Dr. Jürgen Höher has served as the Chief of the Division of Arthroscopy and Sports Traumatology Department at the CHARITE University in Berlin, and is currently heading an outpatient sports clinic at the Merheim Hospital in Cologne, Germany and he is also a consultant of the hospital for knee surgery. (Dr. Höher's personal site) In addition to holding these prestigious academic posts, Dr. Höher has been part of several research groups in Europe. Recently, he has participated in the meniscus repair group ESSKA, which has been investigating a new meniscus repair technology known as FasT-Fix®. He has also served as a reviewer for American medical journals, including the American Journal for Sports Medicine and the American Journal for Arthroscopy. In addition to Dr. Höher’s achievements in sports medicine, he is a sportsman himself: he participates in recreational soccer, skiing, and tennis, and is a three-time marathon finisher. Body1: How did you end up choosing your area of specialty?
Dr. Höher: It was my own knee injury, which took place when I was 18. I tore my ACL (anterior cruciate ligament), so I couldn’t play soccer competitively anymore. The injury raised my interest in the field.
Body1: How did you end up coming to the U.S. to study? Why did you make that decision?
Dr. Höher: While training to become an orthopedic surgeon I was doing studies on knee ligament research. Most articles on the subject are published in the US, and most high-level research centers are located in the US, so it was the obvious choice.
Body1: You also did a year of undergraduate study at Harvard University.
Dr. Höher: Yes, when I was an undergraduate in Germany I coached in New England over the summers for four years. I was a soccer coach for nine- to sixteen-year-olds, and in return, the kids taught me a lot of English. One of the players´ fathers was a Harvard professor and helped me apply for the Harvard exchange program.
Body1: What percentage of your current patients are soccer players, and what other kinds of athletes do you see?
Dr. Höher: I would say 40%, or even the majority, are soccer players. In Germany, soccer is the most popular sport and is the major cause of sports-related injuries, so I think that's why. Skiing is the second frequent cause of severe knee injuries in Germany. However, I'm not located right in the ski area, therefore I do not see skiers right away. But I do see many athletes from other sports, like basketball and European handball.
Body1: What is the breakdown of recreational versus professional athletes at your clinic, and what are the differences between treating a professional athlete and treating a recreational athlete?
Dr. Höher: We treat maybe 10-20% professional athletes. In some ways the two groups are similar, because the sport is very important for all of the athletes. Even for a recreational person, it’s very important to go running or play sports twice a week. It’s a quality of life issue. For professional athletes, their motivation is, of course, different. The sport is how they make a life, how they earn money. They’re more apt to do whatever the surgeon or the doctor tells them might help the healing process no matter the personal effort or costs.
Body1: You mentioned that your greatest contribution to orthopaedic knee care was your research on ACL graft fixation, and in particular your studies on the bungee effect and windshield-wiper effect. Can you explain those effects in layman’s terms for our readers?
Dr. Höher: In the late ‘90s, there was one very common technique that used free tendon grafts. These were tied with a synthetic strip, a very long distance away from the insertion site area in the joint. Although this technique was very easy to do, and it was very popular for that reason, we found out in the biomechanical lab in Pittsburgh, PA that there was a significant amount of motion of the graft within the bone tunnel. The high elasticity of the strip made it similar to a bungee cord, in that it gives way for a very long time before the tissue comes to a stop.
With the windshield-wiper effect, the graft moves transversely in the tunnel, and the graft gets bent over the bone edge. Again, this motion is very similar to what happens with a windshield wiper in a car. The motion of the graft makes the bone tunnel very wide; wider and wider. This impairs the healing of the graft.
Body1: How did orthopedics move away from these procedures and towards something more successful?
Dr. Höher: The research has moved on. Over the last ten years, we have begun using different materials--much stiffer, not as elastic--and many new fixation techniques have developed.
Body1: You are currently doing research on new concepts in meniscus repair as well, in particular on a new meniscus repair technology known as “FasT-Fix.” What can you tell us about these new concepts?
Dr. Höher: In the ‘90s, most meniscus repair techniques relied on sticking a device into the torn meniscus. There were new devices, in the shape of an arrow, which you would stick into the meniscus similar to a wall plug; then you would hope the tissue would stay that way and heal. From this technique, many meniscal arrows developed, but they have not lived up to what they promised. Very recently a new technique has been developed in which a special preknotted suture is used in combination with tiny implants placed outside of the joint capsule. It’s very new, very easy, very efficient, and it brings the meniscus back into position much better so that it can heal more predictably.
Body1: You were responsible for doing some of the first clinical studies in Europe on this new technology; is that correct?
Dr. Höher: Yes, we did clinical studies with the new meniscus device both in Berlin and in Cologne. Currently we are participating in a European-wide multi-center study under the patronage of the European Society of Sports Medicine. The device had to be tested; we had to find the right indications for patients.
Body1: And after doing these studies, were you satisfied with the device?
Dr. Höher: Yes. From what we have learned so far it's a great advance, a great step to the future.
Body1: You also mentioned new ACL reconstruction techniques, in particular the use of new screw devices. What can you tell us about these new techniques?
Dr. Höher: We are currently involved in a clinical evaluation of a new bioresorbable screw for fixation of ACL grafts. With this technique we avoid adverse effects such as the windshield wiper and bungee effect as mentioned above. Also, we can achieve a more anatomic fixation and ideally the implants will completely disappear with time and avoid hardware removal. From what we have found in our studies so far, our patients do not show negative reactions to the devices; so, in the short-term at least, it’s very promising that this will be a very good development.
Body1: What are the major differences you see between medicine as it is practiced in the United States and medicine as it is practiced in Germany?
Dr. Höher: I think the differences are not very big. Medical cases are similar all over the world. People are more and more interested in sports everywhere since it is an ideal counterpart to business life. Since I am a sportsman myself, I have good rapport with my patients in both countries.
However, in Germany, we are struggling with health insurance, and with compensation for the cost of treatment; perhaps more than in the U.S. Many of the treatments we have been talking about are very expensive, and it is difficult to get them used in all of our cases.
Body1: What would you most like to see happen in your field in the next five years or so?
Dr. Höher: There is no perfect ACL reconstruction technique right now, and it would be nice to have “the one and only.” We still haven’t come up with the perfect technique. If you ask many researchers which technique is best, you get many opinions, which always tells you there isn’t one that is the best. There are many things available, and they all work well 80-90% of the time, but they all have some downside. With more clinical studies we can help to identify the ones that work better than the others.
Also, we are waiting for the development of new technologies for ACL reconstruction that will bring recent advances in molecular biology. Currently the rehabilitation process after ACL reconstruction depends on the process of graft ingrowth and remodeling, at least lasting for 6-12 months. However, patients are sometimes not very patient in our times. They would like to receive grafts that heal faster.
The ideas are there right now. Basic research in molecular biology has identified many substances in the body that can speed up the healing process both in ligament and meniscus surgery. The current problem is to identify which ones are essential to help us and how we can administer them in a high dosage into the knee joint. In some ways, we don't see the tree because we're standing in front of the forest. We need to pick the right tree, but we don't know which one it is right now. I would think that in maybe five to ten years we might have something available.
Body1: Is there anything you would like the readers of our site to know?
Dr. Höher: Besides all research we do and promising perspectives we see for the future, the primary goal of our clinic is patient care at a supreme level. Thus we always have to judge the best treatment at the current moment that is able to bring our patients back to their desired sports.
