The Bone & Joint Journal Festive Podcast 2023

Listen to Mr Andrew Duckworth & Professor Fares Haddad discuss the challenges orthopaedic professionals have faced in the last year, their top picks from The Bone & Joint Journal in 2023, as well as celebrating progress made with Bone & Joint Open, OrthoSearch and OrthoMedia, and looking forward to research in 2024.

Papers discussed:

 Artificial intelligence for image analysis in total hip and total knee arthroplasty

A multicentre comparative analysis of fixation versus revision surgery for periprosthetic femoral fractures following total hip arthroplasty with a cemented polished taper-slip femoral component

Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury

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Transcript

[00:00:00] Welcome everyone, I'm Andrew Duckworth and I'd like to thank you all for joining us for our special festive edition podcast to round off our series for the year of 2023. All the positives from how we've recovered from the pandemic over the past year, the world and our specialty continue to have significant worries and challenges ahead.

So to review the past year here at the BJJ today, I'm delighted to again be joined by our Editor-in-Chief here at the Journal, Professor Fares Haddad, who over the next 20- 30 minutes will be giving us an overview of the past year, highlighting some key papers we've published here at the Journal, and finally what we can expect and hopefully look forward to in 2024.

Many thanks for joining us today, Prof. It's great to have you back with us. It's good to be with you. And thank you for doing this. So Prof, another year has passed as the world has really got back into the full swing of things following the pandemic and there are lots of positives that we can take from that and, and, and have been good over the past year.

But obviously the significant challenges continue to present themselves, particularly both to our world and to our healthcare systems. So what do you feel are, have been the positives from the past year for our specialty, but what sort of challenges do you think still remain? Yeah, it's been an interesting year.

And then I think in reality, there are still significant effects from the pandemic and everything else that's going on in the [00:01:00] world. People are still exhausted and haven't quite recalibrated, but they are, I think, largely in a new normal and research is back on a steady footing. I don't think the funding or the research is back to the level that it was getting to pre pandemic, but I think people are working hard and good studies are in train and being funded, which is, which, which is phenomenal.

But I still think there are huge challenges, both in terms of the research world and the focus on what we really want to focus on, which is musculoskeletal disorders and how we deal with them. But also in terms of the workload that we as a community face, not just in the UK. But worldwide, there is still a huge backlog of patients to deal with.

And I think we still have to go out there and emphasize to the world that, you know, elective orthopaedic surgery is not optional surgery. It is something that's really important to our patients and that the [00:02:00] mobility of our patients will impact their overall health. It'll impact their longevity. And I think that message may be lost and that's why we see huge numbers of patients waiting.

So, you know, we still need to do the research to underpin that, but also reinforce that with the paymasters. Absolutely Prof. And I think with regards our patients and their elective waiting lists are waiting a long time. I think it's something, certainly my colleagues have seen here in Edinburgh and others have in, and I'm sure you're the same in terms of our patients are more deconditioned than ever, aren't they?

They're waiting on a long time and a lot of pain on painkillers. And it's a real problem both for, both for us as the surgeons, but for them as the patient as well. Completely agree. It's a different paradigm. And if they're less fit, they recover less well. Once you fall down that slope, it's very, very tough as a patient to climb back up, particularly for an elderly patient with comorbidities.

So I think we need to, we need to advocate for these patients. Yeah, absolutely. Absolutely. And Prof, what about for our team here at the BJJ, what has been the past year been like for the journal and our amazing team? It's been a busy year. It's been an impressive year. We're still got [00:03:00] much of the team working in a hybrid format, but the office has been busy and we welcomed a variety of people, including all the visiting carousel presidents to come and join us at the journal, which has been a great experience.

Probably the key thing has been the real focus on upgrading our electronic offering and in particular the new portal and the new website for the society and for the journal that was much needed. It involved a huge amount of work from inception through development through to delivery. And it seems to have taken place seamlessly, and it's a huge credit to the, you know, the incredible team that, you know, Emma Vodden and Richard Hollingsworth lead at the journal so that they've, they've done this without really anybody feeling any pain along the way.

