Listen to Andrew Duckworth & our Specialty Editor for General Orthopaedics and Editor Emeritus, James Scott, discuss three papers published in The Bone & Joint Journal.
Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention
Tibial shape and size predicts the risk of tibial plateau fracture after cementless unicompartmental knee arthroplasty in Japanese patients
Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty
a multicentre longitudinal observational study using data from the Osteoarthritis Initiative
[00:00:00] Welcome everyone. I am Andrew Duckworth and I'd like to thank you for joining us for one of our special edition podcasts for the month of November. We hope that you've enjoyed our podcasts so far this year, and then you're enjoying all the content from our knowledge translation team here at the BJJ, and that we are achieving our aim to improve the accessibility and visibility of the research and studies we publish here at the journal. As part of this, as many of you know, we're producing special edition podcasts. One of these is the insights from the US series with our amazing guests so far- Professor Heather Vallier chatting about trauma, Professor Matt Abduls joined us to discuss about adult hip and knee recon literature, and coming soon is a great chat with Professor David ring, covering upper limb and the importance of the psychosocial factors in our practice. So I do encourage you to look out for those coming up soon.
The second of our special edition series this year has been with our specialty editors here at the journal. And the aim of these is to sort of give our listeners an insight into the vital work they do here at the journal and what they feel the current recent trends are in their area, as well as maybe highlighting some papers from the past year that we have published.
So today I have the absolute pleasure to welcome for the first time, not only one of our specialty editors [00:01:00] for general orthopaedics, but also our editor Emiratis here at the journal, Mr. James Scott. A huge welcome James. And thank you so much for taking the time to join us today.
Not at all, Andy. Very nice. Thank you for asking me.
Pleasure. So, James I've asked all the specialty editors, so I know obviously you're retired now, but over the past 18 months or so, you know, it's been a strange, difficult time for all of us. Can you sort of gives you a brief overview, I suppose, your own insights of the pandemic, and I suppose predominantly in your role as a specialty editor for general orthopaedics here at the BJJ and your involvement and how you feel that's impacted things over the past year or so.
Well, there were initially more papers because people were doing less work in the hospitals, so they were sending more stuff and there were more papers that had taken longer time to prepare and they took more time to rewrite. My main role in life these days is to rewrite for you. And it's a very great privilege to do it, and I'm very happy to do it. But I noticed during the pandemic suddenly at [00:02:00] the beginning that there were more papers and they were in more depth and more, and they were very interesting and they sort of dried up towards the end as people got back to work. But the essence, why we rewrite became highlighted again for us. What is the purpose of this? Are we actually helping? And in what way are we doing it? And other than that, the great good work that keeps on being sent to the journal was there for all to see. And that was very, very exciting.
That's really interesting. In terms of the rewriting, has that changed over the past few years? Has it become more difficult. Is it easier? Is there anything changed about that at all?
Well, there are many, many things, Andy, which during the last 25 years more that I've been associated with the journal there are very, very, very many things that have changed substantially and wonderfully for that. And maybe we'll, we'll come to some of that. But one thing that very strangely has not changed, well, there are [00:03:00] two things in relation to this. One is the fact that underpins the work of the journal has not changed if you like what used to be called the mission statement. So that although you're reviewing database is absolutely essential and you have to remember that the reviewers are the heroes of the whole business ultimately and of course, authors, you've got to be very nice to your authors and encourage them, but the end product, what you get is for the readership. And it's very important to remember in all our work, particularly when you're rewriting that who are you doing this for? You're not doing it for the authors or for them reviewers. You're doing it for the people that were going to read it. And that has not changed. And I'm rather surprised it hasn't changed 'cause I used to tell Emma that, you know, we're going to stop all this nonsense. It takes up much too much time. And you will very wisely cut me off one of these days and I was absolutely wrong [00:04:00] and she was quite right. It goes on and on and on.
And furthermore, Andy, what is very interesting about the way in which things have changed in the journal is the way in which this material is set out has not changed and you would expect, because of all the phenomenal changes that have happened in methodology and statistics and all of that, that maybe we'll talk a little bit about, but the basic thing that you are reading it doesn't change. And that is a surprise.
So, I mean, we remember one thing which is that each paper, every paper really, only deals with one issue and that issue will be in the last sentence of the introduction. The method that it is chosen, they've chosen to ask this question. It will be in the method. The results will be in the results and the discussion of it will be in the discussion. And that absolutely hasn't changed. It's a little bit different of course, with open access material, but basically the readers of the BJJ get the material [00:05:00] presented in exactly the same way as has happened through the years.
And this of course began in 48 with Watson Jones. Very, very, very beautiful, clear writing. And that was again and again by John Adams and by Frank Horan who I started with. But the issue then was, when Frank and I did it, every paper was rewritten twice.
