Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:19] Speaker B: Well, good morning, Mark. It's another fall morning in Canada. I'm sitting at the Art Gallery of Hamilton with some nice indigenous art behind me and of course, a good old fashioned Canadian coffee. How's your, how's your morning? How's your morning?
[00:00:34] Speaker C: That, that's, that's, that's perfect. But as some of our listeners know, we started this podcast. It must be going on five years now. But the original Joe came from the combination of the Journal and Orthopedic Evidence, so that gave the Joe J O E. Right. But we've also always had the tradition of coffee.
And some of the listeners may know that I have been on the editorial board in one form or another since the 90s. So I have a huge affinity for the Journal and was pleased to hand over the reins to you.
Getting close to two years now, which has been a great thing for the Journal. But I've made countless trips to Boston and my brethren there, as many may know, are devout Dunkin Donuts people to the core. It's a, it's a religious movement in the Boston area. And of course the headquarters are in Needham, which is very close to Boston. And in view of the fact that we're in the midst of the World Series and your Toronto Blue Jays, the only Canadian franchise, has have tied it up against the Dodgers, I felt this required something drastic. So I got up early and I drove to a Dunkin Donuts to counteract the force of the Tim Hortons cup in hopes that the states can come back and somehow vanquish the Blue Jays. But it required some very, very special heavy work this morning. So cheers.
[00:02:07] Speaker B: I'm glad we both got Kofken at the end. At the end, both teams are amazingly impressive or have gotten as far as they have. But you're right, I mean, the challenge you might face is you have a state facing a country. Canada is behind the Jays, so. Right. So we have a little bit of a. I'm not, I'm not saying all us is behind the Dodgers, but I suspect there's some, I suspect there's some silos in the US when it comes to baseball.
You know, I can't imagine any New Yorkers chilling. I can't imagine New York with the Dodgers. But maybe I'm wrong. Maybe I'm wrong.
Well, listen, we could chat all day about friendly rivalries, but let me first, if I could introduce a scientist researcher, Thomas Triddendall, who is a PhD physiotherapist and researcher at Aarhus University. And the thing that makes this really interesting for me is, as you know, Mark, we have had a huge interest at the journal for really learning a lot from not only our surgical colleagues around the world, but our colleagues who are doing a lot of the rehabilitation science around the world. And I think Thomas brings just that type of insight to us.
He did a trial, I presume, during one of his research fellowships. And we'll learn more about this, entitled Total Hip replacement or resistance training for Severe Hip Osteoarthritis, published back in October of 2024. And I will tell you, this trial of about just over 100 patients or so was published in the New England Journal of Medicine, had an interesting result, I would say. And I would say interesting in the context of definitely from the rehabilitation science side. You know, it's a trial that actually in many ways demonstrated that a surgery may actually have some meaningful benefit. Surgeons have always thought that. But I'm curious, Thomas, from your stake and thank you and welcome to joining us today.
You tell us a little bit about the actual trial results and maybe we'll speak a little bit about what that, what life has been like since publishing in the New England Journal of Medicine for you personally.
[00:04:12] Speaker D: Well, Mo, thank you for having me on the podcast. I'm deeply honored to be a part of this. And good afternoon from Denmark.
I just finished my afternoon coffee, so I'm on that bandwagon as well.
[00:04:26] Speaker B: And Thomas, Thomas, Thomas, you're not drinking these big cups, right? You have, you have, you have legitimate, reasonable size cups. Am I correct here?
[00:04:34] Speaker D: Yeah, yeah, yeah.
[00:04:35] Speaker B: Okay, okay.
[00:04:35] Speaker D: Small, small European cup.
[00:04:37] Speaker B: Okay, okay, okay.
[00:04:39] Speaker D: I did this crazy study, I will call it, as a part of my PhD.
Everybody said when we will start planning it. Are you sure you want to do this trial in your PhD? Because it's not easy.