It's, it's it's wonderful to see the new brand and the new offering. I couldn't agree more. I think it looks great. And I think for, I'm sure a lot of our listeners and users have used it already, but I think it's a really something that is worth visiting and seeing how it has all been brought together in a really modernized, really [00:04:00] effective way.

And then, and that sort of moves on to a few other things I wanted to talk about in terms of maybe talking about our you know, before we move on to the papers, you know, you know, again, to highlight the bone and joint open, which, you know, you know, our gold open access journal, which really has gone from strength to strength and has a great impact factor in sort of first attempt as well.

Hasn't it? That's been remarkable. I mean, you know, we see BJO as the place where we put in protocols, pilot studies those, you know, sound studies that just don't fit into the limited space in BJJ and, you know, some new ideas, for example, but It has grown, it has a big following, an impact factor of 3.1 at the first attempt is absolutely outstanding and we're increasingly seeing submissions direct to BJO, you know, it's, it's reasonable as an APC.

It is a good quality journal in its own right. And, you know, allied to BJJ, I think both will grow stronger together. Absolutely. And like you say, the APC is very reasonable when you compare [00:05:00] to many of the other journals out there. And, and in terms of our other sort of digital products that have been developed by the team at the journal you know led by Emma and Richard, as you say they are really serving the orthopaedic community well, aren't they?

Yeah, I think it's it's been a lot of work again. I think credit to the team for putting those together. But I think OrthoSearch is a great offering. It is a bespoke search engine for orthopaedic surgeons and I and many others finding it. Increasingly useful and it's becoming refined as we go along. So I think that's been great.

OrthoMedia is a resource that is gaining both in terms of its content and in terms of its popularity, which I think is fantastic. And those kind of those on the website reflect the direction of travel in the journal and the society are offering much, much greater breadth of what our readers can get.

Absolutely. Absolutely. So Prof to move on to the papers now, you know, and these are just a few [00:06:00] highlight papers of many good ones excellent ones that have been in the journal the past year. And and you've kindly picked these out for us. And I think again, this selection of papers, as, as we, I think we've seen over the past couple of years emphasizes the really high level of evidence of the quality of work that we are now publishing here at the journal and have done for many years now.

And the first of these is it sort of highlights an area that continues to be very topical and it's from the team at SWLEOC who, which was a scoping review on, on how AI is being used in the analysis of radiographs following total hip and knee replacement and how accurate these tools are.

And I think this. This was a really interesting study, I thought, because I think we are getting more and more in this area, a lot of excitement, but also we need to temper that excitement with waiting for the evidence, really, and making sure it's good. No, I can't agree more. I mean, yeah, it's a fascinating area that is moving incredibly fast.

And, you know, from the scoping review coming out to now, there's been phenomenal work in certain centres on how to look at radiographs and what to be able to predict. From what you can predict from those radiographs and, you know, [00:07:00] facilitating something that is ideal, the review of images, particularly, you know, large volumes of images or images over time is ideal for this sort of thing.

So I think, you know, there's two elements to it. The first is it's undoubtedly going to grow and we have to adapt and evaluate it as it goes with an open mind. And number two, we need to really start to study it very carefully because this concept of. Here's a black box, and we put something in, and something came out, and isn't it wonderful?

That needs to be replicated. All good research needs to be reproducible, and therefore people, you know, the IP within this, this, this area needs to somehow become transparent enough so people can check whether it is delivering what it says on the tin. But, you know, keep a careful watching brief, because this is the way things are moving.

And, you know, the, the, the ability to, you know, look at someone's knee or hip on a, on a plain image or on a CT scan and predict what they need, what [00:08:00] alignment, what positioning they need in terms of their implant, or, or in fact, what the outcome of that joint's going to be over time without an arthroplasty is, is, is really within, within the bounds of possibility.

