Journal of Trauma & Orthopaedics – Vol 5 / Iss 4 by British Orthopaedic Association

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 05 / Issue 04 / December 2017 boa.ac.uk

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Read the News and Updates section for the latest from the BOA and the orthopaedic community

In our Features section you will find articles that focus on Elective Care Reviews, ISCP and Curriculum update, NJR’s transparency and accountability systems and Scaling Up HIP QIP

For the latest updates on our clinical issues, see our Subspeciality section; the focus of this issue is oncology

News & Updates ––– Pages 02-19

Features ––– Pages 20-55

Subspecialty Section ––– Pages 56-65

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From the Editor

Contents

Phil Turner As we approach the end of 2017 we face a world of uncertainty. The Christmas break is a time for reflection and also a time for looking forward. I hope that the articles we publish give some reasons for optimism. The BOA Annual Congress in Liverpool reflected the breadth and diversity of our profession. Our reporters clearly took inspiration from their positive experiences and I hope that Congress 2018 in Birmingham is even bigger and better. Two of the greatest challenges to a career in our specialty are selection and the Intercollegiate Examination. Applicants for ST3 posts should be reassured by the transparency of the process outlined by Lawrence Moulton. The examination is a particular challenge to those who are not working in a recognised training scheme. Kebba Marenah gives some sound advice on how to overcome this hurdle.

The orthopaedic curriculum has been criticised for being too centred on process and ticking boxes. We hope that the new version due for publication in August 2018 will correct this by focusing on a trainee’s capabilities and the expert trainer’s judgment on progression. Lisa Hadfield-Law explains the changes. Our clinical articles look at two areas of concern and controversy. Spinal surgery is under the microscope as never before. Lee Breakwell and Michael Foy explain the particular problems this specialty is facing. The anxiety of dealing with potential malignant disease is never far away from our minds whatever our subspecialty interest. Paul Cool as our guest editor covers soft tissue sarcoma, metastatic bone disease and primary bone tumours in a way that is relevant to all of our readership. In this issue we publish the obituaries of two of the giants of contemporary arthroplasty practice. Whilst it is sad to report the passing of Robin Ling and Michael Freeman, we should take heart and inspiration from their drive, innovation and leadership. Finally, we have the distraction of our Christmas quiz to test you and your family. I also take this opportunity to thank Fred Robinson for his enthusiasm, skill, knowledge and support as our co-editor over the last two years. With very best wishes for the New Year from me, Fred and the JTO Team.

JTO News and Updates

02–19

JTO Features

20–55

Elective Care Reviews

The HIP QIP Scaling Up Programme

Supporting SAS Surgeons in Career Development

What you need to know about the new T&O Curriculum 28 Using National Audit Data to Drive Greater Patient Safety and Quality of Care for Joint Replacement Patients 30 Operations I no longer do... Harvest bone from the iliac crest

How I Do... Whither (wither?) Spinal Surgery

JTO Festive Fun Quiz

Relevance of the BOA in Scottish T&O

The Evolution of Trauma Courses in European Practice 40 The Key Issues and Current Health Landscape in India

The Implementation of Rota Changes to Optimise Training Opportunities in the East of Scotland

Review of the AO Trauma Seminar: Introductory Seminar for Foundation Doctors and Undergraduates 46 An alternative route to passing the FRCS: A non-trainees perspective

ST3 National Selection, a look behind the scenes

Loss of malpractice insurance for spinal surgeons: why you need to know about the discount rate

Subspecialty Features

Soft Tissue Tumours – Diagnosis and Pitfalls

56–65 55

Controversies in the Management of Metastatic Bone Disease

Malignant Primary Bone Tumours

In Memoriam General information and instructions for authors

66–70 72

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JTO News and Updates

From the President Ananda Nanu I think that you will all agree that we are living in most interesting times. I never remember myself a time in which our history was so full, in which day by day brought us new objects of interest, and, let me say also, new objects for anxiety. This extract is from a speech by Joseph Chamberlain in 1898, and is thought to be the origin of the apocryphal Chinese curse “May you live in interesting times”. Well, the times are certainly that.

The BOA 2017 Congress in Liverpool was attended by almost 2,000 delegates, and our membership now stands at 4,843. Browsing through the pictures on the BOA website available at congress.boa. ac.uk/2017-congress-gallery, it was wonderful to see so many young and enthusiastic faces, and the buzz in the circulating areas was a sign of a healthy and invigorated polity. All credit for the organisation of the course go to the BOA Senior Management team, who put on the largest Congress to date. Deborah Eastwood, our Honorary Secretary organised the programme with help from our specialist societies.

Ananda Nanu

Since the Congress we are faced with continuing restrictions on access to musculoskeletal services. The state of the economy,

the budget cuts and the uncertainties engendered by the looming Brexit have put us in the invidious position of having to prioritise care. There are several ways to do this, but the least acceptable is to restrict care based on arbitrary cuts to achieve short-term savings, especially those targeting hip and knee replacements by labelling them procedures of limited clinical value. Further to our letter to all members on 30th January 2017 available on the website at www.boa. ac.uk/publications/boa-letterto-the-times-rationing-of-hipknee-replacements-30-01-17, we have heard back from the CCG with an anodyne response abdicating responsibility. This is disheartening, especially as I have heard back from several of our home fellows indicating that this disease is endemic with outbreaks

in Shropshire CCG, Surrey, Merton and Sutton CCGs and Worcestershire CCGs. Hip and knee replacements are two of the procedures we perform that have the best cost utility analyses as measured by QALY. For those of you who are airily informed that you are performing too many procedures of limited clinical benefit I append references below to help refresh the information you may wish to pass on to your local CCG mandarins. What I find particularly difficult to reconcile is the token medical person who is used to front such initiatives. Perhaps anyone who has passed through medical school on the way to an administrative post should reflect on the harm this is causing to a hapless population. I would urge our membership to write to me with specific restrictions in your areas, so we can liaise and support the continuing free access to appropriate surgery for our population. n

References 1. Clement, N. D., et al., ‘Predicting the costeffectiveness of total hip and knee replacement’, BJJ, VOL. 95-B, No. 1, 2013, 115-121 2. Dardennes, Charles, et al., ‘Health-Related Quality of Life in Total Hip and Total Knee Arthroplasty’, BJJ, VOL. 86-A, No. 5, 2004, 963-974

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John Skinner - Incoming Honorary Treasurer I am currently Professor of Orthopaedic Surgery and a Consultant at the RNOH Stanmore with an interest in complex arthroplasty and tumour surgery. I am married with three children. I was an ABC Travelling Fellow in 2004 and President of the British Hip Society in 2014-15. My research interests are many, but I am best known for my work on metal on metal hip replacements and the London Implant Retrieval Centre which I set up ten years ago with Alister Hart.

John Skinner

At Stanmore, through the years, I have chaired the Infection Control Committee for 13 years,

the Medical Staff Committee for five years and have sat on the Local Research Ethics Committee for six years. I chaired the BOA and MHRA Advisory Committee on metal hips from 2008 and gave evidence, under oath, to the FDA on this subject in 2010. I am on the Editorial Board of the Bone and Joint Journal and have been Treasurer of the Seddon Society, which is the Alumnus Association of the Royal National Orthopaedic Hospital for 16 years. I am on the Executive Committee of the BOA, and

have been appointed Honorary Treasurer in January 2018. It is an honour to take this role and I look forward to joining the strong Financial and Leadership teams at the BOA. The current political climate makes these challenging times for orthopaedics, but the BOA is in great shape as it enters its Centenary Year. I have enjoyed contributing to the Executive discussions and our role of caring for patients and supporting surgeons has never been more relevant. n

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JTO News and Updates

The New BOA Trustees (2018-2020) Peter Giannoudis

Rhidian Morgan-Jones

International level (Chair AO Davos Courses, Polytrauma, Masters and Limb Salvage). Moreover, I host six courses/ masterclasses annually in Leeds focusing on fracture fixation, surgical techniques, and surgical approaches.

Peter Giannoudis

I am the Professor of Trauma and Orthopaedic Surgery at the University of Leeds. My clinical work is focusing on the management of patients with multiple injuries, pelvic and acetabulum reconstruction, upper and lower limb fractures and post fracture fixation complications amongst others. My research portfolio is diverse with active involvement in clinical trials. I am the author of 600 peer reviewed publications and editor of ten orthopaedic textbooks. I am actively involved in education at the National and

Throughout my career, I have served in a number of positions of responsibility including President of the British Trauma Society (BTS), President of the European Society of Pelvis and Acetabulum (ESPA), International Chair Orthopaedic Trauma Association (OTA), President Elect of the European Society Tissue Regeneration in Orthopaedics and Traumatology (ESTROT), Clinical Director of Trauma Services in Leeds, Executive Member EFORT Trauma Education Committee and Editor in Chief of the Injury Journal. I have contributed to the evolution of trauma services in Britain with my work on the BOA National Trauma Committee, expert group for NCEPOD report 2007 (Trauma: Who Cares?) and advisory member of NICE. During the past five years, I have delivered over 100 international lectures promoting British Orthopaedics and establishing international connections worldwide which are invaluable to further promote and establish links with other associations. n

albeit within my increasingly niche sub-speciality. I have had the pleasure of founding and running national knee/ infection meetings from which I continue to learn from my peers. A personal philosophy, when possible, has always been to organise crossspeciality meetings, which broadens oneâ&#x20AC;&#x2122;s perspective and heightens respect for colleagues in other medical and non-medical areas. The ability to network and coerce friends to help is perhaps a strength.

Rhidian Morgan-Jones

I trained in Cardiff at the University of Wales College of Medicine as it was then, qualifying in 1989. I returned as a Consultant in late 2000. My training rotation was between Oswestry and Stoke-on-Trent and included fellowships in Johannesburg and Sydney. Since my appointment, I have specialised as a revision knee surgeon with an interest in infection, a field which remains both challenging and rewarding, although not always in equal measure. I have a strong interest in education at all levels and continue to lecture widely,

My research interests reflect my clinical practice, combining revision knee replacement and prosthetic joint infection. In these two areas I feel we are progressing but have so much more to learn. Increasingly, I enjoy collaborative research with surgeons and units both within the UK and internationally. I have three children, Myfanwy 21, Ioan 19 and Bronwen 16 who will be delighted to have their names in print. They remain the best grounding a surgeon can have. I am proud of them all. I am honoured, and still surprised, to have been elected as a BOA Trustee. I hope to serve the membership in any way I can and reflect the pride I have in being part of the orthopaedic community. n

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Hamish Simpson

Duncan Tennent

and infectious diseases colleagues. After many happy years in Oxford, I moved to Edinburgh to take up a fulfilling post as head of the academic department.

I have been the education Chair for BESS and the undergraduate education lead for the BOA. I am currently on the SAC and Treasurer of BESS. I am also the Director of Education for the South West London Elective Orthopaedic Centre as well as being a Reader in Orthopaedic Education at St George’s Medical School.

I am currently President of the Combined Services Orthopaedic Society and previously have been President of BLRS, APOS and BORS, and have been Chairman of SCOT.

Hamish Simpson

I am Professor of Orthopaedics and Trauma, and Consultant Orthopaedic Surgeon in the Department of Orthopaedics and Trauma at the University of Edinburgh, specialising in limb reconstruction, musculoskeletal infection and paediatric deformity. I was trained in Cambridge, Oxford, Bath and Gloucester. I carried out fellowships in Toronto and with Ilizarov in Kurgan, before taking up post as Reader and then Professor of Orthopaedics in Oxford, where I was fortunate to be mentored by Professor John Kenwright. In Oxford, I ran the limb reconstruction unit and established the bone infection unit in collaboration with microbiological

I have a strong interest in training and have sat on the SAC and currently Chair the T&O Scottish Training Improvement Group (TOSTIG). Having completed my term as examiner on the intercollegiate board, I now examine for the FRCS (Trauma and Orth) in Hong Kong. I am keen to help trainees carry out higher degrees and have supervised over 50 successful doctoral theses. I have research interests in stem cells for musculoskeletal repair, musculoskeletal infection, novel cutting methodologies and impaired bone healing. Consequently, I have been awarded Hunterian and King James IV professorships by the English and Edinburgh colleges respectively. I have research interests aimed at optimising patient outcomes and have run multiple multicentre studies to help achieve this. I am married to Helen and we have a daughter, three sons and a dog. I am honoured to be elected and look forward to serving you as a BOA trustee. n

Duncan Tennent

I qualified from St. Bartholomews Hospital in 1992 and after SHO jobs at the Royal Free and the RNOH registrar rotation, I spent a year in Virginia on a sports fellowship discovering what you can do with an arthroscope. After another short stint at Stanmore I was appointed as a Consultant with a special interest in shoulder and elbow surgery at St Georges Hospital in 2003. I was fortunate to have fantastic mentors including Paul Calvert, Deborah Eastwood and Ian Bayley who taught me so much about teaching and training.

Being involved in education from undergraduate to fellowship I see all of the difficulties that arise from all the different pressures. I’m also lucky enough to be able to see the innovative work that individuals and organisations are doing. How we train has to evolve and I very much enjoy being a part of this process. I am fortunate to have very supportive colleagues in an excellent department which enables me to spend some of my time doing all this work and I’m looking forward to the next three years helping to shape the education of the future. n

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JTO News and Updates

BOA Latest News Procedures of Limited Clinical Value (PLCV) in Derbyshire BOA President, Ananda Nanu, wrote to members to bring their attention to a commissioning policy that is being introduced in the Derbyshire area with Erewash, Hardwick, North Derbyshire and South Derbyshire CCGs defining hip and knee arthroplasty as â&#x20AC;&#x2DC;Procedures of Limited Clinical Valueâ&#x20AC;&#x2122;. The CCGs are instructing clinicians to hand out information to patients that describes these procedures using this term. In response the BOA wrote a letter to state that it is absolutely unacceptable to ask clinicians to distribute leaflets to patients on this basis and to ask for the rationale behind considering hip and knee arthroplasty interventions in this category. In order to address this ongoing issue, the BOA will be monitoring the potential implementation of these policies and is engaging with national bodies, CCGs, the press and locally, through its Regional Advisers and Clinical Champions, to ensure that these issues are brought to light and strongly opposed. Members are urged to get in contact if a similar issue arises in your unit, Trust or CCG by emailing policy@boa.ac.uk. A copy of the letter sent to the Derbyshire CCGs is available online at www.boa.ac.uk/publications/boa-response-to-derbyshire-ccgs-proceduresof-limited-clinical-value-05-10-17.

Revised commissioning guides published We are pleased to announce the recent publication of four revised commissioning guides with the Royal College of Surgeons of England. These NICE-accredited guides set out best practice care pathways to assist CCGs in designing optimal care for their populations. We are extremely grateful to all those involved in the rigorous development and accreditation processes. The guides are: l Pain Arising from the Hip in Adults l Painful Deformed Great Toe in Adults l Painful Osteoarthritis of the Knee l Treatment of Carpal Tunnel Syndrome

Following the recent BOA and ARMA position statements on the rationing of elective orthopaedic services, the BOA urges members and wider stakeholders to consider these guides and to promote their adoption wherever appropriate with local CCGs. Available online at www.boa.ac.uk/ pro-practice/commissioning-guides.

Training Orthopaedic Trainers (TOTs) Course The Training Orthopaedic Trainers (TOTs) course will be held from 9th-10th January 2018 at the BOA offices in London. The TOTs course was established to improve the standard of teaching for those in T&O training and practice. The basic premise of the course is that if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. If you are interested, please visit www.boa.ac.uk/events/training-orthopaedic-trainers.

New screencasts Better Supervisor Reports Supervisors are struggling under the burden of writing trainee reports. However, these reports are pivotal to ARCP panel decisions. The BOA have found ways to make the process of writing such reports easier and quicker. You can watch the screencast at www.boa.ac.uk/orthopodcast/better-supervisor-reports. Cauda Equina Syndrome Cauda equina syndrome if not picked up early, can result in serious and debilitating consequences. Aprajay Golash, a neurosurgeon, and Niall Eames, a T&O surgeon, on behalf of the British Association of Spinal Surgeons explore ways of recognising and dealing with this critical condition, early and effectively. You can watch the screencast at www.boa.ac.uk/orthopodcast/cauda-equina-syndrome.

Wikipaedics

The project is moving forward with great pace. The Basic Science and Hip sections have now been finalised by Out of House Publishing, our specialist medical copy-editors. The sections currently under review are: Spine, Elbow, Shoulder, Sports, Clinical Examination and Rheumatology. The Wikipaedics Steering Group held a Trainee Focus Group at the BOTA annual conference in Manchester on Friday 17th November 2017. The aim of the meeting was to receive feedback from trainees on different case-based formats.

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Hip Fracture Review Training Day

UK and Ireland In-Training Examination (UKITE)

POSTPONED TO: Wednesday 23rd May 2018

From this year, the UKITE will be hosted on the BOA Learning Hub, our new training and education platform supported by Moodle Learning Management System. All deaneries in the UK and Ireland, as well as South Africa, will be sitting the UKITE from 4th-11th December. We have also reached out to China, Egypt, Thailand, Tanzania and Zambia who have all shown interest. For information regarding the UKITE, please contact ukite@boa.ac.uk or visit the website www.boalearninghub.com.

Venue: De Vere Venues, Colmore Gate, Birmingham Attendance: Free

The Hip Fracture Review Training Day is open to Orthopaedic Consultants, Anaesthetists, Orthogeriatricians and Nurses involved in Hip Fracture Care, and who are interested in taking part in multidisciplinary reviews of Trusts whose NHFD data show an above expected mortality rate for patients. The aim of the day is to understand the BOA’s coordinated hip fracture review process, reflect on the reviews undertaken to date and consider future directions. For further information and to register please visit www.boa.ac.uk/pro-practice/multidisciplinary-hip-fracture-review. For any enquiries please contact Natasha Wainwright on n.wainwright@boa.ac.uk.

