Journal of Trauma & Orthopaedics - Vol 1 / Iss 1 by British Orthopaedic Association

The journal OF the British Orthopaedic Association Volume 01 / Issue 01 / June 2013 boa.ac.uk

Inside Read the News and Updates section for the latest from the BOA and beyond

Our Features section includes articles on the Francis report, specialised commissioning and medicolegal issues

For the latest updates on clinical issues, see our Peer-Reviewed Articles which, in this issue, focus mainly on upper limb surgery

News & Updates ––– Pages 01-14

Features ––– Pages 16-39

Peer-Reviewed Articles ––– Pages 40-56

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News and Updates

Welcome to a new journal

Contents

Martyn Porter, BOA President

The BOA is pleased to introduce the Journal of Trauma and Orthopaedics (JTO); a new professional and instructional journal for all professionals involved in trauma and orthopaedics. We hope you enjoy reading it.

This journal will be distributed to both members and non-members of the BOA free of charge, and will replace the BOA’s member-only publication ‘British Orthopaedic News’ (BON). Readers may be asking ‘why the JTO?’ and why ‘pass the baton’ from BON? Firstly, we have chosen to build on the news and ‘magazine’ style that BOA members found in BON; while this was very good and an important communication portal, we have felt that more could be provided in terms of structured educational material that would be of benefit to members and also the wider audience. We were aware, for example, that there are outstanding invited or guest lectures that are given at the BOA Congress or at Specialist Society meetings and then are lost in the ‘ether’. JTO is an opportunity to capture these lectures and publish and preserve them for the wider benefit of all. These articles will be peer reviewed to reinforce the direction of travel and standards of the new Journal. There are also opportunities for the Specialist Societies to have a regular section in the journal and to promote other areas of interest such as medicolegal practice. As you will see from this issue we have a wide range of articles, from latest news to peer reviewed instructional content later in the journal. We believe this provides a complementary offering to existing

publications, such as The Bone and Joint Journal, and will serve to keep BOA members and the wider community fully up-to-date on the latest issues of policy and practice. Secondly, the new journal has the potential to attract an advertising income which will offset production costs and allow the BOA to reinvest previous expenditure into other areas. This new structure will allow us to distribute the Journal free of charge to a much wider audience to promote the work of the BOA, its members and the Specialist Societies. The transition from BON to JTO has been very rapid and as BOA President I have accepted the responsibility of being the interim Editor of this new journal, but we aim to make a substantive appointment in the near future. I would also like to recognise the popularity of BON which was produced under the able editorial control of, successively, Christopher Ackroyd, Frank Horan, David Jones, Neil Rushton, Michael Benson and Alistair Ross, assisted by the evergreen David Adams. We thank all these Editors very much for all their hard work and commitment to BON (and to the BOA) over the last 24 years; it has been very much appreciated by all. I hope you enjoy reading this issue and welcome your articles and comments.

News and updates

01–14

Features:

16–39

Francis report Specialised commissioning Charnley Patient liaison BOA Congress BODS Certification of medicolegal experts Whiplash

16 20 24 28 29 34 35 38

Peer-Reviewed Features 40–56

Wrist arthroplasty, Parts I and II IA Trail and AC Watts PROMs – how was it for you? CR Howie and DF Hamilton Distal humerus intraarticular fractures R Amirfeyz and D Stanley

40, 44 49 52

Obituary and in memoriam

General information & instructions for authors

Cover image: Relay race. Computer enhanced X-ray of runners exchanging a baton during a race. GUSTOIMAGES/SCIENCE PHOTO LIBRARY

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News and Updates

In this issue Martyn Porter, BOA President

These are times of great change for the NHS and for orthopaedics, and the JTO is designed to reflect this, across its three sections.

The first section is for news and updates, covering both what the BOA is doing and policy developments in the health sector that are relevant to us. In this issue, we include articles on a range of issues from our commissioning guidance workstream (p. 03) to our Training Orthopaedic Trainers course (p. 11), and from implementing the ‘Getting it Right First Time’ report (p. 12) to the EFORT 2014 congress (p. 10).

The second section is for opinion, reflection and debate on topics of current interest and specialty significance. This issue provides Tim Briggs’ thoughts on specialised commissioning (p. 20), mine on the Francis report (p. 16) and Mike Wroblewski’s on Charnley and the origins of the low frictional torque arthroplasty (p. 24). You can also read about the invaluable work of the BOA’s Patient Liaison Group (PLG) (p. 28) as well as the first articles of our medicolegal section (p. 35). Thirdly, we are providing in-depth peer reviewed articles for clinical and instructional purposes, and over the forthcoming issues we plan to cover the full range of orthopaedic subspecialty areas. Contained in this issue are two articles on arthroplasty of the wrist and another on patient-reported outcome measures.

Finally, can I highlight the BOA Congress information on the centrefold page. This year’s programme and event details are provided, and I hope these will entice you. If you have already registered, please do share this with colleagues. For future issues of the journal, we welcome contributions from readers, either in the form of letters to the editor responding to the current articles, or features and articles on new topics (for further details on submission, please see p. 60). I look forward to hearing from you.

Three BOA members appointed as National Clinical Directors In March, the NHS England Medical Director Professor Sir Bruce Keogh announced the names of the 21 National Clinical Directors (NCDs) appointed to provide expert advice and to support policy development across a range of conditions and services.

Peter Kay

Charles Greenough

Chris Moran

Three of these positions are related directly to T&O and we are delighted that three of our own members have been appointed to these roles:

Upon the announcement, Sir Bruce commented that:

“We have appointed high-calibre clinicians to all these posts, and they will play a key role in the development of clinically-led, patient-focused’ care across all areas of the NHS.”

Musculoskeletal – Professor Peter Kay (Wrightington) Spinal – Professor Charles Greenough (South Tees) Major Trauma – Professor Chris Moran (Nottingham)

“The restructured NHS has clinical leadership at its heart, and will make its decisions based on the very best possible clinical evidence and expert advice. Our national clinical directors will provide the expert insight, knowledge and research we need in order to understand and address the challenges we face in all different aspects of NHS care.

The creation of a national position for MSK has been particularly welcomed, both by the BOA and the wider MSK community. Peter Kay will bring a wealth of expertise and experience to the role and provide valuable strategic direction to this broad area of clinical practice.

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Clinical commissioning guidance for orthopaedic services One strand of the BOA’s 5-point Practice Strategy, entitled ‘Restoring Your Mobility’, has been focused on bringing about improvements in the commissioning and delivery of orthopaedic services through the development of evidence-based guidance for commissioners.

Last year, we embarked upon a programme of identifying high volume, high cost procedures within each sub-specialty area of orthopaedic practice, and commissioning guidance documents have been developed for each. The project is overseen by Professor Dias from the BOA and supported by BOA staff led by Julia Trusler. The documents in progress so far include:

Specialty Topic

Group chairperson

Hip

Painful osteoarthritis of the hip

Foot & Ankle

Painful deformed great toe in adults

Knee

Painful osteoarthritis of the knee

Andrew Price

Elbow & Shoulder

Subacromial shoulder pain

Rohit Kulkarni

Hand

Painful tingling fingers

Prof. Ian Trail

Spine

Low back pain

John Carvell

Prof. Gordon Bannister Kartik Hariharan

The commissioning guides have been developed using a defined process, accredited by NICE, and will bear the NICE accreditation mark. Each guide is put together by a dedicated guidance development group. These groups are chaired by a clinician who specialises in the particular area of care, and have representatives from primary care, physicians, commissioners and patient groups as well as other clinicians involved in the delivery of the service. In this respect, the development process is intended to produce a consensus statement from different stakeholders to define optimal commissioning of services for these conditions. These commissioning guides are intended as a resource to help commissioners specify high quality and evidence based high value care across England for these common musculoskeletal disorders. They outline services across primary, intermediate and secondary care, and note tertiary and specialist provision that is commissioned separately by NHS England. Each has been written to include

recommendations of audit and peer review measures and suggest quality specifications for CQUINs to assist in preparation of contracts and service level agreements. The Commissioning Guidance project has been run in partnership with RightCare and The Royal College of Surgeons of England. The BOA has devoted considerable resources to this project especially in quality assurance. RightCare has provided funding to facilitate meetings and for literature reviews. Each document includes a ‘Dashboard’ that has been developed in collaboration with the BOA and each development group by Methods Insight Analysis, and an online ‘Procedures Explorer Tool’ has been developed to provide further data for CCGs and Providers allowing timely performance monitoring. Several of the guidelines were put out for public consultation and peer review just prior to the publication of JTO (deadline for responses will be mid-June), and further guidelines will follow soon. Further details are available on our website.

BOA Instructional Course 10–12 January 2014: Save the date! The next BOA Instructional Course will be taking place on 10th – 12th January 2014 at Manchester Conference Centre. The course is designed to assist surgical trainees who are preparing for their FRCS examination. Each session at the course will be chaired by experts in the field of trauma and orthopaedics, and the topics will be: knee, elbow, paediatrics and basic science. More information about the registration process will be available soon, and in the meantime please visit http://bit.ly/boainstructional An extract from a commissioning dashboard

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News and Updates

Advisory Committee on Clinical Excellence Awards 2012 We were delighted to learn that a number of BOA members were successful in their applications for Clinical Excellence Awards in the 2012 round. No doubt readers will agree that too frequently orthopaedic surgeons are not successful in their applications, so these awards represent an excellent achievement.

We would particularly like to recognise the success of the candidates listed below, and our appreciation for the work they do for the BOA:

Gold Awards:

Professor Andy Carr – Chair of BOA Research Board

Silver Awards:

Professor Amar Rangan – Chair of BOA Research Committee Alistair Stirling – BOA Council

Bronze Awards:

Mike Reed – BOA Training Standards Committee

Advisory Committee on Clinical Excellence Awards 2013 As you may be aware, ACCEA remains under review but we have been advised that the Board is in the early stages of a ‘possible’ round for 2013. It is assumed that, should the 2013 round go ahead, the award scheme will proceed in a manner similar to that for 2012, with the application process remaining the same. We will be keeping BOA members informed of any updates from the ACCEA so look out for updates on the website. Please note: the shortlisting for BOA members who applied for BOA support in the 2013 round has already taken place, and applicants have been notified of the results. If for any reason you have not heard from us, please contact Rosanna Raison (r.raison@boa.ac.uk).

Appointments Congratulations are due to the following BOA members, on their recent appointments: Mr Ian Ritchie, President, Royal College of Surgeons of Edinburgh (2012-2015) Professor Jimmy Hutchison, Vice President, Royal College of Surgeons of Edinburgh (2012-2015) Mr Steve Cannon, Honorary Treasurer, Royal College of Surgeons of England (from 2013) and President of EFORT (from 2014) Professor Tim Briggs, Elected Member of Council, Royal College of Surgeons of England (from 2013)

Publication of individual surgeon outcomes For surgeons of all specialties across England, the NHS England (formerly NHS Commissioning Board) initiative to publish individual surgeon outcomes information has sparked debate and reflection. The initiative was first outlined in “Everyone Counts: Planning for Patients in 2013/14” last December, which advised that the first publication should happen by the end of June 2013.

The BOA’s position on this has been carefully considered, and we have been engaged in various meetings and discussions with specialist societies and other stakeholders, as members will know from numerous emails and letters. There are wide-ranging issues that we continue to address, including handling of outliers, consent and details about the presentation and communication of the information.

At the time of going to press for the Journal of Trauma and Orthopaedics, the next important milestone is the planned communication to surgeons to provide them access to their data for validation and final instructions on consenting to publication. This is due to take place soon, and surgeons will have two weeks to respond. The final publication of the information is due to follow later in June, and will feature on the NJR website.

The publication is expected to attract significant publicity - we are working with the Royal College of Surgeons, Department of Health and other players to ensure there is consistency and coordination here. BOA members will continue to be updated on the website and by email.

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News and Updates

BOA Business updates The BOA undertakes a wide range of activities for and on behalf of members. Some of the recent areas of work include the following.

BOA E-learning appointments and ‘wikipaedics’ Tim Chesser has been appointed as Chair of the BOA Trauma Group, taking over from Professor Chris Moran, following his appointment as a National Clinical Director. Two further members of this group have been appointed: John Keating and Cheryl Baldwick. Two new appointments have also been made to the Professional Practice Committee: Ian McDermott and Ivan Brenkel. Our newly reconfigured Research Committee has held its first meeting recently, in the form of an away day. Its members are: Professor Ashley Blom, Matthew Costa, Professor Alan Johnstone, Professor Andrew McCaskie, Andrew Price and Mark Wilkinson, with Professor Amar Rangan as Chair, and they will be reporting in future issues of JTO on their plans and progress.

We are grateful to all those who undertake a committee or honorary role on behalf of the BOA, and the time, energy and commitment they give to their work. If you are interested in contributing, please look out for opportunities in the Presidential email.

T&O curriculum The GMC has approved the BOA’s major curriculum review, which will go live from August this year. The Training Standards Committee are working on a strategy to launch this as well as designing a simulation curriculum with the aim of improving patient safety. The simulation curriculum will take the form of recommendations for low cost and often low tech simulation which can be made accessible to all trainees.

As some members may be aware, the BOA has acquired the content previously featured on the Orthoteers website in order to create our own e-learning platform for members. The project is currently under the working title of Wikipaedics and is being led by Steve Cannon as Editor in Chief and Chris Colton as Executive Editor. The intention is to style it as a ‘wiki’, with the opportunity for readers to submit edits, which would go through a review process to be approved, to ensure the ongoing accuracy of the information. The e-learning platform will be structured according to the ten areas of the recently revised T&O Curriculum, and will act as a ‘one stop shop’ for trainees to provide not only a trusted online revision aid, but links to other useful online resources. We are currently recruiting specialist section editors to work on each area, and they will recruit authors to support them. If you are interested in being involved, or you would like to suggest an alternative title for the project, please contact Craig Dove (c.dove@boa.ac.uk). We are very grateful to everyone who is contributing.

Invited reviews for hip fracture services The BOA has been asked to conduct multidisciplinary reviews of the hip fracture services in some NHS Trusts that have been identified as potential outliers. These requests have come in following reports from Dr Foster and the National Hip Fracture Database suggesting higher than expected mortality in patients treated at these Trusts.

The reviews are being overseen by the Trauma Group and designed to be supportive and pragmatic. The reviewers include representatives of the relevant societies including Trauma and Orthopaedic Surgeons, Anaesthetists, Orthogeriatricians and Hip Fracture Specialist Nurses. So far this year, two reviews have taken place and one further review is planned for later in the summer. Initial feedback from the reviews has been very positive and a similar peer review process is expected to be recommended for outlying Major Trauma Centres.

National selection of trainees into ST3 As readers may be aware the selection process into ST3 took place in March at the Elland Road Stadium in Leeds. Although National Selection is used widely in other specialties, the BOA has had some concerns about its implementation for orthopaedics, and we continue to engage with the Lead Dean and others involved in the process design. The initial feedback from both interviewers and interviewees has, on the whole, been positive; however, we are actively involved with this and continue to take a keen interest in the results and data that stem from it. We remain committed to our principles of a selection process that is fair, transparent and cost effective, and appoints the candidates who will be best able to provide care to the population.

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News and Updates

BOA advisory Learning book on agreements consultant T&O services The BOA’s advisory book was last updated in 2007, and is currently undergoing a review. The Professional Practice Committee is overseeing this (with Alison Armstrong leading on this initiative), and is working with various members with different areas of expertise to ensure this is brought fully up-to-date. If you have suggestions for improving this book or areas you feel should be covered in future, please contact Rosanna Raison (r.raison@boa. ac.uk).

The BOA has become aware of an area of confusion with Learning Agreements, in that there are two types available on the Intercollegiate Surgical Curriculum Programme (ISCP) website. When setting up a placement in ISCP the trainer/ trainee are prompted to select either an ISCP or Orthopaedic Competence Assessment Project (OCAP) agreement. The trauma and orthopaedic OCAP agreement was introduced to the website when OCAP integrated with ISCP in 2011. The OCAP agreement is procedure based and is aimed at those in ST3 and above placements. The ISCP agreement is topic based and trainees are required to populate their agreements with topics taken from the syllabus. To demonstrate progress against each topic, trainees must attach work-based assessments to them. On the other hand, those using OCAP agreements are not required to attach topics to their assessments and can ignore this option when recording assessments. The BOA’s Training Standards Committee is looking into ways of removing this confusion, and will provide further updates in JTO.

Update on Beyond Compliance Beyond Compliance (BC) was formally introduced to the BOA membership at last autumn’s Congress. As was stressed then, BC is a completely voluntary process which can come into play after granting of the EU CE mark and this firmly remains the case. The principal aim is to lessen the likelihood of another poorly performing implant being widely used before being identified as an outlier. Since last September, the first version of a dedicated website (www.beyondcompliance.org. uk) has been designed and a pilot study is well underway. Keith Tucker of the Beyond Compliance team welcomes feedback on the website (ktucker77@aol.com or via the BOA office). As explained on the website, BC is overseen by an advisory group (that essentially comprises the members of the Orthopaedic Data Evaluation Panel) with two main areas of responsibility.

Their first job is to discuss with the manufacturer and the champion surgeons the inherent level of risk in any new device (or modification to an existing device) and then to agree a rate of introduction to the market. The second duty of the advisory group is to monitor the performance of the device through a post-market surveillance process which runs through the National Joint Registry (NJR). The post-operative upload of the operation to the NJR is completed in the usual manner. The implant will then be identified by the NJR (by its code number) as a BC device: the NJR database will immediately copy the upload into a designated BC file. The champion surgeons, the manufacturer and the responsible member of the advisory group will be able to access this file to which PROMs, Office of National Statistics and HES data will automatically be added. The surgeon will also be able upload X rays, operation videos, operation and follow-up notes to this file. The patient’s file will be collated with the other files for that particular BC device and that data will be available for analysis and discussion on a regular basis. The Pilot study should be completed later this year.

