BJJ News
BJJ News from The Bone & Joint Journal
Formerly known as JBJS (Br)
BJJ News | I ssue 4 | S eptember 2014
Issue 4
Orthopod’s view
The Chavasse Report Bridging the gap
Global Clubfoot Initiative S. Mannion, R. Owen
T. Briggs
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IFC
Editorial
BJJ News
Issue 4
from The Bone & Joint Journal
The Military Covenant
D. Jones
and the Chavasse report
A. Ross
1
Orthopod’s view The Chavasse report
T. Briggs
2
L. Wicks
4
The Global Clubfoot
S. Mannion
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Initiative
R. Owen
Bridging the gap
September 2014
World Orthopaedic Concern (UK) Annual Conference
Fellowships The Charnley Legacy
J. Hodgkinson
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Report of the Mark
A. Di Martino
10
Paterson BJJ / EFORT
E. Altan
Travelling Fellowship 2014
M. Skowronek
Notes from the road Journal Office: 22 Buckingham Street, London
The Welsh Orthopaedic
D. Jones
13
A Letter to the Editor
A. Ross
15
Northern Lights
C. Galasko
17
Society
WC2N 6ET, UK bjjnews@boneandjoint.org.uk
Edited by: Mr David Jones Honorar y Consultant Or thopaedic Surgeon, London Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath
Advertising enquires: Dr Pam Noble ADmedica pnoble@admedica.co.uk
A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299. All ar t icles within BJJ News are published under the Creat ive Commons Attribut ion License (CC-BY 3.0)
Orthopod’s view
Spines and spikes: an update M. Greiss
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Letters RE: The Glasgow Fracture
P. Jenkins
Pathway: the right answer
A. Ireland
to the wrong question
L. Rymaszewski
Re: Non-technical skills
J. E. Tomlinson
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M. Yiasemidou Obituary Henry Poirier 1931 – 2014
D. Nairn
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BJJ News
Editorial he Military Covenant is an unwritten social and moral commitment between the State and Service personnel in the Armed Forces that has developed through long standing convention and custom.1 In 2000, this was articulated in the clearest possible terms as follows: “Soldiers will be called upon to make personal sacrifices – including the ultimate sacrifice –; in the service of the Nation. In putting the needs of the Nation and the Army before their own, they forego some of the rights enjoyed by those outside the Armed Forces. In return, British soldiers must always be able to expect fair treatment, to be valued and respected as individuals, and that they (and their families) will be sustained and rewarded by commensurate terms and conditions of service. In the same way the unique nature of military land operations means that the Army differs from all other institutions, and must be sustained and provided for accordingly by the Nation. This mutual obligation forms the Military Covenant between the Nation, the Army and each individual soldier ; an unbreakable common bond of identity, loyalty and responsibility which has sustained the Army throughout its history. It has perhaps its greatest manifestation in the annual commemoration of Armistice Day, when the Nation keeps covenant with those who have made the ultimate sacrifice, giving their lives in action.”2 However, the military covenant itself originates far earlier than this. In 1593, during the reign of Queen Elizabeth the First there was passed the “Act for the Necessary Relief of Soldiers and Mariners”3 which placed an obligation on the state to provide for its injured soldiers. After this, it was generally accepted that the state had a responsibility to look after its Service personnel and in particular the Army. The history of warfare and that of medicine are closely intertwined, ‘advances’ in the former demanding and usually eliciting astonishing advances in the latter. Sadly, although major improvements in the care of the acutely injured mean that lives are routinely saved where they would previously have been lost, the NHS services required to support the rehabilitation of grievously injured veterans have failed to keep pace.
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The Armed Forces Covenant, published by the Government on 16 May 2011, gives the highest priority to the injured stating “Veterans should receive priority treatment within the NHS where it relates to a condition resulting from their Service, subject to clinical need; while those injured in Service, whether physically or mentally, should be cared for in a way which reflects the Nation’s moral obligation to them, while respecting that individual’s wishes.”4 In his article in this issue about the Chavasse report, Tim Briggs lays out the issues in some detail. While the treatment of injured service personnel provided within the Armed Forces is excellent, the care of veterans who have been transferred to the NHS is fragmented and subject to the vagaries of a system with which we are all familiar. He makes a number of suggestions as to how this situation may be improved. Fast-tracking service personnel through centres of excellence and providing co-ordinated specialised prosthetic and rehabilitation services will not only improve the care of the injured but will have a transferable beneficial effect on the care of the civilian injured within the NHS. This is one of the most important initiatives that the BOA has undertaken. If the progress of the injured soldier from the battlefield to recovery can be made seamless and given due priority in centres of excellence, the nation will have faced up to and discharged its moral obligation, something that is perceived to have been lacking in recent years. This is a thoroughly commendable report. Tim Briggs and the BOA deserve not only the thanks of the Armed Forces but the congratulations and support of the whole orthopaedic profession. Read both his article and the report.
The Military Covenant and the Chavasse report
References 1. Taylor C. 2011 Armed Forces Covenant: House of Commons Library, International Affairs and Defence Section. 2. Soldiering – The Military Covenant, Army Doctrine Publication, Volume 5, February 2000. 3. 35 Elizabeth c.4, 1593 and 39 Elizabeth c.21, 1597. 4. MoD: The Armed Forces Covenant: interim report 2011.
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BJJ News | I ssue 4 | S eptember 2014
Orthopod’s view
The Chavasse Report
T. Briggs
Improving the medical care of our armed forces and veterans while raising NHS standards for all
ince 1945 our armed forces have been involved in 25 conflicts affecting UK interests and it is likely that this number will increase in years to come.
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Those who serve in our armed forces put their lives on the line for our country. In return for this, the very least they should receive, if sick or injured, is high quality medical care. They have given the most and deserve the best. Sadly, that ideal is not always provided by today’s NHS. Some veterans and former reservists, who have been discharged from the forces through injury, find the health service failing to match their own sense of duty, dedication and commitment. In parts of the NHS, care for veterans is disjointed and inadequate, with little co-ordination with the rehabilitation services run by the military. The result is that former personnel feel that they have been forgotten, and left to fend for themselves. As a senior consultant in orthopaedics, I should stress that the picture is not universally gloomy. Indeed, the medical care and rehabilitation provided within the armed forces is world-class. Soldiers injured in action in the war against the Taliban, for instance, received treatment first at Camp Bastion in Afghanistan, then at the Queen Elizabeth Hospital in Birmingham, followed by highly effective spells of rehabilitation at the excellent Headley Court facility in Surrey. This care is second to none. In a recent study, which looked at the outcomes for 52 British combat amputees from Afghanistan and Iraq, only eight were discharged, with the other 44 continuing to serve. Even more impressively, 33 of them returned to active service.
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Problems arise when injured or disabled service personnel have to leave the medical care of the armed forces, and are compelled to rely on the NHS. The Armed Forces Covenant holds that special consideration should be given by our society to veterans in recognition of the sacrifices they have made on our behalf. Although the Department of Health has done much for mental health, with the creation of 10 mental health teams across England, that fine sentiment is not always translated into reality. Often, access to care and the quality thereof can be a lottery. The NHS is facing unprecedented challenges. Financial austerity, a rapidly expanding and ageing population, and significant advances in medical technology make it increasingly difficult to provide universal free care for the population. The finances of the NHS remain under extreme pressure, with experts predicting a shortfall in funding of no less than £30 billion by the end of the decade. Some of my medical colleagues believe that even more money is needed to save the NHS: I, however, believe that we as a profession need to “step up to the plate” to help solve this problem as 80% of the cost lies in the secondary care sector. Financial constraints are not solely to blame for the problems in the NHS. The NHS is still undermined by operational failings due to its bureaucratic structure, inefficient working practices, and poor co-ordination between depar tments. Currently, at the request of Government and NHS England, I am undertaking a national review of orthopaedic practice in England through the “Getting it Right First Time” (GIRFT) pilot. I have visited over 170 hospitals, which has given me a unique insight into elective orthopaedics in the NHS. The final report is due in August, and, on the basis of my findings, will suggest fundamental changes in the way we deliver orthopaedic services.
These will increase the quality of care, reduce complication rates and reduce variations in practice. By getting the provision of care right in our hospitals, commissioners will be confident that the services they buy are of the highest quality and best value. This will result in massive savings for the NHS without compromising care. This is an example of how co-operation between Government and senior clinicians in specialist associations such as the British Orthopaedic Association can provide solutions that will allow timely care for patients as we move into the future. The current problems within the NHS affect the care of veterans, which is all the more regrettable given the nation’s moral obligations to these men and women. During the GIRFT visits I was also able to see how the health service treats personnel with musculoskeletal injuries arising from their military service. In my research, I was greatly assisted by the Defence Medical Services. Musculoskeletal injuries account for about 60% of discharges from the forces, compared with around 15% for mental health problems. As a result of these findings the Chavasse Repor t was published on 1st July 2014 (www.thechavassereport.com). It is named after an inspiring and heroic doctor in the Royal Army Medical Corps, Captain Noel Chavasse, one of only three men to have been awarded the Victoria Cross twice.
