Journal of Trauma & Orthopaedics – Vol 6 / Iss 2

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 06 / Issue 02 / June 2018 boa.ac.uk

Inside

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 VC Heroes, Using NJR in Data Appraisal, On-line Supervisor Training – eTOES, Re-branding T&O: The Undergraduate Experience and our regular features

For the latest update on our clinical issues, see our Subspecialty section; the focus of this issue is military

News & Updates ––– Pages 02-23

Features ––– Pages 24-57

Subspecialty Section ––– Pages 58-67

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Volume 06 / Issue 02 / June 2018

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From the Executive Editor

Contents

Phil Turner The second edition of our centenary year marks the close links between our association and the armed forces.

Sir Robert Jones is illustrated on the front cover wearing his military uniform. This could give the impression that these links are purely historical, but the three articles in our themed section show that orthopaedic trauma and reconstructive surgery remains at the core of the Defence Medical Services. Nick Ward describes his career trajectory and his experiences during two tours in Afghanistan. Sarah Stapley and her co-authors cover the advances made in the areas of blast injury, severe pelvic and extremity trauma,

the complications of infection and heterotopic ossification and the importance of outcome measures for those suffering severe trauma. Jon Kendrew and his co-authors describe the ground-breaking field of direct skeletal fixation of prostheses for those where limb salvage is impossible.

News and Updates

02–23

Features

24–57

Orthopaedic Traumatology Following an Urban Terrorist Attack

26

Sadly, these advances are increasingly relevant to civilian practise in the UK and across the world. Many of us have been involved in treating the victims of terrorist incidents and the article by Juan de Dios Robinson vividly describes the breadth and complexity of injury patterns that we have to be prepared to assess and treat when the need arises.

The History of the Victoria Cross Hero, Harold Ackroyd - Doctor, Scientist and Gentleman (1877-1917)

30

Chris Ackroyd returns us to the most direct involvement of surgeons in war. His eloquent story of profound bravery recognised by the award of the Victoria Cross gives a totally different perspective.

Before reading it, guess how many VCs have been awarded to medical personnel.

I hope you will enjoy reading the full content of the Journal.

The editorial team would be pleased to receive proposed submissions from our members or any comments on this edition.

Quality Improvement in Surgical Teams (QIST): Anaemia and Infection

24

JTO Quiz

34

How I do... The Elite Athlete’s ACL Reconstruction

36

Operations I no longer do...

Shoulder and elbow – ten years on

38

Using NJR Data in Appraisal

40

Key Issues and the Current Landscape of Orthopaedics in South Africa

42

BOA Bootcamp Course for ST3 Trainees

44

On-line Supervisor Training – eTOES

46

Re-branding T&O: The Undergraduate Experience

48

The Cost of Training in Trauma and Orthopaedics: Where Do All The Pennies Go?

52

The Continuing Saga of Informed Consent

54

Subspeciality Features

58–67

Army Orthopaedic Surgeon – A Different Career

58

The Current Direction of Military Orthopaedic Research 62 Direct Skeletal Fixation - a new treatment paradigm in combat amputees?

In Memoriam General information and instructions for authors

66

68–70 72

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JTO News and Updates

From the President Ananda Nanu The crisp mornings are fading away as spring tardily arrives in the North-East. As winter recedes, the pressures on our hospitals have not diminished as projected, certainly in T&O.

In early April, we published our position statement relating to T&O waiting times in England, highlighting that: l The proportion of patients on

the T&O waiting list for less than 18 weeks fell to 83.4% – the worst this decade, and far short of the national NHS target of 92%.

l 76,000 people had been

waiting over 18 weeks for T&O surgery – the largest number since published records began in November 2010.

There are further difficulties right across the UK:

l In Scotland, the proportion of

patients on the T&O waiting list for less than 18 weeks fell to 75% against a national standard of 90%.

l In Wales, those on the T&O

waiting list for less than 26 weeks fell to 73.6% - here, the national standard is 95%.

l In Northern Ireland, 38.8% of

Ananda Nanu

inpatients were seen within 13 weeks and 23.8% of outpatients were seen within nine weeks – far short of the 55% standard for inpatients and 50% for outpatients.

This is an important issue that we are actively pursuing. Thank you to all our members who completed our recent survey about their experiences of winter pressure. We are continuing to collect further data, engage politically and collaborating with BOTA, patients and TPDs under the ethos of ‘caring for patients, supporting surgeons’.

As at the end of April, we are still aware of some trusts that have not resumed elective operations.

And finally, there is just enough space for brief updates on three emerging new initiatives.

We have stressed repeatedly in our communications that elective surgery is not optional surgery. Cancelling elective orthopaedic surgery in winter months is a short-sighted measure that consigns the most vulnerable, long suffering elderly population to an unconscionable wait caused by a combination of under resourcing and inefficient practices in acute care. The knock-on effect is a stockpiling of deteriorating patients without the resources to mount an escalated response to deal with them in spring and summer. The destructive effect on training and morale should not be underplayed. I attended the BOA/SAC/TPD session held in April in Leeds and a show of hands from the TPDs suggests around half of the programmes had considered moving trainees in an unscheduled manner to try and ameliorate the damage caused to training by a cessation of elective operating. Despite these efforts, some trainees may need an extension to their training time.

1) We are pursuing opportunities for new fellowships in large volume centres in India. More information will follow for members soon.

2) We are exploring with NCAS a route for BOA members to undergo mentorship programmes with well-established Consultant trainers and centres. Again, more information to follow.

3) Our Elective Care Review initiative is well underway. This is a supportive process to review hospital units where NJR data raises potential concerns with revision outcomes. This is a very important quality improvement measure, demonstrating the profession responsibly acting on patient data analysis it has instigated and instituted.

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JTO News and Updates

BOA Latest News The Duke of Edinburgh’s Hip Surgery - BOA statement

ABC Travelling Fellowship

In April, the Duke of Edinburgh underwent planned hip surgery due to osteoarthritis. Ananda Nanu, President of the BOA, released a statement highlighting hip replacement as the best form of pain relief for arthritis and painful hip conditions. He stated, “Hip conditions are incredibly painful and disabling. The commonest hip conditions affecting people in later years are arthritis, inflammation and if there has been a fall there can be hip fractures. Total hip replacement is a very successful operation in all age groups. It is the best form of pain relief that we have for arthritis and painful hip conditions.”

The BOA would like to congratulate four members Nemandra Sandiford, Arul Ramasamy, Paul Baker and Phil Walmsley as the selected ABC candidates this year. They will be travelling to Albuquerque at the end of May and tour through the USA and Canada throughout June.

The full statement is available online at www.boa.ac.uk/latest-news/boastatement-the-duke-of-edinburghs-hip-surgery-04-04-18/.

NHS England Figures – BOA response On Thursday 12th April 2018, NHS England released new data on waiting times for elective orthopaedic surgery during February 2018. Figures show the number of people waiting over 18 weeks for trauma and orthopaedic surgery to be the highest since records began. Ananda Nanu, President of the BOA, responded, “Elective surgery is not optional surgery. Many patients suffering with arthritis are in significant pain, which severely affects their quality of life and their ability to perform the simple activities of daily living.”

The full statement is available on the BOA website www.boa.ac.uk/latestnews/boa-statement-response-to-nhs-england-figures-12-04-18/. If you have any comments on this issue, please contact policy@boa.ac.uk.

Blue Book on the Management of Distal Radial Fractures The BOA and the British Society for Surgery of the Hand (BSSH) have collaborated to produce a best practice guideline on the management of distal radial fractures (DRFs), which has recently been published.

The ‘Blue Book’ discusses the treatment options available based on a thorough review of the current evidence, and covers the management of patients from presentation right through to rehabilitation with reference to PROMs. For more information or to download a copy, visit the BOA website www.boa.ac.uk/publications/guidance-documents/.

Travelling Fellowships 2018/19 Travelling Fellowships offer BOA trainees a unique opportunity to visit centres of excellence overseas, sharing best practice, gaining invaluable knowledge, experience and different cultural perspectives within trauma and orthopaedic surgery. The BOA offers a number of fellowships and applications will open in September 2018.

Further information is available on the BOA website www.boa.ac.uk/training-education/boa-travellingfellowships/ . Also, turn to page 22 to read about the experience of one of our recent fellows.

Training Orthopaedic Trainers (TOTs) Course l 10th – 11th July (BOA, London) l 11th – 12th October (BOA, London)

The TOTs course was established to improve the standard of teaching for those in trauma and orthopaedic (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. For any queries, please contact policy@boa.ac.uk.

If you would like to sign up, please visit www.boa.ac.uk/events/training-orthopaedic-trainers/.

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UK and Ireland In-Training Examination (UKITE) The dates for UKITE 2018 have now been confirmed.

UKITE 2018 will take place between 7th-14th December.

The UKITE is an online annual assessment that allows trainees of all grades to practice for Part I of the FRCS (Tr and Orth) examination, with similar formatted questions based on the UK and Ireland T&O Curriculum. For any queries about registration, please contact: ukite@boa.ac.uk.

FORTE Summer School The BOA is pleased to support three places this year at the FORTE Summer School in Milan, Italy, for two trainees and one SAS surgeon. These places have been recently awarded to Aziz Ahmad, Carol Chan and Edward Jenner.

A full description of the Summer School can be found at www.forteortho.org/forte-summer-school-2018-2/.

BOA Instructional Course 2019 Save the date!

Date: Saturday 12th January 2019 | Venue: Macdonald Hotel Manchester The Instructional Course is a highlight of the BOA calendar. This one-day programme will run in two parallel streams and provide curriculum driven clinical updates and critical condition assessment opportunities aimed at T&O trainees and SAS surgeons. Make sure to save the date as places are limited. Registration will open in July and the provisional programme will be published in June. For further information, please visit www.boa.ac.uk/events/instructional-course/.

Joint Action Spring Appeal – now open!

This Spring, please consider giving to Joint Action to help make a difference to the future of Trauma and Orthopaedic research. We really do appreciate the support you have given us. Please donate to Joint Action at www.boa.ac.uk/research/donate-to-joint-action/.

Robert Jones Golf Tournament New Guidance on Paediatric Surgery The British Association of Paediatric Surgeons have published guidance on ‘Working together to improve the local delivery of the General Surgery of Childhood’. The guide looks at the decline in the provision of General Paediatric Surgery/General Surgery of Childhood at a local level and proposes several solutions to ensure delivery of this care is performed safely, by competent staff and as close to the patient’s home as possible.

This is available online at www.baps.org.uk/content/ uploads/2018/04/WorkingTogether_final_170418.pdf.

The Robert Jones Golf Tournament has had a long standing history with the BOA. This year’s tournament will be held on Tuesday 25th September at the Harborne Golf Club, a beautiful parkland course steeped in history and surrounded by splendour. The course has a fantastic landscape that offers a superb golfing experience, and situated just three miles outside of Birmingham city centre and five miles from junction 3 of the M5, it is easily accessible.

Online registration rate for participants are as follows (inc VAT): £76 for Golf only, £168 for Golf with dinner.

Registration now open; please contact events@boa.ac.uk or visit the BOA website at www.boa.ac.uk/events/the-robert-jones-golftournament-2017/ for more information.

National Institute for Health and Care Excellence (NICE) Updates 1. NICE has published the NICE Trauma Quality Standard which covers the assessment and management of Trauma in adults, young people and children. This standard contains six statements to assist priority areas for improvement and is available online at www.nice.org.uk/guidance/qs166/resources/trauma-pdf-75545603800261.

2. NICE has recently announced it is working on a new guideline, ‘Joint replacement (primary): hip, knee and shoulder’. The BOA will be following developments closely, in conjunction with BHS, BASK and BESS. At the time of going to press, the Scope had recently been published and recruitment was underway for the Guideline Committee.

3. The latest guidance (NG8) from NICE for the prevention of venous thromboembolism (VTE) for patients in hospital aged 16 years and older has recently been published. This is online at www.nice.org.uk/guidance/ng89. The next JTO will feature an article commenting further on this publication.

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

BSCOS Annual Meeting, Crewe 2018 The British Society for Children’s Orthopaedic Surgery 2018 was hosted by The Royal Stoke Children’s Orthopaedic Unit in the elegant surroundings of Crewe Hall, with around 220 delegates including consultants, trainees and allied health professionals (a group whose numbers are increasing year on year).

Presidential handover: Mark Flowers (left) to Tim Theologis (right).

The meeting was well-attended by national and international speakers, including Professor Theddy Slongo from Bern (paediatric trauma), Philip Henman from Newcastle (update on paediatric trauma centres), Dr Jo Fairhurst from Southampton (NAI) and Nic Nicolaou from Sheffield (the adolescent knee).

Symposia were led by Jon Dwyer and Jo Thomas, with two lively research paper presentation sessions moderated by Belen Carsi and Dan Perry.

Ibrar Majid spoke on the experience of the Manchester Children’s Hospital after the Manchester Arena bombing and Piers Mitchell presented on virtual fracture clinics. Dr Kath Wilkinson spoke on the NCEPOD report on Neurodisability.

A case discussion session moderated

by Emma Shears brought educational proceedings to a close on Thursday, followed by the course dinner and a Ceilidh.

The best research paper was won by medical student Tom Leaver, who presented the work of the Southampton Professor Theddy Slongo unit on the lifetime radiation risk in children undergoing deformity The mantle of the presidency correction (minimal). Next was passed from Mark Flowers year’s Orthopediatrics Travelling to Professor Tim Theologis.

Fellowship was awarded to Alex Aarvold who will visit units in Next year’s meeting will be held Texas and Tennessee. in Norwich in March. n

OTS Annual Meeting, Bristol 2018 the status quo asking ‘why’ we do what we do. Pierre Guy, guest speaker from Vancouver, delivered a talk on artificial intelligence in surgical systems.

OTS Annual Meeting 2018

The fifth Orthopaedic Trauma Society annual meeting was held in Bristol in January this year. The attendance was the largest to date, double the previous numbers.

This complimented the heavyweight research and instructional program of the meeting. Alongside the usual surgical instruction, there is always something different at the OTS. Previous ‘Dragons’ Den’ forums for research proposals gave way this year to an ‘Innovation’ session with

Brian Thornes (inventor of the Tightrope™️) and a patent lawyer from Murgitroyd, who gave a great introduction to bringing surgical inventions to market. Orthopaedic surgeons are good at many things, but writing trademark applications isn’t one of them.

Not content with knowing that there is a fracture and we need to fix it, the OTS has moved on to randomised control trials.

And lots of them. Nigel Rossiter and Matt Costa are causing this paradigm shift; challenging

David is the recipient of the first honorary membership of the OTS. The breakout sessions allowed like-minded colleagues to reflect on their work, as well as at the dinner where networking went on well into the early hours.

The next morning started early with the lessons learned from 2017’s terrorist attacks and their aftermath. Two hours of absolutely riveting and essential information for anyone involved in trauma care. The OTS looks forward to another forwardthinking session in 2019. n

The trauma research movement is becoming a reliable source of top quality evidence and is ranked alongside cancer and heart disease. This progress has been driven by surgeons and their academic colleagues instead of charity cash. David Marsh provided an update on the Fragility Fracture Network. If a movement or an idea has a clear vision and mission statement, it makes a big difference in getting things done and keeping people focussed on the end result; the National Hip Fracture Oliver Blocker, Senior Clinical Fellow at the OTS meeting.

Database.

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.”

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BLRS Annual Meeting, Southampton 2018 The British Limb Reconstruction Society held its annual conference in Southampton on 15th and 16th March 2018. This was hosted

by Amir Qureshi, who with the invaluable help of his excellent team, compiled a programme of exciting topics, interesting speakers and an unrivalled evening’s entertainment.

Delegates at the BLRS dinner.

There were an unprecedented number of attendees; in excess of 230. A large number were from allied health professions, including specialist nurses, physiotherapists, occupational therapists and theatre staff.

This was in no small part owing to Amir’s inclusion of specific sessions focused on these disciplines. This is in keeping with the nature of limb reconstruction, which is heavily reliant on a sound team structure. We are delighted to see this collegiate spirit reflected in the conference.

The scientific programme featured themes of biologics in limb reconstruction, gait analysis, reducing patients’ time in a frame, and a very lively session from our more experienced surgeons on ‘What the years have Bhangra dancing at the dinner ending the BLRS meeting. taught me’. Our guest speaker was Dr Robert Rozbruch street food, accompanied by a from the Hospital for Special Surgery delightful musical arrangement in New York, a name which is

by Amir’s registrars, who were synonymous with limb reconstruction. no doubt pressed into service!

He delivered a stimulating keynote Bhangra dancing and an Indian lecture on new paradigms in limb meal followed, and our international lengthening and reconstruction. guests joined in with gusto!

At dinner the delegates, many dressed in traditional Punjabi attire, were greeted with an array of Indian

The next conference will be the World Congress in Liverpool in August 2019. n

BritSpine Biennial Meeting, Leeds, 2018 The tenth BritSpine conference at Leeds University, 20th-23rd March 2018, was very well-received by over 500 delegates each day as well as industry colleagues from 40 companies who attended the trade exhibition.

The pre-conference day consisted of a trainees’ cadaver lab and the second National Back Pain Clinical Network meeting, as well as a spinal Masterclass.

The theme of the conference ‘The Spine - from Cradle to Grave’ included days devoted to genetics, inflammatory conditions and oncology/trauma.

Contributions came from a diverse range of surgical and non-surgical invited speakers and podium presenters, reflecting the wide variety of professionals involved in spinal care. The organisers were pleased to be able to welcome their overseas guests including Dr Todd Wetzel from the USA and Prof Kenneth Cheung from Hong Kong.

The prize for the best surgical paper went to Paul Thorpe from Taunton for his paper on the consent processes in spinal surgery. The prize for the best non-surgical paper was awarded to Richard Cuthbert from Leeds for ‘First description of γδT-cells in human spinal enthesis.’

Alistair Stirling, UKSSB Chair 2015-2018

On the first afternoon non-clinical presentations including talks from Tim Briggs and Mike Hutton on GIRFT, Ashley Cole and Elaine Buchanan on the

BritSpine 2018 meeting; speakers - Ken Cheung (top middle), Almas Khan (bottom middle).

Improving Spinal Care Project and the National Back Pain Pathway and Todd Wetzel, Tim Pigott and Ian Winson discussing spinal care funding.

There was a well-attended conference dinner at the Royal Armouries where £3000 was raised for the Horatio’s Garden charity.

The UKSSB extends its thanks to Almas Khan and his colleagues

in Leeds and Archer Yates Associates for their hard work and dedication in organising and running the conference so well. The UKSSB also thanks Alistair Stirling and Nick Birch who demitted from the roles of Chair and Treasurer and who are replaced by Patrick Statham and Neil Orpen.

The next BritSpine conference will be held in Wembley in early 2020. n

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Volume 06 / Issue 02 / June 2018

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JTO News and Updates

BASK Annual Spring Meeting, Leicester 2018 The British Association for Surgery of the Knee 2018 Annual Spring Meeting was held on 20th – 21st March at the King Power Stadium in Leicester, with 360 delegates and invited speakers in attendance.

osteoarthritis. There was also considerable interest in a study on improving the consent process in elective orthopaedics following the Montgomery ruling, using an interactive tool entitled Consent Plus.

A lively opening session on knee arthroplasty featured an interesting paper on the analysis of retrieved failed implants, and the soft tissue knee session included an algorithm for single-stage ACL revision proposed by Andy Williams (London), based on an experience of 106 cases.

An instructional session on ACL revision the following day included a comprehensive summary from James Murray (Bristol) on surgical planning and graft choice.

Registry updates on the NJR, NLR and UKKOR followed the free paper sessions, and Andrew Porteous (Bristol) explained that knee arthroplasty constructs (tibia, femur, poly +/- patella) are assessed together as a single entity for ODEP ratings, unlike hip replacements, where each component has an individual rating.

The highlight of the day was a fascinating presentation from Dr Piers Mitchell, a consultant paediatric orthopaedic surgeon in Peterborough and biological anthropology lecturer at the University of Cambridge. His team’s investigations had confirmed that the skeleton discovered under a Leicester car park in 2012 belonged to Richard III, who had received a somewhat hasty burial more than 500 years ago at the former Greyfriars Church on the same site, soon after being killed at the Battle of Bosworth Field.

BASK President Colin Esler presents the award for the Lorden Trickey Lecture to guest speaker Dr Wolfgang Klauser

The afternoon comprised instructional sessions on improving the outcomes of total knee arthroplasty, and the management of periprosthetic joint infections. This was especially relevant to trainees, who will face the burden of increasing demand for primary and revision arthroplasty in the coming years, together with the importance of Getting It Right First Time. Prof Andrew Toms (Exeter) gave an excellent talk on different philosophies (such as measured resection or gap balancing, mechanical or kinematic alignment) and encouraged each surgeon to reflect on which fits best with their objectives in total knee arthroplasty. Prof Mike Reed (Northumbria) then discussed considerations for the prevention of infection, whilst Rhidian Morgan-Jones (Cardiff)

emphasised the importance of a multi-disciplinary approach to PJI, and reminded us that ‘antibiotics without debridement is like deodorant without showering!’