Position statement on ‘emerging technologies for collecting patient data’ We published a position statement on ‘emerging technologies for collecting patient data’, in response to a number of emerging companies and products that are aimed at collecting data as part of the patient journey through surgical treatment. These include companies interested in capturing PROMs and rehabilitation and recovery data. Some of these companies or products are marketed directly to patients themselves, and some target clinicians, encouraging them to use the tools with their patients. Individual clinicians who are considering using such a product, are advised that they have a duty to undertake their own due diligence, including asking: Is the product intended to collect patient-identifiable data? What are the stated aims of the product? Do you know anyone else using the product or can you find out anyone else who is using it? And, is the company wanting you to back their product and become involved in marketing it to other potential customers? Available online at www.boa.ac.uk/publications/emerging-technologiesfor-collecting-patient-data-08-09-17.

Never Events - BOA response The BOA responded to an article in the Telegraph which reported that during April 2016 and March 2017 there were 424 reported Never Events including 49 wrong implants or prostheses of which 24 were incorrect hip or knee implants. In response, the BOA supported and advised on a root-cause analysis of these events and encouraged the use of the reporting structure of the NHS to ensure there is full and open discussion of these events as a multidisciplinary team review. Despite the Telegraph’s claim that Never Events are at “near record levels”, the BOA noted that the number is broadly consistent with the previous year (when 442 cases were reported), according to the provisional data. Available online at www.boa.ac.uk/publications/response-to-neverevents-07-09-17.

Submissions for the BOA Medical Student Essay Prize 2018 are NOW OPEN This year, medical students are invited to submit an essay (no longer than 1000 words) on “What Differentiates the Qualities of a Good Orthopaedic Surgeon from those of a Great Orthopaedic Surgeon?” Please submit your essay to policy@boa.ac.uk by Wednesday 28th March 2018. For any further information on this prize, please visit the BOA website www.boa.ac.uk.

For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.

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JTO News and Updates

ABC Fellowship We are pleased to inform you that we have selected four Fellows: Paul Baker, Arul Ramasamy, Nemandra Sandiford and Phil Walmsley to visit host centres of excellence in the USA and Canada on our prestigious ABC fellowship in 2018. The ABC Fellowship is an excellent opportunity for BOA members to gain invaluable skills through international travel. More information on BOA Fellowships is available at www.boa.ac.uk/training-education/fellowships.

BOA (Andrew Sprowson Management of Infection Award) Travelling Fellowship Usman Ahmed

Helios ENDO-Klinik

I utilised the BOA Travelling Fellowship Award to visit the ENDO-Klinik in Hamburg, Germany. I spent one week in July 2017 at this renowned centre and was able to pick up several key skills that I would like to bring into my routine practice. The set-up for the management of prosthetic joint infections (PJI) is immensely focused. The ENDO-Klinik aggressively implements basic principles of management from the changing rooms through to peri- and post-operative care. The multidisciplinary team is decisive and there is a fantastic sense of collegiality and shared vision. Finally, the service itself is rapid and runs like clockwork. The culture is goal-oriented so individuals and teams can get on with the necessary tasks to facilitate smooth running of the theatre unit. There are many features which I believe will be of value in the NHS. Overall, the experience of five tremendous days has given me a lot of material to reflect on as I continue my training in the UK. I would like to thank Professor T. Gehrke and Dr Akos Zahar for inviting me, and the BOA for facilitating this trip.

Usman Ahmed (right) with Dr Akos Zahar (left) at The ENDO-Klinik, Hamburg, Germany

Why commercial medical indemnity is the future “Some clinicians are slightly nervous about moving from a medical defence union (Mutuals) to commercial insurance. But with so much discussion around discretionary indemnity provided by Mutuals, I am convinced that commercial insurance is the future.” The foundations of Bespoke Medical Indemnity Passionate about sports and with early ambitions of a career in football. Andy moved into medical indemnity insurance after a 16-year career in medical recruitment and technology in 2010.

“I was on the board of Finsbury Orthopaedics – a global distributor of orthopaedic implants – at the time, and I started advising surgeons on business development. This is when I realised the medical indemnity insurance market was changing.” Armed with this knowledge, Andy founded his company and has many satisfied clients which are in no small part due to his specialist market knowledge and exceptional communication skills. “Understanding the challenges faced by clinicians, and being able to articulate it to underwriters, is essential.” says Andy. These challenges include having a thorough understanding of the potential risks faced by consultants in private practice. Many clinicians work in a variety of situations, mixing private work with the NHS, and many rely on the medical defence unions to provide cover. However, this cover is not always adequate to cover all aspects of a consultant’s work, and Andy has seen many clinicians opt for commercial insurance instead.

The future of indemnity So, what does the future hold? With indemnity costs continuing to rise on a yearly basis and private medical insurers pushing fees down, clinicians can benefit from looking for cover outside of the traditional medical defence union avenues. “I really enjoy interacting with clinicians, trying to make it easy for them to practice,” says Andy. “And at Bespoke Medical Indemnity we recognise that affordability is a challenge for clinicians trying to participate in private practice.” How can Andy & Bespoke Medical Indemnity help? Taking care of your medical indemnity not only helps to reduce your fixed costs, but also provides contract-certain cover that protects you and your family. Bespoke Medical Indemnity can offer medical indemnity insurance advice and solutions to consultants whatever your speciality or workload, with a personalised approach to help you find the best deal for your practice.

“The service has been a pleasure to deal with... and saved me a substantial amount of money.” Consultant Orthopaedic Surgeon, London

Contact Andy today for a no-obligation discussion about how he can help you with your medical indemnity cover.

Tel 020 7998 3424 I Mob 07747 624080 I Email andy@medmal.co.uk I Web bespokemedicalindemnity.co.uk

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JTO News and Updates

BOA Congress Reviews Cass Kellett, Consultant Orthopaedic Surgeon at the South West London Elective Orthopaedic Centre

Cass Kellett in a session at the BOA Congress

The BOA Congress gets bigger and better every year. I enjoyed returning to the venue, familiarity makes travel and navigation easier. The redeveloped Liverpool docks area is ideal, with many good restaurants within walking distance. This yearâ&#x20AC;&#x2122;s Congress App helped me to plan which sessions to attend, mark them in my schedule and sit back and relax while my phone told me where to go!

The App even allowed me to connect with and arrange to meet colleagues for coffee. Indeed, this is one of the benefits of the new, larger Congress attendance; there are more colleagues, old and new, to meet and with which to exchange ideas and news. As much learning seemed to take place during coffee and the drinks reception as it did during the enormous variety of sessions, which catered for every specialty. It was good to see a diverse range of nonspecialty sessions - BOTA on Hammer it out; the Combined Services Orthopaedic Society on terrorist attacks, a sad but relevant reflection on recent events; simulation, with a very high standard of research. There were also superb presentations from all, from the seniors - the Carousel Presidents - to the juniors - medical students presenting amazing research and forming their own BOA Medical Student Group. The guest lectures were fantastic, the lecturers, hard work and clarity of thought were impressive. Finally, Phil Hammond amused us greatly with his history of the NHS, which reminded us why we were there â&#x20AC;&#x201C; to constantly try to improve orthopaedics for our patients.

BOA Welcome Drinks Reception

Many thanks to the BOA team and Liverpool for another great Congress. See you next year!

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Peter S E Davies, Trainee The Annual BOA Congress took place at the ACC Liverpool in late September, with almost 2,000 delegates, ranging from medical students to consultants. The City of Liverpool was the European Capital of Culture in 2008 and the legacy of this was clear to see, with a decade of investment. The Congress offered a packed programme of educational content, with ample opportunity to meet with industry, partners and colleagues. I divided my time between educational sessions, manning the BOTA stand and working with my colleagues in organising the BOTA Educational Congress. Over 250 delegates attended the BOTA Congress in Manchester this November, making this the biggest BOTA meeting ever!

The industry area was huge and I cannot recall a company which was not represented. Many hours could be spent browsing and discussing anything from implants to textbooks. As usual, many were drawn to the stands touting free coffee and food! The poster displays offered a couple of hours of entertainment and inspiration. The City of Liverpool offers a vast array of restaurants, bars and other amenities which kept the delegates entertained in the evenings. The large waterfront footpath also provided the perfect setting for a morning run to burn off the extra calories from the night before! The Congress was a fantastic week of education and entertainment which clearly took a significant amount of organisation and planning. I look forward to Birmingham 2018.

Jan Willem K Louwerens speaking at the Presidents Guest Lecture

Geoffrey Lee, Student After a year away, the BOA 2017 Congress returned to the bustling city of Liverpool, with its crisp ocean air and outstanding ACC venue. With many parallel sessions there

was an abundance of learning options. It was excellent to hear updates on the latest advances and challenges in orthopaedic clinical practice, research, and training.

In particular Prof Matt Costaâ&#x20AC;&#x2122;s Hunterian Lecture about the relevance and necessity of multicentre clinical trials followed by the discussions at the Trainee Research Collaborative Meeting

was indicative of a progressive vision and a practical way forward for even more robust clinical trials. Yet I think the most memorable session for all was probably the drinks reception! It was good to see a strong attendance at all talks and the free paper sessions demonstrated the depth of talent and wide interests in the British Orthopaedic community, with trainees reporting on experiences from various far-flung places call-out to Dr Rebecca Mills for her epic Antipodean journey! Lastly from a studentâ&#x20AC;&#x2122;s perspective, it was excellent that registration was complimentary for BOA members. I would encourage other students to make use of this opportunity and the BOA to continue with this positive policy.

Matt Costa speaking at the Hunterian Lecture

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JTO News and Updates

BOA Membership Update New BOA members benefit for 2018! We are pleased to offer the first 100 new BOA members of 2018, 50% off the BJJ and BJ360, this includes print and online copies. Please share this offer with your colleagues. To apply for BOA membership, please complete the online application form www.boa.ac.uk/ membership/join-today. For further information visit the membership page www.boa.ac.uk/membership/ categories-and-subscriptions.

FINAL PLACES REMAINING! BOA Instructional Course 2018 6th-7th January Macdonald Hotel, Manchester Register now for Januaryâ&#x20AC;&#x2122;s Instructional Course and join fellow Trauma and Orthopaedic trainees preparing for their FRCS examination. This is an outstanding opportunity for you to not only gain a number of Case Based Discussions (CBDs) in a range of topics, but also network and attend lectures delivered by expert clinicians. Take a look at the 2018 provisional programme and register before the places go! Please visit www.boa.ac.uk/events/instructional-course.

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Thinking of the future? Leave a legacy Whether you’re someone who is suffering from a musculoskeletal disorder or whether your life’s work is helping those who are suffering; you can really make a difference. Once you have considered your immediate friends and family; please consider leaving a lifechanging gift to Joint Action (the orthopaedic research appeal of the BOA). No one likes to think about their own passing, but just a short time spent talking to a solicitor or professional Will writer and sorting out your affairs will safeguard your family’s future. By writing a Will you can decide how your estate is divided between loved ones, and if you wish you can leave part of your estate to a charity.

By choosing Joint Action you are able to affect the lives of so many people suffering from musculoskeletal disorders throughout the UK. Your choice of orthopaedic research means you believe in helping and advancing this field of medicine. We need your support more than ever and you can make a difference. Remembering a charity in your Will is simple. For an easy stepby-step guide to everything you need to know about leaving a legacy to Joint Action, please visit www.boa.ac.uk/research/ leaving-a-legacy.

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JTO News and Updates

BORS Annual Meeting 2017 The British Orthopaedic Research Society (BORS) annual meeting took place in September at Imperial College, London. Bringing together basic scientists and clinical researchers to discuss emerging trends in orthopaedics. Invited keynote speakers from London, Oxford and Southampton discussed novel and topical research in key themes including: Big Data, Lifelong Health and Personalised Medicine. The conference provided a forum for young researchers to present their research, including 40 podia and 90 poster presentations – continuing the mission of BORS to promote young researchers. BORS presented the Presidents Medal to Prof Sean Hughes who gave a thought-provoking talk about the relevance of basic

Prof Sean Hughes receives the BORS President’s award from Prof Mark Wilkinson.

sciences to the understanding of clinical conditions in the musculoskeletal system. Followed by an engaging public involvement lecture by Prof Julian Jones on the potential of 3D-printed, self-healing scaffolds to be used for regenerating bone and cartilage.

Conference dinner at Oginsko Polski.

The 2018 BORS Travelling Fellows were also announced at the meeting. The evening was rounded off by a sumptuous dinner at Ognisko Polskie in South Kensington. BORS and the organising committee would like to

extend a big thank you to the sponsors Mat Ortho, Bioventus, DePuy Syntheses, Bruker, Ceramtec and ESSKA. As well as the MSk Lab staff and students for setting up and running the meeting. We look forward to Leeds in 2018!

Royal College of Surgeons Update Since the last update, the RCS Project 2020 has moved on to the first stage of construction work, following the successful moving of the College and associated organisations into the Nuffield building. As we have all moved into half the space previously

available, there has been the need to rationalise space, and to get to know colleagues that we wouldn’t regularly meet. The College is grateful to all who have been accommodating, especially those who have given up space to welcome others. As the main building project has commenced on the demolition phase of work, there will be the unavoidable potential of noise. However, this will be a small sacrifice for what will be on offer on completion of the project in 2020.

Nuffield Building

Internally for the College, once we have confirmed that all the services are running correctly, and any issues that have arisen have been addressed and resolved, planning will start for the move into the new building. This will include the

Barry Building

planning of the designs for the Library and Museum spaces, and other public areas; the physical creation of the teaching and examination spaces, and other staff spaces; and the logistics for moving all staff across.

Over the next few years, the college will be continuing through its programme of change, and we look forward to working alongside the Associations to progress advances in surgery.

JTO News and Updates

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JTO News and Updates

Conference Listing: OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 10-12 January 2018, Bristol

BSCOS (British Society for Childrenâ&#x20AC;&#x2122;s Orthopaedic Surgery)

www.bscos.org.uk 8-9 March 2018, Crewe

BHS (British Hip Society)

www.britishhipsociety.com 14-16 March 2018, Derby

BLRS (British Limb Reconstruction Society)

www.blrs.org.uk 15-16 March 2018, Southampton

EFORT (European Federation of National Associations of Orthopaedics and Traumatology)

www.efort.org 30 May-1 June 2018, Barcelona

CAOS (Computer Assisted Orthopaedic Surgery - International)

www.caos-international.org 6-9 June 2018, Beijing

BOOS (British Orthopaedic Oncology Society)

www.boos.org.uk 8 June 2018, Edinburgh

BESS (British Elbow and Shoulder Society)

www.bess.org.uk 20-22 June 2018, Glasgow

BASK (British Association for Surgery of the Knee)

www.baskonline.com 20-21 March 2018, Leicester

BRITSPINE

www.britspine.com 21-23 March 2018, Leeds

BSSH (British Society for Surgery of the Hand)

www.bssh.ac.uk 3-4 May 2018, Cardiff

CSOS (Combined Services Orthopaedic Society)

www.csos.co.uk 10-11 May 2018, Birmingham

BOA (British Orthopaedic Association)

www.boa.ac.uk 25-28 September 2018, Birmingham

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Quality Improvement in Surgical Teams (QIST): Transfusion and Infection Ashley Scrimshire Building on the success of the Quality Improvement in Surgical Teams (QIST) initiative we are now recruiting centres for the upcoming QIST: Transfusion and Infection study. This will be a 40 centre randomised trial run in collaboration with York Trials Unit, NHS Improvement, industry and the BOA. We will be testing the introduction of two interventions aimed at reducing complications in hip and knee replacement. The interventions briefly consist of: QIST: Transfusion – Pre-operative anaemia screening with iron

treatments targeted at patients with borderline anaemia. QIST: Infection – Preoperative Methicillin Sensitive Staphylococcus aureus (MSSA) screening with decolonisation with body wash and nasal gel treatments, targeted at carriers. Randomisation will occur at Trust level due to the complex nature of introducing the interventions. Teams from 40 Trusts each randomised to one or other intervention will come together in two collaboratives to learn the interventions at a series of learning events in the spring and summer of 2018, and then measure the effect of

the implementation over 12 months. At the end of the study, each Trust will learn the other intervention to maximise the benefit of being involved in the study. These interventions have significantly reduced transfusion, critical care admission, length of stay, readmissions and MSSA prosthetic joint infections in the host organisation (Northumbria). Participating NHS organisations in England are projected to save around £6.3M per annum once the interventions have been introduced. Both these interventions are recommended for hip and knee replacement in best practice guidelines.

To register your interest in becoming a trial centre please contact the study lead Prof Mike Reed at qist@northumbriahealthcare.nhs.uk. For further information, please visit www.qist.co.uk.

Wisepress Book of the Quarter Ultrasound Guided Musculoskeletal Injections Authors: Gina M. Allen, David J. Wilson ISBN: 9780702073144 Date published: 18th Sep 2017 Price: £89.99 BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.

An ideal “how-to” guide for those who perform musculoskeletal injections, this unique multimedia resource by Dr Gina M. Allen and Dr David John Wilson demonstrates how to make the most out of the clear visualization provided by ultrasound-guided techniques. High-quality line drawings, clinical photographs and ultrasound images clearly depict patient presentation, relevant anatomy, and sonoanatomy, and each technique is accompanied by a video showing exactly how to perform the procedure. Clear, concise text and numerous illustrations and videos make this reference your go-to source on today’s ultrasound-guided musculoskeletal injections. Bulleted text follows a quick-reference template throughout: clinical/ultrasound findings, equipment, anatomy, technique, aftercare, and comments. Each chapter covers the entire injection process with text on the left-hand page and corresponding images on the right. Every technique is supported with a video available online. Useful for clinicians in radiology, sports medicine, rheumatology, orthopaedics, pain medicine, and physical therapy - anyone who needs a clear, current guide to this minimally invasive treatment option for pain relief.