IN 1917, DURING THE BLOODY B AT T L E O F PA S S C H E N DA E L E ( T H I R D B AT T L E O F Y P R E S ) A N D D E S P I T E B E I N G S E R I O U S LY I N J U R E D E A R LY O N I N T H E AC T I O N H E R E F U S E D T O L E AV E H I S P O S T S O T H AT H E C O U L D C O N T I N U E T O T R E AT T H E W O U N D E D. H I S I N J U R I E S W E R E TO P ROV E FATA L .
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A uthor
details
Tim Briggs President of the British Orthopaedic Association twrbriggs2912@gmail.com
Through my work as a surgeon, I have seen that NHS services for veterans need to be improved and better co-ordinated. In the case of a young Royal Marine veteran, David Martyn, who was shot in the knee in the Afghan campaign and received excellent treatment at Camp Bastion and Queens Elizabeth Hospital in Birmingham, when he came under the care of the NHS, he was told there was little that could be done except amputate the leg if the pain worsened. He was eventually referred to a specialist centre, where appropriate treatment significantly improved his quality of life. He should have been referred and seen much earlier. This is not an isolated event. In 2007, in response to complaints from the Royal British Legion about veterans’ needs being ignored, the then Health Secretary, Alan Johnson, ordered that they should receive priority treatment and by-pass waiting lists. That instruction has only been implemented to a limited extent. One recent study found that half of GPs did not know that veterans were meant to be prioritised, while a survey by the Royal British Legion discovered that only 22% of veterans had been offered fast-track care. Although there have been improvements since then we need to do much better especially in the care of musculoskeletal injuries. The present Government has provided £22 million to support veterans’ physical and mental health from 2010 to 2015. It also commissioned a report from Dr Andrew Murrison, MP, on how improve the care of military amputees. The result was the identification of a number of centres which would be responsible for the care of veterans with amputations, providing them with state of the art prostheses. However, we need to do much more.
We have a moral duty to transform the and the wider world by delivering the highest healthcare of veterans. In the Chavasse report standards of care to both veterans and NHS I suggest a number of ways that this could patients. done. One is to make fast-track treatment a T h e re w i l l i n e v i t a b l y b e q u e s t i o n s reality. Just as importantly, we need to improve about costs, but I believe that each of the the co-ordination of care and offer a seamless rehabilitation units will cost around £2 million transition from the armed forces to the NHS. to set up. These could be funded par tly This can be achieved through the creation of a from charitable donations or wholly by the network of about 30-40 NHS service hospitals Government, using the LIBOR fines. identified and chosen on the grounds that If we get the provision of care right, then they currently follow the best practice in commissioners and NHS England, who are orthopaedics. These are NHS hospitals which already working hard on this issue, will be treat patients to a very high standard and have able to commission in confidence, knowing already been identified through the hospital that they are commissioning high quality care visits I have undertaken. They will continue and getting best value for each pound spent. to treat their own population as well as the Setting up networks within the NHS is not a veterans. In addition, we should create about new phenomenon and can be very successful. 14 dedicated NHS Veteran Rehabilitation Units inspired by the care afforded within We have a moral duty to transform the armed forces. These will the healthcare of veterans. also provide psychological suppor t and chronic pain management. These will link up with the rehabilitation units within the The result of setting up the Major Trauma military and the personnel recovery centres Networks has seen a massive improvement funded by Help for Heroes and the Royal in outcomes for patients with major trauma. British Legion as well as the prosthetic and The Chavasse report has the support of the rehabilitation centres named by Murrison. This public, t he Defence Medical Ser vices, will ensure the seamless transition of care and politicians, charities, leading figures in the allow the exchange of ideas between the NHS armed forces and the Duke of York. On Armed and the Armed Forces. The services of these Forces Day in late June, there were many rehabilitation units will also be available to heartfelt words spoken about the debt we owe other NHS patients, leading to a reduction in to our veterans. Now is the time for us to medical complications, and improved recovery honour our debt and finally resolve this issue. and rehabilitation. This would benefit our If we fail to do this now while the focus is on workforce and have positive consequences our armed forces because of the 70th for the economy. anniversary of the D-Day landings and the There is an opportunity for NHS service 100th anniversary of the outbreak of WW1, hospitals and NHS rehabilitation units to act then we never will. Your support for the as centres of excellence for the rest of the NHS Chavasse report is vital to its success.
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BJJ News | I ssue 4 | S eptember 2014
L.Wicks
Bridging the gap
World Orthopaedic Concern (UK) Annual Conference
University of Leicester, May 10th 2014
Laurence Wicks reports had the pleasure of organising this year’s WOC-UK conference. In this I was assisted hugely by Deepa Bose, consultant in Birmingham and current secretary of WOC-UK, and my wife Lauren. The meeting was held in the excellent facilities of the University of Leicester on 10th May (Figs 1 and 2). With 45 registrants, excellent speakers and lively discussion, the day was informative and stimulating for all. The meeting started on a sombre note with a minute’s silence in memory of Abbas Khan, a member of WOC-UK, who died in a Syrian prison, and Dr Jerry Umanos, who was killed along with two colleagues at the CURE hospital in Kabul. This was followed by two lectures from Syrian surgeons working in England. The first was given by Omar Gabbar, a spinal surgeon in Leicester. He is a Trustee and medical lead for the charity Hand in Hand for Syria (www.handinhandforsyria.org.uk), and spends much time organising and delivering humanitarian aid there. He described a once tolerant Fig. 1 Delegates during Steve Mannion’s presentation country which became polarised during the Arab Spring of 2011 and how the government response led to the formation of The Free Syrian Army in 2012. He tracked the subsequent last year and £6 million in total over the last three years. Syria Relief’s degeneration into civil war and the widespread destruction of buildings biggest project is The Bab Al Hawa Hospital on the Syrian/Turkish border, and infrastructure, including hospitals. Between 2012 and 2013 the death which deals with 2000 patients a month, many with horrific injuries. toll rose from 35 000 to 130 000 and the refugee population increased Following these presentations Steve Mannion (WOC-UK chairman) from 350 000 to 2.5 million. All this was endorsed by the second speaker, delivered the first Ginger Wilson Memorial Lecture on ‘Global Disaster Mounir Hakimi, an orthopaedic trainee in the North West, and co-founder Management’ and talked about his experience of working in countries of the charity, Syria Relief (www.syriarelief.org.uk). Not only has he in the wake of natural disasters. The difficulties of providing a cobeen pivotal in raising awareness of the conflict and funds, but also ordinated international response were highlighted and exemplified by makes regular visits to operate in the most inhospitable surroundings. his reflections on the recent ‘UK Internal Emergency Trauma Registry’ Large aid organisations, such as the UN or Red Cross, are generally (www.uk-med.org/trauma.html) response to typhoon Haiyan in the ineffective in this situation because they require an invitation to enter an Philippines. However, the international community seems to be learning affected area. Therefore, the cross-border humanitarian aid needed has to from past mistakes and, with better understanding of the problems and a great extent been provided by independent charities such as Hand in global health partnerships, international aid is improving. Hand (HIH) for Syria and Syria Relief. With the destruction or occupation WOC-UK’s main focus is to improve education and training in the of hospitals by government forces, ad hoc facilities have been set up to developing world. Vaikunthan Rajaratnam (‘Raj’) travelled from Singapore deal not only with the injured but also with day-to-day illnesses, and to give a passionate talk about the changing shape of education resulting also the emergence of polio and malnutrition. from the global mobile phone and internet revolution which reaches Over the past two years, HIH raised more than £2.15 million and even the remotest parts of the world. His thesis was ‘Technology is the supplies more than 75 medical facilities. Syria Relief raised £2.5 million answer; what is the question?’ Raj challenged the traditional model of
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Fig. 2 Steve Mannion (lef t), Magdi Greiss (centre) and Laurence Wicks (right) teaching and presented many fresh ideas. Of note was his suggestion to break up long talks into single-minute lectures, which can be uploaded onto the internet. I was particularly interested in the concept of ‘flipped model’ teaching, in which students watch ‘lectures’ at home on a computer, and then meet in groups to do ‘homework’ with a supervising tutor. This model has many benefits for surgeons visiting low and middle income countries (LMICs) for short periods at a time. He also discussed ‘Massive Open Online Courses’ (MOOCs) as a way of delivering teaching material to a far bigger, international group of doctors. Raj impressed upon the audience the importance of education in the developing world, highlighting the philosophies of Paulo Freire in his book ‘Pedagogy of the Oppressed’. Country reports were delivered by Paul Ofori-Atta (Ghana and West African College of Surgeons); Steve Mannion (Malawi); Louis Deliss (Palawan - www.britishpalawantrust.org.uk); Magdi Greiss (Ukraine); Laurence Wicks (Ethiopia); Dalton Boot (Cambodia) and Antoon Schlosser (WOC international). Prof Iqbal Qavi sent an update for delegates on progress in Bangladesh and the surrounding countries, where there is a drive to develop a regional orthopaedic training programme. It was encouraging to hear upbeat reports from the projects that fall under the WOC-UK banner. It is clear that there are a huge number of people participating in LMICs work both from the UK and other countries. There is a sense that WOC-UK should be playing a larger role in linking surgeons and organisations who are working in similar parts of the world. It is hoped that this can be developed in the coming months. There is not enough space to write about each of the projects mentioned above. To highlight Ethiopia, the long-standing relationship with the Black Lion Hospital (BLH) in Addis Ababa has been given a boost by the presence of Rick Gardner, who is working at the CURE hospital. Through his work with senior colleagues at BLH, it is hoped that a wellorganised and sustainable teaching programme will be established, with more regular visits from UK-based surgeons.