The BASK Annual Dinner was held at the National Space Centre in Leicester, where attendants were treated to an immersive planetarium experience, and entertainment from impressionist Jan Ravens.

The second day of the meeting featured a paper on the outcomes of the Avon Patellofemoral Joint Replacement, which was subsequently awarded best podium presentation.

Interestingly, the rate of revision to TKA for patients with previous trochlear dysplasia was significantly lower than for those who underwent the index procedure for patellofemoral

Professor Leela Biant (Manchester) presented an update on cartilage repair and the international cartilage registry, with an important reminder that most orthopaedic interventions are remarkably cost effective in terms of QALYs. Stephen McDonnell reported on his travelling fellowship to the Hospital for Special Surgery (HSS) in New York, and the Boston Children’s Hospital, where the bridge-enhanced ACL repair (BEAR) technique was developed. It was inspiring to see that such valuable opportunities are available each year to trainees with membership of BASK. The Lorden Trickey Lecture was delivered by Dr Wolfgang Klauser, Chief Physician at the Helios Baltic Sea Hospital in Germany, on ‘Principles of Revision Knee Arthroplasty’.

Distilling the lessons learned from two decades of high volume revision practice is not easy, yet the lecture was structured incredibly well and contained a wealth of practical suggestions for both consultants and trainees. The importance of understanding the implications of particular choices (such as cemented or uncemented fixation and degree of constraint) was emphasised, echoing themes from Professor Toms’ lecture the previous day.

Many thanks to BASK President Colin Esler, the BASK Executive Committee and event organiser Sam Carroll on an excellent meeting, and we very much look forward to next year. n

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BHS Annual Meeting, Derby 2018 The British Hip Society meeting was held at the Derby Velodrome in March, hosted by 2017-18 President, Peter Howard.

The BHS was delighted to welcome Professor Khaled Saleh as guest lecturer. Khaled chose quality and patient safety as the theme of his excellent lecture.

120 scientific presentations were delivered and the five best will be submitted for presentation at AAHKS, in Dallas, in November, where BHS is the guest society.

There was a session on complex primary surgery, with talks on hip surgery with sickle cell, obesity, femoral deformity, hip

dysplasia, previous fracture surgery and following acute pelvic fractures. A second session presented current evidence in Non-Arthroplasty Hip Surgery, including assessment, indications, outcomes and commissioning.

A third looked at ‘finesse’ in hip surgery and the fourth provided an update on hip fracture management. Each session provoked discussion providing useful information to integrate into clinical practice. A ‘Hot Topic’ session was introduced, where blood management, DVT prophylaxis, anterior approach, day case surgery, and rationing in hip surgery were discussed.

and Robin Ling, who sadly passed away recently.

The meeting saw the first Industry involvement in the BHS, with four industry sponsored seminars during the first afternoon.

A detailed summary will be found, alongside much other useful and topical ‘hip’ information, on the BHS website.

Andrew Manktelow, President of the BHS

The BHS spent time to recognise two of our founding surgeons, Michael Freeman

Plans are in progress for the 2019 BHS meeting held from 27th February to 1st March, in Nottingham, hosted by the BHS executive and BHS President Andrew Manktelow. n

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JTO News and Updates

AAOS Annual Meeting, New Orleans 2018 Phil Turner

New Orleans Ernest N. Morial Convention Centre

The American Academy of Orthopaedic Surgery (AAOS) annual meeting 2018 was held at the Morial Convention Centre, New Orleans from 6th to 10th March.

For those who have never attended the AAOS, the sheer size and scale of the meeting is remarkable. The choice of sessions covered generic and sub-specialty themes across 25 symposia and 243 instructional courses. Over 900 papers were presented and 1000 posters displayed, including a selection of e-posters that included a very professional video presentation as well as the written content.

Most of the material is delivered in a conventional way, but increasing use

was made of highly focussed up-dates, debates between experts on contentious topics and a few interactive sessions where the delegates sat at a round table with a moderator who ran through challenging cases leading to some excellent discussions on management of complex problems.

A particularly interesting discussion took place at the ‘Presidents’ Breakfast’ where we compared how different organisations tackled the problem of influencing national healthcare policy. The BOA /

BJJ reception was well attended and gave the opportunity to meet up with the many UK attendees as it was unlikely you would bump into them accidentally.

The trade exhibition was huge!

There were 650 companies represented with the larger ones having enough space to run a self-contained lecture theatre. In the same area was the ‘Technology Theatre’ for presentations of the most cutting-edge material which also attracted delegates into the trade area.

The event used virtually all of the convention centre and considerable planning was needed along with the inevitable Congress ‘App’ to ensure you reached the next venue in time. I easily logged over 10,000 steps per day.

There was still time to enjoy the superb local food and listen to some of the live music on the streets and in the jazz clubs. New Orleans has not yet fully recovered from hurricane Katrina but it is still a remarkable city. AAOS 2019 will be in Las Vegas so I hope to see some of you there. n

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Conference Listing: CAOS (Computer Assisted Orthopaedic Surgery - International)

BOTA (British Orthopaedic Trainee Association)

BOOS (British Orthopaedic Oncology Society)

www.sbpr.info 15-16 November 2018, Netherlands

www.bota.org.uk www.caos-international.org 14-15 November 2018, Newcastle upon Tyne 6-9 June 2018, Beijing

SBPR (Society for Back Pain Research)

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

BSS (British Scoliosis Society)

BESS (British Elbow and Shoulder Society)

www.britscoliosissoc.org.uk www.bess.org.uk 28-30 November 2018, Belfast 19-22 June 2018, Glasgow

BOSTAA (British Orthopaedic Sports Trauma and Arthroscopy Association)

BIOS (British Indian Orthopaedic Society) www.britishindianorthopaedicsociety.org.uk 29-30 June 2018, Huddersfield

www.bostaa.ac.uk 5 December 2018, London

BORS (British Orthopaedic Research Society)

BHS (British Hip Society)

www.borsoc.org.uk www.britishhipsociety.com 27 February-1 March 2019, Nottingham 10-11 September 2018, Leeds

BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk 7-8 March 2019, Norfolk and Norwich

BASS (British Association of Spinal Surgeons) www.spinesurgeons.ac.uk 2-5 April 2019, Brighton

BSSH (British Society for Surgery of the Hand) BOA (British Orthopaedic Association)

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

BTS (British Trauma Society)

www.bssh.ac.uk 25-26 April 2019, Swansea

CAOS (Computer Assisted Orthopaedic Surgery (International))

www.caos-international.org www.bts-org.co.uk 19-22 June 2019, New York 7-8 November 2018, Manchester

BOFAS (British Foot and Ankle Society)

BOA (British Orthopaedic Association)

www.bofas.org.uk 7-9 November 2018, Edinburgh

www.boa.ac.uk 10-13 September 2019, Liverpool

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JTO News and Updates

Centenary Congress 2018 25th – 28th September, ICC Birmingham

congress.boa.ac.uk #BOAAC #BOAcentenaryyear to this year’s programme is a physiotherapy revalidation session. The aim of these sessions is to highlight current issues and updates within each of the specialist areas in Trauma and Orthopaedics.

The Welcome Drinks Reception will take place on Tuesday 25th September in the registration area from 17:45.

The provisional programme is available at congress.boa. ac.uk/programme-2018/.

Carousel and Visiting Presidents

Congress Registration FREE member registration closed on Thursday 31st May. Full member and non-member registration is open from Friday 1st June 2018. Late registration rates will open on Tuesday 11th September; further information is available on the Congress website at congress.boa.ac.uk/ registration-2018/.

Programme Update We are delighted to be celebrating the BOA’s Centenary year with you at the Annual Congress this September. As we mark the last 100 years and move forward into the future, the BOA’s work in transforming lives is as important as ever.

Together with your support, we look forward to continue to Care for Patients, Support Surgeons and Transform Lives.

The theme for the Centenary Congress is ‘Taking stock: Planning the future.’ The programme will be a dedication to the growth and value of the BOA since 1918, comprising of specialist topics including trauma, spines, the National Joint Registry and many more.

Throughout Congress we will have a wide range of revalidation sessions including Knees, Hip and Trauma. A newcomer

We are delighted that the President of each of the following international Orthopaedic Associations will be at this year’s Congress: American Orthopaedic Association, American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, Australian Orthopaedic Association, New Zealand Orthopaedic Association and South African Orthopaedic Association. We are extremely pleased to have India as our Guest Nation for our Centenary year with Professor Mandeep Dhillon, President of the Indian Orthopaedic Association, in attendance, as well as Dr Wong Yiu Chung, President of the Hong Kong Orthopaedic Association.

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Guest Lectures Presidents Guest Lecturer Dr Matthew Varghese Dr Mathew Varghese is currently the Head of the Department of Orthopaedics, St Stephen’s Hospital, New Delhi, and served as Director of the hospital 1999-2006. He was instrumental in changing the profile of the hospital to a super-specialty tertiary care centre even while maintaining a large community outreach programme. An expert in injury control, epidemiology of injuries, pre-hospital care and emergency care of trauma patients, Dr Varghese received the Award of Honour for Reconstructive Surgery in Polio Patients in 1996, the National Award for Excellence in Medicine.

Howard Steel Lecturer Mark Ormrod

Naughton Dunn Lecturer Professor Dr C. Niek van Dijk

Robert Jones Lecturer Professor Hamish Simpson

Mark Ormrod served for ten years as a Royal Marine, in both Iraq and Afghanistan.

While on manoeuvres in Helmand Province he was caught in a landmine explosion and lost both legs and one arm.

After defying the odds and surviving the explosion, Mark competed in the Invictus Games, in cycling, rowing, swimming and athletics, where he won four medals and was singled out for praise by Prince Harry.

Professor Dr C. Niek van Dijk, MD, PhD is a leading authority for arthroscopic surgery of the ankle. He is the founder of the Amsterdam Foot and Ankle school and currently working in the FIFA Medical Centres of Excellence.

Between 2002-2016 he was the head of the Orthopaedic Department of the AMC hospital (Academic Medical Centre in Amsterdam) and a professor in orthopaedic surgery at the University of Amsterdam.

Professor Hamish Simpson is Professor of Orthopaedics and Trauma, and Consultant Orthopaedic Surgeon in the Department of Orthopaedic Surgery at the University of Edinburgh, specialising in limb reconstruction, musculoskeletal infection and paediatric deformity. He is President of the Combined Services Orthopaedic Society and an elected BOA Council Member.

King James IV Professorship Lecturer Fergal Monsell

King James IV Professorship Lecturer Jon Clasper

Charnley Lecture Professor Wayne Paprosky

Fergal Monsell has been a Consultant at the Royal Hospital for Children, Bristol since 2005.

His paediatric practice is broad based with a special interest in the management of patients with limb deformity.

In 2000, he was an ABC Travelling Fellow, and is currently the immediate past President of the British Limb Reconstruction Society (BLRS), a member of the Board of the Society for Children’s Orthopaedic Surgery and a member of the BOA Education Committee.

Jon Clasper was the Defence Professor of Trauma and Orthopaedics from 20092014. He has written widely on trauma and upper limb surgery and has gained doctorates in both Medicine and Philosophy. As Clinical Lead in the Royal British Legion Centre for Blast Injury Studies (CBIS), Jon is responsible for the clinical direction of all its research activities.

Professor Wayne Paprosky works at the Mid-West Orthopaedic Group at Rush University Medical Centre in Chicago USA. He has been at the forefront of lower limb arthroplasty surgery for years. Wayne has made a huge contribution to the management of primary, complex primary and hip revision surgery and has become a ‘household’ name in revision surgery with his development and popularisation of the most widely used, and clinically relevant classifications of bone loss on both the femoral and acetabular side.

>>

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JTO News and Updates

Archive of the BOA’s One Hundred Years We are celebrating our Centenary year and to mark the occasion we will be featuring a special session on achievements of the BOA on the first day of Congress. There will also be remarkable items on display from the BOA archive, so do make sure you find time to view some of the amazing documents, photographs and items of interest recording the history and development of the BOA over the last 100 years.

For further details, please visit congress.boa.ac.uk/programme-2018.

Centenary Video

Awards and Prizes

To celebrate 100 years of the BOA we have produced a Centenary video, which documents the journey of the BOA, and some of its key milestones over the last century.

We hope you enjoy and share the video available to watch here at www.boa.ac.uk/latest-news/boa-centenary-video.

Each year the BOA runs a best of the best session. This brings together the winners of the best paper awarded from each training region in the UK. Trainees compete with each other to be awarded the Best of the Best.

Awards and prizes also presented at Congress are: • Presidential Merit Award • Honorary Fellowship Scrolls • Robert Jones Essay Prize and Medal • BOA Young Investigator Award • Clinical Leaders Programme Poster Prize • Innovation in Simulation Prize • Simulation Free Papers Prize • Best of the Best Award • UKITE Trainee • Medical Students’ Essay Prize • Medical Students’ Podium Prize • Exhibitors Cup for Best Large Stand • Exhibitors Prize for Best Compact Stand

Centenary Congress 2018 25th – 28th September, ICC Birmingham

‘Taking stock: Planning the future’ congress.boa.ac.uk #BOAAC #BOAcentenaryyear

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Exhibition The exhibition will run from Tuesday 25th to Thursday 27th September in Hall 3 and on the Hall 3 gallery at the ICC Birmingham. Each year over 80 companies exhibit at the event which is attended by over 1,900 medical students, trainees, consultants and allied health professionals. Every exhibitors will have their logo and company information listed on the Congress website, in the programme book and on the Congress App. For further details please visit congress.boa.ac.uk/exhibitors-2018/.

Travel The 2018 Congress will be taking place at the ICC Birmingham, and with its centralised location traveling to the ICC could not be easier.

Birmingham Airport is the only ten-minute away by train which links directly into Birmingham New Street. There are also a number of rail links available that leads into the city centre.

We hope you will join us in Birmingham at what promises to be a fantastic Centenary Congress. Visit congress.boa.ac.uk for more information.

Sponsorship Opportunities Once again the Congress will be supported and sponsored by a number of industry bodies. There are a number of sponsorship opportunities still available, including several branding opportunities around the venue. For further details, please visit congress.boa.ac.uk/exhibitors-2018/ to download the sponsorship brochure. Alternatively please contact the events team at events@boa.ac.uk with any queries.

Accommodation TSC Hotel and Venue is the official hotel booking agency for Congress 2018. Please note that the exclusive rates for the BOA Annual Congress are guaranteed until Thursday 23rd August. Visit our Accommodation page at congress.boa.ac.uk/travel-and-accommodation-2018/ for hotel choices and further details.

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JTO News and Updates

BOA Membership Update Joint Action Challenge Events: London Marathon Fundraisers We would like to offer huge congratulations to Zaid Ali, Thomas Barwick, David Cohen, Paul Harnett, Robert Jordan, Rosie Tansey and Mark Roussot for running the 2018 Virgin Money London Marathon on Sunday 22nd April!

Paul Harnett

Robert Jordan

Rosie Tansey

Mark Roussot and family

Zaid Ali

Thomas Barwick

Well done to all of our participants, this year being one of the hottest Race Days in the UK. Thank you for raising tremendous donations for Joint Action.

If you are interested in participating in the 2019 London Marathon, please contact jointaction@boa.ac.uk.

Free Membership Subscription Prize Draw Congratulations to Professor Christina Doyle, who was chosen at random in April by Ananda Nanu, BOA President, to receive FREE membership for the year!

To celebrate our Centenary year, throughout 2018 one BOA member will be chosen at random every month to receive a year’s free membership subscription.

BOA Members Handbook 2018 All BOA members should have now received the special edition of the members’ Handbook, along with the Centenary booklet and Centenary leather bookmark in the post.

Joint Action Challenge Events Participate in the British 10K (15th July) and Prudential RideLondon-Surrey (29th July) this summer and get involved with Joint Action Challenge Events! Run, walk or cycle to raise much-need funds that really make a difference in advancing this field of medicine. To register for a Joint Action event please contact jointaction@boa.ac.uk or visit the BOA website www.boa.ac.uk/research/ challenge-events. Good luck to all of the participants!

New BOA membership benefit for 2018!

We are pleased to offer BOA members a new membership benefit with CRC Press, a premier global publisher of science, technology and medical resources.

BOA members will receive a 20% discount on the latest edition of Apley and Solomon’s System of Orthopaedics and Trauma and more. Please contact membership@boa.ac.uk for the discount code. For further details, please visit the BOA website www.boa.ac.uk/membership/benefits.

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The National Joint Registry Celebrates its 15th Anniversary Year 2003-2018 Tuesday, 3rd April 2018, marked the 15th Anniversary of the start of data collection for the NJR. Working across the NHS and independent healthcare sector and with circa 2.56 million records, the NJR has developed to become the world’s largest arthroplasty register and one of the most influential healthcare registries in the world, playing a major role both nationally and internationally.

NJR data supports patient safety and quality of care, providing a

valuable source of evidence for patients, hospitals, surgeons, implant manufacturers and regulators, to monitor performance and outcomes, and reflect on practice.

NJR data also supports an extensive research programme and key national initiatives such as NHS Improvement’s delivery of Getting It Right First Time (GIRFT) and Model Hospital wherein NJR price benchmarking data facilitates review and comparison of

the cost effectiveness of orthopaedic implants and joint replacement surgery.

Endorsed by the BOA and NHS Improvement, NJR recently implemented its innovative Accountancy and Transparency performance-monitoring model which incorporates prevention and surgeon engagement.

Surgeons are alerted to deteriorating outcomes for early remedial action and are encouraged to review and reflect on their own practice

Prevee-Prep

and performance data. NJR Chairman, Laurel PowersFreeling confirmed it is expected to be “ground-breaking for the NHS and for patient safety and reassurance.”

Never complacent, the NJR will continue to ‘drive quality improvement in the orthopaedic sector as a whole’ and enhance its value through developing its information systems and data access for researchers. n

Prevee-prep collar formed on the limb.

This collar helps prevent the migration of prep solutions under the tourniquet cuff

for use with disposable & re-useable tourniquet cuffs

Prevee Prep is a tourniquet cover that: l Helps to prevent the migration of prep solutions l Protects tourniquet cuffs from contamination

from the surgical site

l Comes in a full range of sizes from paediatric to XXL l Designed with reference to NHS safety notice

SAN(SC)99/33 Medical Devices Surgical Cuffs - Risk of Burns

l Comes in boxes of 100 l One use only l Latex free l Comes flat packed l Fitting guide measure tapes available

Fitting guide measure tapes available

Power-Pod Try Oak Medical Services new range of power “Power-Pod” units!

Oak HQ, Unit 5A Albert Street Brigg, North Lincolnshire DN20 8HQ T: 01652 657200 F: 01652 657009 E: info@oakmedicalservices.co.uk W: www.oakmedicalservices.co.uk

6-10 gang sockets version available l Lockable castors l Service and testing l

Volume 06 / Issue 02 / June 2018

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JTO News and Updates

The BOA National Clinical Leaders Programme Anwar Jafri The BOA National Clinical Leaders Programme (CLP) is a one-year course with the aim to develop leadership skills and to provide the tools to produce and deliver a Quality/ Innovation Improvement Project (QIIP).

The Programme The BOA CLP has evolved from a generic leadership course to one tailored to the needs of the Orthopaedic Practitioner (Senior Trainee, SAS or newly appointed Consultant). Participants are selected after a competitive selection process.

The programme is delivered over one year with four, two-day modules (Table 1) in Newcastleupon-Tyne. It culminates with poster presentations of the QIIPs at the BOA Congress.

The first aim is to produce a QIIP. Participants propose a project when they apply.

The programme provides the knowledge, tips and tricks on how to implement the project.

This is delivered through interactive master classes, small group tutorials and coaching sessions.

The second aim of this course is to produce inspirational leaders for the future and to deliver ongoing innovation and quality.

The first module sets the scene: projects are discussed and timescales for progress are agreed. There is an initial focus on self-analysis and reflection. Subsequent modules then explore what makes a good leader, motivational techniques, conflict resolution and the concept of ‘win win’.

Throughout the course progress of the improvement projects are reviewed at the study days and through telephone coaching calls.

Module 1

Module 2

Module 3

Module 4

Clinical leadership

Quality improvement tools

Consultant interview skills

Project completion

Leading quality improvement

Personal effectiveness and coaching skills

Developing resilience

Legal aspects of medical records

Behavioural profiling

Healthcare policy masterclass

Understanding clinical coding

Inspiration leadership

Project planning

Managing clinical careers

Conflict resolution

Emotional intelligence

Table 1: Clinical Leaders Programme

Clinical Leaders Cohort (2016-2017) - Poster Presentation at the BOA Annual Congress, Liverpool 2017.

