EDITORIAL
Progress through collaboration
F. S. Haddad, L. Zagra From The British Editorial Society of Bone & Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK. L. Zagra, MD, Head, Hip Department Istituto Ortopedico Galeazzi IRCCS, Via R. Galeazzi 4, 20161, Milan, Italy. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2016 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.98B2. 37881 $2.00 Bone Joint J 2016;98-B:145–6.
In November 2015 the British Hip Society and the Italian Hip Society (Società Italiana dell’Anca) combined to hold a first ever joint meeting. We had the privilege of co-chairing this and we have both reflected on the many positives that can be seen from combining intellects and experiences from different cultures. This editorial briefly summarises some the highlights of that meeting with particular reference to work that we have seen in The Bone & Joint Journal in recent months. The continued debate around implant fixation and bearing surfaces generates great emotion and tremendous tribal rivalries. It was clear that the big United Kingdom and Scandinavian push for cemented implants which is changing practice in the United Kingdom and some parts of the world for the elderly population, has yet to gain ground in Italy where cementless implants are favoured. The pros and cons of both have been well covered in recent literature,1-3 but there are undoubtedly areas where more research is needed, particularly in relation to the economics of the use of each type of fixation both in terms of operative time and use of the very valuable hospital facilities, as well as an assessment over the lifetime of the patient rather than medium-term followup which is what is currently covered by registries. The audience was left with a clear message that, if used correctly, many implants and techniques can be made to work and that none are suitable for all patients and all seasons. There is also a great need for robust research and clinical trials on “emerging” short stems and new designs.4 The interpretation of fixation data and implant survivorship is predicated upon an understanding of the bearing surfaces used as the last two decades have clearly shown. Metal-on-metal (MOM) has seen some success with resurfacing, but only in a highly selected group of patients, and the use of hip resurfacing in both the United Kingdom and Italy seems to have decreased dramatically even if never very popular in the latter. The use of
VOL. 98-B, No. 2, FEBRUARY 2016
large head MOM hip arthroplasties has effectively ceased based on very strong data and our understanding of corrosion issues.5-7 Only time will tell what types and sizes of ceramic and new polyethylenes with or without vitamin E, are optimal, or whether a ceramic-onceramic bearing is worth the risks that have been well documented, particularly of noise and fracture, or whether novel bearings such as Oxidised zirconium will have an increasing role to play.8-12 The issue of modularity and recent research on corrosion was very much at the heart of the meeting. Modular stems have been very popular in Italy, although the evidence is really starting to mount against their routine use as we still cannot predict completely which cases will or will not suffer corrosion-related complications or breakage.13 Registry data was discussed in great detail. It was a great opportunity for surgeons coming from a country like Italy where the registries are on regional basis and the national one is still in progress, to interface with the longer United Kingdom and Scandanavian experiences. There is a great deal to be learnt from current registry data, particularly as some registries are increasingly being validated and longer-term data is becoming available.14 The differences between registries, however, are fairly dramatic, and harmonisation over the next decade will be a great bonus that will allow us to cross-reference across different populations. It is also important to bear in mind, as illustrated by many presentations in this meeting and some recent papers, that registry data represents one key outcome measure which is survivorship. There are others that can be linked in such as Hospital Episode data or patient-reported outcomes, but ultimately some functional outcome data also needs to be factored in. Another great focus of the meeting was infection. There appears to be an increasing move towards single stage revision across both Italy and the United Kingdom compared with 145
146
F. S. HADDAD, L. ZAGRA
the well-established two-stage approach, but developments are clearly needed in many areas including prevention, host stratification and optimisation, implant selection, surgical technique, implant modification and coating, antibiotic prophylaxis, post-operative care including wound management and interventions both to diagnose and treat infection once it occurs.15 This type of meeting was a very good opportunity also for “third” parties such as industry. For the companies it was a unique opportunity to meet surgeons from different countries, and generated collaboration and opportunities for research in different settings and environments. There were also opportunities to compare the political, economic and regulatory landscape across Europe and to introduce trainers and the trainees, to alternative training concepts. While the aforementioned issues will undoubtedly remain key debating points over the next few years, the model of bringing disparate societies together in order to generate debate, discussion, consensus and future collaboration is one that appears to be very fruitful and should probably be replicated worldwide both for scientific, educational and social purposes.
