The Hip Society supplement - 2020

Listen to Mr Andrew Duckworth interview Professor Fares Haddad and Dr Craig J. Della Valle in a podcast to accompany The Hip Society supplement comprising of 19 articles from the 2019 closed meetings.

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Transcript

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

As some of you may know, as we did last year for the months of June and July, 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 July Supplement of The BJJ that includes 19 papers from the American Hip Society closed meeting in 2019.

We hope to give you a brief overview of the hip society and who the members are as well as discuss how our collaboration came about and has developed over the past year, along with how we hope this will benefit you as our listeners and readers. We also hope to give you a behind the scenes insight into how the studies in the supplement have been chosen, as well as some brief description on a few select papers.

So firstly, today I have the pleasure of being joined by our editor-in-chief at the, BJJ Professor Fares [00:01:00] Haddad. Welcome Prof and thank you very much for joining us today. 

Thanks Andrew. Great to be here. 

Prof, and I are delighted to be joined by the guest editor of the Hip Supplement, Dr Craig della Valle, who is Professor of Orthopedic Surgery and Chief of the division of Adult Reconstruction at Rush University Medical Center in the US. Welcome Dr Valle and a big thank you for taking the time to join us. 

Thanks for having me. So Craig, if I could start with you, could you give our listeners just a brief overview of The Hip Society and what role it plays?  

Yeah. So The Hip Society was created in the late 1960s and basically to foster interest in North America about hip surgery. You know, right about that same time, John Charley's total hip replacement was getting very popular. There were surgeons from the US who were  going over to watch sir, John do his operation and when the surgeons got back, they kind of needed a forum to really discuss with each other what was going on, what they were doing in the US and that's, [00:02:00] I think, where things really started for The American Hip Society.

And just to give you a sense of scale in terms of active members, the membership is capped at a hundred members, so it's a relatively small society and it's folks who are real interested in the hip, the hip joints. We have the majority of our members are surgeons who perform total hip arthroplasty and its variance but I think we all recognize that in a couple of hundred years, or maybe sooner than that, hopefully we're not replacing people's joints with metal and plastic. So we have a strong contingent of very skilled and forward-thinking hip arthroscopists and young adult hip specialists who try to convince the rest of us that we shouldn't be using metal and plastic to approach every problem.

That's interesting. And in terms of, you know, obviously that was the original setup of the society. How has that morphed over time and what are the main aims of it now? How does it sort of get across [00:03:00] its message? 

You know I think when we talk about a couple of the papers that are in the supplement, we'll get a real good sense of, in my mind, how these societies function by transferring knowledge. But the basic idea is to share ideas. I think you see a combination of different presentations at the meeting and we run two meetings. We run a closed meeting that we call the summer meeting, which is usually in September. And then we do a quote unquote open meeting, which is in concert with the American Academy of Orthopedic Surgeons annual meeting at special that specialty day. 

But the closed meeting is really for members and people who are leaders in the world of the hip in North America to share ideas. And I think you see a combination of things, I think I always feel pressured to bring my best things to the hip society because you know, I just feel like these are my peers. These are the people, honestly, who I want to [00:04:00] impress and I want to share with them the cool stuff that we're doing, the great stuff that we're doing, but we also do see a lot, and it's really encouraged in many ways to bring early research, to bring stuff that maybe this is not the final format. And that's why, you know, when you look at how many papers are presented and how many wind up in the supplement. Some of these papers that we see at The Hip Society don't get published for a couple of years, but they are earlier ideas that are still kind of jelling. And I think in, in some ways, those are the most important parts of the meeting because I, as a member, and getting to go to the closed meeting, I get to see stuff that people working on. Again, that's not final form yet. And well, maybe they've looked at the data and they haven't figured out exactly what it all means, and maybe they're presenting it to help figure out what it all means. And that's really exciting and really fun. 

Yeah. Yeah, absolutely. So, cause I think we got that feel from the supplement last year, but you  can pretty much when we come [00:05:00] onto it, you can see it this year. It's sort of setting almost the trends of where general hip research is going to be as we go forward. Isn't it. And also, do you find, it also helps you refine the data and make it make it better almost? 

