Journal of Trauma & Orthopaedics – Vol 6 / Iss 3

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 06 / Issue 03 / September 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 Trauma Networks, The Use of the Internet by Orthopaedic Out-patients, Rationing and Barriers to Access in Orthopaedic Surgery and our regular features

For the latest update on our clinical issues, we focus on ‘T&O in the Digital Age’

News & Updates ––– Pages 02-36

Features ––– Pages 38-67

Subspecialty Section ––– Pages 68-82

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From the Executive Editor

Contents

Phil Turner The Congress issue of the JTO contains a broad spread of articles to inform and stimulate our readership. This is my final “From the Executive Editor” after two years in post and I find it no easier to select those articles that receive comment from me in this section.

We are very honoured to have received a letter of congratulations from our patron, HRH the Prince of Wales. It is optimistic and farsighted and includes a challenge to use our influence to help those countries less fortunate than ourselves.

The BOA is rightly proud of its leading role in training and education. Many enthusiastic and committed people have worked together to deliver the national trainee Bootcamp which is outlined

by Matt Gray. The framework for this course should be the basis of an enhanced induction for all our trainees so they really do hit the ground running.

A recurring theme for our Association is the unremitting pressure to limit access to effective surgical treatment for those with musculoskeletal disease. Commissioners are themselves struggling to cope with financial restrictions and are taking aim at perceived soft targets and using selected or misquoted evidence for support. The article by John Skinner

should be mandatory reading for those who are negotiating with purchasers of healthcare so that they can ensure our patients are not disadvantaged or discriminated against.

One of the success stories of recent years has been the development of Major Trauma Centres and the demonstrable impact this has had on outcomes across the UK. Paul Dixon describes the next steps to ensure the best possible management of those with complex orthopaedic injuries by utilising the skills which reside across an extended network.

Many of us have felt the frustrations of using IT at work which seems designed to impede rather than facilitate. Multiple log-ins, interminable start-up times and an inability for the systems to cope with running more than one programme at a time are common gripes.

Nevertheless, the future undoubtedly is digital and we have a section of articles that show what can be achieved by persistence and entrepreneurial spirit. They demonstrate how we can utilise technology to inform, educate, assess and engage for the benefit of our profession and our patients.

As I hand over the executive editorship of our Journal, I would like to thank the editorial team who have made it such a pleasure and I wish my successor well as I move to take over the Presidential role.

News and Updates

02–36

Features

38–67

Rationing and Barriers to Access in Orthopaedic Surgery

38

PLCV: Purchasers Likely Commissioning Victory?

An insight into spinal rationing

40

Trauma Networks – Where Next for Orthopaedic Trauma? 44 The Use of the Internet by Orthopaedic Out-patients in 2015 compared to 2001

48

BOA “Cut it Out” Survey 2018

50

Are Technology Advances in Orthopaedic Implants at an End?

52

How I do... Emergency Care of the Diabetic Foot

54

Operations I no longer do... MACI for Chondral Grafting 56 Historical Canvas of Orthopaedics in Pakistan: From Trauma to the era of Subspecialties, a Paradigm Shift 58 High Court Rejects Claims on Metal on Metal Implants

60

Heroes in Disguise: How the best trainers make the greatest differences and longest lasting impressions

64

Subspeciality Features

The Introduction of an Electronic Inpatient Referral System (EIRS)

68–82 68

Survey of Senior Frontline Clinicians on Information Technology Quality in Trauma and Orthopaedic Departments across the UK

70

The Future of Orthopaedic Surgery

76

The Role of Simulation

78

Optimising Surgeons’ Education to Optimise Patients’ Outcomes

80

In Memoriam General information and instructions for authors

84–86 88

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JTO News and Updates

From the President Ananda Nanu Fugit inreparabile tempus, fast flies meanwhile the irretrievable hour. While the original context of this statement from 29 BC has all to do with every living thing burning in the flames of amore, its relevance here is to the swift passage of time in the President’s chair.

This is my last act of privilege in print and I am deeply conscious of the responsibility I have carried on behalf of members of our society. As the time draws near to handing the medal of office to the current Vice President, I look forward to welcoming all of you to our Centenary Congress in Birmingham, and thank Deborah Eastwood, our Honorary Secretary for putting together one of the most intriguing and interesting programmes I have seen in the last 25 years.

India is our Guest Nation this year, and we in turn are the Guest Nation for both the Chinese Orthopaedic Association and the German Orthopaedic Association.

The presence of experienced clinicians from other health systems at our annual Congress and the interactions this allows are extremely valuable.

