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Study finds freezing nerves prior to knee replacement improves outcomes

The first study of its kind has found that freezing nerves before knee replacement surgery combined with traditional pain management approaches significantly improves patient outcomes. The results of the preliminary retrospective study led by Vinod Dasa, MD, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine, were published online Feb. 10, 2016, in the journal, The Knee, as an Article in Press.

The study, a retrospective chart review, investigated the cases of 100 patients with advanced osteoarthritis requiring total knee replacement in Dr. Dasa’s LSU Health New Orleans orthopaedic practice. Half of them were treated with standard multiple pain management options, before cryoneurolysis (nerve freezing) was introduced to the practice. The first 50 patients to undergo cryneurolysis in addition to multimodal pain management comprised the treatment group, which was compared to the control group who had standard therapy alone. The treatment and control groups were similar in terms of gender, age and body mass index. The only difference is that the treatment group received cryoneurolysis via an FDA-approved handheld device five days prior to surgery. The KOOS (Knee Injury and Osteoarthritis Outcome Score), PROMS (Patient-reported Outcomes Measurement Information System), WOMAC (Western Ontario and McMaster Universities Arthritis Index) and Oxford Knee Score were used to measure outcomes.

“Patients in the treatment group had significantly shorter hospital stays, were prescribed significantly fewer opioids during the first 12 weeks post-operatively and had significantly fewer knee symptoms,” notes Dr. Vinod Dasa, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine.

The ability to decrease hospital length of stay following total knee replacement should substantially reduce costs for hospitals and payers. In the present study, only 6% of patients treated with cryoneurolysis prior to surgery stayed in the hospital for two or more days compared to 67% of patients who did not receive this treatment. Similarly, almost half of patients treated with cryoneurolysis were discharged on the same day of surgery compared with only 14% in the control group. The shorter length of stay of the patients in the treatment group may be due to better local control of pain and a reduced need for nerve blocks that can impair motor function, as well as reduced use of opioids for pain control, which allows patients to walk and function well enough to go home sooner.

Approximately 600,000 knee replacements are performed each year, and this number is expected to increase in coming years. Although knee replacements usually are very successful in the long term, patients often experience a significant amount of pain during the immediate post-operative period, which can be a major hindrance to effective rehabilitation and restoration of function following surgery.

MNT 12 February 2016

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Muscle Strengthening Aids New Knees

A new study suggests that a carefully focused program of muscle strengthening can make an important difference in how well patients recover after knee replacement.  Patients who underwent six weeks of progressive muscle strengthening aimed at the quadriceps did much better than patients given conventional treatment. The study appears in the February issue of Arthritis Care & Research.  Almost 500,000 knee replacements are done in the United States each year, and patients often report that they still have problems doing things like walking and climbing.  For the study, more than 200 patients were divided into groups and given different treatments about four weeks after surgery.  One received conventional treatment. Another was also given quadriceps strengthening, while a third was given the strengthening and electrical stimulation to make the muscles contract.

While the electrical stimulation did not appear to make a difference, the muscle strengthening appeared to bring the patients back to a level of functioning almost normal for their age.  One of the authors, Lynn Snyder-Mackler of the University of Delaware, said in an e-mail message that knee replacement patients and their doctors should not underestimate the ability “to really improve their function.”

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Patient and Doctor

Caring for Hips and Knees to Avoid Artificial Joints

PROTECT your joints now, or pay later.

That’s the message of today’s column, which could be headlined Joint Economics.

If you are one of the more than 400,000 people a year who have already had one or more hips or knees replaced — or someone who already has no choice but to consider joining their ranks — we offer our sympathies or encouragement or even congratulations, depending on how you are faring. But this column is for people who are not yet destined to necessarily become part of those statistics.

Although the human body has an amazing capacity to repair itself, our joints are surprisingly fragile.  When the cartilage that cushions bones wears away, it does not grow back. Thinning cartilage contributes to osteoarthritis, also known as degenerative arthritis, a painful and often debilitating condition.

