio Montenegro, MD

ICL #13: Knee Meniscus RepairChair: Dieter Kohn, MDFaculty: Andrew Amis, DSc, Romain Seil, MD, UffeJoergensen and K. Donald Shelbourne, MD

ICL #14: Complex Issues in ACL ReconstructionChair: Kai-Ming Chan, MDFaculty: Freddie Fu, MD, Savio Woo, PhD, DSc,James Lam, FRCS and Hsiao-Li Ma, MD

ICL #15: Elbow Arthroscopy (Ligament Injuries and Tendinopathy)Chair: Luigi Pederzini, MDFaculty: Gary Poehling, MD, Champ Baker, MD andGregory Bain, FRACS

Friday, March 14, 2003, 07:00-08:30

ICL #16: New Frontiers in Shoulder ArthroscopyChair: W. Jaap Willems, MDFaculty: Stephen Burkhart, MD, Ben Kibler, MD,George Lajtai, MD, Anthony Miniaci, MD, FRCS andJoe De Beer, MD

ICL #17: Knee OCDChair: Lars Engebretsen, MD, PhDFaculty: Anthony Miniaci, MD, FRCS, Lars Peterson,MD, PhD, Jon Karlsson, MD, PhD and Andre Frank,MD

ICL #18: Hip Arthroscopy (Osteochondromatosis)Chair: J.W. Thomas Byrd, MDFaculty: James Glick, MD, Michael Dienst, MD andRomain Seil, MD

ICL #19: Stress FracturesChair: Gideon Mann, MDFaculty: Ingrid Ekenman, Sakari Orava, MD, PhD,Peter Brukner, MD and Charles Milgrom, MD, PhD

ICL #20: Allografts in Knee SurgeryChair: Stephen Howell, MDFaculty: Dieter Kohn, MD; Konsei Shino, MD; DavidCaborn, MD

6 • ISAKOS NEWSLETTER • WINTER 2003

Our teaching center holds courses in arthroscopic surgery of theknee, including:

• ACL and PCL reconstruction;• Medial and lateral (mini-invasive ligamentous plasty);• Meniscal surgery (out-in and in-out techniques);• Patellar surgery (mini-invasive proximal and distal realignment);• Osteotomies around the knee (femoral and tibial); and • Knee replacements.

We also offer courses in:• Arthroscopic surgery of the ankle;• Mini-invasive ligamentous plasty;• Sports traumatology;• Elbow and ankle overuse tendinopathies;• Courses on one-day surgery (knee, shoulder and ankle); and• Post-surgical rehabilitation.

The center is connected to the Faculty of Motor Sciences, and theResearch Center of Sports Medicine of the University of Turin. Surgerytakes place every Tuesday, Wednesday, Thursday and Friday morning inthe Sports Traumatology Center located in the Koelliker Hospital.

Last year the Koelliker Hospital was ranked the best in northwest-ern Italy. Applicants may observe and, if allowed, scrub in. Applicantsmay follow each case before and after surgery, and during rehabilita-tion.

Applicants may review the documentation of every surgery and dis-cuss it freely with the surgeon. They may also attend the annualInternational Congress held by the center. Applicants may be activelyinvolved with research (prospective randomized studies). Low-costaccommodation near the center is available. In some special cases, no-cost accommodation may be available.

Spotlight on Teaching Centers:Sports Traumatology Center Koelliker – University of Turin • Torino, Italy

A s described in the Summer 2002newsletter, ISAKOS is embarking on an

ambitious program to increase memberservices in education. Bringing together sup-pliers, local organizations and our members,ISAKOS will create an international frame-work for the exchange and dissemination ofinformation in arthroscopy, knee surgery andorthopaedic sports medicine that will bene-fit each member, partner and patient.

Over the next five years, ISAKOS will

focus on:

• Hosting regional hands-on workshopsand pertinent lectures in arthroscopy,knee surgery and orthopaedic sportsmedicine;

• Effectively utilizing online technology tooffer members continuing educationopportunities, including CME-accreditedcourses;

• Initiating special committee projects and

traveling fellowships; and• Bringing together the leaders of regional

societies to collaborate in ways thatenhance the overall profession while pro-viding the best benefits to members in allparts of the world.