Benefits of BOA membership The BOA is pleased to announce four new additional benefits of membership of the BOA, that have been arranged through the establishment of affinity schemes with relevant companies. All existing members are able to access these benefits with immediate effect. We hope that these offerings will provide added value to our membership. For further information about all these benefits and how members can take advantage of them, please visit www.boa.ac.uk.

Medical malpractice cover from CJ Coleman (www.cjcoleman.com) Lloyd’s Brokers, C J Coleman is offering Medical Malpractice cover with carefully chosen insurers for orthopaedic consultants and surgeons in private practice in the UK. Arranging cover through C J Coleman will entitle you to a free legal insurance policy covering the following: Employment disputes Bodily injury Attendance expenses at jury service Commercial property protection Tax enquiries

Income protection insurance from PG Mutual (www.pgmutual.co.uk) PG Mutual is a not-for-profit membership organisation that provides income protection insurance. They are offering a 20% discount off the standard rate for 36 months for new BOA customers. Wisepress (www.wisepress.com) Wisepress Medical Bookshop has agreed to offer a 15% discount for all BOA members purchasing books from their online store, including ebooks. (See p. 14)

Private healthcare insurance from Western Provident Association (WPA) (www.wpa.org.uk) WPA is offering preferential rates for BOA members and their families when joining. The arrangements include: A substantial discount in the first year and a 10% on-going discount for the life of the policy. Easy to switch terms from your current insurer Clinical freedom to choose your consultant and hospital

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News and Updates

BOA and the EFORT Executive Committee host 2014 EFORT Congress in London While EFORT 2013 is just getting under way as the Journal of Trauma and Orthopaedics goes to print, plans are already progressing well for 2014. The 15th EFORT Congress will be taking place in June 2014 at the Excel Centre in London. This will be a joint meeting between EFORT and the BOA: the central theme will be patient safety - the motto for London 2014.

The EFORT education committee has planned an extensive programme covering differing topics from basic research to areas within daily practice of orthopaedics and trauma. The BOA’s own cyclical education programme will be incorporated into the meeting and will be open to all participants. The format of the meeting is specially designed to encourage interaction between participants, with symposia and instructional lectures being delivered by distinguished speakers from all over Europe. A delegation from the American Academy of Orthopaedic surgeons (AAOS) will also be joining the Congress. The Mike Freeman and Erwin Morscher Honorary lectures will be delivered by two highly distinguished orthopaedic surgeons, and the Plenary lectures of the BOA will also be included in the programme and open to all participants.

A number of Specialist Societies will be represented at the Congress and will host a series of regionally focused sessions throughout the programme. There will also be representation from industry whose symposia workshops and technical exhibits will form an important segment of the Congress as a whole. We hope that the Congress will be well-attended by members of the BOA and other UK trauma and orthopaedic surgeons – do note the date for your diary: 4 – 6 June, 2014. We also hope that many may submit abstracts for the conference, and would highlight that the timetable for this will require these to be submitted by 4 November, 2013. For BOA members’ information, we plan to hold a closed national meeting in September 2014 with a focus on clinical leadership and the future shape of the BOA.

Conference listing: Organisation Conference/meeting (BESS) British Elbow and Shoulder Society http://www.bess.org.uk

24th Annual Scientific meeting 19 – 21 June 2013, Leicester

(BSCOS) British Society for Children’s Orthopaedic Surgery http://bscos.org.uk/index.html

BSCOS Summer Meeting 28 June 2013, Leicester

(BORS) British Orthopaedic Research Society http://www.borsoc.org.uk

British Orthopaedic Research Society/ Bone Research Society joint meeting 4 – 5 September 2013, Oxford

(BSS) British Scoliosis Society http://www.britscoliosissoc.org.uk

BSS Annual Meeting 12 – 13 September 2013, Stoke on Trent

(SBPR) Society for Back Pain Research http://www.sbpr.info

SPBR Conference 14 – 15 November 2013, London

(BOFAS) British Orthopaedic Foot and Ankle Society http://www.bofas.org.uk

Annual Scientific Meeting 6 – 8 November 2013, Belfast

(BOA) British Orthopaedic Association http://www.boa.ac.uk/Pages/Welcome.aspx

Annual Congress 2013 1 – 4 October 2013, Birmingham

(EFORT) European Federation of National Associations of Orthopaedics and Traumatology https://www.efort.org/index.php/events-calendar/efort-event-directory

15th EFORT Congress 4 – 6 June 2014, London

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News and Updates

Training Orthopaedic Trainers (TOTs) programme

The BOA’s TOTs course continues to go from strength to strength, as you can read from these two accounts from recent courses. Places are now available for our November course, which costs just £400 for BOA members and £700 for non-members. More information is available online at bitly.com/boatots.

Lisa Hadfield-Law, BOA Education Adviser and TOTs trainer, describes her experience of the January Wrightington course Wrightington was one of the locations hit hardest by snow on 25 January 2013. Despite the adverse weather conditions, participants battled through to attend the two day TOTs programme. Peter Kay resorted to chopping up fallen trees with the axe he carries in his boot (but that’s another tale).

[Fig. 1]

[Fig. 2]

Watching and learning…

…then doing

Aside from learning how to maximise teaching opportunities in surgical practice, Adam Watts learned how to play a forward defensive from Mukesh Hemmady. Ian Trail taught Rob Smith how to tie a sling and Michael Walton taught Martyn Porter how to fold his clothes more efficiently (Figs 1,2). So... important lessons were shared alongside some great fun. Participants were also able to satisfy both revalidation and trainer recognition requirements It took me eight hours to get home afterwards, but I can honestly say, it was worth every minute. The Wrightington surgeons are a cohesive, wise and committed team.

Lisa Hadfield-Law

Dennis Kosuge

Dennis Kosuge, TOTs attendee, describes how he put theory into practice

I know the challenges of putting theory into practice, considering time pressures commonly encountered in the NHS: the patient who requires a straightforward Weber B ankle fracture ORIF; an overbooked trauma list; an anaesthetist who insists this is not a ‘teaching case’ and staff wanting to go home on time. However, one important point that I have taken away from TOTs is that teaching is not all-or-nothing – it is perfectly reasonable to focus on learning one aspect of a procedure (e.g. trainee to learn how to and perform reduction of the fracture intra-operatively whilst the trainer performs the rest of the procedure) when time is scarce. The trainee is likely to gain much more in the long-term by taking a structured approach, compared to overloading them with the entire procedure under pressure.

I was on-call over the weekend after TOTs, so had an excellent opportunity to put learning into practice, whilst everything was fresh. I learnt that giving constructive feedback and reflecting on a learning experience is extremely important and I am confident that the trainee who performed a distal radius fracture ORIF and a hemiarthroplasty, under my supervision, took home the positive points of his performances and just as importantly what he could consider doing differently next time. I have been guilty of, and have experienced myself, the all too common focus on unconstructive negative feedback after a learning experience in theatre – it is not productive. When registering the cases on elogbook, I marked the box ‘Training a trainee’ and on this occasion it had more meaning to me than previously.

This course has highlighted to me the importance of the principles of learning and how we, as trainers, can influence the trainee’s learning experience – the trainer must be flexible and adapt to individual trainee needs to ensure engagement. I put it to you that we can all be better trainers.

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News and Updates

Getting It Right First Time wins Government funding for national professional pilot Tim Briggs

Professor Tim Briggs, BOA Vice President, Chair of National Clinical Reference Group in Specialist Orthopaedics, Chair, Federation of Specialist Hospitals

The report ‘Getting it right first time’ (GIRFT), which was launched at the House of Commons in September1, has now won Government backing for a full national trial across England. I will be working closely with the BOA and the Executive Group, and a number of key stakeholders, to deliver a full scale national analysis of the key metrics identified in the report and network recommendations for each health economy. A steering group of key stakeholders will provide project governance. This report reviews the current state of England’s orthopaedic provision and sets out clear solutions where changes can be made to improve pathways of care, patient experience and outcomes with significant cost savings. This approach can deliver a timely and cost effective improvement in the standard of orthopaedic care across England. The project will be a national professional trial funded by NHS England aimed at auditing national orthopaedic performance and rolling out the principles of GIRFT, while integrating the outputs of the work of a range of complementary workstreams. The reports produced by the national pilot will also provide a clear foundation for the incoming National Clinical Director for MSK in respect of routine and specialist secondary and tertiary elective orthopaedics.

Tim Briggs

What we hope to achieve is complementary to the work that the BOA’s Restoring Your Mobility programme is undertaking to develop a suite of best practice pathways for high volume orthopaedic procedures and the Beyond Compliance framework. It also complements the work of the Clinical Reference Group, which I chair, that is drawing up the service specification for the specialised commissioning of specialist orthopaedics. Indeed, the programme will drive forward the implementation of the recommendations of these important pieces of work. Finally, our programme will be complementary to the findings of the National Spinal Review, the Spinal Disorders Clinical Reference Group and a project to review musculoskeletal networks in primary care that the Arthritis and Musculoskeletal Alliance (ARMA2) is working on with the BOA and BSR amongst other organisations.

It will evaluate a number of key quality indicators to assess the safety, effectiveness and patient experience indicators relevant to the above services at every secondary and tertiary care provider to highlight best practice and outlier areas of concern – for example infection, revision rates, readmission, mortality, patient experience feedback, National Joint Registry data and PROMs. It will also make academic activities (training, education and research) relevant to supporting the above services now and in the future.

In terms of the wider medical and orthopaedic community the project has buy-in from stakeholders, including the British Orthopaedic Directors Society, ARMA and the Specialist Orthopaedic Alliance.

Once these reports have been shared with the CCGs and providers, a visit will be made to each Trust to meet with key staff to understand the ‘stories’ behind the data and to map the informal and formal networks that are in place. A year-long rolling programme of reports and site visits is planned. Visits will be undertaken by members of the project panel who will include key stakeholders from members of the Spinal Taskforce or ARMA and the Executive Group of the BOA, as well as local clinicians. It is planned that each visit should include meetings or contact with the clinical director and manager in charge of orthopaedics, representatives from the consultant body, representatives from the lead commissioner and from radiology and physiotherapy.

The project will focus on care within secondary and tertiary acute, urgent, specialist and routine elective orthopaedic surgical procedure pathways and associated medical, pain management and rehabilitation pathways and the relevant clinical support activities.

The pilot will involve producing a data profile for providers across England – done in a rolling programme, where invited. The baseline data set for these reports will include: HES, NJR, PROMs, variation, litigation, readmissions, infection, mortality, day case arthroscopies, atlas of variation and fractured neck of femur best practice adherence.

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It seems vital that we embrace this opportunity to provide clinical leadership and share excellent practice to reduce variations in quality of outcome Particular focus will be given to understanding how the Trust’s pathways vary against the model pathways developed for six high value pathways as a part of the BOA’s Restoring Your Mobility programme. After the year-long programme of research and meetings, reports will be produced for each health economy, region and for the whole country in the form of a final national report produced for Sir Bruce Keogh and the Secretary of State for Health. These reports will combine the outcomes of the data analysis and meetings to comment upon the quality of the elective orthopaedic service that the provider, health economy or region delivers. The reports will also make recommendations relating to critical mass volume thresholds across routine and specialist activity, network and partnership changes; and governance relating to the selection of prostheses and the adoption of new procedures or ways of working. They may also include recommendations to support the configuration of academic activities that will ensure training, education and research is effective.

In terms of measuring the effectiveness of the programme a number of key metrics will be suggested. These will include reductions in prostheses costs, loan kit costs, readmission rates, length of stay and surgical site infection. In the longer term it is intended that there will be a measurable shift in national variation of outcome for a number of high volume procedures, a reduction in outliers on the National Joint Registry, an improvement across the board in revision rates and a reduction in the number and rate of increase in orthopaedic litigation. The project began in April 2013 and will report in April 2014, with implementation of report recommendations to start in the second quarter of the financial year 2014-2015, the intention being to see improvements in provision, where this is required, and evidence of savings within that year.

The annual budget for musculoskeletal disease is about £10 billion. Currently 25% of all surgical interventions in secondary care are for musculoskeletal disease. With an ageing population who are living longer, and with an increasing BMI, orthopaedic referrals will continue to rise at about 7- 8% per annum. Within this context we have an economy where our national debt, according to the Office of Budget Responsibility, will be greater than that of France and Spain’s within three years and close to 100% of GDP. This means that further savings by the NHS, in addition to the £20 billion savings promised by Sir David Nicholson by 2015 will be required. It is clear that if we are to maintain timely treatment for orthopaedic patients and improve the quality of care we provide then we, as front line clinicians, have to stand up to the plate and show the clinical leadership necessary to embrace change and do things differently. Failure to do this now will mean further rationing of care for patients, especially the elderly.

Further, in light of the recent scandals that have come to light such as that at Mid-Staffordshire, it seems vital that we embrace this opportunity to provide clinical leadership and share excellent practice to reduce variations in quality of outcome or patient experience. I sincerely hope that you will all support this once in a lifetime initiative which seeks to reempower clinicians to drive forward the changes required and provide us with the environment in which we can continue to provide a high quality and timely service to our patients.

References 1 http://www.timbriggsgettingitrightfirsttime.com/ 2 http://arma.uk.net

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Features

Charnley Low Frictional Torque Arthroplasty – 50 Years of Clinical Success – Annotations from Professor Sir John Charnley Mike Wroblewski

“In a specialty as vast as that of orthopaedics, surgeons yearn for an easy hip operation or, if a good operation is difficult, they hope that having mastered its performance through trial and tribulation it should be universally applicable. The only type of operation that ever could be universal would be an arthroplasty, because this is the reconstruction of a normal joint… “A successful arthroplasty would eliminate the intellectual task of choosing the best operation for the individual problem … it is obvious that the surgery of the hip, far from being a small subspecialty, is the beginning of a large subject…

[Fig. 1]

Professor John Charnley

“This type of surgery demands training in mechanical techniques, which, though elementary in practical engineering, are as yet unknown in the training of a surgeon. Nowhere in the locomotor system would a liaison with University Departments of Engineering and Colleges of Technology be more rewarding than in the biomechanics of the hip joint.” “For this reason, one of my aims is to indicate the need for establishing surgical centres to concentrate on the study of the reconstructive surgery of the hip joint.” (Charnley 1959/60).[Fig. 1]

Clinical problems “The hip joint, which is an almost perfect ball and socket, is frequently affected by types of arthritis which destroy the rubbing surfaces and the geometry of the concentric spherical surfaces, with the result that motion is restricted and pain develops.” “Past attempts at joint replacement offered only a short term solution … failure can commonly be traced to the failure to maintain a sound mechanical bond between the artificial part – the prosthesis – and the living bone.”

Mike Wroblewski

[Fig. 2]

A judet, with an x-ray

Joint Lubrication “I have collected the evidence to show that the coefficient of friction of normal articulate cartilage is phenomenally low and in fact lower than anything encountered between solid substances in engineering practice.” “The starting point of the research was the well-known observation that after the Judet operation the hip sometimes squeaks.”[Fig. 2] “A squeak indicates that frictional resistance to sliding is so high that the surfaces are seizing together.” “This led to the idea behind the use of a low friction substance in arthroplasty not merely to eliminate wear, the low friction concept would eliminate stresses being transmitted to the bond between the living bone generated as a result of frictional resistance in the hip when walking.”

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I was not the first to use acrylic cement to bond orthopaedic implant to bone but I was the first to be successful.

Acrylic cement

[Fig. 3]

Ptfe shells

Polytetrafluoroethylene (PTFE) In order to give the slipperiness of a natural joint “we should need a substance with a low coefficient of friction which could be well tolerated by body tissues “… in my initial experiments with polytetrafluoroethylene (PTFE) I used this substance as a synthetic cartilage – hoping that motion will take place preferentially between two slippery PTFE surfaces – rather than between PTFE and bone – while bone will grow into irregularities provided for the purpose” (The entry in the Hip Register 11/02/1960 reads: “Very good immediate post-operative result lasted about six months.”) [Fig. 3] “The most serious aspect of the failure of the PTFE was tissue reaction to wear debris.” Charnley’s experience with Teflon is, unfortunately, better known for the failures rather than the contributions made to the development of hip replacement. It was during that period that the design of the components, the technical details of the operation were stabilised, the wear patterns of the cup and factors affecting wear identified.

[Fig. 4]

Reducing head sizes

From low friction to low frictional torque “In the design of a load bearing joint I have rather lost interest in the coefficient of friction between the materials of the rubbing surfaces as a guiding factor in design. It is possible to circumvent the coefficient of friction by concentrating on the frictional torque in the assembled unit by reducing the diameter of the ball.”[Fig. 4] “It was pointed out to me that the best engineering practice would be to use the smallest diameter ball which could cope with the expected load. Resistance to movement of the head in the socket is greatly reduced by reducing the radius of the ball and, therefore, reducing the ‘moment’ of the frictional torque. If at the same time, the radius of the PTFE socket is made as large as possible, the ‘moment’ of the frictional force between the socket and the bone will be increased and this will lessen the tendency for the socket to rotate against bone.”

