Dr. Andree Ellermann is the Head of Orthopaedic Surgery at the ARCUS-Sportklinik in Pforzheim, Germany, where he performs a high number of surgeries every year. In addition to leading his own department, he is the author of numerous articles and the founder and organizer of a large multidisciplinary conference on sports medicine. He is sought after as a clinical consultant for the orthopaedic medical industry, and was one of the first physicians to use computer-assisted navigation in ACL repair.
Knee1: Dr. Ellermann, you perform an unusually high number of surgeries. How many operations do you personally perform in a year?
Dr. Ellermann: About twelve hundred a year. The whole group, consisting of three partners and a couple of coworkers, does about four thousand operations, so I believe we’re among the leading arthroscopy units in Germany.
Knee1: Since you specialize in sports medicine, are most of these patients athletes?
Dr. Ellermann: Well, there are not thousands of high-level athletes you can operate on in a year; but they are mostly athletes, professional or nonprofessional. ACL repair, for example, is not only an operation for a young active person, but for anyone who needs a stable knee to participate in sports or a sports-related activity.
Knee1: Another one of your current interests is treating cruciate ligament injuries in children. What are the special challenges involved in working with child patients?
Dr. Ellermann: It became a new interest of mine a couple of years ago because there’s so little literature on the subject. If we were looking at midsubstance tears in particular, they seemed to be rather infrequent in children, but as we looked at it more closely, we found that there’s an increasing number in children and adolescents. Meanwhile, after a couple of years, I had a lot of children referred to my practice. I have the impression that my colleagues are quite happy that they can send this particular patient group to someone who’s dealing with it more frequently.
A lot of problems are associated with children. You have to talk to parents to make it clear that children need the operation even more than adults might; you have to tell them that if you do it properly, the risk of growth disturbance is quite low. That’s the biggest concern of most of the surgeons, but fortunately, there have been very few cases reported in the literature. These were mainly associated with fixation devices close to the epiphyseal line.
It’s a little bit of an emotional problem as well, if you have a small child. Operating on children is always different. You need to be extra-careful, not only with the patient, but with the parents, and with the doctors that referred them to you; it’s quite a delicate situation. Fortunately, we haven’t seen any growth disturbances so far, and last year I operated on almost 40, maybe 45 children with an ACL-lesion, which is quite a high number.
Knee1: You're currently specializing in using computer-assisted navigation in orthopaedic surgery. Can you tell our readers a little more about how this technology is used?
Dr. Ellermann: Computer-assisted surgery is not a new item. Especially in ACL surgery, I think I was one of the very first to use the system clinically. That started three years ago. Navigation in general has been in the operating rooms for a few years now, but that’s especially true for spine surgery, and for hip and knee joint replacement.
I don’t believe that at the moment the current systems are good enough to help us in our everyday routines. Because it is a time consuming procedure we cannot use it routinely since we are operating over 1000 ACL´s per year.
A crucial thing about ACL surgery is the placement of the tunnels, and if in the future we get more information and more precise identification of these insertion points, we will improve our results. It’s still not a tool which you can use in every operation today, but I'm sure that the system and the techniques will improve, and that in the future this will be a major part of almost every orthopaedic operation.
Knee1: What would this new technology look like?
Dr. Ellermann: I believe that we have to be able to rely one hundred percent on virtual models we create, which means we need perfect tools to help us create this model. We need some kind of image that helps the surgeon to identify the anatomic structures. We have to create a virtual model of the patient’s knee to work in, in which to identify certain points and then refer these points back to the patient’s knee.
I believe that this is the most important thing for the future. Those tools could be MRI, CT, X-rays, fluoroscopy; they could even be ultrasound. But I think the major improvements will come with better image processing, in whatever field.
Knee1: For the last five years, you've organized two annual meetings which bring together experts in your field. What led you to begin this effort?
Dr Ellermann: In Germany, sports medicine plays an important role in general, just like in the U.S. I always found it important not only to see the athletes from an orthopaedic point of view, but also to integrate other subspecialties. An athlete, no matter if he’s professional or nonprofessional, should always be looked at from different standpoints. Especially if it’s a professional athlete, you should take all the help you can get from other colleagues, to help the athlete go back to what he has to do, as soon as possible.
