Spire Southampton’s Ski Clinic

Mr Frame specialises in all surgery of the knee but in particular complex primary knee replacements, partial knee replacements, revision (second time) knee replacements and soft tissue ligament reconstruction. He has built a specific interest in problems of the knee cap, both for unstable knee caps and for arthritis. He is trained in the surgical technique of trochleoplasty (creation of a new groove for the knee cap) and has combined this with his research in 3D printing to create a model of the patient's knee from scans to help plan surgery and provide the best possible outcome.

Mr Frame is an internationally trained surgeon, having completed multiple fellowships in trauma and knee surgery. These include; Zimmer Orthopaedic Knee Fellowship - University Hospital Southampton - Prof D. Barrett, Mr P Chapman-Sheath; Royal College of Physician & Surgeon of Glasgow International Traveling Fellowship Award - Complex Trauma - Parkland Hospital, Dallas, Texas - Prof Adam Starr; Trauma Traveling Fellowship - Massachusetts General Hospital, Boston - Dr. David Ring, Dr Malcolm Smith; Soft Tissue knee and Trochleoplasty Fellowship - Ortho-Lyon Clinic, Lyon, France - Dr David Dejour.

Mr Frame is currently leading the implementation of the innovative 'Virtual Fracture Clinic' model originally developed in Glasgow Royal Infirmary in to University Hospital Southampton. From 2010-14 Mr Frame held the position of official team doctor for the professional ELITE league ice hockey team The Braehead Clan.

Mr Frame qualified in 2003 from The University of Aberdeen and subsequently undertook his orthopaedic training in the very well regarded west of Scotland orthopaedic training program. During his orthopaedic training he developed an active interest in complex surgery of the knee and trauma. He was appointed as a consultant orthopaedic and trauma surgeon at the University Hospital Southampton. He has had national press coverage on his innovative research in to 3D printing technology in Orthopaedics and the creation of custom implants and guides for improving surgical outcomes.

The anterior cruciate ligament (ACL)

The anterior cruciate ligament is a long band of tissue that connects the femur (thigh bone) to the tibia (shin). It helps to stabilise the knee.

ACL injuries

ACL injuries are common, particularly in young active individuals. The ACL is often stretched and, or torn during a sudden twisting motion (the foot stays planted in one direction, but the knee turns the other way). Sports with a high risk of ACL injury include football, skiing and basketball. Males tend to participate more frequently in sports that are associated with a high risk of ACL injury, but females are up to three times more likely to sustain an ACL injury during like for like activity than males.

ACL reconstruction surgery

The current ‘Gold’ standard treatment for an ACL tear is ACL reconstruction. Traditional ACL reconstruction surgery involves replacing the torn ligament with a graft using the patient’s own hamstring or less commonly patellar tendon (the kneecap) The technique is normally carried out arthroscopically (keyhole surgery) and usually involves removing any remaining ACL, without any attempt to repair the ligament.

Although traditional ACL reconstruction surgery with graft restores knee function it does not produce a ‘normal’ feeling knee, with loss of proprioception, this is the knowledge of the position of the knee and leg in space. Loss of proprioception is important as this mechanism provides feedback to the muscles surrounding the knee to help limit knee movement and prevent overloading of the ACL graft. Loss of proprioception may also play an important role in the confidence that athletes have in their knee after ACL reconstruction. It is estimated that less than 50% of patients return to sport after ACL reconstruction and those that do often find that they cannot perform at the same level as before their injury or surgery.

Reconstructive surgery using tissue harvested from the patient can lead to muscle weakness with hamstring grafts and pain at the front of the knee with patella tendon grafts.

Studies on how well traditional ACL grafts do in the long term suggest that 1 in 9 patients will experience graft failure and need more surgery.

A number of variations have been introduced to the ACL reconstruction technique such as the use of double bundle rather than single bundle graft, retention of the remains of the ACL and variations in graft fixation techniques. However, none of these variations have been shown to make significant difference to the results of the surgery.

It is for these reasons that we are interested in new techniques to improve the outcomes of ACL surgery.

ACL repair with an internal brace

Rather than replacing the torn ligament, this new technique involves repairing the ACL where it has pulled off from its attachment on the femoral side of the knee.

We believe that around 70% of ACL injuries might be suitable for repair and that repair might be possible for up three months following injury.

The ACL repair technique is very similar to traditional ACL reconstruction surgery using hamstring grafts. You will have:

• the surgery as a day case which means that you don’t have to stay overnight
• keyhole surgery. The surgeon will drill holes in the tibia (shin) and femur (hamstring) to repair the ligament and attach the internal brace.

The surgeon stitches the torn ACL ligament together and then protects it using a 2.5mm polyethylene tape (the Internal Brace), which allows healing to occur.