So when it was decided that the paper was to be published, he did half and I did half. And then they went off to the office and when they came back, I did the ones that he had done first or the other way round. And I thought when I became editor, this is nonsense. Really all this stuff. It's so time consuming. And anyway, on it goes and Emma was, Emma was absolutely right. And it's very important that. And my guess is that we may be the only journal in the world that allows old fools to tamper with the material on and on and on.
No, no, I [00:06:00] think that's fascinating and really interesting, like you say, that it's interesting things that have not changed and that things that hold firm and stand the test of time, I suppose. And I suppose that leads us on nicely. I think, I mean, one thing I wanted to spend quite a lot of time talking about today is how you feel that the journal has evolved in other areas over the past couple of decades. Cause I know you've been involved with the journal for 20, 30 years now with the editorial board, the editor and editor emiratus now, what do you feel have been the big changes, you know, that you've really noticed and that I hope often for the better?
All the major changes have happened since I left, I think. I may have been holding a lot of them back, but the changes have been absolutely fantastic and all for the better. I mean you must stop me if I'm boring, but at the very beginning, my first involvement with the journal, was as a reviewer of course. And in those days you got a big white envelope with a paper in it to [00:07:00] review, and they seemed almost always to come at the end of the week on a Friday. So when you went into the hospital on a Saturday, you took your paper to review and you went to the library, of course, because you know, there wasn't the internet and you would look up all the stuff in the library.
But then now when I then started working at the journal, the nature of the journal was of course, very, very, very different to what it is now. I mean totally different title apart from anything else. But the material was very differently done. We had the papers at the front and then at the back, there was a lot of traditional stuff. There were abituaries, letters to the editor, book reviews, notice of meetings. I mean, just stuff that was very, very, very traditional and the papers at the front, now I look back at it, the quality of them was very low. I mean, they will retrospective, case [00:08:00] series, cohort studies. I mean, all observational and there was an occasional case report, of course, which was very exciting. I used to love putting in case reports. And that material all came from a very, very traditional, basic platform of people. There would be those from America, from the UK, a lot from institutions, well-known institutions in Europe and a bit from Commonwealth Canada, Australia, New Zealand. And this was the tradition. This was how it had been for years and years and years. And while during the time that I was editor, the material from America went down quite a bit, partially because of the politics of orthopaedics in American's relationship with the JBJS and with the academy. And partly because of the upcoming separation, which I have to say, I was very much in favour of it. And I was sorry, in retrospect that it took such a long time. And why was I so much in favour, but predominantly, because it seemed to [00:09:00] us that the American journal was becoming, because of local politics, there's becoming more and more American centric, if you like. And I wanted to get more international stuff and Emma was keen to help with that. And I started visiting places, went to India and China and the stuff when I first went to see *inaudible*, what they were doing with trauma, with general orthopaedics, particularly pediatrics, and what George Anderson was doing at the centre in Velour. And that was absolutely thrilling to me. And I wanted to get some of that stuff going and generate it ourselves. So that was nice.
And then remember that in those days, of course it was a general journal, it was very difficult to get material, good material in the subspecialties.
Very few good papers came in hand surgery. And I mean, the fact that now that [00:10:00] there are prospective randomized controlled trials in trauma it's of course absolutely fantastic. I mean, I have to note that that of course started in Canada with Rick Buckley and that lot.
Anyway, so it was difficult to get good papers. And what Fares and Emma have been able to do is fantastically is to not only increase very dramaticly the quality of the papers submitted, but increase them across the board so that now there are very, very good methodological papers in the subspecialties and that speaks volumes for them. And of course started very early on with the subspecialty editors, which was a very, very, very good move. So we have a lot to be grateful to them for. And this also brings to the for a very, very, very fundamental question about the work of the BJJ, which is of course the place that was general orthopedic journal. Is there such a thing? Is it required because you know [00:11:00] specializing much younger and going rightly off your specialist journals. And is there a need? And of course, what Fares and Emma have been able to do is to show absolutely they were on the right track completely. And that this journal is completely holy, absolutely needed. And the fact that that the impact factor is now more than five is fantastic for great, wonderful achievement.
So the main ways in which it has changed is that the failure of the whole thing has changed and the quality has shot up and all that old stuff has gone. So there aren't all that, all that stuff at the back, those are all the ways in which it has changed fabulously for the good and the ways that it has not changed bar that there are old people like me allowed to continue interfering with prize material.
That's really fascinating James how It's been quite a [00:12:00] rapid change, hasn't it? You know, even over the past 10 years, the quality of the methodology, like you say, across all the, all the subspecialty areas of orthopaedics has just shot up so rapidly. And it's almost a self perpetuating thing, isn't it? You know, people see it being done. People believe they can do it as well, and they can do it. And it all, it's a snowball effect that in like you say the quality across the board now is quite extraordinary. Isn't it?