References 1. Syed MA, Hutt NJ, Shah N, Edge AJ. Hydroxyapatite ceramic-coated femoral components in young patients followed up for 17 to 25 years: an update of a previous report. Bone Joint J 2015;97-B:749–754. 2. Pennington MW, Grieve R, van der Meulen JH. Lifetime cost effectiveness of different brands of prosthesis used for total hip arthroplasty. Bone Joint J 2015;97B:762–770. 3. Biemond JE, Venkatesan S, van Hellemondt GG. Survivorship of the cementless Spotorno femoral component in patients under 50 years of age at a mean follow-up of 18.4 years. Bone Joint J 2015;97-B:160–163.
4. McCalden RW, Korczak A, Somerville L, Yuan X, Naudie DD. A randomised trial comparing a short and a standard-length metaphyseal engaging cementless femoral stem using radiostereometric analysis. Bone Joint J 2015;97-B:595–602. 5. Matharu GS, Pynsent PB, Sumathi VP, et al. Predictors of time to revision and clinical outcomes following revision of metal-on-metal hip replacements for adverse reaction to metal debris. Bone Joint J 2014;96-B:1600–1609. 6. Lainiala O, Eskelinen A, Elo P, et al. Adverse reaction to metal debris is more common in patients following MoM total hip replacement with a 36 mm femoral head than previously thought: results from a modern MoM follow-up programme. Bone Joint J 2014;96-B:1610–1617. 7. Berber R, Skinner J, Board T, et al. International metal-on-metal multidisciplinary teams: do we manage metal-on-metal hip patients the same way? An analysis from the International Specialist Centre Collaboration on MOM Hips (ISCCoMH). Bone Joint J 2016;98-B:. 8. Langlois J, Atlan F, Scemama C, Courpied JP, Hamadouche M. A randomised controlled trial comparing highly cross-linked and contemporary annealed polyethylene after a minimal eight-year follow-up in total hip arthroplasty using cemented acetabular components. Bone Joint J 2015;97-B:1458–1462. 9. Jonsson BA, Kadar T, Havelin LI, et al. Oxinium modular femoral heads do not reduce polyethylene wear in cemented total hip arthroplasty at five years: a randomised trial of 120 hips using radiostereometric analysis. Bone Joint J 2015;97B:1463–1469. 10. Selvarajah E, Hooper G, Grabowski K, et al. The rates of wear of X3 highly crosslinked polyethylene at five years when coupled with a 36 mm diameter ceramic femoral head in young patients. Bone Joint J 2015;97-B:1470–1474. 11. Bisseling P, de Wit BWK, Hol AM, et al. Similar incidence of periprosthetic fluid collections after ceramic-on-polyethylene total hip arthroplasties and metal-on-metal resurfacing arthroplasties: results of a screening metal artefact reduction sequenceMRI study. Bone Joint J 2015;97-B:1175–1182. 12. Jassim SS, Patel S, Wardle N, et al. Five-year comparison of wear using oxidised zirconium and cobalt-chrome femoral heads in total hip arthroplasty: a multicentre randomised controlled trial. Bone Joint J 2015;97-B:883–889. 13. Whitehouse MR, Endo M, Zachara S, et al. Adverse local tissue reactions in metal-on-polyethylene total hip arthroplasty due to trunnion corrosion: the risk of misdiagnosis. Bone Joint J 2015;97-B:1024–1030. 14. Sabah SA, Henckel J, Cook E, et al. Validation of primary metal-on-metal hip arthroplasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant Retrieval Centre: a study using the NJR dataset. Bone Joint J 2015;97-B:10–18. 15. Parvizi J, Haddad FS. Periprosthetic joint infection: the last frontier. Bone Joint J 2015;97-B:1157–1158.