What are the possible risks or disadvantages?

If you want to go ahead with ACL repair the surgery will have to take place within 3 months of your injury, whereas traditional ACL reconstruction can be delayed and done at any time, e.g. if the timing does not suit your work or home life.

The risks associated with this new technique are low.

Should the ACL repair fail, then a traditional ACL reconstruction can be carried out using the same tunnels used for the ACL brace. The tunnel used for the ACL repair is narrower than that used for a reconstruction and therefore the tunnel can easily be widened to accommodate an ACL reconstruction. However, you would need a second surgery should the repair fail to heal properly.

The risks include infection, blood clots, nerve and vessel injury, bleeding and fractures associated with any surgery on the knee, but these are not thought to be any greater than with traditional

ACL techniques and altogether these risks are all very low.

What are the perceived advantages of the ACL internal brace?

The potential benefits of the ACL internal brace include:

• maintaining proprioception (knowledge of the position of the knee and leg in space)
• avoiding problems associated with hamstring grafts,
• more normal knee movements and
• decreased risk of developing early osteoarthritis.

There might also be faster recovery as the ligament heals by direct fibrous repair rather than the slower process seen in ACL reconstruction.

This novel approach to ACL repair has been piloted and early results suggests that results from this technique are at least as good as outcomes achieved using traditional ACL reconstruction with hamstring grafts.

Mr Mark Frame, Consultant Orthopaedic Surgeon sat down with the Spire Southampton to talk about his love for skiing, how to prepare for the ski season, injuries and the new Rapid Access Ski clinic Mr Frame is offering at the Spire Southampton.

What got you into skiing? How do you get into University racing?

I have always been a keen skier, It definitely helped coming from Scotland with mountains (and snow!) on my doorstep. I actually grew up virtually next door to a dry ski slope and spent any free time I had in a pair of ski boots! As soon as I possibly could I grasped the opportunity to do my ski instructor qualifications and spent years teaching from beginners up to race training. I also had the chance to teach those less fortunate and expose them to a sport they might not otherwise have had the opportunity to experience. It was then a natural step to join the Aberdeen University Ski Club in the cold and snowy North East. It was a great club and great to be part of the race team. I have always been competitive, and bashing slalom poles down on a cold and rainy Scottish night never dampened my enjoyment. 

Do you still get a chance to teach skiing with your commitments as an Orthopaedic surgeon?

I kept up regular teaching when I was an orthopaedic trainee in Glasgow, but like anything life became busy and it is not something that I could fit in between shifts. I now have 2 children and my teaching skills are coming in useful to encourage them to enjoy the sport I love. 

Where is your favourite ski destination?

I loved skiing in Scotland. It’s not for the faint-hearted! Skiing in sleet and over heather, but if you can ski in Scotland you can ski anywhere! My favourite place is Tignes in France. The food is also slightly better there!

With the ski season fast approaching what do you do to prepare?

The key thing I do before skiing is making sure I am as physically fit as I can be. Running or cycling to prepare your legs. Stamina is the key. Injuries happen when you get tired and don't concentrate. Keeping your quads in good condition and having the stamina to resist the afternoon burn is vital!

What's the best advice you would give people preparing for the ski season?

Give yourself plenty of time to prepare. Gauge your level and work out what your goals are. Everyone is different and that's where having someone else to guide you through a program is great. 

Is there anything you can do while on holiday or is all the preparation done before you go?

Best thing is to make sure your gear is in top condition and as much as we all like the race skis, make sure your ski gear matches your ability. Have a professional set your bindings so they release correctly if you fall. Last but not least, stop when you’re tired, that one more run might be the worst thing you ever did. It is never to early for apres!

What ski injuries do you commonly see?

The most common injuries are tibial fractures and ACL injuries. Getting diagnosed quickly is important as we can now consider you for ACL repair rather than doing a reconstruction. This is only possible in the first 4-6 weeks.

How common are they? Should we be worried?

These injuries are still rare and you shouldn't worry. Its just good to be aware and maximise your chances of having a great injury free holiday.

What made you want to set up the ski clinic at Spire Southampton?

I felt there was a need to have a rapid means for anyone who has had an injury whilst skiing to get diagnosed and treated as quickly as possible. Being able to book your clinic and MRI whilst still in your chalet in France just puts your mind at rest. The advantage of a quick diagnosis also opens the door for ACL injuries to be possibly treated with a new technique of ACL repair and Arthrex Internal Bracing rather than a traditional ACL reconstruction using your hamstring tendons as a graft. This new ACL repair technique could get you back on your feet quicker and with less pain. This needs to be assessed quickly as the window of opportunity is 4-6 weeks.