Dear Sir,
Now in its sixth year, The Great Debate allows the audience to join with the Faculty in teasing out truth from marketing hype in the hot topics of hip and knee arthroplasty. Using bramble-like handsets, delegates both voted and texted comments to the chairs of each session. Trunnions, bearing couples, and head size were subjects of intense debate in the hip session, while in the knee session the unicompartmental versus total replacement issue is still as hotly debated as it was five years ago. Johan Witt’s promotion of the posterior approach to the hip convinced the audience more than Paul Beaulé’s advocacy of the anterior approach. Despite Graham Gie’s reasoned talk on the Exeter stem, the audience reflected worldwide opinion in preferring cementless fixation of hip implants.
Larger femoral head sizes did significantly reduce hip dislocation rate, according to Robert Middleton, but corrosion at the trunnion was now an issue even against polyethylene for these larger head sizes. Bill Maloney, Tom Schmalzried and Bill Walter were provoked by Adolph Lombardi and Paul Beaulé to defend their bearing choices. The audience literally roared its applause for a comment from the floor denouncing product promotion. Derek McMinn tore into the National Joint Registry report, showing how mortality and revision should not be separated, while Fares Haddad showed how resurfacing enabled a better function, as measured by the lateral frog jump, which he declined to demonstrate on stage. This light-hearted end to the hip session set the stage for David Morgan, the ex-president of the Australian Orthopaedic Association. He gently goaded presidents of the BOA past and present, as well as the Editor of 360, as they wrestled with a hypothetical ethical issue.
Patient-matched cutting blocks, ably explained by Adolph Lombardi, have been transformed from ‘new kids’ to ‘technology of choice’, according to audience sentiment. Both navigation and robotics were discussed and discarded by this audience as not delivering on the essential combination of speed and clinically significant improvement in outcome in joint replacement today. Total knee replacement design remains a hotly disputed topic. Tom Schmalzried had to admit under pressure from his chairman that the design he favoured, the so-called single radius, actually had three radii. Jean Alain Epinette produced the evidence that the ‘straight’ knee beloved of the engineers and navigators has no foundation in clinical evidence, and Fares Haddad showed how the University College London functional outcome group had shown the superiority of the medial pivot design. Medial, lateral, and patellofemoral partial replacements were passionately promoted, but the audience most enjoyed David Barrett’s exposition on the combined medial and patellofemoral replacement. With support from his chairman and challenger, he was able to convince the majority of a sceptical audience that this was a procedure with a future, while total knee replacement was clearly a procedure that needed consigning to history.
With no lack of controversy in our world, great debates in hip and knee arthroplasty will continue.
Professor Justin P. Cobb, Chair, Section of Orthopaedics, Imperial College London, Charing Cross Campus, London, UK.
Editor-in-Chief’s comment
The annual Great Debate meetings have developed enormously in recent years. From both an audience and Faculty perspective, the meetings are simultaneously highly informative and, dare I say it, fun. Let us hope the organisers are planning another event for 2013. See you there perhaps?