Ananda Nanu

As more cuts are applied to MSK services across the

country, the variations in restrictions by CCGS are themselves worthy of a GIRFT. The Health Services Journal published the excerpts of my response to a query regarding Sussex CCGs intention to prevent referral for hip and knee replacement, which required patients to be in intense, uncontrolled pain for six months and the use of opiates to control pain.

Against the backdrop of an overwhelming drive to reduce opiate prescription for chronic pain in the US and Canada, this seems a retrograde step with a possibility of creating a dependence problem in a proportion of patients who are on this medication for up to six months. In the clamorous mob that comes to the fore claiming to be the patients’ advocate, I find very little resistance or outcry against these measures that selectively disadvantage our patients. We are the ultimate patients’ advocates, with the knowledge of the

evidence base of our practice, and we should not be complicit in the spread of disinformation and non-evidence based restrictions.

Virgil writes, Carpe diem, quam minimum credula postero – seize the present; trust tomorrow as little as you may. Some matters remain relevant despite the passage of two millennia. n

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Incoming President - Phil Turner As I take on the role of President at Congress in Birmingham, I am well aware that the complexity of the issues facing our profession has never been greater. I know that we will be able to tackle them with confidence given the support, knowledge and wisdom that come from the Executive and Council and particularly the staff who have been through a period of considerable change. The BOA is united and strong but we will have serious challenges ahead; some of them can be predicted, though many will be unexpected.

Phil Turner

We are told that increased funding is to be made available to support the NHS. However, there is no mention of priority for trauma and orthopaedic surgery or musculoskeletal conditions in general. I fear our long-running struggle to secure timely access

to treatment for our patients will continue throughout my Presidency and beyond. Tied in with the lack of resource comes the challenge of distorted and inappropriately selected data to further restrict elective services.

The resulting impact on morale is brought into stark focus in the annual trainee survey.

These issues will not go away simply by complaining about them. We need high quality and timely intelligence so that we know what is going on. We need to demonstrate with sound evidence that we are caring for our patients effectively and that we are providing an efficient service. We will succeed by collaborating with our specialist societies and working with our members and all the other groups involved in the full pathway of patient care.

There are good reasons for optimism. After a year of reflection and celebration of our centenary, the theme of the next year is “New Horizons”. We should look to the future with confidence based on our strengths in education, research, technology and leadership. During my term in office, we will be renewing our strategy which will be finalised for Congress in Liverpool in 2019. A key theme over the next five years is to review how we engage internationally. In a rapidly changing world, we need to reconsider our relationships with developed and developing nations for the benefit of patients and the extended workforce.

It is a great honour to lead our organisation and I look forward to meeting as many of you as possible during the next twelve months. n

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HRH The Prince of Wales Patron of the British Orthopaedic Association

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JTO News and Updates

The BOA honours outstanding members The BOA is pleased to announce the recipients of the 2018 Honorary Fellowship and Presidential Merit Awards, which will be presented at the Centenary Congress in Birmingham.

For over 30 years, Paul has been involved in organising and running postgraduate education courses for surgeons in the UK and around the world. As past Chair of the BOA Education Committee he championed restructuring of the BOA instructional courses, determined to make them less didactic and more interactive.

David Jones – Honorary Fellowship

Mathew Varghese – Presidential Merit Award

Mathew Varghese is a distinguished alumnus of Maulana Azad Medical College, University of Delhi.

He is currently the Head of the Department of Orthopaedics, St Stephen’s Hospital, 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. He is an associate faculty at the Transportation Research and Injury Prevention Programme, a WHO collaborating centre, Indian Institute of Technology, Delhi.

He is as an expert on injury control, and emergency care of trauma patients. Specialising in reconstructive surgery for Polio patients he runs one of the last remaining Polio wards in the country. With 50,000 children on rolls he also led the largest clubfoot programme in the world.

Mathew received the Award of Honour for Reconstructive Surgery in Polio Patients in 1996 and the National Award for Excellence in Medicine by the T. P. Jhunjunwala Foundation for the year 2004-2005.

David Jones qualified from Manchester and undertook his orthopaedic training through the Percivall Pott rotation, based at Bart’s Hospital, London.

He was a consultant from 1978-1995 in Gwynedd and Oswestry, doing general orthopaedics and trauma. He moved to Great Ormond Street, undertaking specialised children’s orthopaedics. He has been BOTA Trainer of the Year, Hunterian Professor of RCS and, for JBJS-B, Associate Editor and long-serving member of its Editorial Board.

David was Secretary, then President of the British Orthopaedic Association, Elected Member of Council of the Royal College of Surgeons of England, Chairman of The Intercollegiate Board in Orthopaedic Surgery and President of the Welsh Orthopaedic Society.

Paul Szypryt – Honorary Fellowship

Paul Szypryt is an orthopaedic surgeon working at Nottingham University Hospital NHS Trust.