Since ISAKOS was founded in 1995 fromthe merger of the International ArthroscopyAssociation and the International Society ofthe Knee, our membership has grown 60 per-

ISAKOS Initiative Will Increase Member Services in EducationBarry R. Tietjens, FRACS, New Zealand, 2001-2003 ISAKOS President; Per A. Renström, MD, PhD, Sweden, 2001-2003 ISAKOS 1st Vice-President; John A. Bergfeld, MD, USA, 2001-2003 ISAKOS 2nd Vice President

For more information, contact:Gian Luigi Canata, MDCorso Duca degli Abruzzi 30, 10129 Torino, ITALYTel: +39 011 581 756Fax: +39 011 580 5014E-mail: canata@libero.it

ISAKOS NEWSLETTER • WINTER 2003 • 7

cent; our biennial congress has been hailedby participants as a pre-eminent conferencenot to be missed; and our committees havetackled issues of international importance,including plans under way for developinginternational clinical standards, a complica-tions registry, and an international diction-ary of related terms.

We have an accomplished record to buildupon, and we have an exciting task beforeus.

By providing high-quality opportunitiesto continually develop skills and foster theexchange of information internationally,ISAKOS will help propel our specialties inthe global orthopaedic community towardgreater achievement and even greater poten-tial.

Thanks to the interest of several majorinternational firms, we are already off to agreat start! To be successful we will need thesupport of all our members and industryfriends. We invite you to learn more aboutthis special initiative at the ISAKOS FourthBiennial Congress in Auckland March 10-14,2003, and join us in support of this excitinginternational effort.

We look forward to seeing you there!

IN MEMORIAMAlexandra (Sandy) Kirkley, MD, FRCS(C), MSc

1962-2002

Peter J. Fowler, MD, Canada, 1995-1997 ISAKOS Past President

A ll of you will know that Sandy Kirkley and her husband Michael were killed in asmall plane crash early in September 2002. This loss has been deeply felt not just

here at our clinic and our university, but throughout the orthopaedic world. Most of youin ISAKOS will have met Sandy and witnessed first-hand her intelligence, integrity andcommitment to orthopaedics and orthopaedic research. Many of you will, like us, havebeen privileged to share in the extraordinary energy and enthusiasm with which shelived her life.

The tributes to Sandy have been fitting, and the countless messages of condolencewe have received from you in the past three months have been heartfelt. On behalf ofall of us here, I would like to thank you, for these have given us, and her family, greatcomfort during a truly terrible time.

ISAKOS is an organization Sandy believed in, supported and wanted to improve.She had yet to miss a congress. Since 1997 she had been a member of theDocumentation Committee as well as Co-Chair and Head of the Clinical TrialsCommittee. There is no question that this is the area in which she would make her mostvaluable contributions. At the 2001 Congress in Montreux, she took on the symposium“Designing Outcome Studies.” As she was preparing for this and organizing her faculty,she asked me to participate along with herself and Bob Marx. I was flattered but con-fessed my fear that I would be of little use to her. My knowledge of this subject wasembarrassingly poor. “Don’t worry,” she told me, “I’ll tell you what to say. I just wantsomeone with white hair to say it.” It is no surprise that it turned out to be a very suc-cessful symposium.

In the past year she made it a personal mandate to work toward improving the sci-entific validity of research done by orthopaedic surgeons. To this end she spearheadeda collaborative effort among members of the ISAKOS Scientific Committee to create areference manual on the topics of outcome tools and how to design, implement andrun orthopaedic randomized clinical trials. Individual members would focus on his orher area of expertise, and the combined manuscripts would become a comprehensiveand valuable resource. Nicola Maffulli and the Scientific Committee are continuingthis work. We wish them success and look forward to a fine finished product.

I am pleased to tell you that Sandy and Michael’s young boys, Colin and Connorare both doing well in the care of their guardian family. They are recovering satisfacto-rily from their injuries, have returned to school and are adjusting to their new home.