69 %

reduction of deep infections in hip hemiarthroplasty after fractured neck of femur *

Bone cement with gentamicin and clindamycin * Sprowson AP et al. Bone Joint J 2016; 98-B: 1534â&#x20AC;&#x201C;1541

PRODUCTS & SOLUTIONS YOU CAN TRUST

www.heraeus-medical.com

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JTO Features

Elective Care Reviews Ananda Nanu

The process of data gathering and analysis is not perfect, and is not likely to ever be so. It does not however absolve us of responsibility to act on analyses that are forthcoming, once we have satisfied ourselves that the necessary scientific rigours have been applied.

caring for patients; supporting surgeons could be looked at by individuals affected by the fallout from NJR data analysis with some scepticism. Variance is down to use of a certain implant, patient selection, or rarely technical ability or technical errors that are repeated. I also think that the way we publish data may well need another look, once this matter comes out of the closet and is the subject of debate at the BOA, BHS and BASK in the first instance, as data for the other joints is not quite there yet. At the moment, some may regard individuals who have been identified by the NJR process as having some contagious and faintly disreputable disease, and discussions tend to be on an elevated, academic plane between individuals affected and their institutional mechanisms. If it is thought that individuals need retraining, then they have to go cap in hand to neighbouring trusts asking for this as a personal favour. Why should it be beyond the wit and ability of an organisation/organisations that purport to support their members while caring for their patientsâ&#x20AC;&#x2122; safety to organise this with a modicum of dignity and support?

The BOA has not hitherto been involved in the downstream effects of this data analysis, and this is an area that we intend to cover. Our mission statement

In this light, the BOA proposes to assist by forming a review process for units that are identified as being at negative variance. The process will >>

The NJR has been active for more than a decade, and is quoted widely as being a tremendously valuable resource. There are those who cavil, and point out that big data is all very well from a population statistical viewpoint, but it doesnâ&#x20AC;&#x2122;t tease out the detail required to apply it to individual patient care.

It is also true that Registry data is used to highlight individuals and units that show a marked degree of variance, with an alarm being raised when an individual is at the three standard deviation mark. Those individuals amongst us who have had the invidious pleasure of being marked out for this attention have had to look at our data, validated and/or corrected it and returned it to the NJR. The process where the data has highlighted a genuine aberration has usually been addressed on an individual level, and I hear from some affected in this manner that the process has been less than supportive.

Ananda Nanu

Nevertheless, if we undertake to gather data involving patients, and invest clinician time and money in the process, we have a responsibility to look at what the data indicates, and question it. The process should not be punitive, but

undertaken in a scientific spirit to see if the data is representative, the analysis just, and the conclusions drawn therefrom justifiable. If the analysis indicates there is a possibility that patients may be coming to harm from our interventions, then we must act early to address the cause of harm.

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JTO Features

draw upon the relevant specialist societies to help staff, the review team, to ensure that the review will be conducted in a spirit of supportive analysis of the reasons for identification of variance. The BOA process will ensure there are no conflicts of interest in the personnel forming the review team, and will look at the entire team involved in care, from procurement, prosthesis use, team structure and dynamics and surgeon support structures. It is anticipated that the process will take two days, and be as thorough as possible. Any findings will be reported back to the unit that commissions the review for implementation as appropriate. This process grew out of a meeting with the NJR Medical Advisory Committee, the Care Quality Commission and the BOA. The fact that a number of units nationally had been identified on the standard analysis of data as being significantly at variance was identified and the unit Medical Directors notified. There was no mechanism to ensure that any action taken was fed back, either to the Care Quality Commission or to any NHS body or responsible specialist society. Indeed there was no requirement to demonstrate that any action had been taken at all. This trended on successive

NJR yearly analyses, showing no improvement. This was inevitably picked up by NHS England, and the pertinent question asked; if there is no intention to alter and improve a position which has been deemed unsatisfactory, then why bother going to the trouble and expense of collecting it in the first place? Recognising that any process run by nonclinical administrative personnel with unselected clinicians of variable credibility and expertise advising the process is likely to create antagonism and an unsatisfactory outcome, the BOA agreed to create and coordinate a process that would satisfy all requirements of specialist expertise in that area, combined with credibility and accountability and inform the same unit of its findings. The Care Quality Commission were happy to accept the fact that identified units would commission a BOA led review and they would have recourse to ask the Medical Director of the concerned unit if an action plan had been agreed and implemented. This would then, it is expected, lead to a reversal of the trend in subsequent NJR reports of that unit. This then is the path that has led to the BOA Elective Care Review process. This is only applicable to units, and not to

individual surgeons. The process is time-consuming, and will involve surgeons taking time out of Trust clinical activities as well as their private time to service this requirement. Several people have expressed difficulty in getting time off to take part in national NHS activity that is not directly related to their Trust, and the combined NJR, CQC, and BOA representatives called for and attended a meeting with Sir Bruce Keogh to explain that the BOA would lead a review process to ensure that Quality Improvement would stay at the forefront of orthopaedic activity. The BOA has sent a letter to the Times available on the website at www.boa.ac.uk/publications/ boa-letter-to-the-times-rationingof-hip-knee-replacements30-01-17,when this issue first cropped up, and I have sent a letter to the CCG, available on the website at www.boa.ac.uk/ publications/boa-response-toderbyshire-ccgs-procedures-oflimited-clinical-value-05-10-17, after the latest incarnation of this disease in Derby. It is not appropriate that annual leave is being used to allow examining or teaching on Nationally accredited and recommended courses and exams. To drive this process for the first few reviews, we have asked Sir Bruce to write directly to certain Trust CEOs asking for named persons to be released to facilitate the ECR process. If you

are a member of BHS, BASK or the BOA and are able and willing to assist in this process, write to one of these organisations, contact details available at www.boa.ac.uk/about-boa/ specialist-societies. The process will initially be carried out by Executive members of the organisations, until the process has been refined, and it is anticipated that there will be a BOA Elective Care Review day held in Spring 2018 to train willing reviewers in the process. Having taken the responsibility and ownership of the ECR, we are now as a diligent clinical body tasked with explaining, after clinical review, whether these data peaks are measurement aberrations owing to mixed populations being studied or reflections of skewed choices. This will lead to further debate in our public clinical bodies and meetings. Hopefully this will clear some of the misconceptions we hold and help us affirm and reset our belief in ourselves as the best advocates for our patients, using data we collect to drive quality improvement. n Ananda Nanu is the President of the BOA and takes a keen interest in education. He is a Consultant Trauma and Orthopaedic Surgeon working in Sunderland.

See You in Scotland!

18th ESSKA Congress 9 – 12 May 2018 Glasgow, UK

Your Congress 2018 Best clinical practice in arthroscopic joint surgery, knee surgery and sports traumatology with special focus on the translational science in these fields Call for Submissions Submit your work for one of ESSKA‘s Awards ➟ Deadline: 15 December 2017 Registration now open For Information, Registration and Accommodation Booking:

ESSKA President Romain Seil (Luxembourg) Congress President Jón Karlsson (Sweden)

www.esska-congress.org

Scientific Chairmen Gino M. Kerkhoffs (The Netherlands) Fares S. Haddad (UK) Michael T. Hirschmann (Switzerland)

Organiser & Contact Intercongress GmbH esska@intercongress.de

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JTO Features

The HIP QIP Scaling Up Programme Lianne Brkic The hip fracture quality improvement programme (HIP QIP) Scaling Up Improvement Programme is a safety collaborative across six UK NHS hospital trusts. The aim is to improve safety and care for patients with hip fracture using a multidisciplinary pathway. The programme commenced in September 2016 and the aim is to save 100 lives by December 2018. The programme is funded by The Health Foundation and led by Northumbria Healthcare NHS Foundation Trust. The team is partnered with the British Orthopaedic Association, Royal College of Physicians (RCP) and the Academic Health Science Network for the North East and Cumbria. High quality, safe care requires the coordinated effort of a multidisciplinary team, and the implementation of best practice, evidence-based care. A key component of the programme is funding a nutritional assistant for 12 months, as evidence suggests that prioritising nutrition in patients with a hip fracture reduces the acute hospital death rate¹.

Lianne Brkic

HIP QIP also requires the establishment of a multidisciplinary audit framework. The care includes patient experience monitoring, the number of fascia Iliaca blocks given in the Emergency Department and the undertaking of surgery within 36 hours. A root cause analysis is undertaken of any deaths.

The NHS trusts involved in the programme are: l Gloucestershire Hospitals

NHS Foundation Trust

l Great Western Hospitals

NHS Foundation Trust

l South Tees Hospitals

NHS Foundation Trust

l Weston Area Health NHS Trust

Overall, the collaborative follow the Institute for Healthcare Improvement Breakthrough Series Collaborative approach. The teams come together over five learning events to review the evidence supporting best care, exchange ideas and identify any potential for improvement. Between learning events (“action periods”), teams test and implement changes in their local settings and collect data to measure the impact of the changes. Person-centred care lies at the heart of this work. The patient leaders programme, based at Northumbria Healthcare, trains and supports the patient leaders. The outcome of the programme is being evaluated by the RCP and Dr Winifred Tadd.

l NHS Greater Glasgow and Clyde l Northumbria Healthcare

NHS Foundation Trust.

Programme approach The programme was launched at each NHS site with a multidisciplinary peer review, coordinated by the BOA. Coordinating this review was complex, but it provided a more detailed understanding of the context and challenges at each site. This allowed recommendations to be made, which in turn informed local improvements. This review was highly valued at each of the sites.

What has been achieved so far? The multidisciplinary teams are enthusiastic and engaged in the project. They are innovative which helps deliver solutions locally. The Trust have come together for three learning events to date. We were joined by our evaluation partners, members of the BOA and the Health Foundation. The NHS teams, retain ownership of the events and report their progress, learn teaching skills, share ideas and learning.

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Locally, with support from the collaborative, all NHS sites have:

Measurement and reporting

l Delivered their own local launch

Measurement of improvement is key. A measurement and reporting framework was agreed at the start with participating teams and collated into a quality account. Each quality account outlines the standards that are core to the HIP QIP programme. Individual sites also add measures reflecting their local improvement work.

events to promote their work and ensure the effective engagement of all their stakeholders

l Commenced their improvement

work and established local steering groups which meet regularly

l Introduced new practice, for

example the implementation of fascia Iliaca nerve blocks in the Emergency Department

l Recruited a nutritional assistant

for a year who is funded by the programme grant and AHSN

l Recording outcome and

Figure 1a: A 30-day mortality run chart for the collaborative. There is a trend of reducing mortality.

reporting them monthly to the RCP. As a collaborative we have:

l Provided monthly feedback

to each NHS team. This is coordinated by the RCP

Progress is being monitored locally and nationally using the Hip Fracture Database. We are seeing early improvements which is exciting. We are looking forward to presenting our project at the BOA Congress in 2018. n

l Run workshops at Northumbria

Healthcare to collect and report patient experience data, as well as supporting the newly appointed nutritional assistants

l Undertaken monthly calls to

support each NHS team leader

l Disseminate ideas across

the different organisations; for example, a short film was shown at learning event three which explained a novel way of introducing the nutritional assistant. The film described a weekly tea party for patients with a hip fracture, set up and run by the nutritional assistant. This led to teams at two other trusts setting up similar parties. It also led to an exercise class being set up.

As part of the project, Northumbria Healthcare NHS Foundation Trust have recruited five patient leaders who have been trained. They meet regularly with the programme manager and they have joined local improvement teams with specific projects; for e.g., developing personalised end of life care. Feedback indicates that the patient leaders are welcomed by healthcare professionals and they work well together.

Key measures are mortality at 30 days, fascia iliaca nerve blocks administered in the Emergency Department, additional nutrition provided to patients and patient experience (Figures 1 and 2). Real time measurement and reporting commenced in January 2017.

Figure 1b: The 30-day mortality in control sites matched to collaborative sites, based on size and baseline 2015 mortality.

Lianne Brkic is the HIP QIP Scaling Up Improvement Programme Manager. Lianne commenced her career as a clinical physiotherapist prior to working as a research physiotherapist at Newcastle University. She was awarded her PhD in 2016. Lianne has a special interest in quality improvement.

Reference 1. Duncan, D. G. et al., â&#x20AC;&#x2DC;Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma wardâ&#x20AC;&#x2122;, Age and Ageing, 35, 2006, 148â&#x20AC;&#x201C;153.

Figure 2: A run chart for the proportion of patients who received a Fascia Iliaca Nerve Block in the Emergency Departments. It shows a rise in number of blocks.

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JTO Features

Supporting SAS Surgeons in Career Development Mamdouh Morgan What’s on the Horizon? SAS Surgeons Advisory Book The BOA is committed to supporting all orthopaedic surgeons including the SAS (Staff, Associate Specialists and Specialty doctors) surgeons. The BOA wants to incorporate an “Advisory Book” for SAS surgeons with an updated “Consultant Advisory Book”. This will be called the “Orthopaedic Surgeon’s Advisory Book” and will include advice for all grades.

The SAS surgeons session at the BOA Annual Congress allowed the section on “Professional Development Requirements for the SAS Surgeons” to be launched. It has been approved by the BOA Educational Committee and includes advice on training, education, assessment and level of autonomous practice for SAS surgeons.

Mamdouh Morgan

SAS surgeons play an important role in NHS service delivery. In recent years increasing numbers have chosen to become SAS surgeons, rather than enter

higher specialty training. As a result of the evolving demographic of the medical workforce, this trend may continue in future years. SAS surgeons are a diverse group with a broad range of knowledge, surgical skills and experience who can deliver clinical care, in partnership with orthopaedic consultants and other healthcare workers. Sustaining good quality services requires SAS surgeons to remain up to date. Therefore, meeting their professional development needs is vital at organisational and individual levels.

For the successful development of an SAS surgeon appropriate training and regular assessment linked to the annual appraisal are required. To underpin these requirements, it is important to remember that SAS surgeons: 1. Should be supervised at a level appropriate for their capabilities 2. Should have a clear and agreed role and set of responsibilities 3. May be able to practice autonomously with remote supervision. We aim to target all of the Trauma and Orthopaedic SAS surgeons in all of the departments in the United Kingdom to support them in the delivery of high quality patient care and to acknowledge their contribution to the surgical team and surgical training. We aspire to help SAS surgeons deliver safe patient care with the development of appropriate roles, responsibilities and accountability. SAS surgeons should receive similar resources for training and education as other trained surgeons under the “Training for All” initiative. Annual appraisal is central and for development should be linked to the T&O curriculum with a surgical logbook, indicative numbers and work place based assessments.

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Figure 1: Illustration of the BOA 5-Tier Career Model.

Tier 2: Junior SAS Surgeon - Specialty Doctor & Staff Grade Doctor

Tier 4: Experienced/Senior SAS Surgeon - Specialty Doctor & Associate Specialist

Experience: 5 -10 years postgraduate experience in T&O

Experience: >15 years postgraduate experience in T&O

Assessment Level: ISCP Curriculum equivalent to the level of ST5 – ST8 with the ability to take independent decisions and contribute to a wider role in clinical and management fields

Assessment Level: Consultant equivalent with capacity for autonomous work. Ability to take independent decisions and contribute to a wider role including management, audit, teaching and committee work

Level of Supervision: Full supervision

Level of Supervision: Distant Supervision

Tier 1: Foundation SAS Surgeon - Specialty Doctor & Trust Grade Doctor

Tier 3: Middle Grade SAS Surgeon - Specialty Doctor & Associate Specialist

Tier 5: Certified SAS Surgeon - Specialty Doctor & Associate Specialist

Experience: Less than five years postgraduate experience at least one year in T&O

Experience: 10 -15 years postgraduate experience in T&O

We suggest a “Graduated Supervision Scale” with four levels: Full Supervision, Distant Supervision, Limited Supervision and Autonomous Practice. We suggest a five-tier career model (Figure 1). This is for guidance only and should be used flexibly. Defining tiers of SAS surgeons in an organisation can help define the level of supervision, assessment and appraisal required by the individual.

Assessment Level: ISCP Curriculum equivalent to the level of ST3 – ST4 Level of Supervision: Full supervision

Assessment Level: Post CCT with the ability to work independently within a multidisciplinary team Level of Supervision: Limited Supervision

Experience: SAS Surgeon with CESR and on the Specialist Register of T&O Assessment Level: Consultant equivalent with capacity for full autonomous work Level of Supervision: Autonomous and Independent. n

Mamdouh Morgan is a senior orthopaedic surgeon in Birmingham. He graduated from medical school in Egypt in 1984 and started his orthopaedic career in the Army in 1986. He has a passion for training, educational and developmental needs of SAS doctors as Associate Postgraduate Dean. His mission at the BOA is to work with other stakeholders to ensure the educational activities for SAS Surgeons is incorporated into the assessment of Royal Colleges and the CESR application process.

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What you need to know about the new T&O Curriculum Lisa Hadfield-Law

IV) Trusted to act unsupervised

The 2018 T&O Curriculum will reflect the feedback patiently and repeatedly provided by T&O trainers and trainees throughout the UK and Ireland. Lots of you have become increasingly concerned about the over-refined structure of ISCP with tick boxes and forms. Trainees need to learn to perform in differing conditions and circumstances, respond to the unpredictable, and make decisions under pressure, frequently in the absence of all the desirable information. They must learn professional judgement, insight, leadership, the ability to work with others and the Generic Professional Capabilities required of all doctors. The latest Curriculum to be submitted to the GMC for approval will be based around nine Capabilities in Practice (sometimes referred to as Entrustable Professional Activities), which are units of professional practice or tasks/ responsibilities that trainees can be entrusted to perform. Trainees will be assessed according to whether they are able to:

Lisa Hadfield-Law

1) Manage an out-patient clinic 2) Manage the unselected emergency take 3) Manage ward rounds and ongoing care of in patients

4) Manage an operating list 5) Manage a multi-disciplinary meeting 6) Study and adapt practice to improve patient safety and deliver quality improvement 7) Carry out and assess the quality of clinical research 8) Act as a supervising clinician 9) Work within the Health Service. The assessment levels will be based on supervision level required and for CCT, trainees will be expected to reach level IV: I) Able to observe only IIa) Trusted to act with direct supervision: supervisor needs to be physically present throughout the activity IIb) Trusted to act with direct supervision: supervisor needs to guide all aspects of the activity. Guidance may partly be given from another setting but the supervisor will need to be physically present for part of the activity III) Trusted to act with indirect supervision: supervisor does not need to guide all aspects of the activity

V) Gained mastery of Capability and developing skills in teaching. Indicative numbers of operative procedures are also being carefully reviewed and incorporated, to support the demonstration of a sufficient breadth of experience and achievement of competence in T&O. We will bring you up to date with specific numbers in the next edition. Validating a new curriculum is a long and arduous process, but we hope to have the new version ready for use in autumn 2018. In the meantime, we will look for ways of helping our trainees and trainers adjust. One way is for trainers to attend a TOES or e-TOES programme. If trainees would like to create groups and provide a venue, the BOA Education Advisor will facilitate half day sessions on “Getting the Most from your Training” (please email at lisa@baileysconsulting.co.uk). The continuous feedback, the need for evidence for portfolios won’t change, but the structure will be more authentic and useful for us all. The change will be the most significant since the creation of ISCP, and will require patience and commitment from all of us to make it work. n Lisa Hadfield-Law, RGN, MSc, FAcadMEd and Education Advisor to the BOA.