Over time, arthritic joints can become so sore and inflamed that they need to be replaced with mechanical substitutes. A result: more pain, at least in the short term, and big medical bills.  Fortunately, you can act to protect your joints now, to reduce your chances of needing to replace them later.  And protect you should. The cost for a new hip or knee — the joints most commonly replaced — is $30,000 to $40,000. If you have insurance, your total out-of-pocket costs will be much less, but may still be $3,000 to $4,000. And don’t forget to factor in all those days of work you will miss before you get your new prosthetic.

Creaky joints are a growing national problem. The population is getting older, more people are overweight, and an increasing number of children and young adults are playing serious sports and getting seriously injured — all factors that contribute to osteoarthritis.

“Arthritis used to show up in people during their late 40s and 50s, now we’re seeing it earlier, like in the 30s and 40s,” said Dr. Patience White, a rheumatologist and the chief public health officer at the Arthritis Foundation.

The total national bill for hip replacements in 2007 was $19 billion, and $26 billion for knees, according to the federal Agency for Healthcare Research and Quality. Those figures are expected to rise significantly in the coming decade, Dr. White said. So protecting your joints will do more than save wear and tear on you and your budget. You could also be doing your part to curtail the national health care bill.  If your joints are still intact, or just beginning to creak, here are some ways to keep osteoarthritis at bay.

CONTROL YOUR WEIGHT The more you weigh, the more pressure on your joints, which can lead to joint damage. When you walk, each knee bears a force equivalent to three to six times the body’s weight. If you weigh a mere 120 pounds, your knees are taking a 360-pound, or more, beating with every step.

Studies have found a connection between being overweight and developing osteoarthritis of the knees, and to a lesser extent the hips. One recent review found that 27 percent of hip replacements and 69 percent of knee replacements might be attributed to obesity.  For reasons not well understood, weight is more of risk factor for women than men.

“A woman’s risk for developing O.A. is linearly related to her weight,” Dr. David Felson, a rheumatologist and arthritis prevention specialist at Boston University School of Medicine, said, referring to osteoarthritis.

“Men who are moderately overweight are not as at high a risk as a woman of the same weight,” Dr. Felson said.

But a woman can substantially lower her risk by shedding pounds. One study in which Dr. Felson was a co-author found that when a woman lost 10 pounds, her risk of arthritis of the knee dropped by half.

GO LOW-IMPACT Although no definitive link has been found between osteoarthritis of the knee and running (or any other sport), sports medicine doctors discourage their patients from running on hard pavement, playing tennis on concrete or activities like skiing over lots of moguls.

“Impact sports put too much stress on the joints, particularly the knees,” said Dr. Donald M. Kastenbaum vice chairman of orthopedic surgery at Beth Israel Medical Center in Manhattan. “These activities may lead to O.A. and they definitely can escalate the progression of the condition.”

If you run regularly, try to do so on a track or treadmill and consider swapping one run a week for something low-impact like swimming, biking, lifting weights or tai chi.

AVOID INJURY Easier said than done, of course. But major injuries, typically the type that require surgery, greatly increase your risk for osteoarthritis.  According to one big study, 10 to 20 years after a person injures the anterior cruciate ligament or menisci of the knee, that person has a 50% chance of having arthritis of the knee.

Those rates are even higher when the injury happens in your 30s or 40s, Dr. Felson said. “As you move into middle age, it’s crucial to avoid sports that predispose you to injury,” he said.  Weekend warriors, who sit at a desk Monday through Friday, and then run or play basketball for five hours straight on the weekend, are at a high risk for injury, and thus for osteoarthritis.

GET FIT It makes sense. The better toned your muscles are, the less likely you are to injure yourself (unless you are also playing football every Saturday morning).  And “building muscles up around joints acts like a shock absorber, spreading stress across the joint,” said Dr. Laith M. Jazrawi, chief of the sports medicine division at NYU Hospital for Joint Diseases. Pilates, moderate weight lifting, vinyasa yoga and swimming are all nonimpact forms of exercise that firm up your muscles without jeopardizing your cartilage.

No definitive link exists between increased flexibility and lower, or higher, rates of osteoarthritis. But some doctors interviewed said they believed that by regularly stretching your muscles you are less likely to injure your joints. It can’t hurt to judiciously stretch your muscles after a workout. And even if it won’t protect your joints from deterioration, it will certainly make your muscles feel better.