The real forte of this course is the impressive expert speakers: Mike Reed’s talk on the difficulties encountered when introducing new innovations and strategies in overcoming tribalism, and entrenched and non-evidence based behaviors.

A real highlight was Pat Oakley who captivated the audience about the inner workings of the Department of Health and the future direction of the NHS: the Sir Humphrey’s of Whitehall have already preordained this - and it seems irrespective of party politics!

My QIIP Our aim was to reduce the lower limb arthroplasty length of stay.

Our hypothesis was that this would reduce morbidity/mortality, improve patient satisfaction and produce cost savings.

Engagement of key stakeholders (surgeons, anaesthetists, nurses, physiotherapists, occupational therapists and managers) was a key step.

By presenting our baseline data and comparing it to centres

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Reducing length of stay following lower limb arthroplasty in a District General Hospital -A quality improvement project (QIP) BOA National Clinical Leaders Programme (Cohort 2)

Anwar Jafri*, M Adeel Akhtar, Helen Ward, Linda Wildberg University Hospital of North Tees and Hartlepool * anwar.jafri@me.com Over the last decade the traditional model of staying in hospital after joint replacement for 4-5 days has been replaced by earlier discharge. Proponents of enhanced recovery for lower limb arthroplasty report improve patient satisfaction and reduction in morbidity and mortality. In addition to medical drivers enhanced recovery also results in reducing the length of hospital stay with financial savings and availability of more beds for elective surgery. Our unit had adopted some facets of enhanced recovery but had not embraced the concept others, such as of Day 0 mobilisation or patient education to manage expectations. Prof Briggs GIRFT report highlighted that our mean length of stay (LOS) was 5.2 days in May 2016 which was above the National averages for lower limb arthroplasty- this galvanised our QIP.

The programme has polished my leadership skills and provided me with a framework to deliver a quality and innovation project.

Team members were encouraged to contribute ideas towards reducing length of stay. Interventions were implemented sequentially and their effects on length of stay were observed with real time data continuously fed-back to the stakeholders.

By going through the stages of realisation, collaboration, innovation, implementation, interpretation and reflection we observed that length of stay reduced from a mean of 5.2 to 3.2 days. No increase in morbidity/mortality was seen, the re-admission rate was not affected and patient MITAscores Recon improved. advert.pdf satisfaction

Background

What I got from this course

of excellence we convinced stakeholders there was a real issue to be addressed.

I have found that with enthusiastic leadership and team ‘buy in’ patient care and experiences can be improved, financial savings can be made and staff morale and team ethos can be boosted. Win-win!

Scope the literature on methods employed at reducing LOS Visits to Beacon units of excellence Engage all stakeholders to buy into QIP Measure LOS. To monitor the effects of different interventions aimed at reducing LOS. To share our experience and results so other units can emulate and reduce their length of stay.

Baseline Primary

Mean Length of Stay 7

5

5.9 5.2

5.4 4.6

4

4.0

4.1

4.4 3.8 3.8 3.7 3.6 3.6 3.6 3.6 3.7 3.2

3

0

Consensus and evidence based opinion drove through changes such as Day 0 mobilisation, regular anti-emetics, addition of IV steroids, preloading patient expectations at time of listing, MDT patient education classes for patients and family, Improved Discharge criteria (knee flexion of 80 degrees, use of novel walking aids, community anticoagulant monitoring, bowel management, community discharge liaison pathways). We implemented f/u phone calls from arthroplasty nurse practitioners at 48 hours and easy access for patients to return for review or telephone consultation for any concerns. PDSA cycles 1-8

were completed.

Methods

Outcomes

• Dramatic reduction in mean LOS • Decrease in cost to trust and increase in bed availability.

• No increase in post-op readmission rate was found

Limitations

• Difficult to ascertain the role of individual interventions to reduce LOS.

Next Phase

–Time Line

• Real time LOS reporting Mechanism - continuous review of LOS, strive to safely reduce LOS through multiple marginal gains.

• Disseminate our experiences

June 2016 Focus group meeting to engage the stakeholders November 2016

Re-organisation of physiotherapy staff (Return of experienced Ortho Physio ) January 2017 Improved criteria for post discharge care following lower limb arthroplasty

Leadership Challanges • Engagement of all stakeholders to share vision of QIP • Countering entrenched practice

March 2017 Discharge planning (discharge script, weekend discharge, LMWH dispense from pharmacy) April 2017 Day 0 Mobilisation (Safe to mobilise check-list produced)

1

1

metric- LOS in days

We conveyed a meeting of all the stakeholders (surgeons, anaesthetists, physiotherapist, occupational therapist, nurses and managers) to discuss and implement ways to safely reduce the length of hospital stay following lower limb arthroplasty. It was a cost neutral project with no additional staff required.

2

Measurements

Design / Strategy

Further information about the programme can be accessed via the BOA website: www.boa.ac.uk/ training-education/boa-clinicalleaders-programme-201819/. n

After implementation of a variety of interventions the mean LOS has significantly decreased from 5.2 to 3.2 days during the last year. Total number of arthroplasty cases performed during last year at our trust was 791 with average cost of hospital stay of £457 per night. We have calculated that the trust can save approximately £722,974 a year by reducing the length of stay.

6

Aims and Objectives 1.

2.

3.

4.

5.

6.

Results & Benefits

May 2017

Anwar Jafri is a Consultant Trauma and Orthopaedic Surgeon at the North Tees NHS Foundation Trust.

His specialist interests include 08/05/2018 17:20 revision arthroplasty and education.

Regular oral anti-emetic (Ondansetron) after feedback from Physio and nurses June 2017 Patient education classes (MDT approach) July 2017 Steroids as part of the enhanced recovery program (6.6mg IV Dexamathasone)

Bibliography 1. Sutton JC III, Antoniou J, Epure LM et al. Hospital discharge within 2 days following arthroplasty following hip or knee arthroplasty does not increase major complication and readmission rate. J Bone Joint Surg [Am] 2016:98:1419-1428.

2. Length of stay following primary total hip replacement Julian foote et.al. Ann R Coll Surg Engl 2009; 91: 500–504 3. Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients Gregory Tayrose, M.D., Debbie Newman, B.S., James Slover, M.D., M.S., Fredrick Jaffe, M.D., Tracey Hunter, B.S., and Joseph Bosco III, M.D. Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6 4. Predictors of length of hospital stay after total hip replacement Kashif Abbas, Masood Umer,Irfan Qadir,Jaweria Zaheer, Haroon-ur-Rashid Journal of Orthopaedic Surgery 2011;19(3):284-7 5. Do shorter lengths of stay increase readmissions after total joint replacements? U.S. Sibia et al. / Arthroplasty Today 3 (2017) 51e55

QIIP Poster 2017

Meeting the requirement of ISO 9001 (Clause 10) on continuous

KNEE TRAINER V3

improvement

PATENT GRANTED

accuracy

C

M

Y

CM

MY

CY

CMY

K

realism

stability

New locking clamps - hip and heel with variable rotational load

In situ leg alignment mechanical axis - 2nd toe / femoral head

Adjustable hip bench clamp for left and right sides

Right-hand side now available for pre-order

www.medical-models.com

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JTO News and Updates

Royal College of Surgeons Update For the College, discussions are being held internally for the start of the move back, and the plans are being created to ensure that this happens with as few issues as possible.

This will include celebrations of major and significant milestones in the construction and opening of the new building, the completion and

opening of the new Hunterian Museum, and the return of the Surgical Associations.

To watch the demolition occur, the College has installed a time-lapse camera with a view over the Barry site: URL: www.lobstervision.tv Username: BarryBuilding Password: kJhAGL36

Barry Building demolition in progress.

With everyone settled in the Nuffield Building, the Barry Building programme progresses on. One half of the building has been demolished, and work has started on the demolition of the other half next to the boundary with what used to be Number 44. At the time of

writing, archaeological surveys were starting, with the hope of not finding anything unexpected, no matter how exciting. Further internal and external design aspects have been decided upon, adding to the future presence of the home of the RCS and Surgical Associations.

Barry Building façade demolition, Portugal Street.

BOA (Soli Lam General Fellowship Award) Travelling Fellowship Kim Boyd Ferguson Through the Soli Lam Fellowship, I went on a month long travelling fellowship to the USA. I spent the first two weeks at the Ponseti Clubfoot Clinic at the University of Iowa Hospital and Clinics (UIHC) followed by two weeks at Shriner’s Hospitals for Children in Philadelphia. This was an incredible learning experience and one I feel very honoured to have been able to undertake.

The Ponseti method for the management of clubfoot in children is now almost universally accepted as the gold standard treatment. To be taught on a one to one basis the nuances of the casting method in the unit where the technique was developed has been invaluable. I was also able to learn the procedure for tibialis anterior transfer as originally

described by Ponseti. The experience I gained in the clinic with Dr Morcuende has provided me with tips and tricks which I could not learn from a textbook.

Shriner’s Hospitals for Children in Philadelphia has a large subspecialist practice. I was able to spend time with attendings who have a wide-ranging practice including arthrogryposis, congenital hand deformities, obstetric brachial plexus injury, sports injury and spine. This practice gets a large volume of tertiary referrals providing me with the unique opportunity to gain more experience in these less common conditions.

In particular, I now have an algorithm for addressing complex upper limb problems in a growing child. n

Dr Morcuende (left), Kim Boyd Ferguson and two other observers (right)

Dr Morcuende teaching Kim Boyd Ferguson on a model.

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Wisepress Book of the Quarter

Gartsman’s Shoulder Arthroscopy

Covering the entire spectrum of operative shoulder arthroscopy, including both routine and complex shoulder procedures, Gartsman’s Shoulder Arthroscopy, 3rd Edition, provides a straightforward, “classroom” approach that walks you through each step of these challenging surgeries.

Two master surgeons in the field, Drs Hussein Elkousy and T. Bradley Edwards, present clear explanations of the standard approach to each procedure, plus variations and complications that frequently arise. Focused, concise coverage includes review of anatomy, indications and contraindications, non-operative options, pre-operative assessment and imaging, and more.

Authors: Hussein Elkousy, MD, T. Bradley Edwards ISBN: 9780323529013 Date published: 13th Apr 2018 Price: £183.99 BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.

19 - 22 September 2018 10th Course · Pisa · Italy

Management of the Diabetic Foot Welcome to Pisa!

This 4-day theoretical course and practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot.

Lectures will be combined with practical sessions held

in the afternoon at the diabetic foot clinic at the Pisa University Hospital.

Lectures will be in agreement with the International Consensus on the Diabetic Foot and Practical Guideline on the Management and Prevention on the Diabetic Foot.

ANNUAL CONFERENCE 7th - 8th November, 2018 MANCHESTER ◆ It's 30 years since the BTS was founded ◆ Are you involved in patient care: from the point of injury to rehabilitation?

Pisa International Diabetic Foot Course www.diabeticfootcourses.org The course is endorsed by EWMA

◆ Then join us at our 30th Anniversary Conference: contribute and celebrate!

www.bts-org.co.uk

#BTS2018

Volume 06 / Issue 02 / June 2018

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JTO Features

Quality Improvement in Surgical Teams (QIST): Anaemia and Infection Ashley B Scrimshire Co-Author: Mike Reed MSSA surgical site infection

Building on the successful Quality Improvement in Surgical Teams (QIST) Collaborative model, we are pleased to introduce an ambitious new collaborative project aimed at improving surgical outcomes through the preoperative treatment of mild anaemia and decolonisation of carriers of Methicillin Sensitive Staphylococcus aureus (MSSA).

The project is led by Northumbria Healthcare NHS Foundation Trust, in partnership with the British Orthopaedic Association.

It is funded for £1.5M by NHS Improvement, Northumbria NHS Vanguard, and industry (Vifor and Schülke), with independent evaluation by the University of York Trials Unit.

This innovative Quality Improvement, Patient Safety and Research trial aims to improve care after hip and knee replacement in two evidence based domains:

Anaemia

Ashley B Scrimshire

Anaemia is very common in older people and 13% of all patients with joint replacement will have anaemia as a complicating factor.

This equates to over 20,000 people per year in England alone.

Anaemia is associated with higher risks of blood transfusion and operative complications1–3.

The successful management of anaemia in joint replacement surgery was established by the Airedale team who devised and implemented a surgical care bundle to introduce pre-operative anaemia screening, treating those that need it with iron4.

This has since proven to be a scalable intervention, having been successfully delivered to over 9,000 patients. Better management of mildly anaemic patients resulted in reduced blood transfusion, reduced likelihood of critical care admission, reduced hospital length of stay and reduced readmission rates5.

Both National and International Guidance recommends optimisation of anaemia prior to surgery. The cost of treatment is under £30 per patient and in one study delivered an average total saving of £160 per patient5.

For an average sized Trust this equates to an annual saving of £120,000.

Public Health England has identified that both MSSA and MRSA are common causes of infection in joint replacement surgery6. Whilst MRSA infections have received attention in the press and action has been taken to reduce their impact, MSSA continues to be a dominant cause of infection.

A Dutch study published in the New England Journal of Medicine has shown that MSSA screening and decolonisation of carriers can reduce the risk of having an infection caused by staphylococcus aureus by 60% in a range of surgical procedures7.

This has been adapted into a care bundle specifically to meet the needs of joint replacement patients and has been implemented at one Trust for over 9,000 patients. The before and after data is very encouraging and shows a statistically significant reduction in overall infection rates and this is dominated by the reduction in MSSA8.

The cost of screening is £8 per patient and the treatment costs an average of £9 per patient, for the 20% of the population that carry the bug7. It costs less than £2,000 to avoid an infected joint replacement, which would cost many tens of thousands to treat8.

Screening and decolonisation is now a recommended intervention by the World Health

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Aintree University Hospitals NHS Foundation Trust Barking, Havering & Redbridge University Hospitals NHS Trust Barts Health NHS Trust Basildon and Thurrock University Hospitals NHS Foundation Trust Bradford Teaching Hospitals NHS Foundation Trust Calderdale and Huddersfield NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Chelsea & Westminster Hospital NHS Foundation Trust Derby Teaching Hospitals NHS Foundation Trust

Figure 1: IHI Breakthrough Series Collaborative Model Using an “all teach, all learn” philosophy, the QIST collaborative will include on boarding through a set up phase and Launch event, team coaching, face-to-face meetings, and web-based meetings where teams learn from our expert faculty and each other. Teams will be trained in the Model for Improvement, a framework for testing, implementing, and spreading changes and innovations. It includes use of plan-do-study-act (PDSA) cycles or rapid cycle improvement — allowing teams to start small, adapt the evidencebase to their local settings, and implement only those changes that result in improvement. Teams use data to monitor their improvement efforts and are provided with support and coaching throughout the collaborative.

Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust Dorset County Hospital NHS Foundation Trust East and North Hertfordshire NHS Trust East Lancashire Hospitals NHS Trust East Sussex Healthcare NHS Trust Epsom & St Helier University Hospitals NHS Trust Gateshead Health NHS Foundation Trust Harrogate and District NHS Foundation Trust Isle of Wight NHS Trust

Organization for orthopaedic surgery, but uptake rates in the UK remain low.

Both of these interventions are effective in their own right, but implemented together they represent a significant improvement in patient safety and cost effectiveness.

The project aims to help to spread the learning from this work to help drive up the quality of joint replacement care in England.

The project takes the form of a cluster-randomized trial, whereby participating Trusts are randomized to receive either the anaemia or MSSA quality improvement intervention first.

Teams from each Trust will come together in one of two parallel collaborative groups to receive coaching and support in developing their local Trust-wide pathways and services following the Institute for Healthcare Improvement Breakthrough Series Collaborative model (see Figure 1). This is a globally recognised methodology for implementing large-scale quality improvement measures.

Teams from across England will be working together in a collaborative manner to develop and implement these quality improvement measures locally, helping each other to overcome common obstacles along the way to improve patient care on a large scale.

Data will be collected on a range of outcomes including surgical site infection and transfusion rates to assess the effectiveness of the collaborative. Each arm of the trial will act as the control group for the other, so the control group for the anaemia intervention will be the infection group and vice versa.

Outcomes including transfusion and surgical site infection rates will be measured by staff employed locally. In addition, the growing network of orthopaedic trainee research collaboratives, such as the Collaborative Orthopaedic Research Network (CORNET), will be utilized to engage trainees as collaborators to report surgical site infections. Following the initial study period teams will crossover and receive the same level of coaching in the other arm of the trial to maximize the benefit to all Trusts taking part.

From over 80 Trusts who expressed an interest, we have now selected those who will take part in the QIST collaborative trial (see Table 1). Trusts have been randomised and we have successfully run the first learning events in London. Teams are hard at work developing their services and we are providing on going support and are in regular contact. We are due to all meet again later this month and we look forward to continuing our work with all of the teams on delivering large scale change across the NHS, to improve patient care and outcomes in elective hip and knee arthroplasty. n

London North West University Healthcare NHS Trust Manchester University NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Milton Keynes University Hospital NHS Foundation Trust Royal Free London NHS Foundation Trust Royal Liverpool & Broadgreen University Hospitals NHS Trust Salisbury NHS Foundation Trust South Tees Hospitals NHS Foundation Trust Stockport NHS Foundation Trust Surrey & Sussex Healthcare NHS Trust Surrey & Sussex Healthcare NHS Trust Tameside & Glossop Integrated Care NHS Foundation Trust The Ipswich Hospital NHS Trust The Leeds Teaching Hospitals NHS Trust The Mid Yorkshire Hospitals NHS Trust The Princess Alexandra Hospital NHS Trust The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust United Lincolnshire Hospitals NHS Trust University Hospital Southampton NHS Foundation Trust Walsall Healthcare NHS Trust West Suffolk NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust Wrightington, Wigan and Leigh NHS Foundation Trust

Table 1: Trusts randomised in the QIST: Anaemia and Infection collaborative trial.

Ashley B Scrimshire has taken time out of his Northern Deanery higher surgical training to study for his PhD at the University of York and is the clinical lead for the QIST: Anaemia and Infection collaborative trial. He has been trained in quality improvement methodology at the Institute for Healthcare Improvement.

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

Orthopaedic Traumatology Following an Urban Terrorist Attack Juan de Dios Robinson “He who wishes to be a surgeon, should go to war” (Hippocrates 460–370 BC). Tragically, as the events of the last few months have shown, ‘war’ can come to us. Terrorism is not a new phenomenon in the UK. We all remember the 7th of July 2007, when 52 people were killed and more than 700 were injured following the bomb blasts in London. The human toll from the most recent four attacks in the UK was 37 fatalities and 173 injured. With up to 75% of casualties of an attack with bombs or high velocity rifles presenting with musculoskeletal injuries, orthopaedic surgeons must be prepared to manage patients with injuries that are normally seen in battle fields.

The weapons 1. Explosive devices Blasts result in many casualties, cause chaos and panic which often adds to the casualty toll as well as hampering rescue efforts.

Blast injuries are classified as: l Primary

Caused by pressure waves and are characterised by the absence of external injuries. Hollow and air-filled viscera are injured.

Examples of injuries include: ear drum perforations, bowel injuries or lung injuries such as ‘blast lung’, the commonest cause of primary blast injury death.

l Secondary Juan de Dios Robinson

Responsible for most casualties, as fragments reach well beyond the area affected by the pressure

wave. Fragments or shrapnel can cause major internal bleeding despite a small entry wound and can also cause fractures throughout the body. l Tertiary

The force that pushes the victim away and against other objects causes blunt injuries. Fractures, internal bleeding and brain injury from coup-countercoup mechanism of injury may occur.

l Quaternary

Quaternary injury includes flash injuries, crush injuries resulting from collapsed structures trapping limbs, etc.

Enclosed spaces The blast wave is reflected from surface to surface increasing the effect of blast injuries.

Examples of explosive devices (i) Suicide vests and rucksacks The explosive device is concealed and transported by the perpetrator. The capacity to injure is maximised by including nails or ball bearings.

Case example: The suicide bomber in the attack of 22nd May 2017 in a concert in Manchester used a small rucksack with a small metal case containing the bomb and augmented with screws and nuts. The shrapnel was ejected with enough force to penetrate metal doors. The blast resulted in 22 dead and 250 injured. (ii) Improvised Explosive Devices (IEDs) Manufactured and deployed by non-military entities. IEDs can be manufactured with military explosives such as artillery rounds which are wired together or they can be ‘homemade bombs’.

Case Example: On 15th April, 2013, two terrorists detonated a ‘pressure cooking bomb’ during the Boston Marathon. The blast killed three people and caused hundreds of casualties, including 16 people who suffered traumatic amputations. (iii) Car bombs A car, truck, van or motorcycle bomb, also known as a vehicle borne improvised explosive device (VBIED), is an explosive

>>

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JTO Features

5. Improvised weapons Motor vehicles have been used in recent times to attack victims. The recent spate of acid attack victims suggests that this could also be another form of terror that could be adopted soon.

