Listen to Mr Andrew Duckworth interview Professor Fares Haddad and Dr Bryan Springer in a podcast to accompany The Knee Society supplement comprising of 31 articles from the 2020 closed meetings.
Click here for The Knee Society Supplement
[00:00:00] Welcome everyone to our Special Edition BJJ Podcast for the month of June. I am Andrew Duckworth and a warm welcome from your team here at The Bone & Joint Journal. As many of you may know over the past few years now, for the months of June and July, we're doing podcasts to accompany our supplements from The American Hip and Knee Society member meetings in 2020.
So over the next 20 minutes or so we'll be discussing the June supplements of the BJJ that includes 30 papers from the American Knee Society members meeting in 2020. For those of you who have not listened in before, we'll give you a brief overview of the society, who the members are, as well as discussing about the collaboration with the journal over the past three years, along with how we hope this has benefiting you as our listeners and readers.
We also hope to give you a behind the scenes insight into how the studies within the supplement have been reviewed and chosen as well as some brief discussion on a few select papers, including the award papers. So with that in mind, firstly, I have the pleasure of being joined again by our Editor-in-Chief, here at the journal, Professor Fares Haddad. Prof, it's great to have you back with us.
Andrew, thank you. Thank you for doing this.
Prof and I are delighted to be joined again this year by the returning Guest Editor for The [00:01:00] Knee Supplement, Dr. Bryan Springer, who is the fellowship director at Ortho Carolina Hip and Knee Centre in the US. And yes, Brian it is great to have you back with us.
Thanks for joining us. Thank you, Andrew and Fares. It is always always a pleasure. So Brian, if I could sort of kick off with yourself , I know we've talked about this before in our previous podcast that have accompanied the supplement, but for those who are unaware or haven't listened to those, could you give us a brief overview of The Knee Society, and sort of how it has developed and came about and what its main roles and aims are?
Sure. Of course. I always find it quite fascinating to go back and read about the history of The Knee Society and where it started and where it is now. And, you know, to think that we're approaching now almost 40 years, you know, since the first meeting, which was 1983. And the first meeting actually took place at the American Academy of Orthopaedic Surgeons meeting. And it was essentially a dinner. And that's, you know, that's kinda what they log as their first meeting. And, you know, [00:02:00] if you think back to kind of the history of knee replacement, really in the late seventies, hip replacement had already been established. In fact, The Hip Society have been established about 15 years prior to The Knee Society. And of course, knee replacement was just going through this rapid evolution, designed surgical techniques, you know, things along those lines. And I think the leaders at that time, and if you think about who's involved in this early organization of The Knee Society. I mean it's literally the hall of fame of knee replacement society. It's *inaudible* Townley, Hungerford. I mean it's the giants in the field from back then who had the vision and the wisdom to sit down and say, hey, we're going in a lot of different directions here. How can we put together a team that can help push the science of advancing the knowledge of knee replacement forward. That was really the impetus to start The Knee Society and how can they create this kind of optimum [00:03:00] environment to promote this aspect of education research, advancing the treatment of osteoarthritis. And that was really what their mission, you know, moving forward. And I think about that small group sitting at the dinner table in 1983 at the academy meeting to where we are evolved now, 206 members, nine countries, 30 states, 72 academic institutions. It's really, it's really pretty incredible.
So the membership in the society is by an academic invitation only. So it really tries to recruit, you know, the best of the best, those that are sticking to the mission of advancing education and advancing research. And you know, now we have new members challenging the old guard with science and research, which makes for really dynamic meetings. The Knee Society and Hip Society have really branched out now so it's more than just a closed meeting, members only meeting that take place once a year. There's an open meeting at the academy annual meeting. There's other meetings that have come about, CCJR, there's fellowships, like the Insall Traveling [00:04:00] fellowship, you know, things along those lines. So it's really become a very diverse organization, but still with that theres dedicated core values.
Yeah, that's a great overview. I mean, I know having spoken to you Prof and yourself before, you would really say that when you go to that meeting and there's a lot of good meetings out there, but the level of what you're listening to and the discussion you're having is really exceptional isn't it?
