In a profession where good evidence can be hard to come by, consensus is formed by forceful argument. And so it was at The Great Debate, held at the Science Museum in South Kensington, London on January 18th-19th 2008. The theme was early intervention in the hip and knee, and the topics covered nearly all aspects of knee and hip replacement with respect to the younger patient. Professor Justin Cobb, the chairman, had gathered a selection of national and international experts in all the relevant fields, and we the onlookers, were to witness a fine display of intellectual thrust and parry, mixed with occasional flat denial. At various points Professor Cobb would ask the audience a question, to which we responded on our interactive key-pads, and the results were immediately displayed on a giant screen (and I do mean giant; the event was held in an IMAX theatre)!
I was surprised at the mix of delegates; as a junior surgeon, I had been attracted by the prospect of hearing opinion-leaders defending their corners; there is nothing better for grasping the current state of ideas than to witness, and take part in, reasoned argument and discussion about those ideas. However, less than a quarter of the delegates were of trainee rank; consultants and SAS grades made up the majority, probably another indication of how much of the discussion was at the cutting edge level.
Firstly, we looked at the knee, beginning with the role of high tibial osteotomy and debridement, as well as arthrosurfacing. This was more a presentation of options rather than competition of superiority of one technique over another. We then heard about unicompartmental arthroplasty, with some debate as to bearing type and comparison with total arthroplasty. Turning to the patellofemoral joint, two competing designs were presented, both from Bristol, with Mr Christopher Ackroyd championing the Avon, and Mr John Newman the Journey, which seems to have some possible improvement for the future, but lacks the length of follow-up of its older brother.
There was then a consideration of the ACL-deficient knee. Mr Andrew Williams presented the case for meniscal allograft and reconstruction, despite not having performed one. Nevertheless he made a good case for watching that particular space. Mr Fares Haddad spoke about HTO and reconstruction and Mr Christopher Dodd UKA and reconstruction, with Professor Johan Bellemans from Belgium finally making the case for TKR. The knee session then came to a close after discussion on the options in bi- and tri-compartmental OA. Professor David Murray showed how patellofemoral OA is not a contraindication to UKA, while Professor Norberto Confalonieri from Italy demonstrated successful bicompartmental UKAs and Mr Martin Porter stuck with total arthroplasty.
At this point the debate became exothermic as navigation took centre stage. Arguing forcefully that it is unnecessary in knees and hips were Professor David Murray and Miss Sarah Muirhead-Allwood, against confirmed navigators Mr Ajeya Adhikari and Professor Scott Banks. I found this debate extremely interesting as strong personal opinions added an extra tension. The messages I took home were that at present, navigation probably has no advantage over the specialist high-volume arthroplastist, but may well have a role in assisting lower-volume surgeons. It would have been interesting for such a surgeon to have taken part as well, and I also wondered what might happen in the future if trainees learn with navigation and possibly never gain the ability to drive freehand.
One of the hot topics in orthopaedics at present is hip arthroscopy and treatment of femoro-acetabular impingement, and we were treated to an excellent discussion about the merits of open and arthroscopic surgery. To close the first day were some presentations about acetabular osteotomy and, as had been brought up in the navigation discussions, the great importance of cup position; both version and inclination was emphasized.
That evening was the course dinner, beautifully located within the museum. After a champagne reception we sat down among historic cars, boats, planes and engines to enjoy the fantastic food. After dinner we were treated to a talk by Will Carling, ex-England rugby captain. I was genuinely disappointed, as a Scotsman, when he came across as quite likeable. I almost felt guilty for 1990 (it quickly passed). A big thank you must be given to the many Finsbury representatives who made the remainder of the evening highly enjoyable.
Saturday morning came too quickly, as is usual for such occasions. Up for debate were the role of resurfacing, cemented versus uncemented THR, and minimally invasive surgery. Again, the point became clear that in the hands of a high volume surgeon, any of these techniques can work well. Much of the argument on these subjects can be heard ad nauseum in any meeting of orthopaedic surgeons in the world, and some of the best value came from hearing the international speakers, Professor Thierry Judet and Dr Nobuhiko Sugano (from France and Japan respectively) relate their techniques of MIS.
From the point of view of a junior surgeon these meetings are excellent for hearing proponents of techniques to which we have not been exposed, and I learned a great deal on a couple of subjects which had previously been a source of personal ignorance. No issue was conclusively settled, but I imagine a large number of offshoot discussions have occurred in orthopaedic departments throughout the UK. Much of the argument could not be backed up by overwhelming evidence, and I think in our current world of devotion to evidence-based medicine, it is highly instructive to see top experts form their practice largely on the basis of personal experience.
This was the second Great Debate, and I found the format an excellent one. It is equally valuable for consultants and junior surgeons alike, but perhaps more junior trainees would need to be familiar with some of the more recent developments to really get the most out of it. Not only were the votes illuminating (it is always nice to see significant proportions of colleagues agree with your opinion), but as the keypads doubled as microphones, audience participation was greater than other meetings I have attended.
Professor Cobb and the main sponsors, Finsbury Orthopaedics, are to be congratulated on a fine meeting, and I very much look forward to attending the next one.
The third annual Great Debate meeting will be held over the 23rd and 24th January 2009. For more information visit: www.thegreatdebate.uk.com.
Registration opens September 1st 2008.