Frequent orthopaedic presentations following a conventional terrorist attack l Traumatic Amputations

Figure 1: Lower Limb Injuries secondary to a blast.

device of variable sizes that are placed in vehicles and are either driven or parked near targets.

Case example: On 15th August 1993, a car bomb exploded in Omagh, County Tyrone, Northern Ireland. The bomb detonated in a crowded shopping area. 29 people were killed and 220 injured.

2. Firearms Internationally, the rate of fatalities in terrorist attacks involving firearms between 19702014 reached 70%, and in the attacks not involving firearms the fatality rate was 29%.

Figure 2: Bowel perforations caused by ball bearings from a suicide bomber vest.

circulation today. Similar weapons include the AK-74 made in Bulgaria.

and wound 48 in a combined van and knife attack in London Bridge.

Case example: Friday 13th November 2015. Three men armed with AK-74s entered the Bataclan concert venue in Paris during a concert as part of a larger orchestrated terrorist attack on Paris. 89 people were killed and at least 99 were injured.

4. Chemical, biological, radioactive, nuclear weapons (CBRN) All health workers must be aware to respond in cases of multiple casualties resulting from CBRN attacks.

3. Blade Weapons Between 2013 and 2016, 23.6% of terrorist attacks and plots involved a knife.

Case example: 3rd June 2017.

Three attackers kill seven people

Case example: 20th March 1995. Tokyo subway sarin attack.

Domestic terrorists released the neurochemical compound sarin on three lines of the Tokyo underground killing 12 people and injuring 50 while causing vision problems to 5000 people.

As it was tragically illustrated after the Boston and Manchester attacks, it is necessary for any surgeon to be versed in the basics of management of traumatic amputations. There is no place in modern practice for guillotine amputations. It only takes a few more minutes to carry out a proper amputation, leaving sufficient bone length and soft tissue cover from which to fashion a proper stump later.

l Open fractures

Open fractures must be treated with early antibiotics and thorough systematic debridement. The wound requires extension for proper exploration, as the zone of injury may extend well beyond the obvious wound and the explosion may have pushed contaminants deep inside the soft tissue envelope.

l Wound Ballistics

The type of wound is a function of both the projectile’s design and velocity of impact. There are broadly three types of bullet design objectives: (i) Maximum accuracy (ii) Maximum penetration (iii) Maximum target damage by expansion or fragmentation of the bullet.

Examples of firearms High velocity rifles; The AK-47 and AK-74 The AK-47 is the most popular weapon used by terrorist groups internationally. There are approximately 75 million AK-47 in

Figure 3: Traumatic amputation resulting from an IED explosion.

Figure 4: Chest x-ray showing a nail which penetrated the chest following the explosion of a home-made device.

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THERE IS NO PLACE IN MODERN PRACTICE FOR GUILLOTINE AMPUTATIONS. IT ONLY TAKES A FEW MORE MINUTES TO CARRY OUT A PROPER AMPUTATION, LEAVING SUFFICIENT BONE LENGTH AND SOFT TISSUE COVER FROM WHICH TO FASHION A PROPER STUMP LATER.

l High velocity rounds

All high velocity round injuries are contaminated by definition, and exploration and debridement are mandatory. A small entry wound with a massive exit wound is characteristic.

l Shrapnel injuries

Leave the shrapnel alone in the acute phase and only remove it a later stage if causing systemic or local toxicity as when it has penetrated a joint.

Paediatric casualties Children suffer more penetrating injuries, internal injuries to the torso, open head wounds, and other critical injuries. Children, due to their small size and soft skeleton, are more vulnerable to all forms of blast injury.

Mass casualty incident (MCI) A ‘mass casualty’ event, is when the local healthcare system is overwhelmed by the number of casualties that vastly exceeds the local resources and capabilities in a short period of time. Trusts must ensure that their hospitals and staff are properly trained to respond.

Triage In a mass casualty situation, the focus must be on identifying patients who have a realistic chance of survival.

Damage control

External Fixation

Security and safety

1. Damage control resuscitation Damage control resuscitation (DCR) involves haemostatic resuscitation, permissive hypotension (where appropriate) and damage control surgery.

DCR aims to maintain circulating volume, control haemorrhage and correct the ‘lethal triad’ of coagulopathy, acidosis and hypothermia.

Always consider the future requirement for flaps. No pins should be placed through a wound and none within the ‘zone of injury’.

Remember that patients brought in may be carrying weapons or explosives. Do not touch them.

Security services should dispose of any firearms or weapons.

Secondary and tertiary surveys

Ethical dilemmas

2. Damage control surgery The objective is to control bleeding and spillage from viscera. Patients are then transferred as soon as possible to ICU for further stabilisation.

Damage Control Orthopaedics (DCO) 1. Stabilise long bone fractures.

This helps prevent fat embolism and reduce blood loss.

2. Reduce dislocated joints.

3. Stabilise pelvic fractures to reduce blood loss.

4. Wash out and close open joints.

5. Wash out and debridement of open fractures.

6. Packing of pelvic fractures to control massive bleeding.

7. Fasciotomies of limbs with suspected compartment syndrome or following revascularisation.

8. Work closely with vascular surgeons to stabilise open fractures with vascular injuries.

Do not neglect the need for a thorough secondary and tertiary survey.

Complications l Acute and chronic

osteomyelitis from poor open fracture management

l Neuromas and prosthetic

complications from initial inadequate amputations (guillotine amputations)

l Neurological injuries from

missed or mismanaged spinal injuries

l Volkmann’s ischaemic

contracture from missed compartment syndrome.

Organisation Your institution should have a plan to respond in case of a terrorist attack. Make sure you are aware of what your role is and where you should be.

1. Triage (see above) 2. Potentially treating ‘the enemy’ 3. Religious issues: during an MCI, you may not have time to find out personal sensitivities or beliefs.

Rehabilitation The survivors of terrorist attacks will have both physical and psychological rehabilitation needs.

Conclusion Orthopaedic surgeons must prepare to face injuries that hitherto were almost only encountered in regions of the world afflicted by conflict. n Juan de Dios Robinson trained in the UK, Canada and New Zealand. He completed trauma fellowships and the BOA National Clinical Leadership Fellowship.

He has worked for MSF and the WHO in Afghanistan and Iraq. He published the book ‘Orthopaedic Trauma in the Austere Environment- A Practical Guide to Care in the Humanitarian Setting’.

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JTO Features

The History of the Victoria Cross Hero, Harold Ackroyd - Doctor, Scientist and Gentleman (1877-1917) Christopher Ackroyd It was 104 years ago on 4th August 1914, that Britain declared war on Germany drawing the British Empire into one of the greatest conflicts of the 20th Century. At the start of the war, Britain had a professional army of 80,000 men, facing a German army of over one million men.

After initial reverses, Britain and France pushed the German forces back to eastern France and Belgium to the stalemate that was to form the Western Front and the long and vicious war of attrition which resulted in the loss of over one million men and countless more severely injured, both physically and mentally.

Field Marshal Lord Kitchener, a veteran of the Boer war, realised by mid-September that the war was not going to be over quickly and so started the massive recruitment campaign to form his New Model Army.

Christopher Ackroyd

In 1916, after the Battle of the Somme failed to achieve a breakthrough, Allied High Command decided to plan a second major campaign further north on the Ypres salient. On 31st July 2017, the third battle of Ypres began four months of slaughter to take a few miles of Belgium territory. It resulted in over 245,000 British and Commonwealth deaths and serious injuries in what became known as Passchendaele.

WE Dixon’s laboratory in the Pharmacology Department on the Downing Street site and then in the newly formed Institute for the study of Animal Nutrition, Department of Agriculture working with Sir Frederick Gowland Hopkins the first Professor of Biochemistry. He published six papers on Purine metabolism, the last in 1916 with Sir Frederick.

Harold Ackroyd was born in In early 1915, recruitment to the 1877 in Southport. He went army had reached fever pitch. to Shrewsbury school before Harold was now 37 years old and coming up to Gonville and Caius had no recent acute accident or College to study medicine. He medical experience. He decided went on to Guy’s Hospital and to join up, and after initial training >> qualified in 1904.

After resident jobs at Guy’s, Birmingham General and Liverpool Northern Hospitals, he took a post at the Strangeways Research Hospital in Cambridge where he met his future wife Mabel Smythe who was the matron. They married in 1908 and had three children. The same year, Harold was awarded a three year BMA research scholarship and he immersed himself in academic work; Figure 1: Portrait of Harold by Jerry Hicks (Bristol artist). first in Professor

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JTO Features

joined the Royal Berkshire regiment as the medical officer and they sailed for France in July.

The regiment was involved in numerous actions in 1915, but it was at the battle of Delville Wood in July 1916 early in the Somme campaign that Harold showed true courage, treating over 1,000 casualties, British, South African and German. He received 11 commendations for bravery and was awarded the Military Cross.

Exhausted after continuous bombardment and probably injured, Harold was sent home in August on sick leave, but within two weeks he was demanding a return to the regiment. The medical board insisted that he take six weeks leave but Harold in a letter to his brother Edward on 4th September described them as “an awful lot of old fossils!”

Harold returned to the regiment in December and they moved up to Ypres to prepare for the third battle (Passchendaele) in July 1917. On 31st July and 1st August in the action to secure

Glencorse Wood, Harold repeatedly rescued injured men from no-mans-land and at the end of the action there were 23 separate commendations for bravery which resulted in the award of the Victoria Cross.

Sadly, 10 days later on 11th August, Harold was attending to casualties in Figure 4: Harold Ackroyd’s medals; VC., MC., 14/15 Star, War Medal, Victory Medal. a shell hole in Jargon trench in no-mans-land when he was widow Mabel and their eldest 1963, they passed to his brother shot in the head by a German son Stephen aged five years.

Anthony, my father. After his sniper and died instantly. He Harold’s death had a devastating death in 1988, he bequeathed was buried at Birr Cross Roads effect on Mabel and the family. them to me. The medals had Cemetery near Ypres which was She remained in mourning for the actually been on loan to the designed by Sir Edwin Lutyens. rest of her life.

RAMC since the Centenary The award was gazetted on 6th Exhibition at Marlborough House September and at an investiture The final piece of the story is in 1956. In 1993, I decided to outside Buckingham Palace on the fate of the medals. In 1947, take possession of them and 19th September, King George Stephen inherited them from put then on display in my V bestowed the medals on his his mother. When he died in consulting rooms in Bristol.

Harold’s Victoria Cross Citation

Figure 2: The gravestone at Birr Cross Roads Cemetery, Zillebeke, Ypres, Belgium.

Figure 3: HRH King George V bestows the medals on Mabel Ackroyd and her son Stephen on 19th September 1917.

“For most conspicuous bravery. During recent operations, Captain Ackroyd displayed the greatest gallantry and devotion to duty. Utterly regardless of danger, he worked continuously for many hours up and down and in front of the line tending the wounded and saving the lives of officers and men. In doing so, he had to move across the open under heavy machine-gun, rifle and shellfire. On another occasion, he went some way in front of our advanced line and brought in a wounded man under continuous sniping and machine-gun fire. His heroism was the means of saving many lives, and provided a magnificent example of courage, cheerfulness and determination to the fighting men in whose midst he was carrying out his splendid work.

This gallant officer has since been killed in action.”

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Name

Regiment/Corps

Date

Conflict

Location

Harold Ackroyd

Royal Berkshire Regiment

31 July–1 August 1917

First World War

Passchendaele

William Allen

Royal Artillery

3 September 1916

First World War

Near Mesnil

Henry Andrews

Indian Medical Services

22 October 1919

Waziristan campaign

Khajuri Post

William Babtie

Royal Army Medical Corps

10 December 1899

Second Boer War

Colenso

William Bradshaw

90th Foot

26 September 1857

Indian Mutiny

Lucknow

Noel Chavasse

King's Regiment (Liverpool)

9 August 1916 31 July–2 August 1917

First World War First World War

Guillemont Wieltje

Thomas Crean

1st Imperial Light Horse

18 December 1901

Second Boer War

Tygerkloof

John Crimmin

Bombay Medical Services

1 January 1889

Karen-Ni Expedition

Near Lwekaw

Campbell Douglas

24th Foot

7 May 1867

Andaman Expedition

Little Andaman

Henry Douglas

Royal Army Medical Corps

11 December 1899

Second Boer War

Magersfontein

Joseph Farmer

Army Hospital Corps

4 July 1879

Zulu War

Ulundi

John Fox-Russell

Royal Welch Fusiliers

6 November 1917

First World War

Khuweilfe

Andrew Fitzgibbon

Indian Medical Establishment

21 August 1860

Third China War

Taku Forts

John Green

Sherwood Foresters

1 July 1916

First World War

Loos

Thomas Hale

7th Foot

7–8 September 1855

Crimean War

Sevastopo

Henry Harden

No. 45 (Royal Marine) Commando

23 January 1945

Second World War

Brachterbeek

Anthony Home

90th Foot

26 September 1857

Indian Mutiny

Lucknow

Neville Howse

New South Wales Army Medical Corps

24 July 1900

Second Boer War

Vredefort

Bellenden Hutcheson

75th (Mississauga) Battalion, CEF

2 September 1918

First World War

Drocourt-Quéant

Edgar Inkson

Royal Inniskilling Fusiliers

24 February 1900

Second Boer War

Hart's Hill

Joseph Jee

78th Foot

25 September 1857

Indian Mutiny

Lucknow

Ferdinand Le Quesne

Army Medical Corps

4 May 1889

Burmese Occupation

Siallum

Owen Lloyd

Army Medical Corps

6 January 1893

Kachin Hills Expedition

Fort Sima

Valentine McMasters

78th Foot

25 September 1857

Indian Mutiny

Lucknow

William Maillard

HMS Blake

6 September 1898

1898 Occupation of Crete

Candia Fauquissart

George Maling

Rifle Brigade

25 September 1915

First World War

William Manley

Royal Artillery

29 April 1864

New Zealand Wars

Tauranga

Arthur Martin-Leake

South African Constabulary Royal Army Medical Corps

8 February 1902 8 November 1914

Second Boer War First World War

Vlakfonteiu Zonnebeke

Richard Masters

141st Field Ambulance, R.A.S.C.

9 April 1918

First World War

Béthune

James Mouat

6th Dragoons

29 January 1856

Crimean War

Balaclava

William Nickerson

Royal Army Medical Corps

20 April 1900

Second Boer War

Wakkerstroom

Harry Ranken

King’s Royal Rifle Corps

19–20 September 1914

First World War

Hautevesnes

Herbert Reade

61st Foot

14–16 September 1857

Indian Mutiny

Delhi

James Reynolds

Army Medical Corps

22–23 January 1879

Zulu War

Rorke's Drift

Francis Scrimger

Canadian Army Medical Corps

25 April 1915

First World War

Battle of St Julien (24 April – 5 May)

John Sinton

Indian Medical Service

21 January 1916

First World War

Orah ruins

William Sylvester

23rd Foot

8 September 1855

Crimean War

Sevastopol

William Temple

Royal Artillery

29 April 1864

New Zealand Wars

Tauranga

Harry Whitchurch

Indian Medical Service

3 March 1895

Chitral Expedition

Chitral Fort

Table 1: List of medical recipients of the Victoria Cross. Source: Wikipedia, the free encyclopaedia.

By 2003, the medals had risen considerably in value. After much debate within the family, I finally decided to sell the medal set to an anonymous purchaser and donate the proceeds to Gonville and Caius College Cambridge to fund a four year medical scholarship and an annual medical lecture.

Fourteen scholars have now been elected, and there have been fourteen annual lectures given by distinguished medical scientists including six Nobel Prize winners.

In 2006, Lord Ashcroft published his book on ‘Victoria Cross Heroes’ and it was revealed that Harold’s medals were part of the Lord Ashcroft Trust collection and would be exhibited in a new gallery at the Imperial War Museum. On 10th November 2010, the Princess Royal opened the Lord Ashcroft Gallery and lilies of the valley were presented to the Princess

by Harold’s six year old greatgreat-granddaughter, Mia Pearlman.

Our family hope that the scholarship will continue in perpetuity and that Harold’s extraordinary story will be a lasting example and an inspiration to the medical students of the future. n Christopher Ackroyd is a retired Orthopaedic surgeon from Bristol. He was Honorary Secretary of the BOA in 1990, founded British Orthopaedic News (BON) and as an NHS consultant in Bristol helped to establish the Bristol Knee Group and designed the Avon Patellofemoral Arthroplasty.

Retirement has led to farming a cider orchard of 1,000 trees and enjoying his large family.

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JTO Quiz

JTO Quiz Conflict is a constant theme in human history. These images all relate to war or terrorism, real or threatened, close to home or far away. When you read the articles on military surgery (pages 58 – 67), remember that some of the greatest advances in the care of severe trauma have their origins in war. The BOA itself resulted from the vision of surgeons who dedicated themselves to the treatment of both acutely injured service personnel and their long-term care and rehabilitation.

Use your knowledge of history, architecture or geography to say where each image is taken.

3.

There are no prizes for this quiz – it is just to make you think for a while about our specialty and how the lessons of war are more relevant than ever in both civilian and military practise.

1.

© Albert Bridge (cc-by-sa/2.0)

2.

© Richard Peter

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4.

6.

8.

5.

7.

9.

Answers on page 71

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JTO Features

How I do...

The Elite Athlete’s ACL Reconstruction Andy Williams Introduction

Graft Choice

This patient group will test surgery to the limit and will differentiate good from bad in all aspects of management.

A good result can be obtained using any autograft but the type is chosen to suit the athlete’s sport.

Patellar tendon graft is best for professional footballers. The only indication for allograft is an in-line power athlete, e.g. sprinter.

First Consultation Injured athletes are frightened, suspicious and sad. The first consultation therefore has to be of the highest quality and empathy from the surgeon is key.

Timing of Surgery Since the athletes are human beings, the usual rule of waiting for the knee to be quiet applies. A surgeon has to resist considerable pressure to operate too soon.

Mid 1/3 patellar tendon (n, %)

Overall rate of re-rupture

14/ 125 (11)

7/ 81 (8.6)

Anteromedial bundle position

5/ 72 (6.9)

1/ 22 (4.5)

Central ‘anatomical’ position

9/ 53 (17)

6/ 59 (10.2)

Table 1: Rates of ACL graft re-rupture according to femoral tunnel position and graft type.

Tunnel Positions

It is a Weird World

A central tibial footprint tunnel is used and on the femur the anteromedial bundle position within the ACL footprint.

A change to a central femoral footprint position (‘anatomic’ placement) leads to a doubling of the re-rupture rate in professional footballers1.

Sports vary in their capacity to generate money, but professional football is a multi-million pound entertainment industry. The current TV deal for the English Premier League for 2016 to 2019 is worth over €6.5 billion, a 71% increase on the previous three-year deal. The average English Premier League first team wage is £2.4 million a year (£46,150 per week). With this finance comes immense pressure.

‘Non-medical medical experts’ appear from everywhere and are happy to give their opinions.

The money attracts ‘gurus’ and ridiculous treatments, which must be resisted. It also attracts huge media interest, which adds pressure. Nevertheless, the highest professional and ethical standards must be upheld by surgeons involved in this work. Keeping in the background and never offering comment is the way to deal with this. Whilst tempting, it is best to avoid being named in the papers.

Rehabilitation A surgeon’s duty is to allow a return to play for an athlete only as soon as it is safe and not before. The minimum time should be six to nine months.

Working as a team with the player’s team doctor and physiotherapists is vital.

Return to Play Criteria

Andy Williams

Quadrupled hamstrings (n, %)

The knee must lack effusion.

The player must be aerobically fit. They must have confidence.

The final aspect is restoration of symmetry in terms of muscle bulk and in dynamic neuromuscular control. There are a number of functional tests that can help assess but not guarantee readiness.

Finally, the medico-legal challenge of professional sport is already being felt. The Appleton Case meant that the MPS, and shortly thereafter the MDU, refused to cover professional

football cases. Surgeons like myself had to seek their own indemnity as a result. This still fails to give adequate coverage.

Top Tips l Less surgery is often more l Get it right first time – there is

no room for manoeuvre

l Attention to detail is the way

to excellence. n

Andy Williams undertakes all aspects of knee surgery, especially ligament reconstruction and sports injuries dealing with many UK sports teams. His research is prizewinning (over 100 publications and edited Gray’s Anatomy). He was Hunterian Professor (2005), ABC Travelling Fellow (2002) and named in the UK’s Top 100 Doctors (The Times 2011).

Reference 1. The Anatomy of the Anterior Cruciate Ligament and its Relevance to The Technique of ACL Reconstruction. R. Śmigielski, U. Zdanowicz, M. Drwięga, B. Ciszek, A. Williams.