It really is. I mean, it's, often times in the academic year where all the research has presented first. You know, before a lot of the other national meetings and because it's in kind of a closed door environment let's just say, no one's real worried about getting their feelings hurt, you know, being up on the podium or people standing up in an audience in a closed meeting and telling you very frankly, how they feel about the research that you're doing, which can be good and bad, but it really creates an extremely dynamic and diverse intellectual discussion.
Yeah. Yeah. Robust peer review, but informative. Yeah, absolutely. So [00:05:00] Prof, if I could come to you next then. Could you give some sort of insights into your, you know, the collaboration has been going for three years now, you know, how that sort of developed over that period of time and what you feel the benefits have been to the readership and the journal?
So it's been, you know, it's been a wonderful relationship, Andrew. This is a very select group of intellectual, highly driven, very research focused and education training focused individuals and there are some US, but there's a small proportion of non US Knee Society members. There really is an impressive cohort. So it's been great to look at the outlook from all those individuals to be able to work with Brian and thought leaders like Brian to really see the shape of thinking in North America and the direction of travel. So we've begun to see trends of the really important issues , you know, selection of patients for different procedures, optimization of the pathway and new [00:06:00] technology, 3D-printing , you know, enhanced technologies like robotics that you can see the movement in that direction. I think one of the huge benefits, for the readership is they are really seeing some insights into the direction of research in North America and seeing it at a fairly early stage and being able to sort of develop and follow that direction, but relatively quickly.
So it's really been a very, very healthy relationship. We can take stock at this stage and evaluate in future whether this has been beneficial to our readership and get feedback from our users. But I think so far, it's been outstanding to deliver this to our readership and also to give this product of North American Orthopaedics a much broader international readership than it would have been.
No. I totally agree Prof, and with that in mind, in terms of the content of the supplement before we go on to sort of discussing the individual papers , I think we've covered it before, but I think very [00:07:00] important for the listeners and the readers, you know, in terms of how the papers are chosen for the supplement and reviewed prior to acceptance cause it's a fairly robust process isnt it?
It is, you know, it's a process we do at pace. And actually I have to thank and congratulate Emma Vodden and the publishing team for really helping us do this so efficiently and so effectively, but each paper that comes in, so there are, if you like I'll pluck a number from the air cause I can't remember whether there were 80 or so papers in the meeting this autumn, but it's roughly in that range. All are invited to submit the full manuscript. And then those manuscripts are submitted to the journal. They come in by mid December, at which point they will go to two Knee Society reviewers and to BJJ non-Knee Society reviewers. So they'll go through a pretty robust peer-review process. And then we will feed back to the authors and a significant number of papers were not accepted, [00:08:00] but a load were revised and then have been shaped by the primary editors to the product that our readers will see.
There are also the three award papers. They are slightly different in the sense that they are selected from a number of submissions that are international. They didn't have to be presented at the meeting and they don't have to be Knee Society members although frequently they are. Those are chosen by the programme committee of The Knee Society. We get those a little bit later, but we still send those for peer-review and try to evolve those papers to make them as good a product as they can.
So it's definitely a very rigorous process. These are papers by a select group of individuals presented at a meeting and then subsequently taken through a fairly strong BJJ process.
Yeah, absolutely. To maintain that quality. Yeah, definitely Prof. So if we can come onto the supplement, because there's some interesting papers for us to talk about. And Brian, if I just come back to you before we do talk about them, I think it's always interesting for someone particular who's [00:09:00] more, a bit outside the knee world, you know, what do you feel? The sort of core and topical themes from the papers are this year? Where has the research been going?
Yeah, it's a great question. And you know, one of the things as I look through this supplement and was going back through it, one of the things that struck me in particular about this supplement was it's a pretty diverse range of topics. It really is. You know, in some years we may be heavily focused on one aspect, for example, unicomartmental knee replacement or something like that. And there's certainly that, you know, that flavour and some of the old guard research, if you will, with unicompartmental knee replacements. I mean, we continue to talk about issues with obesity, risk factors, optimizing patients, but there's a tremendous amount of diversity in this supplement, which I think speaks to the power and the diversity of The Knee Society in general, in what people are looking at and pushing things forward.