19TH EFORT Congress 2018 www.efort.org/barcelona2018

19TH EFORT Congress Barcelona, Spain: 30 May-01 June 2018

#EFORT2018

Congress Highlights - Main Theme: Innovation & New Technologies Robotics & computer-assisted surgery

Minimally invasive surgery

3D printing

New diagnostic techniques

Biomaterials

Virtual learning environment

Advanced implant technologies

Innovative rehabilitation programmes

New tissue regeneration techniques

Patient involvement in treatment & research

Patient specific treatment

Telemedicine

Key dates Registration opens: 08 January 2018 Advanced Programme online: 15 March 2018

Abstract status notification: 01 February 2018

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JTO Features

Using National Audit Data to Drive Greater Patient Safety and Quality of Care for Joint Replacement Patients Martyn Porter Co-authors: Matthew Porteous, Peter Howard Patient registries serve an invaluable function helping the NHS be the safest healthcare system in the world. The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) is the largest of its kind in the world and it plays a crucial role.

Established in 2002, the registry ensures that robust evidence is available to monitor the performance of implants, the effectiveness of different types of surgery and to improve clinical standards — all with an absolute focus on patient outcomes. I have outlined here how the registry’s monitoring processes have been enhanced to drive greater patient safety and quality of care for joint replacement patients.

Martyn Porter

Whilst the NJR’s remit has broadened since its inception, monitoring outcomes continues to be a core function of the registry. NJR data now provides an important source of evidence for regulators, such as the Care

Quality Commission and NHS Improvement, to inform their judgements, as well as being a fundamental driver to inform improved quality of care for patients. During 2017 we have further reviewed the NJR’s processes in monitoring implant and surgeon performance as part of the development of the NJR’s Accountability and Transparency Model. A huge amount of work has gone into the review, including a significant consultation between the NJR, regulators and the profession. Undertaking such a comprehensive review of the NJR’s monitoring processes has enhanced relationships, ensuring that national audit is

integrated across a regulatory and professional framework. I am very grateful to Ian Winson (BOA past President), Ananda Nanu (BOA President) and Julia Trusler (BOA Quality Outcomes Programme Director) for their support during this period of change for the NJR. Unequivocally, the NJR’s scrutiny has led to increased patient safety with poorly performing devices being removed from the market. A spotlight has also been shone on poor surgical practice. However, it is important for the NJR to routinely review its processes and ensure we are continuing to best serve patients. So what is new about the NJR’s Accountability and Transparency Model? Firstly, ‘prevention’ is now a key element of the NJR’s monitoring processes. Implemented for the first time this year, Alert (borderline) notifications were issued, acting to prevent surgeons from becoming Alarm (outlier) status by informing them of deteriorating outcomes at an earlier stage, enabling

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The enhanced monitoring processes will also help to encourage hospital management to better understand the importance of national audit data. We have seen how such unit level scrutiny of the NJR’s Data Quality Audit work can help. Several hospitals have seen a marked improvement in their year-on-year data once known barriers, such as resource problems, are overcome.

them to correct substandard practices and reduce, or eliminate, poor outcomes. This will also be extended to unitlevel data and should ensure even greater public confidence in the NJR’s monitoring processes as it reduces or eliminates poor outcomes overtime.

hospitals are managed in a clear and robust manner. To kick-start this process the NJR’s Surgeon Performance Committee has recommended several hospitals, with historically poor performance, undergo BOA Elective Care Reviews in the current financial year.

Secondly, formulating an agreed process to allow appropriate review of units who fall below expected performance thresholds has been an important development in the new model. As outlined above, we are now working closely with healthcare regulators and the BOA to ensure that all hospitals are fully engaged with the registry and are submitting timely and accurate data. Submitting data improves outcomes for patients and allows the NJR to monitor poor performance more accurately.

Importantly from a patient perspective, this way of working will provide a robust holistic view of surgical performance which will better inform patient choice. This collaborative approach will ensure that

Looking ahead, ‘practitioner reflection’ will also become a key pillar in the NJR’s monitoring process. Formalising and monitoring the use of national audit data as part of a surgeon’s annual appraisal and revalidation is a bold new approach. Once embedded, the National

Joint Registry audit data will constructively inform the appraisal process by allowing joint replacement surgeons to demonstrate and record their performance. It will also be important to reflect upon the results. We hope that similar processes can be rolled out across the health service to encourage best practice and drive a positive professional culture - with a sharp focus on patient safety. It is important that the public has confidence that all surgeons who carry out joint replacement procedures review their NJR data in a structured and accountable way. At the time of writing, we are at an exciting juncture but once implemented the NJR data will be groundbreaking for the NHS and for patient safety. Data is already driving change across the orthopaedic sector. I hope that the processes outlined here demonstrate how the NJR is supporting surgeons and keeping practice safe. Whilst standards in British orthopaedics are high, surgeons must use the NJR’s dataset to

better understand the factors that influence the outcome and longevity of joint replacement procedures. Crucially, this includes reviewing one’s own practice by reflecting upon individual performance data. I would encourage you to explore all the further information and supporting documents relating to the NJR’s Accountability and Transparency Model, including the detailed process maps, via the NJR’s website www.njrcentre.org.uk. n Martyn Porter is the National Joint Registry’s Medical Director and Vice Chairman, appointed by the Department of Health from 1 February 2014. He is a consultant orthopaedic surgeon based at Wrightington Hospital, Lancashire, a past-President of the British Orthopaedic Association (BOA) and immediate past-President of the International Society of Arthroplasty Registers (ISAR).

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JTO Features

Operations I no longer do... Harvest bone from the iliac crest Bob Handley Harvesting bone from the iliac crest can be a skilled and pleasing procedure. When I was a junior it was a task that you may have been given with relatively limited instruction. Those first crude aggressive pillaging raids on a virgin crest evolved, with experience, into the delicate work of a cat-burglar.

A small incision, a crafted trap-door and then, with curved gouges, the bone was delicately mined. Finally the trap-door was closed and the tracks covered. I havenâ&#x20AC;&#x2122;t done this for years and nor has anyone on my behalf. No matter how cat-like the approach there could be complications, post-operative pain being the most common. Additionally, bleeding, damage to the lateral femoral cutaneous nerve and, on one occasion, the anterior superior iliac spine split off with an alarmingly large wedge of crest. Despite these problems the procedure was very common, but then the indications began to dwindle.

Bob Handley

Primary bone grafting during the open reduction and fixation of a fracture has all but disappeared

with the more biological approach to fracture surgery. I no longer use cancellous bone graft as a structural support for a tibial plateau, or other articular fractures. I now usually rely on reduction, particularly the restoration of metaphyseal volume, which is very occasionally supplemented with a bone substitute. I have also come to understand that there is a difference between a structural defect and a void. With a void the potential risk is of infection following contamination of the space. My current approach to managing a void is first to appreciate the nature of the problem and then fill it with healthy soft tissue. If I cannot thus fill it I use a synthetic, antibiotic carrying, bio-absorbable material, not autogenous graft (Figure 1).

Figure 1: A distal tibial metaphyseal void following open fracture filled with antibiotic loaded calcium sulphate/carbonate beads.

A distal radial osteotomy was once routinely supplemented with a bone graft. Now with more modern fixation they seem to heal perfectly satisfactorily without graft. Cancellous bone graft was routinely used in the management of delayed or non-unions. I now consider, in normal practice

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(i.e. out with a specialist bone infection or bone loss unit) that the vast majority of the problems with union are resultant on a mechanical problem. In managing these cases now, not only would I not use bone graft, as far as possible I do not interfere with the fracture site at all (Figure 2). On the occasions that I have used bone graft it has most often been as part of a procedure dealing with a larger defect, as in the Masqulet technique. Here the quantities of graft required are usually greater than the iliac crest can supply. Consequently, I now harvest the bone from an intramedullary source, for its greater quantity and the reduced post-operative pain.

In summary for an Orthopaedic Trauma surgeon the indications for harvesting small amounts of cancellous bone have all but disappeared, whilst the potential for complications has not. The iliac crest can now remain unsullied, as a support for trousers. n

Figure 2: A delayed union of open tibial fracture initially managed with an intramedullary nail and free flap, which united after the percutaneous insertion of two screws to add stability.

THE WORLD’S FIRST ULTRASOUND KIOSK JUST GOT BETTER.

has been an examiner for the FRCS Orth for seven years and is a past president of the Orthopaedic Trauma Society. Bob was on the NICE guidelines development group for hip fractures and currently co-chairs the NICE groups for complex and non-complex fractures.

Bob Handley was a medical undergraduate in Sheffield where he also did an intercalated degree in physiology. Since 1994 Bob has been a full-time consultant on the Trauma Service at the John Radcliffe Hospital in Oxford; during this time his work has been entirely related to trauma. The service is consultant based and for the last 21 years, he has been resident when on duty. He

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JTO Features

How I Do… Whither (wither?) Spinal Surgery Lee Breakwell Forgive me for a little hyperbole, but spinal surgery is facing something of an existential crisis currently. Sadly, many of the factors are of our own making, but not all.

Lee Breakwell

The latest insult is the unilateral withdrawal of indemnity for spinal surgery by the largest UK indemnifier the MDU1. This followed the Lord Chancellor’s reduction of the discount rate for claimants to minus 0.75%. This is the interest rate applied to compensation claims to reflect the growth of the sum awarded over time. The rate had previously been static since 2001 at 2.5%. This had the immediate effect of raising the quantum of future claims.

surgeons offering “expert” opinions on procedures they almost certainly never undertook. In addition to this, GIRFT has shown a huge and unwarranted variation in index procedure rates and implant usage. All of these factors increase the risk of litigation.

The MDU cites the increasing costs of greater than 10% year on year as being unmanageable. Awards for successful claims in spinal surgery can be high, with cord injury, epidural abscess, and cauda equina syndrome all attracting large pay-outs. Quraishi et al2 showed an actual decrease in NHS claims between 2002 and 2010. GIRFT shows an average cost of £90 per spinal admission to cover litigation claims. Costs in the private sector are less clear.

So, where does that leave us...? Will spinal surgery be a realistic career choice in the future?

Whilst it is tempting to blame the legal profession for driving the process, however, it is clear that our house is far from being in order. There are numerous cases of long retired orthopaedic

Furthermore NICE has produced the evidence to say spinal fusions must no longer be performed for low back pain unless as part of an RCT.

The BOA and the specialist societies, including BASS, are working hard to improve communication with the neurosurgeons to tighten our ship, and to steady the course. Since the Montgomery ruling4 BASS has sought to improve consent5, oft the cause of litigation. The confluence of GIRFT and the BSR will aid the harmonisation of indications and outcomes, hopefully for the benefit of all. The spinal surgery community is beginning to recognise the height of the oncoming tidal surge. I hope we have seen it in time. It

is also important that individuals reflect on their part in this, now and in the future. We need to recognise where surgery sits in the management of spinal pain and control those factors we can control, such as consent and outcomes assessment. Whilst I defend the right of a person to seek compensation when harmed, we need to take a look at our part in the burgeoning process of litigation. If we do not, I fear the erosion of elective spinal surgery in both the NHS and private sectors and subsequently in the management of spinal emergencies. n Lee Breakwell is a full-time spinal surgeon at Sheffield Children’s and Teaching Hospitals. He is a current Trustee of the BOA and past President of BOTA. He co-designed the British Spine Registry and represents the BSS. Lee is Secretary of the UK Spine Societies Board, as well as Chairman of Sheffield Orthopaedics Ltd.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Features Festive Fun

JTO Festive Fun After filling up on food over the festive season, here’s something else you can get your teeth stuck into. Gather the family around and complete our festive puzzle and quiz.

Christmas Quiz 1. What edible poultry delight is Japan’s biggest seller at Christmas?

6. Which country has kindly sent the UK a big Christmas tree every year since 1947?

2. What was the Christmas #1 of 1975 and the third best-selling UK single of all time?

7. It’s more guesswork than science but, where do biblical scholars think Jesus was born?

3. How long was the world’s largest Christmas stocking?

8. Which (non-scouser) was #1 on Christmas Day 1972 with nauseating hit, ‘Long Haired Lover from Liverpool’?

a) Roast Duck b) KFC c) Three Bird Roast d) Turkey Katsu Curry

a) White Christmas – Irving Berlin b) Candle in the Wind – Elton John c) Bohemian Rhapsody – Queen d) Mr Blobby – Mr Blobby

a) 33 Elephants’ Trunks Long b) 51 Metres c) 33 Olympic Swimming Pools Long d) 34,000 Metres

4. Which animal is traditional for Bolivians to take with them to Christmas Eve mass?

a) Norway b) Denmark c) Sweden d) Finland

a) A Bird’s Nest, in an Egg b) A Cave c) Under a Tree d) In Some Hay, in a Manger

a) Jimmy Nail b) Jimmy Osmond c) Jim Reeves d) Jimmy Sommerville

9. What does the name Rudolph actually mean?

a) Pigs b) Rabbits c) Roosters d) Donkeys

a) Famous Wolf b) Rude-elf c) Son of Jesus d) Santa’s Helper

5. The use of mistletoe to coax women for a kiss at Christmas has been passed on from generation to generation, but it’s actually a parasite and its Germanic translation is what?

10. In which city is Kevin left ‘Home Alone’ at Christmas? (the first Home Alone movie)

a) Toes on a Stick b) Pass the Gravy Mate c) Please Don’t Touch Me d) Dung on a Stick

a) Paris b) London c) Barcelona d) Chicago

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Page 37

Festive Word Search

Festive Word Search Y

K O L

N E

E N K M R

B O F G D X

B O Q K W C H

Y G U C M R

P A A

A A H

H R

R U O M U

H C F

B H N N Q Z

H U C X

X O T

P U

S N A K N

B W E

P V R

Y V

F C A

R S

Z C

S N H H M Z

T C A C Z

E O E

F Q Z

H X H

H M K

P V

B Q V

R W K N Q N M V A R N V Y A O

G R Q Y D A O L

O S O Y C P

T Q V

J G O E

E G F M E

P U

N D M D S

R U G

H N V O A E

Y C

P A R

S G L M T

A N

A E N O B O C T C R U

P V

A B

R W E N K N C Q N M L

T O Z

A N E

N H W E

P H

L M U R

Y W E I

H R

T G P

M E D

O H X

R M U

Find the following words in the puzzle. Words are hidden and

R W T C G E

C A

D X

N N O N

C W Y

X U W E

Christmas Crossword Christmas Crossword Puzzle

ARTHROPLASTY BONE CONSULTANT 1 FRACTURE GRAFT 7 HOSPITAL JOINT

KNEE MEDICAL MEDICINE3 ONCOLOGY OPERATION ORTHOPAEDIC PATIENT

SARCOMA SPINE 5 SURGEONS 6 TRAINEE TRAUMA TUMOUR

ARTHROPLASTY BONE CONSULTANT FRACTURE GRAFT HOSPITAL JOINT KNEE MEDICAL MEDICINE ONCOLOGY OPERATION ORTHOPAEDIC PATIENT SARCOMA SPINE SURGEONS TRAINEE TRAUMA TUMOUR

4. Guided the Wise Men (4) 7. Gifts (8) 10. “O Come, all _ _ Faithful” (2) 11. White flakes that cover the ground (4) 13. Why the shepherds were in the field (5) 15. Santa’s colour (3) 17. Striped candy (4) 18. “Silent Night, _ _ _ _ Night” (4) 19. The wise Men came from a _ _ _ country (3) 20. “They looked up and saw a _ _ _ _” (4) 21. Christmas log (4) 22. “The First Noel, the angel did _ _ _” (3)

Down

Across

Across 4. Guided the Wise Men

Down

7. Gifts

1. Where Christmas decorations are hung

1. Where Christmas decorations are hung (5) 2. “_ _ with Gladness, Men of Old” (2) 3. “_ _ Came Upon the Midnight Clear” (2) 5. “Glory _ _ the New-born King” (2) 6. Pull Santa’s sleigh (8) 8. Toy makers at the North Pole (5) 9. He lives at the North Pole (5) 12. Decorations that hang on doors (7) 14. Traditional Christmas bush (5) 16. What stars do (5) 17. Christmas song (5) Answers on page 71

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JTO Features

Relevance of the BOA in Scottish T&O Edward Dunstan Dunblane Hydro hosted the combined Scottish Trauma and Orthopaedic Trainees Symposium (STOTS) and the Summer Scottish Committee of Orthopaedics and Trauma (SCOT) on the 7th and 8th September 2017.

The event commenced with STOTS. All the Scottish orthopaedic trainees came together for a national day of education and an evening of fun. The day was a roaring success, filled with paediatricthemed lectures and breakout sessions. We were honored to host Professor Sir Keith Porter from Birmingham who gave a motivational lecture on CitizenAid. Lisa HadfieldLaw also delivered a fantastic afternoon breakout session on Leadership in Surgery, leaving the delegates eager for more.

