Journal of Trauma & Orthopaedics - Vol 2 / Iss 1 by British Orthopaedic Association

The journal OF the British Orthopaedic Association Volume 02 / Issue 01 / January 2014 boa.ac.uk

Which is correct? 1) License to Practice 2) Licence to Practice 3) Licence to Practise 4) License to Practise

You Choose! (Answer on page 26, alongside David Limb’s article on CPD)

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

Our Features section includes articles from the new NCD for Spinal Disorders and on how the BOA is taking research forward.

News & Updates ––– Pages 01-16

Features ––– Pages 18-49

For the latest updates on clinical issues, see our PeerReviewed Articles which focus on lectures given at BOA Congress. Peer-Reviewed Articles ––– Pages 50-67

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Section??????????????????

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JTO News and Updates

Welcome from your new Editor

Contents

Colin Howie – BOA Vice-President

Welcome to the latest issue of the JTO.

JTO News and updates

You heard from Peter Kay last issue in his position as NCD for MSK; this issue’s focus is the new NCD for Spinal Disorders – Charles Greenough, who gives us an overview of what his primary focuses are and what he hopes to achieve (page 18). Adam Brooks challenges us to improve procurement in the NHS (page 33).

Firstly I have to pay tribute to Martyn Porter for getting JTO off to a great start, setting an extremely high standard. In this, my first issue as JTO Editor, I’d like to welcome my Deputy Editor, Ananda Nanu to the Editorial Team, Mike Foy as Medico-legal Editor and Jeya Palan as Trainee section editor. These well-deserved appointments reflect the very positive comments we have had for these subjects in previous editions. To ensure comprehensive coverage of other areas in future issues, we plan to involve Guest Editors for each issue to focus on a topic or specialty. Next issue it will be Trauma with Nigel Rossiter editing the peer review section.

In our Medico-legal section of the JTO, you will read an article from a psychiatrist on Orthopaedic surgeons (guaranteed a chuckle) (page 48) as well as a learned article on the Jackson reforms (page 44). Finally, our Peer-Review section focuses on some of the lectures given at this year’s Congress. If you missed the lectures then we hope you will find the articles of interest.

This issue is packed full of news, especially following the fantastic BOA Annual Congress (pages 8-11), a word from our new President Tim Briggs (page 2) and the new T&O Curriculum app that has a buzz amongst the trainees (page 3) to pick a few.

JTO Features

01–16 18–49

National Clinical Director for Spinal Disorders Continuing Professional Development and Revalidation The BOA Research Committee CORNET: Trainee led Orthopaedic Research Network PMI and the Orthopaedic Patient Improving Procurement in the NHS AOTrauma Fellowship – Chikamori Hospital, Kochi, Japan Getting your Patient Plastered A guide to ISCP Learning Agreements for Trainees, Assigned Educational Supervisors, and Clinical Supervisors The ‘Jackson Reforms’ in Civil Litigation and the Impact on the Expert Witness (Part 1) Uneasy Bedfellows in Court?: A Psychiatrist on Orthopaedic Surgeons

18 23 27 30 31 33 38 41 42 44 48

JTO Peer-Reviewed Features 50–67

THE JOURNAL OF THE BRITISH ORTHOPAE DIC ASSOCIATION Volume 02 / Issue 01 / January 2014 boa.ac.uk

Which is correct? 1) License to Practice 2) Licence to Practice 3) Licence to Practise 4) License to Practise

You Choose! (Answer on page 26, alongside David

News & Updates ––– Pages 01-16

Our Features section includes from the new NCD for Spinal articles and on how the BOA is takingDisorders research forward. Features ––– Pages 18-49

A New Approach to VTE Prophylaxis Robert L. Barrack Evidence vs. Anecdote in Foot and Ankle Surgery Judith Baumhauer Principles of Ligament Balancing in Total Knee Replacement James B. Stiehl

50 57 63

Obituaries

General information and instructions for authors

Limb’s article on CPD)

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

For the latest updates on clinical issues, see our PeerReviewed Articles which focus on lectures given at BOA Congress. Peer-Reviewed Articles ––– Pages 50-67

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JTO News and Updates

From the President:

Representing and engaging on issues that matter Prof Tim Briggs point to a different conclusion and my aim is to keep trainee numbers as high as possible. I must emphasise that our engagement with the CfWI is an entirely productive one: they base their recommendations on evidence and clinical judgements and have asked me for these extra data so that the stocktake can be as well informed as possible. Please watch this space.

As this issue of JTO reaches you, I will already be a quarter through my time as BOA President, having succeeded Martyn Porter at our Birmingham Congress in October. Further Congress coverage appears elsewhere later, but I would like to thank, again, all the speakers, delegates, the organising team and especially the Honorary Secretary, David Stanley, who made it such a fantastic occasion – certainly the biggest and best in recent years. Tim Briggs

Since Congress I have spent the majority of my time visiting Trusts around England as part of the NHS funded Getting It Right First Time programme. With around 30 Trusts (45 hospitals) covered to date, and over 40 more in the diary so far, it has been great to see unequivocal clinician and management buy-in for this initiative at so many centres. I am convinced this will act as a catalyst for productive changes in service delivery. That aside, I relish the opportunity to engage with BOA members and non-members up and down the country, seeing where they work and hearing about the challenges and opportunities they face: this has been enjoyable, insightful and invaluable. Outside England, I have been actively engaged with the CMO in Northern Ireland to ensure appropriate transparency in the commissioning of the regional foot and ankle service, while in Wales I have supported the National Specialty Advisory Group (NSAG) and local consultants in the Hywel Dda Health Board. The latter recently announced draconian winter pressures proposals that

appeared to involve suspending most elective orthopaedic surgery in the region. The local T&O clinicians contributed significantly to a subsequent proposal with a much reduced impact, and a final decision is imminent at the time of writing. In addition, the BOA agenda continues to focus closely on individual surgeon outcomes. The second wave of publication in England will occur later this year, and is due to include ankle, elbow and shoulder in addition to hip and knee replacement. Our priority is to concentrate principally on ensuring effective validation of data (especially for revision rates, which are a priority for the next round of publication), and careful selection of any additional indicators on which to report. We will continue to press hard on these issues, and BOA members will be kept informed in our e-updates. (More information also available on page 12.) Another important issue that the BOA is currently engaged in is workforce planning as part of the current stocktake by the Centre

for Workforce Intelligence (CfWI). Conscious that the demand for orthopaedics is increasing rapidly and that pension changes are leading some to choose to retire earlier, I am determined to ensure that we have the workforce we need to provide a high quality T&O service in the future. As such I am providing as much supporting data to the CfWI as possible on productivity, demand and future trends. I am very grateful to all those BOA Fellows who responded to my recent survey on retirement, as we had an excellent response. The impact of pension changes comes at an unfortunate time as demand for our services is growing so dramatically, but this makes it all the more important that we support effective workforce planning. At the present time, and based on the work completed to date, it looks likely that the stocktake may recommend reductions in trainee numbers. However, the emergent findings from my GIRFT work and the current rate of hip fractures

Last but by no means least, I would like to highlight the publication in November of the first BOA Commissioning Guidance documents which were jointly developed with the Royal College of Surgeons and other stakeholder groups using a defined process, accredited by NICE. The documents cover a wide range of conditions, and there is currently a second series of documents in development. I would like to express my thanks to Professor Joe Dias for all his hard work in leading and overseeing the formation and delivery of the documents, as well as the Guideline Group Chairs and Members for all their contributions to these important documents. As always, I welcome comments and communications from BOA members, and look forward to meeting as many of you as I am able during GIRFT visits or at Specialist Society and other meetings.

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The 2013 T&O curriculum has gone mobile! T&O has a history of leading the way in embracing technology for learning, and we have done it again. The new mobile app is designed for trainees and trainers. It serves as an interactive quick-reference tool to the complete curriculum, featuring an easy-to-navigate copy of the syllabus. It contains useful tips to make the most of the curriculum, with advice for completing assessments and setting up learning agreements, along with many other topics. It also contains videos that provide further information about the new curriculum.

Real-time progress can be recorded against each topic, making this a useful revision aid for all levels of T&O trainee. It even takes into account your level of training and specialist interest to ensure that you know what to learn at different stages. The latest release supports Push Notification and a news section which will be updated by the BOA to ensure that you are kept abreast of any changes to the curriculum. Trainees can track their progress against the recently published CCT requirements for items such as indicative procedures, assessments and publications. This can be e-mailed as a PDF report that can be uploaded to their ISCP account to provide information for ARCPs. Commissioned by the BOA, the app was developed by James Bale, a computer sciences student, and Ronnie Davies, a T&O trainee who has released a number of successful iPhone

apps, including PatientList and the official ShoulderDoc app. Further contributions were provided by the Training Standards Committee chairman, Professor Philip Turner, in conjunction with Lisa HadfieldLaw, the BOA Educational Advisor. It is freely downloadable from the Apple App Store at http://bit.ly/ TOcurriculum. There are currently no plans to have an Android version as 95% of trainees use an iPhone.

“Free T&O Curriculum App ideal for Trainees to monitor their progress” App Review by Jeya Palan From an educational perspective, the life of an orthopaedic trainee is focused on achieving all the objectives of the national training curriculum. A new mobile app developed by an orthopaedic trainee (Mr Ronnie Davies), in conjunction with the BOA, aims to improve understanding and promote awareness of the new curriculum. The free app for the iPhone and iPad, T&O Curriculum, contains all areas of the new ST3-8 syllabus. The menu allows the user to explore each area of the syllabus and mark off each competency according to the standard scoring system. This record can be easily transferred between units as the trainee moves as part of their rotation. Users can set their training level and the app will adjust the curriculum requirements accordingly. Furthermore, trainees and trainers using the app will be able to easily identify areas of weakness that require further development and enable them to plan their future education accordingly. The T&O Curriculum app is straightforward to use. The intuitive menu system is easy to navigate and clear with all content stored offline for easy access. One of the features many trainees will find useful is the logbook where trainees can log procedures and operations. Whilst the overall view of procedures is extremely helpful, the real utility lies in the ability to generate a PDF of all the procedures for the yearly ARCP. There is also a section for trainees and trainers respectively, which contains useful information related to all the various requirements of the curriculum as well as short concise sections that describe each aspect of the training program. The only real limitation is the lack of Android version that may prove frustrating for a number of would-be users. Overall, the T&O curriculum app is an essential addition for any UK orthopaedic trainee. Its aim is to ensure that trainees and trainers have easy access to the syllabus helping them evaluate and monitor their own progress.

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JTO News and Updates

What do the BOA team do? The CEO provides the answers Q: 20 staff, what do they do? A: We add value by supporting the elected officers to achieve the BOA’s core objectives of excellence in professional practice, training and education, and research. Q: Management speak – can you give us some practical examples? A: Let’s start with revalidation: the BOA Congress provides CPD for surgeons and learning for trainees. Volunteer clinicians set the agenda in conjunction with the Specialist Societies; all work together to deliver the instructional programme; they also review and select free papers and posters. The BOA staff team adds value by coordinating and drawing the various strands of programme activity together. We work to maximise exhibition income, and ensure all the essential enabling processes and infrastructure are in place. These include venue sourcing and selection. Q: Why are these last two important? A: Repeat Association business is highly attractive to venues for future income. By requesting, evaluating and negotiating bids for multiyear deals with venues against a detailed meeting infrastructure requirement, including host city financial support, we have reduced the cost of Congress by some 50%. Realising the BOA’s muscle together with robust financial modelling, we were able to introduce free or modestly priced registration as a membership benefit. Clearly it’s not all about price – other considerations count too: transport links, the hotel stock and our obligation as a national body to move around the UK. The team have become expert in this. Q: Where else have you added value? A: In our communications and information systems: BON cost some £48K a year in printing and distribution costs. For JTO (available to all T&O surgeons) with a more contemporary style those costs are offset by advertising revenues. With journal expertise on the

team we have worked with the publishers to deliver an attractive yet informative product, that has already reduced the overall cost significantly and aims to be in profit by the end of 2014. We are also increasingly active in exploiting App technology and social media to improve communications with fellows and members. Q: What about the future? A: We have just launched a new membership database that will be far easier for people to use (e.g. accessing their individual account and updating their details), will link directly to the online registration function in the website, and will generate the kind of information we need to help support fellows and members and the Specialist Societies. Q: With all this business speak, what has happened to the good old fashioned secretariat? A: The secretariat is an intrinsic governance element of any membership organisation; it still exists and is very active. Skill sets and expectations have changed: we are commissioned by NHS England to support evidence-based policy development and implementation; the outcome transparency agenda necessitates registry knowledge; our NICE accredited guideline development process requires quality assurance of draft Blue Books and commissioning guidance; the trainee surgeons’ learning environment is increasingly digital; and we are supporting the new T&O research infrastructure funded by Joint Action. This calls for people with healthcare policy and programming skills: we now have these skills in house. Q: So what has changed in your four years as CEO? A: The loading on the President and elected Officers has increased exponentially; the staff team has risen to the challenge accordingly. I’m very proud of them.

Conference listing:

Organisation

Conference/meeting

BHS (British Hip Society) www.britishhipsociety.com

Annual Meeting 5-7 March 2014, Exeter

OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk

First Annual Meeting 6-7 March 2014, London

Britspine www.britspine.com

Britspine Meeting 2-4 April 2014, Warwick

BASK (British Association for Surgery of the Knee) www.baskonline.com

Annual Conference 8-9 April 2014, Norwich

WOC (World Orthopaedic Concern) www.wocuk.org

Annual Conference 10th May 2014, Leicester

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk

Spring Meeting 1-2 May 2014, Gateshead

EFORT/BOA www.efort.org/index.php/events-calendar/efort-event-directory

15th EFORT/BOA Combined Congress 4-6 June 2014, London

BOTA (British Orthopaedic Trainees Association) www.bota.org.uk

BOTA Educational Weekend 20-22 June 2014, Chester

BOA (British Orthopaedic Association) www.boa.ac.uk

BOA 2-Day Meeting 12-13 September 2014, Brighton

BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk

Annual Meeting 5-7 November 2014, Brighton

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Section?????????????????? A Patient Education Initiative from DePuy Synthes

“THE PAIN MADE ME SO IRRITABLE I BECAME A DIFFERENT PERSON”

Hip replacement enabled IT consultant Ruth Gower-Smith to maintain her professional and social life. Unlike some, she didn’t leave it too long before considering surgery and once again enjoys the active lifestyle that a painful hip had taken away. This is just one of the positive stories for you and your patients to access at RealLifeTested.co.uk – an educational initiative that aims to improve understanding about knee and hip arthroplasty.

In collaboration with Arthritis Care Registered Charity Nos: 206563, SC038693

Visit www.RealLifeTested.co.uk Where information aids preparation and rehabilitation

Ruth Gower-Smith IT consultant Fell walker Hip replacement

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JTO News and Updates

BOA latest publications Since the last issue of JTO, the BOA has published the following documents (all available in the publications section of our website): BOA Standards for Trauma (BOASTs) on: Management of Arterial Injuries Fracture Clinic Services An expert opinion on Ballistic Injuries A ‘living document’ in relation to VTE prophylaxis Meanwhile, the first commissioning guides produced in partnership with the Royal College of Surgeons, Specialist Societies and other stakeholder groups have been published (available here: http://bit.ly/BOACG-intro). These cover: Painful Deformed Great Toe in Adults Painful Tingling Fingers

Pain Arising from the Hip in Adults Painful Osteoarthritis of the Knee We have been publicising these guides at NHS England events, through Specialist Societies and BODS, and through online and social media publicity. We’d encourage all BOA members and JTO readers to raise awareness of these to commissioners in their networks and communities. All the guides have been produced to standards required by NICE and are intended to support commissioners with clear and accessible information.

Innovation in simulation – BOA competition launched The BOA is pleased to announce the launch of a contest to create a simulator, which replicates one teachable component of T&O surgery - preferably as many different teachable components as possible and most certainly the essential ones. The purpose is to encourage the development of low cost simulators for T&O training purposes. The winning entry will be awarded an educational grant of £500 to the winning team/ person. For more information visit the BOA website (boa.ac.uk). Deadline for submissions: 1st June 2014.

‘Expectations of private patients’ from the BOA’s Patient Liaison Group has been published and is highlighted later in this issue www.boa.ac.uk/PI/Pages/plg.aspx.

Beyond Compliance Working jointly with industry to support the safe and stepwise introduction of new or modified implants (such as joint replacements) is really bearing fruit thanks to the sustained hard work of the Beyond Compliance team, spearheaded by Keith Tucker. For more detail please see www. beyondcompliance.org. uk. Governance options for the longer term are now under consideration, as it will be important that this voluntary scheme has an appropriate fit with EU and US industry compliance requirements.

BOA Appointments We are pleased to announce the following appointees: Education Committee Chair: Mike Reed Training Standards Committee Chair: Phil Turner Training Standards Committee Members: Simon Hodkinson and Vijay Bhalaik Honorary Treasurer (2014-2017): Ian Winson In addition we are pleased to welcome new ex-officio representatives onto Council: Mark Blyth (Scottish Committee for Orthopaedics and Trauma) Nilesh Makwana (National Specialty Advisory Group, Wales) Ian Brown (Northern Ireland Regional Orthopaedic and Trauma Committee) David Large (Specialty Advisory Committee Chair) Rob Marshall (Chairman of the British Editorial Society of Bone & Joint Surgery)

BOA Registry work-stream The orthopaedic profession has a justifiable reputation for being very forward thinking, in regard to registries. The BOA is well ahead of the other surgical specialties. There is a strong desire among Specialist Societies to create a number of new registries; we are keen to support this initiative and have established a new work-stream led by the BHS President John Timperley. Following a scoping exercise and gap analysis of existing registry models, we believe there is the potential for the work-stream to conduct a detailed options appraisal to determine the optimal registry configuration for the whole of T&O. A meeting between Prof Tim Briggs, John Timperley and Sir Bruce Keogh at the Department of Health is scheduled for January 2014 to discuss this further and secure support for this important project.

Coming soon from the BOA •

•

A major report produced by Prof Tim Briggs on the treatment and rehabilitation of members of the armed forces injured in the line of duty (to be called ‘The Chavasse Report’) A new edition of the Consultant Advisory Book for T&O surgeons BOAST 8: ‘Management of Traumatic Spinal Cord Injury’

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JTO News and Updates

BOA Congress – “Putting Evidence into Action” By Don McBride, BOA Trustee

Free registration (courtesy of the pastTreasurer, John Timperley), Specialist Society involvement centre-stage, revalidation, accreditation, instructional courses for trainees and a radical rethink on format. Did they work? David Stanley deserves credit for accepting and shaping these ambitious hopes from the many who contributed to this year’s Congress. Tuesday dawned, nominally a pre-meeting session traditionally not well attended. Inspired programming and excellent presentations (Infection, Technology in Education, GP interface sessions and the BJJ session) were all attended by record numbers, indeed some sessions were heavily oversubscribed with secondary feeds to other halls installed at short

notice. Portents of things to come. The “Official” opening day saw more excellent revalidation/ instructional sessions across Trauma and Orthopaedics that were extremely well attended. The Medico-legal Practice forum was grossly oversubscribed; ironically some attendees unable to gain access for Health and Safety

Peter Kay gives the Robert Jones Lecture in the main auditorium

reasons! A position that always goes down well with Orthopaedic Surgeons. Trauma Boot Camp introduced a new format starting with the upper limb; and BESS completed an outstanding instructional day. As usual, the plenary lectures were diamond gems - James Stiehl on ligament balancing (Adrian Henry Lecture), Bob Barrack on DVT prophylaxis (Charnley Lecture), Henrik Malchau on implant selection (Presidential Guest Lecture) and Jimmy Hutchison on mortality (Walter Mercer Lecture). Howard Steel will be very happy! His eponymous lecture by Mark Stevenson (not a futurologist!) proved inspirational; creating a buzz over lunch which has not been present for many years! I now know why I have been angry since I was 35. “An Interview with Keith Willett”, our very own NHS England National Director, introduced a new

live interview format. Professor Willett’s account of his elevation to this position was enlightening. Trauma and Orthopaedics now appears well represented at high levels but others should consider putting themselves forward to ensure succession planning. Influence is all. Peter Kay (NHS England Clinical Director for Musculoskeletal Services) presented a key plenary lecture entitled “Innovation and Safety – Who Should be Responsible?” thought provoking and challenging as one would expect from a BOA Past-President. The NJR session on Thursday, proved a lively and topical session with the recent publication of surgeon specific 90 day mortality figures. Concerns were expressed about the reliability of data in the public domain and the crude way that it has been portrayed in the media. There was a very lively Q and A session. Following the specialty led theme there was an excellent all day instructional course provided by BOFAS which included the Judith Baumhauer Evidence Vs Anecdote (Naughton Dunn) Lecture. This included the observation that Naughton Dunn may have been the first to advocate PROMs. Basic Science, Trauma, BSCOS, BLRS and Spinal fora together with several free paper sessions, including the Best of the Best provided a balanced choice of knowledge for all on the day. BOTA tried to help the plight of new consultants and the Training Programme Directors had a closed session. Should we know what they were up to? Trauma Bootcamp sections were completed on Friday. The rolling programme and punchy format was very well received by all. The short, sharp, authoritative messages were particularly useful for those preparing for the FRCS

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(Tr&Orth) (as well as those of us trying to stay current). The session on Good Clinical Practice in research was well received. The Clinical Examination Course for FRCS Orth, although unfortunately heavily over-subscribed, was a resounding success - book early next time! There were excellent sessions presented by the Patient Liaison Group (PLG) and ARMA, both of which sparked lively debate, CAOS, BODS and WOC. ARUK presented a Young Investigators Award. Prior to the Closing Ceremony there was a lively discussion entitled “Putting Leadership into Action: Perspectives from T&O”. The Closing Ceremony marked Martyn Porter completing his year as BOA President, and handing the baton on to Prof Tim Briggs. The Congress Dinner was held at the Jam House - a very different setting with good food, music and dancing, all much less formal. This was a very enjoyable change. There was a definite happy hubbub throughout the meeting, or was that networking?