Bone Joint J 2016: 98-B; 1020-26.

1

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Volume 06 / Issue 02 / June 2018

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JTO Features

Operations I no longer do... Shoulder and elbow – ten years on Lee Van Rensburg Over before I began Thermal capsular shrinking of the shoulder I began my higher surgical training in 1999. Thermal Capsular shrinkage is an arthroscopic technique to treat shoulder instability. Radiofrequency probes deliver energy (heat) to capsular tissue; this causes the collagen to denature and the capsule to shrink, effectively tightening up the shoulder. It was used primarily to treat atraumatic multi-direction instability.

Popular in the late 90’s and early 2000’s, reports of axillary nerve injury, articular cartilage chondrolysis and inferior results compared with plication procedures led to enthusiasm waning for this procedure. I was trained in this technique, but never performed this technique as a consultant, having taken up post in late 2006.

A recent meta-analysis in 20161 continues to advise against the use of thermal capsular shrinkage for multidirection instability.

Things I no longer do Intramedullary fixation of the clavicle I returned from my Australian fellowship in 2006 enthused with the idea of intramedullary fixation of the clavicle. It remains a valid procedure and the merits of plate fixation and intramedullary fixation of the clavicle remain a hot topic of debate subject to systematic reviews and meta-analysis. I suspect the problem was the method of intramedullary fixation of the clavicle I chose to use.

Cannulated screw fixation, involving open reduction, retrograde guide wire drilling of the lateral fragment followed by antegrade passage of a 6.5mm cannulated partially threaded cancellous screw. My wound complication in my first year as a consultant undertaking this procedure approximated 30%. In retrospect, I suspect it had something to do to thermal necrosis caused by retrograde drilling of the guide wire.

Ten years on, I no longer operate on the clavicle, thinking it is a two dimensional structure.

Lee Van Rensburg

I now know what works in my hands, plate fixation with a pre-contoured injury specific plating system to return the

3D shape to the clavicle provides a reliable dependable procedure if a clavicle needs fixation.

Intramedullary nailing in my practice is now reserved for simple displaced fractures in adolescents with passage antegrade of a Titanium Elastic Nail.

Primary bone graft A theme prevalent in other articles on this topic. I no longer perform primary bone grafting of fresh fractures, or for the first operation for non-union if I can achieve a stable construct with a shelf to compress across. n Lee Van Rensburg completed his higher surgical training on the East Anglian Rotation in 2005. He then undertook a trauma fellowship at The Alfred in Melbourne Australia. In 2006 he began as a Consultant with special interest in shoulder and elbow surgery at Cambridge University Hospital.

a

b

Figure 1: a) Comminuted displaced midshaft fracture of clavicle. b) Intramedullary fixation with retrograde cannulated screw.

a

b

c

Figure 2: a) PA upper third chest radiograph showing united mid third fracture of right clavicle with 6mm of linear shortening. b) Superior view, Volume rendered 3D CT showing, relatively straight clavicles, Right clavicle united with no significant linear shortening. c) Volume rendered 3D CT angiogram of the same patient, showing thoracic outlet obstruction, combination of relatively narrow thoracic outlet, malunion over first rib.

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

Using NJR Data in Appraisal Martyn Porter This article is intended to provide guidance for surgeons as to how to use their personal NJR data in their annual appraisal.

1. Log into Clinician Feedback.

Click on the green tab at the top labeled Consultant Outcomes and then Consultant Level Report. Download the latest report.

2. Look at the data and funnel plots. You should be familiar with the interpretation of the plots but if not seek advice from a colleague or from NJR. 3. Validate and revisions linked to your primary activity and any 90 day deaths. These will be listed in the CLR with a local (hospital ID).

4. If you are doing this for the first time there may be several cases to check (depending on volume of activity) but if you are doing this annually then the task is much less onerous.

5. There are many ways of validating the cases but access to the hospital electronic records (if available) and digital records can be helpful.

Martyn Porter

6. Creation of an Excel worksheet is a good way of listing cases and adding any learning experiences. Post revision outcome can also be noted.

7. The revision may have been carried out by another surgeon and in another hospital in which case access to data may be difficult. It may be possible to contact the GP to obtain details OR contact the revision surgeon for details.

8. There may be no particular concerns and revision rates may be infrequent, but themes may become evident such as infection, dislocation, periprosthetic fracture etc.

9. Produce a reflective document suitable for appraisal.

Example Reflection Document NJR Reflection for Appraisal 2017 I have downloaded my latest available consultant level report (CLR 2016-17) from clinician feedback. This records activity and outcomes between 2003 and 2017 with detailed data for the 2016-17 financial year.

The CLR was published on the website in July 2017 and represents the most up to date information on my practice.

Demographics Activity In the last 12 months I have carried out X hip replacements and Y knee replacements and in the last three years XX hips and YY knees. I carried out XX revision hips last year and Y revision knees. My revision hip volume is sufficient to maintain competence.

Consent My NJR consent rate is XX% compared to the national average of 93%.

ODEP Rating (Hips only) Femoral component. The stems I use routinely are the uncemented ABC (10A*) and the cemented XYZ (10A). 93% are ODEP 10A or 10A*. Of the others I use custom stems in some complex cases and I believe their use is justified.

Acetabular component. The sockets I use routinely are the uncemented ABC (10A*) and the cemented XYZ. The XYZ was only introduced to the market nine years ago so hasn’t yet had the time to reach a 10 rating but it is 7A and on a trajectory to reach 10A. The reason I use the XYZ is to use XLPE which I believe will result in a lower revision rate compared to conventional PE. I am aware of the latest NJR data on the implants I use and believe that my use is justified.

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Hips Fixation I am using cement for most elderly patients (strong evidence) and Hybrid for younger more active patients (good evidence).

Hips Bearing I predominately use metal on XLPE bearings but in young patients I use Ceramic on XLPE and have almost stopped using ceramic on ceramic because of noise concerns.

Patient Profile For both hips and knees the distribution of age, ASA and BMI are not substantially different from the National averages. I do deal with a number of complex cases that are not reflected in the NJR data (hip dysplasia and deformity).

Linked Revisions I have reviewed the list of linked revisions and checked the cases using the Electronic Patient Record and other hospital records. I have also checked previous years CLR and my validated spreadsheet that contains detailed information.

There were X revisions linked to my primary activity (linked revisions) to validate. Most of these were fairly straightforward to check from my spreadsheet.

There were a few data anomalies that will require correction but the overall data is satisfactory.

The data anomalies included: (Describe what they have been and how they have been dealt with.)

Chronology of revisions Revisions relate to early problems such as infection and dislocation but also to medium term complications such as wear and loosening.

The number of revisions will increase with time as the cohort

boa.ac.uk

of primaries continue to grow both in number but also in terms of years that the implants are under observation (PTIR). For example, I started to record activity as soon as the NJR started in April 2003. There were no recorded revisions until 2005 (1) then two in 2007 and then X in 2009. For the last four years about Y have been added every year.

Reasons for revision The reasons for revision were: ARMD X Infection X Dislocation X PP # X Pain X Loose socket X Loose stem X Learning I have reviewed and reflected on every revision that I have information on to see what I could learn. The main learning was (provide details).

On the positive side I have not had to revise a cementless socket and have only revised one cemented stem for loosening.

Hip Outcomes l Observed events for all indicators are as expected or lower than expected. l For cemented procedures

there are X observed revisions compared to Y expected.

l My last five year data shows

X observed compared to Y expected.

l The unadjusted revision rates

in one, three and five years are as expected or lower than expected (X% compared to Y% at three years).

Trends l The data is also displayed over the last three years (March 2015, 2016 and 2017).

This allows comparisons of more recent performance.

There are no concerns.

Knees Repeat as for hips etc.

Trust Data (ACR) I have reviewed the most recent ACR. Observations: l We are a high volume unit l Compliance is high l Consent less satisfactory l Linkability excellent l Unadjusted revision rates at

one, three, five and seven years for both hips and knees lower than the national average.

Outcomes We are a significant underlier for both hips and knees (good performance) over the whole NJR (2003).

Variation The funnel plots show active and inactive surgeon plots.

The inactive surgeons are those who have retired or left.

Some lead surgeons may not be consultants.

Hips The plots for hips look good in historical and five-year data.

There is one surgeon who is an underlier for last five years (clearly doing something right can we learn from it?).

Knees Similar to hips there is on one active surgeon at the lower boundary (which is good) Reassuring the last five year data looks good (in control).

Mortality No concerns.

Confirmation of Practice l Reflection l My volumes are satisfactory

to maintain competence

l I deal with a number of

complex cases

l I feel that the implants,

fixation and bearings that I use are justified

l I have reviewed my linked

revisions and assessed them to see if there are any learning experiences

l I have reviewed my revision

and mortality data and there are no particular concerns in fact in some areas my revision rates are significantly lower than expected

l My more recent (five year)

performance for hips is also in control

l There is one surgeon who

is doing very well and there may be a learning opportunity - I will look into this

l I will share my data and

learning at the consultant meting for all consultants to discuss their NJR data collectively

l I see no reason to change

my practice

l I will use this reflective

document together with my CLR at my next appraisal. n

Martyn Porter is the National Joint Registry’s Medical Director and Vice Chairman, appointed by the Department of Health from 1st 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

Key Issues and the Current Landscape of Orthopaedics in South Africa Pradeep Makan South Africa has the highest Gini coefficient, a measure of income inequality, in the world. Inequality has worsened despite the elimination of all discriminatory regulations following the country’s first democratic election in 1994.

Healthcare delivery differs between the public and private sectors as a result of this huge socioeconomic disparity.

History One of South Africa’s pioneer orthopaedic surgeons include Dr F.P. Fouche, who started his practice in Johannesburg in 1925. He was the first Chairman of the Orthopaedic Surgeons’ Group which later became the SA Orthopaedic Association. Lord Nuffield, a great philanthropist, founded the Nuffield Trust which sponsored doctors, including Dr G.R. Girdlestone, to help manage South African children stricken with crippling diseases such as tuberculosis and poliomyelitis.

Education

Pradeep Makan

The first orthopaedic academic appointment was Dr Pieter Moll, who took up

a post at the University of Cape Town in 1931. Further orthopaedic appointments followed nationwide, and training facilities were established at all local medical schools. There are currently 193 orthopaedic registrars who are required to complete the single exit examination set by the College of Orthopaedic Surgeons of South Africa. There are currently 784 practicing orthopaedic surgeons in South Africa, serving a population of about 54 million. Orthopaedic surgeons in the urban areas tend to focus on a particular specialty while those in the rural areas tend to be generalists. There are ten specialty subgroups in South Africa, including arthroplasty, foot and ankle, hands, hip

arthroscopy, knees, paediatrics, shoulder and elbow, spine, trauma and tumours.

The Public Sector About 20% of the orthopaedic surgeons are employed in public service. This sector provides healthcare for more than 80% of uninsured South Africans and translates to a ratio of 0.37 orthopaedic surgeons per 100,000. In addition to the problems associated with insufficient personnel, this sector faces a huge burden of disease.

They are challenged by the large number of orthopaedic manifestations of infections such as tuberculosis and HIV as well as trauma from road traffic accidents and interpersonal violence.

The Private Sector The ratio of 5.9 orthopaedic surgeons per 100,000 in the private sector, is similar to the average ratio in most of the developed world. Private care is provided nationwide at numerous private institutions run by either one of the three large hospital groups (Life Healthcare, Mediclinic and Netcare) or independently owned hospitals. Currently,

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insured South Africans enjoy the benefit of accessing private healthcare for all prescribed minimum benefits (PMBs) irrespective of the level of medical aid cover they have purchased. The PMB package, in terms of the Medical Schemes Act, state that any benefit option that is offered by a medical scheme must be paid in full, without any co-payments required by the patient. Orthopaedic PMBs include congenital abnormalities, fractures, spinal injuries, infections and chronic rheumatological conditions.

Traditionally, private doctors were paid on a fee for service basis, but this is changing to

alternative reimbursement models such as global fees for hip and knee arthroplasty.

This transformation will assist in improving patient outcomes as all these packages facilitate review of quality measures, patient enrollment in the South African National Joint Registry and cost containment.

All relevant parties are actively engaged in finding a long-term solution to address the current inequalities in the South African healthcare system with government’s commitment to introduce a national health insurance that would offer appropriate and equitable healthcare to all South Africans. n

Pre-operative oedema reduction in ankle trauma patients Accelerating readiness for theatre in ankle fracture patients requiring Open Reduction Internal Fixation (ORIF).

The geko™ device gently stimulates the common peroneal nerve, activating the calf and foot muscle pumps to accelerate the reduction of oedema.

A statistically significant NHS study shows backslab plaster cast + geko™ accelerates readiness to theatre, compared to current standards of care.

Results show1:

2

2 days improvement in readiness for theatre on average per patient.

Pradeep Makan, President of South African Orthopaedic Association and past President of South African Spine Society, is an Orthopaedic Surgeon based in Cape Town where his practice is focused on the management of degenerative spinal conditions. He maintains an affiliation with the University of Cape Town, where he obtained his under and postgraduate training. He was a Smith & Nephew Travelling Fellow in 1994, completed a spinal fellowship in Oxford in 1996 and was an ABC Fellow in 2002.

1.66

The geko™ +plaster cast = 1.66 days readiness totheatre (average).

£569 2 Backslab plaster cast + geko™ saves an average of £569 per patient compared to current care.

With geko™ use, 60% of patients are ready for theatre in 2 days,compared to 27% in control arm, a 122% improvement.

Quick & easy to fit OnPulse™ ˚ Utilises neuromuscular electrostimulation technology (NMES).

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JTO Features

BOA Bootcamp Course for ST3 Trainees Hiro Tanaka The BOA are proud to announce the launch of the first Bootcamp course for ST3 trainees in 2018. The aim of the four day programme is to provide the fundamental professional and technical skills to allow our trainees to learn faster and smarter during their training. The core content focusses upon human factors to build resilience, practice effective leadership, develop self-awareness and stress management. Delegates will have the opportunity to learn all the common surgical approaches in an informal and interactive environment.

A BOA survey of all deaneries revealed that half provided some form of enhanced induction for their trainees at the start of the rotation. The benefits of learning the principles of professional practice at the earliest stages of training are well recognised internationally with Canada and Australia leading the way. The BOA Bootcamp programme was designed in consultation with psychologists, educationalists, military surgeons and Royal College advisors.

Hiro Tanaka

The BOA Bootcamp course is suitable for trainees at the ST3 level and consists of two parts run over a four day programme.

The first section consists of two days of human factors training otherwise known as non-technical skills. Cognitive simulation is used in facilitated breakout groups so that trainees can learn how they will feel and respond to situations which they will encounter during their training. For example, a case that is going badly or facing conflict with another staff member.

By reflecting and discussing their

behaviour with others, they will learn how to avoid the traps of poor professional conduct, mitigate stress and thrive in a high performance environment.

Resilience, leadership and stress management are skills which can be practiced and developed by all trainees and will enhance their performance during the six years of training as well form an essential foundation for consultant practice.

The next section consists of two days of cadaveric lab training covering all common surgical approaches using case-based learning. With a 1:2 faculty to delegate ratio, they will have the opportunity to learn at their own pace and apply high ordering thinking as to what approach to use for what clinical situation.

The purpose of this section is to focus on surgical approaches only without covering the principles of internal fixation.

Running this type of programme is expensive and we plan to carefully assess the value that

this course delivers to the trainee’s career long term.

Places for the first course were offered without any cost to delegates and this is subject to sustainable sponsorship for future courses.

I believe that as our profession evolves, so must the way we train our future consultant surgeons. It will not be enough just to produce technically able and clinically knowledgeable surgeons.

Our consultants of the future will also be expected to be resilient leaders with the ability to perform well in an increasingly stressful environment. That is our mission. n Hiro Tanaka is a Consultant Foot and Ankle surgeon at Aneurin Bevan University Health Board. He is Chair of the BOA Education Committee and has led the development of the ST3 Bootcamp programme.

He is a Health Foundation Fellow and is passionate about clinical leadership.

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JTO Features

On-line Supervisor Training – eTOES Lisa Hadfield-Law What is e-TOES? The e-TOES programme, created by the BOA, helps T&O educational and clinical supervisors to maximise their impact on training and to achieve recognition as a supervisor, by the GMC. Why?

How?

Nearly 1,000 T&O surgeons have participated in one day, face to face TOES (Training Orthopaedic Educational Supervisors) programmes around the UK and Ireland and it serves its purpose well. However, those who have difficulty taking time away from work and other responsibilities, can now join this highly interactive programme, spread over seven weeks rather than seven hours.

The benefits of such spaced learning, with opportunities for practice and reflection, have proved valuable to over 40 surgeons who have participated so far.

The programme is underpinned by seven standards for trainers defined by the GMC and translated into the surgical context by the Faculty for Surgical Trainers. Building on these, we have created key questions to help participants demonstrate achievement of the required standards. The online components comprise: screencasts, documents, articles, discussion forums, one to one coaching sessions and wikis created by the participants themselves. You can select what you want to use, and nothing is mandatory, but by the end you will need to be able to answer all the questions in the relevant wiki and to get the TOES certificate, to have made a reasonable contribution to the final wiki document, along with the other cohort members. At the end of the programme, a PDF is created from the wikis and activities, which can be uploaded to participant portfolios.

[Wiki - a website on which users collaboratively modify content and structure directly from the web browser.]

Lisa Hadfield-Law

Discussions arising so far during live cohort chats on Skype include: What do we do with trainees who: l Don’t take advantage of the opportunities they are offered l Come to us with a tick box mentality l Confuse need with want l Are difficult to build rapport with l Need to acquire resilience l Are overconfident l How can we handle colleagues who aren’t supervising properly or are mistreating trainees?

In March this year, an e-TOES app was launched, which has enabled us to log on quickly and access content instantly. We have been able to work together on trains, planes, in theatre coffee rooms and even in cable cars.

When?

We have run one cohort of up to 15 participants every three months and began our sixth cohort in April. It runs over seven weeks, with a notional one module per week and approximately an hour required per module. Some completed most of the work over a week or two and others have taken longer than the seven weeks.

Who? e-TOES targets surgeons who have a supervisory role: consultant trainers, senior trainees or fellows, and SAS surgeons. We have had participants working in Australia, Canada, Switzerland and India and the broader mix has provided invaluable insights.

Conclusion For surgeons short of time who want to maximise educational supervision, this on-line programme offers flexibility, whilst preserving the highly valued interactive elements.

If you would like to join, you can find out when the next cohort starts, by visiting www.boa. ac.uk/training-education/e-toes/.

“I initially signed up for this to try and help provide evidence for appraisal for recognition as a trainer, but I have learnt far more than I thought I would and have enjoyed it.” - Quote from participant. n Lisa Hadfield-Law, RGN, MSc, FAcadMEd and Education Advisor to the BOA.

10th Anniversary Annual Scientific Meeting of the International Society for Hip Arthroscopy

SAVE THE DATE

IMPORTANT DEADLINES

4 – 6 OCTOBER 2018

MELBOURNE, AUSTRALIA

Early Registration

Bringing together the world’s best hip arthroscopy surgeons and leading open hip surgeons

31 July 2018

ISHA ANNUAL SCIENTIFIC MEETING

4 – 6 OCTOBER 2018 MELBOURNE, AUSTRALIA www.ishaconference.com

ISHA 2018 - 10th Anniversary Meeting, Melbourne This will be the first time ISHA has officically combined their meeting with premier open hip surgeons under the new banner of “ISHA – The Hip Preservation Society.

There will be open surgery sessions, arthroscopic surgery sessions and combined sessions.

Mr. John O’Donnell, ISHA 2018 Host Chair stated, “During the past 10 years, there has been a massive increase in the number of hip arthroscopies performed each year in all the major hip arthroscopy countries, and in the range of indications for hip arthroscopy.

Pathologies have been identified which would not have been known without hip arthroscopy, such as tears of the ligamentum teres, and whole new areas have become accessible to arthroscopic surgery, such as the deep gluteal space, hamstring tendon attachments and the sciatic nerve.

There will be 2 major themes at the meeting; there are invited lectures presented each year by experts in the field, the major aim of the meeting is to present new and cutting-edge research in hip surgery and this theme will continue. The ISHA meetings are where most of the major new work in hip arthroscopy has been presented

first each year, and ISHA 2018 aims to continue that tradition, presenting the best new work in the fields of hip arthroscopy, open hip surgery, and Physiotherapy.

The second major focus will be on the presentation of the first two major Randomised Control Trials comparing surgical and conservative treatments for Femoroacetabular Impingement (FAI).

In addition, ISHA 2018 will feature major sessions on Physiotherapy and Rehabilitation, and for the first time will feature a Pre-Meeting Day specifically for Asian surgeons.