In the afternoon, the focus of the meeting turned to clubfoot. Rosalind Owen presented the Global Club Foot Initiative (GCI) (http://globalclubfoot.org), an organisation in which WOC-UK is a governing partner. GCI’s vision is that disability caused by untreated clubfoot should be eradicated worldwide. Rosalind described the model used for establishing national clubfoot programmes. One of the biggest difficulties is maintaining follow-up to ensure that abduction bars and boots are used to prevent relapse. There has been considerable success with the project but there are still many countries in which Ponseti casting is not available. The work of GCI is reported more fully in this issue of BJJ News (page 8). Steve Mannion then talked about neglected clubfoot which constitutes most cases in the world and needs operative treatment. He stressed that whereas Ponseti casting is still useful to stretch the soft tissues pre-operatively, the type of operation will vary greatly depending on the severity of the clubfoot and age of the patient. The surgeon needs a wide repertoire of techniques and it is important to achieve full correction at a single operation. Both Simon Graham and James Turner were granted trainee travelling fellowship awards, and they reported on their time working in Malawi. Both of them gained considerable clinical experience and talked with great enthusiasm about their time spent overseas. The huge benefit of working overseas has been enjoyed by many trainees over the years, but there is a worry that these opportunities to take time out of programmes are being threatened by the modern format of training, which many WOC-UK members find disturbing. The final speaker was Peter Lunn. Since retiring from NHS work in 2008, he has played an active role in support and education at Kagando hospital, Uganda. He has found that through a commitment to good education, this small rural hospital has built a sizeable reputation. It is now making progress on sustainability, trying to retain long-term staff, and is already attracting junior doctors and elective medical students. Peter’s talk highlighted the important role of retired surgeons in overseas work. The connection between a commitment to education and the development it brings to a local population was clear. It is exciting to be a part of WOC-UK. The success of the conference is a reflection of WOC-UK’s development over recent years and has been led by Steve Mannion and Deepa Bose. As well as running specific projects, we aim to act as an umbrella organisation which can connect individuals who are working in similar parts of the developing world. As surgeons we can have a great impact on the world by supporting colleagues working with those who suffer as a result of poverty, disease and war. Effective education and training is a powerful tool in freeing people who are oppressed in these ways, and this remains the main focus of WOC-UK’s work. If you are interested in becoming involved in WOC-UK, and indeed if you would like us to know about your own overseas work, please visit www.wocuk.org or contact us (secretary@wocuk.org). A uthor
details
Laurence Wicks Orthopaedic Speciality Registrar, Leicester Royal Infirmary / WOC-UK committee member wickslaurence@yahoo.co.uk
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BJJ News | I ssue 4 | S eptember 2014
S. Mannion R. Owen
Bridging the gap
Global
CLUBFOOT
Initiative
towards a clubfoot disability free world ….
ongenital talipes equinovarus (clubfoot) has a global incidence of 1.2 cases per 1000 live bir ths. Approximately 200 000 babies are born worldwide with the condition each year, of whom 80% live in low or middle income countries (LMIC) where few or no effective options for treatment have previously been available (Fig. 1). Without treatment, as children begin to bear weight through the lateral side & dorsum of their increasingly deformed feet, the condition becomes becomes ‘neglected clubfoot’, a painful and severely disabling deformity (Fig. 2). Children with neglected clubfoot face a lifetime of severely restricted mobility. Being unable to walk to school many are excluded from education and later employment. Affected children and their families are stigmatised by having such a visible deformity. Mothers of babies born with clubfoot may be thrown out of the family
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home due to the belief that it is caused by witchcraft or wrong-doing on the part of the mother. Later in life, individuals with clubfoot may be unable to marry and often end up begging for a living. Clubfoot becomes a burden not just for the individual and their family but for society as a whole due to its economic and social effects. Treatment for clubfoot has changed significantly over the last 15 years. Although non-surgical strapping or casting techniques such as the ‘Kite method’ had long been used, the treatment was prolonged and correction incomplete in a significant proportion of cases. This led to an increasing reliance, from the 1960s, on operations which involved soft-tissue releases alone or combined with bony resections/arthrodeses. Although these techniques could successfully achieve a plantigrade foot, in the long-term the feet were often painful and stiff, with a high rate of recurrent deformity.
Ignacio V. Ponseti, a Spanish orthopaedic surgeon who worked in Iowa City, USA, from the 1950s onwards, was dissatisfied with the results of surgical correction of clubfoot. He devised a method of manipulation which respected the normal anatomy and axes of movement of the foot and ankle joints. The Ponseti technique, ideally started in infancy, consists of serial manipulation and casting, typically at 5 to 7 day intervals. The midfoot contracture is usually corrected over 4 to 6 weeks and any residual equinus deformity is treated by percutaneous Achilles tenotomy under local anaesthesia followed by a final cast. On removal of the final cast the correction is maintained with the use of a Foot Abduction Brace, worn full-time for three months and then only at night until four years of age. The technique has been shown to be far better than other treatments in the rate of correction achieved and long term outcome. One 30-year follow-up study
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A complete course of treatment can cost as little as $250 and uses materials available in most parts of the world.
Asia
Sub-Saharan Middle Africa East
Latin America
Europe
North America
Fig. 1 Geographical distribution of the 20 0 0 0 0 new cases of clubfoot annually. Of these, 80% are from low or middle income countries.
Fig. 2 Neglected clubfoot
reported no significant differences in foot pain between children with a clubfoot treated by the Ponseti method and a group with normal feet. Numerous series have demonstrated that a correction rate of over 90% can be achieved when the technique is carried out correctly. The Ponseti technique is ideally suited to low income settings (Fig. 3). A complete course of treatment can cost as little as $250 and uses materials available in most parts of the world. It can be carried out successfully by non-physician health workers such as physiotherapists, clinical officers, rehab technicians and prosthetists / orthotists. It has been implemented using a public health approach in a number of low income countries, using national programmes integrated into national health services, usually supported by NGOs. Some of these programmes have been successful in reaching close to 100% of expected cases. As such, the technique has the potential to alleviate the heavy burden of disability caused by untreated clubfoot if
capacity can be built and effective services provided that are accessible to the population of every country. This is the vision of the Global Clubfoot Initiative (GCI) and our mission is to support those in low income countries who are working to achieve it by providing opportunities for learning, resource sharing, collaboration and communication. TheGCI was set up as a loose af filiation of NGOs in 2011. Since then, it has become a charit y registered in the UK with 28 ‘par tner organisations’ (www.globalclubfoot.org/about-gci/ partner-organisations). These range from very large international NGOs to small, local NGOs, all of whom share the common vision of a world free from preventable disability caused by untreated clubfoot. GCI enables partners and individuals to collaborate on common issues such as training, supply/production of foot abduction braces and measurement of clinical outcomes. Advice on best practice, new developments
in treatment, information and knowledge are shared among partners in order to increase efficiency and avoid duplication. Through its website, (www.globalclubfoot.org), GCI provides information about clubfoot and its treatment and makes resources for training and programmes freely available. Partner organisations and individuals connected with GCI value the role it plays in connecting them with a wider community and providing a global platform for communication. GCI also maps where services are available and is frequently able to put individuals who are looking for treatment in touch with local providers. Great steps have been made in the last decade towards the eradication of neglected clubfoot globally. However, there is still plenty to be done. A report by GCI on data collected from 2011 showed 12 181 cases enrolled for treatment across 30 countries known to have some form of supported programme for clubfoot (Fig. 4). However, these constitute ►
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BJJ News | I ssue 4 | S eptember 2014
Fig. 3 African baby undergoing Ponseti treatment
around 19% of expected cases. Whereas it is encouraging that 30 countries could be identified as having programmes in place (an enormous improvement on a decade ago), this highlights the urgent need for more capacity, support for service provision and better access to treatment. GCI will continue to do everything within its means to support these efforts and ensure that children in low income countries do not face life disabled by a treatable condition.
