The Bone & Joint Journal Festive Podcast 2024

Listen to Andrew Duckworth and Fares Haddad discuss the challenges orthopaedic professionals have faced in the last year, their top picks from The Bone & Joint Journal in 2024, as well as celebrating progress made with Bone & Joint Open, OrthoSearch, OrthoMedia and OrthoPublish, and looking forward to research in 2025.

Papers discussed:

Cost-effectiveness of enoxaparin versus aspirin in the prevention of venous thromboembolism after total hip or knee arthroplasty: an analysis from the CRISTAL cluster-randomized trial

The characteristics and predictors of mortality in periprosthetic fractures around the knee

Association between surgeon and hospital volume and outcome of first-time revision hip arthroplasty for aseptic loosening

Can blood flow restriction therapy improve quality of life and function in dissatisfied knee arthroplasty patients?

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Transcript

[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 our series for the year of 2024. I'd like to start by thanking all of our listeners for their continued support for our series, which we do hope you've enjoyed the breadth of work we've discussed here over the past year, which highlights just some of the great studies published in the journal each month.

With that in mind, and to review the past year here at the BJJ, today I'm delighted to again be joined by our Editor-in-Chief of the journal, Professor Fares Haddad, who over the next 20 minutes or so 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 maybe can expect and hopefully look forward to in 2025.

Many thanks for joining us Prof, great to have you back with us today.

Thank you, and thank you again for doing this so wonderfully this year. 

Thanks, Prof. So, Prof, another year has passed and there have been, without doubt, a lot of progress and positives we can take from what has and continues to be achieved in our specialty.

But, you know, significant challenges continue to be present both throughout the world as well as close to home here in the UK. [00:01:00] So what do you really feel have been the highlights or the progress from the past year in our specialty, but what do you feel the main challenges are that still remain for us?

Look, I think it's been it's been a good year. It's been a year where our specialty has moved forward on on many fronts, particularly in terms of trying to develop the research that we're doing, trying to enhance the techniques we're using, trying to use technology to help us in a variety of ways from better tools through things that make surgery easier for both surgeons and patients to technologies such as AI and machine learning that are going to help us more in future. But I think the bigger picture is, is still a concerning one in terms of, you know, generalized malaise, the pandemic and other things, you know, worldwide warfare with, you know, people lacking access to basic care all around the world.

And, you know, within our own country, still a massive need for [00:02:00] elective services. It's a pretty worrying place to be, you know, for someone who's a, who's an outsider, who's not particularly involved, they'll see the big numbers of investment in our National Health Service. But in reality, that massive number, you know 20 plus billion investment is purely, is over two years and is largely just going to go into the sort of much needed wage rises. So we're in a scenario here where we've got a huge number of orthopaedic patients needing elective care and I'll come back to that in a second, yet we're going to be asked to do more for less over the next couple of years.

So that is a huge issue and one that's figured in the journal, I think we'll continue to figure in the journal in terms of how we measure the suffering of those patients and how we transition the narrative, if you like, from elective non-emergency care to the fact this is, as I've coined before, non-optional care.

And this is planned activity that needs to happen. And yes, we're better than lots of other countries. But in reality, if you're sitting and [00:03:00] listening to this and you're UK focused, we still have a huge headache to address and we need to make sure we've got access to care for our patients. 

Absolute Prof.. I think, like you say, there's been papers in the journal that looked at not only the suffering our patients are having on the waiting list and the difficulties they are having, and also the difficulties that then creates when they do come to their surgery, eventually, in terms of deconditioning and things like that, but also the amount of capacity we actually need to try and get through this have all been highlighted this year in the journal, haven't they?

Indeed they have. And actually there's one facet that probably hasn't been highlighted is the stress on surgeons and surgical teams and allied health professionals trying to manage all of this because it is, there's a human element here. It is hugely stressful and unpleasant. I think one of the areas that I think we need to look at more over the next five years is going to be the impact of everything that happens both physically, intellectually, emotionally on surgeons and their teams.