BE SKEPTICAL Don’t waste your money on specialized nutrients. Shark cartilage, glucosamine and chondroitin — popular supplements marketed for healthy joints — can be expensive and probably are of limited benefit, many specialists say.

“There’s some evidence to suggest glucosamine and chondroitin sulfate may be helpful in O.A. once it has started, but overall the results are inconclusive,” Dr. Jazrawi said. As for shark cartilage, there is no evidence to suggest that it has any benefit for treating the symptoms or the disease, he said. Joints are like car parts. With proper care and maintenance, they last longer.

New York Times

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Getting a New Knee or Hip? Do It Right the First Time

THERE is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking. No wonder, then, that joint replacement is growing in popularity.

In the United States in 2007, surgeons performed about 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier. Though these procedures have become routine, they are not fail-safe.  Implants must sometimes be replaced, said Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston. A study published in 2007 found that 7 percent of hips implanted in Medicare patients had to be replaced within seven and a half years.

The percentage may sound low, but the finding suggests that thousands of hip patients eventually require a second operation, said Dr. Malchau. Those patients must endure additional recoveries, often painful, and increased medical expenses.  The failure rate should be lower, many experts agree. Sweden, for instance, has a failure rate estimated to be a third of that in the United States.

Sweden also has a national joint replacement registry, a database of information from which surgeons can learn how and why certain procedures go awry. A registry also helps surgeons learn quickly whether a specific type of implant is particularly problematic. “Every country that has developed a registry has been able to reduce failure rates significantly,” said Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn.

A newly formed American Joint Replacement Registry will begin gathering data from hospitals in the next 12 to 18 months.  Meanwhile, if you are considering replacing a deteriorating knee or hip, here are some ways to raise the chances of success and avoid a second operation.

EXPERIENCE COUNTS Choose — or request a referral to — an experienced surgeon at a busy hospital. “The most important variable is the technical job done by the surgeon,” said Dr. Donald C. Fithian, an orthopedic surgeon and the former director of Kaiser Permanente’s joint replacement registry.  Ask for recommendations from friends who have had successful implants and from doctors you know and trust. When you meet with the surgeon, ask how many replacements he or she does each year.

VOLUME MATTERS A study published in The Journal of Bone and Joint Surgery in 2004 found that patients receiving knee replacements from doctors who performed more than 50 of the procedures a year had fewer complications than patients whose surgeons did 12 procedures or fewer a year.  The researchers documented a similar trend when it came to hospital volume. Patients at hospitals that performed more than 200 knee replacements a year fared better than patients at hospitals that performed 25 or fewer.

ADJUST EXPECTATIONS Not everyone with joint pain will benefit from a joint replacement.  An implant can help reduce pain and improve mobility if the joint surface is damaged by arthritis, for instance. But a new joint will not help pain caused by inflammation of the surrounding soft tissue, said Dr. Berry, who is also vice president of the board of the American Academy of Orthopaedic Surgeons.  Some people with mildly arthritic joints, for instance, can manage well with the judicious use of medication. “Surgery comes with complications and risks, and should not be approached lightly,” Dr. Berry said.

Joint replacement is not a minor operation. If you have uncontrolled high blood pressure, chronic infection or another serious chronic condition, a joint replacement operation may be too risky a procedure for you. Seek advice from an experienced Orthopaedic Surgeon.

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New Models Of Implants Not Better, Study Finds

A new study suggests that the recent technology for artificial hips and knees did not perform any better than older, less expensive designs.

The study, which draws on data from Australia’s orthopedic registry, covered implants introduced from 2003 to 2007 and was published this week. The findings are significant for patients in the United States because many of the new designs, like so-called metal-on-metal hips, are widely used here. Those implants, which have both a ball and cup made of metal, are expected to fail prematurely in tens of thousands of patients rather than lasting 15 years or more as artificial joints are supposed to do.