Edward Dunstan

There were tutorials on plastering and a surgical skills session on paediatric flexible nailing. This was followed by FRCS VIVA practice and critical case based discussions on paediatricthemed topics. The day was

closed by Professor Colin Howie with insights from his time as BOA President. In the evening trainees and trainers enjoyed a formal meal

Small group learning: Plaster technique.

and ceilidh. The evening closed with a celebration of the best orthopaedic trainers from each region and Vitty Bucknall was presented with the inaugural trainee ‘Bon Oeuf’ award. On the second day, we celebrated success and innovation in Scottish Orthopaedics. The day started with Rhidian Morgan-Jones reviewing the management of the infected Total Knee Replacement. This was followed by updates from the Scottish Arthroplasty Project (SAP) and the Scottish Orthopaedics Services Design Group (SOSDG). They showed the £46 million

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Small group learning: Flexible nailing.

of efficiency savings that have been made in Scotland over the last five years, with improved patient outcomes: l Time Releasing - 100,000

fewer OP appointments p.a = £10m

l Bed Nights - 50,000 fewer

p.a. through Length of Stay reductions = £25.2m

l Implants - £3m cheaper l Infection rate reduction =

£7.8m cost avoidance.

We also discussed the Live Online Orthopaedic Dashboard, which allows immediate, real time review of performance of not only the Health Boards, but also individual hospitals, on a variety of metrics comparing each other and also national

Based Discussion: Paediatric Trauma.

standards. The CUSUM data plots detailing all the complications for individual arthroplasty surgeons over the past five years were particularly well received. The challenge of low volume surgeons and units invoked reflective discussion. The registrar presentations were of an extremely high standard with John Annan top of the class with his presentation ‘Teaching fluoroscopic guide wire placement – a novel inexpensive open source 3D-printable solution’. Both days were very well attended and demonstrated the strength and forward thinking of the Orthopaedic Community on Scotland. n

Edward Dunstan is an Orthopaedic Consultant based in Fife, Scotland where he is also Director of Surgery. Currently he is Chair of the Scottish Committee of Orthopaedics and Trauma (SCOT) and as such sits on the BOA Council. He has been heavily involved in service redesign, theatre efficiency and enhanced recovery in Scotland assisting with the GIRFT project and has participated in several peer reviews.

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JTO Features

The Evolution of Trauma Courses in European Practice Charlotte Cross In 1976, Dr James Styner, an Orthopaedic Surgeon crashed his light aircraft in rural Nebraska. His wife was killed outright and their four children were injured. He provided first aid in the field. The family were later taken to a small local hospital where the care was so poor that he described their final evacuation as ‘coming out of a hostile hell into civilization’.

He is famously quoted as saying ‘When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed’1. The system was changed and Advanced Trauma Life Support (ATLS) was born. The pilot course ran in Nebraska in 1978, was adopted by the American College of Surgeons and taught nationally by 1980. It made its way to the UK in 1988 and is now taught in over 75 countries. Over 1.5 million candidates have been trained2.

Charlotte Cross

Without doubt ATLS adds structure, a common language, and a stepwise approach to managing trauma, with a focus on early intervention

in life-threatening conditions. However, over the 40 years since the inception of ATLS, trauma care in the UK has changed, in particular with the introduction of major trauma networks in 2012. These included consultant led, multidisciplinary major trauma teams, the increasing provision of pre-hospital care3 and the implementation of the multiple lessons learned from the military4. The European trauma patient demographic also differs from the North American experience, with a predominance of blunt trauma, rather than penetrating5 injuries. With the centralisation of services in the UK, patients are being managed by multidisciplinary teams, rather than by single providers in isolated settings. Consequently, until the recent tenth edition, ATLS

was criticised for continuing to teach and assess candidates individually with little focus on trauma team management. ATLS has been further criticised for its poor evidence base and failure to respond to changes in trauma care in a timely manner. The question as to whether ATLS really reflected the current practice in UK trauma management was asked. There was a growing demand for a European alternative, which would reflect the aetiology of European trauma and recognise the multidisciplinary nature of trauma team working. In 2004 the European Resuscitation Council (ERC) set up a working party with a remit to address the care of the trauma patient, covering both the pre-hospital and early in-hospital periods. It was soon recognised that the heterogeneous nature of pre-hospital care across Europe meant that it would be necessary to split pre- inhospital care. Thirty-one trauma surgeons, anaesthetists, emergency physicians and intensivists from ten countries started work in late 2005. By September 2006 a course manual had been produced. The first pilot was run in Malta in 2006 and following further feedback and pilots the first European Trauma Course (ETC) was held in Ghent in 20086.

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Team brief

Communication with bloodbank, radiology, operating theatres/ICU/MDT

Team introductions Share information Assess competencies Role allocation Anticipate responses

Airway

Teamwork

Communication

Decision making Circulation

The introduction of ATLS not only revolutionised trauma care but also educational techniques in acute medicine. The course is limited to small numbers of participants with a high instructor to candidate ratio. There are standardised lectures with small group practical skills sessions. Currently the course relies heavily on didactic lectures to teach what is essentially a very practical topic. One of the greatest advantages of teaching adult learners is the amount of knowledge and experience they bring. Therefore it is unsurprising that didactic lectures are unpopular. ATLS expects candidates to manage trauma independently in a vertical manner. It leaves little room for discussion and candidates can often find the differences between the course and their day-to-day practice unsettling. By contrast ETC contains only two lectures and one faculty demonstration, but there are over 30 moulage scenarios for candidates to participate in (Table 1). The course expects you to be in your typical role and to perform skills appropriate to this. ETC relies on an assumed prior knowledge of basic resuscitation skills and aims to be more flexible and to allow for regional differences. The expectation is that trauma is

Situational awareness

Breathing

Figure 1: Horizontal preparation and resuscitation.

Educational Style

Task management

managed horizontally by teams (Figure 1). There is an increased focus on team working and non-technical skills including communication, situational awareness and decision-making (Figure 2). The trauma team leader role encourages the development of leadership skills and is the role on which the final assessment is based. Skills teaching is included in scenarios in a more integrated and contextual way to aid decision making, timing and appropriate communication between the team leader and the team.

Conclusion Whilst ATLS has redefined trauma care worldwide, its critics would say it has failed to advance at the pace required and does not reflect current trauma care in the UK. ETC better represents current trauma care and allows for regional variations and flexibility, but does require a grounding and prior knowledge that ATLS does not. Moving forward both courses have a role. ATLS is an excellent introduction to systematic trauma care and provides a shared language of trauma for junior trainees with limited experience. However, for senior trainees ATLS is dogmatic and teaches an individual working style which is unrealistic and often unhelpful.

Figure 2: Non-technical skills in ETC, reproduced from ETC 1.9 Lecture Slides.

We believe that whilst the Joint Committee on Surgical Training requires ATLS certification, trainees will miss out on training opportunities which are more in line with their current working practices and include a focus on non-technical skills. Most trainees will not consider undertaking ETC, as the quantity of and budget for study is limited. Both the Royal College of Anaesthetists and the Royal College of Emergency Medicine recognise ETC and have no prerequisite for ATLS for certification. Our concern is that in the UK two separate models for trauma care will develop and the standard approach and common understanding of trauma will be lost. n

Charlotte Cross is an ST8 in Trauma and Orthopaedics, Health Education North West. She has a keen interest in trauma and her elective preference lies in soft tissue knee and osteotomy. She teaches on both Advanced Trauma Life Support and more recently on the European Trauma Course.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

ATLS

ETC

No requirement for prior knowledge

Requirement for prior knowledge

Mainly lecture based (7 hours)

Minimal lectures (1.5 hours)

Little flexibility for regional variations

Flexibility for regional variations

Individual working

Team working

Fails to keep up to date with trauma practices

Up to date with trauma practices

Same groups throughout

Different groups, simulating trauma teams

2.5 days long

High participant to faculty ratio

Focus on practical skills

Focus on non-technical skills

Table 1: Comparison of ATLS and ETC courses.

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JTO Features

The Key Issues and Current Health Landscape in India Ram Prabhoo Co-author: Ashok Shyam India is one of the most populous countries in the world with one of the largest economies. Along with economic and developmental transition, there is a rapid and significant change in the disease spectrum and the population’s health. There is a partial reining in of the communicable diseases, but an uncontrolled escalation of non-communicable disease. On the other hand not much has changed in healthcare delivery, which is still largely dependent on the private sector. The public sector is in much need of a boost in planning, funds and infrastructure. There is poor collaboration between public and private sectors and the recent rise of corporate hospital chains has further amplified the already wide gap. The provision of health insurance needs attention and a universal health insurance policy is much needed.

Ram Prabhoo

In the last year there have been two major events which have the potential to change the landscape. The first was price capping of cardiovascular stents and total knee replacement implants. The main premise of this decision was to provide essential components at an affordable cost to the large number of lower middle class individuals. The final balance

between the negative response from industry and the as ‘yet uncalculated’ positive impact on healthcare is yet to be reached, as is how these decisions will mould the future of healthcare. However it does show that the policymakers are looking at the healthcare sector seriously. The second major event was approval of the National Health Policy 2017 by the Union Cabinet in March 2017. There is a lot to be hopeful about in this document with Universal Health Coverage (UHC) as a goal. The policy looks balanced with focus on both communicable and non-communicable diseases. It also promotes comprehensive healthcare by stitching together the public and private systems. The policy states that there will be “Free primary care provision by the public sector, supplemented by the strategic purchase of secondary care hospitalisation and tertiary care services from both the public and the non-governmental sectors to fill the critical gaps. This will

be the main strategy in assuring healthcare services”. There are many suggestions and excellent plans with major inter-sectorial collaboration and co-operation to prevent disease and promote health. It is called Swasth Nagrik Abhiyan or Health for All. However, many policies look good on paper, but the issue is with implementation. Current successful roll out of low cost policies such as Rajiv Gandhi Jeevandayee Arogya Yojana, Niramaya Yojana and low cost High Technology initiatives under the ‘Make in India’ programme have raised expectations and hopefully underline the feasibility of such policies. Only time will tell how the 2017 National Health Policy will shape healthcare in India. We believe the healthcare landscape in India is improving. If the promise of increasing healthcare expenditure to 2.5% of GDP is realised, this will further boost the reforms as well as the National Health Policy. n Ram Prabhoo is the President of the Indian Orthopaedic Association. He is the Head of Department at Wadia Hospital and Medical Director of Mukund Hospital. He is involved in research and development of indigenous and inexpensive methods to suit the orthopedically handicapped population in developing countries. He has co-authored four books, two of which have won best book awards.

Courses to support every stage of your career Of our 22 courses, 18 take place in London and Manchester, while 12 are available at over 130 regional and international centres.

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Faculty were engaging and knowledgeable, with a genuine wish to help and inform.

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Definitive Surgical Trauma Skills delegate

FF O % 10 ED T C E SEL SES R U CO R RCS

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Definitive Surgical Trauma Skills (DSTS) Surgical Training for Austere Environments (STAE) Pre-hospital and Emergency Department Resuscitative Thoracotomy

START BUI L DI NG Y OU R K NOW L E DG E TO DAY: WWW.RCS E NG . AC.U K /ED U

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JTO Features

The Implementation of Rota Changes to Optimise Training Opportunities in the East of Scotland Graeme Nicol Co-authors: Stephen Dalgleish, Alasdair MacInnes and Sankar Sripada There is a continual debate about how to optimise surgical training within the constraints of the European Working Time Directive (EWTD). Changes to surgical training have affected junior doctors and their supervision1. Surgical training differs from medical training, in that surgeons must not only have the underlying knowledge to provide acutecare; but the technical competence to operate. There is no consensus on how long it takes to train a surgeon2.

Graeme Nicol

Some educational psychologists believe it takes ten years or 10,000 hours of practice to acquire an elite level of expertise or performance3. Whist this has never been proven for surgical skills, it is not surprising that the majority of surgical trainees remain opposed to working hour restrictions4 due to the perceived detrimental effect on training and patient care5,6,7,8,9. This was re-iterated in Professor John Temple’s independent review of the impact of EWTD on training10. Ultimately trainees retain ownership and responsibility for their own training although. In the early stages of a surgical career, guidance is necessary to maximise opportunities. Other

studies have made suggestions as to how trainees can best meet their training needs and optimise surgical exposure11. However, surgical training is not solely limited to time spent learning practical skills in an operating theatre, but requires exposure to clinical decision making in clinics or on a ward-based environment. In our region (East of Scotland), we had below average ratings in many domains in the 2014 GMC national training survey. Trainee feedback raised a number of factors which were felt to contribute to these results; the most frequent complaint being a lack of adequate theatre exposure with the assigned clinical supervisor. The existing

rota structure seemed to be the main contributor to the low “overall satisfaction” and “adequate experience” domains which, in turn, impacted on “clinical supervision” and “feedback”. Trainees were also struggling to attend postgraduate teaching which affected “access to educational resources”. We redesigned the registrar rota to maximise theatre exposure and access to postgraduate teaching, but avoid jeopardising clinic and ward-based experience. We hoped that these simple alterations would lead to an improvement in areas found to be deficient in the GMC Survey; proving that our training was not deficient, but that trainees were simply unable to fully benefit from all the learning opportunities it could offer. We reviewed the period in 2014 implicated in the survey and recorded the total number of days junior and senior trainees were allocated to theatre sessions, along with postgraduate teaching attendance. We implemented the changes as outlined in Table 1. After implementation of these changes, the same data was collected for the same time period the following year and the GMC Survey results from 2015 were analysed.

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Trainee never held the orthopaedic on-call page during the day when their team was in theatre. Foundation Year 2 Doctors (FY2s) utilised more effectively by inclusion in the daytime on-call duties, with appropriate senior support, in addition to theatre and clinic sessions. Senior trainees were allocated daytime on-call duties, which had previously been done exclusively by junior trainees. This was timetabled, usually when their Consultant had a supporting professional activity (SPA) session to minimise impact on clinical commitments. When possible junior trainees were attached to do the same theatre as senior trainees. For example, a ST3 was attached with a ST6-8 so they did not have conflicting interests. This gave junior trainee’s exposure to basic surgical skills and theatre etiquette which allowed them to see what is expected of a surgical trainee. It also allowed senior trainees experience of delivering surgical teaching of index procedures in a supervised environment. If a trainee was unable to attend theatre due to night shift, annual leave, study leave or zero days, another trainee was allocated and not substituted by advanced nurse scrub practitioner, minimising missed learning opportunities. Trainee on-call weekend shifts were co-ordinated with their supervising consultant, where possible. This allowed trainees to perform at the appropriate level both surgically and clinically. It also meant trainees knew patients under their consultants care, thus improving continuity of care and job satisfaction. The rota was organised in a timely fashion, incorporating all leave requests, reducing the need for excessive swaps and disrupting the daily running of the unit. On-call bleep holding, night shifts and compensatory zero weeks were co-ordinated around planned Consultant leave. Table 1: Rota changes.

After the changes had been implemented, the junior trainees’ theatre allocation increased substantially from 12 days to an average of 17 days with the seniors increasing from 16.5 to 20 days. Teaching attendance increased from 38% to 69% for junior trainees and for the senior trainees this increased from 68% to 75%. The results of the 2015 GMC Survey revealed marked improvements which persist into the 2016 survey (Figure 1). Both rotas were monitored following

these changes and found to be compliant with the new deal and the EWTD. This is an example of trainee-led improvement through a number of small, well-implemented adjustments. The “below outlier” results of the 2014 GMC Survey were a stimulus to change. The changes implemented, produced a 42% increase in the number of days junior trainees were allocated to theatre over a threemonth period. Senior trainees also benefited from a 19%

increase in the number of days operating. Over the duration of an eight-year orthopaedic runthrough training programme, this amounts to an additional 130 days of theatre allocation. Fitzgerald et al. suggested that surgical trainees should be proactive in order to efficiently manage their time12. It can be difficult for junior trainees to be proactive and we believe that surgical trainees cannot afford to miss out on training opportunities resultant on

inefficient rota management, and the experience of senior trainees and consultants should be used to optimise the rota. All trainees within our region have seen an improvement in surgical education and learning opportunities as a result of these changes. Whilst we have measured theatre exposure and teaching attendance to assess improvements, there were also anecdotal improvements noted in patient care, due to improved continuity of care, which are harder to quantify. Whilst theatre exposure is only one component of surgical training, the rota modifications had widespread effects on other domains of training, as recognised in the GMC Survey. By breaking down the barriers preventing optimum exposure to training, it is then ultimately up to the individual trainee to make the most of this opportunity. In many centres, constructing and running the registrar rota is an activity that is managed by support staff, with little or no input from trainees. We feel strongly that taking responsibility for your own training provides multiple benefits; not only increasing surgical exposure, but also providing substantial managerial and leadership experience. These changes could easily be implemented in other regions and specialties. n Graeme Nicol is an ST7 in Trauma and Orthopaedic Surgery working in the East of Scotland Deanery. His interests include hip revision surgery and pelvic reconstruction. He has been accepted for the hip reconstruction followed by the Trauma Fellow post in Bristol Southmead Hospital commencing August 2018.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

Figure 1: GMC Survey Trend.

Volume 05 / Issue 04 / December 2017

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JTO Features

Review of the AO Trauma Seminar: Introductory Seminar for Foundation Doctors and Undergraduates Adam Stott During my medical elective in Trauma and Orthopaedics in Northumbria, it was suggested that I attend the AO Trauma introductory course in Leeds. As a student with many career paths open to me, I am a fan of taster days to whet my appetite.

Adam Stott

The course lasted a day and was aimed at Medical Students and FY1s. I was emailed screencasts demonstrating the principles of bone healing and the different types and uses of screws in advance. The concepts were then explored more thoroughly with practical workshops to consolidate the knowledge. Talks and group discussions on the principles of immediate trauma care and fracture management were interspersed throughout the day, with three practical workshops, where we used screws, plates, external fixators, and dynamic hip screws.

The course was great! It was aimed at the right level and I learned a lot in a short period of time. Being able to use the practical skills was stimulating and helped solidify my knowledge. Using the equipment and observing the compression and stability of fractures in plastic bones, helped me to understand the techniques as well as boosting my surgical confidence. Having completed the course the time I have spent in trauma and orthopaedic theatres has been much more engaging and beneficial. My understanding of the instruments and techniques

has allowed me to ask better questions, be more hands on, and feel part of the team. Meeting people in a similar position was exciting. Many of the students had different experiences and varying levels of interest in orthopaedics. Hearing their reasons for attending and talking with the consultants helped me decide that trauma and orthopaedics really is the surgical speciality for me. I would recommend this course to any medical student or foundation doctor who is interested in orthopaedics, and to any clinician who is teaching a budding. n Adam Stott is currently in the final year of his medical education at Newcastle University. Originally from Barnsley, he hopes to complete his foundation years in the Trent Foundation School, and complete a Masters in Sports and Exercise medicine at the University of Nottingham.

