Listen to Andrew Duckworth & our Knee Specialty Editor, Sam Oussedik, discuss four papers published in The Bone & Joint Journal.
The PAT randomized clinical trial: total knee arthroplasty versus patellofemoral arthroplasty in patients with severe arthritis of the patellofemoral joint
[00:00:00] Welcome everyone I am Andrew Duckworth and I'd like to thank you for joining us for our podcasts for the month of March. We hope all of you are keeping safe and well, as we all hope that brightest times are on the horizon in the months ahead. We also hope that you have enjoyed our podcasts so far this year.
We kicked off in January with a great discussion with Mike Whitehouse, from Bristol, to discuss their systematic review on the effective antibiotic loaded bone cement on the risk of revision, following hip and knee replacements. And last month we chatted with Xavier Griffin about his latest trial from the WHiTE group that compared the X-Bolt dynamic plate screw and the sliding hip screw for fixation of trochanteric hip fractures.
As always, we hope you're enjoying the content from the knowledge translation team here at The BJJ, and that we're achieving our aim to improve the accessibility and visibility of the studies we publish here at The Journal.
As part of this over the upcoming year, we will be producing some special edition podcasts with our guests being the incredibly hard working and invaluable specialty editors here at the journal. The aim of these will be to give our listeners an insight into the vital work they do here at the journal, what they feel the current recent trends are in their area, as well as highlighting some papers from the past year that we've [00:01:00] published.
So today to kick us off, I have the great pleasure of being joined by our very good and very busy, specialty editor for Knee, Mr. Sam Oussedik. Welcome Sam, and thank you for joining us today.
Thanks very much. And thanks for having me.
Sam, if we sort of kick off, you know, 2020 year was a difficult year for all of us. And, I just thought if you could give some brief insights, maybe also of your clinical practice, but also mainly in your role as a specialty editor for Knee here at The BJJ.
Yeah. Okay. So I've been specialty editor, I think for about five years, I lose track now since 2016, and over that time we processed nearly usually between about two, three, sometimes up to 400 papers a year. This is specifically for knees. What we noted of course, with the COVID shut down last year was that all of a sudden, lots of clinician who have been very busy had some more time to write. And so last year we pretty much doubled our input of papers and I think we processed 600 in the last year, which is a reasonable number particularly when the [00:02:00] size of the paper journal doesn't grow. It means unfortunately the chances of being published in the BJJ drop a little over that period, although the gems are still making it through.
Yeah, absolutely. No, absolutely. I think that's an incredible number and I think, as we all know, in terms of the number of submissions we have, that's a very large proportion and how very busy you are. And I think we've all seen that at the journal and all the journals, isn't it, the number of papers coming in has gone up and then trying to find the quality ones makes it just a little bit, a little bit harder. Doesn't it?
Yeah, so there's a little bit more noise in the system. And so recognizing the signal is always a difficult thing. I think just finding time to read them all as is reasonably tricky for me. We do read them all, and hopefully the best ones get through. It's an interesting process actually. So specialty editor really involves curating and managing that whole review system, ending in a place where we've got a recommendation to give to the editor in chief. So, what happens is the paper comes in, it'll be put in my in-tray and I will pick reviewers. One of the things that you learn over the years from doing this is trying to [00:03:00] pick the right reviewer for the right paper. And so knowing the reviewer as well as I do, and we've got probably eight or 900 knee reviewers to select from. Knowing the ones who are going to give me the most insightful reviews on each paper, having the knowledge, having the expertise to really pick it apart. And part of that course is giving good feedback to the authors so that even if they don't make it through, then they've got enough information there to improve the quality of their paper once it does get into a journal.
No. Absolutely. And I think, the quality of the peer review process at the journal is actually exceptional. I think it's managed to maintain that despite how busy it's been.
And with regards COVID, I mean, I don't want us to talk about COVID too much, but how do you feel that has impacted the research in your area, in terms of the papers that have come through in relation to that, and what do you think we've learned and what, what do we still need to know moving forward?
