The Knee Society supplement - 2020

Listen to Mr Andrew Duckworth interview Professor Fares Haddad and Dr Bryan Springer in a podcast to accompany The Knee Society supplement comprising of 27 articles from the 2019 closed meetings.

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Transcript

[00:00:00] Welcome everyone to this month's BJJ Podcast. I'm Andrew Duckworth and a warm welcome from your team here at The Bone & Joint Journal. So far this year our podcasts have accompanied an original paper or review article we have published in the journal. We've also produced two podcast series on the COVID-19 pandemic, which we do hope you found helpful in these strange and difficult times.

As some of you may know, as we did last year for the months of June and July, and we are doing a podcast to accompany our supplements from The American Hip and Knee Society closed meetings. So over the next 15 to 20 minutes or so we'll be discussing the June Supplement of the BJJ. That includes 27 papers from the American Knee Society closed meeting in 2019. We hope to give you a brief overview of the society and who the members are, as well as discussing how this collaboration has developed along with how we hope this is benefiting you as our listeners and readers. 

We also aim to give you a behind the scenes insight in how the studies within the supplement have been reviewed and chosen as well as some brief discussion on a few select papers.

So with that in mind, firstly, I have the pleasure of being joined by our editor-in-chief at The BJJ, Professor Fares Haddad. Welcome Prof and thanks for joining us today. 

Thanks, Andrew. Great to be with you.

 [00:01:00] Prof and I are delighted to be joined again this year by the returning guest editor for the Knee Supplement, Dr. Brian Springer, who is the fellowship director of Ortho Carolina Hip and Knee  center in the US. Welcome Dr. Springer, and thank you again for joining us. 

Thank you. Thank you, Andrew. Great to be here. 

Thank you, Brian. So if we could start off by just for our listeners who are not aware, could you give us a brief overview of The Knee Society, how it sort of came about and what role it plays?

Sure I'd be happy to. And it's, you know, it's quite interesting to go back and look at the history of The Knee Society. It started really about 37 years ago. 1983 was the first meeting and I kind of envisioned it as being a meeting with thought leaders in knee surgery at that time, somewhere around eight or ten of them probably sitting in a room, having pretty massive arguments about knee surgery at the time.

Cause there was, you know, so many things that needed to be ironed out and I guess you could still argue that today, but it was really Dr. Ronald Watts from New York's division to start this society in 1983. And he really put together, I [00:02:00] think what would be considered some of the giants in knee replacement surgery and they really understood the importance of advancing knee surgery from the state that it was in back in 1983. And that's really kind of been the mission of The Knee Society really ever since. Matter of fact, if you look at their mission statement, it is advancing care of patients with knee disorders through leadership in education and in research. And I think it really is that education and research that's at the forefront of The Knee Society. And I think what you see when you look at this supplement and when you look at that at the meetings that have been put on year after year by The Knee Society.

Absolutely brian. And do you think that, do you have a feel for how that's evolved over time as it's grown?

Yeah, I think it is still considered an exclusive club. You know, myself and  Professor Haddad are very honored to be a part [00:03:00] of it. But understanding the as the care of knee replacement patients has come to the forefront and the technology is advancing so rapidly. You know, it's expanded from the small group to a national it's really now an international society, really for collaboration of ideas and sharing of research. And you know, it really from us in our academic calendar, it's really where I think all the cutting-edge research for the year is first presented. 

Yeah,  I definitely get that feeling, you know, from last year supplements and looking at the supplements this year, it's sort of setting the marker in the sand for the coming years ahead of what the region is going to be about. Would you agree with that? 

Yeah, no question. I think it sets the bar very high for the rest of the academic meetings for the year. 

Absolutely. Absolutely so Prof, if I could come to you, we've obviously discussed this before, but I think it's important. Can you give our listeners some insight into how our collaboration first came out with The Knee Society and how it sort of developing [00:04:00] over the years and what the benefits have been to us at the journal?

