BJJ Podcasts

The Hip Society supplement 2021

July 01, 2021 The Bone & Joint Journal Episode 42
BJJ Podcasts
The Hip Society supplement 2021
Show Notes Transcript Chapter Markers

Listen to Mr Andrew Duckworth interview Professor Fares Haddad and Dr John C. Clohisy in a podcast to accompany The Hip Society supplement comprising of 21 articles from the 2020 closed meetings.

Click here for The Hip Society Supplement

[00:00:00] Welcome everyone to this month's BJJ Podcast. I am Andrew Duckworth and a warm welcome from your team here at The Bone & Joint Journal. So far this year, our podcasts have  accompanied n aoriginal paper or review article we had published in the journal. We have covered a range of topics as many of you know, including the management of open fractures, the role of Denosumab in giant cell tumours and recently a really excellent discussion on the role of cell therapies in orthopaedic surgery. 

We do hope these podcasts are improving the accessibility and visibility of the studies we publish here at the journal, for both you as our readers, as well as for many authors. 

As some of you may know for the months of June and July, we are doing an extra podcast to accompany our supplements from the American Hip & Knee Society closed meetings. So over the next 15 or 20 minutes or so we'll be discussing the June Supplement of the BJJ. That includes 17 papers from the American Hip Society closed meeting in 2018. We hope to give you a brief overview of the hip society and who the members are as well as discussing how this collaboration came about and how we hope this will benefit you as our listeners and readers. [00:01:00] We also hope to give you a behind the scenes insight into how the studies within the supplement have been chosen as well as some brief description and discussion on a few select papers. 

So firstly, I have the pleasure of being joined by our editor-in-chief here  at the BJJ, Professor Fares Haddad. Welcome Prof and thank you so much for joining us. 

Thank you, Andrew. It's great to be here. 

Prof and I are delighted to be joined by the guest editor for the hip supplement, Mathias Bostrom, who is the chief of hip surgery at the Hospital for Special Surgery in New York. Welcome Dr. Bostrom and thank you again so much for taking the time to join us today.

It's great being here. Appreciate the time. 

So Dr Bostrom, if I could start with yourself just for our listeners and readers, just a brief overview of what The Hip Society is and what role it sort of plays in the hip community. The Hip Society is a small group of distinguished hip surgeons from the United States and internationally. It is a relatively closed group of individuals. There's less than 100 [00:02:00] members and it is by invitation only. They have a mission of advancing the care of hip disease and taking care of patients who have various hip disorders. And it, it ranges from the adolescent hip to the very geriatric hip. It really encompasses all sorts of hip disorders and trying to improve that. 

The primary mission of the organization is obviously to do that, but through primarily education and research and it's been around for about 50 years. It was started by a number of Americans here in the United States but it has an international membership as well. 

And you obviously have the closed meeting, which the papers come from but you have an open meeting with the Academy as well. Is that right? Is that right?

Yeah, So the group actually traditionally has had two meetings, a closed meeting just for the [00:03:00] members, which is incredibly  stimulating because the group knows each other well and really can get to the meat of the topics without a lot of the fluff.  And then the other main meeting that I think the public is aware of is at specialty day at the AAOS meeting and there they cover a wide range of very timely topics within hip  surgery. I think the important part is it's not exclusively arthroplasty, but other hip disorders as well. So that includes trauma as well as developmental disorders. 

Okay, so that's a really helpful sort of an overview for the listeners about what the Hip Society does. So Prof, if I could come to you, obviously we'll discuss it again next month in the  Knee Society supplement, but can you give us an insight into how our collaboration with the hip Society has come about?

In reality, as you know, we at BJJ always look to [00:04:00] have the broader reach to educate as far a field as we can, and also to get the best material for the Bone & Joint Journal from the best authors, from the thought leaders and those who are really changing the nature of what we do clinically. And improving the care of our patients. 

So we had a win-win here in that a couple of years ago it became clear that the Hip Society and the Knee Society were keen to relook at who published these very important papers from their proceedings. And we felt that this was an ideal partnership for The Bone & Joint Journal. It would deliver for us collaboration with people like Dr Bostrom and the other thought leaders in North America to get their work and their papers, into the Bone & Joint Journal, to get them engaged with the Bone & Joint Journal family, reviewing papers for us and indeed to, for us to spread their work and their message worldwide, whether BJJ has a [00:05:00] great reach.

So when that opportunity came about, we thought this would be an ideal partnership for us to put in place. So we set forth the communications  and went through the process and we were successful and it's really been a privilege to work with Dr. Bostrum for the last few months to put together this particular supplement from the closed meeting that took place last year at the very good closed meeting that  took place last year. I think this is a huge opportunity to profile some fantastic work across the breadth of hip surgery for our readers. 

Yeah, totally agree. And I think obviously we will come in to discuss a few of the papers. I think the, qualities without doubt, but just for, I suppose, for the listeners this, before we move on to some of those individual papers, can you just give a brief insight about how the papers were chosen and peer reviewed prior to acceptance of publication in the supplement?