Well, I think that most of that has happened in the last 10 years. Most of that has happened since I've gone and most of that has happened because of various factors Fares and Emma got on with it. And I had started something when I was editor. I started something called reviewers days because I actually, although I had reviewed a bit, I didn't really feel that I was confident as a reviewer or that I knew enough to be in the position that I was in. So I got reviewers days going and, and they have been very, very, very successful as you know, and out of those days came concentration on aspect of methodology in [00:13:00] our statistics and all of that stuff. And out of those days came the next generation of people like Andy Duckworth, for instance and Matt and Ben, and I mean, all that, you know, who have contributed phenomenally to the increase in the quality of the material in our journal and continues so to do.
That's very kind, I think, you're right, that those research while they were reviewers days, like you say, and I remember going on one myself and now there are research methods and reviewing sort of course. And what they have added, it's really remarkable.
So if we sort of move on from the history of the journal, James, I know you've picked a few highlight papers for us, and I just thought we'd sort of touch on these briefly if that's okay. The first is the multicentre longitudinal observational study from the Netherlands that uses data from the osteoarthritis initiative. And that was to assess whether the patients with or at risk of developing symptomatic OA of the knee who received a steroid injection have an increased risk of requiring arthoplasty. And what made you sort of highlight this paper, James in particular?
Well,[00:14:00] I'm very interested of course in big data and I have a trouble with big data. When I was editor and starting to get seen as statistical advice, the question, how many people need to be asked what question over what period of time to get an answer that will have clinical significance, those sorts of questions became very interesting to me and I had problem with them. And increasingly as I need not remind you, people like Aviva Petrie would say every study needs a past study. And if you do past studies retrospectively suddenly on ordinary case series, you will find more often that there are too many patients in the study than there are too few. So I was always suspicious of big data because I was impressed with the statisticians view that only a certain number of people [00:15:00] I needed to ask to answer a question.
And then when meta-analysis and systematic analysis came along, I thought this must be an answer here. The statisticians, if you pool enough data, you must get something that has more statistical evidence and therefore, hopefully, maybe more clinical evidence, but in fact, that didn't happen. And when I was editor, increasingly we got meta-analyses because of course they are not so difficult to do, although time-consuming.
But the number of times that I looked at a meta-analysis and I said to myself, if we publish this, this conclusion will change clinical practice was very, very, very rare and so are suspicious and worried about big data.
But nowadays of course, the main issue is the quality of the data has changed. So, for instance, in registers, you know, you've got PROM [00:16:00] stuff and there's just much more that is of interest when pooled and therefore I, like this paper because I'm now interested in it in big data. And it seems to me that it was a straightforward issue. And what I liked about it was the straightforwardness that it was large, it was multicenter it involved problems, data. It asked one question - does this injection of steroid in a mean that you are more likely over quite a long period of time to require a knee replacement? And the answer is yes. And there wasn't that much radiology involved. And you could think that that was a limitation of the paper, but it was very nicely set out. It was better set out after it had been rewritten. It was nicely set out. The question was asked. It was a big multicentre trial, a lot of people, all the data, the PROMs were relevant, it seemed to me. They ask the question and they answer it. [00:17:00] Does this increase the chances of needing knee replacement? Yes. I liked that. I just liked the simplicity.
Yeah, no, I, I totally agree. Isn't it often when you read papers and we have a tendency to do that cause there is more statistical analysis performed these days and everything, but what is nice is that relatively straight forward question, that then is answered. It's very nice that when you read it, isn't it? It just, it makes it makes sense.
Those were always the papers I was looking for really as editor. Have you got a simple question? Have you got simple methodology? Have you got rather limited statistics? Have you got your answer? Will it change practice? And that, that hasn't changed. I mean, I'm not sure that this of will change practice, but maybe we'll think twice about, I dunno. Well, I liked it for all those reasons.
Well I think that's right. Isn't it? I think it necessarily these papers do not necessarily give you the total answer, but they raised the question don't they? They make people think and they may be, they think people do more research and that's, that's great. Isn't it? It doesn't have to give you that definitive answer. [00:18:00]
I remember there being an awful lot of papers on this question in the past that were sent to me and very, very, very few were methodologically sound and were just, as you say, simple, straightforward.
Yeah. Yeah. No, absolutely. So if we move on James, I was gonna move on to the second paper that it was the one from Japan. And then sort of highlighting sort of the international reach of the journal.
Again, it's a multicentre study reporting on 212 cementless Oxfords uni knees, which were undertaken in 174 patients in six hospitals with the aim of the study to determine this when cementless tibial components could be safer used in Japanese patients based on the size and shape of the tibia. I thought this was really interesting. I actually hadn't read this study before you'd highlighted it to me, but I thought this was really interesting.