Paul has also contributed to the organisation and success of the AO Trauma courses in the UK and worldwide, first as Chairman and President of AOUK and more recently as Chairman of AO Trauma Europe and Southern Africa. He is committed in local management roles, champion of Trauma co-ordination and high quality ATLS courses.

He has been Director of Research, Clinical Director, Divisional Chairman for MSK (responsible for elective orthopaedics, trauma and rheumatology) and Associate Medical Director in his own Trust (Wrightington, Wigan and Leigh NHS FT). He has three years’ experience as a full Trust Board Member up to a successful Foundation Trust application.

He is the clinical lead for the Specialist Orthopaedic Hospital Alliance in the UK.

Henrik Malchau – Honorary Fellowship

Peter Kay – Honorary Fellowship

Peter Kay is a consultant orthopaedic surgeon at Wrightington Hospital, Lancashire and is former President of the British Orthopaedic Association (2011), British Hip Society (2008) and British Orthopaedics Trainees Association (1992).

He is Honorary Clinical Professor of Orthopaedics at the University of Manchester and Clinical Professor at the University Central Lancashire and currently serves on the Council of The Royal College of Surgeons of England.

Henrik Malchau is a hip and knee replacement surgeon in Boston, Massachusetts and is affiliated with Massachusetts General Hospital and Harvard Medical School. He received his medical degree from Aarhus University Faculty of Medicine and has been in practice for more than 20 years.

He received the Orthopaedic Research Education Foundation (OREF) Clinical Research Award at the American Academy of Orthopaedic Surgeons (AAOS) 2017 Annual Meeting in March.

The award was given for Dr Malchau’s work on studying the impact of implant registries around the world. These registries are a way to collect information about the outcome of joint replacement surgeries at a national level and this helps with effective treatments.

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JTO News and Updates

Letter to the Editor Dear Sir, Following the recent article about the Victoria Cross in the June edition of JTO, it may be of interest for readers to discover whether there are any other orthopaedic surgeons with relatives who have won the Victoria Cross.

In addition to Harold Ackroyd VC, we have discovered that Richard Parkinson has a great uncle, Major Thomas Harold Broadbent Maufe who was awarded the VC for action on 4th June 1917 and Scarlett McNally also has a great uncle with the award. Captain Eugene Paul

Bennett VC, MC, was awarded the medal for action on 5th November 1916. Both men survived the Great War and lived until 1942 and 1970 respectively.

If there are any other orthopaedic surgeons with such distinguished relatives, we would be delighted to hear from them.

Yours sincerely, Christopher Ackroyd, Consultant Orthopaedic Surgeon, Bristol Richard Parkinson, BOA Trustee Scarlett McNally, Consultant Orthopaedic surgeon, Eastbourne D.G.H.

Scarlett McNally with a photograph of her great uncle Paul Bennett VC. “It is awesome to feel a visceral connection to the recent past. My mother still talks of doing work experience with her Great-Uncle, Paul Bennett VC, when he was a judge.”

– Scarlett McNally

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Volume 06 / Issue 03 / September 2018

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JTO News and Updates

BOA Latest News Ian Winson Appointed Civilian President of CSOS Congratulations to BOA past President Ian Winson who was appointed as Civilian President of the Combined Services Orthopaedic Society (CSOS) at their annual meeting in May. CSOS was formed in 1974 to promote orthopaedic specialty training in the Armed Forces as a civilian organisation.

Ian is the past President of both the European Foot and Ankle Society and the British Foot and Ankle Society, as well as a member of the American Orthopaedic Foot and Ankle Society.

BOA Executive, Council and staff members at Buckingham Palace.

BOA attends HRH Prince

Charles’ 70th Birthday Bash BOA Executive, Council and staff members were delighted to represent the organisation at Prince Charles’ 70th Birthday celebrations at Buckingham Palace on Tuesday 22nd May. Prince Charles has been the BOA’s Royal Patron for the last 25 years. Representatives from all the charities of HRH’s patronage, along with the military regiments of his affiliation, were invited to the reception to mark the occasion.

The BOA is proud to be one of 400 charities that attended on the day.

Deborah Eastwood – New Appointment Congratulations to BOA Honorary Secretary, Deborah Eastwood on her recent appointment as the UCL Associate Professor of Paediatric Orthopaedic Surgery at Great Ormond Street and the Royal National Orthopaedic Hospitals. Deborah works in the generality of paediatric orthopaedic surgery, but has particular interests in children with overgrowth syndromes, metabolic bone disease and those with neurological problems. She also deals with hip and foot/ankle problems and acts as the lead surgeon for the Ponseti service for clubfoot deformity.

Deborah is a former council member of BSCOS (British Society for Children’s Orthopaedic Surgery) and former President and Board Member for EPOS (European Paediatric Orthopaedic Society).