So we're seeing a lot of really encouraging [00:10:00] data on cementless total knees. We're continuing to push forward with robotic surgeries and the pros and cons of that, you know, and how is that beneficial? And there were some, you know, a paper that challenges that a little bit, and yet there continues to be papers that are showing, you know, improvements in accuracy and alignment and potentially patient outcomes, which is the data that we really need.
Issues with alignment. So, you know, the continued discussion about kinematic alignment. And is that something that's going to help bend the needle and improve patient satisfaction with knee replacement.
We're starting to see that merge. And I thought there's a very interesting paper that looked at alignment and potentially showed some benefits to a, more of a, kind of a customizable alignment. But, you know, we're also seeing , you know, I found the paper about bilateral total knee replacements and days of work missed to be a really practical study, you know, and something that I can take and have discussions with my patients on in the office right away, you know?
So [00:11:00] very applicable, research from that perspective. For example, talking about outcomes in revisions and in high volume centres versus not. You know, this is an issue we wrestle with in the states. Where things tend to get diluted out, but now there's studies showing that, you know, if you have this done in a high volume centre, revision work, it can be done better. You can have better outcomes. It's probably more cost effective, you know, and I know that that tends to be more of a common theme in Europe. And I think we tend to need to move to models along that as well. So it was really the diversity of the supplement that I think struck me the most this year.
No, absolutely. And just before we on, it's interesting as well, I think as with a lot of the high-level journals, that the papers, the methodology behind them seems to be going up and up in terms of big RCTs multicentre RCTs, but big data usage.
You're just getting the bar seems to be going higher and higher.
Yeah. And I credit BJJ with a lot of that as well, because historically you presented a meeting at a society. It was oh [00:12:00] great, I'm going to get this published. And BJJ has raised the bar for that over the past three years tremendously. And I think people understood and knew that. And if we want to get this study published, we need to have a rigorous methodology. We need to have our results. We need to have this very well done. And that's where I think the benefit of this partnership has been so strong.
Yeah. That's nice to hear. So if we move on that sort of leads into the first paper that we were going to touch upon, which is the Mark Coventry award. And that's a multicentre prospective randomized controlled trial. It's sort of a reasonably topical sort of area looking at the use of smartphone-based care path platform after primary partial and total knee arthoplasty and sort of, I suppose, topical in terms of fact that people are looking more at the sort of technology to sort of maybe improve the experience postoperatively, reduce the burden on the healthcare system. But I suppose as well with the pandemic we've just been through trying to reduce the revisits people have to do to healthcare centres. So a really interesting study in many ways.
[00:13:00] Yeah, I mean, and how timely was it? Right? I mean, they started this study well before we had any idea that we going to be in the middle of a pandemic for a year, but I think what, you know, what you're going to see is just this... we're on the cusp of this explosion of this kind of what we call this remote patient monitoring. You know, whether it's through smartwatches or sensors or where ultimately we're going to have less patient touches in person. And yet we still see the importance of being able to monitor these patients closely. And that's what this study was looking at. Can our patients recover and improve with less physical touches? With, you know, devices that will be able to track how they do after surgery, that will compare it to what our standard treatment was. And so I think, you know, it was a good message, right? It's not necessarily demonstrating that it's the end all be all. That there's still a lot of work that needs to be done. But I think in certainly a good, a certain subset of [00:14:00] patients, for them to be able to do therapy on their own, to have it be based in kind of this smart technology platforms. I think it's going to be you know, I think what we're going to see over the next probably five years or so is really a revolutionary change in how we're managing these patients afterwards. And I think that was just on the cusp of this.
No, I agree. And I think, seeing it like you say, in all walks of surgery, whether it's sort of photographs from monitoring wounds or trying to pick up wound infections. There's lots of ways that technology is now being used. And I think the badness of the pandemic, the good thing that's come out of it is maybe it can be forcing us to do these sorts of things and look into it more.
Do you have any thoughts on that paper, Prof? Or very similar?
Well, very similar. Great topical idea. You know, I love the fact that they thought of this. You know, methodologically, this isn't an earth shattering paper. There are a number of holes you could blow through it, but in terms of innovative thinking and moving things forward, you know, what a wonderful idea and that's where we are all going. It's going to get better and better from that [00:15:00] perspective.