BOA Congress – Exhibitors’ Perspective

That was the week that was

By Brian Cornan, Secretary of BOIL (BOA Orthopaedic Industry Liaison Committee)

Did congress achieve David Stanley’s ambitious dreams… and how?

The BOA Congress has always been an important event for companies that supply products and services associated with the orthopaedic speciality. Many of the companies that exhibit regard the meeting as an opportunity to develop and expand their relationships with the orthopaedic community because, although sales personnel have frequent contact with surgeons, Senior Executives, Product Managers and Development Engineers also attend the Congress. The level of delegate attendance at Congress is critical to exhibitor’s perception of value.

Largest turnout ever, over 2,000 registrations. Specialty led sessions well attended to the end Instructional sessions packed Short courses oversubscribed New formats successful Revalidation ticked (at least in part) Even Industry was happy! The BOA team are to be congratulated in almost achieving the impossible, coping with twice as many as were expected and yet still managing to smile! Yes, there were things that will need to change but the overwhelming atmosphere was the hullabaloo of success. As our new President Prof Tim Briggs said. “We are much stronger together than divided”.

The Congress at Birmingham last year represents a big step forward from an industry perspective. Exhibitors were encouraged by some of the changes to the Congress, especially free registration as part of the BOA membership package to encourage more delegate attendance, and the opportunities for revalidation. Specialist Registrars are very

important to industry because they are potential future customers, so the programme changes that have been made to make the meeting more attractive to this group has been of benefit. Eighteen companies took part in the Basic Science Course that had been organised by Simon Donell and they would like to see something similar repeated

at future meetings. Overall, the value attributed to the Congress by industry was much higher than at previous meetings. Hopefully, the Birmingham Congress will provide a sound basis for substantial delegate attendance growth in the future because, although there were around 2,000 delegates, it would be great to see an even larger proportion of the membership of the BOA in future.

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JTO News and Updates

BOA Congress Focus 2013 Debrief Thanks to all session organisers, speakers, delegates, sponsors and exhibitors for their contributions to the Congress. We echo Don McBride’s words of thanks to David Stanley for overseeing this large and complex event. This was the first time that BOA had made registration free for members. It was fantastic to see so many members in attendance. We will build on this success for future Congresses. We are particularly conscious of managing popular sessions, one of our biggest challenges this year. However, the overall feedback from delegates has been overwhelmingly positive, as demonstrated by the following graphs.

Congress Prize Winners Congress Industry Prize Winners We are always grateful to industry for the support we receive at our Congress, and this year we were pleased to award not just two but three prizes to industry sponsors. These prizes are intended to recognise and promote impact and originality of exhibition stands, and this year there was stiff competition for these awards. The 2013 Exhibitor’s Cup for the best large stand went to Stryker. Michael Green, General Manager (Implants), Stryker commented: “Stryker are delighted to have won the Best Stand category this year. We believe that to engage customers’ in meaningful conversation at the BOA Congress is the way forward and to be recognised for this is very rewarding.” The 2013 Shield for the best small stand went to Neoligaments. Joe Perriman, Sales Director from Neoligaments commented: “Neoligaments were delighted to receive this recognition on only the third time we have exhibited. It was very satisfying to meet with so many interested surgeons at such a well-attended and excellently organised BOA Congress”. An additional prize was awarded this year to Arthrex as a Commendation for Innovation for their combination of a stand and a mobile surgical skills laboratory. Terry Byca, UK General Manager, Arthrex commented: “Arthrex are delighted to receive this BOA Innovation award for the Mobile Lab. Our commitment is to deliver industry leading dynamic Medical

Education to help surgeons treat their patients better.”

Congress Delegate Prize Winners British Orthopaedic Association and Acumed prize for best poster: Title: Changing trends in the management of the Charcot neuroarthropathy through a consultant led diabetic foot service; Sohail Yousaf, Frimley Park Hospital, Surrey Best of the Best, sponsored by Medacta: Title: Effect of TriclosanCoated Sutures on the Incidence of Surgical Site Infection following Lower Limb Arthroplasty: A double blind randomised controlled trial of 2547 procedures; Cyrus Jensen, from the Northern region. Transitional Fellowship poster prize, Winner: Richard Jeavons BORS/BOTA Prize: Title: Increased interfacial bone contact using titanium coated nano-patterned implants on rabbit tibiae; Alistair Brydone, Glasgow. Arthritis Research UK Young Investigator Award winners: Cyrus Jensen (Podium presentation) and Muralidharan Venkatesan (Poster presentation

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Not one but two events in 2014 In 2014, we will not be holding the usual Autumn BOA Congress. However, there are two meetings taking place which we hope will be of interest to BOA members and JTO readers.

mainstays of the BOA Congress, including the Robert Jones, BOA Presidential Guest and other Eponymous Lectures, as well as a range of other topical and free paper sessions.

Firstly, there is our June 2014 combined meeting with EFORT in London where we have integrated our revalidation requirements; this takes place on 4-6 June 2014 and has Patient Safety as its theme. The programme is already taking shape, looks excellent, and many of the British Specialist Societies are involved in the revalidation content for their subspecialty. It will also feature some of the

EFORT/BOA Congress 2014: Combined meeting bringing together international colleagues for a high quality programme of revalidation and instructional content in the city of London. The BOA will be holding a twoday Autumn Meeting in Brighton on 12/13 September 2014. This will be free as part of the BOA membership subscription (under

the same terms and conditions as the 2013 Congress, as agreed by BOA Council and available online). There will be plenary and parallel sessions covering a range of topical issues and revalidation areas of national interest that would be inappropriate for EFORT as well as the Howard Steel Lecture which will be included. While there will be no free papers and no orthopaedic industry exhibition, there will be plenty of social and networking opportunities in the conference centre and around Brighton.

Brighton 2014: A great occasion for UK T&O surgeons to learn, debate and get up-to-date, and reunite with friends and colleagues old and new in this vibrant seaside location. Looking further ahead to 2015, our Congress is already booked for Liverpool in September and will revert back to the 2013 model. Further information about each of these events will follow and we look forward to seeing many of our BOA members and JTO readers at one of these events.

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JTO News and Updates

Publication of individual surgeon outcomes for 2014 July 2013 saw the first publication of individual consultant outcomes for nine surgical specialities in England, including Trauma and Orthopaedics. This was a landmark step for transparency in the NHS that was not without controversy. Looking ahead, it has been announced that this initiative is to grow in 2014 to cover more specialties, more procedures and more outcomes. The BOA is again actively engaging on this issue with NHS England, HQIP and other stakeholders, intending to set rather than react to the agenda. Indeed, this engagement began in November with a meeting with Prof Ben Bridgewater, a cardiothoracic surgeon from Manchester and the HQIP Director of Outcomes Publication, to discuss the next phase of this initiative. In relation to Trauma and Orthopaedics, since hip and knee replacement surgery was included

in the first round of publication, it is clear that these will form a part of the 2014 round also. However, from our initial discussions, there will be a number of changes to this initiative from the first year, which include: •

•

In consultation with the Specialist Societies, we have agreed to extend reporting to include activity covering shoulder, elbow and ankle replacements and the associated mortality rates; We have been asked to consider what additional outcome measures could be reported, and are engaging with the Specialist Societies to consider this further; NHS England have advised that consent from individual consultants will not be required for 2014, as the public interest clause of the data protection act has been brought into effect by the high response and consent rate in the 2013 round.

Recently published reports and policies JTO readers may be interested in the following reports: • National Joint Registry 10th Annual Report: www.njrcentre.org.uk/njrcentre • QualityWatch, funded by The Health Foundation and The Nuffield Trust, published its report on hip fracture care: www.qualitywatch. org.uk/focus-on/hip-fracture • Department of Health publication of the Keogh Review ‘Transforming urgent and emergency care service in England’: www.nhs.uk/ NHSEngland/keogh-review • Academy of Medical Royal Colleges report ‘i-care: Information, Communication and Technology in the NHS’ on achieving a ‘technology revolution’ within the NHS: www.aomrc.org.uk/about-us/news/item/i-care.html • Greenaway Report on The Shape of Training: www.shapeoftraining.co.uk You may also be interested to know that: • Monitor and NHS England have been consulting on National Tariff

One issue that the BOA is aware of, that is of specific concern to members is that of validation of data within the NJR, particularly revision data, if this is to be included. We will continue to work to try to address this in the coming months. Further updates will be available to members through our emails and

online information. Readers may also be interested in the BOA’s contribution to the consultation on the first round of publication, and a report of the responses and an overview from HQIP (available online at: www.hqip. org.uk/assets/Everyone-Counts/ HQIP-Offer-2-report-to-NHSEpublished-31.10.2013.pdf).

Surgeon outcomes mortality funnel plot for primary hip replacement (2013) (courtesy of NJR/HQIP)

2014/15, based on a proposal document (to which the BOA has responded): www.monitor.gov.uk/NT • The Royal College of Surgeons (RCS) is to chair an independent review of the implementation of the Working Time Directive (WTD) on the NHS: www.gov.uk/government/news/royal-college-ofsurgeons-chair-taskforce-to-review-implementation-of-euworking-time-directive-in-the-nhs • The Academy of Medical Royal Colleges has had a letter to the Sunday Times published on the subject of NHS Seven Day Care: www.england.nhs.uk/wp-content/uploads/2013/09/7ds-sun-timlett.pdf • ODEP (Orthopaedic Data Evaluation Panel) have recently launched a new website www.odep.org.uk, which includes a searchable product database and functionality for ODEP submissions to be made online. • The European Parliament has agreed new EU rules on professional mobility for health professionals: www.nhsemployers.org/ EmploymentPolicyAndPractice/European_employment_policy/ Pages/RecognitionofProfessionalQualifications.aspx • Dr Foster Intelligence has published their Hospital Guide 2013, which includes information about hip and knee replacement surgery: http://myhospitalguide.drfosterintelligence.co.uk.

Stop press: BOA Past President Martyn Porter will become the NJR Medical Director from 1st February 2014. More information in the next issue.

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Section??????????????????

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JTO News and Updates

BOFAS Hits Belfast The British Orthopaedic Foot and Ankle Society (BOFAS) annual scientific meeting was held in Belfast on the 5th November 2013, hosted by the President, Simon Henderson.

Over 300 delegates attended , including Michael Aronow from Connecticut, John Kennedy from the Hospital for Special Surgery, Ben Lipsky from Seattle, Mark Easley from Duke University and Niek van Dijk from Amsterdam, ensuring the instructional sessions were both informative and entertaining. The first day’s instructional courses covered talipes equinovarus, ankle and hindfoot trauma and infection. Professor Griffin presented the completed results of the UK Heel

fracture trial showing that internal fixation of calcaneal fractures conferred no advantage over nonoperative treatment. Miss T Walker presented Alistair Henderson’s series of calcaneal fractures, and concluded that operative treatment was superior. We are no further forward, although there seems to be a growing consensus that reduction and fixation reduces the incidence of subtalar arthritis. The second day included a joint instructional session with Allied Health Professionals on tibialis

posterior dysfunction, followed by an instructional session on cartilage injury in the ankle. The American experience of microfracture and osteochondral grafting was presented. Day three focused on ankle replacement, surgical podiatry and revalidation. Dr Easley presented the American perspective on ankle replacement – it appears that in the USA, replacement is being held back by the FDA’s reluctance to license the newer mobile bearing ankle replacements.

The CAOS Meeting CAOS UK (Computer Assisted Orthopaedic Surgery) has been very active this year! Five events were organised under its umbrella and were all very successful.

For the second year, a postgraduate diploma in computer assisted knee arthroplasty surgery and two courses, one each on hip and knee arthroplasty were held and supported by CAOS UK. Additional

information regarding these events can be found on the website www. caosuk.org. CAOS UK organised a symposium at the BOA in Birmingham, where Professor Larry Dorr from UCLA spoke on his vision of Computer Assisted Surgery. This talk is available online on our website. Besides very interesting talks on the use of this technology as a routine measurement tool for joint replacements, we had a fantastic instructional course on the use of CAOS in Orthopaedic Oncology. Later, the annual conference of CAOS UK was held in London on the 20th and 21st November 2013 at the Royal Society of Medicine. More than a hundred and fifty participants attended the meeting over two days. Workshops, lectures, podium presentations

and debates allowed surgeons and engineers to share their vision on new techniques advancing the fields of hip and knee arthroplasty, sports medicine and oncology. During this meeting, several talks, notably a lecture from Professor Davies of Imperial College, confirmed the importance of the use of this technology in the field of computer simulation and robotic controlled instruments. At a time where access to training is becoming more difficult due to regulation restrictions, computer assisted simulation will undoubtedly be key to a successful programme. CAOS UK is an obvious forum to promote this field. A major orthopaedic industry acquired a leading robotic company for more than £1.6 billion, which unquestionably sends a strong message to the orthopaedic

BOFAS Conference in Belfas

Forty free papers and 24 posters were presented over the three days. The scientific content and standard of presentation was very high, with four papers presented by medical students. The meeting closed with the AGM and handover to the new BOFAS president Mr Steve Bendall, who will be hosting next year’s meeting in Brighton, 5th-7th November.

community that CAOS is now firmly establishing itself in the field of orthopaedic surgery. The famous chasm separating the innovators from the mainstream has been transcended. We believe that CAOS UK has a very important role in disseminating relevant, informative and scientific evidence for the use of computer technology in orthopaedics and this year’s meeting just confirmed this position in the BOA.

Prof Brian Davies following his lecture receives a gift from Dr Robin Strachan

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www.opeduk.co.uk

Some Challenges Are Unwanted

Letâ&#x20AC;&#x2DC;s Face This One Together

Indications Ankle Fractures, Metatarsal Fractures, Achilles Tendon Ruptures, Calcaneus Fractures, Severe Distortions, Prosthetic, Arthrodesis. Further information: www.opeduk.co.uk

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JTO News and Updates

Eurospine, Liverpool 2013 The Eurospine meeting is held in different European cities each year, on 1st-4th October 2013 we met in Liverpool at the ACC. Excellent organisation from local hosts Tim Pigott and Martin Wilby, Consultant Spinal Surgeons at The Walton Centre, Liverpool saw 3,400 attendees from 72 countries. There were 240 delegates from the UK…and an amazing 138 from Brazil, with China and Russia not far behind contributing an estimated £5m to the local economy. There were 125 industry stands adding to the atmosphere creating a very exciting and vibrant venue. The meeting combined an excellent scientific programme with a good balance of invited

lectures, debates and scientific papers. There was the usual lively exchange of views in many of the

Liverpool 2013

Eurospine President, Phil Sell

One particular highlight was the Medal Lecture given by Frank Gardner OBE, BBC Security Correspondent, who suffered a spinal cord injury when shot six times in Saudi Arabia in 2004, a podcast worthy of iPlayer!

Consultant Spinal Surgeon in Nottingham and Leicester, who is looking forward to his Presidential year. Phil is keen to extoll the benefits of Eurospine membership. There is access to print and online editions of the European Spine Journal, Patient Line, Research grants and educational events. Members get huge discounts at activities of Eurospine such as the bespoke “Hot Topics in the Lumbar Spine” Prague Spring meeting 8th9th May 2014 as well as the next Annual meeting in Lyon, 1st-3rd October 2014.

The Presidential baton was passed from Ferran Pellisé to Phil Sell,

All can be accessed through the website www.eurospine.org.

discussions, a feature of most spinal meetings. Webcasts of the ‘Best of Show’ are available at www.eurospinemeeting.com/ webcasts-2013.htm.

BSSH/BAHT London 2013 Combined Scientific Meeting The British Society for Surgery of the Hand was combined with colleagues in the British Association of Hand Therapists for the Autumn Meeting held at the Royal College of Surgeons in London on Thursday 17th and Friday 18th October 2013. There was a record attendance of 421 delegates over the two days, 299 of which were hand surgeons and 122 hand therapists to hear an outstanding programme of scientific and educational presentations.

The main meeting theme was tendons. The meeting included symposia on extensor tendon injuries and extensor tendon problems. Live cadaver demonstrations were transmitted via a video link from

the demonstration room on the 4th floor of the Royal College of Surgeons to Lecture Theatres 1 and 2 of commonly used tendon transfers. Keynote lectures on the psychology of recovery from hand injury by Dr Maggie Bellew (Leeds), the biomechanics of tendon transfer by Dr Wim Brandsma (Utrecht, The Netherlands), the fascia of the hand by Professor Gus McGrouther (Manchester) and on the treatment of hand problems in cerebral palsy by Dr Caroline Leclercq (Paris, France) provided in-depth contemporary analysis of difficult problems by the expert.

Parallel sessions organised by the British Association of Hand Therapists included symposia on the future of hand therapy practice and on rehabilitation after tendon transfers. Keynote lectures in these parallel sessions were delivered by Mr Adrian Chojnowski from Norwich and Dr Wim Brandsma. As usual a good time was had by all with numerous networking opportunities and informal discussions around the venue. The next BSSH meeting will be on 1st2nd May 2014 in Gateshead.

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Choose SYNVISC or SYNVISC ONE to help your patients with osteoarthritis (OA) of the knee move beyond pain. SYNVISC and SYNVISC ONE are the only viscosupplements which mimic the high molecular weight and elastoviscous properties of healthy, young synovial fluid1,2 • Provides pain relief and long-lasting efficacy3-10 • Potential cartilage preservation11,12 • Delay in time to total knee replacement13 For further medical information on SYNVISC or SYNVISC ONE, please email Sanofi Medical Information on uk-medicalinformation@sanofi.com or call us on 0845 372 7101. To speak with someone from our Commercial team, please email us on GB-SYNVISC@sanofi.com

References: 1. SYNVISC/SYNVISC ONE Instructions for use, 2011. 2. Balazs EA, et al. Arthritis Rheum. 1967;10(4):357-376. 3. Raynauld J-P, et al. Osteoarthritis Cartilage. 2002;10(7):506-517. 4. Raman R, et al. Knee. 2008;15(4):318-324. doi:10.1016/j.knee.2008.02.012. 5. Dickson DJ, et al. J Clin Res. 2001;4:41–52 6. Chevalier X, et al. Ann Rheum Dis. 2010;69(1):113-119. 7. Adams ME, et al. Osteoarthritis Cartilage. 1995;3:213-226. 8. Caborn D, et al. J Rheumatol. 2004;31:333-343 9. Wobig M, et al. Clin Ther. 1998;20:410-423. 10. Bellamy N, et al. The Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.:CD005321.pub2.DOI:10.1002/14651858.CD005321.pub2. 11. Wang Y, Hall S, Hanna F, et al. Poster presented at: European League Against Rheumatism (EULAR); June 16-19, 2010; Rome, Italy. 12. Hall S, et al. Ann Rheum Dis. 2010;69 (suppl 3):701. 13. Waddell DD, Bricker DC. J Manag Care Pharm. 2007:13(2)113-121. GBIE.SYN.13.06.01 Date of preparation: July 2013

3412 Synvisc_BOA_130x190.indd 1

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JTO Features

National Clinical Director for Spinal Disorders Charles Greenough

As we are all too aware, the entire landscape of the NHS in England changed completely on the 1st April 2013. NHS England, formally known as the NHS Commissioning Board, now has a mandate from the Secretary of State to provide NHS Services in England. The total budget is £95.6 billion of which £63.4 billion is devolved to the 211 Clinical Commissioning Groups (CCGs) who commission local services in primary and secondary care. £11.8 billion is allocated to specialised services which are directly commissioned by NHS England Specialised Commissioning. The new NHS England Structure has essentially been designed to put clinical advice at the heart of commissioning.

Charles Greenough

Specialised commissioning advice is taken from the clinical reference groups (CRGs) which are clinically constituted. It is the CRG that produces the Specification of Service which forms the basis of commissioning contracts. There are 74 CRGs providing clinical advice on the very many different specialised services. The CRGs of particular interest to orthopaedics are specialised orthopaedics, specialised rheumatology, specialised spinal surgery, spinal cord injury and major trauma. In spinal surgery we also have close relationships with adult neurosurgery. Within the orthopaedic ambit the work of the CRGs has, in general, been proceeding well. Some problems have been experienced at the boundary between Specialised Commissioning and the CCGs, which might have been expected after such a major reorganisation. One particular point of difficulty has been the position of procedures, implants etc. that were previously funded separately by PCTs. Under the new structure, in many cases CCGs have not wished to continue funding items that are seen as Specialised Commissioning but NHS England Specialised Commissioning has been unwilling to take these up without policy development by the relevant CRG. This has been the source of considerable frustration, but is gradually being resolved. For issues of this nature the initial contact would be the Chair of the relevant CRG1.

As far as the National Clinical Director for Spinal Disorders is concerned, the job description comprises five pages and includes “to take the clinical lead in driving improvement and quality across all relevant domains of the NHS outcome framework”; “design and delivery of the commissioning tools, systems, professional and care pathway changes at National and Local level”; “increased quality and value”; and “define outcome measures by which services should be judged”. It remarks “the post holder will act as the conductor of the orchestra in whom analysts, finance, contract developers, improvement partners come together to enable the delivery of NHS mandate and outcome framework”. All this in three sessions a week! At the present time it seems like a great success if one can assemble more than two violins and a tuba in the same room at the same time. Taking up this challenge would have been quite impossible without the substantial work that has been undertaken in the past. Two major reports, produced by multidisciplinary representative groups, have laid out a consensus blue print for the future. The first report “Organising Quality and Effective Spinal Services for Patients”2 was published in 2010 and provided advice to local commissioners on the structure of services from the community through general practice into secondary care. >>

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Section??????????????????

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JTO Features

An area of concern is the lack of a level playing field between “any qualified provider” and local NHS Units. The second – “Commissioning Spinal Services – Getting the Service Back on Track”3 was published in January 2013 and undertook a detailed assessment of all spinal conditions. In addition to these major reports, significant work has been undertaken by the BOA under the leadership of Joe Dias on High Value Pathways of Care, which is informing strategy in low back pain and radicular pain4. The National Clinical Directors face significant shared challenges. The most pressing commissioning challenge remains the interfaces between services directly commissioned by the Area Team in General Practice, services commissioned by the 211 CCGs (which are of course spread between primary care and secondary care) and services commissioned directly by Specialised Commissioning. It is obvious that for any individual patient care will start with a General Practitioner consultation and move through to CCG commissioned services, and then in some cases to Specialised Commissioning. Our challenge is to make this pathway seamless from the patient perspective. The second shared challenge is the newness of the entire structure. In March of 2013 NHS England had some 200 employees and now there are over 6,000. This means that navigating the system is extraordinarily difficult and although there is a palpable willingness to assist, it seems that most people are in the same boat.