Fragility Fracture Global: Call to Action!

The BOA is pleased to be one of 81 leading organisations endorsing a call for action to improve the care of people with fragility fractures, in particular to restore function and prevent subsequent fractures. The initiative will focus on improving the medical care of a patient sustaining their first fragility fracture; prevention of a subsequent fracture and rehabilitation of people whose ability to function is impaired by major fragility fractures to restore their mobility; and independence. For further information, visit the website of the Fragility Fracture Network at fragilityfracturenetwork.org.

Training Orthopaedic Trainers (TOTs) Course l 11th-12th October (BOA, London) l 29th-30th November (Newcastle)

The TOTs course was established to improve the standard of teaching for those in T&O training and practice. The basic premise of the course is that, if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. The course is facilitated by Lisa HadfieldLaw, 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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BOA Appointments We are pleased to announce the following appointments: l BOA President for 2021/22: Bob Handley l BOA Trustees for 2019-2021: Grey Giddins, Robert Gregory,

Fergal Monsell and Arthur Stephen

New BOA/BESS Publication

Hip Fracture Care Day ‘Lessons Learnt’ The BOA held a Hip Fracture Care day on Wednesday 23rd May. The event was organised by Paul Dixon, Chair of the Trauma Group and was attended by orthopaedic surgeons, anaesthetists, nurses and physiotherapists. Topics covered within the event included the BOA’s hip fracture review process, the importance of nutrition and mobility, and several case studies of practice, in particular units, with lots of networking opportunities for attendees. The event received positive feedback and the BOA would like to thank all who attended and contributed to the success of this event.

The BOA and BESS have published guidelines on the investigation and management of Periprosthetic Joint Infection (PJI) in the shoulder and elbow. These guidelines focus on best practice and management of PJI based on the available evidence combined with consensus developed by a working group of BESS surgeons, infectious disease physicians and BESS physiotherapists. Read the full document at europe.nxtbook.com/nxteu/sageuk/bess_201807/.

BOA Instructional Course 2019 – Register Now! Saturday 12th January 2019 (Macdonald Hotel, Manchester) The Instructional Course is a highlight of the BOA’s calendar, and we are pleased to announce registration is now open for 2019.

The course will follow a different format than in previous years.

The 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. l Stream One: Clinical Based Discussions (CBDs) in diabetic

foot; necrotising fasciitis; spinal infection and metastatic spinal compression.

l Stream Two: Foot and ankle; shoulder and elbow; hand and

wrist; hip and knee, spine and paediatrics.

Places are extremely limited, so we encourage those interested in the 2019 course to register as soon as possible at www.boa.ac.uk/ events/instructional-course.

Paul Dixon, Chair of the Trauma Group (front row, middle) with speakers at the event.

Training Orthopaedic Clinical and Educational Supervisors (TOCS and TOES) Do you want to help trainees be the very best they can? The course will provide delegates with a range of learning outcomes, all of which are mapped to the seven domains underpinning the GMC requirement for recognition as educational and clinical supervisors. The next TOCS and TOES course will be held at the BOA offices on 9th November and will be facilitated by Lisa Hadfield-Law. 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-clinical-educational-supervisors-tocs-toes/.

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

European Federation of National Associations of Orthopaedics and Traumatology Congress, Barcelona 2018 This year’s EFORT Congress visited the city of Barcelona, a city to which it will return in 2021. The Fira convention centre provided an excellent venue for what is the largest International meeting of Trauma and Orthopaedic surgeons worldwide (although larger national meetings exist!). The theme of the meeting was ‘Innovation and New Technologies’ and multiple parallel sessions provided a wide range of educational opportunities presenting some difficult choices in terms of what to attend. The sight of delegates wearing a headset and seemingly conducting an imaginary orchestra, whilst actually learning a new approach or technique, was common on the Industry stands. As usual there was a mix of high-end specialist education, provided in conjunction with the European Specialist Societies,

and revalidation-level general education generated through cooperation with the National Societies that form the Federation.

The conference was preceded by the General Assembly – effectively the parliament of the Federation, which is attended by the National delegates, including the President of the BOA, Ananda Nanu. This year saw Klaus-Peter Günther (Germany) elected as second Vice President and David Limb (past Secretary of the BOA) re-elected for a second two-year term as Secretary General. Later the meeting also allowed a fruitful coming-together of the leadership of EFORT with SICOT, the AsiaPacific Orthopaedic Association and the Pan-Arab Orthopaedic Association who together represent tens of thousands of Orthopaedic and Trauma Surgeons across the globe.

David Limb awarding the best trauma paper prize.

Delegates enjoy the Advanced Hip and Knee course, part of the EFORT congress.