And you know what, this is a real example. This would not have been a randomized study five years ago. What we've done in orthopedics is we've started to push the standard towards more and more level one data. You don't always need level one data, and you can't always get level one data, but actually we've encouraged and pushed people to do randomized studies. And the more randomized studies are done in North America, the better they will get.
Really pleased to see that.
Yeah, no, I totally agree. So if we move on to the second prize paper, Brian, that was from Houston and that was a retrospective review of just over a thousand patients who underwent primary TKA. And they were reporting on the incidence of infection and adverse reaction complications. And what they were comparing was either IV versus interosseous vancomycin. This was quite interesting. And again, topical and maybe has similar sort of applications or studies that we've seen in other aspects of orthopedics. And they were looking at sort of outcomes of 30 days, 90 days and one year and some [00:16:00] interesting results there wasn't there.
Yeah. This has become a really interesting topic in not only the primary world, but also in the infection world. You'll see in the supplement, there's another paper that looks at interosseous vancomycin delivery for treating infections. Very early data, but potentially some promise there. And this all gets back to this concept of how do we deliver high enough local concentrations to the site of surgery without creating systemic toxicity? Which is the issue we run into with giving a lot of these patients intravenous vancomycin, and other antibiotics et cetera.
And this really builds on the work that Simon Young out of New Zealand has done, some of the basic science work, some of their preliminary work clinically , some of the work that Mark Van Galen, his group out of Mayo clinic, Arizona have done. And this just continues to build on it.
Ideally I think a larger study, prospective randomized is the way to truly show the benefit of this, right? Cause there's going to be some selection bias and some confounding issues that [00:17:00] are looked at whenever you look at any kind of retrospective infection study.
But I think they demonstrated good safety. You know, we see in a lot of these patients where we're giving intervenous antibiotics, it's not an insignificant amount of acute kidney injury in some of these patients. And the nice thing about the interocious delivery is they're going to get very high, local concentrations as very minimal systemic issues related to it, you know?
And they did demonstrate at an early period than the 90-day mark. They had lower incidents of periprosthetic joint infection in that group. Interesting the 30 day and the one year weren't really, you know, weren't really any different, but certainly that 90-day window that we're all focused on, you know, did show a difference.
So I think it's encouraging. I think what a lot of these papers are going to do is going to, it's going to spawn a future and bigger and better research on these topics. Right. So I think that's really one of the benefits of a paper like this.
Yeah, no, I it's sort of, it's setting the scene and, and raising the question, isn't it for, like you say, a large randomized [00:18:00] study in the area. I completely agree. And I think it's sort of interesting cause it's slightly related, but you know, there has been some big studies in trauma about topical vancomycin and also in spine surgery and actually getting that antibiotic to where it needs to be. And actually the effect it has is quite, it's quite interesting for more research, would you agree with that profit from what you've seen before as well? Yeah, no, I think the reality is these studies have such small numbers of the index events that they add to the weight of the evidence and they add to the signal that they cannot be the final answer.
But if we have a number of different signals coming together like this, it will generate the big studies and the funding for the big studies to allow us to study this properly.
That's right, isn't it? Because like you say, the actual number of events is quite small, so you're going to need such a big trial to do it, but it gives you that weight to do that trial. No, I agree.
So if we move on to the final award paper, Brian, if that's okay? The John Insall award, and that was this large single centre study from the Rothman [00:19:00] Orthopaedic Institute, and that focused on the role of aspirin in the management of *inaudible* DVT following total knee arthroplasty. And obviously again, a big retrospective study and sort of looking at the, you know, how we manage these.
Yeah. I thought this was actually a very interesting study because , you know, clinically, this can be an issue for us. And, you know, oftentimes a lot of centres still do a lot of screening for DVTs. You know, they do ultrasounds, a discharge, even though it may or may not be cost-effective, you know, and a lot of times we will pick up incidental inferpopliteal DVTs, you know, postoperatively in patients. And the gestalt answer has always been, you gotta treat it. You gotta treat it. These patients have to go on powerful anticoagulants and what this group has demonstrated in the past and the point they make in this paper is those are not benign treatment. Right. And the risk of having a major [00:20:00] complication from, you know, a pulmonary embolism from a infrapopliteal DVT is relatively low.