In our day-to-day lives, Sandy’s physical absence is a harsh reality. Our clinic hasreturned to what can be called “normal.” What we at first thought would be impossibleto handle is being dealt with because Sandy’s indomitable spirit inspires and her greatvision endures. We all know that ultimately, good patient care is at stake. And so wewill carry on her work.

there is a paucity of information in the sci-entific literature compared with traditionalmedicine. We are constantly searching formore information to provide our patients,ourselves and our families. In light of theserealities, I am grateful to Vladimir Bobicfrom Great Britain, a renowned cartilageexpert who submitted an excellent summaryon viscosupplementation for this newsletter.

Over the course of the past two years, Ihave been using intraarticular injections ofhyaluronic acid for severe osteoarthriticknees where no other treatment can beapplied other than the inevitable total knee.I also started to give some of the orallyadministered products, including monosac-charides and heteropolysaccharides (such asglucosamine, chondroitin sulfate andHyaluronic acid), to my patients aftermosaicplasty. Lars Peterson tells me that heis planning to do a study on glucosamineafter ACI.

But which drug to select? It is appropri-

Editor’s Note(continued from page 1)

ate to look critically into the marketplace toenhance our treatment armament in a fieldthat is full of veracity and benefit. We mustcarefully analyze the most beneficial approachto caring for cartilage defects. Cartilage

repair alone may not be sufficient; osteotomiesmay be needed, and nutraceuticals or visco-supplementation may even be utilized.

We shall carry on with this discussion inthe next newsletter.

8 • ISAKOS NEWSLETTER • WINTER 2003

The Indian Arthroscopy Society, foundedin 1983, organized its official annual

meeting in Coimbatore, India, on October 9-10, 2002. The society had already organizedseveral meetings in the past. I had previouslyvisited Coimbatore in 1995, when a smallcongress was organized by Dr. David Rajan.

This year’s congress took place in theGKNM Hospital, which boasts a nicely builtand well-equipped convention room. Onehundred and fifty orthopaedic surgeonsattended the congress. The live surgery wasperformed in modern, air-conditioned the-atres, with all the arthroscopic tools avail-able to perform arthroscopic shoulder andelbow surgery.

This year’s congress was also organizedby Dr. Rajan, with cooperation from Dr. Joshifrom Mumbai and Dr. Antao from Mumbai.As education chairman, I was invited andhonored to officially open the congress onbehalf of ISAKOS.

About 10 shoulder and elbow procedureswere performed with a good connection fromthe theatre to the convention room. There

were lively discussions between the surger-ies, which followed lectures given by inter-national and national faculty. There wasample exposure to arthroscopic knee sur-gery and ACL reconstruction, as well as astarting interest in shoulder and elbow pro-cedures. The operative procedures I per-formed were collected by Dr. Rajan and histeam and were all interesting cases of shoul-der instability.

During the nightly social events, thehosts showed a great hospitality, providingsome very interesting cultural activities.

I witnessed a great interest in our Indiancolleagues for the advancements in arthro-scopic surgery. This annual meeting, whichwill undoubtedly be followed by other meet-ings in the future, contributed to the propa-gation of arthroscopic surgery on the Indiansub-continent.

First Annual Meeting of the Indian Arthroscopy SocietyOCTOBER 9-10, 2002 • COIMBATORE, INDIA

W. Jaap Willems, MD, Netherlands, 2001-2003 Education Committee Chairman

The 6th Turkish Sports Traumatology,Arthroscopy and Knee Surgery Congress

was a meeting of the Turkish Society forArthroscopy, Knee Surgery and OrthopaedicSport Trauma. The congress takes place onceevery two years and rotates between thethree chapters: North in Istanbul, Central inAnkara and South in Antalya.

The meeting in Antalya addressed allfields of sports trauma and arthroscopy. Ledby many international guests and a vastamount of research originating in Turkey, it

gave an excellent opportunity to discuss,argue and often disagree on many controver-sial issues.

The congress, organized by Prof. Aydin,Prof. Pinar and Prof. Doral, along with manyothers, was outstanding. It was superiorlyorganized with an excellent scientific pro-gram and superior translation and technicalback-up.

Turkey is slowly advancing to a leadingposition in the field of arthroscopy andsports trauma.