I have received a lot of support; from the BOA, from the specialist societies, from the CRGs and from many other organisations. This support is highly appreciated and essential if the changes we would all like to see are to be implemented. I am always ready to receive comments and suggestions to my email address which accompanies this article. The remit of spinal disorders is wide, but there are three areas in which I would particularly like to make progress. Pathfinder Projects are an initiative of Specialised Commissioning in NHS England. There are about five of these projects which have been chosen as representing pathways of high value and also of significant difficulty in implementation. In the Trauma Programme of Care “Low Back Pain and Radicular Pain” has been adopted under my Chairmanship. Low back pain is the biggest single cause of disability in the UK5. The pathway runs from public education through to General Practice consultation, to multiple services provided by CCGs, and in a few cases to specialised surgery under Specialised Commissioning. Services are still fragmented and few patients experience the seamless progression of care for which there is a good evidence base. Delays are too common a feature throughout. Implementation of previous advice such as NICE guidance G88 has been poor as the commissioning structures to implement such a pathway across commissioning bodies did not exist.

The purpose of the Pathfinder Project is to construct a clinical pathway running across these commissioning boundaries with a specification for what services the patient should expect and at what time, detailed entry criteria for each stage, contract monitoring points, outcome measurement and most particularly formal arrangements for progression of seamless care across the commissioning boundaries. To maximise the use of local strengths and resources there won’t be any prescription of how or by whom these services should be delivered. Thus the same pathway may be delivered in a number of different ways depending on local facilities. It is hoped that this will be complete for the 2015/16 contracting round. In parallel with this Pathfinder Project the NICE guidance on low back pain is being updated and may be published in 2016. These processes are separate but complementary. The main failure of the original NICE Guidance was in implementation and this failure was caused by a lack of commissioning structures. It is hoped that the implementation of the Pathfinder Project will build these necessary structures which will, in turn, allow implementation of updated advice when this is available. It is also hoped that construction of a commissioning pathway for low back pain will form a generic structure which may be adopted widely across the NHS for the many similar patient pathways that experience these cross boundary barriers.

The second area is the access to spinal cord injury and rehabilitation. It is widely recognised that the current provision of spinal cord injury rehabilitation is inadequate, with patients remaining in major trauma centres for long periods and some patients never being admitted to a spinal cord injury rehabilitation centre at all. The problem is both the absolute numbers of rehabilitation beds and their geographical distribution. An Access and Capacity project has been adopted by the CRG in spinal cord injury to measure the gap and to build on this data a forceful business case for improvement. A key part of this data collection is the implementation of the electronic referral system6 which will provide a registry of every spinal cord injured patient in England. It is important to the access project that every cord injured patient is logged on this referral system and I would encourage colleagues to do so. A third area of concern is the lack of a level playing field between “any qualified provider” and local NHS Units. It has been widely noted that the independent sector does not provide some services and obligations carried by NHS units, such as the management of complications, training of medical (and sometimes nursing and other health professionals), transparent and published audit and governance. Presentation and tendering skills are significantly different. This leads to pressure on adjacent NHS units, who may be deprived of cases suitable for training, and find themselves under-resourced to maintain complex surgery and emergency services I know that Peter Kay, NCD for musculoskeletal disorders, shares these concerns. >>

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boa.ac.uk

Britspine 2014

Section??????????????????

Warwick Arts Centre • The University of Warwick

April 1st - 4th 2014

www.britspine.com The Biennial Scientific Congress of the United Kingdom Spine Societies Representing: • The British Association of Spinal Surgeons (BASS) • The British Scoliosis Society (BSS) • The Society for Back Pain Research (SBPR) Confirmed Keynote Speakers: Hanne Albert University of Southern Denmark “Antibiotic treatment in patients with chronic low back pain and Modic Type changes: a double-blind RCT of efficacy” Eugene Carragee Stanford University School of Medicine “The Infuse Affair: how BMP-2 came to America”

Wilco Jacobs Leiden University Medical Centre “Spondylolisthesis and Spinal Stenosis, a review of surgical interventions”

Joseph Perra Minneapolis Spinal Centre “Managing Complex Cervico-Thoracic Deformity” Wilco Peul Leiden University Medical Centre “Is Surgery for Adult Spinal Deformity Cost-Effective?”

Max Reinhardt CEO DePuy Synthes Spine “Spinal Implant Companies and Spinal Surgeons: The Past, The Present and The Future” Tapio Videman University of Alberta “When disc height decreases - the vertebra height increases”

Pre-meeting Trainee’s Day Tues April 1st West Midlands Surgical Training Centre, University Hospital Coventry and Warwickshire NHS Trust

Scientific Meeting Wed April 2nd - Fri April 4th Warwick Arts Centre and Social Sciences School, The University of Warwick

Debates: “Should antibiotics be given for back pain?” “Degenerative scoliosis requires full deformity correction.”

Symposia: Industry Question Time » Managing, not Curing, Chronic Spinal Pain Negligence and Indemnity in Spinal Practice » New era of healthcare in the U.K. United Kingdom Spine Societies Board at the British Orthopaedic Association The Royal College of Surgeons of England 35-43 Lincoln’s Inn Fields London WC2A 3PE

Switchboard: Fax: Email: Web:

020 7405 6507 Ext 224 020 7831 2676 ukssb@boa.ac.uk www.britspine.com

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JTO Features

I believe that the new NHS England structure has significant capacity to improve the quality of the patient experience. I believe that the new NHS England structure has significant capacity to improve the quality of the patient experience, to improve the quality of services delivered and to improve the quality of outcomes. Input from clinical colleagues is essential to this process. The clinical voice must, however, be coherent and clear to be effective. Debate and discussion are important and will continue to be part of clinical practice in our Centres, in the Speciality Societies, in the BOA and in the CRGs and other structures of the Health Service. However, it is equally important that consensus

is achieved wherever possible so that I and other NCDâ&#x20AC;&#x2122;s can take into NHS England a powerful and undiluted message. n

References 1. www.england.nhs.uk/ resources/spec-commresources/npc-crg/group-d/ d15 2. webarchive.nationalarchives. gov.uk/20130107105354/ http://www.dh.gov.uk/en/ Publicationsandstatistics/ Publications/

PublicationsPolicyAnd Guidance/DH_114528 3. www.nationalspinaltaskforce. co.uk 4. http://bit.ly/BOA-CG-lbp 5. UK health performance: findings of the Global Burden of Disease Study 2010. Murray CJL, Richards MA, Newton JN et al, Lancet 381:997-1020, 2013 6. www.SCIreferrals.org.uk

C J Coleman is pleased to announce affinity benefits for BOA members. Lloydâ&#x20AC;&#x2122;s Brokers, CJ Coleman are able to arrange Medical Malpractice cover with carefully chosen insurers for orthopaedic consultants and surgeons in private practice in the UK.

Key Factors l Seamless cover when you join l Bespoke individual quotation specific to your needs l Contractual Guaranteed run-off cover l 24/7 Helpline giving access to experienced Medico-legal lawyers l 40 years insurance and claims handling experience

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If you arrange cover through CJ Coleman you will be entitled to free legal protection insurance policy covering the following:l Employment disputes l Bodily injury l Attendance expenses at jury service l Commercial property protection l Tax enquiries

For more information please call Andy Foley on: +44 (0) 7747 624 080

As well as being National Clinical Director for Spinal Disorders, Professor Charles Greenough is a Consultant Orthopaedic Spinal Surgeon and Clinical Director of the Regional Spinal Cord Injury Centre at James Cook University Hospital, Middlesbrough. Research interests have been low back pain, spinal surgery and spinal cord injury. He Chairs the CRG in Spinal Cord Injury and was a member of the National Spinal Taskforce. Email: charles.greenough@stees. nhs.uk

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Continuing Professional Development and Revalidation David Limb, BOA Honorary Secretary

Training programmes arm young orthopaedic surgeons with the knowledge, skills and behaviours needed to manage the role of a day one Consultant. However, once the training programme is finished it is the duty of the surgeon to keep up to date and indeed to extend their learning into new areas that allow, or are dictated by, developments in their career. It is a fundamental principle of revalidation that all doctors who have a license to practice will ultimately be responsible for ensuring that they do keep up to date in this way. It is also a requirement that evidence of participation in relevant Continuing Professional Development (CPD) is documented and that the documentation is available for review and discussion at the annual appraisal.

This article summarises the CPD requirements for revalidation and examines how these requirements can be met – for the vast majority of orthopaedic surgeons this will simply mean documenting what they have done spontaneously for years!

CPD includes all of the educational activities that a doctor undertakes that help them keep abreast of developments in their own field of practice and move in new career directions. It will therefore be different for just about every orthopaedic surgeon.

The requirement for revalidation is that doctors should participate in at least 50 hours (points) of CPD activity each year. If all of this was to be done in SPA time it would equate to only a quarter of one SPA. The requirement is the same for part time workers as it is for full timers, as the need to keep up to date is the same for both. However, if there is a career break due to sickness or maternity leave, for example, then shortfalls in CPD can be ‘made up’ over the five year revalidation cycle.

Courses that have relevant educational value, accredited for example by the BOA, will of course be appropriate for the CPD portfolio. However, the courses relevant to a knee surgeon will be different from those relevant to a spinal surgeon. The 50 points that have to be accumulated will include courses but also educational events in ones place of employment, meetings of peers, journal reading, online education and a myriad of other sources. To help organise the recording of CPD the surgical colleges have devised a grid to categorise CPD activities (Fig 1). >>

External Internal Self-directed Totals Clinical

Academic

Professional (managerial)

Totals

For year: 86

Figure 1 - A typical CPD grid with points available by attending BOA Congress, a specialist society meeting and less than one hour a week of other CPD

David Limb

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JTO Features

CPD should map to one’s routine work and the areas into which one is developing.

Activities can be External, Internal (to one’s normal place of work) or Self-directed (e.g. journal reading or online education). CPD can be relevant to the different areas in which we practice, categorised as Clinical, Academic and Professional (including Managerial). Thus, external courses are only one of the nine areas in which CPD points can be acquired. CPD should map to one’s practice both in terms of one’s routine work and the areas into which one is developing. Early in one’s career much of one’s CPD activity will probably take place in the clinical and academic arenas, whereas later some clinical interests may have been dropped whilst new roles, for example managerial roles, may have appeared. CPD should reflect the balance of practice and aims for the coming year. However, it is imperative that one keeps up to date in all areas in which one practices, whether or not certain areas hold more interest than others. All those on the trauma rota should participate in CPD in trauma - the CPD portfolio should cover all areas of practice with appropriate allocation for the need to keep up to date, not the declared level of interest of the surgeon. Although CPD is owned by the individual, and it is recognised that individuals differ in their preferences for different learning environments, it is recommended that CPD is spread across a range of activities and locations. The Royal Colleges guidance suggests that no more than 20 points should normally be claimed for any one type of activity. This effectively puts a recommended ceiling on the number of points that can be claimed for clinical external courses, though events such as the BOA Congress can spread points across the clinical, academic and professional

categories and facilitate a very balanced portfolio. Online learning and journal reading can both be very effective for some individuals, so it may be appropriate for up to 20 points to be claimed for such activities, but it is difficult to foresee a circumstance in which a surgeon could carry out all of their CPD activities in the comfort of their own home.

Recording CPD It is a requirement for revalidation that doctors don’t simply document that they have done CPD, but that they also provide evidence. Course certificates demonstrate that the course has been assessed for its educational content and approved for revalidation (though even this does not prove relevance to the individual). Employers differ in how they prefer their employees to document material

for appraisal. Many will have purchased appraisal software that has a facility to document CPD activity, though this may mean scanning course certificates to upload them. However CPD is recorded, there should be some way of documenting what has been learned so that its relevance to one’s practice and one’s planned development can be seen at appraisal. This applies to reading relevant papers as much as to attendance at meetings. Ideally a short reflective note should be written after the CPD has taken place. Many appraisal software packages allow such reflective notes to be documented with the record of the event. For courses organised by implant manufacturers, how much is education and how much is advertising? For meetings with free papers, will the free papers be of good quality and relevant

to the practice of everyone in the audience? Often courses are now accredited only for the sessions that are clearly of relevance to the audience and are almost guaranteed to be highly educational – free paper sessions, even at the BOA Congress, are not accredited with CPD points. However, this does not mean that points cannot be claimed for such sessions if they are relevant. A course run in Vienna by an implant manufacturer which is focused entirely on one implant may be simply advertising material for one surgeon, may be an excuse to see Vienna for another yet for many in the audience could be the best possible CPD if they have been told that their Trust is switching wholesale to the device in question. Free paper sessions in Specialist Society meetings are quite likely to contain some, or a lot, of good material relevant to most in the audience. >>

Recommended credits

Recommended annual maximum

Self-directed learning – journals etc.

Pro rata

Courses / e-learning

6 per day

Teaching on specialty association courses

6 per day

Writing exam questions

Pro rata

Examining for MRCS / FRCS(Tr&Orth)

Pro rata

Presentation at BOA/similar

Peer reviewing for journals

Per review

Publication of paper or chapter

Figure 2 - Suggested allocation of CPD points for various activities

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Sponsored Content Section?????????????????? Advertiser’s Content

Concerned by the impending tax charges on your pension savings? You may need to take a 24-hour break Dr Mark Martin, former anaesthetist and now specialist financial planner for doctors, writes:

Consultants on the 1995 pension scheme aged 60 or over can access the lump sum without penalty, while those who have moved to the 2008 scheme must wait until they are over 65.

Having already faced changes to the NHS pension scheme, higher pension contributions, reforms to the NHS and an effective pay freeze, doctors will be frustrated to be targeted again with the tax relief cuts coming into force this year. What are your options to avoid large, unnecessary tax bills?

Before you resign, you must make sure that your trust will take you back. A personality clash with management will make this unlikely. Fortunately, doctors returning after a break in service are popular as they are cheaper, as the trust no longer pays their pension contribution.

From April, new government measures mean individuals face an annual restriction to their tax-free pension contributions of £40,000 and an overall cap to their pension pots of £1.25million. Many senior doctors will exceed these new lower limits. As a result, we have seen a rise in the number of high-achieving doctors considering ‘24 hour retirement’ or ‘retire and return’. This allows you to reduce your professional commitments, while often maintaining or even increasing your earnings. Despite a lower base salary and the loss of clinical excellence awards, doctors taking this route save on pension contributions and receive pension benefits while working. Many are better off financially. The move caps your pension pot and could provide a welcome escape from the new lifetime allowance of just £1.25million – if you breach this, you face a tax charge of up to 55% on the excess. Are there other advantages? Some consultants, concerned by the further changes to pensions' caps, believe it is safer to lock-in their benefits now. Others want to access a taxfree lump sum when they or their dependents most need it. Most of us require considerably more money at 60 than at 80. You can often negotiate a more flexible working contract and cherry-pick your current position to lose less attractive parts. You may be able to reduce your number of PAs or drop on-call commitments. It is better to achieve that elusive work-life balance while you are still fit enough to enjoy it. To qualify, you must resign from your NHS contract of employment and take a 24-hour break in service. You stop paying pension contributions and gain access to your tax-free lump sum plus a regular pension payment. You can then return to work on a new contract, but must not work more than 16 hours a week in the first month. After that, you can choose to return either full or part-time.

And the disadvantages? Your new contract is likely to be on a one-year renewable basis. This can lead to less career security, as well as a perceived change of status, which can be difficult to accept. By giving up a long-term contract, you also lose some of your rights if subsequently made redundant. Redundancy compensation would apply only to the period of your new contract, with statutory payments applying to the rest of your NHS service. You will also lose valuable death in service payments (worth twice the relevant pensionable salary) and ill-health benefits, both of which are more likely to be useful to you as you near retirement age. Should you opt out instead? A minority of professionals nearing retirement could fare better by opting out of the NHS pension scheme altogether. The ongoing pay freeze makes this more appealing, as pension benefits accrue on the basis of salary. If you are not in the scheme, you can choose to defer your benefits until you retire. Your benefits will continue to increase by the rate of inflation, as measured by the consumer price index, which could well be at a higher rate than your current salary growth. Savers who already hold ‘fixed protection’ on their pension savings may opt out to meet the scheme’s strict criteria, which do not allow further pension contributions. With the April deadline looming, it is vital that you consider your situation now, as retiring from the NHS can take several months to arrange. If you are concerned by the forthcoming tax changes, you should seek expert help to get the best value from your pension.

Cavendish Medical is a specialist financial practice helping senior medical practitioners in private practice and the NHS. To discuss your financial plans in confidence, call Cavendish on 020 7636 7006. www.cavendishmedical.com

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Self accreditation of CPD activities is entirely appropriate where accreditation by an external agency, such as the Colleges or the BOA has not been given. Thus self-accreditation of CPD activities is entirely appropriate where accreditation by an external agency, such as the Colleges or the BOA, has not been given. The surgeon simply has to document the number of hours/points claimed and write a reflective note on the event and how it impacted on their own personal development. Not all activities lend themselves to measurement by translating hours into points, for example writing a paper or book chapter. For these activities the colleges have issued guidance on the level of points to be claimed (Fig 2 - previous page). Although no more than 20 CPD points should be claimed for any one type of activity, it is important to note that not all meetings automatically fall into the ‘clinical external’ category. This applies particularly to the BOA Congress, which supplements Specialist

Society meetings and has a lot of content related to professionalism and academic practice. Many of the 24 points available for the four days (meetings are not normally accredited with more than six points a day) can be allocated to academic and professional categories

Summary All doctors should participate in at least 50 hours of CPD that is relevant to their current practice and intended direction of travel. This should include external courses and meetings, but CPD points can also be self-accredited and this is the norm for selfdirected learning. No more than 20 hours of any particular activity will usually be counted, though many meetings and courses will be split across clinical, academic and managerial categories. Meetings that are accredited have

Front cover answer: All are correct! Practise is a verb - Practice is a noun. Similarly, License is a verb - Licence is a noun. Consultants and SAS doctors will have 2. The GMC will perform 1. The Postgraduate dean will give trainees 3 by performing 4. According to the OED the American version may have become accepted therefor (sic) 4 may be the only correct answer for all circumstances in the future!

already been identified as having good educational content but nevertheless a short reflective note should be made of what has been learned and how it will influence one’s practice. For the vast majority of orthopaedic surgeons the entire requirement for external CPD can be met by attending their own Specialist Society meeting and the BOA Congress, the latter filling in all the areas of their work that fall outside their main clinical interest plus a lot of Academic and Professional material that brings balance to the portfolio. For self-directed learning the onus is on the doctor to document evidence of what activity has been undertaken and how it is relevant to, and impacts on, practice. As an action point, many of the electronic portfolios used in Trust appraisals ask why a recorded activity is relevant to the personal development plan. If you have not written your personal development plan (PDP) to indicate how you intend to use your CPD time then

this can be a difficult question to answer. For the coming year consider what sort of activities you would plan to do that will keep you up to date and write an entry in your PDP to outline this plan. For further information see the ‘Revalidation’ sections on the BOA or College websites. Summary CPD guidance is also directly accessible through http://bit.ly/ BOAcpd2013. n

David Limb is the BOA’s Honorary Secretary and a Consultant Orthopaedic Surgeon based in Leeds. David is formerly the Chair of the BOA’s Education Committee, Editor in Chief of “Orthopaedics & Trauma” and Associate Editor for the “BJJ” and “”Shoulder & Elbow”.

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The BOA Research Committee Amar Rangan, Chairman of the BOA Research Committee

The Research Committee has the operational role of driving the new BOA Research Strategy. This feature outlines how we will deliver the BOA Research Strategy, and why we need a paradigm shift to sustain high quality research. The scale of this project means that it will take at least five years to fruition.

The new BOA Research Strategy “Improving Mobility” was approved by Council and published in February 2012. The full document is available for download from the Research & Joint Action section of the BOA website. Research investment in T&O in the UK only attracts a minute slice of overall funding and to change this, we need a paradigm shift in our culture and thinking. The new Research Board and Research Committee will facilitate this. The Research Board decides overall strategy and the Research Committee performs the operational role of delivering the strategy.

The area where we can create maximum impact is in clinical research, through multi-centre clinical trials. This is high impact research to which potentially the entire T&O workforce can contribute and share ownership. There are four strategic areas where implementing change should bring major improvements to the T&O research landscape: 1. Culture 2. Infrastructure 3. Research priorities 4. Engagement with stakeholders

Research Board

Current UK Health Research Policy is based on the Cooksey Report, which clearly highlights that the NHS should not be just a receptacle of research, but should be an active partner in research. In clinical research, collaboration should be the norm rather than the exception. We have made good progress on some fronts, with a number of multi-centre clinical trials in shoulder surgery and trauma either having successfully completed recruitment, or actively recruiting. It is likely that some clinicians with training and research experience will take on a research leadership role, while others could become active collaborators and research recruiters by forming UK wide clinical research networks.

Andy Carr (Chair) Amar Rangan (Chair of Research Committee) Tim Briggs (BOA President) Martyn Porter (Immediate past President) BOA support – Julia Trusler & Lauren Rich

Research Committee Amar Rangan (Chair) Ashley Blom Matt Costa Alan Johnstone Andrew McCaskie Andy Price Ramsay Refaie (BOTA rep) Mark Wilkinson BOA support – Julia Trusler & Lauren Rich

Culture

We propose providing structured research training to our T&O trainees who will be our future workforce and change the emphasis in their training from research output (which commonly leads to low impact publications) to research input. >>

Amar Rangan

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It is anticipated that all trainees will achieve Level 3 by the time they complete higher surgical training.