Well, I like this for old fashioned reasons. I remember when I first went to Japan, one of the first times that I went, there was a meeting of the knee section at a Japanese meeting [00:19:00] and suddenly I saw all this tibia vera in adults with a very, very, very prominent beak sort of thing on the medial tibial plateau and the rest of the knee was fine. And it seemed that this was very, very, very, very common in Japan. And at that time, we were getting an awful lot of papers about kadka. All this stuff, you know, the whole future of after plastic surgery is going to be transformed by this stuff. You show this joint to a 3D computer model it will make a model of what you need to put in its place. And that's obvious.
I thought looking at this, this is the answer. I wonder what David Murray is going to do with this funny shape there. And I've been wondering ever since and there it is. A very, very, very nice straightforward paper that tells me exactly what anybody would be doing with this problem. And I've, every so often at night, turned over in bed and thought, I wonder what the hell is going on with these Japanese medial compartment of [00:20:00] patients with OA? And there it is, again, a finished straight forward paper and nicely big centre.
And well illustrated and very well rewritten giving you a very simple message.
I just liked it.
I think that's right. And again, it shows not only the importance of getting data from across the world, doesn't it? And how relevant that is and how different potentially practice can be across the world. And that's a great insight for, for me as well.
Absolutely. It's wonderful that all those centres were involved. We had it.
No, I, I agree. So if we move on to this, the final paper you kind of picked for us, which is actually from some of my colleagues here in Edinburgh, that was from our shoulder team here, which was a 10 year view of almost two and a half thousand distension off the grounds for the treatment of a TC capitalized to the shoulder. And the aim of that was to determine the efficacy of the procedure, you know, sort of what factors affected recurrence. So what sort of made you pick this paper out, James?
I absolutely loved this paper again for very old fashioned reasons. [00:21:00] I remember when we first got a paper about distention arthrography of the shoulder and I thought for God's sake, honestly what are we doing putting a needle in the shoulder and blowing up the capsule and telling me that will make people feel better. I said, don't be stupid. You lads in Edinburgh. And so I think I may have turned down an awful lot papers. Anyway, and here it is. Absolutely very, very, very well set out and you do need more. You need 50 rather than 30ml. And it absolutely works and it seems to be astonishing. And I liked it for all those reasons and I felt appalled that I felt so, so cynical and critical about those early papers. And I wanted to apologize to the good Mr. Robinson.
That's very good. I know it's interesting. And then I think there's like, you know, like you say, key take-home messages if you use this, you know, the, what was there? Arthroscopic reduced rate was 1.7% across the...
It's amazing. And for that long period of time, because you would think at least the catch [00:22:00] will get stuck back again.
Yeah, absolutely. Isn't it. And it's, I like you say again, a simple message, very simple technique. It works.
So moving on from the papers, just to finish off James, you know what do you, I suppose, what'd you see the challenges are ahead, I suppose, not only maybe for research, what of our next steps, but also what's next for the journal do you think?
Well, I think the journal is in a fantastically strong place now and very, very lucky to have you all doing all this wonderful stuff. There are hidden problems that will go on like open access, for instance, will go on and on and on forever. And I don't know what the answer is. I mean, I suspect that some aspects of open access will be of very great interest to some research workers. I mean, not so much in the [00:23:00] clinical field as in the engineering field or the genetic field or the biochemical field, because of the way in which those workers work. They need their answers quickly. And it shouldn't be difficult for open access to answer their problems. And I'm sure that that will continue like that.
The other issues. Whether they will go on being a need for general orthopaedic journal is being answered. Whether how many people will want to be looking at it online and how many will want to be having it hard copies. That will, that will continue. And I'm not sure that it matters. That argument will turn out. I think that there are terribly important issues that have always been the one thing that really worries me is the relationship between the journal and training programmes, because there's so much that the journal ought to be involved with training [00:24:00] programmes and it just seems too difficult. And you're all too busy. And the time that is set aside, you see, we have journal clubs and all that stuff, which was such fun. And all our bosses came. God, you looked at the journal carefully in those days. Well, quite carefully. And I've always been very sad about that and I don't know what the answer is and I dunno, maybe there isn't an answer, but we need to think about the trainees, all the way, all the way, all the way, because they hopefully will be the people who run the journal in the future, of course, and, and the people who will determine the, the the, the style of clinical practice, you know.
Absolutely. They're the future. Absolutely. Well, James, I think that's all we have time for, but thank you so much for your excellent overview of not only the specialty area, but a really amazing insights into the recent history of the journal and how it's evolved over the past few decades.
It was fantastic to talk to you really interesting and informative and thanks so much for joining [00:25:00] us and our listeners. We do hope you've enjoyed joining us today. Feel free to tweet a post about anything we have chatted about today. Thanks for listening and take care everyone.