This year, as in all previous years, the UK provided both the biggest proportion of posters and papers and the biggest share of around 5,000 registrants.

Educational opportunities are on the increase, with a large number of instructional lectures by invited experts, the cream of which are published in ‘EFORT open reviews’, its open access journal published by the BJJ and now listed in PubMed Central. Although the large majority of the meeting is open, the Interactive Expert Exchange sessions provide a real chance to become involved in peerto-peer debate for those who have paid a small additional registration fee. The need to pay this additional fee is almost the only aspect of the Congress that received any negative feedback and, rumour has it, may lead to liberation of these sessions to the larger audience they deserve in coming years.

As might be expected in such an important meeting, there were

a large number of distinguished guest speakers including Prof Reinhard Graf who delivered the Erwin Morscher honorary lecture, relating his experiences of a lifetime spent developing hip sonography. This year’s Michael Freeman lecture, the first since that EFORT founding father’s death, was delivered by Prof Phillipe Hernigou, who has greatly advanced the science of stem cell therapy in Trauma and Orthopaedics with contributions spanning decades. Mike Freeman’s passing was also commemorated with the award of the first Michael Freeman medal for the best paper on knee biomechanics.

Overall, EFORT 2018 proved to be a meeting that had something for everyone. Everyone who is a member of the BOA is automatically a member of EFORT and EFORT looks forward to providing further opportunities and education for its members at the next Congress in Lisbon, 5th-7th June 2019. n

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JTO News and Updates

BSSH Spring Scientific Meeting, Cardiff 2018 The British Society for Surgery of the Hand (BSSH) held its spring scientific meeting in Cardiff, at the Hilton Hotel on 3rd-4th May. It was attended by over 250 delegates and focused on controversies and dilemmas that perpetually trouble us, with interactive debates – a model which will be continued for the October meeting.

There were sessions on the challenge of failed carpal tunnel

decompression with some personal reflections, medical negligence which, as expected, provoked a dichotomy of opinion and debate and an entertaining debate on dilemmas in scaphoid fracture management, moderated by Tim Davis. A session on soft tissue infection, a topic likely to be a growing problem, included a somewhat terrifying talk by Dean Boyce on Necrotising Fasciitis.

Sue Fullilove, Lindsay Muir, Chris Little and Jonathan Hobby debate scaphoid dilemmas.

David Shewring, President of BSSH

Professor Neil Jones from California gave the Douglas Lamb Lecture with a stunning overview of the contribution that microsurgery has made and Dr Mike Solomons from Cape Town gave several illuminating and entertaining talks.

One of our heroes was the Honorary Secretary, Jonathan Hobby who, despite having had some heavy duty treatment the week before, kept everything running smoothly, as well as making crucial contributions to specific sessions. Carlos Heras-Pelou was another who had had a very difficult time recently, but showed great stoicism to attend to give his presentation.

The Society Dinner was at the National Museum of Wales which houses the largest collection of impressionist

Professor Neil Jones from California (originally from Merthyr Tydfil and the third “Brit” to be President of ASSH) receives the medal for giving the Douglas Lamb Lecture.

art outside Paris. Guests were able to view works by Monet, Cézanne, Renoir, Rodin and many others with pre-dinner drinks.

BSSH is truly in a rich vein of productivity at present. n

CSOS Annual Meeting, Birmingham 2018 Leading the way, this year’s Combined Services’ Orthopaedic Society Meeting was held in Birmingham at the Birmingham Rep Theatre on 11th May 2018.

Although the principal organiser, Wg Cdr Spurrier, was deployed at an inopportune time during the run up, his colleagues Lt Col Rodger, Maj Wood and Maj Tunstall stepped in to ensure a very successful meeting with good turnout, not only from regulars and reservists in all three services but also from civilian members and colleagues.

in joint replacement surgery through the impact of clothing on ballistic injury to the potential use of helicopter drones to evacuate casualties. The fourth session focused on osseointegrated prostheses with a multidisciplinary overview of the risks, benefits and potential of this still developing technology.

The main meeting was preceded

by ICSOS, on 10th May, at Queen Elizabeth Hospital covering key topics for the FRCS; finishing with some viva practice.

The osseointegration talk was complimented by a call for action by our guest speaker “Supervet” Professor Noel Fitzpatrick who covered not only his use of osseointegrated prostheses in animals but also highlighted the potential benefit to human orthopaedics of closer collaboration with the veterinary world.

A healthy mix of topics was covered from thromboprophylaxis

Col Standley L/RAMC delivered the state of the Nation Address.

Members and guests at the Combined Services Orthopaedic Society Annual Meeting, Birmingham 2018.