World Orthopaedic Concern (UK), an affiliated society of the BOA, is proud to be a founding and governing partner of the Global Clubfoot Initiative. Senior members of WOC (UK) hold key positions within GCI and have incorporated clubfoot education and training into WOC’s network of orthopaedic projects in the less developed world. More information can be found on our website www.wocuk.org
A uthor
details
Steve Mannion
Chairman, World Orthopaedic Concern (UK)
Ros Owen
Programme Director, GCI
SteveJMannion@aol.com
Fig. 4. Distribution of 30 countries sharing data with GCI on 12 181 cases enrolled in 2011.
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BJJ News
Fellowships
J. Hodgkinson
The
Legacy
John Hodgkinson brings to our attention the history and objectives of The Charnley Trust ir John Charnley will always be remembered for the development of the low friction hip arthroplasty. His pioneering work in the 1950s and early 1960s changed the lives of millions of people, restoring their pain-free mobility and independence. His work established the value of elective orthopaedic surgery. In 1962, the hip replacement became a practical reality. It is still the gold standard. He was an innovator who dedicated his life to research and improvements in materials, surgical technique and prosthetic design. His research was concentrated at one notable centre of excellence. Charnley knew that it was important for the progression of orthopaedics that research and development were nurtured and encouraged. It is important that his legacy is kept alive and following Sir John’s death we are fortunate that Lady Charnley established a charitable trust fund in his name. The aims of The Charnley Trust are as follows:
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The promotion of research
into the field of human joint replacement and in particular that of Low Friction Arthroplasty
The sponsorship of lectures, seminars and conferences
to further the technique of Low Friction Arthroplasty pioneered by Sir John Charnley
he Trust fund has been supportive of many projects and more recently a bequest by the late Mrs Doreen Latta, a grateful patient who enjoyed 30 years of painfree walking after a Charnley hip replacement, has allowed the trust to provide further opportunities for surgeons to visit centres of excellence in reconstructive hip and knee surgery worldwide.
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One recipient travelled to Malawi to study patients with HIV who had total hip replacements. Another travelled to the famous Endoklinik in Hamburg, Germany, to study the management of the infected total hip replacement. Several visits have been arranged over the years to Vancouver to consider the success of revision following primary total hip replacement. Other centres visited include Ontario and Boston. The fund also has provided support for projects across the UK.
The creation of research fellowships
and the award grants to enable young committed orthopaedic surgeons to visit centres of excellence in orthopaedic surgery
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Applications Applications for this type of support and research in this area more generally can be made to the Trust using the application form that can be downloaded from the Trust web page www.johncharnleytrust.org and returned to: McMillan & Co LLP, Secretaries to the John Charnley Trust, 28 Eaton Avenue, Matrix Office Park, Buckshaw Village, Chorley PR7 7NA.
details
John Hodgkinson Consultant Orthopaedic Surgeon, Wrightington, Lancashire jphodgkinson@tiscali.co.uk
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BJJ News | I ssue 4 | S eptember 2014
Fellowships
Report of the Mark Paterson BJJ / EFORT Travelling Fellowship 2014 ur arrival in the UK and subsequent visits to leading hospitals in the NHS has been a journey from tradition to scientific advance. Surgeons in the UK are very proud of their history, more so than we expected. Yet, while respecting their traditions, they readily accept innovation in their clinical practice. The three of us, Alberto from Rome, Egemen from Turkey and Michal from Poland, represented an interesting mix of cultural and professional experience. However, we were united by a common desire to improve our knowledge of healthcare in the UK, to meet new people and exchange ideas. We were also able to lay the foundations for longstanding friendships and collaboration between our respective hospitals. The fellowship is a memorial to Mr Mark Paterson, a prominent UK orthopaedic surgeon who died on 15th October 2013, aged 59 (Fig. 1). He was appointed as a children’s orthopaedic surgeon to the Royal London Hospital in 1990 where he worked for the next 23 years, notably in the management of children with cerebral palsy. He was an Associate Editor and Member of Council of Management of The Bone & Joint Journal and President of the Orthopaedic Section of the Royal Society of Medicine. The BJJ Council and EFORT renamed the Fellowship in Mark’s honour as an inspiration to young orthopaedic surgeons. During our travels, we met orthopaedic surgeons who knew him, and all described him as a kind and friendly person who was devoted to children’s orthopaedics and improving clinical practice. We are honoured to have been chosen to undertake The Mark Paterson Travelling Fellowship. The trip consisted of visits to hospitals and other institutions in London, Nottingham and Edinburgh and we ended the Fellowship by attending the combined BOA/ EFORT meeting in London. London and Stanmore London and Stanmore
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After meeting at Heathrow Airport, we started to get to know each other by sharing our experiences. Taxi time was useful for three strangers to create bridges. The first English person who took care of us was Mr Martin Bircher. He hosted an informal dinner
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A. Di Martino E. Altan M. Skowronek
and gave us information about Mark Paterson, the Fellowship, and our programme in London. The next day, we went to the Royal National Orthopaedic Hospital (RNOH), Stanmore. We began at the London Implant Retrieval Centre (LIRC) which was founded in 2008 by Alister Hart and John Skinner to collect and analyse failed (retrieved) implants from around the world, thereby providing information on the in situ performance of orthopaedic devices and offering clues into their mechanisms of failure. Currently, the research is focused on the examination of microscopic wear and corrosion at the tapered junction between the head and stem of metal-on-metal implants, but ceramic couplings and implants are also being studied. Moreover, in the LIRC, many young researchers and PhD students study implant failure and fatigue in hip and knee implants, and, more recently, in spinal and shoulder implants. Afterwards, we visited the operating theatres (Fig. 2). The following morning began with a visit to the Royal College of Surgeons of England in central London. Mr Bircher explained how surgeons split from the physicians in 1541 to form the Company of Barber Surgeons. A further split in the eighteenth century led to the establishment of The Royal College of Surgeons in 1800. Afterwards, we had a private visit to the Hunterian Museum. We learned of the unusual life of John Hunter and his anatomical and surgical works, and understood his influence on future surgical, medical, dental and veterinary science. We saw the ethical dilemma posed by the skeleton of Charles Byrne, The “Irish Giant”, who in life expressed the desire to be buried at sea, but after betrayal by a friend, his cadaver was sold, dissected and his skeleton displayed in the museum. We also had the chance to visit the upper rooms where the development of modern surgical techniques, anaesthetics and control of infection are on display. Mr Bircher then brought us to the BJJ building for a meeting with the Editor-in-Chief, Professor Fares Haddad, Emma Vodden (Head of Editorial Publishing Services and organiser of the UK tour) and Mr James Scott, the Editor Emeritus, who presented the history of the Journal, while Professor
BJJ News
Fig. 1 Mark Paterson
Fig. 2 Michal Skowronek (lef t), Egemen Altan (centre) and Alber to Di Mar tino (right) at the Royal National Or thopaedic Hospital
Haddad introduced us to the changes BJJ has undergone in the last few years and challenges for the future. In the afternoon, we attended a regular meeting at the Institute of Sport, Exercise and Health, where all the registrars and fellows gave presentations and made comments. Under the chairmanship of Professor Haddad, we gave lectures on spinal metastases (Alberto), reconstruction of bone loss around hip cup implants (Michal) and ankle injuries (Egemen). Nottingham Our next visit was to Nottingham, where our host was Mr Ben Ollivere, Associate Professor in Trauma, Editor-in-Chief of Bone & Joint360 and Editorial Secretary of the British Orthopaedic Association. We first visited Nottingham City Hospital, where Mr Peter James and Mr Andrew Manktelow, introduced us to the activity of the orthopaedic unit and discussed clinical cases in hip revision surgery and the latest generation of knee replacements. The following day, we visited the Department of Orthopaedics and Traumatology at the Queen’s Medical Centre, which is one of the leading trauma centres in Europe and serves a population of over four million. Michal had the chance to visit Mr Manktelow’s operating theatre, Alberto joined the spine team and, after attending the morning trauma morning round, Egemen joined Mr Ollivere in ribcage fixation and reconstruction in a trauma patient. Egemen also had the chance to meet a sports orthopaedic surgeon, Mr Hahn, and was involved in his morning clinic. We attended the trauma conference in the afternoon, where we met respected trauma, pelvic and acetabular surgeons (Mr Hahn and Mr Forward) and gave our lectures on ankle injuries (Egemen), pathological fractures of the long bones (Alberto), and reconstruction of bone loss around hip cup implants (Michal). We learned about centralisation of trauma services in the NHS and its positive effect on mortality rates. Together with Mr Ollivere, trauma fellows and residents, we had the chance to visit England’s oldest pub (Ye Olde Trip To Jerusalem), the Nottingham Castle walls, Robin Hood’s statue and the centre of this ancient city.