6th Turkish Sports Traumatology, Arthroscopy and Knee Surgery CongressOCTOBER 21-26, 2002 • ANTALYA, TURKEY

Gideon Mann, MD, Israel, 2001-2003 Strategic Planning Committee

At the opening ceremony (L to R): Dr. Sugaya(Japan), Dr. David Rajan, Prof. Kempf (France)Dr. Willems (Netherlands), Dr. Antao, Dr. Kon (Japan)

Dr. Rajan directs the surgery.

The GKNM Hospital, where the congress was held.

I N T E R N A T I O N A L M E E T I N G R E V I E W S

C U R R E N T C O N C E P T S

Osteoarthritis (OA) is a major cause of dis-ability. Patients with OA have pain that

typically worsens with weight-bearing andactivity and improves with rest. Unlike therheumatoid arthritis (RA) inflammation isusually mild and localised in the affectedjoint. Although the etiology of OA remainsunknown, biomechanical stresses and bio-chemical changes in the articular cartilage,subchondral bone and synovial membrane,and genetic factors, are all important in itspathogenesis. In joints affected by OA, thesynovial fluid’s capacity to lubricate and toabsorb impact are typically reduced. Thesechanges are partly due to a reduction in thesize and concentration of hyaluronic acid(hyaluronan) molecules naturally present insynovial fluid. Medical management of OA ofthe knee is effective for many patients, butsignificant morbidity is common for thoseusing non-steroidal anti-inflammatory med-ication (NSAIDs). Gastrointestinal toxicityhas been a major problem for many patientson NSAIDs, especially for geriatric patientswho need to take them for extended periodsto treat chronic conditions. Although only aminority of patients using NSAIDs appear todevelop serious GI problems, because ofwidespread usage it is estimated that thereare at least 16,500 NSAID-related deathseach year in the United States amongpatients with osteo- and rheumatoid arthri-tis.1,2 Another 76,000 end up in the hospital.The economic burden of NSAID-associatedgastrointestinal disorders is enormous, withan estimated cost of $500 million. Surgicaltreatment of the knee OA is effective but it isnot appropriate for all stages of the diseaseor for all patients. It is also costly and notwithout risks. With increased understandingof the pathogenesis of OA, new therapies arebeing developed, one of which is viscosup-plementation with hyaluronic acid. A newapproach in the management of OA of theknee is to inject hyluronan or derivatives ofthis molecule (hylans) into the joint. Inrecent years, the concept of viscosupple-mentation has gained widespread accept-ance as a new treatment for the manage-ment of OA of the knee. The safety of thistreatment has been well documented innumerous clinical trials, but controversy per-

sists regarding efficacy and cost-benefit con-cerns.3

IntroductionThe use of viscosupplementation is

based on observation that there is adecrease in viscosity and elasticity of thesynovial fluid in osteoarthritis and thatthe native hyaluronic acid in osteoarthriticknees has a lower molecular weight thanthat found in normal healthy knees.Replenishing the hyaluronic acid componentof normal synovial fluid may play a role insupplementing the elastic and viscous prop-erties of synovial fluid, which may helprelieve the signs and symptoms related toosteoarthritis and improve function. In vitrostudies of human synoviocytes fromosteoarthritic joints have revealed thatexogenous hyaluronic acid stimulates denovo synthesis of hyaluronic acid, inhibitsrelease of arachidonic acid, and inhibitsinterleukin-1_ induced prostaglandin E2synthesis by human synoviocytes.4

Hyaluronic acid (HA) is a glycosaminogly-can that is composed of glucuronic acid andN-acetylglucosamine. It differs from otherglycosaminoglycans in that it is unsulfated;also, it does not bind covalently with pro-teins to form proteoglycan monomers, serv-ing instead as the backbone of proteoglycanaggregates. It is the only glycosaminoglycanthat is not limited to animal tissues, beingfound also in bacteria. It serves as a lubri-cant and shock absorber in the synovialfluid, and is found in the vitreous humor ofthe eye. HA is not well absorbed orally, buthas been widely used intraarticularly in thetreatment of OA in animals and, morerecently, in humans. HA is well toleratedwith no demonstrable toxicity and few sideeffects. Because it is injected directly intothe joint, its onset of action is rapid.Conversely, its route of administration doeslimit its therapeutic applications to somedegree, and high cost is also a factor.5