We would like the ARCP process to assess progression in research training based on our proposed research curriculum toolkit as follows: Level 1: Good Clinical Practice (GCP) in research training â&#x20AC;&#x201C; this is now mandatory for any of us involved in clinical research. GCP training needs to be completed early on in the training. Level 2: Basic research foundation training. This is already part of the current T&O training curriculum. Level 3: Evidence of screening and recruiting patients into clinical studies. Level 4: Research leadership training (only a minority of trainees would progress to this level) supported by Academic Training Pathways. It is anticipated that all trainees will achieve Level 3 by the time they complete higher surgical training, putting them in a strong position to become Principal Investigators when they take up consultant posts. Trainee research collaboratives will be encouraged, providing the mechanism for trainees to progress from Level 1 to 3. CORNET (Collaborative Orthopaedic Research Network) is a regional trainee collaborative that is rapidly evolving in this direction. BOTA has proposed a national trainee network for promotion of research, audit, leadership and management, which will be called BONE (British Orthopaedic Network Environment).

Infrastructure

Research priorities

The UK has perhaps the best infrastructure for running clinical research. The National Institute for Health Research (NIHR) has commissioned regional Research Design Services, which help clinicians develop research ideas into evolved protocols. Clinical Trials Units (CTU) help develop these protocols into grant applications, and if commissioned, will help conduct, analyse and report the results. Such peer reviewed and commissioned studies would be registered on the UK national portfolio. The UK Comprehensive Research Network (UKCRN) provides research nurse support to help recruit patients into such portfolio trials. We need to engage fully with this existing infrastructure to facilitate our research activity.

It is important for us as clinicians to identify and rank our list of research priorities based on clinical importance of the research question, potential benefit to patients and relevance to the NHS. We will be approaching the research committees of the BOAâ&#x20AC;&#x2122;s specialist societies in order to help with this process. A topic that has been ranked as high priority by a body of specialists, patients and other stakeholders will help influence funding bodies to consider research investment in that area. The James Lind Alliance conducts such comprehensive prioritisation exercises on proposed themes and we could seek their help with our prioritisation process.

The relatively limited funds in Joint Action will be used more effectively in a pump-priming role to establish methodological support for generating high quality research grant applications. Such applications in turn are likely to attract substantial funding into T&O research.

Engagement with stakeholders The Royal College of Surgeons of England, along with Rosetrees Trust, has launched a Clinical Research Initiative with which we are fully engaged. They have commissioned four Surgical Trials Units (STUs) in England by providing existing registered CTUs with infrastructure funding. These STUs are tasked with helping surgeons develop two surgical trials per year. This initiative is likely to lead to more T&O clinical trials getting commissioned in the UK. Arthritis Research UK is, among research charities, the largest funder of musculoskeletal research in the UK. Arthritis Research UK is working with the BOA to promote high quality T&O research. We intend to develop this partnership further. In summary, we have to implement fundamental change. It will take sustained effort by successive research committees to fully implement the BOA Research Strategy and achieve its goals. We have a long way to go, but we have made a start. n

Professor Amar Rangan is a Consultant Shoulder Surgeon and Clinical Professor at the James Cook University Hospital, Middlesbrough. He has considerable experience with clinical effectiveness and translational research and is committed to help enhance the UK T&O profile internationally by promoting high quality research.

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Section??????????????????

Aquilant Orthopaedics

The LINK速 Modular Endo-Model Rotational Knee; the Complete Solution for Complex Total Knee Replacement.

For more information or to arrange a visit from your local representative please email contactus@aquilantorthopaedics.com or visit our website www.aquilantorthopaedics.com

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CORNET: Trainee led Orthopaedic Research Network The Collaborative Orthopaedic Research NETwork (CORNET) was set up in January 2013.

In 2007, following recommendations laid out in the Cooksey report (2006)1, trainees in the West Midlands set up the first trainee led research group, the West Midlands Research Collaborative (WRMC)2. This group aimed to utilise the natural connections formed by the rotation of surgical trainees within their deanery to produce high quality multi-centre clinical research. To date the WMRC has successfully attracted >£600,000 in research funding and undertaken two multi centre randomised controlled trials (ROSSINI (ISRCTN40402832) and DREAMS (ISRCTN21973627))2. The London surgical research group3 have a 600 strong collaborative working on a variety of projects and the Welsh Barbers Society have recently secured £1.3million of HTA funding for their Hughes Abdominal Repair Trial (ISRCTN25616490)4. In the UK to date there are >25 trainee led research collaboratives of which the majority (>15) are general surgical. Trainees wanting to undertake

research are faced with a number of barriers. Trainees rotate through departments in different centres, at 6-8 monthly intervals. Commitment to a long term project is therefore difficult and projects often fail due to lack of time and continuity. Research opportunities are also dependent upon trainers and institutions and the majority of trainees lack formal research training. As a result, only a handful of trainees have been able to evolve good ideas into large scale trials and fewer still have produced research that impacts current practice. To help overcome some of these barriers, orthopaedic trainees in Health Education North East (previously Northern deanery) set up the Collaborative Orthopaedic Research NETwork (CORNET www.cornetresearch.co.uk). Currently encompassing over 55 trainees in 10 different centres, CORNET aims to germinate and develop the most feasible projects, helping trainees build key research skills such as team working, research design, networking and

peer review. Linking trainees across a region also allows for multi-centre data collection and higher rates of recruitment across a given population. CORNET’s projects are regionally co-ordinated through a transparent process that helps avoid duplication and ensure project continuity. Trainees with a research idea contact the committee and the project is considered at CORNET’s bi-monthly meetings. Once the project has been developed, it is then rolled out across the region with trainees in each centre coordinating local patient recruitment and data collection. Progress to date includes the organisation of a successful launch event held in Durham (June 2013) which included guest presentations by Prof Dion Morton (Royal College of Surgeons), Prof Amar Rangan (British Orthopaedic Association) and Prof David Torgerson (York Trials Unit). CORNET subsequently has developed a number of projects being run within the region. These include an audit of the barriers to the use of total hip replacements in the management of hip fracture patients; a systematic review of the evidence for the management of acromioclavicular joint injuries alongside an evaluation of current practice which is being done with the assistance of the Royal College of Surgeons; and an examination of the influence of enhanced recovery pathways upon pain, nausea and mobilisation following arthroplasty. CORNET is also helping to coordinate regional involvement in national orthopaedic trials. In time, CORNET hopes to expand these projects nationally using platforms such as the British Orthopaedic Network Environment (BONE) which is currently being developed to support national research and audit by BOTA.

Trainee involvement is monitored by the local training program director and specialist trainee committee members and can be used at the time of ARCP to demonstrate on-going research activity. All publications and presentations produced by CORNET are authored “on behalf of the Collaborative Orthopaedic Research NETwork”. Individual authors are then listed in the authors section at the end of the paper, in order of contribution. Anyone who has contributed to a project, however small, is recognised in this way meaning they are all PubMed citable. As in other specialties, the emphasis in ARCP is likely to shift away from research output and recognise research input and involvement. It is envisaged that ultimately, trainees will work together on national collaborative orthopaedic research projects, producing a distillation of best practice through evidence based medicine. This article was written on behalf of CORNET by Will Manning, Linghong Lee and Paul Baker. Contact: administrator@ cornetresearch.co.uk

References 1. Cooksey D (2006) A review of UK health research funding (www.official-documents. gov.uk/document/ other/.../0118404881.pdf) 2. West Midlands Research Collaborative www. wmresearch.org.uk/ publications.html 3. London Surgical Research Group www.lsrg.co.uk 4. Welsh Barbers Society www.welshbarbers.org

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PMI and the Orthopaedic Patient Nick Welch, BOA Patient Liaison Group Chair

In the last edition, Ian Winson raised important issues about Private Medical Insurance (PMI) from a clinicians’ perspective. The Patient Liaison Group would like to support our clinical colleagues and their views; however, there are matters which more directly concern patients which we have been exploring.

We have met constructively with three of the PMI companies who subscribe to the Association of British Insurers (ABI) following discussions with Martyn Porter, the then President of the BOA. “Expectations of an orthopaedic patient preferring private treatment”, the document arising from these discussions, concentrates on the issues concerning patients and the new, agreed, paper has been distributed to the ABI and BUPA (who have recently withdrawn from ABI). The majority of PMI is provided through corporate membership. In this situation, guidance by the Insurer about which Specialist to see is deemed integral to their policy. However, we all agreed that those offering advice and support to a patient from the PMI companies should be well trained and competent to discuss the whole treatment package. Furthermore, any patient contacting their Insurance Company should expect to have the precise details of what is covered by their policy explained to them and what they will need to pay for themselves should they so wish. The PLG hopes that the aspirations listed in the following paper will help patients to maximise the benefits of Private Medicine and encourage an honest and realistic dialogue between all parties involved in their treatment.

Nick Welch

Expectations of an orthopaedic patient preferring private treatment Among the expectations of people choosing private medicine are: That they will get a more rapid and consultant delivered treatment than if they opt for the NHS. They will be able to choose the time of their consultations, but also that all the healthcare professionals involved in their treatment will have more time to provide a higher quality of care. That Hotel Services will be of the highest standard. As more patients research their condition following their GP’s provisional diagnosis they expect their Specialist and Team to be able to discuss all the options in a clear and precise manner. Not all people who opt for private medicine have Private Medical Insurance (PMI). This leads to three main groups of people seeking private consultations: those who are corporately funded, the privately insured and the non-insured. In every sense there should be no difference in the way these groups access or are treated by their respective healthcare professionals. >>

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In all instances the patient should expect: An informed choice of specialist/ therapist in consultation with their GP, any other appropriate health professional or their policy provider. A full and comprehensive discussion with their specialist/ therapist about the treatment options, and where appropriate the best implant option, that follow published clinically agreed best practice guidelines. Pre-, peri- and post-operative treatment by a comprehensive and competent multidisciplinary team, including physiotherapy and follow-up X-rays, according to best

practice guidelines. Standards of care that are Consultant-led and at least as high as those commissioned within the NHS. That the Private Hospital or Unit is built, equipped and staffed to at least the same standards laid down by the NHS Provider licence and meets CQC criteria. That they are informed from the outset precisely what their policy covers for this procedure, and what extras they may need to cover themselves, and receive written confirmation. The provision and quality of care are matters between the doctor, the hospital and the patient.

The Private Medical Insurance policy is the route through which the benefits and finance are managed. Nevertheless, people who may benefit from these policies, whether self- or corporately-funded, should expect their policy provider to enshrine the following principles: That their PMI Company ensures standards of care that at least match those of the NHS, BOA or NICE commissioning guidelines. That the PMI Company makes it clear what aspects of the pre-, peri- and post-operative needs are covered by the policy, in line with best practice guidelines.

That their policy options are clearly stated with no ‘hidden clauses’. That from the outset of the claim there should be easy access to a helpline staffed by people who can discuss all the policy options and assist, if required, in making the right choice. That there is clear communication between their Insurer, their Clinician and Hospital to ensure there is openness about costs and treatment options to ensure a smooth and seamless course of treatment. n

Wisepress Book Review book of the quarter

now available

Mann’s Surgery of the Foot and Ankle (9th Revised Edition)

Disorders of the Shoulder: Reconstruction

Author/s: Coughlin, M J; Saltzman, C L; Anderson, R B; Mann, R A ISBN: 9780323072427 Publication Date: 1st November 2013 Price: £263.55 Let a “who’s who” of foot and ankle surgeons take your skills to the next level! With comprehensive coverage of the full range of foot and ankle disorders, you can expect the best from this revised “classic” work refreshed for a new generation in one robust multimedia resource.

Author/s: Iannotti, J P; Williams, G R ISBN: 9781451127454 Publication Date: 1st October 2013 Price: £225.00

Designed to address all aspects of shoulder reconstruction, this volume in the Disorders of the Shoulder series provides complete and practical discussions of the reconstructive process - from diagnosis and planning, through surgical and nonsurgical treatments, to outcome and return to functionality. This informative resource offers: comprehensive coverage addresses all aspects of diagnosis and operative management of recurrent or irreparable rotator cuff tears, complications of instability surgery, arthritis, stiff shoulder, shoulder arthroplasty and hemiarthroplasty, management of bone loss, and more.

Disorders of the Shoulder: Sports Injuries

Disorders of the Shoulder: Trauma

This volume in the Disorders of the Shoulder set covers the full spectrum of shoulder procedures - including open and arthroscopic procedures. Features: comprehensive coverage helps maximise diagnostic accuracy, broaden treatment options, optimise procedural performance, and improve patient outcomes; material on both adult and adolescent problems prepares readers to treat patients across the lifespan; broad scope prepares readers for the diagnostic and management challenges of SLAP Tears, Anterior and Posterior Instability, Rotator Cuff Repairs, Acromioclavicular Joint Injuries, and more!

This detailed volume in the Disorders of the Shoulder set covers fractures and dislocations of the shoulder due to traumatic injury. It includes how-to-do-it approach that makes sure readers understand the practical considerations behind every step in each procedure. It covers detailed injury-specific guidance that assists in the management of proximal humeral fractures, clavicle fractures, scapular fractures, acromioclavicular joint injuries, sternoclavicular joint injuries, and shoulder fractures.

Author/s: Miniaci, A ISBN: 9781451130584 Publication Date: 1st October 2013 Price: £180.00

Author/s: Zuckerman, J D ISBN: 9781451130577 Publication Date: 1st October 2013 Price: £175.00

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Improving Procurement in the NHS R. Adam Brooks

The NHS has been charged with saving ÂŁ2bn in procurement, with ÂŁ300m to come from orthopaedics, with the greatest focus on prostheses used for hip and knee replacements. The QIPP Orthopaedic Procurement Group, led by the Department of Health, with representation from the BOA, BODS, experienced surgeons, the NJR and supply chain specialists have been meeting to develop strategies to identify savings and to engage with industry.

R. Adam Brooks

Thirty per cent of the Tariff cost for hip and knee replacements in the English NHS is spent on the implants. Enormous variation in prices paid, even for the same implant. In an era of declining healthcare budgets it is difficult to understand how some relatively simple devices can be so expensive, the NHS must do better. Most surgeons are passionately interested in obtaining the best deal for their implants and are frustrated that the NHS has been ineffective at using its monopoly power to drive down costs further, though implant costs are relatively low in the UK compared to other countries. To date the NHS has not behaved as a single entity, but as multiple independent purchasers, each with their own unique complexity and challenge for suppliers, resulting in the lack of a cohesive purchasing strategy.

To release funds from procurement, all surgeons need to have a better understanding of the commercial impact of some of the choices that they make and the role that they can play to help to release savings that can be passed back for the care of their patients. Consider what costs make up the price that we pay for an implant. This can be considered in four broad areas, with the estimated percentage contribution of each as shown in Figure 1. Where could we make savings? The most obvious target might seem to be profit, with the presumption that the NHS as a monopoly customer should be able to squeeze companies to reduce their profits. This alone is unlikely to be an effective strategy. If we are to obtain better prices for our implants, we need to better understand the concept of Cost to Serve (CTS) and to consider why, at 39%, it makes up such a large proportion of an implantâ&#x20AC;&#x2122;s price, when typical figures across a range of other industries is 17.5% CTS. >>

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We need our suppliers to provide improved visibility of patient level costing for implants.

The CTS includes all the costs that companies incur in getting the completed product from their factory into our operating theatre. There are many elements to this, including: Cost of a sales force, advertising and all other direct & indirect marketing Rep support in theatre and other training costs for surgical / theatre staff Ordering and distribution network Overheads on unused / wasted / out of date stock Value of consignment implants and instruments These are all things that have value. However, in the current system we have little idea as to how our personal or institutional practice impacts on the CTS. Whilst we might think that the CTS is for the implant companies to worry about, in fact they are 39% of our costs. Ultimately, companies pass their costs on to the consumer. Therefore, to get better value, we must take cost out of the supply chain, working with the implant companies to make procurement processes simpler… and cheaper.

Evidence to the QIPP team showed that the NHS is wasteful in its use of implants: Widespread use of consignment implants and instruments, which provide no incentive for Trusts to reduce waste. As a consequence, implants costing £37m are thrown away each year as they become out of date. These costs will ultimately be recouped back from the NHS in the form of higher implant costs The use of multiple competing systems within the same Trust to perform the same operation, both preventing better deals based on volume, but also resulting in high hidden stock and maintenance costs for the hospital and supplying company 58% stock does not get used from one year to the next 63% of loan kits are returned unused; 20% of attempts to collect loan kits from Trusts are unsuccessful, resulting in increased cost Large variations in cost for the same supplier for the same implant between Trusts, and between different suppliers for similar implants, with no correlation with volume used, nor with the evidence of clinical outcome Variation in ordering e.g. a single hospital creating 21 orders on the same day for similar implants, resulting in high administration costs Complex opaque contracts made as part of tendering processes, leading to lack of transparency and unexpected expenditure. Each purchaser flying in the dark when trying to get better value when tendering

We need our suppliers to help us become better customers. This includes: Standardised bar-coding on implant boxes, to support modern stock management and automated re-ordering systems (GS2) Improved visibility of patient level costing for implants, stripping away the confusing current systems of over inflated list-prices paid by no-one. Clarity of the true costs of the technical support that we use in theatre, as well as the cost of the educational support provided Reduction in the use of consignment stock. Hospitals will need to improve stock control to reduce the risk of wasting out of date components Improve confidence in the supply chain to maintain stock levels, to ensure that we don’t run out of standard sized components The logical conclusion from all of this is that we should consider purchasing implants on a “barebox” concept, meaning that we pay a reduced price for the device up front and decide exactly what add-ons we want; for example we might agree to have rep support when we need it, but will pay per case to make it explicit that we only pay for what we actually use. Stock control and ordering become a key process.

This will provide incentives for Trusts to improve their procurement or pay a premium for not doing so. However, this can only work in partnership with the supply companies. There is no benefit to us in reducing their cost to serve yet prices remain the same and profits increase. We must work together, commissioning a lean service from commercial partnerships in a way that benefits both parties taking unnecessary cost out by improving the supply chain. This bare-box philosophy works well in other industries, notably in the low cost airline business; perhaps in the business of health care we now need to consider if we would prefer to pay a low ticket price but print our own boarding cards, carry only hand luggage and expect to pay for extras. Right now, in our relations with industry we are probably flying business class, which is all very nice (or so they tell me!), but can we really afford to continue to do so when we could do just as well flying economy, certainly for common, high volume procedures? We could use our funds better to treat more patients, but will need to do so in partnership with the implant companies. Are we willing and able to become better and leaner customers? n

Adam Brooks is a Consultant Orthopaedic Surgeon at Great Western Hospital in Swindon and is an elected member on the BOA Council. Adam represents the BOA on the QIPP Implant Procurement Group and was formerly the Chair of BODS.

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Section??????????????????

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Section?????????????????? Sponsored Content Content Advertiser’s

Putting Evidence into Action to Address Unmet Patient Needs If you attended the British Orthopaedic Association Congress last year in Birmingham, you will have heard many lectures and presentations around the theme of ‘Putting Evidence into Action,’ about the importance of making sound, data-based decisions in order to achieve good clinical outcomes. They are themes close to the heart of DePuy Synthes Joint Reconstruction* and were the foundation of the development of its new knee product, the ATTUNE™ Knee System, which was launched in the UK at the BOA Congress. When we began the project more than six years ago, we took evidence as our starting point – evidence that there was a significant unmet patient need for a more stable implant with a better range of motion. This was illustrated by considerable differences in the PROM data between hips and knees from this year’s NJR report (just 70.8% of knee patients described their problems as much better since the operation, compared to 85.6% of hip patients). Innovating to improve implant performance and patient satisfaction, driven by robust evidence and sound data, has been the focus of the ATTUNE

Knee project, in three important ways:

Design to Improve Stability and Motion The design of the ATTUNE Knee combines the latest in kinematics, engineering and materials in several key proprietary technologies, exclusive to DePuy Synthes Joint Reconstruction. For example, the patented ATTUNE GRADIUS™ Curve is a gradually reducing femoral radius designed to provide a smooth transition from stability to rotational freedom through a patient’s range of motion. The early clinical performance of this innovative system is being reviewed through the clinical follow up of 1,200 implants and details of the engineering innovations have been published in 27 scientific publications thus far.

Increasing Efficiency of Care We also undertook extensive customer research to develop a deep understanding of how instruments are utilized and how they affect the surgeon, patient and each member of the hospital team. As a result,

the ATTUNE INTUITION™ Instruments are ergonomically designed, colour coded, fewer in number and lighter in weight. The goal of these innovations is intended to lead to a reduction in OR errors and hospital costs through more efficient total knee procedures and reduced sterilization costs.

Patient Safety & Outcomes Key elements of the clinical research program include the collection of data on patient reported outcomes and implant survivorship.

and has been created to provide function for the surgeon in the OR and for the patient after surgery. Throughout each and every innovation, DePuy Synthes Joint Reconstruction has sought to put ‘evidence into action’ through extensive research and data evaluation. For it is only through robust, science based innovation that DePuy Synthes Joint Reconstruction will succeed in providing patients with greater stability and motion, in order to achieve better patient outcomes and satisfaction. Third party trademarks used herein are trademarks of their respective owners.

For this reason, the ATTUNE Knee will be extensively studied in several in vivo studies in more than 12 countries, involving more than 2,300 knees, in addition to its reporting in the national joint registries. We are also one of the first three companies to put a product through the new Beyond Compliance™ initiative, because we believe strongly in the importance of comprehensive evidence generation for patient safety. Each aspect of these innovations is a significant breakthrough for DePuy Synthes Joint Reconstruction

*DePuy Synthes Joint Reconstruction is a division of DePuy Orthopaedics, Inc. ©DePuy Synthes Joint Reconstruction, a division of DOI 2013 i 10th National Joint Registry Annual Report2013, http:// www.njrcentre.org.uk/njrcentre/ Reports,PublicationsandMinutes/ Annualreports/tabid/86/Default. aspx

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Section??????????????????

The ATTUNE™ Knee System is the largestever research and development project from DePuy Synthes Joint Reconstruction. Novel testing protocols and methods were used during development. Each aspect of knee replacement design and surgical process was evaluated. And it was this rigorous process that has produced patented technologies to address the patient need for stability and freedom of movement.