Yeah, I mean,  I think presenting your work, you get very good feedback because you have a lot of very smart people in the room who really care about hip surgery. So it's really meant to be an open forum, an open forum, you know, at a quote on quote safe  place. Now you know, we know that's not true, right? Because we're dealing with orthopedic surgeons and we're dealing with people who have big personalities and who are really smart and who are not afraid to share their opinions, but nonetheless, you know, I think one of the things that's always fun with the meeting is the discussions. And we've really tried in the past several years to make the talks shorter, really limit people to five minutes, 10 slides. You know, you don't [00:06:00] need an introduction slide. We all know what you're talking about to allow a lot more room for discussion and I would say the majority of the discussion remains gentlemanly and scholarly, but some of it gets heated, but I think, I mean, you know, everybody's, you know, friends at the end of the day and there's lots of social events along with it, but it's in certain respects nice to see people get excited. And get up and say, you know, I don't really think you're telling the truth there, or looking at this the right way or have you considered... so I think that's a big part of the meeting and I always walk away with a meeting with ideas for new research, which I think is one of the things that, you know, you go to these meetings for as, not only to improve patient care, because I always learn things and I'm like, we should be doing that, but also to generate new ideas because maybe someone presents something and I look at it in a slightly different way. Let's, let's try to look at this. So it's [00:07:00] a fun meeting. It's definitely one of the highlights of the year. The meetings usually somewhere nice. There's usually good food and time to, you know, see people who you haven't seen. You know, I think hopefully we're going to have a meeting this year. I think it'll be that much more special this year, because I think, you know, I think people miss the personal interaction and the scholarly interaction. You know, they love getting into a room and talking about orthopedics and we'd been deprived of that for the past couple of months. And, you know, there's been a lot of stuff in the US with residency and fellowship programs, collaborating with other programs and doing zoom calls and stuff like that. Cause I think people just really crave that interaction with their colleagues to discuss cool stuff that they're learning or they're seeing, or they're not understanding. 

Absolutely great. No, totally agree. And that's a really good overview and insight into what The Hip Society is for our listeners. So Prof, [00:08:00] if I come to you next, could you give us some insights into how the collaboration between the journal and The Hip Society has sort of come about and developed over the past year for those who don't know?

 Thanks Andrew. So this is a three-year process that we have agreed to together. So this supplement will be the second year output and the supplement last year, it really was extremely well received. There was some excellent papers. And as Craig has said, it's a synthesis of some of the new work of the thought leaders in hip surgery in North America. I think that's extremely valuable to take those thoughts, take those ideas, take those discussions, synthesize them into papers that stand up to what is a very robust peer review process at BJJ and bring it together to something that can be disseminated internationally. 

So we have from all over the globe received feedback on how welcome it was to see such richness of [00:09:00] high quality work disseminated together. And also to see some of those ideas, some of which are not necessarily those ideas that are driving hip surgery outside the United States quite so feverishly at that time, but will inevitably spread outwards. And so people are getting an insights into things that are going to affect them in one way in future, or at least an understanding of where the biggest volume of work is going on and quite how they're working. 

So I think it's been a very positive thing for the BJJ. I've had the privilege of attending those meetings that Craig has described. They are truly wonderful and added to that of course, we have got the prize papers, which are really very hard fought, but you know, international submissions from all over the world, a very competitive process and, I think some very impressive output sometimes, you know. For the journal and for our readership it's wonderful to see all this in print in this medium. And I hope that for The hip society it is a benefit to have this [00:10:00] material disseminated beyond the United States in a very clear, very crisp way. 

Absolutely.  I think the benefits are without doubt there to the reach of the journal and like you say we hope to The Hip Society,and you mentioned the prize papers, which were about to come onto, but before we do that Prof, just the papers in the supplement, just for our listeners who don't know, can you just give them an oversight about how the papers are chosen and the sort of peer review process they go through prior to acceptance in the journal?

Absolutely. So all the papers submitted outside the prize papers are papers that would have been presented at The Hip Society, autumn meeting or what Craig called the Summer meeting. And so out of  those, those authors who feel their work is complete enough for publication, submit to The BJJ for a review process. We've been very careful to ensure that that review process includes both North American and non-North [00:11:00] American reviewers for every paper, so that we get an international review process that's pretty robust. And then once these papers are reviewed, they come back to myself and our guest editor Craig and Craig looks at them and advises us as to how we can improve those papers. And then we agree on which papers make it into the supplements and which don't. And there are quite a few that don't make it through, but those that do are usually outstanding and are usually improved by that peer review process.