BiochemistryGlycosaminoglycans (GAGs) are carbohy-

drate polymers that are among the mostabundant components of the ground sub-stance of connective tissue throughout the

body. GAG molecules are long, homoge-neous, unbranched polysaccharide chainsthat are formed by repeating disaccharidesubunits. Hyaluronate is the most abundantGAG in synovial fluid. It is produced andsecreted by synoviocytes. Hyaluronate isalso prevalent in the extracellular matrix ofarticular cartilage, where it is produced bychondrocytes and where it forms the founda-tion for proteoglycan aggregates. The recur-ring disaccharide subunit of hyaluronateconsists of N-acetylglucosamine and glu-curonate. These sugar subunits are joined byglycosidic bonds. These bonds are extremelyflexible in solution; therefore, hyaluronatehas no defined tertiary structure. The car-boxylate group on the glucuronate sugar isnegatively charged. Thus, hyaluronate is apolyanion chain. The recurring electronega-tive charges along the chain repel oneanother and attract water molecules. Hence,hyaluronate has been likened to a “molecu-lar sponge.” These properties account for theviscosity and elasticity of the hyaluronatemacromolecule.

Pharmacology of ViscosupplementationThe notion of supplementing osteo-

arthritic synovial fluid with exogenoushyaluronate stems from the fact that themolecular weight and concentration ofhyaluronate in osteoarthritic synovial fluidare reduced. This phenomenon diminishesthe viscosity of osteoarthritic synovial fluid.Appropriate synovial fluid viscosity isbelieved to be critical for maintaining nor-mal joint lubrication and is also believed tohave chondroprotective effects. It is hypoth-esized that the reduced concentration anddecreased molecular weight of hyaluronatein osteoarthritic synovial fluid renders artic-ular cartilage more vulnerable to mechanicaland enzymatic injury.

The goal of viscosupplementation is toincrease the molecular weight and concen-tration of hyaluronate in arthritic joints sothat the intra-articular milieu more closelyresembles that of healthy synovial fluid.

The mechanism of action by which visco-supplementation alleviates arthritic kneepain is a subject of debate. It has been pro-posed that exogenous viscoelastic sub-

Viscosupplementation for the Osteoarthritis of the KneeVladimir Bobic, MD, FRCSEd, United Kingdom, 2001-2003 Communications Committee

ISAKOS NEWSLETTER • WINTER 2003 • 9

10 • ISAKOS NEWSLETTER • WINTER 2003

stances act biomechanically by providing a“cushioning” effect. However, some authorshave suggested that viscosupplements areeliminated from the knee too rapidly to exerta significant and lasting biomechanicaleffect. Indeed, the half-life of hyaluronate insheep is less than 24 hours. In vitro researchsuggests that exogenous hyaluronate maystimulate endogenous production of addi-tional hyaluronate by human synoviocytes.This could lead to more durable biomechan-ical consequences. Other studies suggestthat hyaluronate supplementation has adirect anti-inflammatory effect on synovio-cytes by inhibiting arachidonic acid releaseor by blocking prostaglandin-E2 production.It has also been suggested that exogenoushyaluronate inhibits damage mediated byoxygen free radicals and phagocytosis.Research has also found that hyaluronatemay exert a direct analgesic effect on articu-lar nociceptors. Possible mechanisms bywhich HA may act therapeutically include:providing additional lubrication of the syn-ovial membrane, and controlling permeabil-ity of the synovial membrane, thereby con-trolling effusions. Other possible, thoughless certain, mechanisms include: promo-tion of cartilage matrix synthesis and reag-gregation of preoteoglycans. One manufac-turer has cross-linked hyaluronate chains inan effort to further enhance the molecularweight (and, hence, the viscoelasticity) of itsproduct, Hylan G-F 20 (Synvisc™). A syn-thetic hyaluronic acid Arthrease™ is notcross-linked, but does have a high molecularweight. Arthrease™ has to be stored within acontrolled temperature range of 2-8 C0 . Itcontains no animal protein and no residualcross linking reagents. Several studies havesuggested that viscosupplements with high-er molecular weights have greater therapeu-tic efficacy.6,7