“ … it would follow that the smallest volume of harmful particulate matter would be generated by using the smallest head which anatomical and mechanical considerations would permit.” “The result of reducing the size of the femoral head was to prolong the period during which the success was absolute.” Conclusion was drawn “that, from consideration of the geometry and the wear characteristics of metal spheres in plastic sockets, the sphere should have a diameter not greater than half that of the external convex diameter of the socket.” “Since there was no way of estimating rigours of service in the human hip joint over a period of years, we had to proceed by trial and error … from the starting size of 41.5mm diameter … this was first reduced to 28.5mm, then 25.25mm and finally 22mm.” (actually 22.225mm 7/8th inch). It is this change from ‘low-friction’ (the property of the materials) to ‘low-frictional torque’ (the principle of the design) that marks the turning point in the evolution of the low-frictional torque arthroplasty, henceforth referred to as the Charnley LFA.

“The crux of this operation lies in the use of cement. By means of cement the load of the body weight is distributed over a large area of bone.” “Acrylic cement does not adhere to bone like glue, it merely forms an accurate cast of the interior of the bone so that the load is transmitted evenly over all parts of the interface between cement and cancellous bone.” “I was not the first to use acrylic cement in attempting to bond orthopaedic implant to bone, but I was the first to be successful.”

Bone cement interface “If we are to contemplate total hip replacement in adults as young as 45 years of age with the idea of 25 years of trouble-free life ahead, it is necessary to hold definite opinions on the histological nature of the bone-cement interface.”[Fig. 5] “At Wrightington Hospital by about 1965 it became obvious that it was imperative as soon as possible to obtain post-mortem material from highly successful cases.”[Fig. 6] “I am writing to some of my patients who have had the new operation, ‘Low Friction Arthroplasty’ performed on their hip … to see whether they might be prepared to help me in medical research on this important problem of arthritis of the hip.”

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Features

The Charnley low frictional torque arthroplasty has withstood the test of time. Clinical results in correctly selected patients remain outstanding.

Ultra-high molecular weight polyethylene (UHMWPE): the missing link

36-year follow-up of a Charnley done at Wrightington [Fig. 5]

This came, fortuitously, in November 1962. “I was not interested and said so in no uncertain terms. But my technician [Harry Craven] hating to see the apparatus idle, and unknown to me, loaded the apparatus with four specimens. After three weeks of day and night running, the test had not worn as much as we would have expected in one day using polytef. From that moment the game was on.” “I am rather optimistic about the properties of the new plastic – High Molecular Weight Polyethylene.” “The coefficient of friction is not particularly low, but, by mechanical design, the frictional resistance of the unit can be made very low.”

[Fig. 6]

Charnley with post-mortem studies

“I am selecting patients whose ages are such that they are likely to predecease me by more than ten years, in the hope that they will bequeath their operated hip to medical research.” (On completion, 78 hips were bequeathed. Detailed histological studies of the bone-cement interface were carried out by Professor Archie Malcolm. The project was funded by the John Charnley Trust set up by Lady Charnley).

Conscious of the Teflon experience “the operation was reserved exclusively for the very disabled patients … and a warning that a second operation might be necessary” was given: “I am making no attempt to encourage other surgeons to adopt this procedure for at least another three or four years. For this reason the designs of the apparatus have not been made available to the manufacturers of surgical implants.” It was not until the end of 1970 that Charnley, under pressure from the manufacturer, Chas F Thackeray, and in view of mounting attempts at copying, allowed the general release of the hip components.

A new surgical science

[Fig. 7]

The ‘greenhouse’

Infection “The most likely source of infection that was not under control by standard aseptic precautions appeared to be the air in the operating room. It was therefore decided to build a clean-air operating enclosure.”[Fig. 7] “ … enclosure was constructed to contain the lower half of the patient’s body and … the operating team.” “Filtered air is forced at the top … and the surgeons wear respirators through which the exhaled air is extracted as not to mix with the filtered air of the enclosure.” (In time total body exhaust suits were introduced and used routinely). “Deep infection after this operation can never be overlooked if sufficient time is allowed to elapse.”

“A new surgical science – total prosthetic joint replacement – has suddenly come into being. A heavy workload has suddenly been created in response to the availability of a successful new operation … orthopaedic departments planned for the future district general hospitals will be unable to cope if they are to handle the routine orthopaedics for which they were designed.” “When one tries to consider how highly specialised techniques can be best made available to a large number of patients … one has to face the fact that it is impossible, now and in any time in the future, and even in the most wealthy countries, to avoid some type of rationing. Rationing will have to be a product of educating surgeons in the methods of assessing the priority for surgery and selfdiscipline in patients fostered by education.” “Uniform criteria can be established in large centres. The most dangerous unit is a small unit looking for work.”

Planning for the future “An important aspect of the use of total prosthetic replacement is acceptance by the patient of a planned policy of ‘revision’ with the establishment of a centre which holds itself permanently responsible for maintenance of this type of surgery.” “I regard it mandatory that any surgeon aiming to take up the ‘total prosthesis’ should make available to the public a services which can cope with the maintenance operations.”

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“I visualise the establishment of a limited number of special centres such as this at Wrightington Hospital to train the postgraduates in the technology. It is essential that the technical skills acquired by members of the staff of a special surgical centre should be handed on continuously so as to keep a body of men capable of handling the difficult secondary operations of the future.” “To countenance the insertion of a total hip replacement into a patient of 25 years of age without a service station planned and organised is like selling motor cars without providing mechanics and workshops.” “We have continuously to ask ourselves what type of late failure we must be prepared for, and we must protect patients too ready to submit to this practice after seeing patients who have been dramatically ‘cured’ by this method.”

Conclusion The Charnley low frictional torque arthroplasty has withstood the test of time. Clinical results in correctly selected patients remain outstanding. Pain relief, because the natural symptomatic joint is replaced with an artificial neuropathic spacer, has a liberating effect; conveyed to others as a tangible activity level, it becomes the objective in line with common commercial practice. Pressure of numbers and cost implications lead to abandonment of follow-up. Delay of necessary revision increases technical problems and become subject to litigation. If “ … arthritis destroys the rubbing surfaces and the geometry of the concentric spherical surfaces” then it is inevitable that an arthroplasty will be subject to comparable problems: wear and change of the mechanical characteristics.

Added to this are the challenges related directly to this type of surgery: component fixation and complications both local and general.

When the artificial replaces the function of the natural, and does not fail, then the natural moves away from the artificial in line with Wolfe’s law.

Long-term results can only be results in young patients; unfortunately they could not have had the benefit of advances made over the 50 years of clinical experience, except possibly at revision.

For a young patient hip replacement is merely the beginning of the treatment. It is “… obvious that the surgery of the hip is the beginning of a large subject.”

Clinical success with the Charnley LFA, past 40 years of follow-up, has been achieved through the continuity and the application of sound mechanical principles by three generations of surgeons. The Charnley LFA has reached the stage where the ultimate challenge has been identified; it comes from teenagers where the underlying hip pathology, quality of bone stock, expected life span and activity level are setting the limit.

Since clinical results do not reflect the mechanical state of the arthroplasty, one question remains: Who should bear the clinical, moral, financial and legal responsibility for continuing follow-up? [All quotations in this article are taken directly from Sir John Charnley. Further information about John Charnley’s work can be found at www.charnleyresearch.co.uk]

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Features

The role of the BOA Patient Liaison Group and how surgeons benefit Don McBride & Nick Welch, Clinical Vice-Chair and Lay Chair, BOA PLG

The patient-doctor relationship remains the bedrock of modern medicine. Given significant current political pressures, this has never been more important. Lay input is now an integral part of the development of guidelines, patient pathways and commissioning.

The British Orthopaedic Association was proactive in this regard and in March 2004 the BOA Patient Liaison Group (PLG) was formed, comprising lay members and orthopaedic surgeons. It was considered invaluable to have advice and input from patients when the BOA was planning orthopaedic and trauma care, guidelines and when responding to changes in healthcare systems, including training and education. The PLG meets at the BOA three times each year and provides a regular report for BOA Council meetings, which the Lay Chairman attends as an ex officio member. However, the committee remains highly active on several fronts throughout the year strongly supporting trauma and orthopaedic patients and surgeons.

Roles The principal aims and objectives of the PLG are stated on the BOA website. These are: 1. To support and provide a resource for the BOA to deliver a professional service that meets the needs and aspirations of patients requiring treatment for trauma and orthopaedic problems 2. To communicate areas of patient concern to the BOA Council 3. To respond to requests for comment from Council or its Committees. However, these have been expanded to include the following:

Patient Standards A variety of documents covering a wide range of topics have been completed. They form the basis of a contract between the patient and surgeon, from initial assessment through pre-assessment, hospital stay and follow-up. They set the expected standards of care, which should be afforded to patients but also include the important components that patients should attain for their optimum outcome. Don McBride & Nick Welch

Medico-Political

NICE

The power of patients and patient groups should not be underestimated. Medical opinion may be swiftly politically disarmed even when correct. However, the patient voice travels far in the media and politically, particularly, when an injustice has occurred. The PLG has been very active in providing support to the BOA in these areas and has facilitated pathways where concerns are not only heard but are acted upon. Good examples have been the recent difficulties with the private medical insurance sector and podiatry.

The PLG is actively involved with NICE on several levels. Patient representatives have been members of Guideline Development Groups in Musculoskeletal Conditions, for example, VTE and osteoarthritis, providing valuable comment and criticism. Patient members may also be invited to attend Single Technology Assessments and more recently Medical Device Assessments, the latter being highly important in view of the recent metal-on-metal hip concerns. The PLG is an independent stakeholder with NICE and is regularly asked to comment on proposed guidelines in this capacity.

Interaction with other patient groups and ARMA The PLG has developed and continues to develop strong ties with other patient groups at a national and local level. Recently, successful interaction has occurred with the PLG at The Royal College of Surgeons of England, and ties with similar groups at the other UK Royal Colleges are being considered. Contact has been re-established with ARMA, which already has national and local groups and members of ARMA have attended PLG meetings to enhance this developing relationship. At a local level, in the near future it is proposed that active patient groups for Trauma and Orthopaedics will be formed in NHS Trusts to facilitate the setting of standards expected and to assist with any concerns raised, perhaps, initially through the Patient Advice and Liaison Service (PALS).

Clinical Commissioning Groups The PLG has several members who have been involved in commissioning nationally and locally for many years in many different political guises since the infliction of market principles in the NHS. They continue to do so in clinical commissioning at a local level but have recently provided invaluable support in assisting the BOA with this enormous process nationally.

Conclusion The title of this short article refers to â&#x20AC;&#x153;How surgeons benefitâ&#x20AC;?. However, from the preceding it should be quite clear that that this benefit is mutually inclusive and the best twoway process we have available. This continuing relationship will provide a strong and healthy partnership in to the future and help protect the interests of patients and surgeons alike.

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BOA Congress, 1-4 October, ICC Birmingham

BOA Congress better than ever David Stanley, BOA Honorary Secretary

This year’s BOA Annual Meeting in Birmingham promises to be the biggest and best that we have ever organised.

I have reduced the number of ‘Free Papers’ this year, so that only the highest quality submissions are delivered from the Podium which ensures that it is a significant achievement to present at the BOA Annual Meeting. Once more we are extremely grateful to the Specialist Societies who are organising high quality Instructional/Revalidation seminars on a wide range of topics which will build over a 5 year period into a comprehensive programme of educational material. This year, we are again running “Best of the Best” which allows training programmes in the UK to showcase their best Trainee presentations. New this year is “The Good Clinical Practice Course” for those who require revalidation in research

methodology, and we are also strengthening the trauma input with the new “Trauma Boot Camp”. Both of these are covered in more detail below. In addition to the regular Plenary Lectures we will be receiving lectures from the Visiting Presidents on a wide range of trauma and elective topics. If you have not yet attended a BOA Annual Meeting, do consider coming to Birmingham this year. I hope you will be pleasantly surprised and will be able to benefit from a “One Stop Revalidation Facility” that will enable you to mix with new and old friends and enjoy a relaxed social atmosphere in the evenings. I hope to see you there, and if you are a BOA member don’t forget to book soon to take advantage of free registration.

BOA Congress ‘Trauma bootcamp’ Michael Kelly, a Bristol Trauma Surgeon who was international guest speaker at this year’s Australian Orthopaedic Association’s ‘Continuing Orthopaedic Education in Trauma’, explains more about these sessions: “The introduction of Trauma Networks throughout England in April 2012 marked a major evolution in orthopaedic trauma care. This is now focused in Major Trauma Centres and Trauma Units. The BOA Trauma Updates sessions address contentious topics and problems highlighted by the non-specialists on trauma rotas across the nation. Trauma specialists will deliver the latest opinion from the specialist trauma meetings and literature. The sessions will give an immediate summary of the latest opinion then focus on interactive casebased discussions to highlight the areas of controversy. There are British faculty members who are all leaders in the trauma field and an international faculty that draws on expertise from North America and Australia. The programme will benefit those contributing to orthopaedic trauma or undertaking medical reports related to trauma.”

Good Clinical Practice (GCP) in research – Mandatory training Amar Rangan, Chair of the BOA Research Committee, explains why you should attend: “Are you ‘research ready’? “GCP certification is a bit like ATLS for research, with a requirement for regular recertification. It has become mandatory for any of us involved in clinical research. R&D departments of NHS hospitals are now actively monitoring this as a research governance requirement. “Are you aware of regulatory requirements for clinical research? “GCP training helps you understand what is required, within the current research governance framework, from different levels of involvement in clinical research. From ethics of consent to handling of research data, this training will discuss various issues encountered during the design, conduct, analysis and reporting of clinical studies.” **Places are limited to 60 - GCP training is provided free of charge to BOA Congress attendees. Please note advance registration will apply to these sessions.”

JTO Congress pull-out section Register for congress online at congress.boa.ac.uk

BOA Members: Free registration extended until 30th June* Non-BOA members: Registration opens 1st June, or if you become a member and register by 30th June you too can attend Congress for free.* * Terms and conditions apply, see congress.boa.ac.uk for details

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BOA Congress, 1-4 October, ICC Birmingham

BOA Congress – President’s highlights Martyn Porter, BOA President

One of my many privileges is to choose the Presidential guest lecturer for this Congress. I had no hesitation in inviting Henrik Malchau from Boston to speak to us on his thoughts of ’Putting Evidence into Action‘. Henrik has a wealth of experience working with registers, initially in Sweden and more recently in Boston. He is a fantastic and erudite speaker who I am sure will provide great insight into the use of evidence and how this does or frequently does not lead to change in practice. Henrik is also an internationally acclaimed researcher and has published most recently on the wear properties of cross link polyethylene. . One of the other highlights I am particularly looking forward to in this year’s programme is the opportunity to interview fellow trauma and orthopaedic surgeon Professor Keith Willett from Oxford. He has kindly agreed to be interviewed in his official capacity as National Director for Acute Episodes of Care (Domain 3) within NHS England. Keith, who still practises trauma

orthopaedic surgery at Oxford was previously the National Clinical Director for Trauma from 2009, played an important part in the development of trauma networks and has contributed significantly to the National Hip Fracture Database. The format will be very much conversational question and answer and I am already busy preparing questions. I hope you will as well. We are moving away from the traditional gala dinner to something hopefully slightly more informal and potentially more exciting. On the Wednesday evening we have booked Jools Holland’s Jam House, just a mile away from the Congress centre, for a fairly informal meal, music and possibly a few drinks. This is turning out to be very popular and places are selling out fast, so if you are interested please sign up as soon as you can.

BJJ sessions at Congress 2013 Peter Richardson, The Bone & Joint Journal ‘Orthopaedic Publishing in 2013’ is intended to provide an essential guide for orthopaedic surgeons and researchers on all aspects of writing and publishing. Presented by the highly experienced editorial and publishing staff of The Bone & Joint Journal (formerly known as JBJS Br), topics will include peer review, statistics, publishing metrics, fraud, editing and marketing scientific journals, and many more. You will also find sessions on what journal editors are seeking, and on what to expect once your paper has been accepted. Whether you are aiming to publish your first paper, or are already an experienced author, reviewer or even editor, this comprehensive update of current publishing practice will prove invaluable.

BOA Clinical Examinations Skills course returns for a second year Fazal Ali, Consultant Orthopaedic Surgeon, Chesterfield Royal Hospital The BOA Clinical Examinations Skills course will cover techniques suitable for core and higher surgical trainees. Any orthopaedic surgeons wishing to refresh their skills, especially those involved in teaching trainees in their own departments, will find it useful. It will also be important for revalidation. Participants will be placed into the relevant groups and will be able to practice on each other in an informal setting. It is a comprehensive course covering all regions of the body and run by faculty who are all experienced and talented teachers of clinical examination. Last year we ran this course for the first time and the feedback was exceptional. We are hoping to make this year’s even better!

JTO Congress pull-out section Register for congress online at congress.boa.ac.uk

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Features

British Orthopaedic Directors Society David Clark, Chair, BODS

BODS acts as a forum for communication between Clinical Directors and Clinical Leads. It is of great value to us to spread news and share our experience of the trials and tribulations of running an orthopaedic department. Our web forum allows instant discussion of day-to-day issues and we also carry out surveys to try and get a national picture of the state of orthopaedics (see table). The Department of Health introduces policies and initiatives nationally so it is helpful to be able to see how these are enacted or challenged in different departments across the country. In addition, we hold two or three meetings each year. Through the committee, we are able to represent orthopaedic clinical director views to the BOA Council, BMA and the Professional Practice Committee. The challenges of 2013 include the Government Health and Social Care Act, which was implemented in April. This new legislation saw the abolition of Primary Care Trusts and the introduction of GP consortia to hold the budget

for commissioning. This creates new challenges for orthopaedic departments and it is still unclear how enhanced clinical involvement in commissioning will play out. Running alongside the changes – the biggest re-organisation of the NHS since its inception – is also a requirement to save £20 billion through efficiency savings while still continuing to meet the 18-week target. I hope the BOA/ NICE-approved guidance on commissioning which is currently being developed will provide a benchmark for orthopaedic departments to use. The Francis Report encapsulates the pressures faced in all departments in providing safe clinical care while at the same time saving money and meeting politically-driven targets. It may offer a chance of a change in direction and it represents an opportunity to put patients’ interests above political targets. Political manoeuvrings around the publication of this report started just after Christmas, the focus being placed by politicians on more regulation and the improvement in training for hospital managers as a possible solution to the issues raised in the report. The Health Secretary has stated that the events at Stafford and a series of failings at other hospitals represented “the most shocking betrayal of the NHS founding principles in its history”.