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Volume 05 / Issue 04 / December 2017

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JTO Features

An alternative route to passing the FRCS: A non-trainees perspective Kebba Marenah Co-authors: Mohammed Al Kooheji, Stephen Bendall The FRCS (T&O) postgraduate exam for most trainees is the culmination of many years of training. A guide to passing the examination itself has recently been published in this journal1, so this article will focus on successfully navigating this exam from the perspective of a non-trainee. Whilst the overall pass rate of the exam hovers around the 60% mark, when broken down into trainee type, it is upwards of 80% for trainees whilst it is significantly lower for non-trainees, especially for Section Two2. Non-trainees account for almost half of the candidates at most sittings2. We do not feel that those who opt for the non-training route should be put off by these statistics.

Kebba Marenah

As with any postgraduate examination, the key to success is adequate preparation. For trainees this starts from ST3 when they start attending regular teaching sessions. We decided that when we made the transition from “SHO” to registrar we were going to opt for the non-trainee route. This involved a considered approach to the jobs we undertook, in essence creating our own rotations through the sub-specialties, in much the same way as trainees. This was reflected in our logbooks. We feel that this prospective approach lends itself better to passing the exam, as opposed to the usual retrospective approach that most non-trainees adopt,

after they have settled on a subspecialty. We recommend working at teaching trusts or major trauma centres, as these units tend to offer a greater amount of registrar teaching as well as morning trauma meetings which replicate the approach of the Part Two viva. We undertook the majority of our self-created rotations in a single trust, which was supportive of our plans. We had made our plans clear from the outset. We prioritised targeted learning along the way. Our registrar rotations were completed over four years, as were our trainee colleagues. We used the ST6 waypoint checklist3 as a reference guide in choosing rotations as we progressed through our training, finishing at a similar time to those who followed the traditional route. The sign off for the exam requires three structured consultant references, including the department clinical lead, after a review of log books and with adequate personal knowledge of the applicant. From this

point onwards the preparation for the exam itself is much the same as that recommended for trainees. One difference was that despite similar levels of knowledge to trainees, being able to produce answers in the “higher order thinking” manner required for Section Two was a little harder without the regular practice. This was remedied by joining revision groups which included trainees, allowing us to get adequate viva practice. Having passed the exam we are now eligible to apply for a Certificate of Eligibility for Specialist Registration (CESR). The advantage of our custommade route is that we have used the ISCP and adhered to the preCCT checklist4, which should ease the application process. n Kebba Marenah is a Senior Clinical Fellow in Trauma and Orthopaedics at Brighton and Sussex University Hospitals NHS Trust, where he did most of his training. Having now passed his FRCS (T&O), he intends to return home as the first Gambian Orthopaedic Surgeon.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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Volume 05 / Issue 04 / December 2017

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JTO Features - Trainee Section

ST3 National Selection, a look behind the scenes Lawrence Moulton Prior to 2013, selection to trauma and orthopaedic higher training was run locally. After 2013, national selection with a single interview centre was introduced. Whilst Wales and Northern Ireland are not part of this process, all English and some Scottish rotations participate. As one of the trainee representatives on the Selection Design group, I thought it would be useful to shed some light on how the process of designing national selection works.

Question preparation National selection usually runs in March or April. The selection design group usually meets in July, once the outcomes of the previous yearâ&#x20AC;&#x2122;s process is known. The outcomes of the interviews are reviewed, strengths and weaknesses identified and any changes required are identified.

Lawrence Moulton

Subsequently, themes for the different stations are developed and the selection design group is split into teams, each focussing on writing a question and its marking schemes. This process takes place over several weeks. After each group has had time

to work on their questions, the group meets and every question is presented. Each question is reviewed, line by line, to ensure that it is clear, fair, representative and that it maps to the curriculum. The final changes to the questions are made and finalised. As trainee representatives, our views are considered, particularly when assessing whether a scenario is fair and reasonable. Some of the communication skills scenarios are based on our experiences of common scenarios encountered during our clinical practice as junior doctors.

To ensure that the questions are reproducible, the questions are scripted so that exactly the same questions are asked to each candidate. There are clear scoring matrices for the questions to enable reproducibility.

On the day At the beginning of the day there is a general interviewer briefing so that all are aware of how the process will run. Each interviewer will be on one station type for the whole day. Following the general interviewer briefing there is a specific briefing for each station. In these briefings, the station leads explain the station and how it should run. The leads answer any questions and try to ensure clarity of the marking scheme. This ensures reproducibility. After the first round of interviews, the interviewers for each station meet again to discuss any issues that have arisen during the first session. This allows clarification of any issues, for example if any of the elements of the mark scheme are not clear. In addition to the interviewers, there are others quality assuring the interview process. These include,

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As trainee representatives,our views are considered, particularly when assessing whether a scenario is fair and reasonable. Some of the communication skills scenarios are based on our experiences of common scenarios encountered during our clinical practice as junior doctors.

lay representatives, trainee representatives from the design group, station leads and other consultants. These individuals move between stations to ensure that the stations are being run as they were designed to. This allows early identification of any problems. Finally, all the scores are collected and double checked by members of the selection design group. They are then entered into the scoring matrix. At this point if there are any large differences in scoring between interviewers, this is flagged to ensure that no error has been made.

Top tips for your core trainee l All the questions are based

on the curriculum and job description. Do know the curriculum and job description.

l Do come prepared – make

sure that you bring everything that you are asked to bring.

l Do put the evidence in your

portfolio – if you have stated that you have completed a number of audits, this needs to be verified to get the points.

l Don’t worry if there is an extra

person on your interview station,

they are usually quality assuring the process. They are assessing the interviewers – not you! l Don’t listen to your friends

too much – multiple questions are written so that they can be changed between days and on the day. It isn’t helpful to know what your friend had as you are likely to get something different and it may make your performance worse.

l Don’t tell your friends too

much – it is unlikely to help and it may even hinder them. Also, it may be the difference between you getting OR not getting a job.

l Don’t rely excessively on past

questions – all the questions are written from scratch each year.

Conclusions Having been a part of the selection design group for the past year, I can say that the process is rigorous and fair. A significant amount of time and effort is taken to ensure that the questions are well written and reflect the practice of a new ST3. Whilst the interviews take place over four days, every effort is made to ensure consistency. Some disagree with national selection as a principle, however, I believe that the current system works well. n

Lawrence Moulton is an ST8 in Trauma and Orthopaedics on the Owestry-Stoke rotation, currently working at University Hospitals of North Midlands, Stoke-onTrent. He is the current BOTA SAC representative and the BOTA representatives on the ST3 Selection Design Group.

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JTO Medico-Legal Features

Loss of malpractice insurance for spinal surgeons: why you need to know about the discount rate Michael A Foy The Medical Defence Union (MDU) have recently announced that it is impossible for them to continue to provide indemnity to members practicing spinal surgery because the cost of settling claims in spinal surgical cases has escalated massively due to the Governmentâ&#x20AC;&#x2122;s recently announced policy to cut the discount rate from 2.5% to -0.75%.

The general response from my clinical colleagues (spinal and non-spinal) when this subject has been raised has been a look of blank disinterest. They have enough concerns in day-to-day clinical practice with issues of patient management, issues with hospital/departmental policies, protocols and guidelines, junior staff, Montgomery etc., etc. Why on earth should a Government policy like this have any relevance to them?

Michael A Foy

However, it is an interesting saga and worth telling. What is the discount rate? The discount rate (also known as

the Ogden rate) forms part of the overall mechanism to determine the level of compensation awarded for cases involving serious injury, whether that injury is caused by medical negligence or by a road traffic accident or an industrial injury. The majority of claimants who have a serious injury which requires long-term care, for example, someone who has been judged to have been negligently paralysed by a spinal surgeon, choose to take their compensation as a lump sum rather than as an annual payment over the rest of their lifetime. Since 2001, when the discount rate was last changed, it has

been set at 2.5%. This means that any lump sum is discounted to allow for a predicted 2.5% per annum investment return. On Monday 27th February, the then Lord Chancellor Liz Truss announced that the rate would be reduced to -0.75%. The change will apply to all claims settled after 20th March 2017, regardless of when the injury occurred. The discount rate is linked, by law, to returns on low risk investments, typically index linked gilts, i.e. Government Bonds. With low interest rates the returns on these investments have fallen dramatically since 2001. Therefore all future settlements will be increased to reflect a predicted negative investment return on the lump sum awarded to claimants...! Consider this, you have been fortunate enough to win, be given or inherit a million pounds and wish to place it in a safe investment environment to provide for your dotage. What do you do? Most, if not all of us, would consult a trusted independent financial

Volume 05 / Issue 04 / December 2017

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adviser (IFA) and explain that we are risk averse and ask for an investment strategy that mirrored that risk averse position. No one in their right mind would put a million pounds solely into Government linked bonds. It would be crazy. Yet this is the model that the Government have used to predict investment returns. The effect will not only fall on the insurance industry but also, massively, onto the NHS. The Lord Chancellor obviously recognised this pointing out that the Government was committed to ensuring that the National Health Service Litigation Authority (NHSLA), now NHS Resolution (NHSR), had sufficient funding to cover

boa.ac.uk

changes to hospitals’ clinical negligence costs. As you might expect, the position taken by claimants solicitors and insurers differs somewhat. The solicitors complain that it is a disgrace that it has taken so long for the rate to change and that their clients have been undercompensated. The insurance industry believes that it is a reckless decision from the Lord Chancellor’s Department. You may then ask what difference does this make, and the answer is a huge difference, particularly to large claims in younger people. For example, a 21 year old

requiring long-term care, but with a normal life expectancy after a spinal cord or similar injury having been awarded £1 million prior to 20th March 2017 would now, at the new discount rate of -0.75%, receive £2.3 million. A similar claim at £5 million would now settle at around £12million. In view of the number of variables there is ‘no rule of thumb’ which can be applied to assess the overall impact to the total value of a claim due to the increase in the discount rate. An analysis by Mark Burton at Kennedys Solicitors (2017) set out below an early ‘broad-brush’ assessment of the impact of a –0.75%

discount rate on a £5 million claim of a claimant with normal life expectancy (Figure 1).

Age

% increase in value of claim

Revised total

10 – 20

100 – 200%

£10m - £15m

20 – 30

80%

£9m

30 – 40

75%

£8.75m

40 – 50

70%

£8.25m

60 – 70

40 –50%

£6m - £7.5m

Figure 1: Calculation of the impact of a -0.75% on a £5 million claim on an individual with a normal life expectancy.

The change in the discount rate from 2.5% to –0.75% has had a dramatic impact on reserves for nearly all claims where >>

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Volume 05 / Issue 04 / December 2017

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JTO Medico-Legal Features

You may then ask what difference does this make, and the answer is a huge difference, particularly to large claims in younger people. For example, a 21 year old requiring long-term care, but with a normal life expectancy after a spinal cord or similar injury having been awarded £1 million prior to 20th March 2017 would now, at the new discount rate of -0.75%, receive £2.3 million. A similar claim at £5 million would now settle at around £12million.

there is a future loss element. This determines the amount of money the defence unions, insurers and NHSR have to set aside to provide for future predicted losses. Ultimately, this will come from increased subscriptions for indemnity, selective indemnity or refusal to indemnify at all, as with the MDU and spinal surgeons. It will also lead to increased insurance premiums and as far as NHSR is concerned an increased drain on the Treasury. According to the NHSR Annual Report for 2016/17, “The Government recognises that there will be a significant impact on public finances, and therefore has added around £1.2 billion a year to the budget reserve to meet the expected costs to the public sector, in particular to NHS Resolution.” The latter will probably be compounded by a move of higher risk procedures from the private sector to the NHS. It should be noted that in calculation of settlement costs all future medical/care requirements are calculated on a private, not NHS, basis and this is another area that may merit discussion/consideration. The change is seen most dramatically in catastrophic injury claims. This is demonstrated by an analysis of the percentage increase in Ogden Table 1 multipliers (Burton 2017). These are the tables that the legal profession

use to calculate settlement for future losses in catastrophic injury cases (Figure 2). Age

2.5%

-0.75%

Percentage increase

34.08

108.32

217.84%

32.10

88.96

177.13%

29.60

71.43

141.32%

26.52

55.66

109.88

22.69

41.44

82.63%

18.30

29.19

59.51%

13.44

18.85

40.25%

Figure 2: Percentage increase in Ogden Table 1 multipliers (Burton 2017).

On the basis of this the MDU issued a statement indicating that they have, “reviewed the indemnity risk in relation to certain types of work undertaken by members and, regretfully, have concluded that the impact on the cost of settling spinal surgical claims make it impossible to provide indemnity for members undertaking private practice in this speciality”. They went on to outline how the effect of the change in discount rate is profound and will, potentially, more than double the cost of many high value clinical negligence claims such as those arising from spinal surgery. The MDU will honour existing memberships up until the end of the current membership year but after this spinal surgeons will have to source alternative indemnity.

According to Stride (2017) the Medical Protection Society (MPS) and the Medical and Dental Defence Union of Scotland (MDDUS) will continue to provide cover for spinal surgeons, with new applications being assessed on a case by case basis by the former and for consultants who hold a substantive NHS contract by the latter. However, there may be some light at the end of the tunnel. The Ministry of Justice (MoJ 2017) recently published its response to the discount rate consultation together with draft legislation. The salient features from this document are: l The rate will be set with

reference to “low risk” rather than “very low risk” which better reflects the actual investment habits of claimants

l The rate should be reviewed

every three years

l The Lord Chancellor will

conduct a panel of independent experts when setting the rate

l The proposals envisage that a

review of the discount rate would be started within 90 days of the law coming in to force. Whilst it is difficult to provide an estimate, based on currently available information, if the new system was to be applied today the rate would probably be in the region of 0-1%. Whilst this may mitigate, to a degree, the

predicted increased settlements to claimants with a discount rate of -0.75%, it will still cause increased demands in the areas discussed, i.e. indemnity payments, insurance premiums and Government provision. Of course, the final point to be made is that if someone is genuinely, seriously or catastrophically injured by someone else’s negligence, whether that someone is a surgeon, a car driver or an employer, the injured person deserves to be suitably and adequately compensated for those injuries and the effect that they have had on their life. That is the rule of law in a civilised society. n Michael Foy is a Consultant Orthopaedic and Spinal Surgeon. He is Chairman of the BOA’s Medico-legal Committee, coauthor of Medico-legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Subspecialty Section

Soft Tissue Tumours – Diagnosis and Pitfalls Gillian L Cribb The assessment of patients with soft tissue swellings is now common place for orthopaedic surgeons. With the publication of NICE guidelines in 20061 and further guidelines in 20152, as well a huge awareness campaign by Sarcoma UK to general practitioners (‘On The Ball’), increased numbers of patients with soft tissue swellings are being referred to secondary and tertiary orthopaedic care.

Benign soft tissue tumours outnumber malignant tumours by a factor of at least 1003, so an effective, timely strategy to identify concerning swellings is required. Soft tissue sarcomata are malignant tumours of mesenchymal tissues and account for less than 1% of

malignant tumours. They become more common with increasing age, but can present at any age with the majority affecting the limbs and trunk. The recorded incidence has increased over the last 18 years; however, this may be due to increased reporting4. The size of the tumour at presentation is significantly related to survival5, therefore early diagnosis is of paramount importance. Lymphoma, metastatic disease and melanoma can also present with soft tissue swellings. Most soft tissue sarcomata of the extremities and superficial trunk present as a painless soft tissue mass. In 2006, NICE Lump > 5cm Lump Increasing in size Lump deep to the fascia Pain

Gillian L Cribb

Table 1: NICE ‘Referral guidelines for suspected cancer’ (www.nice.org.uk/CG027).

published guidelines to identify those swellings which are more likely to be concerning (Table 1). In addition, any lump which is recurrent, following previous excision, should be treated with increased suspicion. These clinical features help formulate further investigation. We believe that all soft tissue swellings should be imaged, after taking a thorough history and examination. Ultrasound scanning (USS) is a quick, cheap and effective method of assessment of soft tissue swellings superficial to the deep fascia. It is operator dependent and requires an operator who is experienced in musculoskeletal ultrasound. Ultrasound scanning is the suggested modality of imaging under NICE 2015 guidance (NG12) and NICE recommends that primary care practitioners have urgent, direct access to USS to assess any unexplained lump that is increasing size. If ultrasound

findings are uncertain or clinical concern persists referral to a cancer pathway is recommended. When there is USS uncertainty a Magnetic Resonance (MRI) scan is usually required. However, swellings which are less than 5cm and superficial to the deep fascia may also be treated with excisional biopsy. Excisional biopsies should be performed through an extensile approach, which in the limb would always be longitudinal. It should always be kept in mind that wider excision may be required. Transverse incisions are not extensile and wider excision of these scars will often require plastic surgical reconstruction. Excised tissue should always be submitted for histological analysis. An MRI scan is required to further evaluate any swelling where there is USS uncertainty, size is greater than 5cm and for all lesions deep to the deep fascia. The MRI protocols for tumours should be tailored to soft tissue tumour assessment, rather than usual musculoskeletal protocols used to look at the knee joint, for example. Following MRI scanning biopsy is often required and this should be performed in a Regional Soft Tissue Sarcoma Unit with an MDT to help diagnose and manage the patient. A percutaneous needle biopsy is usually obtained with image guidance under local or general anesthesia. The biopsy track should be in the line of any subsequent extensile approach.

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Analysis of the sample by a suitably experienced pathologist is of paramount importance – there are over 50 histological subtypes of soft tissue sarcoma and accurate subtyping will dictate management (Figure 1).

the history is inconsistent with the size of lesion. A follow up scan, as well as further clinical assessment, should be performed to ensure resolution. A haematoma that is increasing in size is likely to be a bleeding soft tissue tumour (Figure 2).

