BJJ News | I ssue 8 | S eptember 2015
Patellofemoral joint (PFJ) disease was next on the agenda, with Jonathan Eldridge (Bristol NHS Trust, UK) presenting data which oddly suggested more favourable results in younger and older age groups when compared to those in middle-age. David Barrett (Southampton, UK) used extensive video evidence to advance the view that treating the knee compartmentally, with, for example, a UKA and patellofemoral joint arthroplasty (PFJA) results in better kinematics and function than a TKA. Dr. Fitz agreed with this philosophy, but suggested that a patient-specific combined UKA and PFJA might be preferable to individual components. The topic of registry data was hotly debated on both days. Of those present, 75% said that fear of the registry changed the way in which they practiced surgery. Ashley Blom (Bristol, UK) tasked with defending the usefulness and validity of registry data, argued that it provides information based upon real-life results, as opposed to designer or high-volume surgeon series. Widely-voiced concerns by both faculty and audience regarding the limitations of the NJR and its lack of data on basic confounders led to Ashley’s confession that he actually used cementless devices much of the time… Fares Haddad (London) sharpened concerns about the future implementation of limited implant choice within the NHS, and the role registry data might play politically. ‘Generic’ implants were debated on both days, with interest resting on whether there would be a requirement to undergo the same rigorous clinical trials expected of all new implants under ‘Beyond Compliance’. The first day concluded with David Morgan (Queensland, Australia) using an old TV series format, ‘The Hypotheticals’, as a vehicle to explore the murky world of industry and marketing pressures in orthopaedic surgery. With a star-studded cast of world experts all playing a predefined comedy role, a light-hearted medium allowed a serious exploration of the potentially serious conflicts of interest that exist in our profession. Day two started with a discussion on the relative merits of short and long hip stems, including when exactly these terms should be used. Johan Witt (UCH, London) talked delegates through his decision-making process when choosing a hip prosthesis, building a convincing argument for why one stem does not ‘fit all’. Nonetheless, everyone seemed to be in agreement with Tom Schmalzried, who delivered a consistent message throughout a number of these debates - do the operation that has the most reliable results in your hands. Bearing couples were also explored with John Skinner (Stanmore, UK) reviewing registry data results, and Bill Walter presenting his own data supporting the use of ceramic on ceramic. Orhun Muratoglu (Boston, USA), provided an insight into the highly crosslinked polyethylene he has developed, with clinical data supporting significantly improved wear rates at 10 years. He outlined the role vitamin E might have to play, supported by in vitro data, and early clinical results. On the topic of the ideal femoral head size, Bill Walters suggested that the anatomical size was ideal, although there was some discussion as to whether this was necessary given the superior head/neck ratio offered by prosthesis. Iliopsoas impingement was proposed as a significant issue by Orhun Muratoglu, who presented cadaveric data on the use of a novel design of femoral head which tapers towards the neck, potentially reducing deflection of
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the iliopsoas tendon. Bill Waters was first to point out that this deflection occurs in the native hip, where it acts as a natural fulcrum for iliopsoas, suggesting that it was something we might wish to avoid. As this device had not yet reached clinical trial, a yellow card was produced, requesting a pause in this discussion until human data was forthcoming. Technology was considered helpful in the knee, but the audience were less convinced of the need for it in the hip. Robert Barrack reported using a single intraoperative digital radiograph to improve acetabular positioning without detailed planning. Jean-Yves Lazennec (Paris) provided an insight into his extensive use of functional EOS scans, to assess pelvic attitude and lumbar spine mobility as a mechanism to identify patients at high risk of dislocation. Jon Bare (Melbourne, Australia) explained how he now uses three static functional radiographs to create a dynamic model of acetabular loading as a means of personalising acetabular placement to minimise edge loading. Once again a yellow card was raised pending clinical results. For this audience, the popularity of hip resurfacing remained undiminished, with almost 90% of delegates wanting a resurfacing, as long as it was not metal on metal, particularly for active men. A quick-fire video presentation by Mr. Derek McMinn (The McMinn Centre, Birmingham, UK) on the results of his large designer-surgeon series claimed a learning curve of 1000 patients, and again highlighted the difference between this type of highly successful patient series, and the NJR data presented by Ashley Blom. The final debate of the conference centred on productivity and approaches to the hip, in particular the rise of the anterior approach. Adolph Lombardi’s experience in his high-volume practice was that it no longer slowed him up, and patients are able to go home later the same day irrespective of whether he used a lateral or anterior approach; however his impression was of a faster recovery period in the anterior approach group, with similar radiological results. Fares Haddad presented a recent meta-analysis he had conducted on evidence for the anterior approach. In his opinion, any slight early functional benefit was not sufficient to warrant surgeons switching to the anterior approach. Johan Witt explained why he sometimes went anterior and sometimes posterior, while Peter Aldinger (Stuttgart, Germany) told us how he and two colleagues managed 3000 joints a year, by using the same Rottinger anterolateral approach, every time for all-comers. Delegates were all impressed by the industry of both Lombardi and Aldinger, each of whom replace a thousand joints a year, and still have time to come to meetings. Both had staff motivated by productivity. Who knows what the hot topics next year will be? After hearing from highly productive surgeons, doing over four times the number of cases a year, delegates all felt that they could and would work harder, performing more joint replacements in a day, in the right incentive structure. That productivity gain would more than make up for surgeons’ strongly felt desire to use the implants of their choice. So - no to generics, and let us work harder. A good message to take away, until the next Great Debate. A uthor
details
Professor Justin Cobb j.cobb@imperial.ac.uk