Yeah. So there are the general points that come with COVID, which are all about managing our elective patients safely. And we've had quite a bit come through the [00:04:00] journal and also through Bone & Joint Open, as to how those processes need to be managed in order to do it safely. I think it probably is going to shift focus a little bit, certainly in the UK and probably worldwide as well there's going to be a lot of work to get through over the next couple of years. We characterize that in a recent publication in BJO. And so getting through that hump of work, that backlog is going to involve different working practice. And I think that stimulates innovation and it probably be an important area for research. So simple things like reducing length of stay, using the procedures or methods to reduce contact with patients. As we know, one of the risk factors for catching COVID has been length of stay, the number of patient contacts with the health service for the outside world in general, and so the more we can minimize that going forward, I think the safer the service we provide will be. So there'll be different aspects of practice that will be emphasized over the next [00:05:00] couple of years. But, overall, I'm not sure it will change the substance of what we do, maybe just the way in which we're delivering it.
Yeah, I agree, Simon. I think, like you say, a lot of these bad times comes good innovation and hopefully good innovation for our patients as well. I think you're right.
Moving a sort of a way from COVID, over the past year or so, what do you feel have been the main themes out with COVID for research in your area? What are the sort of common things coming through the important questions that are being asked, do you think?
So, knee surgery, in the journal has been quite arthroplasty centric. It's something I would like to change actually. I'd quite like there to be more soft tissue, more joint preservation. I think one of the difficulties we have is standardizing methods in those practices, in such a way as to make the results of research rigorous enough to publish it. So we do get submissions on everything through, from meniscal work to ACL, to osteotomies. But the work that's done in a methodical rigorous way tends to be [00:06:00] arthroplasty based. And I think that fits with clinical practice. Arthroplasty tends to be a Procedure which follows a pattern. And so we can control most of what's done and perhaps vary, just a very little bit, and look for those effects, which after all is what we're trying to do with any scientific endeavor, try to isolate the variable of interest. And I think that's easier to do with arthroplasty work, which is why I think the journals output reflects that.
So what's happened in the world of arthroplasty? Well, BJJ, I think has published an awful lot on partial joint replacement. Again, that's not necessarily through choice. It's just that those papers, that work is done in a really good way. And so it's difficult to not end up with those investigations being published.
I think the interest in partial joint replacement will continue, to provide a procedure which has lower morbidity associated with it than a total joint replacement in a safe way, particularly as we focus again on reducing length of stay and those other elements that [00:07:00] we talked about with regards to COVID. I think that will remain pertinent. And that's why I've chosen a couple of the papers we're going to discuss later on.
So I think in the arthroplasty world, the other big innovations really are in the world of robotics. So robotic assisted surgery is probably the hot topic at the moment. And so not just the effect of using a robot, but what it allows us to investigate. Again, we can really control variables in a way that's much more rigorous than in previous times, so that we can look at perhaps putting a prosthesis in just a couple of degrees of variation in what the effect on outcome is for our patients. And that's going to allow us to really drill down and analyze and investigate these, these very subtle differences, which may have profound effects.
Yeah, absolutely. You talk about the methodological rigor, and I think like, as we've all seen, the quality of that has really gone up over the past couple of years. What's your take in terms of the volume of registry type papers you are getting, you know, from all the various registries has that changed over the past [00:08:00] couple of years? Has the quality changed?
So we certainly get a fair few registry papers. So the difficulty with some of those is the registry that they come from so there are certain national registries, which we all know about and the number of cases, inputted, and the penetration of those registries is very good. So you look at the New Zealand registry, the Australian registry, the UK registry, these are mature and we can look at what's coming out of those registries, reflecting practice accurately in those areas. I think where we perhaps have more difficulty in drawing firm conclusions is from some of the less established registries, some of the ones which are emerging the United States, for example, where you might have very low percentage in registry terms of cases being input. And that really does introduce an element of selection bias, not just the centers that are going in, but also the individual cases within those centres. And so knowing a little bit more [00:09:00] about each registry really allows us to, figure out whether the analyses that come from those data are going to make into the journal or not. So it's not just, I guess, all registries are equal, they are certainly very unequal.
I think that is right. I think it's one of these things where the questions the registry can ask isn't it in terms of what they were actually designed to do in the first place, and then actually people now, cause it is, it's very tempting with thousands and thousands of patients to try and get it to answer a question that it probably can't answer, or it's very difficult to answer. Do you think that's fair?
