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The Great Debate 2011 - Hip and Knee Controversies

Josephine

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The Great Debate 2009 A Surgeon’s Perspective

The Great Debate is now in its third year and was once again hosted in the IMAX Theatre at the Science Museum, London. I had eyed the previous two events with a certain jealousy in ‘07 and ‘08, and the gossip amongst previous attendees was that the event was scientifically sparkling, well organised, and here’s the real draw: fun. Definitely one for the 2009 diary; particularly with this year’s faculty.

One of the real draws for me was the interactive voting, which invites analysis and results on-screen seconds after votes are cast. Democracy from rows one to fifty and if you don’t like the speaker, or his choice of metal-on-metal bearing… instant scoring and retribution.

The data showed us that 60% of the audience were Consultants (36% with greater than 10 years experience), and 16% of the audience still in training.

KNEES
Friday’s lectures kicked off with talks from international faculty covering topics such as ‘How can we report knee function?’ and ‘Are very early interventions cost effective?’ Notable speakers included Andrew Amis, speaking authoritatively on kinematics, and Richard Field on clinical follow up at all stages of the patient journey.

From the keypads: “What matters most to you (in arthroplasty scoring)?”
Answer –
Functional: 62% and
Survivorship: 31%.​

We moved on to debates on ACI, MACI and Mosaicplasty with the observation that everything works fine for 1-2 years; finally a great talk from Fares Haddad ending in his call for an ACL Reconstruction Registry, the NARR perhaps..?

Patello-femoral arthroplasty felt the spotlight of peer attention next; the highlight was Philippe Cartier reporting on 115 PFJ replacements followed up for 10-16 years.

Words of wisdom and a fantastic French accent on PFJR and soft tissue balancing. ‘Unis last forever’, true or false? Sounds like the easiest multiple choice question ever, but once again Monsieur Cartier owned-up to 2000 unis over the years 1974 to 1998. His advice: Choose your patients well and when needed revise them to a stemmed tibial component TKR.

Boutique arthroplasty was next with the hardy/gifted/insane faculty on bi-compartmental and tri-compartmental arthroplasties. Stand up and be counted John Skinner with the Deuce implant (S&N) and David Barrett putting in three separate bits of metal for three worn out compartments. I thought I already knew a solution for this… how wrong I was.

Again from the keypads after this lecture: ‘Would you look for patients for these boutique arthroplasties (now)?’ –
No: 39% and
Yes, but I’m not confident: 35%.​

Most fascinatingly from David Beverland’s personal data: - Proportion of patients very happy with their TKR: 4% and THR: 55% - Proportion very unhappy with their TKR: 7%, and THR: 1%

Perhaps the real route to success is a well performed total knee replacement? At the dais Martyn Porter, with the theory that champion surgeons are always going to be the ones reporting great results in the literature. And operations performed on a Friday don’t do quite so well. My analysis: new Consultants tend to be given the Friday list… bias identified!

Bharat Moody spoke of 3000 TKRs with all-poly tibias and the need for >135º flexion in India as a cultural norm. Do we cater for this in the UK? Do we need to? How can I perform a ‘Gold Standard Arthroplasty?’ Is navigation the way forward? Cue a very lively debate, Michael Freeman on a medial pivot/rotation knee, and the audience indicating they were 42% PCL retainers and 21% pivoters. It was gratifying to see how many surgeons were influenced by Freeman, Phil Mitchell and others on the argument for a medial pivot/rotation knee design. We saw an increase in audience voting towards this just from hearing them speak.

Professor Cobb and David Murray slugged it out on navigation, for and against respectively. The result, in three foot high, glorious IMAX characters, “Do you think that navigation makes any difference to clinical outcome?”
Yes: 22%,
don’t know: 14%,
no: 64%.​

The evening dinner was a great chance to chat at leisure with the faculty as we sat in the Flight Gallery on the top floor of the Science Museum. The exhibits there are fascinating with a run-through of major aviation advances from the last 100 years hanging above our heads. Sadly the dinner guests were even more fascinating, and I was drawn away from the Sopwith Camel by someone on my table, who in conversation mentioned he was at MIT just a year below Neil Armstrong. Great food and a memorable evening.

HIPS
Satisfied with having thoroughly debated the blessed knee to death, or at least to a point of intention-to-revise; onto the hip. First up was Koen de Smet from Ghent with ‘My most important lesson’ and a summary of his 3000 hip resurfacings. From the keypads we recorded that 68% of us had performed less than 50 resurfacings, and 72% of us thought the problem with resurfacing MoM is mostly surgeon related. I didn’t see any sign of him giving up MoM, but in general I think it is true to say that the indications are now being refined. Lawrence Dorr from California reinforced the goal of trying to give a patient a “forgotten hip” after surgery; whereby the previously symptomatic joint is now so good that they simply forget it’s there at all and resume life unhindered.

Pseudo-tumour. Whether you like the emotive nomenclature or not, it is here to stay. Is the pseudo-tumour seen after hip surgery a mass or fluid based, a bursa or a neo-inflammatory response? One wonders what the press will make of the term, now that they are so enamoured with terms like Superbug and MRSA. In considering the MoM couple, we heard from Mike Tuke from Finsbury on the pure mechanics of edge loading and inclination of the acetabular cup with a large inner circle bearing surface. Take home message: A MoM cup put in at a true external shell inclination of 45º can actually produce over 54º inclination at the internal articulation, red lights flashing… Despite the complications, my take was that the failure rates are still low and there was no major move away from hip resurfacing or MoM. Indeed Alistair Hart and the Oxford Group are doing a great job to help us understand the pseudo-tumour phenomenon. I thought it was highly significant that when asked, Alister endorsed the use of metal-on-metal.

David Murray’s data highlighted the most powerful predictor of pseudo-tumour was women under 40 years. More red lights flashing. Then a fantastic presentation from Antonio Moroni of the Rizzoli Institute focusing on the limits of resurfacing. He feels he can augment a chamfered short femoral head with 12mm more length made up of bone chips, and then put a resurfacing component on top. Bone cysts in the femoral head? No problem, just fill with bone chips. Audience response in light-hearted, non-keypad feedback was 50/50 either crazy or genius.

The day finished with talk on novel bearing couples, as no post-Charnley meeting should be without. A valiant rebuttal from John Timperley (again) on a hard-on-soft bearing.
Audience response: “Would you use metal-on-metal?”
Yes I would: 67%,
no I wouldn’t: 18% and
don’t know: 15%.​

Who has trouble with squeaking hips? Well, clearly the high volume hip surgeons see more of it, but surgical errors (in technique) were given the nod for a potential cause. “Would you try a novel bearing… now?” we responded 64%: likely or very likely.

The meeting broke and the delegates dispersed and I for one took some very important messages away.

Firstly, The Great Debate has broken the significant inertia barrier in being such a good meeting that not only are the delegates drawn to attend, but the faculty see it as a major meeting on their calendar.

Secondly Finsbury Orthopaedics has done a superb job of marketing and running the event once again. And lastly the early interventions in the hip and knee are broad and fresh in the marketplace of orthopaedics and the registries are going to be the acid test for our patients who want outcomes stretching beyond 20 years. I shall be attending again and would highly recommend it to others.
 

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