BJJ's Festive Podcast 2021

Listen to Mr Andrew Duckworth & Professor Fares Haddad discuss this year's challenges and accomplishments at The Bone & Joint Journal, including the achievements made by Bone & Joint Open in her second year of publication and the new digital products, OrthoSearch and OrthoMedia.


Papers discussed:

Click here to read: The EBJIS definition of periprosthetic joint infection
Click here to read: The lifetime risk of revision following total hip arthroplasty
Click here to read: Robotic arm-assisted versus conventional medial unicompartmental knee arthroplasty: five-year clinical outcomes of a randomized controlled trial
Click here to read: Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures

Transcript

BJJ 2021 Festive Podcast

[00:00:00] Welcome everyone, I am Andrew Duckworth and I'd like to thank you all for joining us for our special festive edition podcast, to round off of our series for the year of 2021. We hope you've enjoyed our knowledge translation work here at the journal over the past year, including our podcasts, which have had two special edition series this year.

We've had our insights from the US series with some orthopaedic giants from the US discussing their specialty areas and giving their own insights into the pandemic. In our other special edition series we've heard from many of our specialty editors here at the journal, where they've given us all a great behind the scenes look into the amazing work they do here, as well as highlighting some key recent papers from their specialty area.

So to finish off the year, today I'm delighted to be again, joined by our Editor-in-Chief here at the journal, Professor Fares Haddad, who over the next 20 to 30 minutes will be giving us his overview of the past year including, maybe discussing some ongoing effects that the pandemic is having on our specialty, highlighting some key papers we've published this year at the journal, and finally what we can expect and hopefully look forward to in 2022.

Many thanks for joining us Prof, its great. Thanks for inviting me and I always look forward to this. Thanks, Prof. So, when I was preparing this, I thought back to a year ago and where we were at the end of [00:01:00] 2020, and you know, another year has passed and, you know, The past year really has focused on emerging from the pandemic as best we can, not just for the world as a whole, but for our healthcare systems, our specialty, and also for our team here at the journal.

And what do you feel Prof being the biggest achievements and challenges over the past year for, our specialty, really? Well Andrew, it's been tough. Little did we know in March or February, 2020, that we would still be in the midst of a pandemic and still mounting emergency responses. You know, and as, as we record this, I've spent half my day with COVID related meetings and considering what happens to elective surgery

over the next few weeks and quite how we're going to continue to look after our patients. So I think, it's been a horribly challenging time, even as we've re-emerged from the depths of the first couple of waves, there are still huge challenges, particularly for our patients. I mean, our patients have truly suffered by being delayed,

by not having access to surgery and, [00:02:00] to a certain extent, by a lot of our procedures being inappropriately de-prioritized, you know, elective surgeries, not optional surgeries, I've said many times before. And so for, for many of our patients in a massive backlog, that there is in the UK, but also worldwide of patients who haven't had access to care,

it's a huge amount of suffering. It's some measurable harm. And frankly, a group of people who are coming to us less mobile, less fit, less active, and potentially getting less good outcomes. I think that's interesting Prof, I was going to ask you about that. I think that's definitely the feeling I'm getting from my elective colleagues is that people coming up for surgery have been waiting so long

it's a more difficult operation, they're less well, deconditioned shall we say, coming up for their operation? And actually the outcomes of this are probably going to be more severe than we actually probably expect in some ways aren't they in the long term? Yeah, there are all these unintended consequences of mounting the COVID response and dealing with cancelled surgery and the so-called P2 surgery in other [00:03:00] specialties that have rendered some very important, very effective orthopedic procedures, particularly, you know, I focus on hip and knee replacement, but there are many others, of course fallen by the wayside in many centres.

We've been very fortunate, I have to say in London, that I think we've managed to do more than in most places. But when I look particularly at Ireland and Wales and, you know, some parts of Scotland, it's really been pretty grim for our patients. And then there are knock-on effects. You know, the challenge doesn't stop there.

You know, we must keep patients at the centre of everything we do, but the reality is it's been a torrid time for our trainees from that phase where they got sent to do other stuff where their sort of whole identity was relatively challenged. We've then got this period where we're not quite operating like we did before, not as efficiently as before, as we said on a different group of patients, perhaps not so fit.