The prize papers go through a slightly different pathway in that multiple papers from all around the world, people do really cherish these prizes and some of the best work that there is gets submitted for these awards. So these papers are submitted in, and that in fact, they are reviewed by the hip society team that create leads with Josh Jacobs, the president for the past year. And they will determine those prices. Once [00:12:00] they've determined the three prize papers, they then go through a BJJ peer review process just to make sure that we're looking at the methodology and ensuring that those papers are presented in absolutely the best possible light, and as clearly as possible.

Yeah. So without that proper, a rigorous review process to three in supply, and particularly for those prize papers, which we're going to come on to. So Craig, if I come back to yourself, looking at the supplements, what do you feel have been the topical themes have been of the papers over the past year. 

Yeah. You know, looking at it it's always such a mix. It's always so interesting, but there were definitely a couple of themes. Dual mobility was definitely one of them. You know, and at the meeting, there were quite a few more papers presented on dual mobility and in many ways, that makes sense. All the data that comes out consistently shows that dislocation is one of the most common complications that we deal with that complicates a [00:13:00] primary replacement as well as a revision replacement. So, you know, it makes sense that that we're looking at that and you know, The Hip Society, not like any other group has early adopters and people who are suspicious of any type of new technology.

And it was again, very fascinating at the meeting to really see that interplay between the early adopters and the people who were more suspicious of any type of new technology. And yeah, that interplay was interesting. It was interesting to see how the two different groups in certain ways interpret each other's data.

Absolutely. And it's good to have those two extremes almost. Cause I think you get a balanced argument for it and that sort of moves on to the first prize paper I thought we would discuss. That's the one that won the Otto Aufranc award, which was from HSS in New York, which as you say was part of a range of dual mobility papers discussed at the meeting. [00:14:00] And that was a combined clinical in vitro study that looked at the mal seating of the modular dual mobility liners. So if you could just give us a brief overview of what you think the key messages were from that paper. 

The thing I like about this paper is that it's a simple take home message. I think the take home message for me was you need to be careful when putting in these modular, dual mobility liners. There has definitely been concern over, you know, since they came out, about the possibility of corrosion between that metallic shell and that metallic liner that you're inserting. And I think you just need to be real careful when you put that in there.

You know, obviously HSS is surgeons who are competent and do a large volume of procedures. And to see that just over 5% of them were malseated is striking and just shows you how careful you have to be. And I think is a lesson to us, [00:15:00] all that, you know, you really need to expose the socket, you really need to ensure that that modular liner is flush and that it's seated correctly. 

I think that's right. And it's like you say, even in a big center, like HSS, you know, the overall rate was one in 20, you know, even in a high volume center. Often the best papers they have to have a simple take home message like that don't they?

Yeah. And as we pulled the audience and ask them, there were several surgeons and this really hasn't clinically been reported to my knowledge, there were several surgeons who said that they felt they'd seen an adverse local tissue reaction, a patient with clinical symptomatology that required a reoperation because of a mal seated liner.

Again, I have not seen that published yet. And aagain, I think that's one of the reasons why it's fun to be in The Hip Society. Cause you see this stuff first, you got a bunch [00:16:00] of high people who do a lot of surgery and they're going to see stuff first.

Prof have you got anything  to commens about that?

 Yeah, no, I was fascinated by this paper. I agree entirely with Craig. A simple message but  tough to know whether the modeling for the corrosion based on the worst case scenario they measured on the x-ray is truly going to be reflected clinically and how frequent that's going to be. Like Craig, I haven't seen a true clinical correlate, but I've seen one or two people talking about this and being concerned about it. And ultimately the increased  usage of dual mobility is something that we're seeing rise exponentially, but we're just going to have to be mindful of this problem. And it's amazing how many of these things come back to very basic messages, which is expose what you're trying to do, make sure you see the socket, make sure you put the liner properly, whatever liner it is, because whether we're talking about dual mobility or ceramic, or frankly, anything else if you cannot see what you're doing you're more [00:17:00] likely to get it wrong. 