The Australian study showed that not a single new artificial hip or knee introduced over a recent five-year period was any more durable than older ones. In fact, 30 percent of them fared worse. The Australian study concluded that both patients and taxpayer-financed health care programs were paying a high cost because surgeons were using newly designed implants, introduced with little test data, over existing designs that had track records.  ”Not only has the introduction of this technology been potentially detrimental to patient care, but the current approach may be an important driver of increased health care costs,” the review concluded.

Dr. Stephen E. Graves, the director of the Australian registry and a co-author of the study, said he believed that surgeons, hospitals and regulators should closely look at the review’s results. In the case of the all-metal hips, some experts say they believe that replacing them may cost companies, insurers and taxpayers billions of dollars.

”There needs to be a careful re-evaluation of current deficiencies in regulation,” Dr. Graves said in a recent e-mail.

The Australian review is part of a special issue of a medical journal, The Journal of Bone and Joint Surgery, devoted to studies that examine the benefits and the limitations of orthopedic registries. While America does not have a registry, the Food and Drug Administration is financing efforts to see whether data from sources like overseas databases and registries run by hospitals here can be used to better monitor device performance.  Many experts argue that such efforts are essential because 700,000 Americans undergo hip or knee replacement every year, and that number is expected to increase sharply as the population ages.  In a registry, information about a patient is entered into a database when he or she receives an implant. Then, when that patient undergoes surgery again to replace that device, more data is added. By looking at large numbers of patients followed in a registry, researchers can tell whether certain device models are failing prematurely at significantly higher rates.

But researchers in England, which has a registry, pointed out in another article in the same medical journal that a product-related disaster had likely already occurred before it was detected in a such a database. As a result, some experts say they believe that there must be greater scrutiny of implants either before or after they go on the market to detect problems earlier.  Another review in the same issue found that the results of published studies that accompany the introduction of new implants could bear little resemblance to registry findings about a device’s success once it went into broader use.  That problem occurs, the review by Australian researchers found, because surgeons involved in the original published reports are often involved in its development and may have a financial stake in them. In addition, such reviews tend to be short term.  Some surgeons say they believe that one type of all-metal implant known as a resurfacing device is permitting some patients to remain more active. However, data indicates that such benefits are limited to one group of patients, namely larger, middle-aged men.

This month, bipartisan legislation was introduced in the Senate that could force manufacturers to track the performance of implants like artificial hips after they have been approved for sale. Proponents of the bill acknowledge that the measure faces an uphill fight.  Both device producers and their allies in Congress have maintained that any additional F.D.A. regulations would slow the development and marketing of innovative products that benefit patients. For his part, Dr. Graves, the Australian official, said he believed that such arguments were misleading.

”The purpose of regulation is not to impede innovation but to ensure safety and effectiveness of medical devices,” he stated. ”This protects patients, but it also protects companies.”

New York Times December 23, 2011

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Social care cuts ‘major cause’ of A&E problems

Older people in England are being left “high and dry” by councils cutting back on the care they provide, Age UK says.  Research by the charity showed the numbers getting help had fallen from just over one million three years ago to 850,000 last year.  Age UK said the cuts were one of the major causes behind the growing pressures on A&E units.  But councils said they had been left with little choice because they were “chronically underfunded”.  The overall cut in numbers getting help from councils represents a drop of one-fifth.  But the research – based on an analysis of official figures – also provided a detailed breakdown of which individual services had been cut.

It found between 2010-11 and 2013-14:

  • The numbers getting help at home for tasks such as washing and dressing fell by a third to just over 370,000
  • Day care places have dropped by two-thirds to just under 60,000
  • The numbers getting meals on wheels fell to 29,500 – a decline of 64%

Age UK director Caroline Abrahams said: “Our state-funded social care system is in calamitous, quite rapid decline.  “The more preventive services like meals on wheels and day care are being especially hard hit, leaving the system increasingly the preserve of older people in the most acute need, storing up big problems for the future.  “Hundreds of thousands of older people who need social care are being left high and dry. The lucky ones have sufficient funds to buy in some support, or can rely on the goodwill of family, neighbours and friends. But there are many who are being left to struggle on entirely alone.”  Previous research by the charity has shown there are nearly 900,000 people who do not get any help for their care needs.