And so our trainees and, you know, that's the next generation of people who are going to look after all of us, haven't had the training that they necessarily would have expected. And you [00:04:00] know, in terms of the journal, of course, we're a lot about research, about changing practice and research studies have really struggled.

They got stopped, research funding got diverted towards COVID to a certain extent. And so research studies have either been delayed or sometimes completely compromised. Yeah, absolutely. And you were sort of talking about our trainees and our colleagues as well Prof, so you mentioned it earlier, this idea of wellbeing.

I think it has really taken a toll on everybody really in different ways and, people in different situations. But again, that's something that I think is lingering on isn't it really? And just the longer, this goes on, the harder it sort of gets really. Oh, I mean, I think, you know, we are surrounded by a stellar group of people, both medical and nonmedical professionals

who've risen to the challenge very, very effectively, but there's a limit to everybody's tolerance. And I look around me right now and you know where this is a end of year, Christmas time. And when we approached last Christmas, it was again, another wave and more resilience needed, more [00:05:00] hands to the fore to help everybody.

And I think this time I look around and actually our colleagues are exhausted. I agree. And that's, and that's not a, you know, I've focused on elective surgery, but, you know, recognize our non elective surgery has also been incredibly busy recently. So in reality, I think we do need to look after our trainees, our colleagues, and actually everybody around us because the medical profession has been challenged by everything they've had to do.

And also increasingly I think challenged by uncertainty. It's tough to cope with not knowing what's coming next and quite how the decisions are being made around you. Cause we focus a lot on science and data at the journal, but actually the decisions being made around us, aren't always based on either strong data or good science, and politics

of course plays a big role. I think that's right. And I think if you try and sometimes rationalize some of the decisions made, it gets increasingly hard to do that. Doesn't it for, for us? I know. I agree. So if we move on, Prof, we want to, just, before we talk about the highlight papers you've kindly picked for us, I just want us to sort of [00:06:00] maybe touch briefly and to mention two things, really. First of all the BJO, our gold open access journal, and really how that has really gone from strength to strength over the past year or so.

I think last time we spoke like this, it was in its first year and it had a tremendous influx of papers. And, you know, it's a big credit to the publishing team, to our team at the society and at the journals, who've been working from home, have adopted new ways of working that they've really helped us manage to launch a new journal

that's now really in the public consciousness. That's getting the good papers that we can't fit into BJJ or BJR. And now getting an increasing number of direct submissions because people recognize it's got a you know, a slick review process. Some very good reviewers and a good editorial team, you know, Alex Liddell's risen to the fore and helped me with BJO, but actually it's tremendous.

We're turning papers around quickly. We're publishing them in a very neat style. You know, the journals and the society have a reputation for, [00:07:00] and it's had tremendous impact so far. It's on PubMed now and I think we're looking forward in due course to getting it an impact factor and really getting it to rise to where it belongs.

It has really been a meteoric rise for it hasn't it, in terms of how quickly it has achieved a lot of the goals that we wanted to achieve in such a short period of time. And I agree, I think when you see that people are actually, it's not just, you know, going to the BJO from the BJJ, people are directly submitting there because they have the quality, you can see that with the quality of the research that's now published in there. And sort of related to that Prof. I just wanted to just take a minute to discuss two amazing new digital products that have been launched by BJ publishing recently and that's OrthoMedia and OrthoSearch, which I know our colleague Emma Vodden has had a huge amount of inputs into, and they're two really exciting platforms aren't they?

Absolutely. Big kudos to Emma and Richard Hollingworth and the team for, you know, tremendous amount of work to do this. And this is part of the society and the journals it's offering. I mean, I think, you know, OrthoSearch, you finally have a platform for [00:08:00] searching that's designed for orthopaedic surgeons.

This is not a generic thing. It is designed to help you find the orthopaedic material you need. And it's not all about getting you to the journal or the BJJ society. It's all about getting you to find the best material in orthopaedics. It's genuinely neutral from that perspective, but it will help all researchers, it'll help people who are trying to improve their orthopaedic education from that point of view. And Orthomedia,

likewise, is going to be a tremendous resource because there is one central resource that's easily accessible, well presented that can give you the products of multiple meetings, you know, multiple outputs from various places and bring it all together. And at the end of the day, what we're all after is easily digestible material that lets you see, learn, assimilate what you need to do for the question that you're trying to address at that time.