Absolutely. I think as that, as the that's good. That review shows it. It says, I think at the conclusion is very apt. And it says that these studies show that AI is promising, but we still still have insufficient high level evidence. And we need to build that. And I think it's one of the things that we can't just adapt.

Like you say, we need the data. to make sure we're doing it right. And it is actually effective. And I couldn't agree more. And if we sort of move on to the the next two papers Prof, they're sort of looking at again, an important area of hugely, it always seems to be a topical area, periprosthetic fractures, traumaplasty, it's always very trendy at all the big meetings and continues to be for good reason.

And the first of those is the multistandard study led out of Leeds that was comparing fixation with revision, revision surgery. Sorry for the surgical management of UCS type B periprosthetic femoral fractures around a cemented polished tapered slip femoral component following primary total hip arthroplasty.

And this was a nice sort of study [00:09:00] for several centres in UK and sort of, I suppose highlights the good collaborative research that is ongoing, not just in trials, but in other areas as well in the UK. No, I think it's really important. So, you know, periprosthetic fracture has been close to my heart since I was a trainee.

I did a thesis on it. I, you know, I helped Clive Duncan develop the Unified Classification System that was the evolution of the Vancouver System. And the fractures around polished tapers are an issue that doesn't fit into the traditional classification system well, and that really deserves attention. Both in terms of how to manage them, but also, frankly, in terms of it's an area that probably hasn't been focused on enough in the past because these weren't picked up by the registries, the joint arthroplasty registries picked up revisions and didn't necessarily picked up those fractures that were fixed.

We then face in this area. The challenge of those who like fixing things, those who like revising them, and then actually making the right decision for that patient as they come through the door, which kind of needs to remove the intrinsic [00:10:00] bias of the trauma surgeon versus the arthroplasty surgeon.

So unpicking exactly what to do with that cohort of patients is really important. And to look at this in any big way requires collaboration. And we've seen collaboration in a number of ways. We've seen it in pragmatic randomized studies. We're seeing it with trainee collaboratives. And here it's really, really great.

There are weaknesses to this. Of course, this is not a strong study because we cannot remove the confounding by, you know, by surgeon in terms of the decision making here, but ultimately bringing multiple centers together, treating these both highlights. This is a problem and shows that. For a patient for whom fixation is a reasonable option, the morbidity mortality is less than that of a revision and that's food for thought for us arthroplasty surgeons.

Absolutely. I think, I think, and sort of goes well with that is the, you did an annotation, obviously led by involving yourself and, and, and one of our other colleagues, Chloe Scott on the editorial board about that sort of [00:11:00] accompanies that. And I think this has been a really great thing that the journal has been doing in terms of, we have the, the sort of some data that's come out and also putting it into context as well, and sort of, you know, cutting it down to what, what it sort of means and how it all fits in, in a really nice way.

Absolutely. You know, Chloe did a wonderful job of creating the examples and illustrating really that the key bit here is making that decision in that we don't, we don't want to push everyone towards fixation because actually we've learned 20 years ago, 30 years ago, the inappropriate fixation of unstable

stems doesn't work. It leads to high failure rate. So we've got to get that initial decision right and then choose the right operation. And so to be able to frame that in a way that was a parallel and doesn't diminish that paper is really important. That's where I see the front matter of the journal is something that's going to grow.

I think what we're keen to do. is share the best research with our community but also frame that into context, both for practicing trauma [00:12:00] surgeons, practicing arthroplasty surgeons, whoever it is relevant to both in the UK and worldwide. So I'm hoping to increase the amount of front matter in the number of annotations because there are some key topics where the data is not quite ready, but the opinion, the context is important to share in a clear way.