THE BONE & JOINT JOURNAL
Progress through collaboration
F. S. Haddad, L. Zagra From The British Editorial Society of Bone & Joint Surgery, London, United Kingdom
F. S. Haddad, BSc MD (Res), FRCS (Tr&Orth), Professor of Orthopaedic Surgery, Editor-inChief The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK. L. Zagra, MD, Head, Hip Department Istituto Ortopedico Galeazzi IRCCS, Via R. Galeazzi 4, 20161, Milan, Italy. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2016 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.98B2. 37881 $2.00 Bone Joint J 2016;98-B:145–6.
In November 2015 the British Hip Society and the Italian Hip Society (Società Italiana dell’Anca) combined to hold a first ever joint meeting. We had the privilege of co-chairing this and we have both reflected on the many positives that can be seen from combining intellects and experiences from different cultures. This editorial briefly summarises some the highlights of that meeting with particular reference to work that we have seen in The Bone & Joint Journal in recent months. The continued debate around implant fixation and bearing surfaces generates great emotion and tremendous tribal rivalries. It was clear that the big United Kingdom and Scandinavian push for cemented implants which is changing practice in the United Kingdom and some parts of the world for the elderly population, has yet to gain ground in Italy where cementless implants are favoured. The pros and cons of both have been well covered in recent literature,1-3 but there are undoubtedly areas where more research is needed, particularly in relation to the economics of the use of each type of fixation both in terms of operative time and use of the very valuable hospital facilities, as well as an assessment over the lifetime of the patient rather than medium-term followup which is what is currently covered by registries. The audience was left with a clear message that, if used correctly, many implants and techniques can be made to work and that none are suitable for all patients and all seasons. There is also a great need for robust research and clinical trials on “emerging” short stems and new designs.4 The interpretation of fixation data and implant survivorship is predicated upon an understanding of the bearing surfaces used as the last two decades have clearly shown. Metal-on-metal (MOM) has seen some success with resurfacing, but only in a highly selected group of patients, and the use of hip resurfacing in both the United Kingdom and Italy seems to have decreased dramatically even if never very popular in the latter. The use of
VOL. 98-B, No. 2, FEBRUARY 2016
large head MOM hip arthroplasties has effectively ceased based on very strong data and our understanding of corrosion issues.5-7 Only time will tell what types and sizes of ceramic and new polyethylenes with or without vitamin E, are optimal, or whether a ceramic-onceramic bearing is worth the risks that have been well documented, particularly of noise and fracture, or whether novel bearings such as Oxidised zirconium will have an increasing role to play.8-12 The issue of modularity and recent research on corrosion was very much at the heart of the meeting. Modular stems have been very popular in Italy, although the evidence is really starting to mount against their routine use as we still cannot predict completely which cases will or will not suffer corrosion-related complications or breakage.13 Registry data was discussed in great detail. It was a great opportunity for surgeons coming from a country like Italy where the registries are on regional basis and the national one is still in progress, to interface with the longer United Kingdom and Scandanavian experiences. There is a great deal to be learnt from current registry data, particularly as some registries are increasingly being validated and longer-term data is becoming available.14 The differences between registries, however, are fairly dramatic, and harmonisation over the next decade will be a great bonus that will allow us to cross-reference across different populations. It is also important to bear in mind, as illustrated by many presentations in this meeting and some recent papers, that registry data represents one key outcome measure which is survivorship. There are others that can be linked in such as Hospital Episode data or patient-reported outcomes, but ultimately some functional outcome data also needs to be factored in. Another great focus of the meeting was infection. There appears to be an increasing move towards single stage revision across both Italy and the United Kingdom compared with 145
146
F. S. HADDAD, L. ZAGRA
the well-established two-stage approach, but developments are clearly needed in many areas including prevention, host stratification and optimisation, implant selection, surgical technique, implant modification and coating, antibiotic prophylaxis, post-operative care including wound management and interventions both to diagnose and treat infection once it occurs.15 This type of meeting was a very good opportunity also for “third” parties such as industry. For the companies it was a unique opportunity to meet surgeons from different countries, and generated collaboration and opportunities for research in different settings and environments. There were also opportunities to compare the political, economic and regulatory landscape across Europe and to introduce trainers and the trainees, to alternative training concepts. While the aforementioned issues will undoubtedly remain key debating points over the next few years, the model of bringing disparate societies together in order to generate debate, discussion, consensus and future collaboration is one that appears to be very fruitful and should probably be replicated worldwide both for scientific, educational and social purposes.