And we recognize that whilst the BJJ is the ultimate in terms of [00:09:00] practice-changing quality research, there's a whole load of material around that from presentations to standards to materials produced by societies to guide their members, that all comes together and also, bringing all that into a bigger mass guides practice.

So it's important to have that there. So any of our listeners and readers who have yet to access OrthoMedia, great resource and OrthoSearch they will love. I couldn't agree more Prof, and I think I was saying with OrthoSearch, it really is for us, it's for orthopaedic surgeons and the breadth of what it covers, but actually quite concisely in many ways and draws all those resources together for us is, is quite unique and the alerts as well, that it provides in terms of covering a lot of journals that I wouldn't generally 

maybe month to month look at, but actually you're not really missing anything out now. I think it's like you say, from a completely independent, way. It's brilliant and I couldn't agree more. This sort of talking about, you know, the high quality research and the BJJ, I think if we move on to the four papers you've picked for us, I think it really does highlight the quality of what's being published in the journal these [00:10:00] days.

And the first. Well, we, you you've picked for us, is from the European Bone and Joint Infections Society. And is a practical guide for clinicians proning a definition for periprosthetic joint infection, it really just presents a sort of novel three level approach to diagnosis based on the most robust evidence available.

And which will really be useful to clinicians in daily practice. I think this is critical. This isn't the typical sort of paper you find in BJJ, but this is going to be a seminal paper. And, you know, we all recognize it's a tricky problem, defining infection. I've written a couple of editorials about it, first of all, 2012.

And again in, into late 2018, early 2019, again, profiling how complex this issue is and how quite frankly, having got something we could all work with in 2013, it all went a little bit horribly wrong in 2018. And this is the infection world recalibrating and coming out with something that the clinician out there can actually understand and use looking at infection is unlikely, [00:11:00] likely or confirmed.

Cause that's the level we're at right now. Let's not get lost with conflicted tests and, you know, the madness of using D-dimer as the main focus of infection and under mining, the role of culture. I think we're in a better place now with this. And I think we've got to bear in mind for reporting we cannot keep changing this definition.

So, you know, we, we have the 2013 definition, Now I think we've got this excellent paper, the beautiful infographic that goes with it, that I think everybody should look at, and that should be the standard for the next few years until we really learn more and understand more, but if we're not all using the same definition, it's going to be incredibly difficult to compare studies, to compare what happens longitudinally over generations.

And there's, there's no question that this has limitations, but in terms of what we have out there right now, that's pragmatic, its sensible, and I think it's something that everybody needs to get used to, it's the best we've got. No, [00:12:00] I couldn't agree more Prof. I think, like you say, not only for helping your day stay clinically and actually that is reality, isn't it?

The way that they define those three categories is, is what we see day-to-day, that's real. They know that's what we're all we're all dealing with. But also, as you say, in terms of research, allowing us to actually categorize patients in a reasonable way, it makes us better understand what we're trying to do.

And like you say, the infographic and even the figure that's in the paper is very clearly and nicely laid out. And it's very good in terms of allowing us to sort of define these different categories. So I think it's it's not a normal paper we would potentially publish, but it is so, so different

isn't it, in terms of the impact it will have moving forward? So Prof, if we move on to the next paper. This is from the team in Christchurch, New Zealand and reports on the lifetime risk of revision, following total hip replacement. And this paper provides a nice approach, using data from the New Zealand Joint Registry, as it considers lifetime risk of revision as the primary outcome, rather than just survival rates at sort of a set time point, which is probably what we're more used to.

An interesting study, and again, an example of the breadth of type of papers we publish as well with a big registry study like this, but having a [00:13:00] really important message. Absolutely. And I, you know, I deliberately picked this and those who've seen my criticisms of some of the use of registry papers over the years will perhaps be surprised, but this is a great use of registry data.

