At the great debate 2016, in the Royal College of Surgeons, we spent a couple of June days debating the big issues in hip and knee replacement with help from around the world.

Total knee design remains the single most ‘valuable’ topic in arthroplasty – if the cost of the devices and the size of the market are taken into consideration.. The thorny old PS/CR debate has been rewritten, with the medially conforming devices now established in clinical use, and an ACl/PCL preserving device is also now in clinical use. So it was fascinating to see how 4 highly respected surgeons were each going to promote an entirely different sort of knee replacement. From the audience’s perpective, the medial pivot designs were the most popular, which isn’t reflected in current implant usage, but may predict a trend. Interestingly each speaker prefaced his remarks in the debate by admitting that he used a uni knee whenever possible – a sentiment that is also not reflected in implant usage in the NJR  anyway.

On the hip front, Ronan Treacey made a compelling case for the continued use of resurfacing - a safer cheaper alternative for men anyway. Ceramic bearings were well received in general, and shorter femoral stems were promoted enthusiastically, with no one in the room demanding a return to the old longer stem days. Approaches to the hip and the advantages of minimally invasive surgery were explored thoroughly. The direct anterior approach was vastly more popular with the audience than its place on the registry would suggest.

The role of robots, navigation and PSI in arthroplasty was described and debated. The audience seemed to prefer the expert surgeon using his hard fought skills. Both Bill Walter and Johan Witt were more persuasive this year than any navigators, roboteers or PSI users. Knee alignment was discussed in a debate led by three French surgeons - Jean-Noel Argenson, Michel Bonnin and Charles Riviere. Delegates were enthusiastic about kinematic alignment, once again showing that those attending the Great Debate are well ahead of the curve. There would have been no appetite for anything other than mechanical alignment a couple of years ago. Similarly the topics acetabular orientation and intra-operative assistance were hotly discussed and related back the individual devices and their particular sensitivities to malpositioning. Robert Barrack was persuasive that a digital xray on the table to check positioning was the cost effective and indeed moral option.

Perhaps the most heat was generated in the politics session, where Ronan Treacey locked horns with Henrich Malchau over registries, and the extent to which they were a progressive force. Henrik’s description of the nested trials within a registry environment was novel and encouraging.  Richard Field, Emmanual Thienpont and Tim Briggs all contributed to the debate over productivity in the joint replacement environment, thrashing out the problem of increasing output while keeping costs down. The Delegates also made their feelings known: the large majority felt that the GIRFT process had not helped their working life, despite delivering the savings that Tim was demanding.

Our world continues to be both rewarding and demanding in equal measure: we are all looking for the safest way to help out patients. Debate seems a good way to ensure that as a profession we are going in the right direction.

12 CPD Points were awarded

New in 2016: The Great Debate was held at The Royal College of Surgeons, England

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