Absolutely. As you know, [00:06:00] we pride ourselves on a very rigorous process of peer review of the Bone & Joint Journal. And we also have this unique process where the papers then go through primary editing by orthopaedic surgeons to get them to a point where they are really very readable, very crisp, very clear, probably the best presented material, find out that.

So these papers really have been through the mill because they're initially presented by members of the Hip Society. They have to be  members of the Hip Society to get into the closed meeting. And they're selected by Dr Bostrom and his team to be presented at that meeting. Out of those papers presented there was a call for papers to be submitted to peer-review at The Bone & Joint Journal. And these were sent in by December one at which point all these papers went out for peer review and this was a complex peer-review in that we ensured they were reviewed both by BJJ regular reviews who were used to our processes, [00:07:00] but we also introduced Hip Society in North American reviewers to this process, so that we got their context on these papers as well. So each paper had multiple reviewers and then came through a process that involved Dr Bostrum as  guest editos. So really this is, we hope this is really selected some key papers that deliver very important messages and that will influence practice in Hip Surgery moving forward worldwide. 

The other question we did anything you would add to that? 

Yeah, I was going to say that there's no question that, you know, this starts out with well, over 150 papers that are presented at the closed meeting and is, you know, basically come down to, you know, a dozen and a half really top-quality papers. So it is, it's sort of the best of the best. And you know, this is a group of individuals and the, the context of thought leaders is really the most important part here. This group of thought leaders presents their best [00:08:00] material and then that best material is what's being published in the BJJ.

So it is sort of the best of the best, in terms of content and timely also, you know, I think themes within medicine change continuously and certainly within hip surgery the themes continued to change. 

 No, absolutely. It's obviously very robust and it's like a two tier sort of review process there. And like you say, it's almost less than 10% of what's published at a really high-end meeting. So it really is high quality. So I mean, given that, so we should probably move on to the supplement itself, Dr. Bostrum. So just, obviously there's a range of topics there that are discussed throughout hip surgery as you've already described, but what do you feel the sort of the core or topical themes from the papers over the past year that presented in the supplement?

Well, I think the timely topics remain surgical approaches has been obviously a very hot topic for a while. We continue [00:09:00] to follow what's happening in the adolescent hip surgery realm as well. In the United  States cost- effectiveness and perioperative care, pain management are very, very topical topical and it really important topics in terms of how we manage our patients. 

You know, the usual topics of bearings and outcomes and infection and revisions are also a theme. So it's a broad  range of topics. Some are sort of time-honored revision, hip surgeries remains a topic infections unfortunately are not going away, but I think there's some really interesting ideas out there in the infection world as well.

And then things that may be a little bit, you know, I certainly see the excitement about different surgical approaches is coming to a close and new [00:10:00] things are coming up instead. So it's a broad range of hip surgery topics, but also peri-operative management which is a big deal in the United States. You know, outpatient surgery for these disorders is a big deal, not so much in Europe and certainly in the United States. And it is pushing the envelope on how quickly we can get people moving after hip surgery. 

Yeah, absolutely. That's a really good summary of them, Prof and I think as well, you know, not just in hip surgery but it seems to them the core topics that seem to run through a lot of the meetings now is as you say about sort of pain relief for opiod use in particular and also just, you know, getting our patients perioperatively optimized so we can get them through the system as quickly as possible.

But just sort of moving on. So the two, there's obviously two prize or awards in the supplement. The first is sort of a large study of over 6,000 patients from a single centre that looked at the impact [00:11:00] of surgical approach, as you said, on the joint infection rates. And the second was from the Mayo Clinic, looking again at a large series of patients having hip and knee arthroplasty. And the role of, it is quite interesting, about the role of allergy testing and comparing infection rates when you use, or don't use a *inaudible*. Could you give our listeners just a brief overview of the two papers. 

Sure. I'll start with the surgical approaches paper, and this was done from a single centre here in the United States. And they looked at a several year period of over 6,000  patients and they looked at whether they did a direct anterior or what they refer to as a non-direct anterior. That includes obviously anterior lateral as well as posterior and over this relatively contemporary period of time, two things they found - one certainly the rate of infection within a direct anterior approach was two and a half times that of the non-direct anterior [00:12:00] approach. A little bit surprising, I think especially if you consult Dr. Google in terms of what kind of approaches should have. The other was that they also instituted some pretty aggressive protocols to decrease their at PJI rate which was rather on the high rate, certainly relative to other institutions. And they found during this relatively short period of time of, you know, three or four years, they basically, you know, basically have their infection rate. And so two major take-home messages from this paper was one, it looks like approach does matter in terms of infection rate. And two, if you institute appropriate protocols to decrease the rate, you can actually have a pretty profound effect in terms of diminishing the risk of infection, and to the point where at the tail end of this study, although the direct anterior approach it [00:13:00] still had a higher infection rate, it was a much more reasonable rate at that point.