Figure 1: A 10cm, growing, painful, deep swelling in left thigh adductor region. Biopsy confirmed a high grade soft tissue sarcoma.

Unfortunately, despite NICE guidance and a general increase in awareness, the fiveyear survival rate for soft tissue sarcomas remains at 51% and has not changed significantly over the last 12 years3. Many patients still present to the Regional Soft Tissue Sarcoma Units following lengthy delays. Some delays are certainly patient related. Swellings in the buttock and periscapular regions can become very large before being recognised. Further delays occur in primary care with patients reporting several consultations prior to referral. Delays in secondary care are usually as a result of a failure to consider soft tissue sarcoma as a possible diagnosis. The diagnosis of a ‘haematoma’ is the most common pitfall, as small soft tissue sarcomata that are very vascular and bleed can give the radiological appearance of a haematoma. A diagnosis of haematoma should be treated with caution, particularly where

Figure 2a, 2b, 2c: Images at presentation, after four weeks and 12 weeks of an upper arm swelling though to be a haematoma secondary to warfarin use not settling with surgical drainage. Histology revealed a high grade soft tissue sarcoma. An emergency amputation was required as tumour was fungating and bleeding on arrival at sarcoma centre. Patient died from metastatic disease six months following initial presentation.

Lipomata often cause anxiety. Superficial lipomata can be confidently diagnosed with ultrasound. The size is not of concern providing all the tissue is of a lipomatous nature. Excision or an observation are both reasonable. Deep lipomata need more careful consideration and require MRI assessment. The majority are benign and have no risk of progression. A small subset (Atypical Lipomatous Tumour / Well Differentiated Lipoma Like Liposarcoma: ALT/WDLLL) do not metastasise; however they can dedifferentiate to a dedifferentiated liposarcoma, with a risk of metastases. Unfortunately, a radiological diagnosis cannot be made with certainty with experienced observers having a 69% chance of making the correct diagnosis6. A biopsy could be performed, however specialist gene studies are required to distinguish between the two (MDM2). In practical terms, deep lipomatous tumours should either be completely excised or monitored with MRI scans (Figure 3). n

Figure 3: An atypical lipomatous tumour / well differentiated liposarcoma.

Gillian L Cribb is a Consultant in Orthopaedic Oncology at the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust and Honorary Senior Lecturer at the University of Manchester. Her higher surgical training was on the Oswestry / Stoke rotation and she completed a fellowship in Brisbane, Australia.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Subspecialty Section

Controversies in the Management of Metastatic Bone Disease Karen L Shepherd Metastatic bone disease (MBD) is a significant issue in orthopaedic surgery. Extrapolation of cancer registries incidence and mortality data indicates that greater numbers of people are living with cancer1. Both breast and prostate cancers - common tumours with MBD potential - have increasing incidence, yet mortality is reducing2, reflecting a potential cancer burden in an ageing population3.

The British Orthopaedic Association revised their guidelines for the management of MBD in 20154. They include a guide to decision making, investigations, surgical implant choice and when to operate.

Should we operate?

Karen L Shepherd

The first question to be posed is, ‘Is this a metastasis?’ If doubt exists as to the nature of the lesion, biopsy will give a definitive answer. The second question should be, ‘Is the lesion painful?’ If the lesion is asymptomatic surgery is usually not indicated4.

Presenting with a fracture is not an automatic passport to surgery. However, the decision to operate is easier, usually to palliate, than whether to prophylactically operate on an asymptomatic, intact lesion. The decision-making process involves an understanding of the behaviour of the primary tumour, the likely prognosis and the location of the lesion and its risk of pathological fracture. The prognosis is usually relatively good in metastatic breast, renal, prostate and thyroid cancers. Virtually all other lesions have a poorer prognosis. Mirels’ score5 can be helpful but

it should be applied with caution, as it lacks specificity6. Further important predictive considerations are age, coexisting extra osseous disease, previous radiotherapy, and comorbidities7,8. It is difficult to accurately predict life expectancy9,10,11; consequently, there has been increasing interest in developing a quantifiable measure of prognosis via biochemical markers. In many tumour groups an attempt has been made to determine their prognosis with inflammatory markers and other tumour specific data. Low haemoglobin and albumin or high C-reactive protein, urea, alkaline phosphatase, calcium, and platelets suggest a poorer prognosis,13,14. Unfortunately, these parameters have limited use in guiding management in patients with functionally debilitating disease. Of minimal scientific value, but no less relevant is ‘the end of bed test’. Will the patient tolerate major surgery? Does the patient want to undergo surgery? In metastatic disease the end of the bed

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Figure 1: Assessment of the patient is key to decision making. 58-year old patient with humeral fracture in a metastasis from a low rectal carcinoma (a). There were multiple bone metastases and biopsy of the arm confirmed metastatic rectal carcinoma. Symptoms were well controlled and patient was comfortable in a brace. Surgery was not offered given the poor prognosis, minimal symptoms, large soft tissue mass (b – dotted line indicates soft tissue component). Following this decision the patient rapidly deteriorated.

test can be misleading. When comparing an elderly patient with multiple comorbidities and an osteoporotic neck of femur fracture to a patient with metastasis – the patients with the metastasis often appears healthier. However, the cancer patients’ physiologic reserve and therefore their ability to cope with the trauma of the surgical insult are more important. The blood indices and trend in these are a valuable indicator. In the presence of visceral disease the reserve and ability to compensate is poor and therefore operative outcomes are less predictable. Decisions are often made remotely without reviewing or including the patient. Nevertheless, the patient is central to the decision-making process15 and therefore should be integral to the discussion. The surgeon who would undertake the procedure, ideally one with an MBD subspecialty interest, should review the patient.

Work-up Surgery following fracture is more challenging to the surgeon and the patient, with increased mortality and morbidity16. On the other hand in patients who have an intact lesion, the decision whether to operate, or not, is challenging, as surgery has risks which need to be balanced against potential benefits. Metastatic disease is common in the proximal femur, and the patients are often admitted as an emergency with a neck of femur fracture. The tariff uplift for getting to theatre in less than 36 hours17 can be counterproductive in these patients. The importance of the NICE guidelines in optimising outcomes in standard NOF patients is recognised, and although the effect on MBD patients is not yet quantified, there is concern that some patients will undergo substandard surgery in the rush to get them to theatre. The potential consequence for

Figure 2: The relevance of biopsy – what appeared to be a metastasis. 81-yearold patient with past medical history of bladder, prostate and non-cirrhotic liver carcinoma presented with a painful shoulder. Intramedullary nailing had been undertaken (a). Bone scan showed a solitary lesion. A biopsy diagnosed an intermediate grade chondrosarcoma, treated with excision and reconstruction (b).

patients where malignancy is present is a missed diagnosis due to inadequate pre-operative investigation, or inappropriate surgery performed as a result of the lack of availability of an experienced surgeon. There is no medical urgency for theatre. Investigate, discuss and plan with the patient and their family. The standard work-up for these patients includes; plain radiographs and MRI of the whole bone, to plan the implant and approach. A biopsy should be considered where doubt remains. A CT scan of the chest, abdomen and pelvis is indicated if the primary is unknown.

What technique/implant? Metastatic bone disease patients can be divided into three groups: 1. Unwell pre-morbid 2. Solitary metastasis 3. The ‘unknowns’

For Group 1, patients have a time-limited prognosis and the MBD guidelines4 recommend conservative management if life expectancy is less than six weeks. The end of the bed test, with routine investigations/ imaging is valuable in this group, facilitating decision making with the patient and family. Although surgery is used to palliate, it can also trigger a medicalised death. Therefore, development of links with local hospices and palliative care is recommended to support these patients without the need for surgery (Figure 1). Patients with a solitary metastasis must be treated with caution, and the team should consider referral to a Bone Tumour Centre, as some patients with a solitary metastasis have a prolonged disease free interval when the tumour is excised, particularly breast and renal metastases. Solitary bone lesions should be biopsied to exclude a primary bone tumour that can be treated with curative intent (Figure 2). >>

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JTO Subspecialty Section

Decisions are often made remotely without reviewing or including the patient. Nevertheless, the patient is central to the decision-making process and therefore should be integral to the discussion. The surgeon who would undertake the procedure, ideally one with an MBD subspecialty interest, should review the patient.

Group 3, the ‘unknowns,’ are more difficult. They are often patients with a known history of malignancy. Expected survival and implant choice are key: arthroplasty / endoprosthesis or internal fixation with or without augmentation. Excision of the tumour and reconstruction may be indicated in those in whom lengthy survival is expected, whereas if a shorter survival is expected bracing, medical management or internal fixation18 may be appropriate. The oncologist should be consulted early and nonsurgical management options such as hormonal, targeted therapies (e.g. denosumab) and radiotherapy may be offered for disease control. There is an increasing body of evidence to support the use of replacement (Figure 3), rather than internal fixation in lower

limb lesions19. Upper limb lesions differ to lower limb lesions. In the lower limb there are effective solutions with arthroplasty and endoprostheses (EPR), resulting in good function and a similar surgical risk to internal fixation. However, in the shoulder, the functional outcome is significantly worse with EPR than after internal fixation. Furthermore, the demands on internal fixation are less; therefore in the upper limb internal fixation is more frequently used for metastatic bone disease. Replacement can include standard implants, longstemmed or revision type prostheses or EPR. Nevertheless arthroplasty has problems, such as infection and cost. These need to be balanced against the risk of multiple operations if a suboptimal implant is chosen

as a consequence of surgeon preference/experience rather than evidence based modern oncological surgery20. Throughout this article we have referred to the MBD team. The BOA guidelines4 state that ‘all hospitals should have an orthopaedic MBD lead’. This is in recognition of the number of patients with MBD in general orthopaedic units, where specialist tumour advice is not available. A number of Trusts are developing their MBD service, which should improve the outcome for this group of patients. As the subspecialty develops we would hope to see investment into the multidisciplinary team, with specialist nursing, radiology, histopathology, and multidisciplinary input from oncology, haematology, palliative care, and orthopaedics. n

Karen Shepherd is a MSK Tumour Fellow at The Robert Jones Agnes Hunt Hospital, Oswestry. Her higher specialty training was on the Yorkshire Rotation. Clinical interests include complex trauma and limb reconstruction, with a subspecialty interest in metastatic bone disease.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

Figure 3: Breast metastasis in the proximal femur treated with endoprosthesis. 42-year-old patient, known with breast cancer. Plain radiographs (a) and MRI (b) showed a left proximal femur lesion. After biopsy the tumour was excised and an endoprosthesis inserted (c). The patient remains well seven years later.

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JTO Subspecialty Section

Malignant Primary Bone Tumours Paul Cool Malignant primary tumours of bone are a diverse group of tumours. Overall, the incidence is around 15 per million people a year. The most common malignant primary bone tumours are osteosarcomas (incidence 3 per million per year), chondrosarcoma and Ewing’s sarcoma1.

b The diagnosis and surgical treatment of malignant primary bone tumours is highly specialised and requires a comprehensive multidisciplinary team. Consequently, the diagnosis and treatment of these tumours is delivered by specialist units. In England, these units are in Birmingham, Newcastle, Oswestry, Oxford and Stanmore. Furthermore, there is a national multidisciplinary team meeting where all cases of Ewing’s sarcoma are discussed.

Diagnosis

Paul Cool

Patients with malignant primary bone tumours often present with a prolonged history as these tumours are rare and the diagnosis is not expected. Night pain, especially in the young adolescent, and nonmechanical pain are symptoms suggestive of a malignant bone tumour. Common risk factors are presented in Table 11.

Osteosarcoma (Figure 1 and 2) is most common in fast growing bones (around the knee and in the proximal humerus), whilst Ewing’s sarcoma (Figure 3) usually affects the diaphysis of long bones, pelvis or scapula. Both osteosarcoma and Ewing’s sarcoma are frequent in young adolescents. Chondrosarcoma (Figure 4) is uncommon in young people and usually presents with a prolonged history of low grade pain. Examination is usually nonspecific but may reveal swelling, local tenderness, joint swelling and dysfunction. Unfortunately, it is not uncommon for patients

Figure 1: Sclerotic osteosarcoma of the proximal tibia (a) that has been treated with neo-adjuvant chemotherapy, excision and reconstruction with a massive endoprosthetic replacement (b).

to present with a pathological fracture (Figure 4). A pathological fracture potentially contaminates the surrounding tissues with tumour cells. Theoretically, this

High Risk

Moderate Risk

Low Risk

Ollier's disease

Diaphyseal aclasia (multiple osteochondromas)

Fibrous dysplasia

Maffucci’s syndrome

Paget's disease

Osteonecrosis

Familial retinoblastoma

Radiation osteitis

Chronic osteomyelitis

Table 1: Risk factors for malignant primary bone tumours.

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Figure 2: Teleangiectatic osteosarcoma of the distal femur.

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Figure 3: Ewing’s sarcoma of the femoral diaphysis (a) and subsequent excision and reconstruction with a distal femoral endoprosthesis (b). Ewing’s sarcomas often have a significant soft tissue component (c).

could jeopardise future limb salvage. However, there are reports that, provided adequate excision margins can be obtained, there is no significant difference in survival2. Blood tests are non-specific and usually of little help in the diagnosis of malignant primary tumours of bone. About half of the patients with osteosarcoma have an elevated alkaline phosphatase; who have a worse prognosis. Similarly, an elevated LDH, ESR and CRP in Ewing’s sarcoma adversely affects the prognosis. The location of the tumour within the bone can help diagnostically. Most tumours (including osteosarcoma and chondrosarcoma) are in the metaphysis. Ewing’s sarcoma is usually diaphyseal. Epiphyseal tumours are unlikely to be malignant (Table 2).

The age of the patient can also help diagnostically (Table 3) Osteosarcomas are malignant tumours that produce bone (Figure 1). However, in teleangiectatic osteosarcoma this is not apparent on the radiographs and a biopsy is required to appreciate osteoid formation1. Classical radiographic features of osteosarcoma include sunray spiculae and Codman’s triangle. The Codman’s triangle is reactive bone formation following elevation of the periosteum from the bone by the tumour. The periosteum is well fixed to the physis; explaining the triangular shape. Similarly, in Ewing’s sarcoma the diaphyseal periosteum is lifted in a fusiform manner with intermittent deposition of reactive bone (onion skinning).

Epiphyseal Tumours

Diaphyseal Tumours

Giant cell tumour (physes closed)

Eosinophilic granuloma

Chondroblastoma

Osteoid osteoma

Intra-articular osteoid osteoma (atypical)

Fibrous dysplasia

Clear cell chondrosarcoma

Adamantinoma (tibia) Ewing's sarcoma

Table 2: The location of the tumour in the bone can help diagnostically.

Figure 4: Chondrosarcoma of the proximal humerus with pathological fracture. The tumour showed de-differentiation, worsening the prognosis.

Chondrosarcoma has usually a longer clinical course. The cartilage matrix often shows speckled calcification (Figure 4). Dedifferentiated chondrosarcoma is a highly malignant tumour where chondrosarcoma is juxtaposed to a high-grade noncartilaginous sarcoma. Plain radiographs are the best diagnostic aid in the evaluation of bone tumours. Although further scans can narrow the differential diagnosis, it is unlikely that they will have a major impact diagnostically. Additional scans are mainly performed for staging purposes, to determine the extent of disease. If following radiographs a malignant primary bone tumour is suspected, it is recommended to refer the

patient directly to the local bone tumour treatment centre for further evaluation, staging, biopsy and treatment.

Staging Patients who present with a suspected malignant primary tumour of bone require further evaluation (local and distant staging). Local staging includes plain radiographs and an MRI scan of the whole affected bone. MRI scans are particularly useful to identify the extent of disease in the soft tissues and bone marrow. Bone formation is better appreciated on a CT scan. In the first instance, bone sarcomas spread to the lungs, followed by dissemination to other bones. Consequently, distant staging should include >>

Age

Diaphyseal Tumours

< 10

Eosinophilic granuloma

Teenage

Ewing’s sarcoma

Adult

Lymphoma

> 60

Metastases / Myeloma

Table 3: Common age for diaphyseal tumours.

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JTO Subspecialty Section

a whole-body isotope bone scan and a CT scan of the chest. Whole-body MRI scan has also been used for further evaluation in some tumours and there are reports which suggest that MRI scanning has a higher sensitivity and specificity than bone scans in identifying metastatic disease3. However, isotope bone scanning remains the gold standard for staging of malignant primary bone tumours. The role of PET CT remains undetermined.

Biopsy Once all staging investigations have been performed, a biopsy is usually required. It is unlikely you will regret taken a biopsy; but you could regret not taking one! 4,5 A bone biopsy should be performed under image guidance (fluoroscopy or CT) in the bone tumour treatment centre. The biopsy site should be carefully planned around an extensile approach which avoids breaching compartments and consequently jeopardising possible limb salvage. All biopsy results should be discussed at the multidisciplinary team meeting for radiological and pathological correlation.

Low grade without metastases

Intra-compartmental

Extra-compartmental

High grade without metastases A

Intra-compartmental

Extra-compartmental

Metastases A

Intra-compartmental

Extra-compartmental

Table 4: Enneking staging of bone tumours is a combination of stage (extent of disease) and grade (aggressiveness of the tumour).

Treatment can then be planned by the oncologists and orthopaedic surgeons. Two staging systems are commonly used to guide treatment and provide prognostic information: the TNM system and Enneking staging (Table 4). Enneking staging is a combination of stage (extent of the disease) and grade (aggressiveness) of the tumour. The compartment is the affected bone and a tumour is extra compartmental if the cortex of the bone is breached on the plain radiographs6,7. The World Health Organisation1 recommends TNM (tumour, nodes and metastases) staging and this has been shown to be of better prognostic value (Table 5).