Absolutely. I think it has been a great partnership so far. This is the second year in a three-year cycle that's been agreed. Between The Hip and The Knee Society and The Bone & Joint Journal, it's something that may or may not continue. But I think we certainly hope it will. It has allowed us to give our readers exposure to the real thought leaders in North America worldwide. And you've got to remember that The Knee Society is a group of very select North American surgeons, but within that, there is a 10% international membership and there are some very eminent non-North American knee surgeons who contribute. So the thinking, the dialogue, the research, the collaborative feeling that you get within those meetings and as you can see within the outputs in the supplement is absolutely unique and tremendous, and it's been fantastic to have it in The Bone & Joint Journal. At multiple levels it [00:05:00] enriches our lives as people who think about knee surgery to see this material. But it's also great for the knee society to have this delivered in the manner that only, I think The Bone & Joint Journal can by taking these papers, putting them through a very robust review process and then rewriting them in this unique format and then delivering them to the rest of the world. So I think this is a platform that is hopefully ideal for The Knee Society to disseminate this great work worldwide. 

Definitely. Definitely, Prof and you mentioned there that the sort of peer review process. Again, I know we've mentioned it in the past, but I think it's important for the readers. It's quite a robust review process these papers go through to get in the supplement. Isn't it? 

Oh, it is indeed. This is something that's been thought through in great detail. And I think that's worked very well and I'm afraid we've had Dr. Springer working extremely hard for the last few months.

There are two types of papers in the supplement. There are the majority, which are those [00:06:00] papers that were presented at The Knee Society meeting. Out of those many papers presented there, a select number will submit to the journal and then they will go through a blinded peer-review process with peer-reviewers that are partly North American and partly non-North American, so that there is a kind of worldwide review of this thinking of these manuscripts and those that come get over the bar will be selected. So those in the supplement are that subset that really have been through a very rigorous process. 

Yeah.

Beyond that there are the sort of real cherry, which are the three prize papers. Now that is a highly competitive process. That's open beyond the members of The Knee Society. So that's open to all of us who aspire to do groundbreaking research and knee surgery. They're submitted at the beginning of December and they are in fact reviewed and selected by the academic board of The Knee Society. [00:07:00] And once these are selected, so that selection process is outside the journal, but then they come to the journal and go through a peer review process at the journal. We try to test those papers and we try and optimize them. And I think those papers are real highlight every year. I think this year in particular, because the American Academy meeting where they are normally presented did not take place. This is really that first big outing for some of them. And I think it's great to see them in The Bone & Joint Journal.

Absolutely. And as you say it's multiple levels of review and refining of these papers to attain that high level that is clearly there when you look at the supplement. And if we sort of move onto that, and I come back to you Brian, we're obviously going to discuss briefly the three prize papers, which Prof has mentioned, but if I could just ask you do you have a feel from, you know, the core or topical themes that have come out in the supplement and from the meeting?

Yeah, I think, you know, this kind of being the beginning when these are presented kind of at the beginning of the academic year, really kind of [00:08:00] sets the stage for the rest of the year. And it's always interesting to, you know, to see some of the themes that emerge from this meeting, as we kind of consider it the leading edge of the research year, if you will, and, you know, we have kind of the categories that you would typically think of, right. There's lots of papers about infection, which continues to be a huge issue for us, not only managing complications, but how we can potentially deal with them better. So you'll see some papers about local antibiotic delivery, things along those lines, which I think are really important as we help to kind of continue to manage this burden. 

And similarly, we talk about, you know, a lot of papers that you'll see dealing with revisions and managing bone loss and, you know, important topics of metaphyseal fixation and how important that has become in our thought process for revision total knee replacement. So it's great to see papers [00:09:00] really showing that, hey, it looks like we really are making some difference in fixation techniques and decreasing our rates of loosening in revisions. 

 There's the other popular topic about uni-compartmental knee replacements and revisions of uni-compartmental knee replacements. And I thought there was an interesting study that showed actually what people have always talked about, which is potentially the threshold for revising uni-compartmental knee replacement is perhaps a little bit lower than if the patient has a total knee replacement. And then kind of along those same lines, I think optimistically some good data showing that outcomes of a lot of revisions are actually improving over time. Because I think historically we've always thought of them as being, you know, several notches below a good primary knee replacement with regards to functional outcomes. So it's good to see some of those papers coming out. 