David Clark

Another challenge facing clinical directors this year is overseeing the introduction of enhanced appraisal as part of the first year of revalidation. This represents a considerable administrative challenge for both CDs and orthopaedic consultants alike. Non-training grade junior doctor appraisal, patient feedback and how best to incorporate the Royal College of Surgeons’ guidance are all areas where there is variation in approach. Revalidation will therefore be a focus for our session at this year’s BOA Congress in Birmingham in October.

Finally if you are an orthopaedic clinical director or lead clinician and would like to be part of the BODS forum please contact orthodirectors@yahoogroups.com

Recent surveys One of the strengths of the BODS network is an ability to survey departments about their approach to different clinical and managerial issues. The following table summarises four recent surveys.

Issue

Key findings

Elective orthopaedic surgery cancellations during winter 2012/13 (covering December 2012 to February 2013) –

28 Trusts responded; 10 Trusts cancelled more than 50 patients; 6 cancelled between 30 and 50, two cancelled between 10 and 30, while for five Trusts, the number of cancellations was less than 10.

Quantifying the extent of medical outliers –

21 out of 22 respondents reported this as an issue. Examples of responses include: • 9/10 per day for 12 months • 200 bed days per month • An 18-bed arthroplasty ward given to medical outliers Other comments from the survey suggested that MRSA screening may be an effective barrier for ring-fencing elective beds; in two Trusts, operating was halted if medical outliers were admitted onto clean elective orthopaedic wards

Orthopaedic departments’ trauma and spinal on-call rotas –

Of the 32 responding departments, 16 were on an on-call rota between a 1:8 and a 1:12, 9 were on a 1:12 and 5 were on rotas between a 1:12 and a 1:16. The spinal on-call varied: in five departments, spines were covered by neurosurgery, one had a 1:8 spinal on-call, two a 1:4, and two departments a 1:5. The remainder did not have separate on-call cover for spines. Departments varied in their criteria used for deciding when Consultants came off the trauma rota: in one department, those over the age of 52 came off the trauma rota, in another, those over 50 (in exchange for more weekend elective operating). In most departments the most senior Consultant was given the option to come off the trauma rota when a new Consultant was appointed.

VTE assessment and thromboprophylaxis for patients in lower limb plaster casts –

Twenty departments responded; five of which used a VTE assessment form routinely in fracture clinic and 15 did not. Of the five that did use the assessment form, two were filled out by the nurse/plaster technician and three by the orthopaedic doctor. The Plymouth VTE assessment form for lower limb plasters was found to be the most user-friendly.

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Medicolegal Features

Should a Medicolegal Expert be certified? Giles Eyre, barrister and author

Background

In this article I argue, not that medically qualified professionals must be mad to provide their services in the legal forum, but that it is essential for litigants, their lawyers and the courts to be guaranteed a high level of competency in all those holding themselves out as providing medicolegal services and in particular in providing medical reports for the purposes of civil litigation.

Medical evidence is crucial in injury claims, whether they be personal injury, disease related or clinical negligence claims. A lawyer cannot make a successful recovery, or effectively defend a claim, without medical evidence, and important parts of any case will be built on the foundations of the medical opinion. Because of the requirement for independence on the part of the medical expert and the expert’s duty to help the court under Part 35 of the Civil Procedure Rules 1998 (CPR), and because the expert evidence addresses matters outside the judge’s knowledge, the court will place great reliance on the interpretation given to the words of the expert. Whether that correctly reflects the expert’s intended message or opinion, and whether the expert has fully understood what it is the report should address, is not often considered by the judge or even the parties’ lawyers. Most claims never go to a disputed hearing, but those same reports, as interpreted or understood by the parties’ representatives, will be used to assess the strength and value of a claim, and to negotiate settlement. If the lawyer, having obtained a medical report, is dissatisfied with it and concerned as to the expert’s understanding of the legal process, or the expert’s ability to communicate effectively in relation to the relevant medicolegal issues, the court is unlikely to permit a change of expert for fear of encouraging ‘expert shopping’, or of allowing legal costs to grow or of delaying the claim should further evidence be obtained1.

Giles Eyre

Is the report fit for purpose? This writer, who has the dubious privilege of reading dozens of reports in the course of a month’s practice, would suggest that a significant majority of medical reports prepared for civil litigation are not fit for purpose. Those failings vary from the subtle to the gross. Let’s consider some examples from the recent past: 1. The quality of the scarring is outstanding 2. She will not make a recovery from these persisting symptoms within the foreseeable future 3. As, despite her limitations, she is managing in her job, in my view she is not at a disadvantage on the open labour market. 4. The left wrist will have a long term disability of ten per cent 5. There is a more than 50% chance that she will require a knee replacement during the next 10 years. She may then require a further revision of her knee replacement as she is relatively young 6. The doctor’s examination was clearly incompetent and negligent in that, as the client reports, he did not ask her to undress and used a stethoscope through her clothing

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Medicolegal Features

Most claims never go to a hearing, but those same reports will be used to assess the strength and value of a claim, and to negotiate settlement

What all of these examples demonstrate is the failure of the medical expert to understand the role of the expert in the claim in which they have been instructed. It is likely that the expert understands the requirements of the CPR (the Rules, Practice Directions and Protocol) and hopefully will have complied with the CPR by stating that fact and complying with those requirements. But those requirements do not address any of the matters which the experts have sought unsuccessfully to address in the above examples. In example 1, the descriptive language is unclear and unhelpful to the lawyer, and may even give the opposite impression to that intended by the expert. Example 2 fails to give any indication as to how long the symptoms will persist and therefore damages cannot be assessed. Example 3 shows a failure to understand the head of claim for a handicap on the employment market and yet expresses an opinion on it and, in example 4, the expert provides an assessment which by using a percentage gives no insight into the nature of limitations or restrictions in the claimant’s domestic and working life. In example 5 again it is impossible to assess what damages will be recovered without greater clarity as to the degree of risk and the timing for both operations. Example 6 fails to apply the Bolam test, ventures into the judge’s area in the case in describing the incompetence as ‘negligent’, and in any event appears to address the situation only on the basis of one reported set of facts, a version which may or may not be accepted by the court.

It may be that a better drafted or more detailed letter of instruction would have avoided some of these issues. However the clinician, holding him/herself out as providing expert reports in civil litigation has a duty to help the court on matters within the expert’s expertise2, a breach of which can result in sanction from the court; a duty of care to the client to use reasonable skill and care in providing their services in writing a report, a breach of which can result in a claim for damages suffered as a result of any failure on the part of the clinician3; and a professional duty under the GMC guidelines to be accurate and not to mislead, to understand exactly what questions the clinician is being asked to answer and to use language and terminology that will be readily understood by a non-medical audience, breach of which may put the clinician’s registration at risk4. In helping the court to decide whether liability is established or what damages should be awarded the expert must address those matters the court needs addressed, applying the expert’s expertise but also applying the appropriate legal test.

1. Is the scarring reasonably described as disfiguring or of cosmetic impact, is it visible at conversational distance, is it capable of improvement or will it fade with time or treatment? 2. How long will the present effect and consequences of the injury probably continue? 3. What restrictions in activity does the claimant have as a consequence of the accident and what is the likely impact on possible future employment of such restrictions? 4. As 3 above, but dealing in addition with the likely impact on all activities of daily living. 5. On the balance of probabilities, what is the percentage risk of requiring a knee replacement operation in a number of years from now, and, if necessary or helpful, giving the risk for different periods (say for example in 5 years, 10 years and 15 years), and the likely time thereafter before a revision operation is needed? 6. What in the circumstances would a reasonably competent doctor have done, what is the standard below which no reasonably competent doctor would have fallen and how does that compare with the evidence as to what in fact happened, for which there may be more than one possible version of events?

Selecting a competent expert Every lawyer wants a competent medicolegal expert. No general accreditation system exists to guarantee that standard and to give lawyers confidence in the selection of an expert. A lawyer selects a medical expert by a number of different routes including: choosing a name from an inhouse approved list of experts, entry to which may be more by anecdote than by objective assessment, a near random selection from a directory or by surrendering the selection process to an agency whose method of selection is unknown. Medical experts holding themselves out as a court expert are not required to have any training or expertise as an expert witness and do not have to demonstrate any particular competency for that role, beyond the limited declaration under the Practice Direction to CPR Part 35 which must appear in the medical report5. The report is not required to state the expert’s expertise as an expert, only ‘details of the expert’s qualifications’ as an expert in the medical field in which an opinion is to be given6. To avoid the kind of issues outlined in this article, whether in the report or in the joint discussion, what is essential is a medical expert who has training and expertise in writing medicolegal reports and acting as a medical expert witness in civil claims and understands what the role entails.

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A lawyer instructing a medical expert should consider the expertise of the medical expert as a court expert dealing with medicolegal issues

Conclusion A lawyer instructing a medical expert should consider the expertise of the medical expert as a court expert dealing with medicolegal issues. However, in the absence of a generally accepted standard, it is difficult for lawyers to have any assurance not only of the expert’s ability to provide a report that the lawyers can understand (as is their right) but also of the expert’s ability to understand and address all the relevant legal tests and the

purpose of the report for the lawyers and the court. Competent and efficient case management requires this level of ability. Medical experts can improve their position in the expert market by ensuring that they can display to those considering instructing an expert a public mark of the expert’s understanding, not simply of the CPR, but of the requirements of high quality medicolegal work which adds real value to the party’s position in the litigation.

Giles Eyre is co-author of a manual for medicolegal experts and those instructing them, ‘Writing Medico-Legal Reports in Civil Claims - an essential guide’ (2011) and co-presenter of the elearning programme ‘Medico-Legal Report Writing (Core Skills)’ (www.prosols. uk.com). Giles is a barrister specialising in personal injury, disease and clinical negligence claims. He frequently gives seminars and workshops for medical experts in medicolegal report writing, giving evidence and

other medicolegal issues. He has co-authored a book and an elearning programme in this area.

References

4 5 6 2 3

see, for example, Jones v Kaney [2011] UKSC 13 and Guntrip v Cheney Coaches Ltd [2012] EWCA Civ 392 CPR. 35.3 Jones v Kaney above General Medical Council Guidance 35PD 3.2(9) PD35 3.2(1)

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Medicolegal Features

Whiplash: What’s Going On? Michael A Foy, Chair, BOA Medicolegal Committee

Whiplash injury has been around for some time. The Quebec Task Force suggested that it should be referred to as Whiplash Associated Disorder (WAD) because of the wide variety of symptoms that may be associated with the condition. Those of us dealing on a regular basis with patients with spinal problems see little to distinguish neck pain and associated symptoms following road traffic accidents (WAD) from neck pain and/or other symptoms in patients who have never suffered an injury.

For those of us who have been involved for some time in the assessment of claimants with WAD (either at the request of insurers or claimants’ solicitors), we have seen great changes in the organisation of the reporting process. Twenty to thirty years ago reports were largely done by Orthopaedic Surgeons. With the advent of the Woolf reforms, Medical Agencies and moves to speed up the litigation process and reduce costs, reports are usually provided by GPs, sometimes working solely in medicolegal practice. Only the higher value, more complex claims come the way of the Orthopaedic or Orthopaedic/Spinal Surgeons. Why has whiplash suddenly been highlighted in the press and come on to the public and Government’s radar? The answer is ‘Jack Straw’. Mr Straw had constituents who were the victims of some rather shady and underhand dealing after they were involved in what sounded a rather trivial road traffic accident. Therefore he made something of a crusade out of the issue in 2011, proposing the Motor Insurance Regulation Bill (which to my understanding has not found its way on to the statute books.) He criticised the industry in general (referring to it as “grubby”) and referral fees in particular. He threw the cat amongst the pigeons to annoy APIL (Association of Personal Injury Lawyers) and the medical profession when commenting, “Whiplash is not so much an injury, more a profitable invention of the human imagination – undiagnosable except by third rate doctors in the pay of claims management companies or personal injury lawyers.”

Michael A Foy

Therefore the Prime Minister became involved and there was an Insurance Summit in Downing Street in February 2012. The Government committed to tackle the compensation culture, reduce legal costs and cut health and safety red tape. The upshot of this was the publication by the Ministry of Justice (MoJ) of a consultation document entitled ‘Reducing the Number and Costs of Whiplash Claims” in December 2012. The consultation closed on 8 March 2013. I have had some peripheral input through a meeting at the MoJ in November 2012 and further comments via a telephone discussion through the Department of Health in early March 2013, prior to the closing date. Broadly speaking the consultation document focused on two areas: difficulties in diagnosing the ‘injury’ and the cost of the Court system and how it works against insurers who wish to contest claims which they believe to be exaggerated or fraudulent. The most relevant area, as far as we are concerned as Orthopaedic Surgeons, is the former. The document questions the impartiality of current reporting doctors. It seems to ignore the Civil Procedure Rules that we all adhere to and quote in our reports. The CPR emphasises the fundamental importance of providing a report for the assistance of the Court, the content of which should be the same irrespective of which side the expert has been instructed by.

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A panel suggests a group of experienced doctors who will carefully weigh the merits of an individual claim. It seems that this will not be the case. It has been suggested that there should be Court- or Governmentappointed Panels to improve the quality of diagnosis of whiplash injury?! A panel, to me, suggests a group of experienced doctors who will carefully weigh the merits of an individual claim. It seems that this will not be the case. The ‘panels’ will probably be individual doctors and the selection criteria for these doctors appears quite vague in the consultation document. In section 41 a National Accreditation Scheme with standards proposed by the Government has been suggested. A certifying body would be appointed by public tender to run such a scheme. The BOA has already been approached by one of the major Reporting Organisations to endorse their accreditation scheme. Perhaps, if the consultation document becomes law, it may be timely for the BOA to consider taking control of this area again by tendering to run the accreditation scheme?

From talking to senior BOA members, this is certainly an area where, as Orthopaedic Surgeons, we have lost influence in the last 10-15 years. Individual doctors, groups of doctors or reporting organisations would be able to apply to the certifying body for recognition to provide the expert medical evidence. In the background, whilst the consultation paper was being considered, are the competing interests of the Association of British Insurers (ABI) and APIL. To the outside observer they seem to have locked horns and have little common ground. James Dalton from the ABI spoke at the International Whiplash Conference in Bristol in April 2012 pointing out that “The whiplash compensation system in the UK is completely dysfunctional. The system is riddled with ambulance-chasing claims management companies and claimant lawyers. So it will come as no surprise to you that fraudulent and exaggerated whiplash claims are an everpresent and increasing problem.”

He expressed consternation at the fact that while Thatcham research evidence suggested that cars were becoming safer, statistics showed that road traffic accidents notified to police had decreased and yet whiplash claims were “rocketing.” Meanwhile APIL fired back with the publication of “The Whiplash Report 2012: Myth or Fact”, claiming that the number of whiplash claims was falling! They conducted a survey of 4,000 people from June to August 2012. They came up with a ten-point plan to eliminate fraud in whiplash claims. In this they emphasised the importance of a medical report before settlement to discourage insurers from settling without such medical evidence. They concluded: “APIL will support any proposals which will eliminate fraud, but will stand firm against any proposals which put barriers in the way of obtaining compensation for people with genuine whiplash claims.”

Therefore we have a dilemma. Where does the truth lie? Whose statistics and their interpretation should we rely on? The Government Consultation document, whilst respecting the individual’s right to “access to justice” seems more allied with the insurers’ position than with that of the claimant. If the recommendations for ‘medical panels’ are implemented we need to decide whether to proceed passively as we have done over the last few years or whether, as an organisation, the BOA should become more proactive and push to be intimately involved with the accreditation process. By so doing perhaps we could regain some of the influence in this sphere that we have clearly lost.

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Peer-Reviewed Articles

Arthroplasty of the Wrist: Part I Radio-Carpal Joint Professor I A Trail & Mr A C Watts, Consultants in Hand and Upper Limb Surgery, Wrightington Hospital

This review will focus on newer arthroplasties developed for use in the wrist and intended to recreate normal anatomy and biomechanics. The surgical implications of these new implant designs are quite different from the traditional silastic arthroplasty in which the implant acts as an internal splint allowing the soft tissues to rebalance. Whilst silastic joint replacement certainly has an important role generally in the management of inflammatory arthropathy with anatomical implants, attention must be paid to soft-tissue attachments, bone resection and alignment to avoid issues of instability, maximise movement and provide longevity. In this review, we would consider surgical anatomy, biomechanics, implant design, reported outcomes and complications for implants of the radio-carpal (wrist) and distal radioulnar joints (DRUJ). Readers are directed to the implant manufacturersâ&#x20AC;&#x2122; literature for information on implantation technique.

[This article is based on the Watson-Jones Lecture given by Professor Trail given at the BOA Annual Congress in Manchester 2012. It is provided in two parts, the first, on the radio-carpal joint, appears here, and the distal radio-ulnar joint is covered in the following article.]

Professor Ian Trail

Radio-carpal (wrist joint) The development and usage of total wrist arthroplasty has slowly followed that of the other major joints. However, even today it has not found widespread acceptance in that most surgeons prefer to recommend arthrodesis to their patients. Certainly, arthrodesis simply performed does not have the same number of potential long term complications. However, with the advent of a newer prosthesis, attitudes are generally changing, particularly for patients associated with bilateral inflammatory of the wrist. Indeed, a number of recent articles have demonstrated high patient preference for arthroplasty1,2.