EWSR1 to FLI1 to create the EWSR1-FLI1 oncoprotein. Alternate translocations have been described for the remaining 15%. The diagnosis of Ewing’s sarcoma should be supported by molecular pathology to demonstrate one of the described translocations. This can be done by FISH (fluorescence in situ hybridization) or RTPCR (reverse transcriptasepolymerase chain reaction). The molecular pathology of osteosarcoma is less well defined and subject to further research. Amplification of the MDM2 (mouse double minute 2 homolog) gene is common in low grade osteosarcoma.

Genetics

IDH1 and 2 (isocitrate dehydrogenase) mutations are found in most chondrosarcomas, but other mutations have also been described and this is the subject of further research.

Approximately 85%1 of Ewing’s sarcoma have a chromosomal translocation t(11;22)(q24;q12) that fuses

The 100,000 genomes project will hopefully give further insight in the molecular pathology of these tumours.

T – Primary Tumour

Can’t be assessed

No evidence of primary tumour

Less than 8 cm greatest diameter

More than 8 cm greatest diameter

Discontinuous tumours in the primary bone

N- Regional Lymph Nodes

Can’t be assessed

No regional lymph nodes

Regional lymph node metastases

M – Distant Metastases

No metastases

M1 a

Lung metastases

M1 b

Metastases at other sites

Extra-compartmental

Table 5: TNM staging of primary bone tumours.

Treatment Ewing’s sarcoma and osteosarcoma are treated with surgery and chemotherapy. Chemotherapy is usually delivered in a neo-adjuvant setting (before and after surgery), according to defined protocols and clinical trials. Radiotherapy is another modality that can be used to treat patients with Ewing’s sarcoma. Chondrosarcomas do not respond to radiotherapy or chemotherapy and treatment is surgical. It is important to excise the biopsy track during the surgical procedure as these tumours are prone to local recurrence. This further illustrates the importance of appropriate planning of the biopsy by the sarcoma unit. Local recurrence is associated with the quality of the surgical margin that has been obtained. The classification of surgical margins is summarised in Table 6. The different surgical options for bone sarcomas are summarised below: – Amputation – Limb Salvage l Excision alone (expendable bone) l Excision and Bone Graft  – Autograft  – Irradiated Autograft  – Allograft l Excision Endoprosthetic Replacement l Excision and Arthrodesis l Rotationplasty l Excision and Bone Transport

Intra-lesional

Within the lesion

Marginal

Within the reactive zone, extra-capsular

Wide

Beyond the reactive zone in normal tissue

Radical

Extra-compartmental

Table 6: Surgical excision margins.

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Endoprostheses are commonly used and have the advantage of immediate weight bearing and reliable function. The main complication is infection. Although surface treatment of the prosthesis with silver can make it easier to deal with infection, it remains a difficult clinical problem.

to integrate with the host bone. During this period, there may be limitations on weight bearing. The main complications of biological reconstructions include non-union, infection and fracture.

Hydroxyapatite coated collars in combination with cemented stems have significantly reduced the incidence of aseptic loosening and improved longevity of endoprostheses8.

Before neoadjuvant chemotherapy was available, 80% of patients with osteosarcoma treated with surgery alone died of disease. There has been a significant improvement in outcome with chemotherapy and 70% of patients who present with nonmetastatic osteosarcoma are long-term survivors. Patients

Biological reconstructions are more difficult and require time for the biological reconstruct

Prognosis

who have metastatic disease at diagnosis, have a much poorer survival rate (< 20%). Approximately two-thirds of patients with non-metastatic Ewing’s sarcoma are cured following successful surgical and oncological treatment. However, large pelvic tumours can be very challenging to treat. The prognosis for metastatic Ewing’s sarcoma remains poor. The prognosis of chondrosarcoma depends very much on the grade and site of the disease. Dedifferentiated chondrosarcoma has a very poor prognosis and most patients die within a year. n

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Paul Cool is a Consultant Orthopaedic and Oncological Surgeon at The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust in Oswestry. He is the current President of the British Orthopaedic Oncology Society and honorary Senior Lecturer at the University of Manchester.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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In Memoriam

Michael Alexander Reykers Freeman

17th November 1931-14th September 2017

Michael Freeman made an outstanding contribution to orthopaedics both in the advancement of joint arthroplasty and his drive to ensure that knowledge was freely exchanged. His capacity to learn and assimilate information was established early as a boarder at Stowe School from 1945 to 1950.

He excelled, gaining an Open Scholarship and Closed Exhibition to Corpus Christi College, Cambridge. He achieved First Class Honours in the Natural Science Tripos in 1953, completing his clinical studies at the London Hospital Medical College in 1956. At Cambridge, he met his lifelong friend John Insall, who accompanied him to London. Subsequently their mutual interest in knee arthroplasty often involved sharing ideas. He obtained his FRCS in 1959 before completing a year of National Service in the RAMC. Thereafter he undertook orthopaedic training at the London, Westminster and Middlesex Hospitals. Michael Alexander Reykers Freeman

His MD thesis in 1964 on Ligamentous Injuries, laid the

foundation of non-operative rehabilitation of the sprained ankle which is still current. That year he received the Robert Jones Medal from the British Orthopaedic Association. His interests in arthritis and arthroplasty lead to a partnership with Prof SAV Swanson at Imperial College becoming Co-Directors of the Biomechanics Unit in the Department of Mechanical Engineering. In 1968, he was an ABC Fellow and appointed as part-time consultant to the London Hospital, succeeding Reginald Watson-Jones, while continuing his research at Imperial. As his ideas developed, prostheses and dedicated instruments were manufactured at Imperial but without the general blessing of the

authorities. As an alternative Finsbury Instruments was established, with members of his former research team. His first joint replacements were designed for the ankle and foot but he was to conclude these could not be made to work with the biomaterials which were available. His attention turned to hip and knee arthroplasty. In 1969, the first condylar knee arthroplasty was implanted at the London Hospital. In the early 1970s the Imperial College London Hospital (ICLH) hip resurfacing was introduced, using high density polyethylene acetabular components and cobalt chrome heads. Developments were meticulously documented and the outcome of each patient recorded. This monitoring

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enabled modifications to rectify any deficiencies which were found. In early 1980s, he discontinued hip resurfacing as the results were inconsistent. He then followed with the development of his full neck retaining total hip prosthesis. His work was founded by numerous grants and he published his findings frequently. Michael soon became a favoured pioneer with whom fellows wished to study. In 1982, the Arthritis and Research Council funded the Bone and Joint Research Unit at the London Hospital Medical College to which Michael transferred his research leaving Imperial. He was extensively published in journals and wrote many book chapters. If the findings were poor, he acknowledged the importance of still reporting, to ensure others did not repeat his errors. The large database provided the source of information for visiting fellows and trainees to advance their careers. In his early career, despite a busy schedule, he served on several grant-awarding committees. Additionally, he was a member of the Board of Governors of the London Hospital and the Brent and Harrow Area Health Authority. He served on the Editorial

boa.ac.uk

Board of the Journal of Bone and Joint Surgery [Br] and the Journal of Arthroplasty where he became the first European Editor-in-Chief of JOA from 1996 to 2001. His standing in the profession led to him being elected as President of the International Hip Society from 1983 to 1985. Together with Hugh Phillips and Robin Ling, he established the British Hip Society, serving from 1989 to 1990 as its first president. He was President of the British Orthopaedic Association from 1992 to 1993. In 1989, he discussed with Jacques Duparc the lack of a European forum for the exchange of ideas. This can be considered the point when the concept of the European Federation of National Associations of Orthopaedics and Traumatology was born. After EFORTâ&#x20AC;&#x2122;s establishment in 1993, Michael was elected as its second President from 1994 to 1995. He retired from the Royal London Hospital in 1996. Rather than take solace in his interests of gardening and reading, he commenced a new enterprise of investigating the three-dimensional shapes of the articular components of the knee joint and their relationship to lateral rollback. Working mainly at the Charles University in Prague with Dr (now Professor) Vera

Pinskerova, using cadaver material, and cadaver and living MRI studies, the mechanism of lateral femoral rollback and medial femoral stability were established. This endorsed his view that a stable knee prosthesis should be designed with a medially-spherical femoral condyle to mate with matched tibial concavity, while the lateral compartment should remain unconstrained. This philosophy has been adopted by several manufactures. He received many awards in recognition of his contributions to orthopaedics, including Honorary Fellowship of the BOA in 2003 and an Honorary Member of EFORT in 2007. Those who were privileged to work with him held him in the highest regard, not just for his clinical expertise and scientific approach, but also for his thoroughness in understanding the patientâ&#x20AC;&#x2122;s complaint and addressing their concerns. If something went wrong he would apologise immediately and agree a remedial action. He was witty and urbane, making him a popular chairman at a scientific congress, as he could stimulate discussion after most presentations. Michael is survived by his third wife Patricia, his six children and 11 grandchildren. The warmth of his personality was displayed with the

children mixing as one large, happy family. They will miss him dearly. So too will the army of former trainees and fellows, and the orthopaedic community. We will benefit from his publications and inventions, and by the values he has instilled in those who follow him. n

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In Memoriam

Professor Robin Sydney Mackwood Ling 7th September 1927-9th October 2017

Professor Robin Ling OBE has died at the age of 90. He will be remembered as a true gentleman, a master hip surgeon, an innovator and a scientist whose research and teaching have influenced surgeons around the world and thereby improved the quality of life for countless patients.

Professor Robin Sydney Mackwood Ling

Robin Sydney Mackwood Ling was born on 7th September 1927 and brought up in the West Riding of Yorkshire where his parents and grandfather were doctors; his grandfather, who looked after the more affluent side of town, was known as “old Dr. Ling”; his father, who cared for residents in the less wealthy areas, was “Dr. Billy”. His mother, Mona, ran the four-man medical practice during the war.

Oxford, and St Mary’s Hospital in Paddington.

Educated in Chelmsford Hall in Eastbourne, Robin was dispatched at the outbreak of war to Canada with his two younger brothers where they lived with the Koerners, a philanthropic family who had emigrated to Canada from central Europe to escape the Nazis.

Throughout his life Robin had a passion for sport. His love of sailing started during his residency at Shawnigan Lake School on Vancouver Island. He and his brothers later persuaded their parents to buy a classic yacht, Veronique. On retirement, he moved to the Dart estuary and fulfilled his life-long ambition of owning his own sailing boat, aptly named Enfin.

On returning to the UK he read medicine at Magdalen College,

It was at St Mary’s that Robin met Mary Steedman who was a casualty nurse. She had been born in South Africa and was preparing to return to Cape Town to read medicine, having been awarded a scholarship. They married after a brief courtship and enjoyed 62 years of a happy and fulfilled marriage.

Robin became interested in hip replacement surgery following his appointment as consultant orthopaedic surgeon at the Princess Elizabeth Orthopaedic Hospital in Exeter in 1963. There were very few types of hip replacement available in the 1960s and he sought to create an implant that could be securely fixed to the bony skeleton using acrylic bone cement. He collaborated with Dr. Clive Lee, an engineer at the University of Exeter, and designed a different geometry of implant that he believed would optimise fixation and thereby the long-term success of a hip replacement. The surgical instruments that he created allowed the hip to be inserted through the posterior approach, with only one assistant. The first Ling-Lee hip was inserted in 1970 and the Exeter

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hip, as it is now known, is at the current time the most implanted cemented hip replacement in the world due to its outstanding long-term function. His observation of how the implant worked in the human body led to extensive research in the laboratories at the University of Exeter. Robin and Clive proved how bone cement (PMMA - a polymer) can undergo time-dependent deformation on loading. This phenomenon (creep) is valuable in transmitting load through the joint, setting the scene for decades of painfree activity in patients. His explanation of how “taper-slip” cemented stems function is part of mainstream orthopaedic teaching around the world and all major hip manufacturers now market an implant that functions in this way. Robin Ling’s work was not just confined to the implant itself - he also developed sophisticated cementing techniques to improve the clinical result. These techniques constitute contemporary practice and are widely taught at symposia and workshops internationally. Robin’s contribution to revision hip surgery resulted from a close relationship with Professor Slooff from Nijmegen in the Netherlands.

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Robin developed a technique of impacting morcellised bone graft into large femoral defects that can result from implant loosening. In combination with a cemented taper-slip stem, healing of the graft with reconstitution of bone stock and an excellent clinical outcome resulted. The technique of femoral impaction grafting in revision hip surgery has become an established technique in the armamentarium of specialist hip surgeons. The technique is less often practiced now as primary stems so rarely loosen. Robin’s scientific work and teaching did not prevent him from contributing in all areas of professional life. He sat on numerous editorial boards and chaired many regional and national committees. He was President of the British Orthopaedic Research Society, 1979-80; President of the British Orthopaedic Association, 1986-87; President of the British Hip Society, 1991-93; President of The International Hip Society, 199799 and Honorary Professor of Bioengineering in the School of Engineering at the University of Exeter. He was awarded numerous Visiting Professorships at universities around the world. He was appointed Officer of the Order of the British Empire in January 1992.

Robin is survived by his wife, Mary, and two daughters, Jenny and Katie, as well as four grandchildren. Jenny is an orthodontist in Wells and Taunton. Katie is an interpreter for the European Commission in Brussels. Robin Ling was a giant in the field of hip surgery. His intellect and world-class contribution to the specialty are recognized by hip surgeons on all continents. As a surgeon, he was a perfectionist, always striving to get the very best outcomes for his patients; he would never leave the operating table until he had completed the most meticulous surgery possible. As a mentor, colleague and friend, he had the wonderful attributes of complete integrity, tremendous personal warmth and, in addition, a disarming modesty. He will continue to be a role model and inspiration to very many people. There will be a Memorial Service to celebrate the life of Robin Ling to be held at 11am on Friday 23rd February in Exeter Cathedral. n

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In Memoriam

Arthur James Nicholas Dennison 12th December 1940-27th August 2017

Nick Dennison was a “character” who was equally well respected by his patients and staff. Before 1995 Nick provided an orthopaedic and trauma service for Burnley and Lancashire with two colleagues, Rham Chatterjee and Peter Cox.

When the former suddenly passed away and the latter retired from the NHS, the department expanded to a team of five. Nick kept a statesman-like overview and was a source of valued advice. During management meetings he was rather quiet until asked for his opinion. He then produced an excellent analysis in a straightforward, to the point manner. He responded to proposals either with “I will give it a good thought” which meant he would consider it, or “I will give it a thought” which meant “NO”.

Arthur James Nicholas Dennison

Nick pioneered hip replacement surgery in Burnley and had very good long-term results with open knee surgery. He was an excellent teacher. His ward rounds were

extremely well prepared. No interruptions were tolerated. Consequently they were succinct, efficient and patient focused. Nick had an excellent sense of humour. He started the yearly tradition of dressing up and doing a ward round with nurses and doctors over Christmas. Patients loved it and the Staff was in stitches. It was no secret that outside the hospital Nick was a passionate theatre man, good singer and Gilbert & Sullivan performer along with his colleague and friend Jim Ogden. He continued to perform at the Burnley Mechanics Theatre well into retirement. He struck a great life-work balance before the term was even invented. He will be fondly remembered. n

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JTO Festive Fun Answers

Answers to Christmas Quiz: 1 b; 2 c; 3 b; 4 c; 5 d; 6 a; 7 b; 8 b; 9 a; 10 d.

Answers to JTO Christmas Crossword: Across: 4. Star; 7. Presents; 10. Ye; 11. Snow; 13. Sheep; 15. Red; 17. Cane; 18. Holy; 19. Far; 20. Star; 21. Yule; 22. Say Down: 1. Trees; 2. As; 3. It; 5. To; 6. Reindeer; 8. Elves; 9. Santa; 12. Wreaths; 14. Holly; 16. Shine; 17. Carol

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Imprint

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Introductory Course for Foundation Doctors & Undergraduates

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Basic Principles of Fracture Management for Surgeons

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Shoulder & Elbow Course for Surgeons (cadaveric)

Mar 19-21 Newcastle

Foot & Ankle Course for Surgeons (cadaveric)

Apr 16-18

Current Concepts Course for Surgeons (cadaveric)

Apr 25-27 Coventry

Principles Level Specimen Course for Surgeons

Wrist Course for Surgeons (cadaveric)

Jun 4-5

Bristol

Jan 26-27 Belfast

Introductory Course for Foundation Doctors & Undergraduates

Jun 24

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Basic Principles of Fracture Management for Surgeons

Jun 25-28 Leeds

Advanced Principles of Fracture Management for Surgeons

Jun 26-29 Leeds

Advanced Principles of Fracture Management for ORP

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Pelvic Course for Surgeons

Sept 3-5

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Hand Fixation Course for Surgeons

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Periprosthetic Course for Surgeons

Nov 8-9

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Introductory Course for Foundation Doctors & Undergraduates

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WWW.CORAILPINNACLE.NET The CORAIL® PINNACLE® construct has grown to become one of the most widely used and clinically successful cementless constructs for total hip replacement.1-6

The first PINNACLE was implanted on the 17th of July 2000 and since then PINNACLE has been provided for over

The first CORAIL was implanted on the 25th of August 1986 and since then CORAIL has been provided for over

patients.2

2,500,000

2,000,000

Issued: 01/16

References 1. Data on file -CORAIL PINACLE Unit Sales 2016, DePuy Synthes Companies of Johnson & Johnson 2. Orthopaedic Data Evaluation Panel. ODEP product ratings. Available from www.odep.org.uk [Accessed 01/10/2015]. 3. Hallan G, Lie SA, Furnes O, Engesaeter LB, Vollset SE, Havelin L. Medium and long-term performance of 11 516 uncemented primary femoral stems from the Norwegian arthroplasty register. J. Bone Joint Surg. 2007;89-B:1574-1580. 4. Chatelet J-C. Survivorship in 120 consecutive cases at 12 years. Rev Chir Orthop Reparatrice Appar Mot. 2004;90(7):628-635. 5. Bedard N, Callaghan J, Stefl M, Williams T, Liu S, Goetz D. Fixation and Wear with Contemporary Acetabular Components and Cross-Linked Polyethylene at 10-Year Follow-Up. Journal of Arthroplasty. 2014; 29: 1961-1969. 6. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, 12th Annual Report, 2015. Table 3.10. Available from: www.njrreports.org.uk