Many of these surgeons will be presenting for the first time in an English-speaking forum. It is anticipated ISHA 2018 will be the start of a period of greatly increased cooperation with Asian surgeons, and an opportunity for the society to support surgeons in the region in the development of hip preservation surgery in their countries.

“We expect ISHA 2018 to continue the remarkable growth of previous years’ meetings, and we will be focusing on the development of all aspects of hip preservation surgery.

It will certainly be the major hip preservation surgery meeting of the year” said Mr. John O’Donnell.

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JTO Features

Re-branding T&O: The Undergraduate Experience Mariea Brady The T&O Image The orthopaedic surgeon is often the butt of undergraduate jokes: What’s the difference between a rhinoceros and an orthopaedic surgeon? One is thick-skinned, small-brained and charges a lot (for no very good reason)...the other is a rhinoceros; what’s the difference between a carpenter and an orthopaedic surgeon? A carpenter knows more than one antibiotic. In these jokes, unfairly, orthopaedic surgeons are not renowned for their intellect, academic rigour, humility or patient care.

Mariea Brady

Recently, Subramanian et al.

(2014) challenged the perception of the ‘strong as an ox but half as bright’ orthopaedic surgeon (Figure 1) in a multicentre prospective comparative study.

Their objective was to compare the intelligence and grip strength of orthopaedic surgeons and anaesthetists. Results showed that orthopaedic surgeons were both stronger (significantly greater mean grip strength) and more intelligent (significantly greater intelligence test score) compared to anaesthetists. The authors hoped their findings would show that the ‘strong but stupid’ stereotypical image was unjustified and curtail the comedic repertoire of their anaesthetist friends (Subramanian et al., 2014)1. In spite of their efforts, the

negative image remains and may be deterring medical trainees from pursuing a career in T&O.

which are making a surgical career less attractive including: demands on work-life balance, dissatisfaction with the surgical training programme and lack of support. They also commented on the fact that the NHS of today doesn’t offer the same peer support that was present in the coherent firm structure that most senior surgeons benefited from - surgical F1 posts today run as part of a shift system, they are more intense (with more ward/ administrative work and less theatre time) and there is not the same continuity of patient care that used to exist (Eardley et al., 2015). The authors concluded that surgeons everywhere have a responsibility to engage with and support all their surgical trainees to ensure that a career in surgery does not become increasingly unattractive.

The medical student body of today bears little resemblance to the one of 20 years ago; most strikingly, the number of female medical students and minorities has significantly increased (Evans and Sarani, 2002)2.

Unfortunately, the T&O specialty has failed to attract these graduates and it remains a male dominated field; in 2012 only 5% of orthopaedic consultants in the UK were women (Vint et al., 2016)3.

In their article, ‘Why a Career in Surgery is No Longer the Golden Ticket’, Eardley et al. (2015)4 addressed some key factors

Figure 1: The stereotypical image of the orthopaedic surgeon: ’As strong as an ox but half as bright.’

(Source: Subramanian et al., 2014)

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THE MEDICAL STUDENT BODY OF TODAY BEARS LITTLE RESEMBLANCE TO THE ONE OF 20 YEARS AGO; MOST STRIKINGLY, THE NUMBER OF FEMALE MEDICAL STUDENTS AND MINORITIES HAS SIGNIFICANTLY INCREASED.

Figure 2: Proportion of graduates applying for core surgical training by medical school (Source: Twigg et al., 2018).

In March 2018 an article was published in The Royal College of Surgeons’ The Bulletin which highlighted the decline in graduate students pursuing core surgical training (CST) posts from 2012 to 2015 competition ratios dropped from 3.8 to 2.3 (Twigg et al., 2018)5. The authors hypothesised that a higher proportion of graduates would apply for CST posts if they had trained in city universities, which had a higher ranking, education achievement and were older. Results showed no correlation between university ranking, age of the institution or the population of the city.

For example, the proportion of Oxford graduates applying for CST from 2011-2013 was only 8% compared to The University of Glasgow, which was nearly double at 15.71%.

Figure 2 shows the proportion of graduates with a primary medical qualification from 2011 applying for CST (in 2013-2015) by medical school. The authors concluded that the choice of medical school does affect a student’s likelihood of becoming a surgeon (though it has nothing to do with universities of higher ranking or educational achievement) and we need to understand what the higher yield universities are doing differently to attract more students to CST (Twigg et al., 2018).

an online questionnaire and distributed it to all UK medical students via e-mail. 949 completed questionnaires were subsequently analysed.

Results showed that the top two motivating factors were previous placements (17%) and positive role models (14%), whilst the top two deterring factors were length (35%) and cost (28%) of training (Figure 3). This indicates that exposure to the T&O specialty and consultant encouragement play significant roles in influencing the career choice of medical students (Young et al., 2014)6. Indeed, exposure and encouragement are two key factors in my own experience which has made T&O very attractive.

Changing the T&O Image At the University of Oxford the undergraduate T&O teaching has recently been restructured in response to the recognised need to attract students to the specialty. Under the direction of Professor Chris Lavy, the T&O ‘Experience Week’ was introduced.

Fundamentally, this initiative involves integrating medical students as part of the T&O teams for a week (rather than students randomly dipping in and out of clinics and theatre during an eight week rotation). I was amongst the first intake of students under this new initiative and detail >> my experience overleaf.

What Medical Students Want In 2014, three medical students from the University of Edinburgh carried out a study to determine why medical students would pursue a career in T&O surgery. They designed

Figure 3: Factors (A) attracting and (B) deterring medical trainees to and from the T&O specialty respectively (Adapted from: Young et al., 2014).

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JTO Features

AT THE UNIVERSITY OF OXFORD THE UNDERGRADUATE T&O TEACHING HAS RECENTLY BEEN RESTRUCTURED IN RESPONSE TO THE RECOGNISED NEED TO ATTRACT STUDENTS TO THE SPECIALTY. UNDER THE DIRECTION OF PROFESSOR CHRIS LAVY, THE T&O ‘EXPERIENCE WEEK’ WAS INTRODUCED.

The Orthopaedic Experience Week Students were able to choose an orthopaedic subspecialty for the Orthopaedic Experience Week; I selected paediatric orthopaedics.

Oxford is lucky to have an exceptional team of paediatric orthopaedic consultants who are enthusiastic about what they do and keen to engage students with their specialty.

I spent my first day in theatre with Andy Wainwright, who, from the very first procedure allowed me to scrub in and assist. The list was nicely varied beginning

with a trigger thumb release, followed by an achilles tenotomy and tibialis anterior transfer, then a more complex femoral neck lengthening osteotomy.

Mr Wainwright was very encouraging both in theatre and subsequently in clinics (cases included: perthes disease, leglength discrepancy, bowed-legs, achondroplasia) where he guided me through relevant clinical examinations with patients (let’s face it, students need to pass the OSCE!). Further, his advice with respect to career development: becoming a student member of the British Society for Children’s

Orthopaedic Surgery, building a portfolio and carrying out audit and research projects was most helpful.

I was also able to spend a couple of days with Rachel Buckingham, an inspiring female role model, who specialises in the upper limb as well as having expertise with cerebral palsy (CP) patients (Figure 4). In clinic I was struck by the challenge of determining and managing musculoskeletal pain in CP patients, some of whom can only communicate through eye movements. It was interesting to attend the gait analysis meeting which demonstrated the combination of clinical acumen and engineering technology for managing a range of joint contractures. From the gait lab to the plaster room, I was able to observe various stages (in different patients) of the Ponseti serial casting method for club foot. Finally, a day in surgery with Mrs Buckingham performing a bilateral femoral osteotomy (‘proper surgery’) dispelled all myths that orthopaedic surgery is for the strong and stupid; it is for the precise and sharp.

Conclusion

Figure 4: A day in surgery with Rachel Buckingham; an inspiring female role model.

In conclusion, I would agree with Young et al. (2014) when they stated that “positive role models and enjoyment of orthopaedic placements are major motivating factors for many students

wishing to become orthopaedic surgeons in the future.” Rebranding T&O may simply be a matter of increased exposure and encouragement of medical students during their T&O rotation; small changes in the way surgeons interact with students can have a significant impact on how the T&O specialty is perceived. Oxford’s attempt to improve the undergraduate T&O image by integrating them into a team for a week has been highly effective; the extended time spent with the same surgical team provided much greater exposure to the breadth of the specialty and enabled consultants to encourage students to consider T&O as the ‘best specialty’. n Mariea Brady is a Medical Student at the University of Oxford. She has research interests in biomechanics, cartilage tissue engineering and minimising surgical blood loss.

Mariea hopes to pursue a career in paediatric orthopaedic surgery.

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 - Trainee Section

The Cost of Training in Trauma and Orthopaedics: Where Do All The Pennies Go? Peter S E Davies Co-authors: Rory J M Morrison and Vittoria Bucknall Trainee surgeons have faced a real-terms fall in income of approximately 14% over the last five years1. This is due to inflation which has not been offset by equivalent rises in salary. Trainees also face frequent increases in mandatory professional fees, such as those for the General Medical Council (GMC) or Joint Committee on Surgical Training Intercollegiate Surgical Curriculum Programme (JCST ISCP), which must be paid to continue training2, 3.

2017 and August 2017, and the survey was open to UK specialty trainees in Trauma and Orthopaedics. A prize of funding to attend an educational course was offered by the Royal College of Surgeons of Edinburgh, and the winner was selected using a random number generator.

Responses to the survey were collated from Google Forms and analysed by the three authors, who are all members of the BOTA Committee.

Results

Peter S E Davies

Trainees are frequently exposed to advertisements for courses in all sub-specialties at variable costs. A tick box on the ST4 and ST6 JCST Waypoint Checklists indicate that trainees should have “...made full use of study leave”. There are three ways to use study leave listed in the checklist: courses, private exam preparation and professional leave. This infers that it is necessary for trainees to attend some courses to pass their ARCP each year 4, 5.

Trainees are free to choose the courses that are most relevant to them, but attendance at some courses, for example ATLS, is mandatory.

We therefore sought to clarify trainees’ activity with respect to courses, study leave and study budgets, as well as obtaining an estimate of personal financial costs incurred by trainees during their training.

Methods An online survey was designed using Google Forms (www.google.co.uk/forms/about/).

The survey was publicised by the British Orthopaedic Trainees Association (BOTA) using social media and email communication. Responses were accepted between May

Demographics There were 78 responses in total from 20 deaneries. Responses were received from 61 specialist trainees with National Training Numbers (NTN), including ST1 and ST2 trainees in Scotland.

Seventeen responses were received from FY2 and Core Training doctors, but these were excluded from the main analysis.

Eighteen responses (30%) were from female trainees, and 43 (70%) from males.

Degrees and Financial Costs Medicine was the first degree for 56 trainees (92%). A median student loan debt of £25,000 was reported at graduation from medical school (range

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£0 - £60,000). Eighteen trainees reported having either completed, or were currently completing, a postgraduate degree, with a median cost of £5,000 (range £0 – £16,860). Thirteen trainees have taken time Out of Programme, with 11 (85%) reporting this to have affected their income.

Membership Fees Trainees report paying a median of £1,500 (range £420 - £4,000) on professional fees each year.

These include GMC and ISCP fees, Royal College of Surgeons membership, BOA membership, and indemnity fees which vary according to seniority. Tax incurred with these costs is, however, reclaimable.

Study Budget The median annual study budget quoted by trainees was £600 (range £350 - £1,500). Seven trainees were unsure what their study budget was. Trainees were asked if they were able to claim beyond their personal annual allowance if any study budget remained: twenty-two trainees said “no” and 13 said “yes”, 11 of whom were training in Scotland.

The remaining 26 were “unsure”.

Study budget was pre-allocated to fund regional teaching for 10 trainees from five deaneries, with 14 stating that this could possibly be the case and the remainder said it wasn’t. In all cases, the reported pre-allocated amount was less than the total study budget available (median £175, range £75 - £600).

Mandatory Courses Trainees were asked if their deanery mandated attendance at a specific course in the most recent year of their training, in addition to those required for CCT (ATLS, GCP, Leadership and Management). Thirteen

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trainees had been asked to attend at least one course, and examples given were the AO Basic Principles course, Trauma boot camp and Training the Trainers. All such trainees indicated that funding was provided for these courses from their personal study budget. For all mandatory courses, including those required for CCT, 46% of trainees reported these were required to be paid for from their personal study budget, and 21% were unsure.

Study Leave and Funding Sources Trainees were asked if they had fully or partially self-funded a course in the last 12 months.

Thirty-nine trainees had paid for a course or conference in part or fully, 10 had not paid anything towards course fees and the remainder did not state whether their course activity was funded.

Estimated costs spent on yearly training by trainees varied widely (range £0 - £3,000) with a median of £400. 23% of trainees invested over £1,000 of their own money into their own training courses over the last year. Trainees would consider self-funding a median of £1,000 on an excellent course (range £200 - £1,500). 72% stated that there were courses they would have liked to have attended in the last year, but were unable to do so for financial reasons.

Forty-four per cent of trainees had used all of their study leave entitlement in the last year, and 43% reported having a study leave funding request rejected.

Reasons included “maximum study budget reached” (38%), missing an arbitrary time limit (2%), deaneries not funding exam courses (2%), or the course was deemed unsuitable

for funding (2%). Three trainees (5%) made an additional note that their deanery supports course fees but does not cover accommodation and transport.

11% reported having study leave requests rejected due to rotarelated issues.

Other costs The median distance travelled (one way) in order to attend a course in the last year was 200 miles (range 0 – 6,000 miles), and 17 trainees stated that they would travel anywhere in the world for the appropriate course.

The survey did not record travel or accommodation costs which are necessary to attend training courses or conferences.

Examinations are mandatory to progress through training, and current costs are £1,479 for MRCS (Part A £526 and Part B £953), and £1,849 for FRCS (Section 1 £536 and Section 2 £1,313). These costs assume passing at the first attempt.

Trainees also reported spending a median of £200 per year on textbooks/other teaching aids.

Discussion This survey has highlighted a number of financial costs incurred by trainees which are deemed necessary to proceed through T&O training. Respondents highlighted significant variation across the UK with regard to study budget allowances and study leave application processes, despite all trainees following a single curriculum.

Trainees must attend some courses to pass ARCP and therefore these non-mandatory courses become necessary.

Due to dwindling study leave budgets, the costs must

therefore be borne by trainees, in addition to mandatory professional and examination fees.

Finally, this survey does not recognise the non-fiscal costs of training, including the time spent for research and writing scientific papers, collecting and analysing data for audits and private studying, which can affect family and social life.

Increases in tuition fees and student debt, dwindling study leave budgets and real-terms reduction in salary may make surgical training financially impossible for some. With reported minimum personal costs of £2,000 per year, this should be borne in mind, particularly at a time when applications to T&O training are decreasing. n Peter S E Davies is a Trainee on the East of Scotland rotation and is currently ST4 Level. He previously attended The University of Liverpool Medical School and underwent Foundation Training in the Mersey Region at Whiston Hospital.

Peter demonstrated anatomy at The University of St Andrews before taking up his training post.

Acknowledgement We would like to thank the Royal College of Surgeons of Edinburgh for kindly funding the educational prize for trainees participating in the survey.

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

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JTO Medico-Legal Features

The Continuing Saga of Informed Consent Michael A Foy It is unfortunate that we need to study cases that have reached the Courts to inform us of how we should be consenting our patients. There are guidelines from the GMC (2008) on the subject and these were widely quoted in the now famous Montgomery Ruling on informed consent in 2015. We have also outlined a proposal for obtaining consent in spinal surgery (Powell et al 2017). Despite all this, the issue of the adequacy of informed consent will not go away.

Recent cases that have reached the Courts where consent has been a significant issue have been discussed elsewhere (Sokol 2016, de Bono 2017). Spinal surgery appears to be particularly vulnerable in this respect.

Another recent case, Hassell v Hillingdon Hospitals NHS Foundation Trust (2018 - spinal again I am afraid) is worthy of consideration and discussion for some of the important points and lessons highlighted therein.

Michael A Foy

Tracy Hassell was born in 1970 and had undergone lumbar spine surgery in 2009. She developed cervicobrachial neuralgia in 2011 and consulted the same surgeon who had carried out the lumbar surgery. An MRI scan showed a C5/6 disc protrusion

that correlated with the clinical findings. Following failure of a CT guided C6 nerve root block a decision was taken to proceed to anterior cervical discectomy with either disc replacement or fusion. There is conflicting evidence about what was discussed between Mrs Hassell and the surgeon pre-operatively as far as the risks of surgery and alternative conservative treatments are concerned.

Mrs Hassell claimed that she was told that the only alternative available was to remove the disc and replace or fuse. She maintained that there was no discussion about the place of alternative painkillers or physiotherapy. She recalled being informed of the risks of infection, general anaesthesia

and hoarseness. She said that she was not told the risks about spinal cord injury or paralysis.

She said that had she known about the risk of paralysis she would not have had the operation.

The surgeon was adamant that he had discussed treatment alternatives including continued conservative treatment, physiotherapy and further nerve root block/s. He also outlined the risks that were discussed with Mrs Hassell including a one in 500-1000 chance of spinal cord injury/paralysis.

It appears that the consent form was signed on the day of surgery. Unfortunately, during the operation, for reasons that were not entirely clear to the surgeon or any of the four eminent experts (two neurosurgeons and two orthopaedic spinal surgeons) spinal cord damage occurred and Mrs Hassell was left paralysed.

Mrs Hassell brought a case against the NHS Trust for damages, alleging a breach in the duty of care in performing the operation and she also alleged that she had not given informed consent to the procedure.

She argued that had she been provided with adequate advice she would not have agreed to surgery. The case is interesting and instructive because it largely revolves around what the involved surgeon said, or rather didn’t say in his correspondence before surgery, his witness statement and the evidence given at trial. >>

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JTO Medico-Legal Features

When considering the quality of care in any case involving surgery it is essential to look at four areas in the assessment and treatment process: 1. The decision to operate 2. The quality of the advice given to the patient prior to surgery (including the consent process and bearing in mind GMC guidelines and the Montgomery judgement) 3. The performance of the surgery 4. Post-operative care.

There were differing opinions among the experts on whether they personally would have advised Mrs Hassell to have the operation. However, it was agreed that it was Bolam reasonable to do so.

With regard to the pre-operative advice and consenting process, when there is such an evidential difference between the two sides, as there was in this case, the judge has to take a view whose evidence is the most credible and is therefore preferred.

Therefore it is really important to ensure clarity in recording what information was relayed to the patient in advance of surgery. It is also important to ensure that there is consistency, in the unfortunate event of a claim arising, in the recording and interpretation of matters surrounding the case in witness statements and in the witness box, should it come to that.

The judge decided in Mrs Hassell’s case that she was not told about the risk of paralysis secondary to spinal cord injury and was not advised of other treatment options including physiotherapy and a further nerve root block. He concluded that the surgeon had not taken reasonable skill and care to ensure that Mrs Hassell was aware of the material risks

of the operation and the alternative conservative options.

Therefore he found that had she been given the appropriate information she would not have consented to the operation and the spinal cord injury would not have occurred. Mrs Hassell was awarded £4.4 million in damages for her residual tetraparesis. I must confess in consenting patients to this operation in the last 29-30 years I cannot recall a single patient refusing to go ahead with the procedure on the basis of a one in 4-500 risk of spinal cord injury (my figure). By definition if they are being offered surgery of this nature, they have significant pain/disability that has failed to respond to conservative treatment and after a proper risk/benefit analysis they accept the very small risk of cervical cord injury and other complications.

surgeon said that this was the risk of spinal cord injury and the risk of hoarseness was two in a hundred. He also criticised failures to correct a significant error in the chief executives response to the complaint concerning a technical/ descriptive error in the operation record (see below).

The learning points from this case are the judge’s reasons for preferring the evidence of Mrs Hassell and her family to that of the surgeon:

4. The surgeon told the court that he also directed patients to his website where there was a more detailed explanation of the risks and benefits of the procedure.

When the website was consulted, there was no mention of paralysis as a risk of this procedure.

1. The surgeon admitted that he believed that Mrs Hassell had undergone physiotherapy treatment for the problem already, when in fact she had not. He concluded that this was evidence that there was not a clear/proper dialogue between surgeon/patient.

2. He concluded that the surgeon was “not a good communicator about the risks of operations”, citing inconsistencies in what was told to Mrs Hassell in correspondence prior to surgery and the surgeons evidence in his witness statement and in the witness box. In a letter a few months before the operation the risk of hoarsenes was listed at one in a thousand but the

3. The surgeon pointed out in a letter some months after the operation that he would have explained that the risks he would have outlined to Mrs Hassell would have been similar to those that existed with the previous (lumbar) spinal surgery.

When the information provided before the lumbar operation was reviewed there was no mention of paralysis and the judge took this as evidence that the surgeon was therefore unlikely to have mentioned it to her prior to the cervical spine operation.