Professor Hamish Simpson, having reached the end of his term in office, has stepped down as President; and we welcome Ian Winson.

This year’s dinner was held at Edgbaston Cricket Ground.

Next year’s CSOS meeting will be on 10th-11th May in London DMG(SE) hosting. n

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JTO News and Updates

CAOS International Annual Conference, Beijing 2018 The 18th annual conference of the International Society for Computer Assisted Orthopaedic Surgery was held in Beijing, China from 6th to 9th June

2018. The Conference Chair was Professor Wei Tian, Director of Beijing Jishuatan Hospital, affiliated with Peking University.

There were 364 attendees from

CAOS Executive Board at the 18th Annual Conference.

a total of 17 countries with over 300 authors. There were eight keynote lectures, while 5,149 people viewed the live broadcast on line.

Prof Wei Tan quoted: “CAOS techniques have been revolutionary, leading to a great improvement in accurate positioning, planning and execution in orthopaedic surgery.�

Spinal surgeons at Jishuatan Hospital have developed the first Chinese surgical robot dedicated to spinal applications, Tianji.

There were two workshops focused on computer assisted musculoskeletal tumour surgery and robotics. During the meeting, the Guidelines for NavigationAssisted Spine Surgery was discussed and released with an unveiling ceremony.

Prof FRY Baena prepared an excellent scientific program consisting of wide ranging applications of CAOS in joint arthroplasty as well as spinal, trauma and oncology applications. Applications like virtual reality, soft tissue assessment, robotic applications, reproduction of planning were discussed in detail. Results of clinical use of the technology in medium and long-term were discussed. Future directions were discussed. There was also presentation of various basic techniques related to CAOS including sensors, imaging, planning, biomechanics and benefits and downsides of the developing technologies. The next CAOS meeting will be held in New York in June 2019 with Prof Patrick Meere as President. n

BOOS Annual Meeting, Edinburgh 2018 The recent the British Orthopaedic Oncology Society meeting in Edinburgh was as always, a huge success.

We had over 100 delegates from 22 countries and heard papers on Basic Science, endoprosthetic replacement, long-term outcome data, a variety of case series on both benign and malignant primary bone tumours, soft tissue sarcoma, etc. The best paper was an analysis of long-term outcome in tenosynovial giant cell tumour (PVNS), the best basic science paper was an analysis of the anatomy of a lesser understood muscle in the quadriceps compartment of the thigh, the genu articularis and the best young investigator paper was a new predictive model for intervention in metastatic disease.

Paul Cool chaired a pre-meeting of surgeons from the major

implant units where outcome measures in endoprosthetic replacement were debated.

A series of basic standards were agreed including an acceptable infection rate, dislocation, return to theatre, etc. We also debated putting in place standards around DVT prophylaxis for massive endoprosthetic replacement and other appropriate perioperative interventions.

BOOS is grateful to Sam Patton for his efforts in organising such a prestigious conference at the inspiring venue of the Royal College of Surgeons of Edinburgh and for organising two superb evening dinners either side of the event. BOOS 2019 will be a joint meeting with the Dutch Orthopaedic Oncology Society in Leiden and as many of you as possible are welcome to attend! n

Delegates at the BOOS Annual Meeting.

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boa.ac.uk

JTO News and Updates

BESS Annual Meeting, Glasgow 2018 This year the British Elbow and Shoulder Society travelled to Glasgow for the 30th anniversary meeting, back where it all began in 1988. Over 540 people joined us at the outstanding Scottish Event Campus on the banks of the River Clyde.

Following on from the success of our first instructional course last year, BESS ran its second course on the day preceding the annual meeting. This year the focus was on ‘Management of trauma to the shoulder and elbow’. The course was extremely popular and fully booked a month before the event.

The annual scientific meeting followed the now well-established BESS format with early morning masterclasses run by the local organising committee. Opening the meeting was the allied

Audience at the BESS Annual Congress.

Peter Brownson with Lord Provost.

health professional symposium ‘Shoulder and upper limb pain, from the rotator cuff and beyond’ with guest lecturers Andrew Crockett, Andrew Cuff, Neil Millar and Rob Patterson. As usual, the scientific research symposium ran in parallel and focused on the ‘Perprosthestic joint infections of the shoulder and elbow’. Lectures were given by Steve Corbett, Mark Falworth, Addie Majed and Amar Rangan. There were the usual free paper sessions covering all aspects of current shoulder and elbow practice as well as the now traditional “hot topic session” on issues surrounding current medical practice and a dedicated session to CSAW. Delegates were also entertained by two eminent guest speakers who delivered their thought provoking lectures: Peter Millett from the USA, entitled “RC repair – state of the art in 2018”; and Mark Frankle, also from the USA, entitled “Improving outcomes in reverse shoulder arthroplasty”.