References 1. Syed MA, Hutt NJ, Shah N, Edge AJ. Hydroxyapatite ceramic-coated femoral components in young patients followed up for 17 to 25 years: an update of a previous report. Bone Joint J 2015;97-B:749–754. 2. Pennington MW, Grieve R, van der Meulen JH. Lifetime cost effectiveness of different brands of prosthesis used for total hip arthroplasty. Bone Joint J 2015;97B:762–770. 3. Biemond JE, Venkatesan S, van Hellemondt GG. Survivorship of the cementless Spotorno femoral component in patients under 50 years of age at a mean follow-up of 18.4 years. Bone Joint J 2015;97-B:160–163.
4. McCalden RW, Korczak A, Somerville L, Yuan X, Naudie DD. A randomised trial comparing a short and a standard-length metaphyseal engaging cementless femoral stem using radiostereometric analysis. Bone Joint J 2015;97-B:595–602. 5. Matharu GS, Pynsent PB, Sumathi VP, et al. Predictors of time to revision and clinical outcomes following revision of metal-on-metal hip replacements for adverse reaction to metal debris. Bone Joint J 2014;96-B:1600–1609. 6. Lainiala O, Eskelinen A, Elo P, et al. Adverse reaction to metal debris is more common in patients following MoM total hip replacement with a 36 mm femoral head than previously thought: results from a modern MoM follow-up programme. Bone Joint J 2014;96-B:1610–1617. 7. Berber R, Skinner J, Board T, et al. International metal-on-metal multidisciplinary teams: do we manage metal-on-metal hip patients the same way? An analysis from the International Specialist Centre Collaboration on MOM Hips (ISCCoMH). Bone Joint J 2016;98-B:. 8. Langlois J, Atlan F, Scemama C, Courpied JP, Hamadouche M. A randomised controlled trial comparing highly cross-linked and contemporary annealed polyethylene after a minimal eight-year follow-up in total hip arthroplasty using cemented acetabular components. Bone Joint J 2015;97-B:1458–1462. 9. Jonsson BA, Kadar T, Havelin LI, et al. Oxinium modular femoral heads do not reduce polyethylene wear in cemented total hip arthroplasty at five years: a randomised trial of 120 hips using radiostereometric analysis. Bone Joint J 2015;97B:1463–1469. 10. Selvarajah E, Hooper G, Grabowski K, et al. The rates of wear of X3 highly crosslinked polyethylene at five years when coupled with a 36 mm diameter ceramic femoral head in young patients. Bone Joint J 2015;97-B:1470–1474. 11. Bisseling P, de Wit BWK, Hol AM, et al. Similar incidence of periprosthetic fluid collections after ceramic-on-polyethylene total hip arthroplasties and metal-on-metal resurfacing arthroplasties: results of a screening metal artefact reduction sequenceMRI study. Bone Joint J 2015;97-B:1175–1182. 12. Jassim SS, Patel S, Wardle N, et al. Five-year comparison of wear using oxidised zirconium and cobalt-chrome femoral heads in total hip arthroplasty: a multicentre randomised controlled trial. Bone Joint J 2015;97-B:883–889. 13. Whitehouse MR, Endo M, Zachara S, et al. Adverse local tissue reactions in metal-on-polyethylene total hip arthroplasty due to trunnion corrosion: the risk of misdiagnosis. Bone Joint J 2015;97-B:1024–1030. 14. Sabah SA, Henckel J, Cook E, et al. Validation of primary metal-on-metal hip arthroplasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant Retrieval Centre: a study using the NJR dataset. Bone Joint J 2015;97-B:10–18. 15. Parvizi J, Haddad FS. Periprosthetic joint infection: the last frontier. Bone Joint J 2015;97-B:1157–1158.
THE BONE & JOINT JOURNAL