Surgical Anatomy Like all arthroplasties, every wrist replacement design is constrained by anatomy. For the distal radius there are a number of bone- and soft tissue-limiting structures. Firstly, to align the base of any component perpendicular to the shaft seems appropriate both to maximise the surface area of contact and evenly distribute the forces transmitted. To do this optimally requires the use of an alignment jig as well as a stem on the implant. If you consider the anatomy of the radius, this obviously entails the stem being offset in a more radial and, to a lesser degree, dorsal position. Secondly, the level of cut is important as for surgical ease this should be at the level of the most proximal articular surface which, in most cases, even for the severe rheumatoid, is the lunate fossa. Obviously, however, this can be quite proximal if there is a lot of erosion resulting in significant removal of bone as well as a disruption of the distal radio-ulnar

joint. An alternative to this would be bone grafting of the defect or modifying the prosthesis, allowing it to fill the defects. Neither of these options, however, is in common usage. For the carpus the principal if not insurmountable difficulty for designers is the number of bones and articulating surfaces. Obviously, it is not possible to fix a prosthesis satisfactorily to any one of these small bones or, indeed, replace each individual bone. As a consequence, virtually all designs use the second and third metacarpals for stem fixation, the carpal bones themselves either being resected to a large degree or fused into one mass. For the former, whilst excision of the lunate and triquetrum is relatively straightforward, as is removal of the head of a capitate, the distal pole of the scaphoid can be difficult to excise given its ligamentous attachment and the proximity of vital structures on the volar side of the wrist. Obviously the more bone that is removed the bigger the space and the larger the implant to fill the gap. If attempts are made to fuse the bones patently, this requires additional procedures and methods of fixation, usually wires or screws. At this time, whilst this technique seems to have some advantages, it is not known whether the fusion actually occurs in all cases or indeed how effective it is in the long term.

Biomechanics and Implant Design The biomechanics of the wrist joint is both complex and as yet incompletely understood. This difficulty is compounded by the number of small bones in the wrist that make up the various articulations. As it will be appreciated for arthroplasty,

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Journal of Trauma and Orthopaedics, Volume 1, Issue 1, pages 40-43 Title: Arthroplasty of the Wrist: Part I, Radio-Carpal Joint Authors: I A Trail and A C Watts

it is not possible to reconstruct the wrist in this fashion and, as a consequence, significant assumptions have to be made. What is known, however, and is of particular importance to arthroplasty are the forces transmitted through the wrist and the movements that normally occur. For load distribution, dependent on variance, it is generally acknowledged that between 70% to 80% or more of the load passes through the radius and 10% to 15% through the ulnar. This has significant implications for total wrist arthroplasty design in that it would be difficult to design an implant to replace both the distal radius and ulna. Effectively all implants currently available replace the distal radius and not the ulna. The importance of removing the head of the ulna if diseased is obvious, although plainly this has a potential deleterious effect on ulnar stability, as all ulna based ligaments are effectively divided. What effect this has on the long term survivorship of a radio-carpal arthroplasty remains, however, unknown. For the carpus, research has again indicated that approximately 60% of load passes through the scaphoid and 40% through the lunate fossa. At the mid-carpal joint 40% passes through the capito-lunate, 20% between the scapho-capitate and 20% through the scaphoid/trapezium/ trapezoid. The relevance of this with regard to implant design is that, for most implants currently available, the majority of the scaphoid and the whole of lunate and triquetrum are removed to allow the implant to be inserted. Effectively, therefore, forces are transmitted, predominantly from the radius to the capitate, hamate and trapezoid and then secondarily through the respective carpo-metacarpal joints. Even then the overall contact area

is probably no more than 40% of the available joint surface3. With regard to movement the normal flexion-extension arc can vary from 140°-155°, movement being almost equally split between the radio-carpal and mid-carpal joints. The radio-ulnar deviation arc can range from 60° to 75°; again occurring at both joints. Radial deviation is often significantly less than ulnar deviation. Whilst the majority of pronosupination, which in some instances can be close to 180°, occurs at the radio-ulnar joint, 10% is said to occur at the radio-carpal joint. This rotational movement therefore can measure up to 15°. Any implant design should obviously have the facility for this rotation built into its design, otherwise significant torsional forces will be imparted to the components. With regard to what movement is optimal in a design, whilst the ‘holy grail’ would be normal movement, in diseased wrists this would rarely be possible. Fortunately satisfactory function can be obtained with significantly less movement. Research undertaken in Syracuse, New York4, using a triaxial electro-goniometer in normal subjects undertaking a number of standardised tasks, found that the vast majority of these can be undertaken with 5° of flexion, 30° of extension, 10° of radial deviation and 15° of ulna deviation. Thirdly, it would seem advisable for the axis of rotation of any implant to be similar, if not identical, to the normal wrist. Research to date has shown that the axis of rotation of the normal wrist for radio-ulnar deviation is 3mm ulnar to the longitudinal axis of the third metacarpal and distal radius and for flexion-extension 9 to 10 millimetres volar to the longitudinal axis of the

third metacarpal and distal radius. It is important to note however, that these axes do not intersect5. A further important feature is that any implant should obviously be stable. This is particularly difficult to achieve at the wrist in so much that at surgery the majority of patients do not have the normal soft tissue stabilising structures. More specifically they have often either been destroyed by disease or released during the surgical procedure itself. Whilst generally this problem can be overcome by correct seating of the implant and, to a degree, design, patently care must be taken with subsequent mobilisation. What is important, however, is that range of motion and appropriate incongruity are not sacrificed to excessive inbuilt stability of the implant. The latter would undoubtedly result in impingement at the edges of the implant, with ultimate loosening. Indeed, this has been seen in the author’s revision practice. Added to this is the fact that a significant number of tendons cross the wrist joint on both the volar and dorsal aspects. Any design must allow these tendons to function normally. This in practice would involve the absence of sharp edges and indeed any structure which could lead to tendon attrition. In addition, appropriate carpal height should be restored to allow optimal finger and thumb movement as well as grip strength to be generated. Finally, whilst many authors have disagreed over implant design, all agree about the importance of soft tissue balancing at the time of surgery. That is that any pre-operative deformity should be corrected by releases and tendon transfers where appropriate. With regard to stem design and positioning for the radial component, various lengths have been used; generally, however,

[Fig. 1a]

Universal 2 wrist replacement

they average between 5 and 8 cms and lie, if anything, slightly radial and dorsal to the midline. Whether this was chosen simply to better align the implant within the shaft of the radius is unclear. It has, however, proved highly successful, particularly with the latest designs. For the carpal components stem, most implants align along the third metacarpal and as such have a stem which passes down its shaft, crossing the carpo-metacarpal joint. Additional short spikes or stems have been added, often in the line of the second or, in some cases, the fourth metacarpal to give better fixation. However, due to a high incidence of loosening, the use of a stem alone has been superseded by the addition of screws down both the second and fourth metacarpals. This, combined with a distal carpal row fusion, was first successfully used by the Guepar group in 1988 and Menon in the early 1990s6.

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Peer-Reviewed Articles

Journal of Trauma and Orthopaedics, Volume 1, Issue 1, pages 40-43 Title: Arthroplasty of the Wrist: Part I, Radio-Carpal Joint Authors: I A Trail and A C Watts

Reported outcome in the Universal Total Wrist Arthroplasty (Fig. 1) The results of the Universal total wrist implant were first reported by Menon in 19986. Here he reported on thirty-seven implants in thirtyone patients, with a mean follow up of 6.7 years. Unfortunately, in three of the patients, the prosthesis had to be removed due to infection and persistent dislocation. Of the remaining thirty-four, however, 88% achieved excellent pain relief. Otherwise, complications occurred in twelve cases (32%), although the majority were resolved with appropriate treatment. The most common complication appeared to be instability. [Fig. 1b] Universal 2 wrist replacement – x-ray of implant in situ

The shape of the articulating surfaces, whilst not controversial with regard to being either convex or concave, has shown some variation as to whether the convex or concave side should be proximal or distal. Most designers have mirrored the normal anatomy of the radio-carpal joint, putting the convex articulation distally and the concave proximally; this does appear to have been the most successful. With regard to the choice of materials, convention taken from work in hip and knee replacements would indicate that the convex material should be made of metal and the concave high density polyethylene. Whether the reverse causes any long-term problems, only time will tell. Finally, the use of methylmethacrylate cement is becoming less controversial. Whilst, historically, it was used to secure both components, its usage initially proximally and more recently distally has fallen.

In 2002, a prospective study of 19 patients with rheumatoid arthritis with a minimum follow-up of one year was reported7. At follow-up the flexion/extension arc had improved from 48° to 76° with radial-ulnar deviation from 17° to 28°; DASH scores reduced from 46 to 22.4. Complications, including instability, occurred in 3 cases, all of which required further surgery. Ferreras et al reported their results of 21 consecutive patients who underwent a Universal total wrist as a primary procedure8. They reported a significant reduction in pain and improvement in function, with 20 out of the 21 patients being satisfied or very satisfied with the procedure. Complications were generally minor and infrequent. Only one patient had early signs of loosening of the distal component. The latest work from Wrightington Hospital, as yet unpublished, revealed in a series of 93 consecutive cases, undertaken predominantly for rheumatoid arthritis, that the majority achieved satisfactory pain relief. Movements were preserved, with a mean dorsi

flexion of 24º and palmar flexion of 23º. Function and patient satisfaction were high, the KaplanMeier survivorship being 91% at 7.8 years (95% CI: 7%). With regard to the incidences of major complications, these were only 8%, which was lower than the comparable smaller series9.

Reported outcome of other total wrist arthroplasties Nydick et al reported initial results with the Maestro total wrist system, in their series of 23 prosthesis in 22 patients, suffering with a variety of diagnoses, including posttraumatic arthritis and Kienböck’s disease10. In a short follow-up there was a marked improvement in pain, with a flexion extension arc of 90º and a grip strength of 60% of the contralateral side. Radiographs showed no evidence of loosening. Complications, however, occurred in 7 of the 23 patients, one of which was a deep infection requiring complete revision. Finally, Reigstad et al reported their results with the Motec cementless modular metal-on-metal balland-socket wrist arthroplasty11, again, a small series with a short follow-up of predominantly patients with post-traumatic arthritis. Clinically and radiologically, most prostheses had integrated well, with no evidence of dislocation or implant breakage. Two implants, however, had been converted to an arthrodesis for persistent pain. Added to that, there was one further case of loosening at five years. Clinical results were also encouraging.

Conclusion Wrist arthroplasty has been undertaken at Wrightington Hospital for many years, this being the result of the large number of patients with inflammatory arthritis who are treated at our institution. The first implant to be used was the silicone implant designed by Swanson. Essentially, and at least in the short term, this was successful in that patients achieved satisfactory pain relief with some movement and improved function. Ultimately, however, it did appear, due to a material problem, that movement and function diminished; more specifically, the wrist became stiff or the implant fractured. As a consequence, for the last ten years or so, the Swanson implant has been replaced by the Biaxial total wrist arthroplasty. Our experience of this implant has been published and, again in the short to medium term, in patients with inflammatory arthritis we have had good results. Subsequently however, with a longer follow-up, problems with the distal carpal component have come to light. Effectively. in a number of cases, the implant has loosened with the stem extending out dorsally from the third metacarpal. Indeed, all the implants that failed seem to fail in the same fashion. An analysis of the reasons for failure indicates that, unless the implant is put in perfect alignment, the likelihood of failure is significantly higher. The shape of the wrist joint itself and the implant unfortunately do not lend themselves every time to perfect insertion. As such, again, the Biaxial total wrist arthroplasty has fallen from favour and is no longer available for use. Having said that, valuable lessons have been learned, particularly that the radial component did not show any evidence of loosening within the

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period of review. This finding has also been reported by a number of other authors. It should be noted that this implant was put in an uncemented fashion, with porous coating only in the majority of cases. This design of radial component would therefore seem to be optimal at this time. Secondly, patients who had undergone total wrist replacement were generally highly satisfied and pleased with the outcome. In a particular sub-group of patients who had had arthrodesis on the contralateral side, the vast majority of patients indicated that they preferred arthroplasty to arthrodesis. Indeed, it was often difficult to persuade a patient who had had an arthroplasty on one side to have an arthrodesis on the other, this despite the fact that, objectively, we felt that the arthroplasty had had a poor outcome. In light of this, we have no doubt that arthroplasty has a role in patients with bilateral inflammatory wrist arthritis. With regard to the future, the fixation system designed by Menon for the distal carpal component appears to be the most successful. Certainly, medium- to long-term results of the Universal implant do not show any evidence of significant loosening at this site. Proof of this is that other implants are now copying this type of fixation. In light of this we have no doubt that a combination of the Biaxial radial component with a Universal distal component will become the mainstay in the design of total wrist arthroplasty. Most have the view that this will result in significantly improved long term survivorship.

Outside of patients with inflammatory arthritis, whether this implant should be used in primary osteoarthritis or, indeed, after trauma remains a moot point. We have no doubt, however, that these more modern implants will be used more and more for these clinical situations and only time will tell whether they are successful. We would say, however, at this time that it is not our practice to recommend to patients who suffer with these conditions that they have an arthroplasty. Having said that, in the older patients and where other treatment modalities, including partial wrist fusion/proximal row carpectomy, are not possible, then this may be a viable option. Finally, with regard to further implant development, there are currently some concerns with regard to the high density polyethylene being on a convex surface in certain implants, the concern being that high density polyethylene in an unconstrained environment could lead to creep and excess wear. Having said that, given the relatively low forces transmitted across the wrist, this may not be of significant clinical importance. What is of importance, however, is modularity, insomuch that these new implants allow far more soft tissue balancing than their predecessors. This should allow stability to be retained and allow a better range of motion. Added to this, significant improvements in instrumentation allow better alignment of the components and resection of the radius and carpus; again, this should result in improved outcome. Obviously, however, all this will need to be combined with improved training, as total wrist arthroplasty is undoubtedly a technically demanding surgical procedure.

References 1 Takwale VJ, Nuttall D, Trail IA, Stanley JK. Biaxial total wrist replacement in patients with rheumatoid arthritis. Clinical review, survivorship and radiological analysis. J Bone Joint Surg Br 2002;84B:692-699. 2 Murphy DM, Khoury JG, Imbriglia JE, Adams BD. Comparison of arthroplasty and arthrodesis for the rheumatoid wrist. J Hand Surg 2003;28A:570-576. 3 Viegas SF, Patterson R, Peterson P, Roefs J, Tencer A, Choi S. The effects of various load paths and different loads on the load transfer characteristics of the wrist. J Hand Surg 1989;14A:458-465. 4 Palmer AK, Werner FW, Murphy D, Glisson R. Functional wrist motion: A biomechanical study. J Hand Surg 1985;10A:39-46. 5 Hamas RS. A quantitative approach to total wrist arthroplasty: development of a ‘precentered’ total wrist prosthesis. Orthopaedics 1979;2:3:245-255. 6 Menon J. Universal total wrist implant: Experience with a carpal component fixed with three screws. Arthroplasty 1998;13:5:515-523.

2014 BOA Travelling Fellowships The BOA is pleased to announce that it will be offering up to 19 specialist and general travelling fellowships in 2014. Travelling fellowships give surgeons the opportunity to develop their knowledge, gain experience or to further a specific research project in an international environment. To qualify for the fellowships, applicants must be a member of the BOA. Applications will be accepted throughout October 2013, and interviews will be taking place in January 2014. Preference will be given to those who can demonstrate specific plans for the fellowship. For more information, please visit http://bit.ly/boatravellingfellowships

7 Divelbiss BJ, Sollerman C, Adams BD. Early results of the Universal total wrist arthroplasty in rheumatoid arthritis. J Hand Surg 2002;27A:195-204. 8 Ferreras A, Lluch A, del Valle M. Universal total wrist arthroplasty: Midterm follow up study. J Hand Surg 2011;36A:967-973. 9 Kailash K. Trail IA. Medium term outcome of the Universal-2 total wrist arthroplasty. Submitted J Hand Surg Eur. 10 Nydick JA, Greenberg SM, Stone JD, Williams B, Polikandriotis JA, Hess AV. Clinical outcomes of total wrist arthroplasty. J Hand Surg 2012;37A:1580-1584. 11 Reigstad O, Lütken T, Grimsgaard C, Bolstad B, Thorkildsen R, Røkkum M. Promising one-to six-year results with the Motec wrist arthroplasty in patients with post-traumatic osteoarthritis. J Bone Joint Surg 2012;94B:11:1540-1545

Correspondence: Professor I A Trail, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP E-mail: upperlimb@wrightington.org.uk

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Arthroplasty of the Wrist: Part II Distal Radio-Ulnar Joint Professor I A Trail & Mr A C Watts, Consultants in Hand and Upper Limb Surgery, Wrightington Hospital

Surgical Anatomy

The management of arthritis at the distal radio-ulnar joint, whether as a result of an inflammatory condition, degenerative change or trauma, has presented problems for clinicians for many years. Indeed its management still remains both controversial and, at times, difficult. Different options range from osteotomy or arthrodesis, specifically the Sauvé-Kapandji procedure1, through to excision, either partial or total. Certainly complete excision or Darrach’s procedure has been used successfully for many years in the elderly and patients with inflammatory arthritis. Undoubtedly, however, problems can ensue, particularly instability of the distal ulnar stump, a problem seen especially in younger more active individuals. It is for this reason that ulnar head replacement has been developed to restore length and stability, whilst allowing pain-free pronosupination and a better grip.