Fig. 3 Egemen Altan (lef t) and Hamish Simpson (right) during discussion at the Royal Inf irmar y of Edinburgh
Edinburgh The last part of our fellowship was in Scotland. We took the train from Nottingham to Edinburgh, a pleasant, scenic journey. It was Saturday afternoon, and in the evening we were invited by Professor Hamish Simpson to his house for a memorable dinner. The following day we had free time in Edinburgh and Professor Simpson had kindly organised some activities. Michal and Egemen went cycling with Mr John Keating, who provided two superb bikes. It was a beautiful tour around the countryside but, unfortunately, one of the bikes broke so we had to walk back home. Alberto played golf with Mr Paul Hindle. The following day we were assigned to different outpatient clinics: Michal visited Mr John McKinley in the foot and ankle clinic, Alberto was assigned to ►
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BJJ News | I ssue 4 | S eptember 2014
Acknowledgements
Mr Alastair Gibson’s spinal clinic, and Egemen to Miss Julie McBirnie’s shoulder clinic. In the afternoon we went to the operating theatres at the Royal Infirmary. Later, we gave presentations at a scientific meeting where Professor Simpson conducted a lively discussion (Fig. 3). Finally, the taste of a Scottish restaurant ended our visit to Scotland. The team from Edinburgh had been very friendly and impressive in the work they do. The following day we returned to London to attend the EFORT Congress where we met Sanni Hiltunen who had arranged the part of our Fellowship from the EFORT side. Each of us then attended sessions of interest and had the chance to meet friends and colleagues from all over Europe. During this Fellowship we had the chance to observe changes in the National Health Service, such as the development of new trauma networks and the attempts to reduce waiting lists for hip and knee replacement surgery. These changes were emphasised in the BOA Presidential Guest Lecture at this EFORT congress. The lecture, ‘Meeting the challenge of reconfiguring health services in the 21st century’ was moderated by Professor Tim Briggs and delivered by Lord (Bernard) Ribeiro. Our time in London and Stanmore highlighted the journey from tradition to innovation, as witnessed by our visit to RCS, the implant retrieval facility at Stanmore and our time at the BJJ. Finally, the influence of research and the differences between surgical practice in different countries characterised our stay in Edinburgh.
We thank EFORT and The Bone & Joint Journal for the organisation of this Fellowhip. We wish to thank all those who took care of us during our stay in UK. In particular, we met some residents, fellows and consultants who spent their free time with us, and enriched the overall quality of our experience in this beautiful country. In particular, we thank Adam Yasen, Paul Hindle and John Keating. A grateful thanks goes to our hosts, and in particular to Hamish and Helen Simpson, Ben Ollivere, Martin Bircher, Emma Vodden, Sanni Hiltunen, James Scott and Fares Haddad. A uthor
details
Alberto Di Martino University Campus Bio-Medico of Rome dimartino.cbm@gmail.com
Egemen Altan Selcuk University Medical Faculty, Konya/Turkey egemenaltan@hotmail.com Michal Skowronek Zeromski Hospital in Cracow, Poland mj.skowronek@wp.pl
half page JBJS/2_Layout 1 05/08/2014 11:56 Page 1
The London Orthopaedic Basic Science FRCS (Orth) Revision Course Organised by Orthopaedic Research UK
25th – 26th September 2014, The Royal Society of Medicine, Chandos House Convenors Mr Sebastian Dawson-Bowling Consultant Orthopaedic Surgeon Barts Health NHS Trust, London
Mr Iain McNamara
Consultant Orthopaedic Surgeon Norfolk and Norwich University Hospital and University of East Anglia
Mr Ben Ollivere
Consultant Orthopaedic Surgeon Nottingham University Hospitals NHS Trust
TOPICS INCLUDE:
■ Limb development and growth ■ Tendon and ligaments ■ Muscle and nerve ■ Articular cartilage and meniscus ■ Bone and bone healing ■ Gait analysis ■ Diagnostic imaging ■ Orthopaedic oncology
■ Musculoskeletal infection ■ Biomechanics ■ Orthopaedic implants ■ Tribology ■ Arthroplasty ■ Genetics ■ Skeletal dysplasias ■ Metabolic bone disorders ■ Study design and biostatistics
REGISTRATION DETAILS £396 for ORUK members £440 for non members To become a member please visit: www.oruk.org To register e-mail: info@oruk.org or Telephone: 020 7637 5789
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BJJ News
Notes from the road
D. Jones
The Welsh Orthopaedic Society David Jones reports on the 27th meeting of The Society in Carmarthen in May 2014
It’s a nice feeling to have been with an organisation since its inception and to watch it grow from a small club to a major player in the Welsh orthopaedic scene. Wales is a land united by culture and language but divided by geography. Although the concept of a Welsh Orthopaedic Society had been around for decades the natural horizontal lines of communication with the North-west, Midlands and South of England and established traditions therefrom worked against a North/South orthopaedic alliance. Nevertheless, the organisation of the NHS in Wales is on a Welsh rather than AngloWelsh model and during my early years as a consultant in the 1980s, working in North Wales and Oswestry and with administrative and educational duties throughout Wales, it was apparent that these were suitable times to launch such a society. Of particular note was the groundwork to foster the idea by Dillwyn Evans (Cardiff, Fig. 1), Rowland Hughes (Oswestry, Fig. 2) and Robert Owen (Abergele, Fig. 3) A President was needed and there was none better than Rowland Hughes. His idiosyncratic ways, humour and commitment were a perfect combination for the role. So, with Rowland as President and myself as Secretary, the inaugural meeting was held in Oswestry in March, 1987. The attendance was good, the meeting successful and highlighted by Rowland delivering a convoluted Presidential Lecture during which he failed totally but uproariously to come to terms with double projection. The annual meetings thereafter alternated between north and south and over the years nearly every orthopaedic centre in Wales has been visited. The earlier afternoon meetings were largely case presentations and words of wisdom from senior figures but as the Society developed it became an all-day event and a forum for poster and podium presentations
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Fig. 1 A group of early Welsh or thopaedic surgeons. Dillw yn Evans is seated right nearest the camera
Fig. 2 Rowland Hughes (lef t) with Peris Edwards, another early stalwar t of The Society
by trainees. An early and popular move was to hold at reasonable intervals a three-day Pan-Celtic Meeting involving the Irish and Scottish orthopaedic surgeons. The first was in Portmeirion in 1991 and others have taken place at Killarney (twice), Celtic Manor and
Turnberry. The common denominator for these meetings is a resort hotel with good conference facilities and an on-site or nearby golf course. The Society has no formal constitution or executive and is therefore able to adapt â–ş
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BJJ News | I ssue 4 | S eptember 2014
to progress in a flexible way. The President serves for two years and the Treasurer/ Secretary usually seven or eight. I attended the 27th meeting in Carmarthen and am pleased to report the Society is in good health, with 100 orthopaedic surgeons of all ages in attendance, strongly supported by a large trade exhibition. Tim James is the current President and Neil Price is completing his seventh invaluable year as
Secretary. The scientific programme was of a high standard and taken seriously by trainees. The eponymous lecturers, Stuart Matthews (Oxford) and Dai Rees (Oswestry) were outstanding. Stuart’s Robert Owen Lecture was ‘Advances in Trauma’ and Dai’s Roland Hughes Memorial Lecture, ‘The knee; from Lucy to Michael Owen’ was a tour de force The Annual General Meeting afterwards reflected the relaxed yet efficient way in which
Fig. 3 Rober t Owen (lef t), well into his nineties and still going strong, with Neil Price
WOS is run.The Society and its finances are in good health and the next item for discussion as ever began with the consideration of a formal constitution with elected officers and ended with all agreeing to leave things as they are. This included re-electing Neil Price nem con for a further year. It’s difficult to demit office in WOS if you are doing a good job! He agreed to do the job for a final year which coincidently would be working with The Irish Orthopaedic Association to bring the next Pan-Celtic Meeting on 17th to 19th June at The Vale Resort in Glamorgan (www.vale-hotel.com). There was lively discussion and much support on how to make the event as successful and enjoyable as possible. The AGM finished on a more downbeat note as various members reported difficulties in training and service delivery throughout the Principality. Such sentiments are sadly commonplace in the NHS in England and Wales. Nevertheless, orthopaedic surgeons are generally an upbeat group and the difficulties of daily practice did not deter the members from repairing to a local restaurant where the day finished in a most enjoyable fashion at the Annual Dinner. Those interested in attending the PanCeltic Meeting next June should contact Neil Price (neiljprice@hotmail.com) or Emer Agnew of The Irish Orthopaedic Association (irishortho@gmail.com).