The other paper, from the Mayo, looked at the use of allergy testing and they obviously have huge numbers of patients, but they've, over the years, have had a very aggressive approach to patients who come in and state they have allergies to various antibiotics. And so they referred patients to their allergist, a fairly large number, almost a quarter of their patients ended up seeing the allergists. Granted that can be done at the Mayo because it's the Mayo and the, and the way the system works. But the interesting finding with them is that if you've use a broader based antibiotics which we do here in North America. The infection-free survivalship was much, much higher. And so the take home message here is if someone states that they're allergic to penicillin, they probably aren't, first of all, [00:14:00] and if you can give them Cefazolin, a broader spectrum antibiotic, their chance of infection is lower. And so if you don't know if they're allergic or not send them to an allergist, chances are they're not going to be allergic. And then you can give a broader based antibiotics and they're going to have a better survivorship in terms of infection. I think an important take home message in this one. 

The risk of infection was pretty significant if they were able to take Cefazolin, it's about a 33% less. And yeah, that's a big deal for even a small institution. If you can cut your infection rate by a third. 

Yeah, absolutely. 

And societaly a huge, huge deal. 

Absolutely. And as you say, like we often experience here is people are not sure about their allergies, so it's difficult to know. And so this is an interesting paper that sort of makes discussion about that. Is there anything you'd add to that Prof, at all about those two papers? 

[00:15:00] Only I think the second paper in particular is going to be practice changing for many people who will need people to reflect on allergy history more carefully and to rethink, you know, we really need to think we've gone around the houses, certainly in the UK with prophylaxis. So I think there's a lot to learn from that. 

No, I totally agree. Prof, just come back to yourself, I was wondering if we could, obviously another paper in the supplement we could just briefly discuss was your paper about the outcomes of repeat two-stage exchange hip arthoplasty for periprosthetic joint infection, potentially an increasingly  topical area I imagine. I just wonder if you could just briefly give us an overview of the paper and what made you look at it in particular? 

No, no, absolutely. As you probably know, just over 20 years ago, I came back from Vancouver and was very fortunate to work with Jeff Ridgeway and set up one of the first MDTs looking at infection. And so we started developing our algorithms and treatments, and we've always seen it a full circle in that initially we were [00:16:00] getting referred the infections primarily in dealing with them as a sort of specialist infection centre. And then more and more revisions were being undertaken for infection elsewhere and we were seeing the more complex failures come our way. And it became clear to me that people were coming to us having had multiple interventions, having had very powerful antibiotics and really being in some difficulty and tough to salvage. 

So we wanted really to take a more recent snapshot of what those cases looked like, where two-stage revision had failed just to sort of backup what was a simple perception that really wasn't benign when that happened. It was a difficult problem to get out of. And so it's a really simple look back at those cases that had a fail to stage exchange to see what happened to them. And the outcomes were pretty predictable. This is a high morbidity, high mortality disease when there's a periprosthetic  infection, in that patients die and our [00:17:00] data looks like the data from the Mayo Clinic and other big infection centres in that there is a high failure to control the infection rate. Although we were lucky to control the infection in over 50%, there was more than a third of the patients that either required repeated surgery, antibiotics supression, or ablative surgery.

So this is a really complex  group. We need to really understand their prognosis and be able to communicate that with them. And I think it will also feed back into that big discussion that we're starting to have about what the right intervention is for an infected arthroplasty in the first place, rather than a lot of very quickly implant retention, single-stage revision, other procedures may have a role before we escalate up to this level. And we also, as Mathias said earlier, need to look at other forms of both prevention and management of infection. It is still a devastating disease for our patients. 

Absolutely. Absolutely. Anything you would add to that, Dr. [00:18:00] Bostrom at all?

I think, Professor Haddads work is really incredibly important because it highlights how really, truly devastating this is, and even though the gold standard in the United States is two-stage exchange arthroplasty. It may not be the right answer for everyone. And I think we have to start thinking outside of that traditional paradigm, especially here in the United States, elsewhere in the world, they're doing that already as being done in England and Dr. Dot and his group. So it's, you know, I think it's a topic that's not going to go away in the next, five, ten, probably unfortunately,  20 years. But I think we have to think about it differently. 

I totally agree. Yeah, no, I think that, I wish we had a bit more time to discuss it, but I think that's, just running out of time there, [00:19:00] but thank you so much to you both for joining us for our podcast today. And congratulations on a really excellent supplement. Thank you very much, Dr Bostrom for joining us all the way from America. 

Yeah, my pleasure. 

Thank you, Prof, that is great. 

So to our listeners, we do hope you have enjoyed joining us today. We really encourage you to share any of your thoughts or comments through Twitter, Facebook and a like and feel free to post or tweet about anything we've discussed here today or any of our previous podcasts. And thanks again for listening.


Summary of The Hip Society
The peer-review process
The themes this year
The John Charley award
The Frank Stinchfield Award
The Otto Aufranc Award