Yeah, no, I couldn't agree more and [00:04:00] moving on from that Prof, you know, our team here at the BJJ, you know, what has the past year been like for the journal and, and our amazing team that we work with?

Look, it's been, it's, it's been a good year. I think for the first time since the BJJ came to be, we are the number one general orthopaedic journal in terms of impact factor. You know, that is a huge achievement from where we were 10 or 15 years ago. With, you know, with the transition, the separation from JBJS back in the day. 

So that is a phenomenal achievement for everybody involved with the journal, you know, those of you who see the impact factor of 4.9, that's not the highest we've ever been, but actually that is higher than our peer group and that is a huge milestone. So I think I, you know, express my thanks to everybody who's involved you know, people like yourself and, other editorial board members and specialty editors who are really putting the hard work in to ensure that we both source the best material, but also review expeditiously and you know, [00:05:00] transition to the output that everybody loves, to all our reviewers you know, and to our readers who support us and correspond with us.

So I think we genuinely have a big worldwide presence. We are attracting some great research, some good authors, some great institutions, and we have a phenomenal publishing and editorial team and editorial board. So this at the end of the year is an opportunity for me to say a big thank you and well done to everybody involved. I'm really grateful for all the support. And you know, we're at a platform where we can move forward. And continue to excel.

Yeah, no, I totally agree, Prof. And I think, like you say, it's such an amazing achievement that, and you know not to go on about it, but I think also with the amazing amount of work that you put into it as well, and all the leadership you provide, it's it's a real, it's a really amazing feat. I think that, and I like to say an amazing team effort that's that's driven us there, which is great. 

And Prof sort of, before we sort of move on to the papers, we're going to discuss, I think just things I always like to highlight, you know, obviously the BJO, you know, our gold open access journal, and again, going from [00:06:00] strength to strength and actually the papers in there, obviously to begin with, there's a lot of COVID work that went in there, but that has really become a, you know, a very good read, you know, and the quality of the stuff and the breadth of stuff in there is quite impressive now.

Absolutely. I am hugely proud of BJO and of the work that yourself particularly and Alex Liddle and others are doing to raise the profile and improve the material that's in there. And I think to be clear, you know, BJO publishes material of excellent quality. There isn't room for everything that is sound in BJJ, and it's great to have a place where we can put some good material that isn't quite at that exalted level we want in BJJ, in BJO.

It also gives us a place for protocols, for systematic reviews, for setting the scene for future research in future studies. So I think, you know, BJO is a great platform for us to have. It's open access for everybody. It's already got an impact factor, you know, second impact [00:07:00] factor 2.8. So in terms of worldwide presence that's really making its mark, but I think it's important to stress this is good-quality material. One of my challenges worldwide, you know, as I speak to you now, I'm sitting in the North American meeting and some of this material I hear quoted from the podium worries me, but that material gets published somewhere. I think I just want to reassure anybody who's listening that the bar for BJO is still pretty high. You know, this is sound material that we're putting out there. 

No, absolutely and as you said about it being open access, but actually the open access fee is incredibly reasonable when you compare it to a lot of the the open access fees that are out there. And, and, and just before we move on to the select papers, but also just maybe just a minute to discuss, you know, the amazing you know, associated digital products that have been developed by our team at The Bone & Joint Publishing, you know, led by Emma Vodden and her team and, and how they really are serving the orthopaedic community really, really impressively. And it continues [00:08:00] to more and more stuff continues to come out. 