And then I think some of the newer themes that are becoming more popular, really centre around the technology realm. So we [00:10:00] continue to see more and more papers being put out about robotics and navigations and you know, what is their place in the field of arthroplasty, but also starting to look into things like wearables, and sensors and how that may have an impact on being able to monitor patients, even monitor patients remotely. And then even a couple of studies that are starting to touch on, you know, machine learning and machine learning algorithms that could potentially help us detect loosening of implants - things along those lines through some of these artificial intelligence algorithms.

So, you know, those are I think some of the newer technology themes that we're starting to see, and that really started to play out in the supplement. 

No, absolutely. And I think when we talk next month about the hip supplement, the same is very much true there, particularly about the machine learning. There's one of the prize papers is related to that, and that does seem to be becoming ever more common in terms of  methodology used.

But if we move on to the prize [00:11:00] papers, Brian, the first one I thought we'd touch upon was the one that when the Mark Coventry award and looks at prosthetic joint infection. It was a multicentre prospective randomized trial looking at the role of continued oral antibiotics and reducing the rate of failure due to further infection, following a two-stage revision for chronic prosthetic infection of the hip or the knee, and really does add to a growing body of evidence there. Would you not agree? 

Oh, I definitely agree. I mean, I think we're all  continuing to look for ways to kind of bend that needle and in helping to improve patients' outcomes when they suffer this drastic complication and the recurrence risk is really quite significant. 

So I thought this was a really interesting paper. It was randomized, it was from multiple centres, you know, they did demonstrate about a 50% reduction in their recurrence risk for infection between those that received an organism-specific oral antibiotic for three months. And those that didn't. And you know as you mentioned, Andrew, I think there's been some other studies out there maybe not [00:12:00] as rigorously done as this one, but I think this really corroborates that idea. I think that the challenge is to be fair in this paper is when they looked at their recurrences, about an overwhelming number, I think almost three fourths of them were for they failed for a different organism than what they initially did, which poses a big challenge.

Now we don't know if those are maybe organisms that were there that weren't detected the first time, whether they've been somehow selected out because of the antibiotics that we use. So while it's encouraging, I would say it's still an imperfect solution that we have right now. But I think this is something that if people weren't already doing it is probably, you know, we always like to talk about papers that are potentially practice change.

Yeah, no absolutely. I think before we move on to the other prize papers, Brian, I think it sort of links in well, obviously that you have a paper in the supplement, looking at the complications in the treatment of prosthetic joint infection. That's quite interesting just in terms of how they've maybe traditionally considered complications for [00:13:00] the infection. Could you just for our readers give a brief overview of that? 

Sure. So that, you know, our impetus for doing this was the tendency with infection is to always look at the end game and rightfully so, I mean, that's how we do things in the research world. And clinically, we want to know how these patients end up, but we haven't focused a lot necessarily on the journey that they go through from when they're first diagnosed with infection until whatever that end game is.

And that's kind of what we tried to focus on in this paper is, you know, it's the complication risk that people go through the recurrence of infection, those that never make it through the full, you know, the full treatment. And oftentimes then are not accounted for in the denominator, in the end result, they tend to be kind of left out a little bit. And this was all data just from our institution here at OrthoCarolina. And actually, you know, for us, it was pretty eyeopening and pretty sobering to see, you know, what these patients had to go through and just that journey and at that [00:14:00] end game, how few of them, you know, really, I think depending on how you define success really had a successful outcome. 

No absolutely. I agree. It's quite humbling, isn't it? And like when you define and talk about not just surgical complications, but medical complications. It's very interesting, but like you say so important because the patient goes through all of this don't they? It's not just the x-rays at the end. Yeah, no, I totally agree. I think it was a very, a very interesting paper. 

Thank you.

 If we move on from infection though, the second prize paper that was from Japan, which was a prospective randomized controlled trial again, and they were looking at sort of the use of peri-operative essential amino acids supplements to prevent rectus, femoris, muscle atrophy, and facilitate early recovery following a TKA. It's quite an interesting study that Brian isn't it? 