And I was a bit cocky and 10 years younger when we applied for the first funding for the study. And I was like, yeah, yeah, we can do it. It's going to be an easy study to conduct. And 10 years later, a bit of hair loss later, and I, I must confess, it was a way harder than expected. But an important trial, I think, because it should have been done 40 years ago.
But now we did it. And Briefly, we randomized 109 patients either to receive total hip replacement or A resistance training program.
First of all, we screened them for eligibility, found out that they had severe hip osteoarthritis on an X ray and symptoms aligning with that diagnosis. So they had severe pain and severe functional disability.
Then we randomized them and we conducted outcome assessments six months after, 12 months after, and 24 months. And then we're planning a five year follow up as well.
And we selected the six months outcome assessment as the primary endpoint for the trial because we could see from the literature that surgery kind of declined the effectiveness after six months.
And the intended program for the resistance training was six months as well. So it was kind of outweighing the benefits because yes, it would have been better for a longer follow up primary endpoint. But we would also wanted to capture the most precise estimate between the two treatments because we did know that someone of the patients would cross over and we tried to minimize the effect of that.
And yeah, the main finding was that we found a superior improvement in the total hip replacement group as compared to the resistance training group on the Oxford hip score, which measures hip pain and function. And we found the difference to be about 11.4 points on the scale that goes from 0 to 48, which is the best outcome. And in that patient reported outcome, there needs to be five point difference between the two treatments to it to be considered clinically relevant. So we found a clinical relevant superior effect of total hip replacement supporting our initial hypothesis.
So yeah, that's the main finding. And then there's a lot of sub findings from the trial.
[00:07:43] Speaker B: Well, I mean, first of all, thank you so much for doing this when you were actually thinking about doing this, when you said that, oh, you know, a lot of the individuals around you saying, why are you wanting to do this trial? What made this trial particularly difficult to conduct? You know, the idea of an operative versus non operative trial, they're not done very frequently, I must say, in surgery. But you did pull one off, and you certainly pulled one off to a degree that did two things. One is, and I don't know what your hypothesis was, but you can share with us what you thought was going to happen. But I can argue that if surgery did a trial in which non operative treatment turned out to be better, it's hard to do. And secondly, it's also from the point of view of surgery, you know, surgeons are often a little more in general hoping, you know, that the work they do is going to lead to benefit. Right. So it's hard sometimes to manage ideas that are contrary to maybe your own beliefs.
[00:08:33] Speaker D: Yeah. And I know from officials perspective, our initial hypothesis was based on previous observational studies and, and trials conducted. We had an hypothesis that the surgery would be superior also because they did a similar study a couple of years prior to ours and where a great physiotherapist from Denmark conducted a study on total knee replacement, also published in the New England Journal of Medicine. So we had an idea that this would, or we believed it would turn out so. But sometimes when you conduct trials they don't turn out how you think it should turn out. So that's actually why we did the study because there were some observational data suggesting this is a really good surgery. But one of my supervisors, sgo, who's an orthopedic surgeon from, at that time he was employed at the Oense University Hospital. He conducted a study where they actually did a similar resistance training program as we used in the trial and found a quite nice effect in the group. They did it before surgery so they wanted to look at the effect post surgery. And some of the patients were actually saying that they were in doubt, that they actually needed the surgery. So and we, we met in the clinic a lot of patients who were actually in doubt or scared of the surgery because before we started our trial there was a huge debate in Denmark about surgery and non surgical treatment and that we needed stronger evidence to highlight that surgery is the better option. And for me it's just, I want to know, to inform the patients the best, the best ways. So for me as a physiotherapist I, I think it's a great result because now if I have a patient and exercise with that patient and the person does not improve with hip osteoarthritis we, we can say we have a really good option, it's a total hip replacement. But you need to be aligned yourself and it's a surgery and you need to like be in the shared decision making process. So. So I think it was a great result.