Yeah, no, it's been a it's been part of the strategy. It's been a great deal of work for Emma and her team. They've been very well supported by the council and the society. But actually, we have now got things like OrthoSearch and OrthoMedia that people really enjoy using and, you know, OrthoSearch is a wonderful search engine that you can really refine to your own needs and their greatest product, I think, is transformative, OrthoPublish, for those of us, you know, spent hours trying to work out where to submit a paper or, you know, trying to reformat it. You know, OrthoPublish has been really well-thought-through and designed and developed and it's part of, you know, our increasing offering as we move forward in the digital world to see what can we do for the community in beyond publishing good-quality research. There's got to be more that the society in the journal can do. So I'd encourage everybody to have a look at OrthoSearch, OrthoMedia, have a look at OrthoPublish [00:09:00] and, you know, have a look at the breadth of the offering, the way we are evolving and actually will continue to evolve moving forward next year. The animations, the infographics, that the whole output from the journal is going to become even more user friendly and accessible.

Absolutely and I think like you say, Prof, I think OrthoSearch and OrthoMedia, OrthoPublish are real examples of how the Bone and Joint try and serve the community. They have gone to the community and say, what are the problems? What are the issues you have? What do you need? And these have all come out of that, that sort of discussion, haven't they really? 

Yeah, you know, we, we are all about the trauma and orthopaedic community out there worldwide. Yeah, we're trying to cater for a very broad constitution. But you know, I think those things are people once they know about them and again, that's a, that's a big challenge. Grateful for this opportunity, for example, to, to spell these things out. We want people on there. We want people feeding back and we want to be able to evolve these platforms, make them broader, make them better, make them more accessible. 

Yeah, absolutely. So if we just move on to [00:10:00] some of the papers we've we've we've picked Prof and obviously thank you very much for highlighting these. And you know, they really just are an example really of the, of the, of the breadth and the quality of the work that's been published in the journal. And I think again, really highlights, as you've just said, the high-level of evidence and quality of the work that continues to be published here at the journal.

And the first of these papers highlights an area that is always topical and debated. I know we've, we've recently did a podcast overview with some of our colleagues in Australia on this. And that's the economic analysis of the CRISTAL trial, which is a RCT from Australia. And again, just adding more high-quality evidence to it, to an area which is often, often debated.

Yeah, no, no, I think this is, you know, the CRISTAL study is an important study. There are no perfect studies. So you can always criticize them and there'll always be people who are anxious for one reason or another about the findings. But actually, you know, this is the orthopaedic community leading the narrative in this area.

And remember in the past, it's been led by pharma, by hematologists, [00:11:00] even in people's own hospitals, you know, just the ability to be able to grasp this topic and say, look, we understand the problem, we can risk assess, and this is what we're going to do. But this is, and I think there was within our community, a huge push away from the factor ten inhibitors and the secondary hematomas and so on towards aspirin flourishing and growing as the answer to everything.

And, you know, as, as you know, having one answer for is, is rarely possible. Absolutely. I think what this study does is it reawakens everyone to the fact that VT is a real problem. Even below knee DVTs have an impact and that can be a long lasting impact for patients. And that we've got to consider the role of low molecular weight heparin, inconvenient though it might be, injections, etc. In reality, there is pretty strong evidence here that we need to be looking at low molecular weight heparin in our protocols, in our guidelines moving forward. And I recognize that the aspirin lobby will continue to try and and, and beat this up. And [00:12:00] we'll look forward to seeing other studies that show good concordance with this, but I think this is a strong study and it's really good to see it in the, in The Bone & Joint Journal. 

No, I agree. And I, like you say Prof, a trial of this size now over, it was over 9,000 patients in the CRISTAL trial. And to have that, the economic analysis published in the BJJ, I think is a real marker of, of where, where we're at in terms of the quality of what data we're publishing and sort of, that moves on quite nicely to the next paper that you sort of picked, which is the study from Birmingham and the, the periprosthetic fracture study collaborative and again, a very, another very topical area that's often published about we've had plenty of good papers in the journal about this area in particular, but and this was looking at sort of the characteristics and predicts of mortality and periprosthetic fractures around the knee, but I think it's another example, and we do see more and more of this, which I think is great in the UK, is these, these really useful collaborative studies on often slightly rarer conditions, but bringing all that data together in a really meaningful way.