[This article is based on the Watson-Jones Lecture given by Professor Trail given at the BOA Annual Congress in Manchester 2012. It is provided in two parts, the second, on the distal radioulnar joint appears here, and one on the radio-carpal joint, is covered in the previous article in this issue.]

Professor Ian Trail

As stated previously the distal radio-ulnar joint has been described as the ‘forgotten joint’ at the wrist. Not only can it develop its own inherent problems but it can also suffer as a result of injuries to the radio-carpal joint, as well as its treatment. It is for this reason that surgeons treating problems of the distal radio-ulnar joint should also have an appreciation of the anatomy of the whole wrist. On the ulnar side, however, there are a number of important soft tissue structures that can be damaged as a result of either trauma or surgery. Cutaneous branches of the ulnar nerve often cross the incision sites and can, if transected, lead to the development of neuromata with prolonged localised discomfort. The surgeon should also be aware that these branches can cross obliquely from volar to dorsal, thus crossing the usual longitudinal incision. Secondly, the extensor tendons, extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU) pass longitudinally over the dorsum of the distal radio-ulnar joint. As a consequence, capsular incisions lie either in the base of their sheaths or between to prevent damage to these tendons and also allow repair. The flexor carpi ulnaris (FCU) and volar capsule can be reflected anteriorly. Directly related to this, distally lies the triangular fibrocartilage complex (TFCC) which links the distal radio-ulnar and the radio-carpal joints. Of particular importance are the volar and dorsal radio-ulnar ligaments, which confer stability on the DRUJ. Effectively, these should be preserved or at least repaired to prevent subsequent instability. Ideally, any implant should lie just under the TFCC, allowing the latter to function

normally as an extension of the radio-carpal joint. Removal of the ulnar head including the ulnar styloid obviously destabilises the TFCC. However, if the capsular attachments remain, they should allow the TFCC and ligaments to heal in an anatomical position, thus conferring stability on the replacement. If the TFCC is worn or damaged, most surgeons recommend direct repair at the time of surgery. Finally, some consideration should be given to the bony configuration of the sigmoid notch. Once osteophytes have been removed, the sigmoid notch will be found to be virtually flat although, to a degree, convex. Previous research has shown significant disparity between the radii of curvature of the ulnar head and sigmoid notch, the latter being the larger2. This incongruity allows a head to be both easily contained and facilitate rotation and translation. Any ulnar head replacement should ideally be the same size as the head removed and, as a consequence, allow the same movements to occur. At the same time the head should not be too large to make repair of the capsule and ligament difficult.

Biomechanics and Implant Design The distal radio-ulnar joint (DRUJ) has not been the subject of such intense investigation as the radiocarpal joint and as a consequence less is known of the biomechanics. From anatomical studies, however, we do know that there is significant disparity between the radius of curvature of the sigmoid notch and ulnar head, resulting in marked incongruity. This allows the head not only to rotate but also translate during pronation and supination and as a consequence confers a considerable degree

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of ‘forgiveness’, i.e. the joint can accommodate significant deformity yet still function. This is particularly well seen after distal radial fracture. The major concern for the surgeon, therefore, is not to place too large an ulnar head component in the joint but, as far as possible, mirror the existing ulnar head. In the anterior/posterior plane, the sigmoid notch can be either vertical or sloped in an oblique fashion, the latter towards or away from the radio-carpal articular surface. Generally, this has little effect on an arthroplasty, although it is important that any ulnar head is placed at the correct level, as any disparity in an oblique sigmoid notch could lead to load concentration and localised wear. Ishii et al3 using pressuresensitive measuring devices confirmed that, with the forearm in neutral, only 12.5% of the sigmoid notch was in contact with the ulnar head, whilst in pronation the contact pressure was distributed dorsally and, in supination, on the palmar aspect of the sigmoid notch. With regard to the relationship between the shaft of the ulnar and the ulnar head, work using CT scans4 quantified the geometry of the distal ulnar and found no correlation between the diameter of the ulnar head and the intramedullary ulnar canal, indicating that monoblock components may not be the most anatomical replacements and that a modular system may be better in recreating the normal anatomy, specifically the eccentric offset of the head. Stability of the distal radio-ulnar joint is conferred on the palmar aspect by the osteo-cartilaginous lip of the sigmoid notch as well as the dorsal and volar radio-ulnar ligaments. Research has indicated that the dorsal ligament tightens during pronation and the palmar ligament during supination5. They also noted that the ulnar

translates at the extremes of movement – dorsally on pronation and volarwards on supination. With regard to the interosseous membrane, whilst this undoubtedly confers stability in the longitudinal plane, it only has a secondary role in the antero-posterior plane. Otherwise, some work is now available on the effect of the presence or absence of an ulnar head replacement on the stability of the DRUJ. Sauerbier et al from the Mayo Clinic identified considerable forearm instability after a direct resection arthroplasty6, much of which was restored after the introduction of an ulnar head prosthesis. This was further improved by directly suturing the triangular fibro-cartilage complex (TFCC) to the prosthesis. Masaoka et al compared two ulnar head replacements, again in cadaveric specimens7. They examined for diastasis but also palmar subluxation, with the forearm in various positions. They concluded that, despite some reduction in movement, both prostheses restored near normal biomechanics when compared to resection alone. Finally Gordon et al undertook further research8, this time an in vitro study using a joint simulator and an electro-magnetic tracking device at the distal radio-ulnar joint. They compared the kinematics of a normal forearm with that after the insertion of a partial or total ulnar head replacement and also after complete ulnar head excision. They found that complete excision produced radio-ulnar instability in the form of radioulnar convergence and increased antero-posterior translation. There were, however, no differences between the kinematics of the normal joint and those having had a replacement.

[Fig. 1a]

Herbert distal radio-ulnar joint implant in situ

Results Of the newer anatomical designs, the only implant with any published or albeit brief clinical evaluation is that developed by Herbert (Figs. 1a, b). Initially, in 2000, Van Schoonhoven et al reported the results9 in twenty-three patients with painful instability following partial or total resection of the ulnar head that had had this implant inserted combined with a soft tissue repair. After a mean follow up of twenty-seven months all but one patient had marked symptomatic improvement including improved stability. In addition, pain diminished and grip strength improved from 42% of the contralateral side pre-operatively up to 68% post-operatively. Range of movement also improved from a prono-supination range of 118° pre-operatively to 158° post-operatively, many of these improvements being statistically significant. Radiological assessment showed appropriate congruity in all cases, with some signs of remodelling of the sigmoid fossa around the ceramic head. All the patients showed

one to two millimetres of bone resorption beneath the collar although this was not progressive. A later follow-up by the same authors reported no long-term deterioration10. They concluded that arthroplasty of the distal radial ulna joint is a reliable and reproducible procedure. In 2006 Fernandez et al from Switzerland also reported the use of the modular non-cemented Herbert ulnar head prosthesis11, consisting of a spherical cobaltchrome head and a porous coated titanium stem, to salvage failed Sauvé-Kapandji procedures. At a mean follow-up of 2.6 years, pain had improved in all patients, as had grip strength. Range of motion had improved in 7 out of the 10 patients in the series. Indeed 9 had returned to their previous occupation. At follow-up radiologically the implant was found to be stable, with no evidence of radio-ulnar convergence. It should be noted that, in this series, the SauvéKapandji fusion was left in situ and the prosthesis subsequently

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a sensory cutaneous nerve dysaethesia. There were four chronic complications: 1 neuroma requiring excision, 1 revision which involved a further soft tissue stabilisation and 2 revision prosthesis related to loosening at 7 and 14 months post-operatively. Mild collar resorption was noted in 8 cases without progression. Overall the authors felt that their early results were encouraging.

[Fig. 1b]

X-ray of Herbert implant.

articulated with the under surface of the fusion mass. As a result of this, 2 patients experienced fractures of the radio-ulnar fusion mass and a further developed a painful periprosthetic calcification. At Wrightington Hospital, the Herbert ulnar head prosthesis had been used for a number of years to treat conditions affecting the distal radial ulna joint. The most recent evaluation of 78 implants with a range of follow-up has revealed active pronation of, on average, 80º and 53º of supination. Grip strength was 67% of the contralateral side. Functional scores had all improved, the overall survivorship at 15 years being 89%. The outcome itself, however, was not significantly influenced by the underlying diagnosis or by whether stump instability was the principal indication for surgery. However, trends towards a worse outcome were noted in the posttraumatic and revision groups. More specifically, the number of prior surgeries had a negative effect. Overall, however, patient satisfaction was high12.

[Fig. 2]

Avanta total replacement

With regard to the Avanta implant ), some early results have been reported by Willis and others. Essentially, this was a follow-up study of 20 consecutive procedures in 18 patients, with an average follow-up of 18 months. The implant appears again to have been used in a salvage situation only, in that 14 patients had undergone an average of 2 or more previous procedures. In 8 cases the implant was used to treat symptomatic instability and, in the other 12, primary osteoarthritis. Post-operatively 80% of patients were satisfied with the procedure and 100% felt there had been some improvement. Eighty per cent reported no pain, 15% mild pain and one continuing pain. There was no significant change in motion of the wrist and forearm, with, on average, 138º of pronosupination. Grip strength, however, did improve by 7% as compared with the contralateral limb. There were two early complications: an undisplaced ulna shaft fracture, which occurred during the insertion of a press fit prosthesis and, secondly,

(Fig. 2

An update on this was presented by Cooney and Berger at the American Hand Society meeting in September 2005. In this study, they reported the results of 28 consecutive ulnar head arthroplasties performed in 26 patients. In this group, the average age was 51 years, with a follow-up of 30 months. At review 80% of patients were satisfied with their procedure and 100% felt that there had been some improvement. With regard to pain 80% were pain-free, there was mild pain in 15% and unimproved pain in one patient. Pronation averaged 75º and supination 70º. Grip strength improved 10% as compared with the contralateral limb. Of the prostheses, 18 were press-fit and 10 cemented. Again, the authors concluded that endoprosthetic arthroplasty is an effective means of providing pain relief, stability and improvement in strength for patients with either chronic instability or arthritis of the distal radio-ulnar joint. They also stressed the importance of soft tissue repair or reconstruction as part of this procedure. Finally, they also recommended that the ulnar stem be secured by bone cement in patients with a previous fusion of the wrist. Latterly, Kakar et al from the Mayo Clinic reported a retrospective review of 47 patients who had undergone this joint replacement13. Generally, there was a decrease in

[Fig. 3] Scheker distal radial ulnar joint prosthesis (published with kind permission of Mike Hayton)

pain and improvement in function. With regard to movement, however, there was no significant improvement and a Kaplan-Meier analysis demonstrated 83% survival at 6 years. A total of 14 patients (30%) required additional procedures. These included soft tissue surgery to stabilise the flexor carpi ulnaris, screw removal and capsule reconstruction. In 2008, Laurentin-Pérez et al from Louisville in the USA reported their results of the Scheker distal radioulnar joint prosthesis14 (Fig. 3). This design is a semi-constrained ball and socket joint composed of a radial and ulnar component. Both components are uncemented and linked by an ultra high molecular weight polyethylene ball. This allows rotation and migration. The study reported the outcome in 31 patients with a mean follow-up of 5.9 years. Pronation and supination had improved, with significant diminution in pain. There was also an improvement in grip strength. They did not report any incidence of radiological loosening.

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Conclusion With regard to distal radio-ulnar joint replacement, again this began a number of years ago with the Swanson silastic replacement. Plainly, for the reasons expressed previously, this was not successful in the long term. More recently, specifically over the last 4 to 5 years, we have gained increasing experience with the Herbert ulna head replacement. Initially this was used purely in ‘salvage’ cases, effectively, in younger patients who, for one reason or another, had a Darrach’s procedure which had resulted in instability of the distal ulna, the latter resulting in a significant functional deficit. In this particularly difficult group of patients, we have to say that the prosthesis has worked extremely well. With regard to the design itself, whilst we are sure that various further modifications will be made, at present the design does seem reasonably optimal, insomuch that the current range of head and stem sizes does seem to fit well at the intended sites. In addition, the surgical technique is straightforward and complications, at least in the early phase, seem to be limited and manageable. With increasing follow-up, however, we are noting firstly some erosion of the sigmoid notch, particularly when ceramic heads are used and, secondly, some stress shielding around the ulna, particularly under the neck of the prosthesis. Whether either of these becomes significant clinically is unknown and will only become clear with longterm follow-up. Certainly at this time we recommend the use of this implant in the salvage situation.

Concerning the use of these implants in primary disease, however, whether in inflammatory arthritis, osteoarthritis or secondary to trauma, this remains controversial. We have no doubt that they will be rolled out for treatment of these diagnoses and as such, with time, the answer to these questions will be known. Whether the results will be any better than a Darrach’s procedure in the older patient with inflammatory arthritis or, indeed, a Sauvé Kapandji procedure in the younger age group is unknown. At this time, therefore, we would recommend that any patient with these diagnoses undergoing this procedure is counselled carefully before surgery is undertaken, since they will need long-term supervision and, possibly, further surgery. Acknowledgements – We would like to acknowledge Diane Allmark for her help in the preparation of this article.

References 1 Kapandji IA. The KapandjiSauvé operation. Its techniques and indications in non rheumatoid diseases. Ann Chir Main 1986;5(3):181-193. 2 Tolat AR, Stanley JK, Trail IA. A cadaveric study of the anatomy and stability of the distal radioulnar joint in the coronal and transverse planes. J Hand Surg Br 1996;21B:5:587-594. 3 Ishii S, Palmar AK, Werner FW, Short WH, Fortino MD. Pressure distribution in the distal radioulnar joint. J Hand Surg 1998;23A:909-913. 4 Gordon KD, Roth SE, Dunning CE, Johnson JA, King GJW. An anthropometric study of the distal ulna: Implications for implant design. J Hand Surg Br 2002;27A:57-60. 5 Van der Heijden EPA, Hillen B. A two-dimensional kinematic analysis of the distal radioulnar joint. J Hand Surg Br 1996;21B:6:824-829. 6 Sauerbier M, Hahn ME, Fujita M, Neale PG, Berglund LJ, Berger RA. Analysis of dynamic distal radioulnar convergence after ulnar head resection and endoprosthesis implantation. J Hand Surg 2002;27A:425-434.

Correspondence: Professor I A Trail, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP E-mail: upperlimb@wrightington.org.uk

7 Masaoka S, Longsworth SH, Werner FW, Short WH, Green JK. Biomechanical analysis of two ulnar head prosthesis. J Hand Surg 2002;27A:845-853. 8 Gordon KD, Dunning CE, Johnson JA, King GJW. Kinematics of ulnar head arthroplasty. J Hand Surg Br 2003;28B:6:551-558.

9 Van Schoonhoven J, Fernandez DL, Bowers WH, Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg 2000;25A:438-446. 10 Van Schoonhoven J, Mühldorfer-Fodor, Fernandez DL, Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using an ulnar head prosthesis: long term results. J Hand Surg 2012;37A:1372-1380. 11 Fernandez DL, Joneschild ES, Abella DM. Treatment of failed Sauvé-Kapandji procedures with a spherical ulnar head prosthesis. Clin Orthop & Relat R 2006;445:100-107. 12 Sabo MT, Talwalkar S, Hayton M, Watts A, Trail IA, Stanley JK. Outcome and survival of ulna head arthroplasty. Submitted J Hand Surg Eur 13 Kakar S, Swann P, Perry KI, Wood-Wentz CM, Shin AY, Moran SL. Functional and Radiographic outcomes following distal ulna implant arthroplasty. J Hand Surg 2012;37A:1364-1371. 14 Laurentin-Pérez LA, Goodwin AN, Babb BA, Scheker LR. A study of functional outcomes following implantation of a total distal radioulnar joint prosthesis. J Hand Surg 2008;33E:1:18-28. Further reading – Trail IA, Arthroplasty of the Hand and Wrist, published by Lawrencekirk UK.

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PROMs - How was it for you? CR Howie and DF Hamilton (Edinburgh) Codman’s ‘End result’ idea:

During the last decade patient reported outcome measures (PROMs) and satisfaction have become accepted as valid tools in orthopaedic research and healthcare policy. In 2008 Lord Darzi1, in his landmark report on the NHS, set outcomes and quality at the centre of government policy, stating that “as important is the effectiveness of care from the patient’s own perspective which will be measured through PROMs”. Measuring treatment results is not a new concept: well over a century ago Florence Nightingale registered the outcomes of care as “Relieved; Unrelieved; and Died”. In 1908 E A Codman (an orthopaedic shoulder and tumour surgeon in Boston) asked, “What actually happened to the patient?”.