5. There was no mention of paralysis in a letter copied to the patient prior to surgery.

The judge accepted that a risk of spinal cord damage was mentioned to the patient on the day of surgery (presumably, when the consent form was signed) but that warning on the day of surgery was not sufficient (as supported by the eminent experts).

Therefore, it appears that there were a whole series of poor communications and record keeping that led the judge to take the view that Mrs Hassel’s evidence was preferred to that of the operating surgeon.

The judge discussed the performance of the operation itself and found that despite a poor operation record describing changes in the recordings of spinal cord monitoring intraoperatively part way through the discectomy (when in fact the monitoring became abnormal during the incision into the annulus of the disc) that the procedure was carried out to an acceptable standard despite the unexplained spinal cord injury.

He believed that the surgeons approach to the operation itself was careful and measured. There was no criticism of Mrs Hassells’ post-operative management.

As discussed, this is one of a number of cases exploring the implications of the Montgomery judgement. Montgomery requires the surgeon to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.” It seems that spinal surgeons are particularly vulnerable in the area of consent. All three cases referred to herein were successfully prosecuted by the claimants.

The duty under Montgomery indicates that we must give the patients choice. We have to go further than just telling them about risks and benefits of a particular treatment/ operation. The failure to advise about conservative options was one of the factors that led to a successful claim in Thefaut v Johnston as well as in the Hassell

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case. Significant risks given to the patient on the day of surgery are not acceptable. As in the Jones v Royal Devon and Exeter Trust (discussed by Sokol) the court found that a consent form signed on the day of surgery did not constitute informed consent.

An eminent barrister informed me that all a consent form proves is that the patient can write their own name. Consent is a process and the details need to be carefully recorded. The personal injury lawyers are well aware that Montgomery can be applied retrospectively and when

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a client consults them with a complication of surgery they will, unfortunately, go through the records with a fine toothcomb to look for absence of any mention of the complication that occurred.

This is an area of clinical negligence litigation where witness evidence to fact is crucial. As can be seen from the above discussion, in the Hassell case the judge strongly favoured the claimant’s evidence over that of the surgeon.

The court considered expert

References

evidence in relation to consent.

Where consent is concerned Montgomery trumps both Bolam and expert evidence. Whether a risk is material or whether advice given was adequate is now a matter for the court to decide, not the medical profession. n

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

Michael A Foy is a Consultant Orthopaedic and Spinal Surgeon, is Chairman of the BOA’s Medicolegal Committee, co-author of Medico-legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.

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Volume 06 / Issue 02 / June 2018

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JTO Subspecialty Section

Army Orthopaedic Surgeon – A Different Career Nick Ward Orthopaedic surgery in the Defence Medical Services offers a challenge and when deployed as a consultant, it is a very different role to the jobs we mostly do in the NHS. Being an army surgeon is 98% training and preparedness, for perhaps 2% of true military surgery which can involve hours or days of intensive challenging surgery. We need to be prepared as our ability to predict future conflict is difficult and military surgeons in today’s modern army must stay current with their military training in conjunction with their NHS responsibilities and duties.

It’s a balancing act that is facilitated through accommodating NHS trusts and it ensures that we are ready to deploy, sometimes at very short notice and often with uncertainty of where we are going and exactly when we may be returning.

Nick Ward

My consultant career began in 2010, but my army career began properly in 1997 on the Post Graduate Medical Officers (PGMO) Course, at the Royal Military Academy Sandhurst. Although it has changed in length and content, it is still a shortened officer’s course to introduce civilians

to army values, standards and business. Medical officers must be brought up to certain military standards but must concentrate on military medicine and how it applies on the battlefield. The triage of multiple casualties, damage control surgery, and the concepts of care in hostile locations are equally applicable in a domestic terrorist incident. We studied tropical medicine, as well as rather morale-depressing subjects such as radiological, biological, and chemical agents and warfare. Recent events at home and abroad would suggest that these subjects

were not as irrelevant or too awful to contemplate as one had originally thought.

Two years in Germany on general duties, looking after a tank regiment and then return to the UK to start basic surgical training lead to a pre-registrar posting to Iraq for a short tour in the military hospital in the aftermath of the second Gulf War. The staff for that deployment came from military units and hospitals from all over the UK, and the operating theatre was a tent, inherently dusty and less than sterile. Surgery was limited to essential procedures only, predominantly life, limb or eye-sight saving. The lessons from the Vietnam War and the unacceptable ex-fix infection rate were heeded as plaster of Paris and traction were used to stabilize wounds and open fractures.

The art of debridement, leaving wounds open and knowing when to cease operating, or not to operate at all, are lessons that have been learnt in military conflicts over centuries. Surgeons have to be judicious with their demands and adapt their skills to the tools available. Personal robustness is an important factor and relationships with colleagues and other staff is critical for teamwork. Communication with family at home may be limited and is constrained by location and security concerns.

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would be in the 40 degrees centigrade outside, and despite some air conditioning, often in the thirties in theatre. It was hot, sweaty and frequently bloody work. I returned to the UK a little more tanned and a lot wiser.

2013 saw my return to Afghanistan, but this time as a veteran! Although colleagues had changed, the workload was similar and the surroundings familiar. The surgical challenges persisted but appeared less daunting and the system was by now well honed. The tours were memorable interludes in my early career, held with proud and fond memories, despite the often challenging circumstances and cases.

Figure 1: Multi-National, multiple-speciality surgical team working on single casualty in Afghanistan.

In 2010, I moved to Frimley Park Hospital to start my consultant career and although the Iraq campaign was shrinking quickly, the Afghanistan mission was in full swing.

My first tour to Afghanistan was in 2011 where a new set of skills and challenges lay.

Again, weeks of preparatory training and rehearsing took place with the aim to hit the ground running. This time it was a multinational concern as although the hospital in Helmand province was British, our coalition partners, the Americans, Danes and Estonians, had soldiers on the ground and contributed to the staff. Despite the hospital in Helmand being well resourced,

it still existed in a hostile place with limited resources and capabilities. The withdrawal of care, difficult ethical decisionmaking and the laws of armed conflict were discussed and debated daily.

The predominantly high energy gunshot wounds of Iraq had been surpassed by the Improvised Explosive Device (IED) as the weapon of choice in Afghanistan.

Medical care, vastly improved in Iraq, was further refined in Afghanistan. The tourniquet, an essential component in limiting exsanguination, was pushed out to all soldiers.

Blood products were placed on the helicopters and senior clinicians went forward to the

point of wounding. Resuscitation was aggressive with blood and clotting factors and all clinical care was consultant lead, often with multiple consultants coordinating specialist care at any one time and it would not be uncommon to have multiple surgeons working on a single patient. The statistically un-survivable, survived, albeit with the legacy of sometimes challenging disability and years of rehabilitation.

Although Camp Bastion, where the hospital was based in Helmand, was relatively comfortable, the work was continuous and at times physically exhausting and mentally draining. As mine was a summer tour, the temperature

As the Afghanistan campaign declined, a move to ‘contingency operations’ has returned us to our highly mobile but resource constrained units with reduced logistical supportthe team will comprise of a single orthopod, a single general surgeon and anaesthetists to provide the surgical capability.

In 2016, I was part of a team working with the Pakistan military medical services in the Combined Military Hospital, Rawalpindi. Colleagues and I deployed to Pakistan for a number of weeks to be embedded in their hospital, work with their teams and live within their environment. It proved to be a fascinating and fruitful learning experience for both sides.

Different parts of the army, and in turn different units of the military medical services are held at different degrees of readiness to deploy. In late 2016 my unit, already on short notice, was tasked to deploy in the spring of 2017 to build a United Nations hospital in one of the >>

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JTO Subspecialty Section

2013 SAW MY RETURN TO AFGHANISTAN, BUT THIS TIME AS A VETERAN! ALTHOUGH COLLEAGUES HAD CHANGED THE WORKLOAD WAS SIMILAR AND THE SURROUNDINGS FAMILIAR. THE SURGICAL CHALLENGES PERSISTED BUT APPEARED LESS DAUNTING AND THE SYSTEM WAS BY NOW WELL HONED.

largely erected the next phase of the hospital, including the incorporation of mobile x-ray machines and a head CT scanner.

After this, it was time to return home to the day job. Never has clean running water, a flushing loo and a comfortable bed been so inviting.

Figure 2: United Nations Camp in South Sudan.

most austere locations in South Sudan. South Sudan has had a civil war and the legacy was a 120-150,000 person refugee camp, not far from the border with Sudan, but guarded by the UN due to continuing conflict between government forces and rebel forces. There was no decent runway near us to take any sizable aircraft so the only way in was by helicopter.

The environment was itself challenging. Every tropical disease I had heard of was present, the water supply would have to be dug by borehole and sterilized by our own engineers after we arrived. Nothing could

be locally purchased so all supplies had to be helicoptered in, one trip per day at a time.

Space and weight limits were challenging constraints. Our own camp infrastructure was primitive and before we could provide any health service we had to build our own living structures, washing and eating facilities and be sustainable.

Living and working in the heat, dust and disease was challenging. Medics became engineers to assist with the build and to better our environment. Disease was not respectful of rank and most consultants spent one or more episodes bedded down with

gastrointestinal upset or fevers of unknown origin. Personal fitness for the rigours of that environment was particularly important.

The initial medical build was for life saving surgery only and comprised of one clinical tent, fashioned from the medical airborne unit where kit and space are at an absolute premium. It comprised of an ED bay, and operating table area, and a recovery/ITU area.

Squeezed in between were the lab diagnostic equipment and the fridge for blood products.

As the principal experts on our own kit, the medical team

My military career continues to bring unique challenges and opportunities. While managing my NHS responsibilities, I have deployed to some extraordinarily inhospitable countries and experienced some of the most challenging surgery I could imagine.

Liaison work and UN duties have been in sharp contrast to the war fighting surgery of Afghanistan, but also fascinating insights in their own right.

I can assure the readership that serving in the Army as an Orthopaedic Surgeon is a very different and challenging but fulfilling job and who knows what the future may hold. n Lieutenant Colonel Nick Ward became a Consultant in 2010 and specialises in foot and ankle orthopaedics. He currently works at Frimley Health NHS Trust and is part of 16 Medical Regiment.

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JTO Subspecialty Section

The Current Direction of Military Orthopaedic Research Sarah Stapley Co-Authors: C Webster and J C Clasper The Iraq and Afghanistan conflicts between 2003-2014 defined the direction of military medical research in recent years.

The severity of the signature injury (see photo), bilateral lower extremity amputations with associated massive haemorrhage as a result of an improvised explosive device, forced much of the research during the conflicts to identify early point of injury care improvements, consultant led medical emergency response teams (MERT) for direct evacuation to suitable hospital facilities and immediate multiple surgical and anaesthetic team management, all combined to deliver a year on year improvement in overall survival1 (Diagram 1).

the military orthopaedic trainees and consultants have assisted in directing current funding and research opportunities. The four key themes of investigation are: 1. The Left of Bang Concept3: Developing a further understanding of the mechanisms surrounding blast and ballistic patterns of injury.

This continues to direct the design of personal and group protective systems to mitigate against the initial injury pattern.

2. Techniques to advance the early management course within extremity trauma and improving functional outcomes as a result.

With the drawdown of combat troops, and no imminent other large-scale conflict on the horizon, the focus from an orthopaedic direction has been channelled to identifying the lessons learnt from what was observed and how the injury outcomes might be improved for future generations.

This has been further directed by the development of a Defence Medical Services Research Strategy document, which can be summarised in the form of a research tree2 (Diagram 2).

Sarah Stapley

Critical examination of the data obtained during the conflict years, and publication of findings in peer reviewed journals by several of

The signature injury – bilateral lower limb blast injury.

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Diagram 1: The Year on Year Improving Probability of Survival in UK Combat Related Trauma Casualties 2003-2012 (Penn-Barwell et al., 2015).

3. Identification of the medium and long-term complications associated with these trauma mechanisms and potential methods of alleviation.

4. Recognising the requirement of Individualising rehabilitation pathways to allow for the best possible functional outcome is achieved.

This article will give the reader a flavour of the cutting edge research being undertaken within the Defence Medical Services in each of those areas.

342 casualties were identified with pelvic blast trauma in the recent conflicts, which were distinguished by the environment at the time of injury: in vehicle (mounted) or on foot (dismounted).

Fatality was similar in mounted and dismounted groups (50% versus 50.7% respectively).

Casualties from vehicles, generally had non-fatal pelvic injury (only 15% dying as a direct result

secondary to the pelvic injury), and their cause of death was due to other body region injury: the majority being to the head and thorax (Figure 1a). The dismounted cohort more frequently died as a direct result of their pelvic injury (74%) (Figure 1b). On review of radiological data, this analysis revealed different pelvic fracture patterns in mounted and dismounted casualties. Those seated in a vehicle sustained predominantly pubic rami, sacral and spinal fractures (Figure 2a).

Patients on foot at the time of injury sustained unstable patterns with disruption at the pubic symphysis and sacroiliac joints (Figure 2b).

Vascular injury was present in all fatalities with pelvic injury. Vascular injury was also mostly associated with unstable injury patterns (i.e. those on foot at the time of injury.)

The location of injury was mostly the posterior pelvis, and arterial.

The casualties from vehicles did not have a high incidence of vascular injury. Traumatic amputation was almost universal in those dismounted at injury, and only rarely occurred in a vehicle.

Taking these results into consideration, in a seated injury pattern, impact mitigation in the seat region, could help to

Injury Mitigation Mortality following blast pelvic injury is high4, due both to associated injuries, and rapid exsanguination within the pelvis, often prior to any possible medical interventions. Therefore, prevention or mitigation for improving outcome in future conflicts is required. Work aimed at identifying pelvic injury patterns in blast injury, cause of death, and determination of a mechanistic hypothesis on which to develop a preventative strategy is underway.

Diagram 2: Defence Medical Services Research Tree

reduce the likelihood of pelvic crush. Out of vehicle, the open and unstable injury pattern is most common, along with traumatic amputation of the lower extremity. Three hypotheses have been proposed for this, more complicated, injury mechanism: axial load via the femoral heads, flail of the lower limb, and blast wind with fragmentation.

Further experimental work is underway to further understand these mechanisms and possible mitigation in dismounted blast. This study is the first to analyse specific patterns and associated injuries in detail in explosive pelvic injury, and relate them to posture at the time of injury, therefore proposing a strategy for injury prevention.

Infection and Bone Healing A study of severe open diaphyseal tibial fractures sustained by military personnel between 2006-20105 demonstrated 57 fractures in 49 patients. At 12 months, 50% were either united or progressing towards union. Infection was associated with 12 out of 52 (23%) of those demonstrating poor bony healing. This finding has led directly to a focused area of study investigating the effect >>

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JTO Subspecialty Section

(a)

(b)

Figure 1: Most severe injury region by body area in mounted (a) and dismounted (b) casualities sustaining pelvic injury.

(a)

(b)

Figure 2: Fracture patterns in the (a) mounted and dismounted (b) casualty.

infection has on bony healing.

Animal models have been used to investigate both the underlying pathophysiology of non-union and also potential treatment modalities. However, these have concentrated more on aseptic scenarios, rather than infected fractures, which are not consistent to the condition observed within the military cohort. Therefore, a novel septic atrophic non-union model is being developed which will allow the investigation of the impact militarily relevant microorganisms have on fracture healing. Furthermore, this will allow the development of improved management options that could be utilised within the initial days to weeks after injury occurs.

Heterotopic Ossification Radiological evidence of heterotopic ossification (HO), as demonstrated in Figure 3, was identified in 64.6% of a cohort

of combat injured patients6.

A similar figure of 62.9% was reported in a series of combat injured patients who had undergone amputations.7 This US data was compared to UK data8. British service personnel sustained 416 combat amputations in 265 patients during the recent conflicts9. Patients with HO experience a wide range of problems as a result of the mechanical effects of hard tissue in extra-skeletal sites. These effects include pain, loss of joint range of movement, joint ankylosis, skin ulceration, skin graft failure, muscle entrapment, neuroma formation, and prosthetic limb fitting difficulties associated with concomitant associated delay in functional rehabilitation as a consequence. Public support for veterans, their involvement in high level sporting events has resulted

in the requirement to prevent or mitigate against the development of HO in future blast injury patients, although HO is not only within the realm of military injury.

Over the last five years, following initial confirmation of the incidence of HO, focus has been directed towards understanding the structural complexities of HO, its similarities to normal bone and its potential vulnerabilities.

MicroCT scanning, scanning electron microscopy, Synchotron x-ray diffraction, x-ray fluorescence, Raman spectroscopy and Nano CT techniques have demonstrated that HO is neither a classically cancellous or cortical bony structure. However, the fundamental constituents of and processes within HO are normal but lack the coordination and direction above the micron to millimetre length scale. As the main effect of HO are its mechanical properties in abnormal places this has led towards a hypothesis concerned with whether HO can be prevented or dispersed once formed.10 Chemical analysis of these structural studies demonstrated that the hydroxyapatite molecule might be vulnerable to dissolution and identification of a non-toxic agent could be developed.

Previous work from the 1960’s, demonstrated a potential role of polyphosphates in regulation of biomineralisation.

Fleish11 demonstrated that polyphosphates were effective inhibitors of calcium phosphate crystal formation, but subsequently received little attention, although this research channel led to the development of bisphosphonates. In the 1970’s, work on dental caries demonstrated that polyphosphates had an effect on increasing the resistance of HA to acid dissolution12.

This work demonstrated that hexametaphosphate is an effective agent for the dissolution of HA. Bench testing has demonstrated that this direction of travel may be successful, and small animal studies using a previously reported HO model13 and the search for a suitable delivery agent/mechanism are underway.

Measuring Outcomes to improve Rehabilitation The responsibility of overall management and long-term outcomes resulting from military combat operations is an area that the Defence Medical Services (DMS) takes

Figure 3: Radiological evidence of heterotopic ossification (HO).

Figure 4: ADVANCE study (Armed Services Trauma Rehabilitation Outcome Study) www.advancestudydmrc.org.uk.

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pride in delivering to the best possible standards within the current realms of rehabilitation.

Multiple collaborations are being undertaken which are focusing on individualising rehabilitation programmes.

Joint areas of study include comparing athletes to combat injured personnel who have sustained lower extremity injury, utilising gait analysis, MRI scanning, ultrasound scanning and strength testing from the musculoskeletal angle. It is hoped that from this comparison directed rehab packages for specific injuries will be achieved for the individual casualty.

Another area of rehabilitation focus is the ADVANCE study

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(Armed Services Trauma Rehabilitation Outcome Study www.advancestudydmrc.org.uk), Figure 4, which is a 20-year cohort study to provide high level evidence of long term cardiovascular, musculoskeletal and other physical, mental health and psychosocial related outcomes following combat related injury.

In summary, military orthopaedic research has a broad direction of travel which in time will not only assist the combat casualties of the future but also many other organisations including the NHS to deliver improved outcomes in multiple areas relevant to musculoskeletal medicine. n

DATE FOR YOUR DIARY National Orthopaedic Infection Forum Thursday 5th July 2018 Cavendish Conference Centre, 22 Duchess Mews, London W1G 9DT

Faculty

Rhidian Morgan Jones (Cardiff), James Murray (Bristol), Marina Morgan (Exeter) Jon Phillips (Exeter), Imran Khan (Karachi), Vanya Gant (London), Ibby Younis (London), D’Jon Lopez (Cardiff), Peter Thomas (Stoke)

Topics Multi-Disciplinary Meetings (MDM) ● Revision TKR MDM in Exeter ● Setting up an Arthroplasty Unit ● Revision Knee Networks Case Discussions ● Patients with orthopaedic and microbiology combined problems Limb Salvage – Using custom made implants ● What microbiologists & orthopods should know

Dressings & what’s new ● Occlusive, incisional vac and anti-bacterial dressings ● Negative pressure wound therapy with installation (NPWTi) ● Vacuum dressings – what’s new?

International Consensus Meeting ● Philadelphia 2018 – bigger & better Thoughts on….. ● External fixator pins: why don’t they get infected?

Antibiotic Complications and Dilemmas ● Antibiotic complications ● Multi resistant organisms

Online registration available at www.hartleytaylor.co.uk For further information please contact aimee@hartleytaylor.co.uk or telephone 01565 621967

Surgeon Captain Sarah Stapley is a Consultant Orthopaedic Surgeon with a specialist interest in hand surgery stationed in Portsmouth and was appointed in 2004. She is one of the most experienced military surgeons within the T&O cadre and lectures extensively at home and abroad.

Sarah is the Defence Professor of Trauma and Orthopeadics and the Training Programme Director in T&O for the Wessex Deanery.

non-union at the University of Edinburgh. Mr Daniel Rothwell from University of Loughborough who is individualising rehabilitation pathways and part of the mini Centre for Doctoral Training in militarily relevant projects, and Gp Capt Alex Bennett RAF who is leading on the ADVANCE study at RAF Headley Court.