Yeah, no, no. And it's like, you know, I travel and try and you know, expose our [00:13:00] material worldwide and I think that's one of the things I try and push forward, the fact that actually we are engaging our trainees in research early, and we're engaging them in a useful way to collect data that's going to have, an impact.

And there's no question, you know, distal femoral periprosthetic fractures are a complex area. They're huge. They are very difficult to manage, you know, whether you're plating, whether you're plating and putting a nail at the same time, whether you're having to do a distal femoral replacement, these are major interventions for patients.

And there's a high morbidity, high mortality risk. You know, there's a question mark who should be doing these cases, how quickly they should be done. And it's in a comorbid population with a high-risk of morbidity and mortality. So I think the more we can do to collect, characterize and optimize care for these patients, the better. So I think this is a really tricky area. 

Yeah, absolutely. And like you say that, you know you know rarer thankfully, but actually very much similar profile to the hip fractures, if not more comorbid and such an important area to get right into and actually [00:14:00] optimize treatment. No, I totally agree.

And, and, and sort of that sort of links us into that to the next paper quite nicely, because that's looking at the association between surgeon and hospital volume and outcome of first time-revision of arthroplasty for aseptic loosening. And this was data from the NJR and obviously we get a lot of NJR papers submitted and occasionally published in the journal as well. But again, it brings this idea and, you know, sometimes a controversial issue of centralization of care.

Yeah, no, no, it's I mean this is a good NJR paper. As you know, I've been up there with the leading critics of registry data use and how the data has been collected, analyzed, and when it gets used and who by, but actually, I think the registry communities got a lot better.

And, you know, those, those who have been willing to listen, have really improved that. And this is an example of the good use of that data. If you like to study the volume-quality relationship, which I think is really, really important. Yeah. And so that feeds into the [00:15:00] impetus for centralization of complex services in orthopaedics very much as it has been done in cancer and other areas very successfully. 

You know, we've got the pain in the UK of having had it done incredibly badly by a misguided group of people in the knee world for revision knees, but ultimately it's being done better by the hip community. I think everybody has learned from those mistakes and this data supports trying to centralize revision surgery.

It does flag up a couple of interesting issues. I think we've got to, you know we've got to look after people early in their career. You know, young surgeons get well trained, go off on fellowship, come back, and feel they're invincible. And we've got to make sure that first five years is well mentored, while they build their volume, build their experience, bed into units because it's, it's about surgeon volume, but I think unit volume is also very important as we see in, in, in similar publications.

So that's one area. The other interesting [00:16:00] product of this paper is that as people tail off at the end of their career, actually the numbers aren't that critical because they've already built that body of experience. But as a principle, it's not going to be possible all the time, but centralizing care, whether it's revisions, whether it's infections, seems to be a sensible way to go so that the, not just the surgical expertise, but the supporting multidisciplinary expertise is in that place. The equipment's in that place, the understanding, the theatre staff, it's the allied, the allied help is all there. So I really enjoyed reading that paper and, you know, congratulations to that team for trying to flesh it out into numbers. 

No, I think, I think that's the point, isn't it? I think it's like this, like I say, it's quite an emotional, emotive area sometimes, but actually the best way to actually approach things like that is with data, isn't it? And good quality data because then that informs decision-making and then you get buy in, don't you?

Absolutely. And they've, you know, I think they've done that. 

So the final paper Prof, I thought was quite an interesting one, you know, because it's sort of, I think it's maybe a world [00:17:00] colliding, maybe the sports and the knee arthroplasty and everything and and I thought it was really, really interesting, you know, and it's maybe, you know, it's not, it's not a huge study, to speak, but actually, I think another way that, you know you know, good prospective study, a novel area, we don't have any, very little data in this area and that's look at the team from Belgium, you know, who looked at can blood flow restriction therapy, improve quality of life and function in dissatisfied knee arthroplasty patients? And I thought this was really fascinating, actually, I thought it was really interesting read.