You know, you weigh that against the risk of giving someone powerful anticoagulation in the early post-operative period. And so I think it's an encouraging study, I think as Professor Haddad brought up in this study before this, you still have to be a little bit careful because even a study like this, that seemingly has large numbers, it's still probably very underpowered when it comes to something like a DVT and probably in particular in inferpopliteal DVT. So I think the association is nice definitive conclusion. I still think we have to be a little bit careful about in a study like this, but I'm glad they're looking at something like this because I think it could potentially be practice changing if we can build on this in larger numbers.
Yeah, definitely a clinically relevant problem that would be useful to know the answer to. Would you agree with that [00:21:00] Prof?
I agree completely. I mean, I think it's a problem that I was brought up to believe it was benign and don't screen below the knee because actually you're looking for trouble. The trouble is our haematologists are busy, really looking for trouble all the time. They're actually having this kind of evidence and having other studies that support this will be important because we do not want to go out with the big guns in every knee replacement.
No. Absolutely. Absolutely. So I think that's a really nice cover of the three award papers. And obviously we've mentioned a few others. Prof, did you have any other papers you particularly wanted to highlight from the supplement? We could talk about several, but anything in particular?
I think Brian summarized some excellent papers all the way through. I'd flag one paper that really took my interest, which was Paul F. Lachiewicz paper on the early failure of a novel knee replacement. And this was really interesting in that this is a reputable centre who had a very high revision rate with, if you like, an [00:22:00] upgrade of a very popular system worldwide from the PFC to the attune. And there'd been signals from elsewhere about that, but it hasn't been picked up quite so well in the registries.
So we hadn't really seen it in the registries yet. There were multiple people talking about it at meetings. There were a few little studies showing revision rates. And there are lots of descriptions of debonding and even in the RSA studies that suggested that although this implant was doing well early on there were already more radiolucent lines.
So I think there's an interesting signal there. And that should lead us to ask some questions particularly around is there camouflage in the registries? Are these being lost amongst bigger numbers? Are they, because the radiolucent lines, it's a knee replacement. It might have some pain. Are we not picking these up early enough? And are we ruining the signal for later. And actually the big thing about this study for the reader is this component has been changed, but there has not been a [00:23:00] recall. And that's, you know, when we look at responsible innovation in orthopaedics, we've really got to be incredibly careful. So here's an implant that's been brought onto the market and the signal has been spotted. These authors have really very bravely come out and published it. And yet the implant has been changed and we don't really have a clear mandate to review patients who have this implant in or know what to do about them. So lots of questions, really important questions from this paper. And again, a signal that we really have to be careful how we innovate.
Yeah, no, it's like you say, it's a very frank and honest assessment of their experience. And like you say, it's not the biggest study, but it does make you want to just raise that question. Doesn't it? Which is the most important thing. Any thoughts on that as well Brian, at all?
I agree with everything you both said. I mean, I think that, you know, in this day and age where it can be difficult to have honest reporting. I give a lot of credit to Paul and his crew for, you know, for [00:24:00] pushing this through. And because in reality, it's good for our profession as a whole. It's good for the orthopaedic community that if we see things that may be signals. We report on them and we report on them honestly. And Paul was one of the surgeons, you know, Sam Wellman was one of the surgeons. So they're very honestly reporting their own results. And I give them a lot of credit for that.
Oh, absolutely. Absolutely.
Well, I think that's all we have time for both, but as always, I really enjoyed that. It was a really enjoyable discussion and congratulations on an excellent supplement that I know will be of real interest to our readers. So thank you, Brian, for joining us.
Thank you very much.
Thanks Prof. It's great to see you.
Thanks Andrew. And thanks again, Brian. It's been a great three years of doing the supplement with you. We will miss you.
The pleasure has been all mine. Thank you for having me.
Thanks very much.
So to our listeners, we do hope you've really enjoyed joining us and feel free to post a tweet about anything we've discussed here today. Thanks again for listening everyone and take [00:25:00] care.