We were pleased to award several BESS funded fellowships and pump priming grants to BESS members along with prizes for the best papers.

During the meeting, we were honoured to be joined by our founding members, Angus Wallace and his wife Jackie, Ian Bayley, Michael Watson and his wife Angie, and Jenny

Peter Brownson, President of BESS

Presidents Dinner

BESS Founding Members

Copeland on behalf of Steve Copeland. We were also delighted to be joined by Helen Kelly whose husband, Ian Kelly hosted the first BESS meeting in Glasgow in 1988. The BESS President, Peter Brownson, bestowed a gift in recognition of their contributions to the society.

Despite the packed programme it was not just work but the evenings were filled by a

conference dinner on the Wednesday at the Glasgow Science Centre and an informal drinks reception on the Thursday, held in the venue itself.

BESS would like to thank our Glasgow colleagues for hosting this most enjoyable and successful conference. We now look forward to BESS 2019, hosted by our Leeds colleagues at Harrogate. n

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JTO News and Updates

BIOS Annual Meeting, Huddersfield 2018 The 20th annual meeting of the British Indian Orthopaedic Society was held in Huddersfield.

BIOS members from Calderdale and Huddersfield NHS trust hosted the meeting held under the helm of the President Prof G Chakrabarty. The objectives of the Society achieving excellence through education were at the forefront again.

The programme of symposia, guest lectures and free papers addressed a wide range of topics. It started with a session on TOCS and TOES run by Lisa Hadfield-Law. Bone and Joint infection symposium had multidisciplinary and Indian speakers speaking on tuberculous and

non-tubercular infections.

Speakers provided evidence based management plans and discussions in the symposia on Prosthetic joint infections, Sports injuries and Management of fractures in the elderly.

Indian guest speakers, Dr R Mehta and Prof Rajesh Malhotra spoke on conditions not frequently seen in UK. Guests, Deborah Eastwood, Prof Peter Giannoudis and Prof Phil Turner lectured on topics that generated a lot of discussion.

Sqn Ldr D Bhasin, Presidential guest lecturer spoke on Leadership and Discipline that we can we learn from the RAF.

This was extremely thought provoking.

The first BIOS Medecta junior travelling fellowship was awarded at the meeting.

The evening entertainment gave the opportunity to showcase classical and Bollywood Indian dance along with Indian food.

The President of BIOS, Prof G Chakrabarty with the organising committee and guest speakers, including Phil Turner and Deborah Eastwood.

BIOS has 500 first and second generation Indian surgeons of all cadres. The motto of the society is to educate surgeons through exchange programmes and meetings.

The BOA annual congress in Birmingham will have a BIOS revalidation session and an Indian summer where leading Indian surgeons will showcase their work. n

World Orthopaedic Concern UK Conference, Blackpool 2018 The 5th annual WOC UK conference was hosted in Blackpool on 9th June, by WOC Chairman Steve Mannion.

Invited speakers attended from Belgium, Zambia and Malawi, and we were honoured to

have the President Elect of the British Orthopaedic Association, Professor Philip Turner.

The session on hip surgery included talks on managing fractures of the neck of

femur, and establishing a hip replacement service in low resource settings, and generated lively discussion.

It was encouraging that many trainees joined in, sharing their experience in the field. It was a sobering thought that a Girdlestone procedure is still a common option even in young patients.

In communities where squatting and using a stick are culturally the norm, the level of function after this operation can be quite good.

Sandy Chimangeni (right) receiving Arthur Eyre-Brooke award from Steve Mannion (left).

Goran Jovic, the sole plastic surgeon in Zambia, gave a wonderful talk on his work with FlySpec, the flying specialists, who fly out into the remote areas to operate.

Goran usually flies

himself, and takes orthopaedic colleagues with him. He joked that he was “the best plastic surgeon in Zambia!�

The service is currently in dire straits, and welcomes support from any source.

Sandy Chimangeni is a longserving orthopaedic clinical officer from Malawi. These officers are invaluable members of the orthopaedic service in a country where there are only six orthopaedic surgeons. Sandy has worked with eminent British orthopaedic surgeons, including Arthur Eyre-Brooke, whose eponymous lecture he delivered.

One of the highlights of the conference was the talk by Prof Turner. This is the first time in our memory that a President Elect of the BOA has expressed an interest in developing world orthopaedics, and reached out to us. We left with a great sense of hope for the future. n

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

congress.boa.ac.uk #BOAAC #BOACentenaryyear Late Registration Full registration will close on Monday 10th September and late registration will open online on Tuesday 11th September; please find the registration rates on the Congress website at congress.boa.ac.uk/registration-2018. Please note: you can still register onsite at the BOA Congress if you have not registered online beforehand.