“Until recently the impact of the decline in social care has been relatively hidden, but social care is a crucial pressure valve for the NHS and the evidence of what happens when it is too weak to fulfil that function is clear for us all to see,” Ms Abrahams added.  Over the past three months waiting times in A&E units have reached their worst level for a decade with hospitals reporting they are experiencing particular problems trying to discharge old and frail patients because of the lack of support available in the community.

Vulnerable people

Izzi Seccombe, of the Local Government Association, said the system was “chronically underfunded”.  “Councils have protected our most vulnerable people as far as possible, often at the expense of other services, and we will continue to prioritise those most in need.  “However, the combined pressures of insufficient funding, growing demand, escalating costs and a 40% cut to local government budgets across this parliament mean that despite councils’ best efforts they are having to make tough decisions about the care services they can provide.”

But a Department of Health spokeswoman said the April launch of the Better Care Fund – a £5.3bn pot predominantly funded from the NHS to encourage greater integration between health and care – would help.  “We know we need to work differently to respond to our growing ageing population.”  She added the fund would “focus resources on helping people to live independently, which will save money and reduce unnecessary hospital admissions”.

BBC News 21 January

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Why the rising cost of social care cannot be ignored

“I’ve never felt so alone.” Those were the words a man in his 80s used to tell me how he felt, after his wife of more than 50 years was diagnosed with dementia.  His words have stuck in my mind because his experience seems to sum up the stories that too many people tell when they need social care.  A consultant had delivered the life-changing news to this man and his wife, then said, “I’ll see you in six months.” They were handed a leaflet and they left, his wife unable to comprehend what they’d been told so the weight rested on his shoulders.

The diagnosis was delivered by the NHS, but with a condition like dementia you largely step into another world, the world of social care.  Social care is provided by local authorities and only to those with very high needs and limited savings. Everyone else pays for themselves.  We’re talking about the support someone may need with everyday tasks such as washing, dressing and getting in and out of bed. If a person has dementia it is often about keeping them safe.  When I met this man, he had been his wife’s main carer for several years, helped by their daughters. He paid for extra support, but only wanted to leave her with the right person, someone he could trust.

Social care uncertainty

The cost of the extra help was draining their savings, making him worry about how he will cope in the longer term. It is pressure that made him fear for his own health.  However, if we get social care right then it should keep people out of hospital and there’s the rub.  We’ve seen the recent pressures on accident and emergency and what happens to the health service, when there isn’t enough care in place in the community to either prevent problems or to help people recover at home.  Social care certainly isn’t the only reason why hospitals started the year struggling, but it is a significant factor.

BBC News

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How to deal with a medical emergency on the Space Station

A major medical emergency has never occurred on the International Space Station – but what would happen if it did? And what lessons could be learnt for treating similar emergencies on Earth?  When Tim Peake blasted into orbit in December, he knew that the 40 hours of medical training he’d received would prepare him for most health problems during his six-month stay on the International Space Station.   In addition to life-saving skills, he had been taught how to stitch a wound, give an injection and even extract a tooth.  According to Nasa, this training would prepare him and his crew members for the most common medical problems faced on the ISS – like motion sickness, headaches, back pain, skin conditions, burns and dental emergencies.  But faced with a far more serious medical emergency – what would they do?

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Cuban healthcare

Prevention better than cure in Cuban healthcare system

Imagine your doctor knocking at your door to give not just you, but your whole family, an annual health check-up.  As well as taking blood pressure, checking hearts and asking all sorts of questions about your job and your lifestyle, this doctor is also taking careful note of the state of your home, assessing anything which could be affecting the health of you and your family.  This is what happens in Cuba and although it might not go down well everywhere, it’s a pro-active approach to healthcare that yields some impressive results.

Leader of the pack

In terms of having healthy people, the Cuban health service outperforms other low and medium income countries and in some cases, outperforms much richer ones too.  Despite spending a fraction of what the United States spends on healthcare (the World Bank reports Cuba spends $431 per head per year compared with $8,553 in the US) Cuba has a lower infant mortality rate than the US and a similar life expectancy.  So how do they do it, and could other countries, rich and poor, learn from the Cuban example?