No, no, no. So, you know, I think lots of things about this paper, it's two of my worlds colliding at an individual level. As you know, I'm involved both in the sports world and in, in the arthroplasty world in my, in my day job, if you like.

And one of the things I think as a country we set out to do when we got the 2012 Olympics you know, we won that bid was to try and see what can we do to effectively translate from elite sport to the general population. And actually it's, it's, you can talk about it in general term that [00:18:00] increased exercise, increased activities, better for people, strength work is better for us as we get older.

But Jan Victor, who has been a phenomenal contributor in in knee arthroplasty surgery has really grasped this and done a great job. So blood flow restriction therapy is very commonly used in elite sport to help people regain muscle mass. Yeah. And to, to, to have the, the, the idea and then to execute an evidence, the fact that you can take this from elite sport and translate it to your patient, you know, your, your, your ink deconditioned patient having a knee arthroplasty and show good results shows phenomenal translation.

And, you know, that's, I love this. I think the cleverest people in our world are the ones who don't just look in their tunnel. But look outside, look across both within our specialty and outside our specialty and translate. And then the really clever thing here is then to demonstrate that there is an effect and that you can make it work.

So although it's a pretty niche paper and people will [00:19:00] think he's gone mad again actually I love it. And I think it's a, it's a great example of what we should be putting, doing and putting forward. Well, I, I agree Prof actually, these are the things which actually they push the boundaries, don't they?

And, sometimes they may, they may not work out and they may be wrong, but you never know. And actually you only need that one in ten and it can be a real game changer. And I think, like you say, there's so much from elite sport that we have actually translated, you know, head injury, you know protocols, for example, you know throughout all sport now, even, you know, in child sports.

So I think all these things are really, really important. I thought it was a great example, like you say, of that translation of that data to the general, the general population, so to speak. That's great Prof. So those are obviously our hallmark papers. Like I say, just, just really a smattering of the, of the high-quality papers that we've, that we've published this year.

And so just to round up Prof, I suppose maybe as we always do is to maybe look to next year, what, what do you think sort of 2025 holds, you know, both for us as a specialty, but also for for the journal?

I think for the journal, it is more consolidation, more visibility [00:20:00] worldwide. I and the team will be traveling more and more trying to, you know, profile the great material that is submitted to us and that is published into North America, into South America, into Asia and Australasia and and hopefully into Africa, although we haven't, we haven't yet planned a visit to to Africa next year, we'll try and do so.

 I think it's really important that we maintain our connections and get material fed in from all those areas. And as I say expound the excellent material that's been sent into us and popularize it in those areas. So I think we will continue to do what we've been doing. We'll continue publishing high-quality material. We'll continue disseminating it well, we'll continue developing the digital products and we'll continue trying to educate the orthopaedic community. 

Absolutely. Prof. Well, I I think that's, that's great. I know, and, and, and I think we're all excited about the, the year ahead and obviously there will be some challenges there, but I'm sure as, as, as a specialty and a profession, we'll face them head on with our patients and, and as you said at the beginning, advocating for our patients as as [00:21:00] best, as best we possibly can.

I think Prof, that's all we have time for. Thank you so much for an excellent overview of what's been another incredible year for us, especially in the journal, but always as always, you know, there are challenges ahead, but I know we'll face them head on. And as ever, it's always great to talk to you.

Andrew, thank you. Thank you for running these podcasts so brilliantly, and I hope you and your family and all our listeners and readers have a great holidays, you know, and a wonderful, wonderful 2025.

Thanks Prof and as I like to echo Prof's sentiments there, you know, we do wish you all and listeners, our wider community, a very happy, very festive period, very best for 2025.

And we at the journal always thank you for all your your support. Stay safe and well, and thanks as always for listening.