[This article is based on Mr Howie’s Walter Mercer Lecture delivered at the BOA Annual Congress in Dublin, September 2011]

Colin Howie

“The common sense notion is that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, “If not, why not?” with a view to preventing similar failures in the future.” This question is equally pertinent in today’s healthcare environment, though how we determine success is important. The Oxford English Dictionary defines an outcome as a visible or practical result. Originally, our criteria for assessing surgical success were based on lack of complications (notably death) and achieving the surgical result we were aiming for (union, stability, osseo-integration etc.). While clearly important, death is a rare orthopaedic event; variation in death rates likely represents case selection, anaesthesia and aftercare, and almost certainly reflects hospital support services for our frail elderly fragility fracture patients. Perhaps this metric is representative of our attention to management issues in hospital rather than our orthopaedic abilities? Death rates cannot discern differences in clinical outcome following planned procedures which are carried out to address morbidity, and is therefore neither specific nor sensitive for the majority of planned orthopaedic procedures. Lord Darzi, in his evidence to the parliamentary health committee in 2008, highlighted that mortality statistics were an imprecise and perhaps inappropriate statistic to measure success in many conditions. Surgical complications (infection, dislocation, non-union), while important and worth monitoring, are now low in orthopaedics, thanks to effective patient safety programmes. If such complications are rare

(or present late), unfeasibly large numbers are needed in controlled trials to show significance. It can be difficult to collect all complication episodes or indeed agree that a complication has occurred: for example, infection, superficial or deep, depends on the quality of bacteriological diagnosis and Pulmonary Embolism depends on the vigilance of staff and the availability of Computer Tomography Pulmonary Angiography. To further confuse the issue, the Swedish arthroplasty register first noted that around half the patients with an infected joint replacement (a bad outcome in the surgeon’s eyes) were satisfied with the results of surgery. This is difficult to explain if we assume that lack of complication is the arbiter of success. For arthroplasty, survival curves have rightly become the standard evaluation for implant longevity, all cause revision is generally accepted as the end-point2 yet unfortunately not universally quoted. This method of analysis has been criticised as neither adequately defining implant failure nor commenting on patient function prior to that failure3. Equally, though apparently a firm and definite endpoint, the threshold for revision may vary from surgeon to surgeon. In addition case mix at primary surgery will affect the figures, and selective reporting of revisions (is a liner exchange a revision?) will also skew results. Finally, failure to revision is rare and often takes place after many years, thus (in the context of new technologies) problems of new failure modes are often not detected until a number of years later. Assessment of ‘results’ has gradually shifted away from a simplistic success vs. failure model towards the use of quantifiable measures. Clinical outcomes such as range of motion, the clinician’s report of pain relief, radiographic

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appearance and patient function marked the next advance on our journey; however, these were very prone to observer (clinician) bias. As our understanding of the science surrounding such measurements developed, we began to realise that many of these metrics varied between assessments and assessors, indeed it has become clear that sometimes what a clinician regards as a good result may not be regarded as such by the patient. Our apparently absolute metrics were neither reliable nor repeatable. To compound these unforeseen errors we took our unreliable measures and collated many different values into a compound score based on logical, well meaning, but arbitrary assessments of the importance of each individual item contributing to the score. More recently our focus has shifted towards PROMs to ascertain the patient’s perception of success. A PROM is any measure reported by the patient (in a validated standardised format); proponents of these suggest they provide a remarkably sophisticated measure of whether a patient feels better – and how much better4. The government now require that providers of planned surgery of NHS patients gather this information. Various scores are now used to compare prostheses or techniques, and in auditing departments and individual surgeons. Generic health status questionnaires such as the EQ-5D, has been widely used and validated to look at the economic benefits of treatments. Unfortunately, these generic scores are insensitive to changes in one joint but reflect the general change in health status of the patient. For specific operations more specific questions need to be used. There are many validated joint or

disease specific scores available of which the most commonly used in this country are the various Oxford scores, the Manchester/ Oxford foot score, DASH, and the Constant Shoulder score. Widely used they also have limitations, most notably a ceiling effect when a patient begins with a good score. The specificity of these questions is also debated, and again a number of extended scores are available for particular situations. Joint or disease specific PROMs are commonly used to assess ‘functional (or clinical) outcome’ as they are cheap, effective at collecting large volumes of data, and don’t require follow-up clinic visits as they can be returned by post or electronically. However, joint specific PROMs are heavily influenced by a patient’s pain levels. As opposed to being an assessment of functional activity, the patient reports their ‘experience’ of performing that activity5. Despite these reservations, there is evidence that PROM scores can highlight potential implant failure. If PROMs are used to measure outcome, what is it that influences this outcome (assuming all surgery and surgeons are equally successful!)? Much has been written on this. Crudely, the worse the pre-operative scores, the worse the post-operative scores. Thus we need pre- and post-op data to assess this in a meaningful way. There are a number of factors known to predict outcome scores: the procedure and joint is one, hips and knees achieve different improvements (accepting the different scoring systems)6. Patient factors such as depression, obesity, age and co-morbidity (often co-existent in the one patient) are all identified in the literature as contributing to the patients’ reporting of pain and function. Social deprivation is also

thought to contribute, though the exact combination and extent of these various factors are difficult to interpret. Interestingly, there is some evidence that we already take such factors into account in our patient selection (co-morbidities and obesity, for example) and perhaps the GP and ourselves wait longer before considering surgery in the ‘at risk’ patients as their scores are worse before we operate. When taking the factors known to affect change in scores into account there is surprisingly little difference around the country in the values achieved for joint replacement. Unscientifically, but unsurprisingly, given the cost and popularity of joint replacement, outcome scores have been used to limit access to healthcare ultimately to reduce cost. This will prove very difficult though as these scores were specifically developed as tools to measure treatment success, as opposed to diagnostic parameters of an individual’s suitability for surgery. Satisfaction is a different metric. Though patient satisfaction is related to the clinical outcome score, it is not the same thing. Indeed some patients reporting a bad clinical outcome, in terms of pain and function, may report good levels of satisfaction with their surgical outcome and vice versa7. We recently reviewed the factors associated with satisfaction in joint arthroplasty and found the only things that really mattered were meeting of pre-operative expectations, achieving pain relief and the hospital experience7. Perhaps patient satisfaction is the most important outcome. This is well recognised in service industries, though remains something of a nebulous concept in clinical care. Because of recent, well publicised failings in the NHS, patient experience is the latest target for measurement. Patient Reported Experience Measures

(PREMs) have been well validated but not widely used. They record the actual delivery of healthcare. Drawing on the widespread use of surveys in the service industries to maintain quality services, the government plans to introduce the ‘friends and family test’ (Net Promoter Score as used in the service industries). Patients are asked whether or not they would recommend the care they have received to a loved one if they were in a similar situation. We have reviewed this measure in the context of joint arthroplasty and found that the same three factors determine this score: the meeting of expectations, achievement of pain relief (PROMs) and the experience of being in hospital (PREMs)9. Importantly, in terms of these satisfaction and experience measures, the patients’ demographics do not affect outcome in the same manner that they affect the PROMs, making them more suitable as an overarching metric. This generalisability is of course at the expense of specificity and detail. We know that patient satisfaction measures do not necessarily relate to the technical quality of the care received10. Recent concern has been expressed that, if asked in isolation, these experience metrics provide little insight. We have found good correlation between satisfaction and ‘promoter score’ when asked in the context of a suite of questions about the episode of care9. Assuming the absence of serious complication, a combination of PROMs, patient satisfaction and experience is perhaps the most appropriate way to determine ‘what actually happened to the patient’. Orthopaedics has little to fear and everything to gain from using and publishing a balance of different PROMs to prove the value of our

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care. Almost universally our results compare extremely favourably with other specialties and are actually better than many well respected service industries. We must remain focused on our patients and apply a little of what Lord Darzi described as “Starbucks style care”. The UK government has appointed Professor Don Berwick as Patient Safety ‘Czar’. He is a senior and well respected figure from the Boston Institute of Healthcare Improvement and latterly headed up the ‘Obamacare’ programme in the US. Berwick believes that E A Codman should be regarded as the father figure for measuring success in the healthcare environment. In the UK we can show that he is correct and that, in orthopaedics, we have learned from one of our own.

References 1 Department of Health. High quality health care for all. NHS next stage review. London: Department of Health. 2008. 2 British Orthopaedic Association. Knee replacement: a guide to good practice, 2010. http:// www.boa.ac.uk/Publications/ Documents/tkr_good_practice. pdf (date last accessed 3 September 2012). 3 Price AJ, Longino D, Rees J, et al. Are pain and function better measures of outcome than revision rates after TKR in the younger patient? Knee 2010;17:196–199. 4 Timmins N. NHS goes to the PROMS. Brit Med J 2008;336:1464–1465. 5 Hamilton DF, Gaston G, Simpson AHRW. Is patient report of physical function

accurate following total knee arthroplasty? Bone Joint Surg Br 2012;94-B:1506–10. 6 Hamilton DF, Henderson GR, Gaston P, MacDonald D, Howie C, Simpson AH. Comparative outcomes of total hip and knee arthroplasty: a prospective cohort study. Postgrad Med J. 2012;88:627631 7 Baker PN, van der Meulen JH, Lewsey J, et al. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007;89:893–900. 8 Hamilton DF, Lane JV, MacDonald D, Patton JT, Gaston P, Simpson AHRW, Howie CR. What determines patient satisfaction with surgery? A PROSPECTIVE COHORT STUDY OF 4709 PATIENTS FOLLOWING TOTAL JOINT REPLACEMENT. Brit MedJ Open 2013;3:e002525.

9 Hamilton DF, Lane JV, Gaston P, Patton JT, MacDonald D, Simpson AHRW, Howie CR. Is the ‘friends and family test’ (Net Promoter Score) a workable metric for the NHS and what does it measure? A PROSPECTIVE COHORT STUDY OF 6912 PATIENTS FOLLOWING TOTAL JOINT REPLACEMENT. [In Press]. 10 Rao M, Clarke A, Sanderson C, et al. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. Brit Med J,2006;333:19–22.

Correspondence: Mr Colin Howie Dept. of Trauma and Orthopaedics University of Edinburgh Little France Edinburgh EH16 4SU

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Peer-Reviewed Articles

The Surgical Management of Complex Intraarticular Fractures of the Distal Humerus Mr R Amirfeyz, Bristol & Mr D Stanley, Sheffield. Correspondence to Mr David Stanley, Consultant Orthopaedic Surgeon

Intraarticular fractures of the distal humerus are difficult to treat. This article reviews the contemporary literature on surgical management of these fractures.

Intraarticular fractures of the distal humerus are complex injuries. The management of these fractures has evolved over the last four decades with research into conservative and operative management, as well as biomechanical studies testing various methods of fixation. Method of fixation remains controversial but most trauma surgeons agree that when it is possible to internally fix, the goal of treatment must be anatomic stable restoration with early motion. 1-17

David Stanley

The overall incidence of distal humeral fractures is 5.7 per 100,000 of the population per year, with a bimodal distribution.18 The mean age of patients sustaining distal humeral fractures is 48.4 years, with the peaks of greatest incidence primarily representing a young male population who injure themselves through sport and road-traffic accidents and an elderly female population injured through simple falls. A recent review of the Finnish National Hospital Discharge Register has shown a substantial increase in the second peak of the bimodal distribution.19 With life expectancy continuing to increase it is anticipated that a greater number of these fractures will require treatment in the future. Improvements in osteosynthesis techniques and instrumentation have changed the treatment of these injuries. Prior to the 1970s, bicondylar intraarticular fractures were traditionally treated conservatively with skeletal traction, collar and cuff, or closed manipulation and cast application.1,20 During the 1970s and 1980s surgical fixation became the treatment of choice. A review of 42 patients with intra-articular bicondylar fractures of the distal humerus by Zagroski et al clearly highlighted the benefits of anatomical reconstruction and rigid internal fixation.21 Patients were evaluated as to their functional results using the criteria defined by Bickel and Perry.22 Results were

[Fig. 1a & 1b]

Intra-articular fracture â&#x20AC;&#x201C; 90/90 plating

classified as excellent, good, fair, or poor. Of the patients treated by open reduction and internal fixation, 76% had an excellent or good result, increasing to 88% if the reduction was anatomical. Of the patients not treated with primary ORIF, only eight percent had an excellent or good result Early fixation methods relied on screws alone before plate constructs were introduced. In vitro biomechanical research however have proved the superiority of a double plate configuration, regardless of the type of plate used.23 The more recent literature has questioned the importance of the traditional 90/90Â° plates configuration (Fig. 1), which was based on the stiffness of the construct when 1/3 tubular plates were used. In-vitro and cadaveric studies have now confirmed the adequacy of both compression and torque stiffness with parallel plating, specifically if locking screws are employed.24-26 The 1/3 tubular plates which once were in favour due to malleability and ease of contouring27 have now been superseded by anatomically

contoured plates, largely alleviating the need for intra-operative plate bending. The option of lock screws has improved the bone-implant anchorage particularly in elderly patients with osteopaenic bone.28 The failure of fixation typically begins in the lateral column, with repetitive varus stresses across the elbow resulting from the force of gravity acting through the forearm lever arm. The resulting varus torque across the elbow distracts the lateral column away from any fixation placed along its posterior surface. To counteract this a lateral plate applied parallel to the medial side has been proposed.2 The theoretical advantage of such a plating configuration is it allows interdigitation of screws in the osteopaenic articular fragments, combined with the stiffness of the plates. The interdigitation and locking of the screws together as they pass through the distal fragments creates the architectural equivalent of an arch (Fig. 2). The majority of fixation failures after a distal humeral fracture occur at the supracondylar level. If fixed with traditional methods, the methaphysis-diaphysis

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Journal of Trauma and Orthopaedics, Volume 1, Issue 1, pages 52-56 Title: The surgical management of complex intraarticular fractures of the distal humerus Authors: R Amirfeyz and D Stanley

[Fig. 2a & 2b]

Intra-articular fracture – parallel plating

junction will be dependent on only 2 or 3 screws for stability. The fixation strategy however should concentrate on maximising fixation strength in this area. The plates should be applied such that compression is achieved at the supracondylar level for both columns. Precontoured parallel plates have the advantages of both maximising construct stiffness specifically at the supra-condylar level and if the fragments do not align with the contour of the plates it is most likely that it is the bone reduction that is imperfect and not the plate position. Another problem with placing the plate posterolaterally is that screw fixation in the lateral column distally is often limited to 1 or 2 small short screws passing through the plate from posterior to anterior. As the capitellum pulls away from the plate, the entire distal humeral segment becomes unstable. For the intra-articular shear type fractures, headless compression screws are usually sufficient (Fig 3). The biology of the fracture is also important and the surgeon should appreciate the insufficiency of the osseous micro-architecture in

the posterior aspect of the distal humerus.29 The thinning of the posterior cortex and the reduced posterior trabecular bone volume potentially has implications for positioning plates posterolaterally. Another factor to consider when positioning plates is the blood supply. Several cadaveric studies investigating the arterial anatomy of the human adult elbow have identified the importance of segmental posterolateral vessels.30, 31 The posterior dominance of the blood supply to the distal lateral humerus suggests that when fractures are fixed with posterolateral plates surgery should be performed with minimal periosteal elevation or alternatively plates should be avoided in this region to avoid damage to these perforating vessels. The outcomes following open reduction and internal fixation (ORIF) have been documented using subjective, objective, radiographs and complication measures.3-17,22,32,33 Various subjective patient rated scores have been used to assess outcomes in these injuries including; the Disabilities of the Arm Shoulder and Hand [DASH], Ulnar Nerve

[Fig. 3a & 3b]

Shear fractures

Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and the Short Form-36 [SF-36].3 Studies have also used objective outcomes alone,4 as well as a combination of subjective and objective measures such as the Mayo Elbow Performance Score (MEPS), Broberg and Morrey functional rating index, the Orthopaedic Trauma Association assessment, the Jupiter outcome and the Bickel and Perry outcome.4-10,22 Overall using the range of scores available, 56-87% of patients have a good or excellent outcome following ORIF.3-10 Patient satisfaction has been reported as high as 85-95%,3,6 with 75% of patients returning to their pre-injury level of occupation and activity.6 Mean post-operative flexion arcs have been measured between 97-112º with average pronation-supination arcs from 151-165º. 5,6,11,34 Age over 50, poor bone quality and open fractures are associated with a inferior outcome.10 Complications of open reduction and internal fixation include; nonunion, mal-union, ulnar neuropathy,

heterotopic ossification, posttraumatic arthritis and infection. Non-union or metal work failure requiring further surgery has been recognised in 0-13% of patients.3,6,8,10,18 75% of these are due to an inadequate initial surgical fixation.32 Deep infection rate is 0-8%.3,6,9,10,218,27,34 Ulnar neuropathy happens in 0-15% of patients post operatively.4,6,9,11,18,27 Heterotopic ossification has been reported in 13% of patients,3 with a trend to develop heterotopic bone in patients’ not receiving indomethacin prophylaxis. There is currently however no level 1 evidence to support or dismiss the use of indomethacin. The current consensus from the literature is that in young patients, anatomical reduction of the joint surface and stable internal fixation is the gold standard. There has however been much debate as to whether internal fixation or primary total elbow arthroplasty is the most appropriate treatment in the elderly with osteoporotic bone. A recent Canadian prospective, randomised, multicentre controlled trial has compared ORIF with primary semiconstrained total elbow arthroplasty (TEA) in complex

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bicolumn intraarticular fractures in the elderly.33 Twenty-one patients were randomised to each treatment group and followed for two years. The primary outcome measure was the reoperation rate, and the secondary outcome measures were patient outcome, evaluated using the MEPS and DASH scores. Reoperation rates for TEA (12%) and ORIF (27%) were not statistically different. There were however 5 fractures (25%) initially randomised to ORIF that underwent intraoperative conversion to TEA because of severe comminution and an inability to obtain stable fixation. Patients who underwent TEA had significantly better MEPSs at 3 months, 6 months, 12 months, and 2 years, as well as significantly better DASH scores at 6 weeks and 6 months but not at 12 months or 2 years. Although there was a trend toward improved motion in the TEA group the mean extension, flexion, and arc of motion of flexion-extension were not significantly different between the two groups at 2 years. There was a significantly decreased operative time in the TEA group. The same experience was noted in a retrospective review.34 24 women older than age 65 who sustained distal humerus fractures treated with ORIF or TEA were followed up for a minimum of 2 years. Using the MEPS, the outcomes of the 12 patients treated with ORIF were 4 excellent, 4 good, 1 fair, and 3 poor. Outcomes of the 12 patients treated with TEA were 11 excellent and 1 good. No patients treated with TEA required revision during the period of the study. The low numbers in each group might be responsible for the lack of statistically significant difference observed. It should also be noted that eight out of twelve patients in TEA group had rheumatoid arthritis.