6 years of development, implantations in over 8,000 patients1, and a series of innovative proprietary technologies: the ATTUNE Knee System is designed to feel right for the surgeon in the OR and right for the patient. To learn more, speak to your DePuy Synthes Joint Reconstruction representative.

stabilityinmotion™ 2013

1. DePuy Synthes Joint Reconstruction 2013. Data on File.

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JTO Features

AOTrauma Fellowship – Chikamori Hospital, Kochi, Japan Dennis Kosuge Orthopaedic Specialist Registrar

Kochi city is located on Shikoku Island, a one hour flight from Tokyo. The local airport is named after Ryoma Sakamoto, a key figure in Japan’s modernisation in the 1830s. Kochi is renowned for its excellent food, the most well-known of which is ‘Katsuo no tataki’ – seared bonito.

Being half-Japanese, curiosity and the ability to speak the language made me choose Japan for my AOTrauma Fellowship. Chikamori Hospital in Kochi is the only recognised AO Trauma centre in Japan. The Orthopaedic Department consists of Professor Kiyoto Kinugasa (Supervising Director) and three other ‘Chiefs’ who are the equivalent of Consultants. There are six orthopaedic trainees who are Specialist Registrar equivalents, all of differing seniority. The senior surgeons are general orthopaedic surgeons whose repertoire ranged from cervical discectomy and fusion, finger fractures, acetabular and pelvic fractures to total hip and knee replacements. The day begins with the trauma conference at 08:20. Pre-operative and post-operative cases are discussed, highlighting the differing practices between Chikamori Hospital and the UK.

Dennis Kosuge

Chikamori Hospital Orthopaedic Department, plus myself

One such example was their use of dynamic MRI to assess femoral head vascularity in cases of intracapsular fractures. In the elderly patient, fixation of displaced fractures would be considered if the dynamic MRI demonstrates favourable vascularity. It is not something I have seen being used in the UK and is certainly worth considering if it will allow us to identify those that will go on to unite without avascular necrosis. The paucity of anaesthetists in Japan requires the orthopaedic trainees to be well-versed in administration of spinal anaesthetics and brachial plexus blocks. All cases that are amenable to surgery under regional block are performed without an anaesthetist. In cases requiring a GA, the anaesthetist was present during induction and extubation sometimes running several operating rooms at once. The monitoring and maintenance was performed by trained, operating room nurses.

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The paucity of anaesthetists in Japan requires the orthopaedic trainees to be well-versed in administration of spinal anaesthetics.

Katsuo no tataki’ (Seared bonito) served in two styles – salted or with sauce

During the trauma meeting, surgeons are allocated to relevant cases and, usually, two to three operating rooms were available for orthopaedic surgery for morning and afternoon sessions. In general, there would be one case for the morning and one case for the afternoon in each operating room. The theatre setup is excellent – there were two large flat-screen televisions on the wall and numerous flat screen monitors hanging from the ceiling, linked via a central system such that they could display image intensifier images, arthroscopic images, and operative images via the video camera which is part of the lighting mechanism. The image intensifiers were operated by the surgeons and nurses. As there are no radiographers in theatre, the nurses had become extremely proficient and would give our radiographers a run for their money! An interesting approach to long bone intramedullary nailing was the use of two image intensifier machines simultaneously – one positioned for the antero-posterior view, the other for the lateral view.

Professor Kinugasa is a firm believer in the importance of respecting soft tissues and the meticulous preparation and draping of the patient; the delicate surgical dissection and exposure and detailed care in closure of soft tissues by all members of the team reflect this. Although this added to the overall operating time, I suspect this translates into enhanced recovery. Personally, this is the biggest take-home point for me. I was fortunate enough to be involved in a procedure developed in Japan – ‘Tibial Condyle Valgus Osteotomy’ (TCVO) – an operation with similar indications to a high tibial osteotomy for patients with medial compartmental osteoarthritis in the knee. In addition to correcting the mechanical alignment, its purpose is also to increase contact area and improve stability in the coronal plane. This is an intra-articular valgus osteotomy that is performed in certain centres in Japan and case series have been published in Japanese literature.

Use of two image-intensifiers for intramedullary nailing

It remains a controversial operation, even in Japan, but the visiting surgeon, Professor Tsukasa Teramoto is a firm believer in its principles and has performed hundreds of such cases. Post-operatively, the inpatient stay was generally longer than in the UK. This is a result of cultural expectation, lack of adequate primary care resources and the medical insurance system, which is based on universal health insurance, which is means based. At Chikamori Hospital there is a dedicated OrthoRehabilitation Hospital (100 beds) with a large gym where patients work with Physiotherapists and Occupational Therapists. The medical record system was all electronic and extremely user-friendly. Photographs were taken before, during and after surgery and then uploaded onto the medical record system. This is not common practice in the UK and perhaps is something we should consider. Their medical documentation is definitely an aspect of healthcare I believe the NHS needs to catch up with.

On my third day, I was invited to give a talk at the Surgical Specialties’ Monthly Meeting. My presentation was entitled ‘Orthopaedic Training in the UK’ as I felt this was a topic that was relevant and would encourage debate. My anxieties before the talk were quickly dispelled as I made use of the simultaneously occurring wine tasting evening. I also attended the monthly ‘Kochi Kossetsu Kai’ (Kochi Fracture Meeting) one evening. This was a meeting for discussing interesting/ difficult cases and was attended by orthopaedic surgeons from in and around the Kochi area. It formed a platform for referral of difficult cases to Chikamori Hospital. The ‘Kuroshio’ Orthopaedic Meeting is an annual all-day meeting organised by Professor Kinugasa. It was very impressive, with the ‘AllStars’ of Japanese trauma travelling from all parts of Japan to be part of the Faculty. >>

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JTO Features

I bonded well with the orthopaedic juniors and we had many nights out for dinner, drinks and karaoke.

The two topics of discussion for the day were Proximal Humeral Fractures and Tibial Plateau Fractures. There were many interesting case presentations followed by heated debates and discussions – fixation or hemiarthroplasty in 4-part proximal humeral fractures; approaches to tibial plateau fractures and arthroscopically assisted tibial plateau fixation were amongst the topics discussed. Currently, reverse polarity shoulder replacements are not licensed for use in Japan, but most of the shoulder surgeons felt that there was a need for smaller components if this was to be considered an option in the future. In terms of timing, March was ideal as it was a relatively busy month for the Department socially. Japan’s academic year begins in April and therefore job changes also follow suit. As a result, ‘Soubetsu-kai’ (farewell party) was a word I quickly became familiar with – farewell parties in Japan were done in style, often with an entire section of a restaurant booked out. This was followed by the ‘Niji-kai’ (second-party), ‘Sanji-kai’ (third-party) and even a ‘Yoji-kai’ (fourth-party), each at a different bar and each time with reducing attendees as it got later and later. The end of March tends to be ‘cherry blossom’ season in Japan and is another reason I would recommend March. The level at which I was looked after was typically Japanese – no stone left unturned. In Japan, doctors have uniforms, generally in the form of scrubs – I had one especially made for me, with my name stitched onto it. This made me feel part of the Department straight away. They even had to specially order a pair of trousers after my arrival as the standard ones were too short for me!

I was also provided with an internal deck phone and allocated a desk within the Department. Other thoughtful touches included the provision of an electric bicycle, a free lunch in the doctors’ canteen and coverage of hotel expenses. In addition, I was invited by Professor Kinugasa into his home one weekend where I was entertained with stimulating conversation, traditional Japanese food and lots of alcohol. I bonded well with the orthopaedic juniors and we had many nights out for dinner, drinks and karaoke. I have met some truly amazing people and will value these friendships for life. I thoroughly recommend any readers who are interested in trauma and Japan to organise their AOTrauma Fellowship at Chikamori Hospital AO and its principles are universal, so do not let your language concerns discourage you from visiting. I would recommend getting a copy of the Japanese Orthopaedic Association (JOA) publication, ‘Terminology of Orthopaedics’ (ISBN 9784524242320), and ‘Japanese for Healthcare Professionals: An Introduction to Medical Japanese’ (ISBN 978-4805311097). Chikamori Hospital delivers high quality patient care, and the team there are excellent hosts and very approachable. As they are expecting more AOTrauma Fellows to follow me, they are currently brushing up their English skills! n

Pre-operative and post-operative radiographs of a patient who underwent a TCVO

Trauma conference demonstrating use of photographs during presentation of a case

The ‘Kuroshio’ Orthopaedic Meeting

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JTO Features Section??????????????????

Getting your Patient Plastered

Colin Ogilvie, MD FRCS Chairman, BOA Casting Committee. Sue Miles, BSc, RGN, ONC, BCC National Casting Training Advisor.

The Orthopaedic Practitioner is an essential part of the Orthopaedic Team, but can be undervalued not only by Surgical colleagues and patients but also by Employing Trusts. In the past, as with Surgeons, training comprised “see one, do one, teach one” and in some Minor Injury Units this persists. Today’s Orthopaedic Technician is no longer the Porter seeking alternative employment. For over 30 years the BOA/AOP/RCN [SOTN] British Casting Certificate has been the only qualification available showing that a Technician has the appropriate training in Casting techniques. The British Casting Certificate (BCC) is accredited by Glasgow

Caledonian University (GCU) and is a Multidisciplinary certificate with appropriate educational standards. For GCU acceptance a review of the teaching, home based learning and a Portfolio of work, and an OSCE style examination is needed. This tests the candidates’ knowledge of Applied Anatomy, basic fracture healing and complications, Orthopaedic conditions, and practical Casting skills. Stations are provided for preparation of notes, patient assessment, informed consent, application & removal of a variety of casts and communication & documentation. Patient and Practitioner interaction is also assessed. A 3,000 word written assignment is also completed post examination. The BCC has 60 credits at diploma level, level 8 SCQF and level 5NQF. These credits further the Practitioners education and development, in time the BCC could become a full diploma certificate.

Colin Ogilvie

CPD is available through the BOA Refresher Course, AOP accredited regional study days and the AOP Conference. BOA members speaking at these events have been impressed with the commitment demonstrated and had a valuable insight into the work of the casting room. The highlight of the 2013 Conference was a seminar by an Autism Charity informing as “How to have a safe and low stress consultation with patients on the Autistic Spectrum.” (Worth repeating for a wider audience, in the authors view, BSCOS and BOA conference organisers take note.) To work independently in a Casting room this formal accredited training, (available since 1982), remains effectively voluntary so no regulation of non-nursing personnel exists. Worryingly, permanent and agency staff may not hold the certificate or have any formal training. The BOA stance in the “Blue Book” advises minimum standards of equipment, facilities and support staff for safe Consultant practice, views supported by the BOA Patients liaison group by some strong statements in their Expectations for Patients documents. The valuable contribution of BCC holders to patient care is not always recognised by Trusts: financial prudence is commendable but most Non-Nursing Casting room staff are on low salaries. While the BCC is not a statutory requirement any negotiation is difficult. A voluntary register of BCC holders held at the BOA can be referred to by a Trust’s HR

department (via email recert@ boa.ac.uk). Generally when a casting related complication arises. “What training has the Casting Technician received”? is often the first question. The Medico-legal aspects were highlighted by Atrey et al1 noting cast problems as the second highest cause for litigation against English NHS Trusts for Paediatric Orthopaedic patients. These cases will need comment requiring further Consultant nonclinical time. The Casting Practitioner’s wide range of duties deserve better recognition. Who does the Ponseti Casts, the Spicas, the Total Contact Casts? Rarely Medical staff. Teaching Junior surgeons casting is usually the Senior Casting Practitioner’s role. Many undertake minor procedures following an agreed protocol. To progress the Casting Practitioner’s cause, Consultants at Trust level must lobby on their behalf. Both can depend on the BOA’s backing through the BOA Multi-disciplinary Casting Committee.

References: 1. Atrey A, Nicolaou N, Katchburian M, Norman-Taylor F (2010) A review of reported litigation against English health trusts for the treatment of children in orthopaedics: present trends and suggestions to reduce mistakes. J Child Orthop 4:471-476

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JTO Features

A guide to ISCP Learning Agreements for Trainees, Assigned Educational Supervisors, and Clinical Supervisors Nicholas A. Ferran, BOTA T&O SAC Representative

From 1st August 2013 Trauma & Orthopaedic (T&O), trainees ST3 and above moved to ISCP Learning Agreements. The move away from the Orthopaedic Competence Assessment Project (OCAP) brings T&O in line with other specialties and conforms to the Gold Guide1. Important definitions Since the transition to the ISCP Learning Agreements, there has been some difficulty with trainees and consultants in terms of getting to grips with the new system. This article aims to bring some clarity and to demonstrate how the new forms are meant to work. In order to adequately explain the changes, it is first important to review the Gold Guide1 definitions of Assigned Educational Supervisors (AES) and Clinical Supervisors (CS):

Educational Supervisor 4.22 An AES is a trainer who is

Nicholas A. Ferran

selected and appropriately trained to be responsible for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements. The AES is responsible for the trainee’s Educational Agreement.

Clinical Supervisor

4.23 Each trainee should have a named CS for each placement. A cs is a trainer who is selected

and appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement. Some training schemes appoint an AES for each placement. The roles of CS and AES may then be merged. The Gold Guide1 also states: 4.19 All trainees must have a named clinical and educational supervisor for each placement in their specialty programme or each post. In some elements of a rotation, the same individual may provide both clinical supervision and education supervision, but the respective roles and responsibilities should be clearly defined.

Setting up an Initial Objective Setting ISCP Learning Agreement Under the OCAP system the Clinical Supervisor (previously Trainer) was responsible for signing off Learning Agreements, however, under the ISCP system this responsibility falls to the AES. Previously when a trainee added a new placement on ISCP they were asked to choose the placement type i.e. ISCP/OCAP. This feature has been disabled so that all new placements will default to ISCP with no OCAP option available. When setting up new placements trainees will be asked to identify their AES (responsible for signing off Learning Agreements) and CS (possible to add more than one). The physical appearance of the ISCP Learning Agreement is very different from that of the previous OCAP Learning Agreements. The main difference is that the Learning Agreement is now designed to allow mapping of the targets to the domains of the Applied Clinical Knowledge and Applied Clinical Skills sections of the T&O syllabus.

The steps of the Learning Agreement process are outlined in Figure 1. Training Programme Directors (TPD’s) will be able through their ISCP logins to set global objectives that may be applicable to all training posts. In addition to these global objectives, trainees and their AES will be able to add additional learning objectives mapped to curriculum topics that may be relevant to the specific post under discussion. The trainee and AES will then be able to set actions that will allow the trainee to demonstrate that they have met the set learning objectives. Finally, the trainee will need to add comments about the agreement before signoff is sent to the AES. The AES then needs to log into ISCP and navigate to the “Current trainees” section of the website. Here they will encounter a dashboard summarising the activities of their trainees. The AES needs to click on Learning Agreements in order to see Agreements awaiting signoff. The AES will need to add comments about the agreement prior to sign off. For the Intermediate, Final Learning Agreement meetings for each post, objectives have already been set and therefore the meeting is focused on progress with the trainee and AES able to enter comments about this.

The role of the Clinical Supervisor While trainees are still advised to have an initial meeting with their CS to discuss the expectations, opportunities, and logistics of the post, the CS does not sign off on the Learning Agreements. The CS, however, may provide valuable insight into what is achievable clinically during that post, and this

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may inform the Initial Objective Setting Learning Agreement Meeting with the trainee and AES.

be signed off by an AES, and the ability through the ISCP format to map learning objectives to the curriculum. This curriculum mapping will hopefully make it easy for trainees to show evidence of progress and competence.

The CS, however, is recommended to make frequent notes about the trainee on ISCP throughout the placement. The CS can do this by logging into ISCP and navigating to the “Current Trainees” section where they will encounter a dashboard summarising the activity of their trainees.

Trainees should ideally at the end of training be able to use the ISCP portfolio to demonstrate that they have undertaken activity to cover every domain of the T&O Curriculum. It remains for TPD’s to decide locally how they appoint AES’s.

These notes can be made at any point throughout a placement; they may supplement the Learning Agreement, can be made in the absence of the trainee, and are viewable to the trainee, AES, CS, and TPD.

For full 2013 Curriculum updates and ISCP screenshots of the Learning Agreement process, use the following link: www.bota.org. uk/forum-topic.php?id=2447 n

Summary The ISCP Learning Agreements achieve a similar goal to the previous OCAP agreements. The major differences between the two formats are the need for the ISCP Learning Agreements to

References:

Fig 1. Flowchart of the ISCP learning agreement process.

1. A Reference Guide for Postgraduate Specialty Training in the UK. The Gold Guide. Fourth Edition. GMC. June 2010.

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JTO Medico-Legal Features

The ‘Jackson Reforms’ in Civil Litigation and the Impact on the Expert Witness (Part 1) Giles Eyre

The so-called ‘Jackson Reforms’ – the changes in the civil procedure process introduced with effect from 1st April and 31st July 2013 – have recently been described as creating ‘the most chaotic period in legal costs and funding since the concept of legal costs was codified in the Statute of Westminster 1275’. The lives and business practices of lawyers, and particularly those dealing with injury claims (personal injury, disease and clinical negligence), have been and will be fundamentally changed by the reforms, and the access of an injured person to professional support in bringing a claim will, in some areas, be substantially restricted.

The impact of the reforms on the medical expert providing reports in civil litigation is both direct and indirect. Some reforms directly refer to the use of medical experts in litigation, while others will affect the approach to the use of medical expert evidence in litigation.

Costs and the ‘Jackson’ reforms For lawyers, the principal impact of the reforms is on the costs which will be recoverable on successfully concluding a claim. At the heart of the reforms is an amendment to the ‘overriding objective’ in part 1 of the CPR, and related amendments to the rules relating to the assessment of the costs that a successful party can recover at the end of the case.

Proportionate costs The overriding objective, which is to be considered at all stages of a claim and in relation to all decisions on case management, is amended to state that it is not only ‘to deal with cases justly’ but also now ‘at proportionate cost’. It is expressly provided that that requires dealing with a case in ways which are proportionate to the amount of money involved, the importance of the case, the complexity of the case and the financial position of each party. How the courts will interpret that, and whether a ratio between the sum in issue and the ‘proportionate’ costs which may be incurred will develop, we wait to see. It is however intended to reduce the cost of litigation, and most probably to do so to a significant degree.

Giles Eyre

Costs budgeting At the first court hearing in any claim commenced after 1st April 2013, the court is required to set a budget for the whole claim. The parties are required to provide a detailed breakdown, in accordance with a court form (in spread sheet style), of the estimated costs for each stage of the proceedings through to trial, however unlikely a trial will be. The court will, in the course of a relatively short hearing and with the minimum amount of investigation, set the budget for each stage, and for the whole claim. Subject to the court subsequently approving a variation because an assumption on which the estimate has been provided has proved incorrect through no fault of the lawyer, that will almost certainly be the basis for the costs recovered at the end of the case by the successful party. The court does not have to identify which particular items are disapproved or reduced, but can simply state the global sum approved for the particular stage. Therefore, if for the stage ‘Expert Reports’ the court decides to allow only half the total sum claimed on the grounds of proportionality, it will be for the solicitor, counsel and expert to resolve how, if successful, they are respectively paid from the costs eventually recovered. The expert is entitled to his contractual fee from the solicitor in any event, but the pressure on fees from this process may be considerable. >>

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Section??????????????????

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JTO Medico-Legal Features

The experts contractual right to his/ her fees will be satisfied by payments from the lawyer or by the client (from damages). Estimates of expert costs Experts will therefore have to provide estimates of their likely fees through to trial prior to this first hearing, or rely on the lawyers to do so for them, and the likelihood is that, particularly in more modest value claims, the fees of the medical expert will not be recovered from the losing party in full. In that case, the expert’s contractual right to his/her fees will be satisfied (assuming it is) by payments from the lawyer or by the client (out of damages). Estimates of fees will need to cover provision for: 1. providing an initial report; 2. re-examining the client and preparing a supplemental report; 3. reviewing reports prepared by other experts; 4. reviewing further documentation; 5. reviewing surveillance evidence 6. replying to questions from the opposing side; 7 attending case conference(s); 8. attending joint discussions and preparing a joint statement; 9. attending trial to give (and if appropriate, listen to) evidence. In providing an estimate, the expert should make clear the assumptions on which the estimate is made, for example the volume of medical records which will have to be read, the hours of surveillance material to be reviewed and the number of days the expert is likely to be required at court for the trial (giving evidence and hearing the evidence of others).

Funding arrangements

Fixed scale costs

Offers to settle

Funding arrangement under which claimants in most injury claims can employ a lawyer are changed so that the success fee under a conditional fee agreement (a ‘no win, no fee’ arrangement) will no longer be paid by the losing party, and the insurance premium on an insurance policy that was taken out to protect the claimant from a liability for the other sides’ costs in the event of losing, is no longer generally necessary or recoverable. Instead a claimant may have to pay out up to 25% of the damages recovered (for the injury and past loss) to the claimant’s own lawyer as a success fee (to help fund the cases the lawyer loses) and up to the whole amount of damages in satisfying a costs’ claim by the opposing party, although the starting position, to which there are a number of exceptions, in an injury claim is that a losing claimant no longer pays the successful defendant’s costs (so called Qualified One-Way Cost Shifting or QOCS). In the case of a fraudulent claim, or if a defendant’s Part 36 offer of settlement is not bettered at trial, this protection is lost.

The pressure on legal costs will be greatest in claims assigned to the Fast Track where damages do not exceed £25,000. Until April 2013 road traffic claims up to £10,000 were dealt with through an online portal with a scale of fixed costs recoverable by the successful claimant’s lawyer, falling out of the portal (and into court) if liability was disputed. For accidents after 31st July 2013 virtually all claims up to £25,000 for road traffic accidents, employers’ liability claims and public liability claims will start in the portal, and should they ‘fall out’ they will be caught by a scale of fixed costs. This will, in future, apply to the majority of all injury claims which are made. These costs are fixed at a level in relation to smaller value claims that are significantly less than before April and which might well make them unattractive to many lawyers who may well no longer run such claims at all.