Absolutely. I mean, we can only ever find associations with registry data. Cause and effect we can't really determine, I think, you know, what were they designed to do really for surveillance of implants, rather than anything else. Most of them don't tell you about case mix. Most of them have very little in terms of *inaudible* and, you know, increasingly that's becoming a feature. And so over interpretation I think is the danger with registry [00:10:00] data. And we have to be very careful with such enormous numbers, everything is statistically significant. So the way in which those data are handled becomes really very important.
Absolutely. Absolutely. So Sam, if we move on that leads us nicely into some of our highlight papers that you've kindly picked for us. With the volume that you've gone through and we've published, it's difficult to pick a few, but I think they've all got nice themes to them. So if we kick off the first paper is from the revision knee replacement priority setting partnership steering group. And that was on behalf of Basque and they use the James Lind Alliance protocol to identify research priorities related to the assessment management and rehabilitation of patients with persistent symptoms after a knee replacement. As many of listeners will know the James Lind Alliance is a not-for-profit initiative that aims to sort of guide collaboration between patients carers and healthcare professionals and so prior to setting partnership that then highlights uncertainties related to a given health care issue and then trying to establish a top 10 research priority in that field. I think it was a really interesting paper, this, cause I think it's important that obviously this is becoming really the [00:11:00] standard of how the main research priorities are being set across our specialty. Isn't it really now?
I think this is a fantastic way to look for questions to answer. And if we think about traditional research, usually it's a small number of people's enthusiasm for *inaudible*. And this really flips that paradigm round and asks, not just, you know clinicians, yes, but also patients - what is important to you? And what I think is really interesting is what comes out is that actually it's not the same answers necessarily as you would get from surgeons, certainly, but actually some of them have very similar themes, but if you ask a patient what's important for you, which questions you need answered, then it tends to be symptom based. And obviously if you ask a surgeon the same question, it might be which prosthesis do I end up using. These symptom related questions, I think are very difficult to answer probably, but really, really important to [00:12:00] ask. And so it's only right I think that this type of work and guides where public funds are put in when it comes to funding research, and I think it will be more and more important for us to ask the public outpatients what's important to them before we launch down the routes of investigation.
Yeah. No, absolutely. And, as many of us know, I think initiations like this, particular James Lind Alliance, they carry a huge amount of weight when you're going to particularly the public funders in terms of funding these big studies and trials.
Before we move on to the next paper, so the top 10 priorities that came out, is that what you were expecting in terms of were they generally the areas that you were anticipating or not? Yeah, I think so. I think it's a good coverage. You know, what brings our patients to us is usually pain and functional limitation. Strangely enough, those are high on their priority list as to what they want fixed. And so to that extent, it's reasonably [00:13:00] predictable. I think some of the diagnostic questions are also really important. So, you know, making sure that we've got an answer to what the problem is before we try to fix it. I think in general terms that's very important. But clearly the patients in this group were very well-informed and made great choices when it came to prioritizing.
No, absolutely no, no. I would encourage all our listeners and readers to read it. I think it's a great, a great paper. So if we move on from that sort of nicely leads into the next paper, which is the Pat randomized control trial, which is based in Warrick and that's a pragmatic single center, double blind randomized clinical trial, comparing total knee replacement versus patellofemoral placement in patients with severe arthritis of the patellofemoral joint.
I'm always a bit *inaudible* to speak to a knee surgeon about anything to do with the patella femoral joint at the moment, to have to say you guys get very excited about it. And just to highlight to our listeners, we'll be having a highlight paper in April about the topic and about resurfacing with a few debate potentially as well, I suspect which will get right heated I hope anyway. But it's an [00:14:00] interesting trial and it is always good to see a randomized clinical trial in any area isnt it really, and this is a good quality one.
So an RCT, not just in orthopedics, but in arthroplasty. I mean, it's extraordinary. I mean the whole group deserves a massive Pat pun-intended on the back. Really, really impressive. And, you know, just to emphasize importance of randomization. It's really so that we try to minimize the effect of unknown confounders. And so we can match patients for the things that we know about so things that we don't know about that can often change the results in unpredictable ways. So that's why randomization is so important. And you know, again, it comes to isolating variables, as we touched on earlier.