That’s why I organize these meetings, to bring together experts, not only in orthopaedics, but also in internal medicine and other medical subjects to discuss these topics. Of course, since I’m an orthopaedic surgeon, there might be a focus on orthopaedics, but I understand that all the participants have been quite satisfied with the mixture of topics and the broad view of sports medicine that we offer them.
Knee1: You've also worked as a consultant to the orthopaedic medical industry. What kind of information do you provide to industry? What do you think you've accomplished in this role?
Dr. Ellermann: I’ve worked together with different industrial companies. One topic has been navigation in cruciate ligament surgery; and then we’ve been judging implants for use in prosthetic and orthopaedic surgery. Since we’re doing a large number of certain operations in a short time period it seems interesting for the industry to use our experience and clinical knowledge. The cooperation between the medical industry and clinical workers is an ongoing process which should be intensified to create a basis for future developments and better results for the patients.
Knee1: What are the new technologies that you are most excited about?
Dr. Ellermann: Just like all the other orthopaedic surgeons who deal a lot with cruciate ligament surgery, we’re having a close look at biotechnology. I’m sure that this is going to play a major role in the future.
Since I don’t have my own laboratory, it’s difficult to talk much about experimentation, but I believe that in the future, for certain difficult situations, we won’t have to look at allografts or autografts anymore. We’ll have a look at meniscal or ACL implants that have been specially bred for a certain patient. I’m sure that in a couple of years we may see transplants designed individually for the patient. Gene technology is going to give us a lot of help there.
Let’s look at ACL surgery. Every transplant that you take away from the patient, no matter if it’s a patellar tendon, a hamstring tendon, or so on, is weakening the patient’s thigh muscle. Harvest morbidity has always been a topic. This has been one of the main reasons why for years, surgeons rejected the patellar tendon in favor of the hamstring tendon graft, because there is a problem with harvest morbidity. If we can just shop for a transplant for the patient, it is going to be a major advantage. It will be faster with less morbidity.
Knee1: What would you most like to see happen in orthopaedics within the next five years?
Dr. Ellermann: I have some personal wishes, of course, but those are related to the political problems we have in Germany where our health system is concerned. We’re facing major problems for the continuation of our health system as it currently exists. This is one of my major concerns at the moment: that we will not be able to treat the patients in the future as we were able to treat them in the past, because the financial situation might not allow this anymore.
This is a serious concern in Germany and in Europe in general. Our patients need high-quality transplants, high-quality implants, operations with the best technology available; and if the system runs out of money, then we will have a problem providing all of that for the patient.
Knee1: Can you provide some background on this problem for our American readers?
Dr. Ellermann: The health system as it is organized in Germany works differently from the health system in the U.S. From what I know of the U.S., the patient more or less pays for the operation himself. He might have insurance that covers certain procedures, but in general the American patients pay, and have somehow accepted this situation. In Germany, the government takes away a certain amount of our salary for health care. If you get into a situation where somehow you become a patient, you go to any doctor--you can choose your doctor rather freely, in any subspecialty--and you get high-quality treatment. I believe strongly that we live in a country where the treatment is of the highest quality you can get.
Over decades, it has been clear that the state is keeping the health system alive, and that we pay a high amount of money to keep it alive. But somehow, it’s not enough anymore.
Our social system has become very weak over the past decades. We have reached a point where the money that is paid by the individual does not help the whole group. The government has to find, on the one hand, a way to prevent the state from going bankrupt, and on the other hand, a way to provide a good health system to the population. Right now, it does not look as if the perfect solution has been found so far.
We have to convince our patients that they will have to receive low-quality help or bring in some of their own money, and this is going to be a major problem here, I’m sure. I strongly believe that this problem has already been occurring, but it’s going to be worse. I am not a politician, but I would think that, no matter which government is going to rule our country for the next five, ten, twenty years, we have to ask them to restructure the system and to establish new ways of financing health. I believe that patients will have to take more responsibility in financing and organizing individual health care.