The provisions in the CPR Part 36 relating to offers to settle have always been important in putting pressure on the parties to settle because of the implications in terms of costs in failing to accept an offer which is not subsequently bettered. The reliability of the expert report in assessing the risks of a claim and its likely value is crucial in assessing such offers. Additional ‘teeth’ have been added to offers made by claimants. From April 2013 if the defendant ends up paying no less than the sum offered as settlement by the claimant, the defendant will pay an additional sum to the claimant of 10% of the amount awarded (reducing on larger sums to 5% and capped at £75,000). On the other hand the new funding arrangements mean that a claimant who fails to do better than an offer from the defendant will pay the defendant’s costs, since the offer was made, out of his/her damages.

Under the portal, the claimant submits medical expert evidence in a standard report form provided under the scheme, or in a report containing the information required in that report form, and medical evidence is generally expected to be in a single report, with the defendant not obtaining medical evidence of its own. The report must identify the relevant medical records which will be served by the solicitor with the report.

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There is therefore a substantial risk that a failure by an expert to comply with a court timetable will result in the claim being struck out. Case management An expert does not always (some would say, ever) see a copy of a court order relating to expert evidence. Sometimes the impression may be given to the expert that if the report or answers to questions or the joint statement is received by the solicitor a little late it does not really matter. An amendment to CPR 3.9(1) is likely to change that. From April 2013 if a party (and that includes a party’s lawyers or experts) fails to comply with a court rule, practice direction or order, in deciding whether, for example, to extend time for the doing of something or for the provision of a document, the court will take into account ‘the need for litigation to be conducted efficiently and at proportionate cost, and the need to enforce compliance with rules, practice directions and orders’. There is therefore a substantial risk that a failure by an expert to comply with a court timetable will result in the claim, or the defence, being struck out, or permission to use the expert being withdrawn. The expert must therefore make sure that he/she is aware of court timetables relevant to their involvement in the litigation, and that they have appropriate insurance in place to cover such an unfortunate default.

The future for expert evidence The pressure on costs means that lawyers will need to deal with cases more quickly and efficiently, and often with a lower grade of fee earner. The rule changes will increase the necessity for high quality, reliable and readily understood medical reports which address all of the matters relevant to the legal issues in the case, and which demonstrate the internal reasoning process, so that the reports can be used efficiently and with confidence within the litigation by lawyers. The expert who provides such evidence should develop a reputation which will assure a substantial medicolegal practice. n PART 2 to follow in the next edition of JTO Giles Eyre 9 Gough Square London EC4A 3DG

Giles Eyre is co-author of a manual for medico-legal experts and those instructing them, ‘Writing Medico-Legal Reports in Civil Claims - an essential guide’ (2011) and co-presenter of the e-learning programme ‘Medico-Legal Report Writing (Core Skills)’ (www. prosols.uk.com). He frequently gives seminars and workshops for medical experts in medico-legal report writing, giving evidence and other medico-legal issues. Giles is a barrister specialising in personal injury, disease and clinical negligence claims. He is mediator and a member of the CEDR Solve Lead Mediators Panel. He was appointed a Recorder in 2004. Giles is a contributing editor to ‘Clinical Negligence Claims - A Practical Guide’ (2011) and ‘Asbestos Claims: Law, Practice and Procedure’ (2011), both published by 9 Gough Square.

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JTO Medico-Legal Features

Uneasy Bedfellows in Court?: A Psychiatrist on Orthopaedic Leigh Neal, MD FRCPsych, Consultant Psychiatrist

Even before working as a medical expert I could personally attest that Orthopaedic surgeons would always beat you at squash, out-ski you and drink you under the table. One common factor shared by these two professions is that they are probably the most frequently instructed medical experts in personal injury litigation and by virtue of this invariably cross-paths in barrister’s conferences and the courts. It is therefore tempting to rely on personal observation or well-worn stereotypes when characterising orthopaedic experts but I have looked at the medical literature, for a more authoritative and less biased view, which is revelatory in its rather bizarre detail.

It is probably no surprise that Orthopaedic surgeons are more inherently verbally aggressive and hostile than psychiatrists (Wright et al, 2012) or that psychiatrists have more open personalities and are more agreeable than Orthopaedic surgeons (Deary et al, 2007), which of course, also means that psychiatrists are more open to exploitation. Psychiatrists, who do not have to get up in the middle of the night to operate and rarely work at weekends, have less work-related stress and they report fewer clinical work demands than Orthopaedic surgeons (Deary et al, 2007). However, this is where the questionably good news for psychiatrists comes to an abrupt end. Orthopaedic surgeons park their cars more quickly and are more attractive and taller than psychiatrists (Antoni et al, 2006; McCail et al, 2010). I also know that they have more expensive and flashier cars than psychiatrists. Admittedly, I do park my car quite slowly, but exceptions always prove the rule and I know a very tall psychiatrist and a short (though unquestionably good looking) Orthopaedic surgeon. Orthopaedic surgeons are stronger and have larger hands than psychiatrists (Barrett, 1988; Fox et al, 1990), which does not particularly concern me - inferences aside. Orthopaedic surgeons are more extroverted and are more emotionally stable and less neurotic than psychiatrists (McGeevey et al, Deary et al, 2007). How many psychiatrists do you know that are planning their holiday steel-head fishing in Columbia?!

Leigh Neal

Slightly more worrying is that psychiatrists are less conscientiousness about their work than their Orthopaedic colleagues (Deary et al, 2007).

They suffer from lower levels of job satisfaction (Baldwin et al, 1997; Firth-Cozens, 2000) and who honestly would not prefer to be praised for replacing a worn out hip than be beaten up by a cocaine dealer? Psychiatrists have more disciplinary actions against them at work than Orthopaedic surgeons (Dehlendorf & Wolfe, 1998) and in particular, psychiatrists have a higher proportion of disciplinary actions for substance misuse than Orthopaedic surgeons (Shore, 1982). Male psychiatrists are more often disciplined than Orthopaedic surgeons for having sexual relationships with patients (Morrison & Morrison, 2001). Psychiatrists (who clearly should know better) are more likely to be depressed and have more burnout than Orthopaedic surgeons (Deary et al, 1996; Kumar et al, 2005). It seems the GMC is impotent to stop psychiatrists in training using more cocaine, LSD, and cannabis than Orthopaedic surgeons (Myers & Weiss, 1987). You may be interested to know that trained psychiatrists tend to favour benzodiazepines, amphetamines and cannabis (Hughes et al, 1992). I find it hard to believe, that psychiatrists are over-represented at Alcoholics Anonymous compared to Orthopaedic surgeons (Bissell & Skorina, 1987) but perhaps they are more “open” to admitting they are alcoholics. Psychiatrists are more like to commit suicide than Orthopaedic surgeons (Hawton et al, 2001), probably because they know the tricks of the trade. The final coup de grâce is that psychiatrists show significantly raised mortality compared with Orthopaedic surgeons and are particularly more likely to contract ischaemic heart disease, injury, poisoning, and colon cancer (Carpenter et al, 2003). I am

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Surgeons

STOP PRESS: Expert Witness Fees Cut Again

fairly sure than even Orthopaedic surgeons eventually die of something. However, much it pains me to admit it, there is no getting away from the fact that Orthopaedic surgeons are the top-guns of medicine; the Maverick’s to the Mr Bean’s and while I am sure this article has not revealed anything to you that you did not know already, the very least you can now do is to recommend me to your instructing solicitors. References available on request from Dr Neal.

www.leighneal.co.uk Dr Leigh Neal is a Consultant Psychiatrist who has been providing personal injury reports to the legal profession for 20 years. He has prepared 100 to 150 personal injury reports a year for defendants and claimants involved in personal injury actions since 1994 He has attended training courses in the responsibilities of an expert witness and report writing. He has considerable experience as an expert witness in the High Court and County Court, giving evidence on average 5 times a year since 1994.

Civil Legal Aid (Remuneration) (Amendment) Regulations come into force on 2nd December 2013. Expert witness fees in legally aided cases have been cut by 20% across the board. For Orthopaedic surgeons, this is a reduction from £144 per hour to £115.20 per hour. The fees for different specialists are at Schedule 2 of the document. This only applies to legally aided work but will certainly have an impact on Clinical Negligence practice where quite a number of claimants are legally aided. There are, however, caveats namely that if there is a paucity of experts in that field and the experts’ opinion is crucial to the patients claim, then the instructing solicitor can apply for an uplift to the fee on a case by case basis. www.legislation.gov.uk/uksi/2013/2877/pdfs/uksi_20132877_en.pdf

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JTO Peer-reviewed Articles

First Do No Harm: A New Approach to VTE Prophylaxis: An Editorial Robert L. Barrack, MD

In a chapter from his classic monograph “Low Friction Arthroplasty of The Hip” John Charnley stated “the possibility of fatal pulmonary embolism (PE) is a total hip replacement surgeon’s constant worry”.1 8% of the nearly 8000 patients he documented had a pulmonary embolism, of which 1% was fatal. In the cohort that received no prophylaxis, the results were twice as bad leading him to conclude that “all methods of prophylaxis are better than none and, therefore, it is no longer justifiable to use an untreated series as a control.”1 This conclusion holds true today. While there is widespread agreement that some type of prophylaxis must be utilised, surveys have revealed tremendous variability in approaches surgeons elect. 2,3 Controversy and lack of uniformity over methods of prophylaxis resulted in the concern that patients were at risk for suboptimal prophylaxis or even no prophylaxis.

Robert L. Barrack

This article is based on the Charnley Lecture given by Robert Barrack at the BOA Annual Congress in Birmingham 2013.

This void was filled by clinical practice guidelines (CPG’s). The effort was led by the American College of Chest Physicians (ACCP) and their first conference was held in 1985.5 There was virtually no orthopaedic surgery input until the 7th conference in 2004, when levels of recommendation were specifically categorised with the highest level being 1A defined as consistent support from large, randomised, multi-centre studies.6 In the same time frame, the U.S. federal government initiated programs mandating prophylaxis and the aggressive promotion of the highest level 1A recommendations became commonplace. The only agents accepted at the 1A level, from 2004-2012 for hip and knee replacement, was warfarin at a higher dose than had traditionally been used (target INR 2.5), lowmolecular weight heparin, or a XA inhibitor, which at the time in the U.S. was only Fondaparinux. This group meets every four years and at the 8th conference, they recommended the same 1A drugs; however, there was more liberal recommendation for extended prophylaxis for up to five weeks, especially for hips and, once again, there was no risk stratification with aggressive pharmacoprophylaxis recommended for all patients.7 The landscape has changed dramatically in the last five years, most dramatically in the past year

Numerous issues were identified with the ACCP Guidelines. The analysis considered predominantly large, prospective, multi-centre randomised clinical trials with the end point of venographically proven DVT (the vast majority of which were asymptomatic). This essentially limited the studies under guideline consideration to the studies utilised to bring anticoagulant drugs to the marketplace. The resources to study low cost generic options such as aspirin, warfarin or compression devices could not reach the 1A level and; therefore, the vast published experience of leading total joint centres was largely ignored. The historical orthopaedic U.S. standard had been low dose Coumadin with a target INR that would be in the 1.5 – 2.0 range. The pooled experience from leading total joint centres across the country has reported results as good as any anticoagulants recommended by the ACCP.8 The other issue with this methodology was the questionable clinical significance of asymptomatic DVT, the effect of lowering the incidence in DVT on the subsequent risk of symptomatic PE or death, which has not been well established, and has recently been brought into question.9 Despite these concerns, these guidelines were rapidly embraced by numerous groups, and the natural tendency was to use these guidelines as the safest standard for compliance.4 The implication clearly was the 1A protocol which was preferable, if not necessary, to meet federal guidelines, which was not the case.

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The actual requirements did include aggressive drug protocols for hip replacement in addition to the option of compression devices for knee replacement but not for hip replacement. The dose and duration, however, was not specified for warfarin and aspirin (although not recommended) could be used with proper documentation. To determine whether there was concern over the routine widespread use of these â&#x20AC;&#x153;relatively aggressiveâ&#x20AC;? 1A protocols, one such protocol was studied. Lovenox was selected because of difficulty monitoring a high number of outpatients from across the region, which was necessary with warfarin, which previously had been utilised. The status of previous DVT prophylaxis at our facility had recently been published.10 The earlier protocol consisted of a short course of low-dose warfarin followed by ultrasound screening all of which was at odds with the Chest Physician Recommendations. In spite of this, the results with this unapproved protocol were excellent. There was high efficacy with no deaths (0.9% pulmonary embolism), high safety, high patient acceptance and relatively low cost.10 The Chest Physicians Recommendations in 2004 were against ultrasound screening at the 1A level, and recommended a higher dose and longer course of warfarin.6

Figure 1A: Appearance of patient readmitted following primary THA treated with Lovenox in accordance with an ACCP 1A protocol

A prospective IRB-approved protocol was started in which patients were evaluated prior to discharge - at six weeks and six months - for wound drainage, complications, readmissions, injection site problems satisfaction and compliance. Data was only collected on about 300 patients, although the original study anticipated studying 2,000 patients. The study was terminated early due to concern for patient safety. The results were compared to the previous study from the same centre. The data showed that the major complication rate was four times higher and there was a higher incidence of DVT and PE because once patients have bleeding or excessive drainage, their anticoagulation is frequently stopped. There was also a higher incidence of wound problems and return to the operating room (Figures 1A & 1B). >>

Figure 1B: Surgical exploration confirmed the presence of a large haematoma

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Journal of Trauma and Orthopaedics: Volume 02, Issue 01, pages 50-56 Title: First do no harm: A New Approach to VTE Prophylaxis Author/s: Robert L. Barrack

The response to the numerous problems identified with the ACCP was the AAOS forming DVT/PE workgroup in 2007, which was updated in 2011.24 The goal was to obtain balance in minimising risk while maximising efficacy. Patients were classified based on risk for PE and risk for bleeding. The data was not sufficient to recommend any commonly used modality. Both aspirin and mechanical compression devices were accepted for hip and knee replacement. A more rational approach was recommended, with more aggressive prophylaxis for those with prior VTE and less aggressive for those with bleeding disorders. This placed the Academy in direct conflict with Chest Physicians in every recommendation until last year.

Figure 2: Postoperative haematoma in a Total Knee which occurred when INR exceeded 3.0, resulting in persistent pain, stiffness and a compromised clinical result.

Our results, and those of the University of Virginia with the unapproved protocol, were excellent and with a 1A protocol were poor.10,11,12 Excellent results have been reported for aspirin from a number of American centres.13,14 Raphael et al recently reported the experience at the Rothman Institute with aspirin and actually had a lower incidence of PE in patients matched for comorbidities and demographics.9 A study from Great Britain using a large database, reported that aspirin efficacy was equivalent to low-molecular weight heparin.15

Another major issue with the ACCP guidelines is under reporting of complications. There are many hospital readmissions of patients on 1A protocols that donâ&#x20AC;&#x2122;t meet ACCP guidelines of a major bleed defined as overt bleeding associated with at least one of the following: death or life-threatening clinical event, bleeding confirmed to be retroperitoneal, intracranial or intraocular, transfusion of more than two units blood, or a decrease in haemoglobin greater than 20 g/l compared with the relevant post-operative level.6,16 Bleeding sufficient to cause a substantial haemarthrosis following TKA (Figure 2) usually will not meet these criteria, yet will frequently lead to a poor clinical result. 17-19

A recent database analysis showed a higher infection rate associated with LMWH and suggested that this should be indicated in future analyses.20 The orthopaedic literature has consistently confirmed a link between prolonged drainage and infection drainage.19,21,22 Yet another issue with Chest Physicians Guidelines was virtually all of the authors had numerous conflicts of interest.23

The matter was resolved in 2012 with the 9th edition of the Chest Physician Guidelines.25 The conflict of interest issue was addressed as the majority of authors had no conflicts to disclose in stark contrast to the previous guidelines. The methodology changed with the focus placed on clinically important outcomes rather asymptomatic DVT with a major focus on bleeding and wound drainage.19 There were no 1A recommendations because of inadequate evidence when only clinical endpoints were utilised. Such events are currently so rare that an adequately, statistically-powered study would require well over 30,000 patients.15,26 The 1B recommendations included every commonly used strategy, including newer anticoagulants (Xa inhibitors and direct thrombin inhibitors), adjusted dose Coumadin, aspirin and intermittent pneumatic compression devices (IPCD) were accepted at the 1C level. >>

boa.ac.uk

G IN ES RV RC SE FO TO D Y E TR RM EN Y/A EE AR FR ILIT M

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JTO Peer-reviewed Articles

It was recently announced that aspirin and compression devices will be viewed as acceptable for THA, TKA, and hip fracture in alignment with the new recommendations of both the AAOS and the ACCP. When an IPCD is utilised, a mobile device with a compliance monitoring chip was recommended.25 This is a new technology that is worn continuously, ideally eighteen or more hours daily. The next generation device has the potential to detect proximal flow obstruction and is currently under development. Results with such a device have been as good as a 1A drug (Lovenox) in a randomised trial27 with similar excellent results in a larger multi-centre registry study.28 New oral anticoagulants advocated by the ACCP have positive and negative features. While they don’t require monitoring and are relatively inexpensive, they are difficult to monitor or to reverse. Also, while they are touted as equivalent to or better than low-molecular weight heparin in preventing DVT29,30 which are largely asymptomatic, the incidence of bleeding and wound complications has been reported by numerous orthopaedic surgeons to be significantly increased.31-35 The ACCP and the AAOS are now largely in agreement for the first time. Both focus on clinically symptomatic events and avoiding complications. Both recognise all major options for prophylaxis, including aspirin and compression devices. The initial experience with a mobile compression device with a monitoring chip has been positive and is clearly adequate for the vast majority of total joint patients.

A final piece of the puzzle has fallen into place just recently. The Center for Medicare and Medicaid Services (CMS) administers the Surgical Care Improvement Program (SCIP) which monitors compliance with VTE prophylaxis practices for hospitalised patients. Previously, their audit guidelines were largely in accordance with the pre-2012 ACCP guidelines (although allowing compression devices for TKA, but not THA). It was recently announced that aspirin and compression devices will be viewed as acceptable for THA, TKA, and hip fracture in alignment with the new recommendations of both the AAOS and the ACCP.36 John Charnley was a visionary regarding most aspects of total hip arthroplasty. Regarding thromboembolism, he stated that “a better quality of early function might have helped to reduce pulmonary embolism,” and, secondly, that “if a prophylactic agent were so effective that it completely suppressed clot formation in the calf it might interfere with the beneficial aspects of the clotting mechanism so necessary inside the operated hip”.37 THA today is a faster, lessinvasive procedure, mobilisation far more rapid and PE risk is far lower, as Charnley predicted. Aggressive anticoagulation is usually not necessary and certainly should not be routine. These important clinical decisions belong, not in the hands of third party oversight groups, but should reside predominately with clinical specialists using their unique insight to act in the best interest of their patients. In addition to observing the prescient observations of Charnley, we should adhere to the most basic principle of medicine of first doing no harm in our approach to VTE prophylaxis for total joint patients. n

References 1. Charnley J. Thrombo-embolic Complications: In: Chapter 18, p. 313. Low friction arthroplasty of the hip : theory and practice. Berlin ; New York: Springer-Verlag; 1979. 2. Markel DC, York S, Liston MJ, Jr., et al. Venous thromboembolism: management by American Association of Hip and Knee Surgeons. The Journal of arthroplasty 2010;25:3-9 e1-2. 3. Mesko JW, Brand RA, Iorio R, et al. Venous thromboembolic disease management patterns in total hip arthroplasty and total knee arthroplasty patients: a survey of the AAHKS membership [abstract]. The Journal of arthroplasty 2001;16:679-88. 4. No authors listed. QualityNet Specifications Manual for National Hospital Inpatient Quality Measures www. qualitynet.org/dcs/ContentS erver?c=Page&pagename=Q netPublic%2FPage%2FQne tTier4&cid=1141662756099. (Accessed October 18, 2013) 5. Dalen JE, Hirsh, J. Proceedings of the American College of Chest Physicians 5th Consensus on Antithrombotic Therapy. 1998. Chest 1998;114:439S-769S. 6. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S-400S. 7. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines (8th Edition). Chest 2008;133:381S-453S.

8. Haas SB, Barrack RL, Westrich G. Venous thromboembolic disease after total hip and knee arthroplasty [abstract]. Instructional course lectures 2009;58:781-93. 9. Parvizi J, Jacovides CL, Bican O, et al. Is deep vein thrombosis a good proxy for pulmonary embolus? The Journal of arthroplasty 2010;25:138-44. 10. Keeney JA, Clohisy JC, Curry MC, Maloney WJ. Efficacy of combined modality prophylaxis including short-duration warfarin to prevent venous thromboembolism after total hip arthroplasty. The Journal of arthroplasty 2006;21:469-75. 11. Burnett RS, Clohisy JC, Wright RW, et al. Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. The Journal of arthroplasty 2007;22:317-24. 12. Novicoff WM, Brown TE, Cui Q, Mihalko WM, Slone HS, Saleh KJ. Mandated venous thromboembolism prophylaxis: possible adverse outcomes [abstract]. The Journal of arthroplasty 2008;23:15-9. 13. Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty [abstract]. Clinical orthopaedics and related research 2006;452:175-80. 14. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty? Clinical orthopaedics and related research 2013.

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15. Jameson SS, Baker PN, Charman SC, et al. The effect of aspirin and lowmolecular-weight heparin on venous thromboembolism after knee replacement: a non-randomised comparison using National Joint Registry Data. The Journal of bone and joint surgery British volume 2012;94:914-8. 16. Barrack RL. Current guidelines for total joint VTE prophylaxis: dawn of a new day. The Journal of bone and joint surgery British volume 2012;94:3-7. 17. Galat DD, McGovern SC, Hanssen AD, Larson DR, Harrington JR, Clarke HD. Early return to surgery for evacuation of a postoperative hematoma after primary total knee arthroplasty. The Journal of bone and joint surgery American volume 2008;90:2331-6. 18. Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD. Surgical treatment of early wound complications following primary total knee arthroplasty. The Journal of bone and joint surgery American volume 2009;91:48-54. 19. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection? The Journal of arthroplasty 2007;22:24-8. 20. Wang Z, Anderson FA, Ward MM., Bhattacharyya T. Association between Surgical Site Infections and Anticoagulant Thromboprophylaxis following Elective THA or TKA. Paper, Posters & Scientific Exhibits AR HIP 2013.

21. Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. Journal of orthopaedic research : official publication of the Orthopaedic Research Society 2002;20:506-15. 22. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. The Journal of bone and joint surgery American volume 2007;89:33-8. 23. Norris SL, Holmer HK, Burda BU, Ogden LA, Fu R. Conflict of interest policies for organizations producing a large number of clinical practice guidelines. PloS one 2012;7:e37413. 24. Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. The Journal of bone and joint surgery American volume 2012;94:746-7. 25. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e278S-325S.

26. Yates AJ, Jr. Prophylaxis against venous thromboembolism after arthroplasty: establishing value requires more than one perspective. Commentary on an article by John T. Schousboe, MD, PhD, and Gregory A. Brown, MD, PhD: “Cost-effectiveness of lowmolecular-weight heparin compared with aspirin for prophylaxis against venous thromboembolism after total joint arthroplasty”. The Journal of bone and joint surgery American volume 2013;95:e102 1-2. 27. Colwell CW, Jr., Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. The Journal of bone and joint surgery American volume 2010;92:527-35. 28. Colwell CW Jr., Froimson MI, Anseth SD, Giori NJ, Hamilton WG, Barrrack RL, Buehler KC, Mont MA, Padgett DE, Pulido PA, Barnes CL., et al. A Mobile Compression Device For Thrombosis Prevention In Hip and Knee Arthroplasty. The Journal of bone and joint surgery 2013; in press. 29. Beyer-Westendorf J, Lutzner J, Donath L, et al. Efficacy and safety of thromboprophylaxis with low-molecular-weight heparin or rivaroxaban in hip and knee replacement surgery: findings from the ORTHOTEP registry. Thrombosis and haemostasis 2013;109:154-63.

30. Russell RD, Huo MH. Apixaban and rivaroxaban decrease deep venous thrombosis but not other complications after total hip and total knee arthroplasty. The Journal of arthroplasty 2013;28:1477-81. 31. Jensen CD, Steval A, Partington PF, Reed MR, Muller SD. Return to theatre following total hip and knee replacement, before and after the introduction of rivaroxaban: a retrospective cohort study. The Journal of bone and joint surgery British volume 2011;93:91-5. 32. Chahal GS, Saithna A, Brewster M, et al. A comparison of complications requiring return to theatre in hip and knee arthroplasty patients taking enoxaparin versus rivaroxaban for thromboprophylaxis [abstract]. Ortopedia, traumatologia, rehabilitacja 2013;15:125-9. 33. Rath NK, Goodson MW, White SP, Forster MC. The use of rivaroxaban for chemical thromboprophylaxis following total knee replacement. The Knee 2013. 34. Sindali K, Rose B, Soueid H, Jeer P, Saran D, Shrivastava R. Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2013;23:481-6.

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35. Adam SS, McDuffie JR, Lachiewicz PF, Ortel TL, Williams JW, Jr. Comparative effectiveness of new oral anticoagulants and standard thromboprophylaxis in patients having total hip or knee replacement: a systematic review. Annals of internal medicine 2013;159:275-84. 36. McKee J. SCIP VTE Measures Changing in 2014 in: New measures go into effect on Jan. 1, 2014. AAOS Now (online) 2013;7(11).

37. Charnley J. Prophylaxis of postoperative thromboembolism [abstract]. Lancet 1972;2:134-5. The author attests that he has received research support for a device related to DVT prophylaxis but has had full control of the article and data used therein.

Correspondence: Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes Jewish Hospital Plaza, 11300 West Pavilion, Campus Box 8233, St. Louis, MO 63110, USA Email: barrack@wustl.edu

Don’t forget that videos from Congress are now available online, including all keynote lectures and numerous sessions on data and research: http://www.boneandjoint.org. uk/boacongress2013/menu This includes the popular and thought-provoking Howard Steel Lecture by Mark Stevenson: ‘The Future ... and what to do about it’.

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Evidence vs. Anecdote in Foot and Ankle Surgery Judith Baumhauer, M.D., M.P.H. Professor and Associate Chair of Orthopaedic Surgery University of Rochester Medical School, Rochester, NY

Evidence: The available body of facts suggesting a belief is true or valid. Anecdote: A short, amusing or interesting story that need be neither true nor valid. Diagnosis and treatment decisions are often based on sketchy information passed down through the years; eventually becoming dogma; gradually assuming the mantle of fact masquerading as knowledge. We must revisit some of these established treatment trends to determine if there is an evidence base to support their use.

The ancient Chinese developed the concept of evidence based medicine, however it was in the early 1990’s that Gordon Guyatt and colleagues brought the current concept of evidence based medicine to the fore1. This led to an evidence based hierarchy that has been peer reviewed published and well accepted2 (Table 1). Table 1: Levels of Evidence in Medicine2 Level 1

Randomised Clinical Trials (RCT)

Level 2

Lower quality RCT

Level 3

Case controlled Studies

Level 4

Case Series

Level 5

Expert opinion

The quality of the information obtained influences the level of evidence ranking. Quality indicators include the type of study, quality of the study design, per cent follow up, statistical methods and enrollment criteria utilised for the clinical trial3 (Table 2).

Table 2: Quality indicators for Clinical Research in Medicine * Type of Study Quality of the Study Design % of Patient Follow up Statistical methods Enrollment criteria

Judith Baumhauer

This article is based on the Naughton Dunn Lecture given by Judith Baumhauer at the BOA Annual Congress in Birmingham 2013.

* Wright RW, Brand RA, Dunn W, Spindler KP: How to write a systematic review. Clin Orthop Relat Res. 2007 Feb;455:23-9. The rigour of these quality measures impacts the level of evidence assigned to the research.

Foot and ankle research has primarily been Level 4 retrospective cases series. A recent publication by Hunt and Hurwit (2013)4 reviewed our foot and ankle literature to assess the level of evidence over a 9-10 year time period. They found 70% Level 4 studies, 12% Level 3, 9% Level 2 and only 9% Level 1 studies. This was actually an improvement over earlier papers looking at the level of evidence in foot and ankle literature5! Although current publications record the level of evidence, older literature did not. Here we will look back on some well held principles of foot and ankle care from older literature to determine whether or not these “peer reviewed” papers were in fact based on evidence or anecdote. >>

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Journal of Trauma and Orthopaedics: Volume 02, Issue 01, pages 57-62 Title: Evidence vs. Anecdote in Foot and Ankle Surgery Author/s: Judith Baumhauer

The index citation tool on the Web of Science was used to provide a listing of the most highly cited peer reviewed papers in the world literature cross referenced for foot and ankle over the last 30 years. Identifying a highly cited paper and assessing whether or not the science behind that paper used quality research principles would give us some insight as to whether or not we are perpetuating dogma or if we are truly using high level evidence. “The rupture of posterior tibial tendon causing flat foot - surgicaltreatment” authored by Roger Mann and Francesca Thompson in 19856 was cited 213 times. In the conclusions that are drawn from the evidence of the article: “Isolated FDL transfer to the navicular arrests the flat foot deformity, relieves pain and restores inversion power of the hindfoot at two years.” Is this evidence or anecdote? Using quality research measures, this paper is defined as a Level 4 paper, a case series with a small subject number (17). There is no control arm therefore all patients underwent FDL tendon transfer to the navicular. The authors did not utilise any validated methodology or outcomes measures. There was no standardised radiographic methodology available at that time and no functional outcomes were obtained. The authors did use standardised surgical techniques and post-operative treatment protocols for this patient group. There were no statistical analyses performed on any of the parameters measured in this paper.

The duration of follow up was a minimum of two years. Based on this information and assessment of the quality measures utilised to determine the conclusion statements, it would seem that this case series described a surgical treatment however; it did not prove that this surgical intervention relieves pain and restores inversion power of the hindfoot. It is therefore a well-meaning anecdote. There are numerous case series available in the foot and ankle literature (Hunt et al). These case series do not have a level of evidence to support universal adoption of the suggested treatment as in the use of an isolated FDL transfer to navicular however; they do provide information that can lead to further study. Pinney published a symposium on evidence based medicine: “What is it and how should it be used?”7. A section looked at case series (level 4) and case reports (level 5)8. These published Level 4 and 5 studies allow clinicians and researchers to be exposed to new ideas which may be the stepping stones for more advanced study. Friedman, JAMA 19999 commented about Level 4 and 5 studies. “These lower level studies provide detailed observations and descriptions of new diseases or conditions. They also provide pilot study data for future power analyses and aid in study design. These Level 4 and 5 studies also may have a quick turn around on time sensitive issues opposed to Level 1 and 2 studies which often can take years to get the available data and conclusions into the literature. These case series and case reports may be the only options for orphan or very rare conditions and they also allow us to detect drug side effects in an expedient manner.”

Hoffman et al10 published an article on the negative implications of case series and case reports. They looked into the percentage of case series and case reports that have been used as stepping stones for Level 1 or Level 2 studies. They highlighted that most new ideas, from these lower level evidence papers, are not substantiated with more rigorous research. They argue that the case series and case reports contain misleading data and conclusions with small subject numbers and wide variation. The data is often qualitative and not quantitative and it lacks validated outcome measures as we saw with the FDL to navicular paper. They summarise their conclusions with a comment “does more harm than good by focusing on the bizarre.” Despite the negative comments made by Hoffman and his colleagues, there are historic examples of Level 4 and 5, evidence that have made great contributions to the advancement of patient care. In the 1980’s, Drs. Conant and Volverg recognised a unique tumor, Kaposi’s sarcoma in eight homosexual males11. It is their recognition of this link that led to the recognition of AIDS and HIV virus transmission. In 1952, Dr. Jonas Salk produced a polio vaccine consisting of a dead injectable virus, and in 1957 Albert Sabin, M.D. produced an attenuated vaccine tested in 19 children that could be taken orally12. Salk was credited with the eradication of polio in the United States while Sabin’s oral vaccine has been utilised throughout the world. These Level 4 case series changed care around the world.

Mr. Naughton Dunn, M.D. recognised the importance of case series and the re-evaluation of his patients to improve patient care. In his presidential address in 1928 he stated, “If we refer to a modern textbook on orthopaedic surgery we find that all the principles on which we rely for the treatment of infantile paralysis are recorded, so that I have nothing new to offer. My only reason for selecting this subject for discussion is that so many alternative treatments are advised that a frank review of these and the results of our own practice and experience may be helpful” 13. Mr. Dunn recognised that anecdotal information had been perpetuated by repetition. He recognised the need for a frank assessment of these treatments. Mr. Dunn published a case series entitled “Calcaneal cavus and its treatment” in 191914. He looked at a wedge resection of the midfoot to correct a cavus foot along with a soft tissue release of the Achilles. He provided pre- and postoperative radiographs and clinical photographs of his patients. This type of surgery and treatment is still utilised today. In summary, the rupture of the posterior tibial tendon causing flat foot – surgical – treatment by Drs. Mann and Thompson was a meaningful case series but not critical evidence. It led to a number of higher level evidence studies with control groups comparing different treatment options for posterior tibial tendon dysfunction. It did advance the science.

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Hallux Metatarsophalangeal-Interphalangeal Scale (100 points total ) Pain (40 points) None

Mild, occasional

Moderate, daily

Severe, almost always present The fifteenth most commonly cited Web of Science article in foot and ankle was out of JAMA entitled “Preventing foot ulcers in patients with diabetes”15. The conclusions are “substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration. These patients might benefit from certain prophylactic interventions including patient education, prescription foot wear, intensive podiatric care, and evaluation for surgical interventions.” If we look at the quality research indicators, this paper was in fact a Level 1 systematic review. The authors looked at 165 articles, 22 of which were randomised controlled trials. The primary outcome measures utilised in the study included ulceration or amputation with or without intervention. They reviewed the factors resulting in diabetic foot ulceration including peripheral neuropathy, vascular insufficiency, increased plantar pressures, poor glucose control and smoking and examined interventions aimed at decreasing ulceration or amputation. These interventions included patient or physician education, custom foot wear, orthoses, preventative surgery, and routine foot exams. In reading this article and the referenced supportive publications from the systematic review, it was clear that patient or physician education, custom foot wear, orthotics and preventative surgery had no impact on decreasing foot ulceration or amputation. The isolated factor that decreased ulceration and amputation was routine foot examination. It appears that seeing the patient in a routine period of time such as every six months does decrease the risk of foot ulceration.

The conclusions stating that the patients might benefit from certain prophylactic interventions should only include routine foot exams. The other aspects of patient or physician education, custom foot wear, orthoses, preventative surgery are only options and not substantiated by this publication. It is often the case that a significant amount of resources and time is spent on patient education, physician education, custom foot wear, orthotics and preventative surgery for diabetic patients suffering from ulcerations. The support for these treatments might actually be regarded as anecdote rather than evidence. A better summary that is supported by the evidence would have included only routine foot exams. Mr. Naughton Dunn recognised the importance of clinical outcomes in assessing our patients and stated in a paper published in 1922 “Orthopaedic surgery is so closely associated with function that perhaps in no other branch of surgery is the patient in a better position to judge of the practical success or failure resulting from any operative procedure”17. Naughton Dunn was certainly ahead of his time in recognising the importance of patient derived outcomes. The number one citation from the Web of Science was a paper entitled “Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes” 16. This particular paper has been cited over 1,200 times. The summary statement from this article is “Four rating systems were developed by the American Orthopaedic Foot and Ankle Society to provide a standard method of reporting clinical status of the ankle and foot. The systems incorporate both subjective and objective >>

Function (45 points) Activity Limitations No limitations

No limitation to daily activities, such as employment responsibilities, limitation of recreational activities

Limited daily and recreational activities

Severe limitation of daily and recreational activities

Footwear requirements Fashionable, conventional shoes, no insert required

Comfort footwear, shoe insert

Modified shoe or brace

MTP joint motion (dorsiflexion plus plantarflexion) Normal or mild restriction (75o or more)

Moderate restriction (30o-74o)

Severe restriction (less than 30o)

IP joint motion (plantarflexion) No restriction

Severe restriction (less than 10o)

MTP-IP stability (all directions) Stable

Definitely unstable or able to dislocate

Callus related to hallux MTP-IP No callus or asymptomatic callus

Callus, symptomatic

Alignment (15 points) Good, hallux well-aligned

Fair, some degree of hallux malalignment observed, no symptoms 8 Poor, obvious symptomatic malalignment

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factors into numerical scales to describe function, alignment and pain.” An example of the hallux metatarsophalangealinterphalangeal scale is provided in Table 3. From: Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994 Jul;15(7):349-53. These clinical rating scales are anatomic outcomes instruments that are clinician derived and administered. There are four anatomic scales and each includes the items of pain, function and alignment in a point allocation system that totals 100 points. It takes about five minutes to complete. Despite high numbers of citations for this paper, many subsequent publications have raised questions over the validity and reliability of the clinical rating scales18-20. This paper, the number one cited foot and ankle paper identified by the Web of Science, is anecdotal and proven to be inappropriate for future use. With the sun setting on the AOFAS clinical scoring systems, comes an opportunity to re-evaluate what type of outcomes measures might be appropriate for foot and ankle. The PROMIS is a Patient

Reported Outcomes Measurement System that has been developed in collaboration with Northwestern University in Chicago, IL and National Institute of Health21. It allows healthcare providers to assess patient reported outcomes through the utilisation of a technique called item response theory (IRT) and computer adaptive testing (CAT). Through the PROMIS system, patients are asked questions in a variety of different domains including lower extremity physical functioning. The American Orthopaedic Foot and Ankle Society is currently organising pilot projects to look at the feasibility of the PROMIS physical functioning CAT tool2224 . First steps included gathering data from 10 academic centres to optimise the data collection and the utilisation process. With the next step PROMIS will be rolled out into a sample of private practices that often do not have the infrastructure for outcomes assessment. Additionally, the Society has been examining the bank of questions that are currently utilised in the lower extremity physical functioning domain and comparing it to other legacy scales such as the clinical rating scales. In summary, evidence is really based on quality research. There are quality measures that can be used to evaluate publications. We need to be critical in the

assessment of research that influences the treatment of patients to determine whether or not the foundation of any research is evidence or anecdote. All levels of evidence have value; however, taking research directly to our patients needs a critical eye to avoid dogma. n

References 1. Cook DJ, Jaeschke R, Guyatt GH (1992). “Critical appraisal of therapeutic interventions in the intensive care unit: human monoclonal antibody treatment in sepsis. Journal Club of the Hamilton Regional Critical Care Group”. J Intensive Care Med 7 (6): 275–82. 2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71. 3. How to write a systematic review. Wright RW, Brand RA, Dunn W, Spindler KP. Clin Orthop Relat Res. 2007 Feb;455:23-9. 4. Hunt KJ, Hurwit D: Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013 Aug 21;95(16):e118(1-9).. 5. Barske HL, Baumhauer J: Quality of research and level of evidence in foot and ankle publications. Foot Ankle Int. 2012 Jan;33(1):1-6. 6. Mann RA, Thompson FM: Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. Bone Joint Surg Am. 1985

Apr;67(4):556-61. 7. Pinney S. Symposium: evidence-based medicine: what is it and how should it be used? Foreward. Foot Ankle Int. 2010 Nov;31(11):1033. 8. Baumhauer J: The use and misuse of Level IV and Level V evidence. Foot Ankle Int. 2010 Nov;31(11):1037-9. 9. Friedman MA, Woodcock J, Lumpkin MM, Shuren JE, Hass AE, Thompson LJ. The safety of newly approved medicines: do recent market removals mean there is a problem? JAMA. 1999 May 12;281(18):1728-34. 10. Hoffman JR: Rethinking case reports. West J Med. 1999 May;170(5):253-4. 11. Rubenstein SA, Jenkin WM, Conant MA, Volberding PA: Disseminated Kaposi’s sarcoma in male homosexuals. J Am Podiatry Assoc. 1983 Aug;73(8):413-7. 12. Katz SL. From culture to vaccine--Salk and Sabin. N Engl J Med. 2004 Oct 7;351(15):1485-7. 13. Dunn, Naughton: Presidential Address: The surgery of muscle and tendon in relation to infantile paralysis. Proceedings of the Royal Society of Medicine. Section of Orthopaedics. October 2, 1928. John Bale, Sons & Danielsson, pub. 14. Dunn, N: Calcaneo Cavus and It’s Treatment. J Orthopaedic Surg. 1:12:1919 15. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 293(2):217-28, 2005.

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15th EFORT Section?????????????????? Congress 2014 www.efort.org/london2014

Briish Orthopaedic Associaion e a dlin e D n o i t A combined programme in partnership with e gis tr a CatiitititiftititiPatititititititititititititititititititititititititi L ate R

y 2014 a M 5 1 ď ˝

the British Orthopaedic Association (BOA)

15th EFORT Congress

A combined programme in partnership with the BOA

London, United Kingdom: 4 - 6 June 2014

Congress Highlights - Main Theme: Patient Safety General Orthopaedics Reconstruction on upper limb Salvage procedures for hip & knee replacement What is evidence based orthopaedics? How to diagnose deep infection? Sarcopenia and osteoporosis Pain control in Paediatric Orthopaedics ACL revision The championship of materials Upper Limb Finger fractures The complicated reverse shoulder Spine Spine Surgeon: European Diploma

Lower Limb Ankle fusion or arthroplasty? Conservative approaches Knee osteoarthritis Trauma The periprosthetic fracture Treatment of bone defects Polytrauma in the elderly Paediatrics New approaches in managing children`s pain

Key dates Preliminary Programme online: 1 March 2014 On-site rates apply: 16 May 2014

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Journal of Trauma and Orthopaedics: Volume 02, Issue 01, pages 57-62 Title: Evidence vs. Anecdote in Foot and Ankle Surgery Author/s: Judith Baumhauer

16. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994 Jul;15(7):349-53. 17. Dunn N.Stabilizing Operation in the Treatment of Paralytic Deformities of the Foot. Proc R Soc Med. 1922;15(Surg Sect):15-22. 18. Guyton GP: Theoretical limitations of the AOFAS Scoring System: An Analysis using Monte Carlo Modeling. FAI 22:779; 2001. 19. Baumhauer JF, Nawoczenski DA, DiGiovanni BF, Wilding GE: Reliability and Validity of the American Orthopaedic Foot and Ankle Society Clinical Rating Scale: A Pilot Study for the Hallux and Lesser Toes. FAI 27:1014, 2006. 20. Pinsker E and Daniels TR: AOFAS Position Statement regarding the future of the AOFAS Clinical Rating Systems. FAI 32:841, 2011. 21. Cella D, Yount S, Rothrock N, Gershon R, Cook K, Reeve B, Ader D, Fries JF, Bruce B, Rose M; PROMIS Cooperative Group. The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Med Care. 2007 May;45(5 Suppl 1):S3-S11. 22. Hung M, Baumhauer JF, Latt LD, Saltzman CL, SooHoo NF, Hunt KJ; National Orthopaedic Foot & Ankle Outcomes Research Network. Validation of PROMIS ® Physical Function computerized adaptive tests for orthopaedic foot and ankle outcome research. Clin Orthop Relat Res. 2013 Nov;471(11):3466-74.

23. Hung M, Nickisch F, Beals TC, Greene T, Clegg DO, Saltzman CL. New paradigm for patient-reported outcomes assessment in foot & ankle research: computerized adaptive testing. Foot Ankle Int. 2012 Aug;33(8):621-6. 24. Hung M, Franklin JD, Hon SD, Cheng C, Conrad J, Saltzman CL. Time for a Paradigm Shift With Computerized Adaptive Testing of General Physical Function Outcomes Measurements. Foot Ankle Int. 2013 Oct 7. [Epub ahead of print] Correspondence: Judith Baumhauer, M.D., M.P.H. Professor and Associate Chair of Orthopaedic Surgery University of Rochester Medical School 601 Elmwood Avenue Rochester NY 14642 Email: judy_baumhauer@URMC. Rochester.edu

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JTO Peer-reviewed Articles

Principles of Ligament Balancing in Total Knee Replacement James B. Stiehl, MD. St Mary’s Hospital, Centralia, Illinois

Knee ligaments function as viscoelastic cords whose mechanical character is described by a force/displacement curve. The key ligaments for total knee replacement are the superficial medial and lateral collateral ligaments as they are important stabilisers throughout the range of motion. The posterior cruciate ligament is an important check rein of the knee and flexion laxity is increased significantly with its release. Surgeons must consider the different situations that arise when they choose to preserve or sacrifice the posterior cruciate ligament. New technologies are available; sophisticated mechanical tensors, computer navigation algorithms, and digitally instrumented tibial trial inserts that will allow the surgeon to better understand surgical variables and to add precision to their surgical techniques.