Anti-inflammatory EffectHyaluronic acid has both in vivo and in

vitro effects on leukocyte function. Theseinclude inhibition of phagocytosis, adher-ence and mitogen-induced stimulation.These properties are dependent on themolecular size of haluronic acid. Intra-articu-lar administration of hyaluronic acid reduceslevels of inflammatory mediators, includingprostaglandin and cyclic adenosinemonophosphate, in the synovial fluid of

patients with arthritis.3

Analgesic ActivityIt seems that intra-articular hyaluronic

acid modulates pain perception directlythrough inhibition of nociceptors or indirect-ly through binding of substance P - a smallpeptide involved in the transmission of painsignals.3

Chondroprotective PotentialThere are some data from human and

animal studies to suggest that viscosupple-mentation could have a chondroprotectiveeffect. Listrat et al. suggest that repeatedintra-articular injections of hyaluronanmight delay the structural progression ofosteoarthritis.7 However, the chondroprotec-tive effect of hyaluronic acid remainsunproved. More research is needed to evalu-ate whether or not viscosupplementationhas disease-altering properties in additionto its apparent palliative characteristics.3,6

Clinical EffectivenessViscosupplementation is a proven

adjunct to the treatment armamentarium ofgeneral practitioners and surgeons. A num-ber of recent clinical trials have evaluatedthe efficacy and safety of intra-articularhyaluronic acid injections.8,9,10,11,12,13,14,15 Thereports of these studies were among thosepresented to the Food and DrugAdministration (FDA) in the course of the

process that resulted in the release of thistreatment modality. The American College ofRheumatology has included viscosupple-mentation in the treatment algorithm forosteoarthritis of the knee.4,16,17

Cost-EffectivenessIn clinical trials of intraarticular hyaluro-

nan preparations, pain relief among thosewho completed the study was significantlygreater than that seen after intraarticularinjection of placebo, and comparable withthat seen with oral NSAIDs. In addition, painrelief among those who completed the studywas comparable with greater than that withintraarticular glucocorticoids. Although painrelief is achieved more slowly with hyaluro-nan injections than with intraarticular gluco-corticoid injections, the effect may last con-siderably longer with hyaluronan injec-tions.17

The price for the course of HA rangesfrom approx. £200 to £300 in the UK. In ourown experience on 104 patients, in Liverpooland Chester (with Hyalgan™, Synvisc™,Orthovisc™ and Arthrease™), from 1999 to2002, the average duration of pain relief wasseven months, but approximately 10 percentof patients did not experience any significantpain relief. We did not observe any signifi-cant complications. The only reportedadverse effects were injection site pain infive patients (lasting less than 24 hours), andexacerbated knee effusion in two patients.

VISCOSUPPLEMENTS

Molecular WeightSubstance (daltons) Treatment Source

Hyaluronate (Hyalgan™, 500,000 to 730,000 1 injection per purified from Sanofi-Synthelabo) week for 5 weeks chicken combs

Hylan G-F 20 (Synvisc™, 6 million 1 injection per purified fromGenzyme Biosurgery) week for 3 weeks chicken combs

A synthetic hyaluronic acid similar to healthy 1 injection per bio-synthetic(Arthrease™, DePuy Ltd, UK) synovial fluid week for 3 weeks product

Hyaluronate in 4 million to 6 million - naturalhealthy synovial fluid

Hyaluronate in 1 million to 4 million - naturalosteoarthritic synovial fluid

SafetyThe risk of introducing infection into an

OA joint is extremely low if standard aseptictechnique is used. The lack of systemic sideeffects make the use of viscosupplementa-tion an appealing option for the manage-ment of the knee OA. Extensive safety andtoxicity tests were performed on Synvisc™before the first clinical trials. Preclinicalstudies showed that Synvisc™ is nonanti-genic, nontoxic, noninflammatory, and doesnot elicit foreign body reactions.Hyaluronan, from which hylan is derived, hasbeen safely used in ophthalmic and orthope-dic applications in millions of patients.There have been no systemic side effectsattributed to Synvisc. No cases of anaphylax-is or anaphylactoid reactions have beenreported in connection with Synvisc™ treat-ment. However, anaphylactic-like reactionshave been reported following intra-articularHyalgan™ injections.18

Unwanted EffectsIn clinical trials, transient redness, local

pain, warmth, and effusion, usually lastingup to three to four days, may occur.Occasionally, severe synovitis may occur

requiring treatment with intra-articular corti-costeroids.