Acknowledgements

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

Major Neil M Eisenstein PhD RAMC for his work on Heterotopic Ossification. Major Louise Robiati RAMC who is developing a small animal model of septic fracture

References

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JTO Subspecialty Section

Direct Skeletal Fixation a new treatment paradigm in combat amputees?

Jon M Kendrew Co-authors: Arul Ramasamy, Louise Mcmenemy and Ben Williamson Ten years of combat operations in Iraq and Afghanistan saw coalition soldiers increasingly exposed to improvised explosive devices (IEDs) either whilst driving in vehicles or on foot1,2. These devastating weapons became increasingly powerful and were soon a leading cause of serious injury.

Early devices were comparable to legacy landmines in terms of power and injury profile. Acute amputation was performed in cases where the limb was deemed to be non-salvageable3.

Reconstruction sometimes failed for reasons of infection, non-union or chronic pain, and for these patients late amputation was necessary. Both of these cohorts tended to be left with relatively standard below knee amputations.

Jon M Kendrew

As the power of the IEDs increased, so their effect became more devastating. The zone of injury extended above the knee, into the thigh musculature and in some cases higher, involving the junctional area of the groin, the pelvic floor and intraabdominal structures4,5. Improvements in trauma care from point of wounding to definitive care led to an increase in unexpected survivors with an unprecedented numbers of soldiers surviving into rehabilitation centres and eventually wanting to walk again6.

The most severe effects of IED’s were seen in those soldiers exposed to dismounted blast.

Improvements in body armour helped mitigate some of the effects of blast but as the power of the IED’s increased, so did the severity of injury. A pattern of devastating lower limb injuries associated with upper limb fractures, burns and soft tissue injury was commonly seen. Traumatic amputation either through or above the knee was treated at the point of wounding with field dressings and tourniquets. Resuscitation and, once stable, surgical debridement followed, usually within an hour of injury. All necrotic tissues were debrided, haemostasis was assured, fractures stabilised and the soft tissues splinted with topical negative pressure dressings.

Aeromedical evacuation back to definitive care allowed second look surgery to be performed by the receiving orthoplastic team usually within 48 hrs of injury.

Soft tissue damage was severe

with progression of wounds and extension of zone of injury being the norm. Once the wounds and systemic inflammatory response had been controlled, the residual healthy femur was usually short and the soft tissues often fragile with split skin grafts giving early coverage to allow closure of the wounds. Despite huge advances in prosthetics and socket fitting, the combination of short residuum and poor quality soft tissue coverage led to problems when these patients began to mobilise7.

Difficulty in obtaining a stable socket fit often led to soft tissue breakdown and the ever-present risk of heterotrophic ossification led to patients failing to achieve their goal of mobilising independently.

This patient group were exceptionally well motivated, well informed and living in the modern IT world had access to scientific literature from all over the world.

They were keen to see if there was another way. In 2014, patients and their Rehabilitation Consultants began to ask questions: Was Osseointegration safe after blast?

Could these soldiers, that had survived such severe injuries, realise a dream and walk?

Osseointegration is not new, its roots can be traced back many decades to the pioneering work of Professor Per-Ingvar Branemark8.

He discovered that implants made of pure titanium formed a stable interface within living bone tissue. This discovery facilitated advances in several areas most

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notably dentistry. Branemark’s early pioneering work in Sweden led to the first amputation prosthesis being used in 19909. Osseointegration is now becoming more widely accepted with teams performing surgery in Europe, Australia and America. Ongoing work has developed the hypothesis that Osseointegration may provide a solution to the complex issues of traditional socket mounted prosthesis, particularly in those patients with a short residuum or poor soft tissues. Several published studies have demonstrated improvements of quality of life10, mobility, ‘donning and doffing’ and even proprioception11 but always with the caveats of infection, loosening and fracture.

As with all things, the implants have evolved and the latest designs to come to market have moved away from the early screw type fixation to press fit, highly porous-coated metal alloy devices similar to those used in arthroplasty12.

There are three main Osseointegration systems in use. The OPRA (Osseointegrated Prosthesis for the Rehabilitation of amputees) system reports 100 cases from a single centre in Sweden and 11 cases from a single centre in England. This stem reports a good safety profile with implant survival of over 10 years. The OPRA protocol currently mandates a slow pace of rehabilitation and a two stage operation.

The ILP (Integral Leg ProsthesisEndo-Exo Femur prosthesis) system reports 69 cases from Germany and two cases from the Netherlands. Implant survival has been reported out to over 12 years. The OPL (OGAP-OPL Osseointegration Group of Australia Osseointegration Prosthetic Limb) system from Australia (Figure 1) reported the clinical outcomes in 50 unilateral trans femoral amputees with a mean age of 49.9 years. Although 27 patients had some form of complication, they demonstrated statistically significant improvements in recorded outcome measures.

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Figure 1: External view of standard prosthesis demonstrating the coated surface used to encourage Osseointegration the dual cone and locking screw. Courtesy of the Osseointegration group of Australia.

A Bazian review13 of published case series performed for NHS England in 2016 showed a substantial improvement in quality of life for the majority of patients. Mobility was also shown to increase with the majority of patients becoming daily prosthetic users.

The most common complication was superficial infection treated with oral antibiotics with relatively few patients needing intravenous antibiotics or hospital treatment.

Periprosthetic fracture or implant failure did occur but in low numbers. At the time of publication, the Bazian group concluded that low quality evidence indicated that the OI prosthesis did improve the quality of life for amputees and appeared to be safe with a low incidence of deep infection.

The severity of soft tissue injury combined with bacterial and fungal infections had left our injured personnel with few options for reconstructive orthopaedic surgery, significant infection rates had become associated with late arthroplasty surgery.

Encouraging results from the Sydney group led to a combined decision by the

then Surgeon General and the Rehabilitation eam at Defence Medical Rehabilitation Centre (DMRC) Headley Court to send a wheelchair bound non-ambulant bilateral above knee amputee patient to Australia for OI surgery.

The patient had reached the end of their prosthetic pathway and was still wheelchair bound.

Successful surgery was performed in 2014. The results were excellent and a further 6 patients (Total 14 femurs) have undergone the surgery using the OGAP-OPL system. All patients were selected via a specialist OI MDT clinic.

Inclusion criteria included being a bilateral Above Knee amputee with no active infection. Single stage implantation with concurrent stump refashioning and stoma preparation was performed.

Post operatively patients were managed with progressive early weight bearing (20kg at three days) progressing at 5kg per day as pain allows. At a mean of 21.1 months from time of surgery, we have had no deaths, episodes of sepsis, loosening or osteomyelitis.

Across the whole cohort, a total of nine courses of oral antibiotics have been prescribed. One patient sustained a proximal femoral fracture after a fall and three patients have undergone stump refashioning. (X-Ray examples are seen in Figures 2 and 3.)

Although the initial results appear encouraging, it is our opinion that Osseointegration surgery should not be considered a definitive procedure with secondary procedures being common.

The stoma or implant skin interface is the main cause for concern - it is difficult to imagine that current systems do not run a significant risk of deep bone infection in the future. Following surgery, these patients continue to undergo regular surveillance of their implant. As this technique becomes increasingly employed in the amputee population, we believe there needs to be a consensus on outcome measures and an international database should be used to compare stems across the globe. n

Figure 2: A standard press fit osseointegrated stem in situ.

Figure 3: A shorter stem with proximal screw to protect the femoral neck.

Group Captain Jon Kendrew is the RAF Consultant Adviser in T&O and is an expert in acute care of and delayed reconstruction of blast and gunshot injuries. Jon leads the surgical team facilitating Osseointegration surgery for veterans in Birmingham. He was awarded the Order of St John in 2015 and the Lady Cade Medal by the Royal College of Surgeons England in 2016.

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

Professor Tim O’Brien 26th November 1951 – 11th October 2017 He developed an interest in paediatric orthopaedics, working as Fellow with Professor Robert Salter in Toronto and with Professor John Hall in Boston before being appointed as Consultant Orthopaedic Surgeon to The Children’s Hospital, Temple Street, Cappagh National Orthopaedic Hospital, and the Central Remedial Clinic in 1987 and to the Mater Misericordiae Hospital in Dublin in 1989.

Professor Tim O’Brien

He established the first clinical gait laboratory in Ireland in 1989, and was appointed as the first Irish Professor of Orthopaedics

in 1991, the Abraham Colles Chair of Orthopaedics at the RCSI. He published extensively on paediatric orthopaedics and gait analysis and also published research in Nature on his investigation into Irish megalithic sites at Newgrange and Loughcrew.

Professor O’Brien was given a diagnosis of motor neurone disease in 1993 and became dependent on ventilator support in December 1996. With his energy and drive, and with the close support of his wife Dr Mary Jennings-O’Brien, he showed that disability need not

be a constraint. Using EyeTech and voice generation software he continued in his post as Professor of Orthopaedics until 2001 and continued to lead the gait laboratory until his retirement in 2016, publishing clinical research in leading journals while also publishing papers on his favourite composer Shostakovich.

Professor O’Brien will be remembered for his contribution to orthopaedics but even more for showing us what the human spirit can achieve. He will long remain in our memory. n

Ian Maurice Pinder 17th February 1933 – 24th February 2018 Ian Pinder died aged 85 in the Freeman Hospital, Newcastle upon Tyne. The same hospital where he practiced for many years as an arthroplasty surgeon and where he was always known as IMP.

Ian Maurice Pinder

Ian started his Consultant career at Hexham General Hospital but subsequently moved to Newcastle upon Tyne where he managed trauma at Newcastle General Hospital and undertook elective surgery at the Freeman Hospital.

He had an insatiable work ethic which allowed him to treat large numbers of patients many of whom had severe deformities often secondary to rheumatoid disease.

This interest in rheumatoid surgery resulted in close collaboration with his Rheumatology colleagues, allowing the formation of a joint musculoskeletal service.

There are many patients around the North East of England who still owe their mobility and independence to his expertise.

In his later years, he “retired” from the trauma service to concentrate on his elective practice which was principally focused on hip and knee arthroplasty of which he had a national and indeed international reputation. Although not a natural teacher, his extensive practice allowed many orthopaedic surgeons in training the opportunity to learn by observation and as of the generation of having “seen it and done it all” he was able to give advice to those who sought it. This was particularly reassuring to his junior colleagues in that, on asking IMP if he had experience of a particular complication, the answer was usually yes, often

more than one, and he would go on to provide advice on how to manage the patient. His large cohort of patients was a source of survivorship publications for those same surgeons in training, not just for successful procedures but also for those procedures that faired less well.

Ian was also at the forefront of outcome measures in knee arthroplasty and published such long before it was fashionable.

To some he seemed a shy individual and perhaps unapproachable; however, he had a keen sense of humour and always revelled in a bit of gossip and political intrigue. He will be missed by many, not least by his wife Sue, son Jonathan, his daughter-in-law and his grandchildren. n

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James Bruce Richardson 18th March 1955 – 18th February 2018

James Richardson was Professor of Orthopaedics at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK. His life’s work was focussed on harnessing the body’s ability to heal through the use of cell therapy. In large part, James’ work led NICE to approve the use of autologous chondrocyte implantation for a loss of cartilage in the knee from 2019. James died suddenly whilst on holiday in India.

James Bruce Richardson was born in England of Scottish parents. They moved back to Scotland within twelve months of James’ birth to an estate on Ross-shire. With his brothers and sisters he had a carefree childhood exploring the estate’s derelict buildings and wild places. He also observed his parents efforts to live a selfsustained lifestyle farming in the highlands. James became a skilled horseman and could turn his hand to most rural crafts.

James was educated in Scotland, Switzerland and briefly at Gresham School in Norfolk before, at the age of 16, successfully applying to enter medical school in Aberdeen. There, through his love of hillwalking and skiing he formed friendships that endured throughout his life. He met his wife, Shona, during his first house job in Inverness, marrying within the year.

James Bruce Richardson

As an elective student in Malawi, James realised maize would be more nutritious as a staple than the local cassava. As an example of James’ imagination, intellect and drive, on his return to Aberdeen, he raised funds to take a pair of millstones from a local disused mill and ship them to Malawi. The following year James returned to Malawi and along with the mission hospital

doctor, successfully installed the Scottish millstones in a newly constructed water powered mill.

James gained a higher degree in connection with fracture healing. His year in Oxford under Professor John Kenwright’s supervision studying the biomechanics of fracture healing was the foundation stone for his surgical practice and rehabilitation of patients. He moved from Glasgow as Registrar to Oswestry as Senior Registrar, to Leicester as Senior Lecturer, and in 1994, aged 38, to Oswestry as Professor of Orthopaedics with a chair at Keele.

A key paragraph in James’ curriculum vitae states: “Patients with significant disabilities are very frustrated as they are usually otherwise fit and well. Once arthritis becomes advanced usually joint replacement becomes necessary. These can function well for years but even new designs fail as they are just artificial joints. With each revision more bone is lost and eventually the joint may have to be excised. Similarly with fractures that fail to heal eventually amputation can sadly be the resulting outcome. I can only conclude that we need to restore the living surface of the joint and learn to use cells to heal bone.”

To address this conclusion, James drove the development of a clinical cellular therapy service for the treatment of articular lesions and non-union.

The cell scientists working in Oswestry were harnessed to improve the techniques necessary to induce articular chondrocytes and bone marrow stem cells to proliferate when cultured, enabling them to be returned to the defect in cartilage or bone to facilitate healing.

A spirit of enquiry and an insatiable curiosity to improve the application of knowledge tinted all of James’ thoughts and opinions. His parents were prescient in their desire to farm in a sustainable fashion and James applied the same principles to his life. Having come to settle in Oswestry, James took the opportunity to design and build a house in the mid 90’s that was thermally efficient.

As a man, James was always a cheerful, hopeful person who treated everyone from porters to his colleagues with kindness.

His patients were particularly fond of him because his dogged persistence extended beyond a research agenda into their personal care. He was the last hope for many patients condemned to immobility or amputation and he very often managed to find a way through for them with his extensive repertoire of techniques and surgical dexterity. James went out of his way to be accessible to his patients giving them his mobile phone number in case they needed advice.

The morning following his death, news spread through the orthopaedic hospital leaving a collective sense of shock and loss. He leaves his wife, Shona, their three children and one grandchild. n

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In Memoriam

Professor Robert Owen 21st December 1921 – 7th March 2018

Bob Owen was a farmer’s son, born in Chwilog in the Lleyn peninsula and a monoglot Welsh speaker until the age of eight.

From local Primary and Grammar schools he studied Medicine at Guy’s Hospital in London, followed by three years in the Royal Air Force, where he met Meg, his wife. They had two children and five grandchildren.

Following orthopaedic training, in which he was outstanding and included an ABC Fellowship, he was appointed Consultant Orthopaedic Surgeon at The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry and North Wales Hospitals at Rhyl and Abergele. He gave sterling service to these institutions, including the introduction of the Charnley arthroplasty, complete with ‘greenhouse enclosure’ to the first centre (Abergele) outside Wrightington. In mid-career, he moved to Liverpool as Professor at The Royal Liverpool Hospital and Alder Hey Children’s Hospital.

He served these hospitals with distinction, concentrating his clinical practice at the latter.

Professor Robert Owen

He was an outstanding orthopaedic surgeon. Aside from his clinical and operative skills, which included complex spinal surgery, he had the wellbeing of patients and colleagues at heart. An example of his concern for patients was as the driving force

behind the establishment of houses for the relatives of those undergoing hospital treatment.

At Broadgreen Hospital in Liverpool, is the rightly named Robert Owen House.

For his colleagues, he is best described as ‘inclusive’. Apart from training and mentoring many young orthopaedic surgeons from around the world, including enthusiastic support for the Liverpool MCh(Orth) course, the value of the whole surgical team was recognised through activities such an annual walk in Snowdonia. Bob had open house invitations worldwide and over the years there were many reciprocal visits between Bob and his flock.

He was the author or co-author of 140 scientific papers, co-editor of two notable textbooks and author of chapters, editorials and reviews. He was a Board member of The Journal of Bone and Joint Surgery and a Robert Jones Lecturer.

He was an elected member of The Royal College of Surgeons of England, Vice-President of the British Orthopaedic Association and President of the British Scoliosis Society and the British Cervical Spine Society. He was particularly proud to be a founder member and the second President of the Welsh Orthopaedic Society.

He gave outstanding service to many developing countries worldwide through ‘hands-on’ representational and teaching visits, including The Lipmann Kessel Travelling Professorship.

In Wales, he was Trustee or Adviser to several charitable organisations helping disabled or ill children, Deputy Lieutenant for Clwyd, Medical Ombudsman for Wales and Member of the Gorsedd of Bards and Honourable Society of The Cymmrodorian. In 1990, he was appointed OBE for services to medicine.

If one adds to all that his family and friends, travel, shooting, fishing, hill-walking and golf, one can see how rich and fulfilling a life he had. He was blessed with a long retirement, during which he was enthusiastic and indefatigable in plans for further adventures, convivial occasions and keeping actively in touch with the many organisations he served. n

Remember them fondly It is with great sadness that we report the passing of the following members.

Our thoughts are with their families and friends at this time.

Peter Alexander Ring

H Marshall Williams

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Sponsored Content 13th Trauma & Orthopaedics Update

Val d’Isere, 28-31 January 2019 www.doctorsupdates.com info@doctorsupdates.com +44 (0) 208 7151924 Doctorsupdates 2019, in their 30th year will feature 13th Trauma and Orthopaedics Update. This meeting is unique as it provides interaction between a number of

different specialities: orthopaedics, anaesthetics, critical care and pain, radiology, plastic surgery, dermatology and general practice.

We also invite speakers from other specialties like haematology, neurology, rheumatology to contribute to our education.

The programme is suitable for consultants and senior trainees.

The format is informal and sessions

include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees.

Each day concludes with a lecture of general interest by an eminent guest speaker.

We have an excellent orthopaedic faculty lined up and the programme when confirmed will be available at www.doctorsupdates.com.

Forthcoming Courses from the Orthopaedic Institute

Orthopaedic Institute at the Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire

27-29 June: 4-5 July: 18 September: 21 September: 28 September: 4-5 October: 18-19 October: 7-8 November: 13 November: 3-5 December:

ORLAU Gait Course 11th Shoulder & Elbow Course 3rd Shropshire Workshop for SAS Doctors Intra-operative Neuro-Monitoring for Spinal Surgery Oswestry Ultrasound for Regional Anaesthesia Course 2nd Hand & Wrist Course Anatomy & Surgical Exposures Spinal Imaging Inaugural Spinal Course 17th Foot & Ankle Course

10th Anniversary Annual Scientific Meeting of the International Society for Hip Arthroscopy Melbourne, Australia, 4 – 6 October 2018 www.ishaconference.com

ISHA has officically combined their meeting with premier open hip surgeons under the new banner of “ISHA – The Hip Preservation Society.

There will be open surgery sessions, arthroscopic surgery sessions and combined sessions.

There will be 2 major themes at the meeting; there are invited lectures presented each year by experts in the field, the major aim of the meeting is to present new and cutting-edge research in hip surgery and this theme will continue. The ISHA meetings are where most of the major new work in

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hip arthroscopy has been presented first each year, and ISHA 2018 aims to continue that tradition, presenting the best new work in hip arthroscopy, open hip surgery and Physiotherapy.

The second major focus will be on the presentation of the first two major Randomised Control Trials comparing surgical and conservative treatments for Femoroacetabular Impingement (FAI).

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Events & Specialist Societies

Important items to note

Director of Events Management ....................... Hazel Choules Events Manager ...................... Charlie Field Exhibition Manager �������������������Janet Mills Events Administrator �������Venease Morgan UKSSB Executive Assistant .... Henry Dodds

Instructions for authors Authors wishing to submit a news item, feature article or peer-review article for the JTO should, in the first instance, submit a synopsis of 120 words explaining what the article is and its relevance within the JTO. This should be emailed to JTO@boa.ac.uk. This will then be passed on to the Editorial Team for confirmation that the subject matter will be appropriate for publication. You will receive an email from the JTO team indicating their decision. In some cases the Editorial Team will request to see the full article based on the synopsis.

This, however, does not guarantee publication. The JTO does not publish audits or case reports. To have an article printed in the journal, you must be a BOA member.

You must submit with your article and images; a photo of yourself and a short bio in the third person (no more than three sentences).

You will be sent a Copyright Form following your article submission and this should be returned by email (signed, dated and scanned) to JTO@boa.ac.uk or posted to JTO Team, BOA, 35-43 Lincoln’s Inn Fields, London WC2A 3PE.

Future publications JTO is published quarterly.

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Copyright Copyright© 2018 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

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

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Oliver Blocker, Deepa Bose, David Emery, Martin Gough, David Jones, Andrew Manktelow, Nima Razii, Andrew Roberts and David Weir.

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