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details
David Jones
Co-Editor, BJJ News davidhajones@hotmail.co.uk
Fig. 4 Tim James (lef t), current President of WOS with Stuar t Matthews
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BJJ News
Orthopod’s View
A. Ross
A letter to the editor...
he Bone and Joint Journal receives a considerable number of Letters to the Editor each month. These are both welcomed and appreciated as contributing to the ongoing scientific debate. Some we receive are crisp, pertinent and written in immaculate English. Others, it is fair to say, are not. So what makes a good letter and when should you consider writing to this (or indeed any other) journal? Indeed, why write a letter in the first place?
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Simply, when you have something to contribute to the debate or a question to ask of those involved in it. You may have picked up an apparent anomaly in a paper which you either believe to be incorrect or which is at odds with your own experience. It is perfectly reasonable to highlight this and to ask the author to comment. If you have published in the field and have peer-reviewed evidence which contradicts the paper in question, so much the better. You might even feel that the authors should have included your paper in their discussion! You may have new information that has not yet been published but which will make a material contribution to the debate. Alternatively, you may simply have a question or point that you wish to raise with the whole
orthopaedic community. All these are entirely valid reasons to write. Just as it is important to know when not to operate, there are occasions when it is important to know when not to write. Firstly, when you are angry about something that has been published which you believe to be complete nonsense, or a rebuttal of a prized (and frequently cited) paper that you have written which has now been proved to be somewhat wide of the mark or, frankly, wrong. Better, under these circumstances, to take a step back from the heat of argument. If others think the paper is nonsense, and have no axe to grind, they will undoubtedly say so. Second, do not write just for the sake of seeing your name in print. We all know of those who are regular letter writers
either to scientific journals or, indeed, to national newspapers. While some (the name of Lord Lexden springs to mind) seem incapable of writing a single dull or irrelevant sentence, there are others who one suspects simply write for the purposes of self-gratification. Third, the letter which is written for the purpose of adding weight and a little cachet to one’s curriculum vitae has a habit of appearing as just that. Fourth, try not to pick up on some tiny fault that has escaped the eyes of the Editor-in-Chief and the three or four other senior surgeons who have also reviewed, read and copy-edited the paper. No paper is perfect: neither are those who prepare it for your perusal. Mind you, if there is a real howler, please let us know! ►
The letter which is written for the purpose of adding weight and a little cachet to one’s curriculum vitae has a habit of appearing as just that.
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BJJ News | I ssue 4 | S eptember 2014
aving decided that you have something relevant to contribute, how should you go about formulating your letter? First, bear in mind that your letter is addressed to the Editor of the journal. The correct salutation is ‘Sir’, however well you might know him. Even if the Editor is a close personal friend and godfather to one of your children, for the purposes of publication of the letter he remains ‘Sir’. In passing, the content of the paper you are referring to should not be referred to as ‘your paper’, it is the author’s paper; the editor is simply responsible for the processes of peer review, editing, subsequent publication and generally holding the whole show together. Next, the content. Keep it brief and to the point. No letter should be more than 300 words long and most should be much shorter. Ideally, a letter should raise one significant point although it is probably acceptable to include two if they are relevant and concisely phrased. A detailed commentary, which might be appropriate for a journal club, is not appropriate in a letter. Try to make your point within the first two sentences. The rest of the letter can back up your argument with evidence. Make sure that the evidence is wellfounded and referenced.
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Try also to avoid an abusive tone to your letter even if you don’t think much of the piece of work in question. Much more effective is to compliment the authors on the quality of their paper and then rebut it point by point!
OCCASIONAL FLASHES OF WIT CAN CERTAINLY HELP TO ENLIVEN A LETTER BUT DO REMEMBER THAT YOU ARE WRITING AS AN ORTHOPAEDIC SURGEON, NOT A STAND-UP COMEDIAN. We estimate that two-thirds of those who read the journal do not have English as a first language. This is also certainly true of some of those who write to us. Nonetheless, it is essential that one group communicates effectively with the other: the way to do this is by writing clear concise English. It’s not easy: our primary editors spend many hours rewriting your papers. We are also happy to do this for your letters but we do have to have somewhere to start! If English is not your first language, it is well worth asking a friend or colleague who writes it fluently to criticise your letter constructively before you submit it. A uthor
SIGNING OFF
It is accepted practice to use ‘Yours faithfully’ having prefaced the letter with ‘Sir’. ‘Yours sincerely’ is used when the salutation is by name. ‘Love and kisses’ is strictly reserved for family. Remember also to give the names of all authors to the letter, their job titles and their institutions. We are encouraging debate: people may wish to correspond.
Much of what I have written will be well known to you. Nevertheless, we see letters on a regular basis which contain examples of the type I have described. This is not a criticism: the style and form of a letter owes much to traditional practice. In the days of electronic communication (yes, I am thinking of text messaging) it can be comforting both to correspondent and reader to have something of a format with which to work. Keep writing: we really do enjoy receiving your letters.
details
Alistair Ross Associate Editor for post-publication debate, BJJ. Co-Editor, BJJ News alistairrossfrcs@hotmail.com
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BJJ News
Orthopod’s view
C. S. B. Galasko
Northern Lights Charles S B Galasko reports on another of his holiday adventures atching the northern lights is, in my opinion, the most spectacular and awe-inspiring phenomenon that the natural world can offer and a sight I will certainly never forget. My wife and I went on a cruise to northern Norway last winter hoping to see them: on the previous cruise we had failed to do so. The northern lights (aurora borealis) can be seen, if the conditions are right, in Northern Scandinavia (Norway, Sweden and Finland), Northern Russia and the northernmost parts of Canada, Greenland and Iceland. There is a mirror image, the southern aurora zone, but this stretches over remote areas of the Antarctic Ocean which are difficult to reach. Rarely, the southern lights (aurora australis) may be seen from the southernmost parts of Australia, New Zealand and the southern tip of South America. In the northern hemisphere, the aurora zone is centred around latitude 65°N which roughly coincides with the Arctic Circle. Within this zone, the northern lights are present day and night but during the summer months it is too bright to be able to see them during the day. The best time for viewing is between September and mid-March. We went in middle to late February. For reasons that are not fully understood, particularly strong auroras tend to occur during the months around the equinoxes i.e. September/October and February/
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March. Auroras can take on many different forms, the colours ranging from a glow on the horizon to the most complex dancing lights. The probability of seeing the northern lights depends largely on the current solar activity and the weather at the location, the most spectacular appearing only during periods of increased solar activity. Auroras occur at a height of approximately 80 to 250 kilometres above the earth. This is above the cloud layer and, therefore, a clear sky is needed. However, it may be possible be see something in clear patches between the clouds. Although we now understand the cause of the northern lights, most northern cultures have a variety of oral legends about them. For example, during the Viking period they were described as reflections of dead maidens or reflections of the shields of the Valkyries, female warriors who chose which slain warriors should be escorted to Valhalla. Other cultures believed that the aurora was a place for the dead, represented the souls of stillborn children or were caused by a wedge of swans who had flown so far to the north that they had been caught in the ice. Each time they flapped their wings, they created reflections resulting in the northern lights. Auroras can extend to lower latitudes and have been seen in northern Britain. In AD37, Emperor Tiberius observed a very red sky north of Rome. He immediately thought that the town of Ostia â–ş
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BJJ News | I ssue 4 | S eptember 2014
(the port of Rome at that time) had been attacked and set aflame and sent his army to protect those living there. In 1938 the northern lights produced the same red hue over central Europe and a fire brigade was summoned to Windsor Castle to put out a fire that turned out to be the aurora! The sun emits visible and invisible light, including ultraviolet and x-rays. It is mainly visible light which penetrates the atmosphere and reaches earth’s surface. The sun also sends out a continuous stream of charged particles, the solar wind. This consists of a shower of electrons and protons which reach a typical speed of about 400 kilometres per second or 1.5 million kilometres per hour. Fortunately, the earth has a protective magnetic field, the magnetosphere. This is where the earth’s magnetic field dominates the solar wind. Without it, our atmosphere would slowly be blown away. Every 11 years or so the sun passes through a “solar maximum” period during which there are many large sun spots, strong magnetic fields and frequent solar storms and about five years later, enters a “solar minimum” when there are few or no spots and infrequent solar storms. During these storms there are large explosions (flares) in the solar atmosphere during which considerable amounts of ultraviolet radiation and x-rays are emitted at the speed of light. Occasionally, large numbers of high-energy particles, mostly protons, are accelerated. When this occurs there is a stronger disturbance in the magnetosphere which leads to prominent northern lights and pushes the auroral oval further south. The activity of the aurora is directly connected with the speed of the solar wind and activity of the solar storm. These geomagnetic storms can be monitored by the Kp index, based on which one can
immediately know if there is a chance of seeing the aurora. Thus, one can obtain aurora forecasts in the same way as weather forecasts. The aurora is formed when the protons and other particles penetrate the magnetosphere.These are projected towards earth along their magnetic field lines which “guide them” towards the polar region. When they reach the earth’s atmosphere, they collide with atoms of oxygen and nitrogen causing their electrons to move to higher-energy orbits further from the nucleus. The electrons rapidly “fall back” to a lower-energy orbit, releasing energy as light. This is why the aurora zones are located around the magnetic north and south poles. Oxygen atoms are the cause of the two most prominent colours of the aurora – green and red. The brightest colour is green or yellowish green. Nitrogen molecules produce a bluish light and deep red, creating the spectacular dancing green, red, white and blue lights in the sky. The two auroras can be totally asymmetric. There is no connection between aurora activity and temperature but the sky tends to be clearer on a cold than a warm night: consequently, the chances of seeing the northern lights increase. Occasionally, the light may be insufficiently strong to be seen by the human eye but will be seen as a green glow in the sky on a picture taken with a prolonged exposure time. The literature advises that to observe the aurora one needs to find a dark place, be suitably clothed to keep warm in the cold winter night and to have patience. This includes having the correct footwear. Nevertheless, the aurora can still be observed where there is light, for example in Tromsø a city in northern Norway which is under the aurora oval. On our trip we had magnificent views whilst the ship was sailing between ports and with its navigational and other lights on (Figs) Patience is required.