And as I've mentioned already, we need to put patients at the centre of what we're doing. And so the metrics that we need to get out of these big data sets need to be relevant to patients and being able to say to a patient that look, if you have this operation, your risk of having another operation in 10 years or in your lifetime is X is actually really valuable information. Right now,

a lot of patients still believe if they have a joint replacement, they need to come back for another one in 10 years. We all recognize, and this paper confirms, that the younger you are, the higher your risk of needing another operation within 10 years, but actually it's a real credit to the orthopaedic community

that even if you're 50 years old, your risk of revision in your lifetime is [00:14:00] still under 30%, 27%, which is, which is remarkable actually. You know, that means when we're doing a hip replacement on a 50 year old, we're not guaranteeing that patient another operation. Now, there are nuances within that, the fitness of the patient, the type of implants that are used, you know, let's not get lost from the fact that the detail really matters, including who does the operation and how they do it.

But those are important metrics and I think the group in New Zealand have done this nicely for hips. They've also now done it for knees. It's not the first time it's been done, the Oxford group of links in the, UK, the NJR with HES data. But I think this is a nice long follow-up of a very good registry and the New Zealand team should be really congratulated for that.

Yeah, absolutely Prof. I think like you say, it just provides really useful, but understandable information from not only us, but for our patients as well. And that was one of the key findings that you've highlighted there that I read, you know, lifetime risk of revision surgery was 27.6% in those age 46 to 50.

That's a really useful bit of information. [00:15:00] And certainly, probably not maybe 5, 10 years ago, but we would often say to patients, well if you have a joint replacement, then you're more than likely going to need another revision surgery, but that gives you something really tangible and interesting to tell them, doesn't it?

No, I couldn't agree more. And it's worse if you're a man. So bear that in mind. Of course, always. So Prof, if we move on to the next paper and again, you know, another, example of the, the quality of the research that the journal's producing, and this is the the paper from our colleagues in Glasgow and reports the five-year outcomes of their RCT comparing

assistive versus conventional medial union knee replacement. And it does really seem to be to my reading anyway, at the moment, the only prospective randomized midterm level data in this area that we've got, you know, in sort of growing. And it's great to see long-term mid to long-term data in RCTs like this.

No, no. And this, you know, this is great. As you know, we've pushed hard for good research methodology. We've pushed hard to move trauma and orthopaedics towards level one studies and level one data. And you know, this is pretty visionary stuff from Matthew Banger and Mark Blythe to [00:16:00] actually get this going when they did and compare what was then really a very novel technique.

In fact, they only had access to this technique for research. They didn't have access to it clinically and to compare it with the standard, and they've published along the way, of course, and you know, shown their differences in gaits and in function in the high active individuals, but actually to go out to five years and show a lower reoperation rate with the use of the robotic arm is impressive.

I mean there are lots of really interesting things about this, but I think as an example of level one data in orthopaedics its really good. I think it's also interesting in that they're clearly very good at doing unis. You know, that their results, even though their results in the control group are way better than most studies and the registries.

That's perhaps a weakness of this paper that actually they're really good surgeons. So, you know, how does this translate outside? But I think as you know, that there's increasing interest, we've published a lot of papers on robotic technology recently, but having level one data to [00:17:00] this, to back up, we published the Australian registry data as well in the last two years, showing that the unis out to three years are doing better for aseptic loosening with robotic arm assistance.

We've got this fantastic operation uni compartmental arthroplasty that is bedeviled by the technical complexity of it, and people being unable to reproduce what they set out to do with the operation. So there's, I think there's great hope that unis will grow if Mark Blythe's data is replicated by other studies.

And as you know, there are, there are similar studies being done to replicate this, including one in our centre. And there's also now some good cohort studies that are going out beyond that. So I think really positive to see a randomized study out to five years in the journal. I know, I couldn't agree more Prof. And before we move on to the final RCT, do you think that's where maybe robotic surgery is going to have its advantage?

If, if you know, if this data is reproducible, which I'm sure it will be across other centres, is that where the sort of value for money, shall we say might come in with robotic [00:18:00] surgery if we do have this lower reintervention rate, isn't that, that's where it may, it may hang its hat? Yeah. So I think we've got to be careful with robotic surgery as a whole, in that, in that this refers to one particular device and one particular product.

And we must, we must never lump them all together. But with this particular robotic arm technology, we've seen great results from many centres now, and this is great out to five years with the uni. I think we will see more and more. The real big question is going to be generalized ability.