[00:11:04] Speaker C: Well Thomas, congratulations on really a, I would say a landmark study and Mo and I have spent our careers advocating for trials and I can't tell you the number of times people would push back in generally in large audiences and say, well you know, the most successful operation in orthopedic surgery is the total hip replacement. And there's never been an RCT done on it and there never will be.
I can't tell you the number of times I've heard it. I know Mo as well. So I would like to dig just a little bit deeper into what gave you the motivation to do what must have been a very difficult trial to convince people that it was worth all this effort and expense.
[00:11:49] Speaker B: No, I was just going to simply add to that mark and say at that time, I can't imagine people were saying, we already know the answer, we already know why are we doing this? Right.
[00:11:57] Speaker C: Presumably, presumably certainly all surgeons would have said that.
[00:12:01] Speaker B: So. Right, right.
[00:12:02] Speaker C: Give us a little more insight in what your motivation was, Thomas.
[00:12:06] Speaker D: My general motivation for doing my research is I want to make the treatment better in the future for future patients. So that's my main goal.
And sometimes I think we, as a physiotherapist, from our kind of perspective, we were like, yeah, surgery is quite, it's, we can exercise this problem away. It, it was the general belief and the surgeon said the other thing, exercise does, does not work.
Then we, we actually met and discussed this. We have a problem here and we're confusing the patients.
So why don't we get aligned and, and then conduct a proper study to end this debate and then we can move forward with a greater information, better information for the patient.
And yes, so that's my main motivation for doing the trial, to be able to support the shared decision making process with better evidence or better quality evidence that we had prior to this study in particular.
[00:13:16] Speaker B: You know, the one thing that reminds me of Market, I think you'd probably get a chuckle out of this is probably Thomas, 10 years ago as a PhD fellow is coming. Of course we can do this. Right. Because he didn't, you know, it's like if you start, if you look now, Thomas, at your life, think how would I have done this? So much of it is having this sense of let's just go do it, like, why can't we? And the question is, why not? Is such a powerful thing. And I think we.
That's the beauty of being in a graduate program. There's a beauty of being early in your career. That's the beauty of having, you know, bigger dreams sometimes than some of the individuals around you who have through life seem to have, you know, thought, well, that's not going to work. Right? So Fascinating, fascinating. I have something I pulled up though. I wouldn't mind just hearing a little bit about you.
Your LinkedIn profile has, has a lovely beginning and I, and I, I want to read it out to folks and I want to get your take on, you know, just a little bit about why you wrote it that way. Because it's, it's, it's, I like it. So you write here.
So if anyone Looks up Thomas, you'll see it says I'm a very positive, outgoing and cheerful person who is eager to create new experiences and develop myself as a physiotherapist and researcher. I have an unstoppable drive for research and teaching as well as the implementation of evidence in clinical practice with the aim of improving treatment and care for the individual patient. Tell us about what the impetus was for writing it that way. It's lovely.
[00:14:36] Speaker D: I wrote it 10 years ago, I think.
[00:14:40] Speaker B: Yeah, of course, the young Thomas.
[00:14:43] Speaker D: I, I just wanted to capture what in, in quite few sensitives that why do I do the things that I do?
I, I think my, my profile needed that instead of just writing what, what have I done and what is my educations and degrees and stuff like that. So, so I wanted to make my personal motivation and share it with people and actually I think I've written it in Danish, so I'm quite impressed about the translation.
It's spot on.
[00:15:19] Speaker B: Is it? Is it? Okay, good.
So what new experiences have you created for yourself in the last 10 years? So this trial itself maybe speak to a little bit. We have lots of residents who listen in. We have fellows and early career researchers, surgeons, physiotherapists who are listening to, who are early in their career and they're probably going through a little bit of a, you know, I wouldn't say crisis but you know, a fork in the road saying if I spend this much time and do something that has impact like you've done, is it really going to lead to anything different in my life? How did this, how did this work or this particular trial change your life? If it did, if it didn't.