Northern Lights: Note for photographers
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details
Charles S. B. Galasko
Emeritus Professor of Orthopaedics, University of Manchester Carolgalasko@aol.com
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If the aurora is particularly bright it may be possible to photograph it with a tripod-mounted digital compact camera if the model has a setting that allows for longer exposures such as “night”. It is preferable, however, to use a digital single lens reflex camera (DSLR) with full manual control. The camera I used was a Sony 300 Alpha DSLR, mounted on a tripod. A wide-angled lens is preferable and the distance is set at infinity. Ideally, one should have a “fast lens” with an f-stop of 2.8 or lower. The lowest on my camera is 6.3. The slower the lens, the higher the ISO setting and the longer the exposure. I used an ISO of 400 with a 30-second exposure. It is recommended that an ISO setting of between 200 and 800 is used and that one tries out the exposure time to obtain the best result. When taking pictures from the boat there are movement artefacts as can be seen by the stars in the photographs. To avoid this one can try to keep the exposure as short as possible and set the ISO as high as 1000-2000.
BJJ News
M. Greiss
Orthopod’s view
Spines and spikes: an update o, not lumbo-sacral spines – a foot surgeon wouldn’t even know where they are but spines and spikes of the prickly variety!! Since my article in British Orthopaedic News (issue 40, 2009) I have been busy enlarging my cactus collection, mainly concentrating on “manageable” plants. Giants are difficult to maintain, re-pot and keep within the restrictions of a standard greenhouse. You can’t keep expanding glasshouses which cost an absolute fortune, only to find that you fill them up in no time. It takes me 2-3 hours to re-pot an 8-foot cereus into a more user friendly 4-foot growing end (top end of plant),
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taking great care not to break the spines (Fig. 1) Yes, spines!! (Figs 2, 3 and 4). Varying in length, areolar distribution, thickness and colour, some can be lethal, others irritating to your skin. Some of the tiny spines appear harmless, but are barbed, inflicting yet more damage. Some are bristly, hairy and quite abrasive. The longest spine is Opuntia’s, reaching four inches (Fig. 5) . Spines not only protect cacti from predatory insects and birds, but they also form a latticework, reducing water loss through evaporation, and provide an insulating layer shielding tender epidermis from extremes of temperatures. Adios, till a future update on cactology.
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Magdi Greiss, retired orthopaedic surgeon in Cumbria, tells us the significance of the spines of his ever-growing collection of cacti
Fig. 3 Thinnest of spines, surrounding Mamillaria, Uno Pico. Again from Mexico
details
Magdi Greiss
caroleg1@supanet.com
Fig. 1 Known as the Golden Barrel, this Mexican cactus is called the Grusonii and can grow to 3 feet in diameter in its native Sierra Nevada, this specimen is 25 years old.
Fig. 2 Straight spines of Mexican Pringlei. Can grow to 16 20 f t tall. This specimen is 10 years old.
Fig. 4 For a peculiar reason, the South American Fero cactus family has hooked spines, the central spine is always pointing downwards Fig. 5 A 3 inch spine belonging to an Opuntia Subulata, native of Peru. Peruvian farmers use this cactus to erect fences around their proper ty for obvious reasons!
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BJJ News | I ssue 4 | S eptember 2014
Letters
BJJ News : your views RE: The Glasgow Fracture Pathway: the right answer to the wrong question
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The response by Gavin Tait1 (BJJ News : your views Issue 3) to our article2 (right), provides a welcome opportunity for further discussion of the process of managing orthopaedic trauma. We believe that our pathway does provide a solution to the question of how to reduce inappropriate and unnecessary recurrent review of the stable fracture with an excellent prognosis. It ensures that more complex injuries are seen by the right specialist at the correct time. Our article did not cover the management of orthopaedic patients who need to be admitted. We believe that the “Glasgow Fracture Pathway” also provides the “right answer” to this question. In one year (2011 to 2012), 2115 patients (23%) who would previously have been referred to a traditional fracture clinic were appropriately and completely managed by the ED/MIU, without any further orthopaedic input. This reflects a significant body of experience in managing these injuries by the consultants, junior medical staff and emergency nurse practitioners in our emergency department and minor injuries unit. These skills are not unique to our hospital and have been replicated in other local and national units. The underlying protocols and consensus have taken effort, persistence and compromise. We believe they can be replicated wherever there is a desire to change. Each unit will have particular local challenges which will require local solutions. Most of Gavin Tait’s response focuses on the question of admitting patients from the ED for further management. We have also addressed this issue as part of “The Glasgow Fracture Pathway”, but the description was outside the scope of the original article. As he correctly points out, patients require a skilled and knowledgeable first assessment. In our
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experience, treatment delays and breaches of the unscheduled care targets did not arise from “active” treatment, but rather from an inexperienced first on-call orthopaedic response, re-examination and clerking in the ED, conflict with other specialties and lack of beds. We have greatly improved the first problem by having a senior trainee as the first on-call bleep-holder during office hours. Most patients do not need to be physically reviewed again in the ED, and after discussion can be admitted directly to the ward for clerking and further management. The senior bleep holder provides an efficient and timely response. Traditionally, delay often occurs in cases of hip pain of indeterminate aetiology, GP referrals of musculoskeletal problems, post-operative complications, back pain and suspected cauda equina syndrome. We have clear pathways and responsibilities. In cases of suspected cauda equina, the ED obtains early imaging, recognising that multiple reviews by increasingly senior specialty staff only delay diagnosis and management. It may appear that the ED has assumed a greater role, but local work has shown that there has been no significant change in the time taken to manage these patients in the ED (BMJ Open publication in press)3. In our experience, there is little additional active management that can be provided in the ED and efforts to explore wounds or remove deep foreign bodies are often doomed to failure because of inadequate instruments, lack of experience and poor lighting. Similarly, repeated attempts at manipulation of many fractures, destined for early operative management, result in unnecessary pain and discomfort for the patient. Obviously, there are exceptions, but early senior discussion provides an effective safety net.
The Glasgow Fracture Pathway
Jenkins PJ et al. BJJ News Issue 2, p22-24. Read it at www.issuu.com/boneandjoint As Gavin Tait acknowledges, the GRI ED has achieved impressive results. This success should be studied and the techniques replicated. At the heart of this evolution is patient safety and satisfaction. We are pleased that the “Glasgow Fracture Pathway” may provide the “right answer” to all these questions.
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Yours faithfully,
P. J. Jenkins A. Ireland L. Rymaszewski
Department of Orthopaedic Surgery Department of Emergency Medicine Glasgow Royal Infirmary
References 1. Tait G. BJJ News : your views. Re: The Glasgow Fracture Pathway: the right answer to the wrong question. BJJ News 2014;Issue 3;19. 2. Jenkins PJ,Gilmour A, Murray O, et al. The Glasgow Fracture Pathway. BJJ News 2014;Issue 2;22-24. 3. Vardy et al. Effect of a redesigned fracture management pathway and ‘virtual’ fracture clinic on ED performance. BMJ Open 2014;4:e005282.