Yeah. So in the, hands of the interested, this seems to work very well, seems to enhance the ability to hit a target and deliver a result and deliver an outcome. If the registry has proved that it's generalizable, that's where the cost effectiveness will come, because although there is an extra outlay at the beginning, there are disposables.

If you're reducing revision rates and improving function, that's going to be a big win at a population level. And you know, we've got a great group of surgeons in this study. If we take a group of surgeons doing lower volumes, perhaps generally not able to [00:19:00] get the implants where they want quite so well, give them a technology which removes that variablility,

I suspect that'll make a big difference. Big difference, absolutely. And finally Prof, so moving on to the final paper, which is the excellent RCT from the team in Oslo, in Norway, that compared non-active management to fixation for volar locking plates for patients 65 years and older with a displaced distal radius fracture and great to see, important question, you know, and then there's been literature in this area before, but a really high quality RCT and sort of highlighting

the importance of looking at nonoperative treatment in all these geriatric patients who sustain these type of fractures. No, I really enjoyed this study. It's I mean, it's a great group and it's an example of the, the change in trauma surgery over the last decade, decade and a half in that we've really taken some of these tricky questions and run randomized studies be it in Scandinavia, be it in the Netherlands, be it in the UK, it's become the way forward.

And, and this belief that orthopaedics trauma surgeons couldn't do this, I think has been truly dispelled. Now, these guys have done a great job and actually they've, they've really [00:20:00] shown that in this older population, fixation fun though it may be for surgeons, doesn't have a significant, you know, it doesn't, it doesn't really make that much of a difference at one year, in fact the outcome of non-operative management is non-inferior, which I think is a really important message.

There's a flip side to this, which I think really interesting that we mustn't lose sight of, is that there may be an advantage early on to fixation. And that's where the rub comes with younger patients and those at work and so on where, where that difference may come in. So I think you've got to always look at the bigger detail, but really important to do these studies and, you know, we've, we've got a very expensive healthcare system to deal with.

And in these over 65s, we should follow the advice of this study. Yeah, I totally agree. And I think it's important that we are asking these questions and not just for just the radius fractures, but for other fractures as well. No, I couldn't agree more Prof. So this cost, this time profit, you know, just be finishing up.

I thought we'd just maybe consider the future, you know, and what do you feel are the positives we can take forward? I mean the past couple of weeks have been [00:21:00] tough and a bit negative all around in the UK, unfortunately and across Europe and the world, but as we head into the next year, what do you think the future holds and maybe what are our challenges moving forward?

Well, I mean, I think, you know, the, the reality is we've learned a lot from the pandemic and although still continuing to challenge us, we've learned how to do more remote consultations. We've learned how to transfer imaging more easily. We've learned to follow up our patients in different ways.

So I think clinical care will be enhanced by some of the things that will stay with us. I think we will be able to show through the pandemic that we need more standalone hospitals for elective orthopaedic surgery, for example, and that we need to prioritize orthopaedic care. So I think we've got to be mindful that, that all those things, but actually I think, you know, we're in a good place.

As a profession, we've got a resilient group of people. We must continue to look after each other. Look after our trainees. We must continue to do good research and we must continue to educate well and to deliver [00:22:00] good training. And I have to say we at the Journal trying to support all those facets, you know, we're keen to encourage good research, good training, good education, and to enhance everything about the orthopedic and trauma community.

So I'd still be positive. I think we will get through this rough period worldwide, no matter what stage you are in the country, where you're listening, we will soon be all together again, we'll be able to travel more often and interface in the way we would wish. And I think we will continue to do the good things we do in terms of research.

And we continue to produce good publications and we'll continue to educate. Yeah, I couldn't agree more Prof. It's a really nice, nice positive to really finish on there. So think that's all we have time for, but thank you so much for you, you know, a great overview of what has been again, a difficult and challenging year for everyone and and it's always really informative and always great to talk to you.

So thanks for joining us Prof. Thank you. And thanks for doing a great job again this year. Thanks Prof. And finally, as ever, we'd like to wish all of our listeners and the wider community, [00:23:00] a very happy festive period and all the very best for 2022. We at the Journal thank you so much for your ongoing support.

Stay safe and well everyone, and thanks for listening.