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Notes from the road
Generics, registries and surgeon choice: the Great Debate 2015
Fig. 1 The faculty
he hot topics at this year’s Great Debate were more political than ever. Three issues recurred throughout the meeting: how do conclusions from registries impact on decision-making, what should drive a surgeon’s choice of procedure and implant, and how as a profession should we compare generic and branded devices? Following a combined meeting with EFORT in Docklands last year, the 2015 Debate returned upriver to the Mermaid Conference Centre, London, where four brief presentations acted as the catalyst for 35 minutes of debate, drawing in presenters, faculty and delegates, who used Twitter and 2poll to let the faculty know their opinion. Under direct questioning, experts had to admit whether they practiced what they preach. This year, Professor Ashley Blom won over the audience by admitting that he only uses cement half the time on the acetabular side, despite giving a registry-focussed tour de force in favour of cement for everyone and everything. Day one belonged to the knee. The audience involved itself from the start, using a mobile-friendly web tool to vote on forthcoming points of discussion. This provided a useful barometer for the faculty; to be forewarned is to be forearmed. Simultaneously, the Twitter feed sprang into life, and provided direct contact between audience and chairmen. The first session focussed on the design of total knee prostheses, with Jan Victor (Ghent, Belgium) in the PCL-retaining corner, Tom Schmalzried (Los Angeles, USA) in the posterior-stabilised corner, and William Walter (Sydney, Australia) contending that a medial pivot design was ready for prime time. Adolph Lombardi (Ohio, USA) admitted a direct conflict of interest when reporting on the bicruciate-retaining TKA. Preliminary results of his multicentre trial suggested no better or worse results than in patients with a cruciate-retaining knee design at this early stage of the trial, while the superior AP stability of the medial pivot was convincingly demonstrated using delegate-rated videos of Lachman, and anterior drawer tests. This prompted a discussion about the limitations of PROMs to detect differences between implants and techniques, and a consensus demand for more sensitive
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J. Cobb G. Jones A. Shimmin
Fig. 2 GIRFT and TGD
patient-specific outcome measures as well as a greater emphasis on objective measures of outcome, such as gait analysis. Next up was surgical technology and planning. Using the 2poll system, almost 90% of those voting saw no future for robotics in arthroplasty. This set the scene for Jan Victor who predicted that a new generation of user-friendly software, increasingly compact equipment and an intuitive workflow, would lead to a renaissance in the use of navigation, but not robotics. Dr Lombardi then made a persuasive argument for using patient-specific instruments instead which, in his hands, improved alignment and enhanced operating room efficiency. Wolfgang Fitz (Boston, USA) contended that efforts to improve prosthesis alignment alone have been superseded by custom implants based on patients’ native anatomy. It is a truism that technological advances designed to help surgeons execute a pre-operative plan will be limited by the quality of the plan itself. In this context Robert Barrack (St Louis, USA) argued persuasively for a more physiological alignment of TKAs, cutting the tibia in three degrees of varus. However, Adolph Lombardi and Jan Victor both felt that the human eye can judge 90° to the vertical more easily than it can 87°. So, arguably, unless technology is being used to guide bone cuts, a 90° cut combined with a lateral to medial sloped polyethylene insert, as used by Professor Victor, may be a safer option. The session on the unicompartmental knee (UKA) had speakers from France, Germany and Southampton; the word “Oxford” was barely mentioned… surely a first. Jean-Noel Argenson (Marseilles, France) reported on the 30-year results of UKA in terms of function and durability. Klaus Schutter-Brust (Cologne, Germany) reported his minimum 10-year results of uncemented meniscal bearing UKAs, which were even more successful on the lateral side than the medial. David Barrett explained that any difference in the performance of fixed and mobile bearings was dwarfed by the importance of recognising that there was a place for the procedure, and actually carrying it out correctly.
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