World Health Organization director-general Margaret Chan certainly thinks so.  She has praised the preventative nature of the Cuban health system and called on other countries to follow the Cuban example.  Healthcare in Cuba is free and universal, enshrined in the Cuban constitution as a fundamental human right, guaranteed by the state.  And the foundation of their preventative health care model is at primary care level, the family doctors who oversee the health of those who live around the clinic.  And Cuba does have lots of doctors.

‘First mission’

To serve its population of 11 million, the country has 90,000 of them. That’s eight for every 1,000 citizens – more than double the rate in the US and in the UK (the US has 2.5 doctors per 1,000, the UK 2.7 per 1,000 according to the World Bank).  And many of these doctors are based in neighbourhood medical centres and, along with a nurse and support from visiting specialists, they monitor closely the health and wellbeing of every single Cuban.  Tanya Rosa de la Cuevas Hill is a specialist in comprehensive medicine and she runs a neighbourhood clinic in Old Havana. Along with her nurse, she looks after 334 families who live in the surrounding streets.  “Being a family doctor, I love it,” she says. “The first mission we have is to prevent illness. That’s the wonderful thing about my job. Prevention of diseases, prevention of accidents, that’s what I like best”.  Key to the prevention model is the annual health assessment, a full health check-up which every single one of their 1,287 patients will undergo, often at their homes.  And there’s no getting out of it either.

Compulsory health checks

“My nurse knows where they live,” Dr Quevas Hill jokes. “They can run, but they can’t hide!”

The data from this check-up allows the family doctor to put her patients into categories according their “risk”. If they’re healthy, the annual check-up is enough. But if they’re showing signs of ill-health, if they drink too much, smoke or have a continuing health condition, they’re seen much more regularly.  It’s an integrated, whole-person approach to healthcare, perhaps too intrusive for some, but widely accepted within Cuba.  The aim is to stop people getting ill in the first place.  According to Gail Read, executive editor of the international health journal, MEDICC Review, Cuba had to focus on prevention precisely because it is a poor country.  “It’s much more cost-effective to treat hypertension by exercise than to do a coronary by-pass”, she says. “It makes sense to go upstream, to catch the problem before it begins or very soon afterwards.”  So in this highly centralised country, data is gathered at the local level, fed up to the second tier of healthcare, the neighbourhood policlinic.  Here, health trends are spotted and decisions taken about how best to intervene.

The model has worked well and produces impressive results. But the health successes that Cuba has achieved have, paradoxically, brought a new set of health challenges, and the preventative approach is being tweaked to tackle them.  Cubans no longer die of infectious diseases because of a hugely successful vaccination programme, so people live longer. And an ageing population presents what one minister described as a “colossal challenge for the nation”.

Living longer and ageing well

Ageing, an increase in obesity and problems with tobacco and alcohol mean Cuba’s citizens are now dying of the same diseases claiming lives in higher income countries: heart disease, stroke and cancer.  It’s been said that “Cubans live like the poor, and die like the rich”, a reference to the fact that Cuba is a relatively poor nation, yet its disease profile matches that of richer countries.  And certainly patients with heart attacks, angina, diabetes, stroke and cancer are seen daily by neighbourhood family doctors.  The response from the Cuban government to these new health challenges is a huge investment in public health education around smoking, alcohol, diet and exercise.  Those delivering the message, overseeing, encouraging, inspiring healthy living, will be the local family doctor and nurse. And they’ll be delivering it, in person, straight to the door.

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Chelsea's French defender Kurt Zouma

Chelsea defender Kurt Zouma suffers Anterior Cruciate Ligament injury

Chelsea defender Kurt Zouma is expected to be out of action for approximately six months after suffering a horrific knee injury in the Blues’ draw with Manchester United yesterday.  The France defender was in agony as he landed awkwardly from a challenge midway through the second half of the clash at Stamford Bridge.  The 21-year-old has found his feet again under Guus Hiddink but he’s now expected to miss Euro 2016 following injury to his anterior cruciate ligament.  The defender took to Twitter today to confirm that he requires surgery on his ACL and the recovery time from such injuries spans from between six to nine months.

Metro 16.2.2016

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