It really is. I thought it was quite fascinating actually. Almost because it was so simplistic in its approach in the outcomes that they looked at. And there's even in the supplement there's other studies that [00:15:00] talk about poor nutrition, obese patients, important nutrition, hypoalbuminemia things along those lines. And that's kind of the category that this falls into, that a fair number of our patients, especially in the US, are malnourished going into surgery. Either we don't look for it or we don't know how to treat it. What I thought was so brilliant about this paper was it's a relatively simple solution that they were able to, you know, establish giving patients a supplement, you know a week before and then two weeks after the surgery. And, you know, really show improvements in their functional outcomes, but also just in, you know, what correlates with that is just in their muscle girth, in their strength and you know, things along those lines. So again, something that I think for a lot of us could potentially be implemented into our practice is relatively small, the numbers. It's a little bit of a short-term follow-up sort of study, but I think it's, like so many of these, it's an impetus for further work that needs to be done on this topic to really prove that what we're seeing is the case. 

I know, I totally agree. And it's sort of, maybe [00:16:00] wrong to call it low hanging fruit, but it's, it's such a simple intervention and relatively cheap, but if it makes such a big difference, it could be quite an important finding really couldn't it? 

Absolutely.

Make a big difference to the patient.

And if we move on to the final paper, The John insula award, and this is quite interesting, so it is a large single-centre study from the Rothman, that focused on the US health policy ramification of the removal of the TKA from the inpatient only list. And then the negative effects this decision has had on bundle care initiative. Now for a lot of our listeners over in the UK, Brian, they wouldn't be particularly aware of this, but this has been a big problem for you guys in the States. 

Yeah, it really has. And I think we've all worried about the ramifications of this decision when our government made this decision to allow total knee replacements, to be designated as an outpatient. And what the potential effects that that had had and basically the effect that it had on us. And as you saw very nicely [00:17:00] outlined in this paper, is it basically filtered off all of the healthy patients that were then able to be deemed as an outpatient and it left the, for lack of a better description, the sicker patients, the patients with more comorbidities, the more complex patients to be in the hospital and then be in what we call our bundled care programme. And so it siphoned off the people that would particularly benefit the most from being in that programme, move them to an outpatient category, kept the sicker more complex patients in that bundled care programme. And as you could see from the conclusions of the paper, that pretty dramatic financial effects that it has on those bundled payments was pretty staggering.

I know they are really quite stark aren't they? Those figures. 

Thos figures are really quite stark. And I think that the hard part is, you never really know what the intentions of the current government are, but I don't think it was ever [00:18:00] necessarily directly their intention for this to happen. It was kind of an unwarranted side effect of it if you will. And it's really played havoc with a lot of the financial institutions and the hospitals in our country.

It's just what you say, it probably wasn't potentially the main reason, but it's certainly a significant side effect from it. Isn't it? It's fascinating. 

Prof, just bringing you back in there, just those three prize papers are there any comments or insights you've had regarding that. 

Yeah, I want to comment particularly about that last one, because I think many readers will look at it and think, Oh dear, that's a very North American centric paper for their financial system. But in reality, we've been through exactly this process in the UK retreatment centres and I suspect over the next decade, every country worldwide will find their tertiary centres penalized by getting the extra complexity as this sort of process takes place. So I think it's really good [00:19:00] to see translation worldwide from this kind of work. So people should think laterally from that point of view. And I really enjoyed the other two papers as well. I think it good to see more randomized studies in orthopaedics. We really need to raise that bar. And this is a very simple one to win that prize. I think that needs to encourage people to go and do randomized studies and ask those questions. And, you know, the infection paper. This ability that The Knee Society has kind of developed to get multiple centres to collaborate is something that we in the UK can learn from and I suspect others worldwide. Cause it really does need to be multi-institutional work to be truly generalizable. And I think we need to learn to do that more. So really very grateful to The Knee Society for this phenomenal output and to Brian who, you know, has reviewed every single paper here. And in fact, put the programme together for The Knee Society meeting. He's done an incredible job. So it's been fantastic working with him. 

No, absolutely. I'd echo that. And, [00:20:00] I think it's an excellent supplement, which will be of real interest to our readers. So, I think that's a good point for us to finish up. So thank you to you both for joining us and congratulations again on a really great supplement and I'm sure it will be of real interest to the readership.

Thank you very much. 

Thank you. 

To our listeners we do hope you've enjoyed joining us and feel free to post a tweet about anything we have discussed here today. Thanks again for listening everyone and stay safe.