I really liked this. I think it's a fantastic study. I love the way it's pragmatic. I love the way they describe a surgeon, you know deviating from the protocol because he fancied it when he opened the knee. I think that's sort of sounds fairly familiar to me and I think [00:15:00] great that they put it in the discussion. So, no, I think hats off to them. It's a great paper.
Absolutely. In arthroplasty, in the trials, I mean, obviously they've used the WOMAC score didn't they, 12 months as their primary measure and they comment in their discussion that the main limitation of the trial probably was the sample size. Cause their estimates of treatment effects were slightly different than they anticipated and I think it's a problem, isn't it, in terms of what is that primary outcome measure in arthroplasty is the best one. We don't really know that do we yet, or do we?
No, we definitely don't and it comes a little bit down to the different reasons people undertake arthroplasty so if we come back to pain and functional limitation. Pain is subjective, you know, there is some surrogates for objective mark you can use, but actually pain is fundamentally subjective. Function, it differs from person to person. And so, you know, one person's view of success might be getting to the shops and back, and others might be running a half marathon. And so that's [00:16:00] where our outcome measures really fall down. And, you know, they all have describes shortcomings and finding something that's going to really address everything in one it is impossible, quite frankly.
So you know they mentioned the *inaudible*, which is of course more of a sports knee score. It doesn't really apply to a patellofemoral arthroplasty, total knee replacement group. And you're right there are definite limitations there. And actually there are two different ways of looking at the findings. You know, one, you could say they've shown equivalence of the two treatments, and you can say therefore why would you perform a patella femoral joint replacement, total knee replacement performed as well. The flip side is, of course we know the reduced morbidity associated with partial joint replacement. So you could say why expose somebody to the risks of a total knee patellofemoral joint replacement. I think it's great because it stimulates debate. It's got, you know, a little bit of answers in there, but it's much more about the general discussion.
I totally green. And like you say, it's great to see such a good high quality trial in arthroplasty. So if we move on Sam, to the third paper, and this is from the Lundbeck [00:17:00] foundation center for fast track hip and knee replacement. And they're a collaborative group in Denmark and they report on just under 4,000 surgery in this prospective multicenter study that aim to describe the trends in length of stay early complications and readmissions following a union knee replacement, and it's performed at sort of eight different volume centers in Denmark using sort of a fast track protocol. And I think in terms of getting people through the system quickly, it's quite an app study really for that. And it's a really, nicely put together cohort study.
And those are the reasons that I thought we'd highlight it because it's the direction of travel for arthroplasty surgery in general with shorter and shorter length of stay. And you know, when you look across the Atlantic in North America, where, I don't know if it's a majority, but certainly a large minority of joint replacements now are carrying out day cases. You start to ask the questions as to why that isn't more of the case on this side of the Atlantic.
And so is interesting. It's of the moment. [00:18:00] Recovery from COVID, as we've talked about, means reduction, length of stay so far as I can tell, it's the only way we can start to balance the equation. We know, again, that COVID risk is reduced length of stay less than three days. I think we're coauthors on that paper actually. And, you know, also unicompartmental knee replacement, another hot topic as we discussed earlier. So I think this brings all of that together and shows us that, you know, a common theme is that the more you do of something the better you tend to get at it. And I think that's one of the things that we can probably pick out from this paper. In the centres that do lots of union, knee replacements, they tend to have shorter length of stay. In the centres that sort of dabbled in it occasionally then there could be managed much more like total joint arthroplasty populations, and length of stay is expected to be a little bit longer.
Again, some clues as to how we can move forward in reducing length of stay and therefore reducing morbidity for our patients and improve their outcomes.
And from reading that paper, do you think some of those can be taken to all aspects really, of [00:19:00] elective surgery really?
Yeah. So I think what we're going to see over the next 12, 18 months, maybe a little bit longer, is that as we start to push the day surgery paradigm for arthroplasty, all length of stay starts to reduce, because we start to put in place structures, which allow us to get patients through the system faster. And perhaps also patient expectations and clinician expectations will change so that length of stay becomes as short as it can safely be. And of course, there's always the flip side of that, which is the complications, the readmissions, which they looked at in this study as well. And so we have to make sure that this is done in the safest, possible manner, but I think it's definitely the direction of travel.