PrecautionsPatients should consult their doctor or sur-geon if they have a history of hypersensitivi-ties to hyaluronan preparations or are aller-gic to avian proteins, feathers and egg prod-ucts. Intra-articular viscosupplementsshould not be given to patients with aninfection or skin disease around the injec-tion site, and should not be used if venousor lymphatic stasis is present in the leg, or ifthe joint is severely inflamed.18

Market Analysis19

The reimbursement of hyaluronic acidtherapy varies greatly from market to market,particularly in Europe, and has become moreimportant in some of these markets thanefficacy or product reputation. Despiteclaims and reasonable clinical evidence frommanufacturers of efficacy and specific prod-uct advantages, many end-users remainsceptical that hyaluronic acid viscosupple-mentation is truly an effective treatment forosteoarthritis of the knee. Therefore compa-nies must increase physician and surgeon

confidence through detailed clinical studiesspecifically designed to address these con-cerns.

The US will become the largest market forHA manufacturers and distributors, valuedat $235 million in 2001, despite per capitausage of only 8.5 percent of that seen inAustria. The Austrian market is growing at avery slow pace, because of extremely highper capita usage. In contrast, the UK marketis growing at a higher rate, but surgeon andGP scepticism, infrastructure problems, andlack of funds interfere with wider acceptanceof viscosupplement therapy. In the UK thereare additional difficulties with “evidence-based-medicine” approach of some NHSTrusts, which are unnecessarily restrictive,and in reality based on rationing policies. Atthe same time most orthopaedic surgeonsrecommend and use a wide range of expen-sive oral NSAIDs, a combination of intra-articular steroids and local anaestheticinjections, and arthroscopic debridementsand washouts, without any restrictions.

As evident from the table below, the$563.9 million global market for hyaluronicacid is dominated by Japan and the US, withthe European market accounting for a com-

ISAKOS NEWSLETTER • WINTER 2003 • 11

SUMMARY OF CLINICAL TRIALS

Study Intervention Design Clinical Assessment Parameters Conclusion Comment

Listrat et al., 1997 3 injections of Randomised, VAS (pain), Lequesne’s index This study suggests that Industry-Hyalgan, every prospective (functional impairment), AIMS2 repeated injections of sponsored study.3 months, for a year (quality of life) hyaluronan might delay Small sample

structural progression of sizethe disease.

Adams et al., 1995 Hylan G-F 20 vs Randomised, VAS (pain) Hyalgan equivalent to Industry-continuous NSAIDs single-blind, continuous NSAIDs at sponsored study

prospective, 12-week follow-upmuticenter

Wobig et al., 1999 Hylan G-F 20 vs a Randomised, VAS (pain) Hylan G-F 20 significantly Industry-low molecular weight double-blind, better than low molecular sponsored studyhyaluronate prospective, weight hyaluronate at

multicenter 12 week follow-up

Bellamy et al., 2001 Appropriate Care Randomised, WOMAC, and SF-36 Results provide strong Industry-(according to ACR prospective, evidence for adoption of sponsored studyguidelines) with or multicenter treatment with hylan G-F 20 without hylan G-F 20 in patients with knee OA. injections Good value for money.