[00:15:57] Speaker D: I, yeah, it led to some interesting things on this podcast. I don't think I would have ever been invited if I didn't have done, done the trial.
So, so yeah, it has made me like someone actually reaches out to me and want to work and like creating a network. So it has opened up a kind of a way larger network for me than previous like the 10 years prior Thomas beforehand and it has also provided with some academic like endorsements. I, I, I won the best presentation for best study last year at the Danish Orthopedic Research Society conference here in Denmark and a nomination for the best clinical trial in Denmark. Unfortunately we didn't take home the title, but it was two really good other studies conducted. So five years ago when I attended conferences, nobody knew who I was.
Now I actually see someone like that. That's the guy who did the New England trial and People are coming towards and want to talk to me and just come and have a chat. I'm not dangerous. I won't bite.
I'm just, I'm just a good old me.
So yeah. Professionally academic honors and opened up network like. Yeah. Networks for other trials and collaborated collaborations with.
With great researchers around the world.
Yeah. And personally I don't think my kids know that it's a kind of big thing. But they actually, they just will.
[00:17:55] Speaker B: They never will. They never will.
[00:17:57] Speaker D: And I have to say to my parents because they, they are not into research that much that it was kind of equivalent to taking home the. The World cup in football or soccer as you will call it across the pond.
That's great.
[00:18:16] Speaker C: Thomas. What are you working on now?
[00:18:19] Speaker D: Currently I'm working on another multi center randomized control trial which I said to myself after doing this study that I would never do again.
But now I'm doing it again.
Again. I'm taking a critical look at my own profession.
So I'm comparing. We are doing a trial called the EDOX trial or the patient education or patient education and supervised train resistance training trial where we are going to. We are currently doing it. So we are randomizing people to patient education alone or patient education and supervised resistance training under the guidance of official therapists. So we are trying to see if doing the exercises with a physiotherapist is actually better than doing like if the patients do themselves.
So yeah.
[00:19:22] Speaker C: That'S impressive. And I can't imagine the resistance you must have come across within your own colleagues to even design such a study. So congratulations on your courage in conducting such a study.
[00:19:38] Speaker D: Thank you.
I think the prohib trial helped me getting along with my new idea. Like yeah, it, it's, it's actually important. So we need to do it because we, we need to get a deeper understanding of the non surgical treatment as well.
So this time it's not in patients who are eligible for surgery because I showed that surgery is superior. So now it's in persons with hip osteoarthritis that's not eligible for surgery. So mild to moderate.
[00:20:10] Speaker B: Yeah.
[00:20:10] Speaker D: Degree symptoms and X rays.
[00:20:13] Speaker C: Well, I would just make one last comment and I'll turn it over to Mo. But your description of how this trial has impacted your career is so spot on. And it's true for MO and myself as well. It's. It's not like we've been elevated to these positions because we know people or because we're smarter than the average person, but it's because we've and you've certainly as well have focused our careers on patience.
What are questions important to them? And we're not particularly smarter than the average person, but we're persistent. So it's the right motivation and it's persistence and the refusal to give up that gives people like us opportunities. And again, congratulations on what you've been able to complete.
[00:20:59] Speaker D: Thank you so much, Mark, Thomas and.
[00:21:01] Speaker B: Thomas, on that note, it has been wonderful interacting with you and I hope this is the beginning of many more conversations that we continue to have. So please do keep us updated on the work doing and the important work that you're doing.
In closing, though, I will say that I am going to honor you with a much smaller cup of espresso. And I would like, I would like, I would like my colleague Mark Notice that we are all blue in Canada.
[00:21:26] Speaker D: All blue.
[00:21:29] Speaker C: Go Blue Jays, eh?
[00:21:30] Speaker B: Go Blue Jays. A have yourself a wonderful day. Thanks again, Thomas. Thanks again, Mark.
[00:21:35] Speaker D: Thank you so much for having me on the podcast.
[00:21:38] Speaker B: Take care. Bye. Bye.