BJJ News
We want your views! E- ma i l : b jjn ew s @ b on e an d jo in t.or g.u k
Re: Non-technical skills
“
We read with interest the article in BJJ News Issue 2 entitled ‘Non-technical skills’1 (right). It raises the important issue of the non-technical skills and leadership which are required by a surgeon or indeed any other hospital clinician. There is increasing recognition of this, not only from within the profession with the development and use of the ‘NOTSS’ (Non-technical Skills for Surgeons) assessment tool, but also following recent failures within the NHS, such as those highlighted in the Francis report. A technically brilliant surgeon who cannot lead, and inspire the best from those around him/her will ultimately be unable to deliver patient care to the highest possible standard. The idea that ‘training an individual to do a manual skill is moderately straightforward’ is perhaps debatable given recent research on psychomotor processes and an increasing suggestion that cognitive function and the ability to remodel may play a role in the individual skills of a surgeon: perhaps the key here is to identify ‘trainability’ rather than absolute technical skills. We question the suggestion that national selection is abandoned. Only one of the five stations in this year’s selection process addressed technical skills, meaning that most marks were given for other assessed attributes. We see no reason why this process cannot be refined to assess non-technical skills more closely and for posts to be offered subject to structured reference, as happens in many other professions. The issue here is surely the fine detail of the national selection process and not the process itself, which could easily be adapted.
Yours faithfully
J.E.Tomlinson M.Yiasemidou
”
Non-technical skills
Buchanan J et al. BJJ News Issue 2 p2-3. Read it at www.issuu.com/boneandjoint
References
1. Buchanan J, Khan S. Non-technical skills. BJJ News 2014;Issue 2;2-3. 2. Francis R, et al. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive summary. http://www.midstaffspublicinquiry.com/sites/default/files/ report/Executive%20summary.pdf
Leadership Fellows, Surgical Simulation, Health Education Yorkshire and the Humber
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BJJ News | I ssue 4 | S eptember 2014
Obituary
Henry Poirier MB BS, FRCS, TD
D. Nairn
1931 – 2014
David Nairn pays tribute to a true polymath
e n r y Po i r i e r w a s C o n s u l t a n t Orthopaedic Surgeon to the Princess Alexandra Hospital in Harlow, Essex. He was born on the 2nd of August 1931 and died on the 13th February 2014, aged 82. His post-war education was at Wanstead County High School during which he immersed himself in all manner of non-academic pursuits, including rugby, athletics, acting, debating, painting and the air section of the CCF. He also joined and attended the Ilford Jewish Youth Club. His father tragically died when he was 15 years old and his uncle became his sponsor. His initial wish was to study architecture but this was vetoed by the family who felt at the time it was not a secure profession but were prepared to fund his education in medicine. Notwithstanding his many and diverse activities at school he managed to achieve a scholarship to St Bartholomew’s Hospital and thoroughly enjoyed
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his time as a medical student, pursuing all the activities he had engaged in at school, especially the stage, performing in plays and acting in and writing Christmas shows. He qualified MB BS in June 1954 and was appointed to prestigious house jobs at Barts. He was house physician to Sir Ronald Bodley-Scott, and house surgeon to Messrs Basil Hume and Alan Hunt. In August 1954 he was conscripted into the army for his National Service and was posted for two years to Malaya at the Military Hospital where he was exposed to substantial amounts of trauma, as there was still an emergency in the region. He also spent three months as the RMO to the 1st Battalion of the Queen’s Royal Regiment stationed in Singapore where he was promoted to the rank of Major. After National Service he joined the Territorial Army and commanded a field surgical team, which committed him to a minimum of two weeks of army camp a year, which he continued well into his time as a consultant. He was awarded a Territorial Decoration with Bar. In order to pursue a surgical career he became an anatomy demonstrator at King’s College in the Strand passing the Primary FRCS at his first attempt, during which time he met his future wife Marian: they were married in August 1959. This was followed by a two-year general surgical registrar post back at Barts which enabled him to obtain the final FRCS exam at the first attempt. In 1960 he was appointed registrar to The Royal National Orthopaedic Hospital at Stanmore and Great Portland Street where he stayed until his consultant appointment at Harlow in January 1965. He wrote peer-reviewed, cited articles on ‘Massive Osteolysis of the Humerus treated with Resection
BJJ News
With his medical knowledge and skiing skills, Henry co-founded ‘The Uphill Ski Club’, a charity which enables disabled young people to enjoy the experience and freedom of skiing
and Prosthetic Replacement’ and ‘Epiphyseal Stapling and Leg Equalisation’ both of which were published in the Journal of Bone and Joint Surgery. From the RNOH he was sent by Seddon to work for four months in France under Professor Albert Trillat of Lyons, one of Europe’s leading knee surgeons: knee surgery was to become his special interest. It also inspired in him a love of France and all things French. In January 1965 he joined Geoffrey Fisk at the new Princess Alexandra Hospital in Harlow at the very young age of 34. He also took sessions at The Herts and Essex Hospital in Bishops Stortford, at the time a busy general hospital receiving acute orthopaedic and trauma admissions. With Fisk he was instrumental in ensuring that orthopaedic Registrars from Barts spent six months at Harlow in what became the prestigious Percivall Pott rotation. He set up a knee clinic at Harlow and joined the International and European societies of knee surgeons and was a founder member of The British Society for Surgery of the Knee (BASK) He was at a point in his career when newly emerging procedures relating to the knee were being introduced, in particular arthroscopy, (although just before the common use of the video stack), total knee replacement and extra-articular stabilisation techniques for ruptured cruciate ligaments. Many procedures, such as tibial and femoral osteotomy, and patellar advancement and realignment, were performed to stave off the inevitable time that total knee replacement would be required. Further papers pertaining to the morbidity of arthroscopy and chondromalacia of the unstable patella were published from his unit and there were many presentations to learned societies. He was a popular and respected trainer of orthopaedic surgeons in the North Thames Region and was appointed President of the Percivall Pott Club in 1991. He had invitations to lecture as visiting Professor at Boston University and also lectured in Canada and Belgium. At various times he sat on and chaired hospital and regional committees, pulling his
A uthor
weight in a medical advisory capacity and involving himself in administration. Outside his professional achievements he continued his love affair with the stage joining the Bishops Stortford Amateur Operatic Society and three other theatre groups with which he played many leading roles, using his fine baritone voice to its full effect. He continued to tread the boards both behind and in front of the stage in musicals and theatre until well after his retirement. He excelled at alpine skiing, having been taught as a teenager, and with his medical knowledge and skiing skills was invited, with the paediatrician, David Morris, to co-found The Uphill Ski Club (now Disability Snowsport UK), a charity which enabled disabled young people to enjoy the experience and freedom of skiing and moving over snow, an organization which flourishes to this day. In addition to these activities he was a natural writer and wrote short stories, books, plays and poems, some of which were published privately. Not satisfied with these achievements he was a prodigious artist creating paintings and drawings ranging from portraits to landscapes, many painted in his traditional house in France. He loved beautiful crafted artifacts and was a knowledgeable collector of oriental cloisonné. He loved good food and became an accomplished cook with a critical appreciation of fine wine. He was blessed with a “twinkly” persona without a trace of conceit or pomposity: everyone who got to know him greatly enjoyed his company, respected and admired him. Unfortunately abdominal surgery in 1989 led to his early retirement in 1991, but allowed him to indulge his wide range of interests outside medicine. Sadly, his final year or so of life was beset by illness relating to his previous surgery which he bore with stoicism and without complaint. In short Henry Poirier was a true polymath with amazingly wide ranging interests and multiple talents who will leave a substantial gap in his community. He is survived by his wife Marian, three children Nicole, Paul and David and seven grandchildren.
details
David Nairn
Consultant Orthopaedic Surgeon, Harlow, Essex david@dsnairn.freeserve.co.uk
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agile thinking in motion
Wrightington Hip Updates Periprosthetic Hip Infection Meeting
Providing Registrars and Consultants an opportunity to explore the full range of techniques and learn from the experienced faculty. Conference Centre, Wrightington Hospital Hall Lane, Appley Bridge, West Lancashire, WN6 9EP Course Convenors: Prof. Tim Board, Mr. Henry Wynn Jones & Mr. Anil Gambhir
Taking place on Friday 14th November 2014, 8.30am - 4pm To register for the course or for more information please
contact: education@orthodynamics.co.uk
OrthoD Industrial Park Bourton on the Water Gloucestershire GL54 2HQ United Kingdom
Places are limited so please register early
tel. email
Course fee - ÂŁ100 for consultants. ÂŁ50 for Registrars
website www.orthodynamics.co.uk
+44 (0) 1451 821311 education@orthodynamics.co.uk