Absolutely. I think it, like you say, it very nicely shows the path we're on and where we may be going in the future. I couldn't agree more. And sort of related to that is actually the final paper you picked, which I thought was, again, it's, it's a really, it's a bit from the team in the Netherlands and it looked at determining whether early surgical treatment results and better neurological recovery.

a year after injury and later surgical treatment in patients who have got an acute traumatic spinal cord injury. And I thought this was, this was great because it's a multi-centre prospective registered study. It's not randomized, it's not a trial from 17 centres in Europe. And I think it's one of these ones where, you know, we've, we often talk about it at the board, don't we, as well as that, you know, if we can get an RCT, great, but actually this is an area where RCT is very, very difficult.

And this is pro this [00:13:00] is probably the next best thing in terms of trying to get the good data in this area. You know, you're spot on with this is a really tricky, contentious, emotive area. Yeah. And like many things, you've just got to look at the research question and say, what is the best data we can get for this?

Because sometimes we have to accept relatively low level data, even in our world, pushing towards level one. You've just got to accept sometimes that this is the best you can get. And whilst this study has limitations. It has brought together a big amount of data and asked some pretty critical questions and I think genuinely challenged the traditional thinking in this area.

And again, a bit like the a bit like the discussion we had about periprosthetic fractures, a bit like the area of networks in orthopaedics. We've once again. Frame this with front matter in this case, to really look at that from all perspectives, you know, to share with the reader. There is no bias here.

We're all keen to [00:14:00] improve the care of these patients. Let's face it. These patients have horrific injuries. This is a huge problem. So anything we can do to improve their medical care, their surgical care to the right thing at the right time is really key. And in this case. We framed that with an annotation, but actually the authors should really be congratulated on having designed and carried out what is probably the best study that could have been done at the time.

And, you know, they registered, they kind of did it, did it in the way we would expect someone to do an RCT without doing CT because an RCT wasn't possible. Yeah, no, absolutely Prof. And I think like I say, I think all those papers really emphasize that sort of, not just all highlight, they're all good level elements, but they are, there's a broad, there's a breadth there as well of how you can answer each question and that there isn't all one size fits all.

And I think it, I think it's really interesting that. So sort of finish up Prof, moving on from those papers, you know what's, what's your anticipation for 2024? What are our sort of maybe what do you think will happen? I suppose, in terms of predicting the future as best you can, but also what, [00:15:00] what our challenge is going to be, I suppose, more than anything.

Well, I think it depends where you are in the world, but there's still a hell of a lot going on. And I, you know, genuinely hope that, you know, we can wake up in 2024 and say that the world's a happier, more peaceful, more, you know, generally easier place to live. I think in terms of our particular world of the journal, we are continuing

to develop the digital products that we have. And there's a great deal of work going on in the background to improve every aspect of those and in fact, some others that we'll hopefully see launched in 2024. I think our dissemination machine, if you like, continues to work incredibly well. So I always highlight to people that there's one thing about delivering the research to print.

The second piece is actually looking at its impact and delivering it to the wider community and making sure to share it appropriately. So our social media, our videos, our podcasts that you do so ably our infographics are all hope going to continue to grow as part of the [00:16:00] offering, and I'm hopeful that the, the musculoskeletal community can get back on its feet.

And deliver some of the weights that we, you know, some of the, the surgery that needs to be done, but also deliver the, some of the research that needs to happen. I'm increasingly seeing good quality orthopaedic research funded, and I'm hoping we'll see more of that in print in 2024. So I think it'll be a busy and exciting year for the publishing team, for the editorial board, for the journal, and hopefully for all of us.

Absolutely, Prof. That's very well said. Well, I think, Prof, I think that's all we have time for, but thank you so much for your excellent overview and the papers you picked and what has been another always really an interesting and informative discussion about what has been sometimes a really challenging year for our specialty and profession and for the world, as you say, and hopefully some more positive times ahead in 2024.

And as ever, it's been great to talk to you. Thanks so much for joining us. Thank you, Andrew. Thanks again for doing these this year. And finally, as ever, we would like to wish all our listeners and wider community a happy festive period and all the very best for 2024. [00:17:00] We at the Journal thank you so much for your support.

Stay safe and well, and thanks as always for listening.