paratively small level of sales. While Japanaccounted for 47 percent of the global mar-ket value in 2001, nearly 86 percent of thetotal number of HA injections were adminis-tered in Japan. Low prices in Japan, and highprices in US, account for the discrepancybetween comparative market values and

comparative market vol-umes.In France, the product is

only reimbursed at 50 per-cent of the price, with onlyone product reimbursedin 2001. In Spain, the useof hyaluronic acid is verylow, due to lack of reim-bursement. In Italy, themarket is fairly mature,with hyaluronic acid visco-supplementation first uti-lized in 1987 when Fidialaunched Hyalgan to themarket. Fidia’s productcontinues to dominate themarket, which reached345,000 injections in 2001.The largest HA market inEurope is Germany. TheGerman HA market con-tinues to exhibit impres-sive growth despite a rela-

tively high market volume, forecasted toapproach one million units sold in 2002. Theyoung US market remains the fastest grow-ing market, and in 2002 will become thehighest value HA market in the world. Onlythree products currently competing on theUS market are contributing to increased

awareness and acceptance of hyaluronic acidamong end-users and patients.

ConclusionThe economic costs of OA of the knee are

enormous. If viscosupplementation doesindeed reduce and defer the need for surgi-cal procedures like arthroscopic knee wash-outs and debridements, and total kneereplacements, the cost savings will be con-siderable. Even more important will be thediminution of the risks associated withanaesthetic and surgical procedures.However, three or five weekly injections arequite awkward for most clinicians andpatients. One single injection, which lastslong enough, would be much more useful.

There is no doubt that viscosupplementa-tion represents valuable addition to currenttreatments for osteoarthritis and an alterna-tive treatment when other forms of medicaltreatment are contraindicated or have failed.

19. Datamonitor Market Dynamics –Hyaluronic Acid Viscosupplementation,Reference code DMHC1776, Publicationdate: June 2002. www.datamonitor.com.

A complete list of references can be found onlineat www.isakos.com/innovations/index.html.

12 • ISAKOS NEWSLETTER • WINTER 2003

GLOBAL MARKET SHARE BY VALUE, %, 2001

Source: Datamonitor (www.datamonitor.com)

Global Market Value: $563.9 million

19th International Jerusalem Symposium on Sports MedicineApril 2-3, 2003Tel Aviv, Israel

Contact: Gideon Mann, MDE-mail: gmann@sportsmedicine.co.ilWeb: www.sportsmedicine.co.ilFax: +972 2 652 823

2nd European Congress of SportsTraumatology European Federation ofOrthopaedic Sports Traumatology (EFOST)May 1-3, 2003Monaco

Contact: Anne Capelle & Marion Le DantecE-mail: marion@mcocongres.comWeb: www.s-f-t-s.orgFax: +33-4-95-09-38-01

7th SMC Arthroscopy Symposium June 11-13, 2003Seoul, Korea

Contact: Seung-Ho Kim, MDE-mail: smcknot@hotmail.comWeb: www.smcarthro.comFax: +82-2-3410-0061

Curso Superior 2003: Ligamento Cruzado Anterior, Posterior y Complejo PosterolateralThe Argentine Arthroscopy AssociationSeptember 5-6, 2003 Buenos Aires, Argentina

Contact: Guillermo Arce, MDE-mail: artroscopia_arg@ciudad.com.arWeb: www.artroscopia.com.arFax: +54-11-4-811-2389

IX Congress of Sports-TraumaAssociations of ArgentinaSeptember 11-13, 2003Buenos Aires, Argentina

Contact: Maria Lorena CapuyaE-mail: aato@aato.org.arWeb: www.aato.org.arFax: +54 11 4804 2975

Upcoming ISAKOS-Approved Courses

Working closely with leading edge medical professionals, Smith & Nephew, Inc., Endoscopy Division,designs, develops, and manufactures endoscopic surgical instrumentation based on a technique-drivenapproach to an innovative surgical solution.

In addition to being in the forefront of endoscopic techniques, Smith & Nephew is a world leader of surgical training programs for the medical community.

Call 1-800-343-5717 for information, or visit the following web sites for more information on clinical studies, online training calendar, and discussion forums.

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©2002 Smith & Nephew, Inc. All rights reserved. 08/02 1518Proprietary and Confidential: Do not disclose, copy, distribute, or otherwise reproduce this information without the written consent of an officer of Smith & Nephew.

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2003 ISAKOS CONGRESSMARCH 10-14, 2003

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