Garcia et al reviewed a consecutive series of 19 patients with fractures of the distal humerus treated by Coonrad-Morrey TEA (Zimmer).35 The indications for surgery were fracture comminution and osteopaenia in patients over the age of 60 years. Two patients died and one patient developed dementia before any prolonged period of follow-up. The remaining 16 patients were assessed clinically and radiologically at a mean follow-up of three years (1 to 5.5). At follow-up, 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one patient had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination-pronation arc was 160°. No elbow was unstable. The mean DASH score was 23 (0.92 to 63.3). The mean MEPS was 93 (80 to 100). 94% was satisfied with the outcome. Radiographs showed that 15 implants were well fixed with no evidence of loosening at final follow-up. Kamineni et al retrospectively reviewed a series of 49 acute distal humeral fractures in 48 patients treated with TEA as the primary option.36 Forty-three patients were followed for at least two years (6 fractures in 5 patients were excluded due to a less than a two-year follow-up), with an average duration of follow-up of seven years. The average age of the patients was sixty-nine years. The average post operative flexion arc was 24° to 131° and the MEPS averaged 93. The concept of humeral hemiarthroplasty has recently been introduced as an alternative option to TEA, with a short series of 4 patients treated with Kudo humeral hemiarthroplasty reported. All four patients had a good or excellent outcome at short-term follow-up.37

These studies confirm the conclusion that primary TEA is an acceptable option for the management of comminuted bicondylar fractures of the distal humerus in the elderly, in younger patients however every effort should be made to primarily fix the fractures as the expected life expectancy outweighs the implant longevity. If the fracture is very complex and fixation is considered to be beyond the surgeon’s technical experience/expertise, then onward referral to a specialist elbow unit is mandatory. Although there is evidence for carrying out a primary TEA for these complex injuries in an elderly population, many surgeons prefer to carry out a primary ORIF to avoid the long-term complications associated with TEA. Unlike TEA a successful ORIF should allow the elbow to continue to function well in the long term without requiring further reconstructive surgery.5 In cases where ORIF fails due to nonunion, TEA still remains a surgical option. Whether the outcome is better after an acutely performed TEA or a TEA following a non-union is a matter of debate. Sivardeen et al retrospectively compared the results of primary TEA and TEA after failed ORIF, with a mean follow up of five years.38 There were nine TEA’s following failed ORIF group and 12 had a primary TEA. The patients receiving a primary TEA had a significantly higher MEPS than those having a TEA after a failed ORIF. Prasad et al however did not find a significant difference in outcome or the rate of complications when they retrospectively reviewed a series of patients undergoing delayed and early TEA.39 A total of 32 patients with 15 in the early treatment group and 17 in the delayed treatment group were studied. Of these patients, 15 had been referred with acute fractures of the distal

humerus and received a primary TEA on average two weeks after their injury. The mean age of these patients was 78 years (61 to 89). There were 17 patients who were referred with painful nonunion of a fracture of the distal humerus that received a delayed TEA 56 weeks (16-96) after their initial injury. Of the 17 patients, 13 had undergone unsuccessful attempts at fixation. The remaining four had been treated conservatively in plaster. The mean age of this delayed group was 73 years (61 to 86). The percentage of excellent to good results based on the MEPS was not significantly different, 84% in the early group and 79% in the delayed group. Subjective satisfaction was 92% in both the groups. The Kaplan-Meier survivorship analysis for the early and delayed treatment groups was 93% at 88 months and 76% at 84 months, respectively. No significant difference was found between the two groups. In summary, intra-articular distal humerus fractures are complex injuries requiring an experienced surgical approach. The literature has identified consistently good outcomes following open reduction and internal fixation. Provided internal fixation is done well it is the most suitable option for these injuries. Total elbow arthroplasty has a role, particularly in an elderly population where the potential of long-term complications is lower. Hemiarthroplasty may also be an option in the elderly, but long term results are not available. There is a need for further prospective studies.

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Journal of Trauma and Orthopaedics, Volume 1, Issue 1, pages 52-56 Title: The surgical management of complex intraarticular fractures of the distal humerus Authors: R Amirfeyz and D Stanley

References 1) Eastwood WJ. The T-shaped fracture of the lower end of the humerus. J Bone Joint Surg 1937;19:364-9. 2) O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elb Surg 2005;14:186S-94S. 3) Gofton WT, Macdermid JC, Patterson SD, et al. Functional outcome of AO type C distal humeral fractures. J Hand Surg Am 2003;28:294–308. 4) Cassebaum WH. Open Reduction of T and Y Fractures of the Distal End of the Humerus. J Trauma 1969;9;915-25. 5) Doornberg JN, van Duijn PJ, Linzel D, et al. Surgical treatment of intraarticular fractures of the distal part of the humerus. Functional outcome after twelve to thirty years. J Bone Joint Surg Am 2007;89:1524–32. 6) Aslam N, Willett K. Functional outcome following internal fixation of intraarticular fractures of the distal humerus (AO type C). Acta Orthop Belg 2004;70:118–22. 7) Leugmair M, Timofiev E, Chirpaz-Cerbat JM. Surgical treatment of AO type C distal humerus fractures: internal fixation with a Y shaped reconstruction (Lambda) plate. J Shoulder Elb Surg 2008;17:113–20.

8) Sanchez-Sotelo J, Torchia ME, O’Driscoll SW. Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. Surgical technique. J Bone Joint Surg Am 2008;90:31–46.

16) Soon JL, Chan BK, Low CO. Surgical fixation of intraarticular fractures of the distal humerus in adults. Injury 2004;35:44-54.

9) Jupiter J, Neff U, Regazzoni P, Allgower M. Unicondylar Fractures of the Distal Humerus: An Operative Approach. J Orthop Trauma 1988;2:102-9.

17) Wang KC, Shih HN, Hsu KY, et al. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 1994;36:770-3.

10) Pajarinen J, Bjorkenheim JM. Operative treatment of type C intercondylar fractures of the distal humerus: results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elb Surg 2002;11:48–52.

18) Robinson CM, Hill RF, Jacobs N, Dall G, Court-Brown CM. Adult Distal Humeral Metaphyseal Fractures: Epidemiology and Results of Treatment. J Orthop Trauma 2003;17:38–47.

11) Athwal GS, Hoxie SC, Rispoli DM, Steinmann SP. Precontoured Parallel Plate Fixation of AO/OTA Type C Distal Humerus Fractures. J Orthop Trauma 2009;23:575–80.

19) Palvanen M, Niemi S, Parkkari J, Kannus P. Osteoporotic fractures of the distal humerus in elderly women. Ann Intern Med 2003;139:W1–61.

12) McKee MD, Wilson TL, Winston L, et al. Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg Am 2000;82-A:1701-7. 13) Gupta R, Khanchandani P. Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases. Injury 2002;33:511-5. 14) Kaushal L, Rai J, Singh SP. Comminuted intra-articular fractures of the distal humerus. Int Orthop 1994;18:276-9. 15) Caja VL, Moroni A, Vendemia V, et al. Surgical treatment of bicondylar fractures of the distal humerus. Injury 1994;25:433-8.

20) Riseborough EJ, Radin EL. Intercondylar T fractures of the humerus in the adult. J Bone Joint Surg Am 1969;51-A:130-41. 21) Zagorski JB, Jennings JJ, Uribe JW. Comminuted Intraarticular Fractures of the Distal Humeral Condyles Surgical vs. Nonsurgical Treatment. Clin Orthop Relat R 1986;202;197-204. 22) Bickel WE, Perry RE. Comminuted fractures of the distal humerus. J Am Med Assoc 1963;184:553-7. 23) Helfet DL, Hotchkiss RN. Internal fixation of the Distal Humerus: A Biomechanical Comparison of Methods. J Orthop Trauma 1990;4:260-4.

24) Arnander MT, Reeves A, MacLeod IR, Pinto TM, Khaleel A. A Biomechanical Comparison of Plate Configuration in Distal Humerus Fractures. J Orthop Trauma 2008;22:332–6. 25) Stoffel K, Cunneen S, Morgan R, Nicholls R, Stachowiak G. Comparative Stability of Perpendicular Versus Parallel Double-Locking Plating Systems in Osteoporotic Comminuted Distal Humerus Fractures. J Orthop Res 2008;26:778-84. 26) Self J, Viegas SF, Buford WL, Patterson RM. A Comparison of Double-Plate Fixation Methods for Complex Distal Humerus Fractures. J Shoulder Elb Surg 1995;4:10-6. 27) Henley MB, Bone LB, Parker B. Operative Management of Intraarticular fractures of the Distal Humerus. J Orthop Trauma 1987;1:24-35. 28) Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B. Mechanical Comparison in Cadaver Specimens of Three Different 90-Degree Double-Plate Osteosyntheses for Simulated C2-Type Distal Humerus Fractures With Varying Bone Densities. J Orthop Trauma 2008;22:113–20. 29) Park SH, Kim SJ, Park BC, et al. Three-dimensional osseous micro-architecture of the distal humerus: Implications for internal fixation of osteoporotic fracture. J Shoulder Elb Surg 2010;19:244-50.

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30) Yamaguchi K, Sweet F, Bindra R, Morrey B, Gelberman R. The Extraosseous and Intraosseous Arterial Anatomy of the Adult Elbow. J Bone Joint Surg Am 1997;79-A:1653-62. 31) Kimball JP, Glowczewskie F, Wright TW. Intraosseous Blood Supply to the Distal Humerus. J Hand Surg Am 2007;32A:642–6. 32) Ali A, Douglas H, Stanley D. Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus. J Bone Joint Surg Br 2005;87B:1107-10.

33) McKee MD, Veillette CJH, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elb Surg 2009;18:3-12. 34) Frankle MA, Herscovici D, DiPasquale TG, Vasey MB, Sanders RW. A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65. J Orthop Trauma 2003;17:473-80.

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35) Garcia JA, Mykula R, Stanley D. Complex Fractures of the Distal Humerus in the Elderly; The Role of Total Elbow Replacement as Primary Treatment. J Bone Joint Surg Br 2002;84-B:812-6. 36) Kamineni S, Morrey BF. Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940–7. 37) Adolfsson L, Hammer R. Elbow hemiarthroplasty for acute reconstruction of intraarticular distal humerus fractures: a preliminary report involving 4 patients. Acta Orthop 2006;77:785–7.

38) Sivardeen Z, Raha N, Anderson A, et al. Total Elbow Arthroplasty For Distal Humeral Fractures- A Comparison Between Primary Arthroplasty and Arthroplasty After Failed Primary Fixation. British Elbow and Shoulder Society, Telford, 2007. 39) Prasad N, Dent C. Outcome of total elbow replacement for distal humeral fractures in the elderly. A Comparison of Primary Surgery after Failed Internal Fixation or Conservative Treatment. J Bone Joint Surg Br 2008;90B:343-8.

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Obituaries

Obituary: James Geddis Kernohan 26 January 1948 – 17 January 2013 John Dinley

James Kernohan, ‘Jim’ to his many friends and colleagues, died peacefully after a short illness on 17 January 2013.

Jim graduated from Queens University Belfast Medical School in 1972 during which time his talents for rowing were rewarded by a seat in the University ‘First Boat’. He first met his wife Sandra in 1971 at the Ulster Hospital, Belfast, where they were both working; Jim as a final year medical student and Sandra as a staff nurse. They were married in 1973 at which time Jim was working as a pathology demonstrator at the Royal Victoria Hospital and studying for his Primary FRCS.

He acquired his FRCS (Ed) in 1977 and, as an added challenge to his training programme and his French linguistic skills, he applied for and was awarded the post of Résident Étranger in Paris at Ambroise Paré Hôpital and Hôpital Cochin from 1977-1978. On his return from France he was appointed registrar at Charing Cross Hospital from 1978-1979 after which he acquired his FRCS (Eng). His orthopaedic training was completed on the internal rotation at the RNOH from 1979-1985 spending time at GOS, Great Portland Street, the Middlesex and Stanmore Hospitals. Jim and Sandra came to Dorset when he was appointed Consultant to Poole and Christchurch Hospitals in 1985, there to join four colleagues. Jim rapidly became an important, respected and influential colleague and always ready for a challenge. He played an important part when the elective orthopaedic unit moved from Christchurch Hospital to its new wards and

James Kernohan

theatres at the Royal Bournemouth Hospital and indeed became its first Clinical Director of Theatres. As orthopaedic consultant numbers and specialisation increased, Jim set up and developed the Shoulder Unit at the Royal Bournemouth Hospital and immersed himself more and more in the practice and teaching of this specialty over recent years. He was a much sought after Medicolegal Expert Witness and had developed a busy medicolegal practice.

Away from the hospital environment, Jim had many and varied interests: he loved the sea and all means of sailing on it. He was also very knowledgeable about horse racing in part influenced by his Northern Irish background. Music played a major part in both his and Sandra’s lives and he was a keen supporter of the Bournemouth Symphony Chorus in which Sandra was an enthusiastic member and played a major administrative role. He was a proud and loving family man with a large and close family of which many members are in Northern Ireland. He will be sadly missed and fondly remembered by his many colleagues, patients and friends. His wife Sandra and his children Robert and Ruth survive him.

Jim was a member of the BOA and The British Elbow and Shoulder Society and a keen supporter and participant in several local Medical Societies.

In memoriam

It is with great regret that we report the death of Sir Rodney Sweetnam shortly before the JTO went to press. A distinguished surgeon and a remarkably gifted individual endowed with great presence and charm, Sir Rodney was a BOA Honorary Fellow, BOA President in 1985 and former President of The Royal College of Surgeons of England. Our thoughts are with Lady Sweetnam and his wider family and friends. A full obituary will appear in our next edition.

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Imprint

JTO:

BOA Executive Martin Porter (President) Joe Dias (Immediate Past President) Tim Briggs (Vice President) Colin Howie (Vice President Elect) John Timperley (Honorary Treasurer) David Stanley (Honorary Secretary)

Information for readers, advertisers & potential authors

BOA Elected Trustees Martin Porter (President) Joe Dias (Immediate Past President) Tim Briggs (Vice President) Colin Howie (Vice President Elect) John Timperley (Honorary Treasurer) David Stanley (Honorary Secretary) Barry Ferris John Hodgkinson Phil Turner Ian Winson Tony Hui Don McBride Ratakondla Ravikumar Martin Gargan Gordon Matthews Ananda Nanu Alistair Stirling

BOA Staff Executive Office

Chief Executive Deputy CEO Personal Assistant to the Executive Interim Assistant JTO Editor Office Co-ordinator Communications Advisor Education Advisor

Policy & Programmes

Head of Policy & Programmes Policy and Programmes Officer Policy & Programmes Assistant Policy & Programmes Assistant Data Analyst

Finance & Membership

Finance Manager Senior Finance Assistant Finance Assistant (Membership) Finance Assistant Membership Administrator

Events & Specialist Societies

Head of Events Exhibition Manager Congress & Courses Project Manager

Information Systems

Information Systems Manager Information Systems Assistant

Joint Action

Support Assistant Registered Charity No.1066994 Company limited by guarantee Company Registration No.3482958

Mike Kimmons CB Julia Trusler Celia Jones David Adams Natasha Wainwright Simon Scott Lisa Hadfield-Law Julia Trusler Rayshum Notay Rosanna Raison Craig Dove Naufil Alam Liz Fry Sherrine Wilson-Smith Miranda Boyce Hayley Oliver Leslie O’Leary Hazel Choules Janet Mills Claire Wilson Daniel Maby Tomasz Rozejowski Lauren Rich

Instructions and information for authors [Note: these instructions are for general guidance; prospective submitters should consult the full instructions on the BOA website before submitting any article.]

News and feature articles Authors wishing to submit news items (of up to 250 words) or feature articles (up to 1500 words) should, before submission, contact the Editorial Team (JTO@boa.ac.uk) for confirmation that the subject matter will be appropriate for inclusion. Illustrations, such as photographs, x-rays, graphs, tables and other figures are encouraged for all articles. [Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.]

Instructional articles for the peer reviewed section The usual length of an instructional article in any one edition is up to 2,500 words. Longer articles may be edited or published in more than one part, if they can be segmented into shorter selfcontained pieces. The article must be fully referenced, and illustrations, such as photographs, x-rays, graphs, tables and other figures are encouraged. Each instructional article is reviewed by the Editor. If judged suitable, it will be sent to two or more referees for double blind peer review. The Editor will decide, based on their recommendations, whether the article should be accepted as is, revised or rejected. If revision is required, the manuscript will be returned to the author, with the reviewers’ remarks. The Editor’s decision will be final.

Copyright Agreement & Patient Identification We require the authors of articles accepted for publication to sign an Assignment of Copyright before the article can be published. The form will be sent with the acceptance email. If a patient is identifiable from the text or any images used in an article, a consent form must be signed by the patient or their guardian/relative – these forms are available from the BOA and must be made available to the BOA on request.

Future publications JTO is published quarterly

How to subscribe If you’d like to subscribe to future issues either for yourself or your organisation, we’d be happy to add you to our mailing list; please contact us at JTO@boa.ac.uk Please note that all issues are free of charge.

Advertising All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box Publishing Regent Court, 68 Caroline Street Jewellery Quarter, Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 608 2300

Disclaimer The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication. Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations. Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.

Copyright Copyright© 2013 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box Publishing Regent Court, 68 Caroline Street Jewellery Quarter, Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 608 2300

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Keith Tucker, Tim Chesser.

BOA contact details The British Orthopaedic Association 35-43 Lincoln’s Inn Fields London WC2A 3PE Telephone: 020 7405 6507 Fax: 020 7831 2676

Volume 01 / Issue 01 / June 2013

boa.ac.uk

Page 61

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Volume 01 / Issue 01 / June 2013

boa.ac.uk

Page 62

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