Absolutely.  As you say, it seems to be on the rise. There's obviously another paper in the supplement, which we may come onto, but talking about the increase analysis of the American joint replacement registry, showing that the trends are definitely going up for you. So have you noticed that? 

Oh yeah. I mean the trends are there. Again, I would fall into the early adopter camp in general. As we started specifically in our revision population to see a high rate of the failure of constraint liners, we started to look for alternatives and we had looked at some data and saw a substantial failure rate of our constraint liners and most of them were mechanical failures - the locking rings broke or whatever. So we started looking at alternatives and had some good early successes with dual mobility. And honestly haven't seen many negative effects of using them other than the cost of the implant.

Sure, sure. So if we move on from the dual mobility , the other two prize papers were on the topic of infection, unsurprisingly obviously [00:18:00] often something that's talked about at these meetings and the first was The Frank Stinchfield award winner, a large international multicentre respective study. They use machine learning to study the results of the DAIR procedure for periprosthetic joint infection. They had over a thousand revision hip and knee arthroplasties. 

And the other was the paper from Bostrom and colleagues that won the John Charney award. And that reports on the use of a murine model of prosthetic joint infection to stay the DAIR procedures. So, Craig, would you give us a brief overview of those two papers and what you feel they've added to the literature? 

Well, I think with the basic  science paper, you know, I think just like when we were talking before, I hope we're not replacing hips with metal and plastic 200 years from now. No, we're definitely missing a bunch of stuff when it comes to treatment of periprosthetic joint infection. You know, it's challenging in a short period of time to go over the methods of this complicated and elegant paper, but you should read it. Because it talks about a lot of stuff that is different ways of approaching the problem of infection and [00:19:00] biofilm and dealing with staphylococcal species. And I'm sure that this was a multi-year project that took a lot of time and a lot of care and probably a lot of money to put this all together. So I definitely think it's award worthy just in the complexity of what it was trying to address and trying to give us some new tools in our toolbox to manage periprosthetic joint infection, which, you know, not only is common, but is associated with significant morbidity, mortality and costs. So I think any type of treatment modalities that we can come up with that are new and that will potentially work are certainly award worthy. 

Absolutely. Absolutely. And the largest study that looked at sort of the machine learning, obviously we're seeing more of this sort of technique and analysis used in the literature. What do you think the main take home from that was? 

 I think a lot of this is in some ways exposure to machine learning and [00:20:00] for people to understand you know, obviously there's, you know, our brain can process only so much. But the question is can we use things like machine learning and artificial intelligence to do things that we just can't do and to get us to better answers. And like you said, it's a very large population of patients. It does give you some very useful parameters in terms of which patients are going to be at higher risk for failure. And again, elegant methods, a large sample size and a multi-center ticket a lot of the boxes for something that can be really useful and important.

No, I, I agree. Prof, would you add anything to that for those two papers on infection?

 No. Again, you know, important to see some studies that aren't getting ready for clinical translation yet, because we need to be in that space. And, you know, like Craig, I spent a lot of my career worrying about periprosthetic infection and working on it. So I think it's nice to see some new thinking and some [00:21:00] novel modalities. And, you know, the machine learning piece I think it's very interesting. It's not so much about that dataset. It's much more about the fact that that's a concept we're going to have to use more and more. And that's, you know, to my mind is likely that because it's a multicenter study, looking at a new process that we should all be using and thinking about whether we're looking at knee alignment, whether we're looking at function or whether we're looking at infection, you know, machine learning is going to have a role to play in helping us as artificial intelligence. So I think that's the future. And that's probably the key takeaway from that paper. 

So it's three excellent prize papers. And we hope our readers will enjoy them. We hope that they will propel people into new studies and better work. 

Absolutely. Well, I think that's a good place for us to stop Prof.  I think that's all we have time for, but thank you to you both Craig and Prof for joining us for our podcast today and congratulations on an excellent supplement that I think will be a real interest to our readers. So thank you to you both. 

Thank you [00:22:00] much.

 To our listeners we do hope you enjoyed joining us and we encourage you to share yeah any thoughts or comments through Twitter, Facebook, a like regarding the supplements and feel free to post a tweet about anything we've discussed today. And thanks again for listening.