Definitely. Definitely. So if we move on Sam, to our final paper, which we're just going to touch on, which is from Sweden and I was really pleased you picked this. I thought it was a really interesting study because obviously the first thing to say, it's a qualitative study, which is something we see so little of in our specialty. And, you know, it is becoming more and more popular, shall we say? And certainly people are embedding studies like this within trials [00:20:00] and other studies. And it involves 18 joint replacement surgeons, and they invested in the experience and emotional impact of joint infection, prosthetic joint infection on these surgeons and aimed to identify holistic strategies to improve the management of PGI and protect the surgeons wellbeing.
I think it's important to highlight the first time you read the title you think, but what about the patients? But they're very clear about that. You know, the patients, they acknowledged go through a huge amount, but I think it was really, eye-opening actually. I think to read this and just reading the insights and actually, you know, not just in joint replacement infection, the feelings we all have when we have a complication and how we feel about it really, and how we deal with it.
Patients want their conditions to care. And I think, you know, anyone I know who works with patients, cares about their outcomes. And some of that obviously take it on a personal level, which is, I think what we really digging down into this paper. And as you say, I think this is really interesting. It's not something that we see a lot about and another good reason to highlight it.
[00:21:00] And you know, the other side of that is of course infection. Of course it's appalling for the patient, who's experiencing it, but it has affects on the surgical team. And those effects can be as high as the guilt. They can be almost a grief response and what you really don't want is for the surgeon to get in the way of the patient's recovery. And I think that's the message here actually. It's not just about managing the surgical teams emotional state and providing support. Although those things, you know, particularly at the moment we are highlighting the importance of being a little bit more nurturing towards each other at work. Those things are clearly very important in and of themselves, but here in addition to that is the impact on the patient's outcome and really emphasizing the importance of spreading the load a little bit throughout an MDT in order to allow the right management to be undertaken at the right time for the patient to come through as unscathed as possible. So I think it's really almost a 360 view of the patient's [00:22:00] experience, but this time focusing a little bit more on the team who were looking after the patients and seeing how they can be supportive to get through it. Yeah, really great paper.
I agree. With a lot of these qualitative studies, obviously there's quotes from the people who've contributed to it. And I think it's quite nice because often a lot of the quotes are in there. You know, we've all said ourselves or felt ourselves. It's really difficult dealing with PJI if we don't have a group of colleagues to talk to. And I think, you know, we all feel that when we're going through those difficult times and have, you know, complex patients, that we're trying to get through difficult times, our colleagues are really important. But no, I agree, it's nice to see a good quality qualitative study in our area.
And that's great Sam. So just to finish off Sam before we go. In terms of, you know, we've touched on it already, but you know, what do you think going forward are going to be the main topics in your area? What do you expect over the next year maybe two is going to be the main themes coming through?
So I think we're going to see a little bit of more of the same in terms of the impact in [00:23:00] arthroplasty of surgical decision-making. I think we're going to see hopefully some advances in infection, both diagnosis and treatment, which is one of, if not the leading cause of failure of arthroplasty, throughout the world. And yeah, you know, how we deliver healthcare to a larger population, that is getting a little bit sicker. Deconditioning is going to be a big theme, I think throughout, one of the things that we've certainly picked up in my clinical practice is that patients have been prevented from presenting to primary care at an early stage and presenting therefore to us in clinic in a much worse state than they would have been 18 months ago. So deconditioning is going to be a big theme and how we work as a team to help get our patients in a fit state to have the procedures or the interventions that would allow them to get their function back on track.
I think there's a whole bunch - it's an exciting time, as you said, you know, at the beginning, often adversity breeds innovation, and I think that's where we are at the moment. And you know, we will have some more robots. That will definitely be there as well.
[00:24:00] No, I agree Sam . well, I think that's all we have time for, but thank you so much for joining us. That was a really actual overview of your special area. And on behalf of the journal, thank you for all the hard work that you do in your area. I know how busy you are looking after the knee area. So that was a really interesting and informative chat and thanks so much for joining us.
And to our listeners. We do hope you've enjoyed joining us. Feel free to tweet or post about everything we've discussed here today. Take care everyone, and we'll see you soon.