James B. Stiehl

This article is based on the Adrian Henry Lecture given by James Stiehl at the BOA Annual Congress in Birmingham 2013.

Figure 1 - Ligament biomechanical function described by a force/displacement curve with zones of laxity and terminal stiffness with transition defined as “breakpoint”.

Instability of ligaments is a direct consequence of inadequate balancing performed during the surgical procedure. Fehring, et al reported that 27% of patients who required revision surgery within five years of the index operation suffered from chronic ligamentous instability.1 Sharkey, et al found 21% of early and 22% of late revisions were caused by instability. From an educational point of view, an important approach to correct this problem is to improve the surgeon’s general understanding of the relevant issues involved. This review surveys the topics of anatomy, clinical outcome studies, and new instrument technologies and elaborates on the important concepts of balancing. 2

Anatomical Studies Markolf, et al described the mechanical features of ligament function as a viscoelastic structure that stretches much as a stiff bungee cord. Ligament stretch is characterised by a force displacement curve where laxity changes with load to terminal stiffness over a brief zone defined as the breakpoint.3 (Figure 1). Surgeons can feel the ‘mushy’ zone and easily assess stiffness, but have a poor sense of the ligament strain that occurs in the zone of stiffness. As ligaments are such stout structures, the strain definition of terminal stiffness has little clinical relevance. >>

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Kennedy, et. al. measured the load to failure of the important knee ligaments finding that the superficial medial collateral ligament withstood 467 Newtons of maximum load, the anterior cruciate ligament about 472 N, and the posterior cruciate ligament at 920 Newtons.4 It could be stated that the ligaments are either ‘loose’ or ‘tight’, basically a binary solution. This is an important concept for today’s new technologies that have been introduced such as mechanical tensors and sensors that are able to define loads or displacements over very small margins. Grood, et al found that in extension, the overall varus/valgus laxity averaged 6.5°. The medial and lateral collateral ligaments provided about 50% of the constraint in extension, increasing to nearly 80% as the knee flexed. The cruciate ligaments were secondary stabilisers providing 14% of the constraint in full extension. Most other structures including the hamstring muscles, iliotibial tract, and posterior capsule were active only in extension. Whiteside performed numerous cadaveric studies with a novel test jig that could assess displacement or the effects of ligament stability throughout the range of motion under a constant load of 10 Newtons/metre and also had the ability to add a 1.5 Newton/metre rotational load.6-9 (Figure 2).

Figure 2 - Original ligament tensor rig developed for Dr Leo Whiteside, which has been updated with state of the art digital integration (image courtesy Dr William Mihalko, 2014)

The collateral ligaments were found to be important stabilisers in all positions. The anterior cruciate ligament was active primarily in extension providing about 3.5° of varus/valgus stability, while the posterior cruciate ligament was active primarily in flexion, providing about 3.5° varus/valgus of stability. Krakow, et al found that PCL absence created about 50% higher laxity in flexion10. These findings have important implications for different approaches that save or preserve the posterior cruciate ligament.

Figure 3 - Test setup for measuring ‘normal’ cadaver ligament gaps using a 10 newton/meter load and computer navigation for data acquisition (Von Damme)

Simply stated the tight check rein provided by the posterior cruciate ligament diminishes the potential for flexion laxity. This allows surgeons to use measured resection bone cuts (cruciate retaining knees) for the femoral anterior/posterior cut, despite the variability in anatomical variation into posterior condylar offset known to exist with these methods. Posterior cruciate sacrifice adds significant laxity to the flexion gap by removing the check rein that must carefully be accounted for. Insall and Ranawat recognised the importance of balancing the knee in extension and flexion as a guiding principle to prevent instability11,12. Gap balancing as was developed by Insall and Ranawat comes from the need to balance the medial and lateral collateral ligaments and then create bone resections that allow for rectangular symmetrical gap spaces in flexion and extension. Several distraction devices have been produced that measure in

flexion and extension reproducing a ligamentous tension between 70 and 180 Newtons23 et al. A recent ‘normal’ cadaver study using computer navigation by Von Damme, et al confirmed the typical kinematic features of ligament function by noting 2 to 3 degrees of laxity in extension which increased to six to eight degrees when measures in flexion with more laxity in the lateral compartment.13 (Figure 3). Recent clinical studies have looked at ligament stability of postoperative total knee patients in full extension measuring in the coronal plane14-20. These studies show medial and lateral laxity to be approximately four degrees or four millimetres. There was no difference in clinical outcome with choice of implants, surgical technique, cruciate retaining or sacrifice, or with the balancing method. This instability is lower than the Von Damme cadaver study mentioned earlier, which showed tighter stability in extension of normal knees.

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Figure 4 - Test setup for metrology validation of ligament gap repeated measures study evaluating a bone morphing software protocol used with computer navigation.(Stiehl)

Tokohura used MRI or shoot through radiographs to look at flexion instability and found that the flexion gap varied from 1-6 mm with asymmetric widening on the lateral side.21 23 Thompson, et al utilised an experimental model to assess ligament strain caused by abnormal femoral rotation using tissue tensioning techniques.24 When the femoral component was rotated up to 15° of internal rotation, which falls within the known range of clinical outliers, the strain in the superficial medial collateral ligament at 90° flexion increased to nearly 450 Newtons which we know is the failure point of this ligament.(Figure 5) Though theoretical, this study allows us to understand the painful consequences for the patient of a ligament that was abnormally balanced by poor implant

placement. Certainly, this explains one mechanism for clinical stiffness where the patient simply finds his knee too painful to bend. Matsumoto, et al investigated the effect of the extensor mechanism on ligament stability intraoperatively using a calibrated tensor that could measure gaps and forces through the range of motion.25 (Figure 6). Reduction of the patella and extensor mechanism produced increased stability at least with posterior cruciate retaining knees. Muratsu, et al used a tensor to assess the effect of prosthetic components on the gaps finding the posterior condyles significantly tightened the extension gap and caused almost 5° of flexion.26 Several recent studies have evaluated intraoperative ligament stability through the range of motion rather than static flexion or extension using either a mechanical tensor or computer navigation. Hino, et al found greater laxity overall

Figure 5 - Test setup for repeated measures study of ligament gaps distracted by simple tensor.

in posterior stabilised knees when examined with computer navigation which was particularly marked at 30° flexion.27 Minoda, et al used a mechanical tensor and showed similar patterns of instability through flexion.28 Assessing gap balance in extension or 90° flexion may not give the true picture of overall stability. Cross et al studied the effect of elevating the joint line on ligament stability in a model where there was a need to elevate the joint line.29 Notably, the higher

the joint line, the greater amount of mid-plane flexion laxity was seen. Additionally, other issues, posterior condyle offset, joint line position, distal femoral geometry, and ligament balancing methods may be relevant. Only by studying these additional variables may we find key factors that may lead to outliers in a given scenario. >>

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reflecting the weight of the leg. Small changes in gap distance of one to two millimetres caused dramatic changes in the ligament tension or the load applied to the surface of the instrumented insert (Figures 4 & 5).

Conclusions

Figure 6 - Data automated tibial tray sensor that measures range of motion, condyle contact point, and load, and is used for ligament balancing after trial component placement. (Courtesy Orthosensor, Fort Lauderdale, Fl)

Future Directions Several new tensor technologies have been presented. Mechanical devices are available that are designed to control the distraction of the gaps and to define the tilt of the asymmetrical gap using standardised tensions; using a new computer navigation system which can measure throughout flexion. We developed a bone morphing protocol that allowed precise gap measure of the medial and lateral gaps at each degree of flexion through the range of motion. We found that in cadaver knees there were significant differences in each specimen’s medial and lateral joint space gaps when comparing five degree flexion points through the range of motion. Additionally, there was high variability from specimen to specimen. All knees were tightest in full extension but became more lax after 10° of flexion. More importantly, we could find that choosing points of flexion at 0 degrees and 90 degrees did not always describe

the overall laxity ‘footprint’ for that cadaver.

Other recent technology includes the instrumented tibial insert (Verasys, Orthosensor, Sunrise, FL).31 which has demonstrated interesting results. Contact point, range of motion, and the applied load onto the device surface reflecting the ligament tension of the implanted devices can all be measured throughout movement on the operating table. Walker, et al studied cadavers with implanted total knee prosthetics using this device assessing a variety of surgical variables such as ligament tightness from prosthetic stuffing or abnormal bone cuts, femoral condyle offset and joint line elevations.32 The pretension status of a knee that had been ‘perfectly balanced’ clinically by a surgeon had a medial and lateral load of about 145 Newtons,

The medial and lateral collateral are the key ligaments to address with total knee surgical technique. They are the only ligaments structures that are key stabilisers throughout the full range of motion. If the posterior cruciate is retained measured resection techniques work well because of the tight check rein of the PCL controlling the flexion space. The surgeon must be concerned primarily with tibial slope and balance through the range of motion to prevent the ‘too tight’ or ‘too loose’ scenario in flexion. Posterior cruciate sacrifice creates significant flexion space laxity which is greater throughout the range of movement. Gap balancing using technology that carefully measures the flexion space after initial ligament balancing is more precise in creating the optimal construct. New, emerging technologies will help the surgeon understand these issues and make the best surgical choices. n

References 1. Fehring TK, Odum S, Griffin WL, Mason JB, Nadaud M. Early failures in total knee arthroplasty. Clin Orthop Relat Res. 2001 Nov;(392):315-8. 2. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Why are total

knee arthroplasties failing today. Clinical Orthopaedics and Related Research 2002; 404: 7-13. 3. Markolf K, Mensch JS, Amstutz HC. Stiffness and laxity of the knee- the contributions of the supporting structures. Journal of Bone and Joint Surgery 1976;58A(5):83-594. 4. Kennedy JC, Hawkins RJ, Willis RB, Danylchuk KD. Tension studies of human knee ligaments. Journal Bone and Joint Surgery 1976;58A:350355. 5. Grood ES, Noyes FR, Butler DL, Suntay WJ. Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. Journal of Bone and Joint Surgery 1981;63A(8):1257-1269. 6. Mihalko W, Whiteside LA, Krackow K. Comparison of Ligament-Balancing Techniques During Total Knee Arthroplasty. Journal of Bone and Joint Surgery 2003;85A(Supplement 4):132-135. 7. Saeki K, Mihalko WM, Patel V, Conway J, Naito M, Thrum H, Vandenneuker H, Whiteside LA. Stability after Medial Collateral Ligament Release in Total Knee Arthroplasty. Clinical Orthopaedics and Related Research 2001;392:184-189. 8. Kanamiya T, Whiteside LA, Nakamura T, Mihalko WM, Steiger J, Naito M. Effect of selective lateral ligament release on stability in knee arthroplasty. Clin Ortho Rel Res 2002; 404: 24-31. 9. Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA. Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Ortho Surg 2009; 17: 766-774. 10. Mihalko WM, Krackow KA. Posterior cruciate ligament effects on the flexion space

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in total knee arthroplasty. Clin Orthop Relat Res. 1999 Mar;(360):243-50. 11. Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis- report of 220 cases. J Bone and Joint Surg. 1979; 61A: 173-180. 12. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone and Joint Surgery 2005; 87A: 271-284. 13. Van Damme G, Defoort K, Ducoulombier Y, Van Glabbeek F, Bellemans J, Victor J. What should the surgeon aim for when performing computer assisted total knee arthroplasty. Journal of Bone and Joint Surgery 2005;87A:Supplement 2. 14. Matsuda Y, Ishii Y. In vivo laxity of low contact stress mobilebearing prostheses. Clinical Orthopaedics and Research 2004;419:138-143. 15. Ishii Y, Matsuda Y, Ishii R, Sakata S, Orrori G. Coronal laxity in extension in extension in vivo after total knee arthroplasty. J Orthop Science 2003;8(4):538-542. 16. Ishii Y, Matsuda Y, Noguchi H, Kiga H. Effect of soft tissue tension on measurements of coronal laxity in mobile-bearing total knee arthroplasty. Journal of Orthopaedic Science 2005;10:496-500. 17. Kuster MS, Bitschnau B, Votruba T. Influence of collateral ligament laxity on patient satisfaction after total knee arthroplasty: a comparative bilateral study. Arth Orthop Trauma Surg 2004;124:415-417. 18. Siston RA, Goodman SB, Delp SL, Giori NJ. Coronal plane stability before and after total knee arthroplasty. Clinical Orthopaedics and Related

Research 2007;463:43-49. 19. Song EK, Seon JK, Yoon TR, Park SJ, Gwon S, Hyeon J. Comparative Study of Stability after total knee arthroplasties between navigation system and conventional techniques.. Journal of Arthroplasty 2007;22:1107-1111. 20. Kobayashi T, Suzuki M, Sasho T, Nakagawa K, Tsuneizumi Y, Takahashi K. Lateral laxity in flexion increases the postoperative flexion angle in cruciate-retaining total knee arthroplasty. Journal of Arthroplasty 2012;27(2):260-265. 21. Tokuhara Y, Kadoya Y, Nakagawa S, Kobayashi A, Takaoka K.. The flexion gap in normal knees. Journal Bone and Joint Surgery (Br) 2004;86B(8):1133-1136. 22. Tokuhara Y, Kadoya Y, Kanekasu K, Kondo M, Kobayashi A, Takaoka K. Evaluation of the flexion gap by axial radiography of the distal femur. Journal Bone and Joint Surgery (Br) 2006;88B(10):1327-1330. 23. Nowakowski AM, Majewski M, Muller-Gerbl M, Valderrabano V. Developement of a force-determining tensor to measure ‘physiologic knee ligament gaps’ without bone resection using a total knee arthroplasty approach. Journal of Orthopaedic Science 2011;16:56-63. 24. Thompson J, Hast MW, Granger JF,Piazza SJ, Siston RA. Biomechanical Effects of Total Knee Arthroplasty Component Malrotation: A Computational Study. Journal of Orthopaedic Research 2011;29:969-975. 25. Matsumoto T, Muratsu H, Kubo S, Matsushita T,Kurosaka M, Kuroda R. Soft Tissue Tension in Cruciate-Retaining and Posterior-Stabilized Total

Knee Arthroplasty. Journal of Arthroplasty 2011;26(5):788-795. 26. Muratsu H, Matsumoto T, Kubo S, Maruo A, Miya H, Kurosaka M, Kuroda R. Femoral component placement changes soft tissue balance in posterior-stabilized total knee arthroplasty. Clinical Biomechanics 2010;25(10):926-930. 27. Hino K, Ishimaru M, Iseki Y, Watanabe S, Onishi Y, Miura H. Mid-flexion laxity is grater after posterior-stabilized total knee replacement than with cruciate-retaining procedures. A computer navigation study. Bone and Joint J 2013 April; 95-B: 493-497. 28. Minoda Y, Iwaki H, Ikebucchi M, Hoshida T, Nakamura H. The gap flexion gap preparation des not distrub the modified gap tecnique in posterior stabilized total knee arthroplasty. The Knee 2012. 29. Cross MB, Nam D, Plaskos C, Sherman SL, Lyman S, Pearle AD, Mayman DJ. Recutting the distal femur to increase maximal knee extension during TKA causes coronal plane laxity in mid-flexion. Knee 2012; 19: 875-879. 30. Stiehl JB. Validation and assessment of computer navigated ligament balancing in total knee arthroplasty. Clinical Orthopaedics and Related Research 2014; Invited submission. 31. Golladay G, Gustke K, Elson LC, Anderson CR. Intraoperative sensors for dynamic feedback during soft tissue balancing: preliminary results of a prospective multicenter study. American Academy of Orthopaedic Surgeons Annual Meeting

32. Walker PS, Meere P, Bell CP. Effects of surgical variables in balancing total knee using instrumented tibial trial. The Knee 2014; (ahead of publication) The author’s disclosures are as follows: Blu Ortho, SAS (stock holder); Zimmer, Inc.(royalties); Kinamed, Inc.(royalties); Innomed, Inc.(royalties); The Knee(Editor-InChief-stipend) Correspondence: James B. Stiehl, MD 1054 Martin Luther King Drive, #226 Centralia, Illinois 62801 Email: jbstiehl@me.com

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Peer-reviewed Articles Obituaries

Paul Harald Osterberg: 28 October 1926 – 25 June 2013

active association that drew its membership from the whole island of Ireland. He served on the Council of the British Orthopaedic Association. A sociable and approachable man, he continued his medico-legal practice well after retirement, and his opinion was well respected in legal circles.

By James Nixon & Vanessa Larmor (née Osterberg) Born in Copenhagen, Paul spent his early years in New York before his father’s civil engineering career brought the family to Ireland. His father, Harald, also served as Consul General for Denmark in Ireland. He received his schooling at St Columba’s College, Dublin, and started undergraduate civil engineering education in Trinity College Dublin aged 17. He enlisted as a volunteer in the British Army three days after his 18th birthday in 1944, stating that he was determined to fight to restore freedom to Denmark. Commissioned as Lieutenant in the Buffs, and attached to the Royal Artillery 1944 to 1947, he served in Palestine. He then decided to study medicine, and qualified from Trinity in 1953. He married Valerie Goodbody a year earlier. His early postgraduate training was in Sir Patrick Dun’s Hospital Dublin, and later in the Royal Victoria and Musgrave Park Hospitals, Belfast when he

opted for a career in orthopaedic surgery. Here he was influenced by Sir Ian Fraser and RJ (Jimmy) Withers. Specialist orthopaedic training took place at the Royal National Orthopaedic Hospital London, where he came under the influence of Sir Herbert Seddon. Appointed Consultant in 1965 to the Royal Victoria and Musgrave Park Hospitals, he also had an appointment to the Northern Ireland Orthopaedic Service, through which he and orthopaedic aftercare sisters provided a visiting orthopaedic service to the people of Fermanagh in the west of the province. Paul continued to provide this service up to his retirement. Throughout his consultant career he enjoyed being a generalist, and was less comfortable with increasing sub-specialisation. He was one of a small group of orthopaedic surgeons in post in Belfast at the outbreak of the civil disturbances in 1969, and he and his colleagues provided care, and developed surgical techniques

Paul Harald Osterberg

to treat all patients, irrespective of their allegiances. He enjoyed the multi-professional and personal side of medicine, so evident in Ulster. He became Visiting Professor at Pahlavi University, Iran 1976, and he and Valerie drove overland to take up this post. He was the founding President of the Irish Orthopaedic Association, and helped transform the Irish Orthopaedic Club into an

John Mark Hamilton Paterson: 21 January 1954 – 15 October 2013 By Matthew Barry When Mark Paterson passed away, paediatric orthopaedics was left with a void that will be very difficult to fill. He was a champion for the disabled child and in his last public speech in June 2013 on “The cost of childhood disability,” he made a passionate and moving case for proper funding for the disabled child. Born in 1954 in Hong Kong, his father and grandfather were medical missionaries in China. His father was a surgeon with an interest in cleft lip surgery and later a medical administrator, ending his career as the medical superintendent at the United Christian Hospital, Hong Kong. Mark’s schooling was in Hong Kong and then London and he qualified from the Middlesex Hospital in 1977. After house jobs, he spent a year in Papua New Guinea as a medical officer. On his return, he started his surgical

training and finished as a Senior Registrar at The London Hospital and The Royal National Orthopaedic Hospital. Mark developed an interest in children’s orthopaedics and spent some time on a fellowship in San Diego (sponsored by The Spastics Society). Mark was appointed to The London Hospital in 1990. When appointed, Brian Roper was providing a children’s orthopaedic service and fairly quickly, Mark dropped his adult practice and took over all elective children’s orthopaedics. The theme of the January 1992 meeting of the British Society of Children’s Orthopaedic Surgery held at the London Hospital was “Neuromuscular”. This was the impetus that Mark needed to switch to a full time paediatric orthopaedic practice with a particular interest in neuromuscular disability. This change in Mark’s

John Mark Hamilton Paterson

practice very much mirrored the development of Paediatric Orthopaedics as a sub-specialty in its own right and he was at the forefront of this specialisation. As well as an expanding surgical practice with children referred to him from a wide area of the south-east of England, Mark was a superb organiser and administrator – it was in his genes. He was clinical lead for the orthopaedic service from 1992 to 1997 and,

Happily settled in Ulster, he and Valerie created at the Old Manse in Hillsborough a celebrated garden, which they continued to develop throughout their lives. He inherited his father’s love of sailing and the sea, and this stretched back several generations of the family in Denmark, his grandfather having been in command of the Danish Lighthouse service. Paul owned a series of elegant sailing boats, and continued sailing with friends in Scandinavian, Scottish and French waters to the end. Throughout their married life, and into retirement in 1989, he and Valerie loved to travel, usually by car. However he was well-known as an erratic driver, with a tendency when talking to ignore traffic lanes and signals. Pre-deceased by Valerie, he leaves two daughters and four grandsons.

during that time, he directed the merger of The London and Saint Bartholomew’s orthopaedic departments. With his charm, wit and tenacity, the two services merged with minimal tears and tantrums. He organised and ran numerous courses on Cerebral Palsy, he was Secretary to the British Society for Surgery in Cerebral Palsy and the British Society of Children’s Orthopaedic Society. He was president of the orthopaedic section of the Royal Society of Medicine and he was closely associated with a number of charities including SCOPE, WhizzKidz and the Foundation for Relief of Disabled Orphans. Mark Paterson was a superb clinician, a compassionate doctor who cared very much for the disabled child, an educator, a source of wise opinion and a valued colleague. He will be greatly missed by all but hopefully, his wife Sarah and their two sons, Jamie and Luke can take some comfort in the knowledge that Mark was a true giant.

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