BOA Centenary Congress App We are delighted to announce that the NEW BOA Congress App is now ready to download!

You can download the BOA Congress App now to your smartphones and tablets through the Apple App Store and GooglePlay – search for BOA Annual Congress and make the most of your experience before, during and after the Annual Congress.

Programme Update The theme for our Centenary Congress is ‘Taking stock: Planning the future’ and we look forward to presenting to you a mix of educational and scientific sessions that allow us to review the past and look at innovations for the future.

We are extremely pleased to have India as our guest nation with Mandeep Dhillon as President for this Centenary year. The Indian Orthopaedic Association’s contributions will enrich our Congress and the programme. We are delighted to welcome Dr Mathew Varghese from India to deliver the Presidential Guest Lecture.

Specialist topics including Trauma, Research, the National Joint Registry and more. There is also the opportunity to attend a session illustrating the History of the BOA and the History of Trauma and Orthopaedics. We will hold a series of focused educational sessions on Friday, including Good Clinical Practice Training and Clinical Examination Course, catering to the needs of all from Medical Students to Consultants.

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

Don’t forget to visit the BOA stand (99) while walking around the venue to meet the BOA team!

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

‘Taking stock: Planning the future’

congress.boa.ac.uk #BOAAC #BOACentenaryyear

Plan ahead and bookmark your sessions in advance, create your own itinerary, view podium and poster presentations, and also check out the local guide of restaurants and bars. Enhance your Congress experience with a full content of the four-day programme, a list of speakers, interactive maps and more.

The App will ensure that you have all the information you need at your fingertips for an enjoyable Congress!

Accommodation Book your Congress accommodation now to avoid disappointment! TSC Hotel & Venues is the official hotel-booking agency for the BOA Centenary Congress 2018. Booking your Congress accommodation couldn’t be easier. Visit our Accommodation page at congress.boa.ac.uk/ travel-and-accommodation-2018 and book online.

Save the date!

BOA Annual Congress 2019 10th – 13th September, ACC Liverpool #BOAAC The programme will be based on ‘New Horizons in Research, Education and Clinical Leadership’, with a focus on a new strategy and a five year plan for the BOA.

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JTO News and Updates

Conference Listing: BORS (British Orthopaedic Research Society) www.borsoc.org.uk 10-11 September 2018, Leeds

BOA (British Orthopaedic Association)

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

BTS (British Trauma Society)

www.bts-org.co.uk 7-8 November 2018, Manchester

BOFAS (British Foot and Ankle Society) www.bofas.org.uk 7-9 November 2018, Edinburgh

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

BASK (British Association for Surgery of the Knee) www.baskonline.com 26-27 March 2019, Brighton

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

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk 25-26 April 2019, Swansea

BOTA (British Orthopaedic Trainee Association) www.bota.org.uk 14-15 November 2018, Newcastle upon Tyne

SBPR (Society for Back Pain Research)

CAOS (Computer Assisted Orthopaedic Surgery - International) www.caos-international.org 19-22 June 2019, New York

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

BSS (British Scoliosis Society)

www.britscoliosissoc.org.uk 28-30 November 2018, Belfast

BOSTAA (British Orthopaedic Sports Trauma and Arthroscopy Association)

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

OTS (Orthopaedic Trauma Society)

BOA (British Orthopaedic Association)

www.orthopaedictrauma.org.uk 10-11 January 2019, London

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

BHS (British Hip Society)

BIOS (British Indian Orthopaedic Society)

www.britishhipsociety.com 27 February-1 March 2019, Nottingham

www.britishindianorthopaedicsociety.org.uk 28-29 June 2019, Leicester

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Volume 06 / Issue 03 / September 2018

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JTO News and Updates

A Past President’s View: The BOA Moving Forwards from its Centenary Ian Winson, BOA Immediate Past President So we have moved through from 2017 into 2018. An organisation which has existed for 100 years should take a bit of time to look at itself. The world has changed from the time of the formation of the BOA.

Following a war to end all wars, the BOA was formed to support the surgeons trying to develop an area of specialist surgical practice that sought to reconstruct the lives of those with injuries that were life-changing and to make the lives of those suffering chronic musculoskeletal disease more tolerable. A hundred years later, the tools have changed somewhat but the terms of reference remain the same.

Ian Winson

During this year the BOA Presidential line, Executive and Council have striven to reanalyse how these tasks are achieved. We have had to make internal changes and effectively restructure the organisation, and those changes will continue to evolve with the strategic review.

There has been a major effort and investment in establishing a more robust IT structure from which hopefully the membership will see more and more benefit.

We want a more engaged system where we know what is really impacting our membership and their patients.

This period of time has been politically difficult! However, in typical fashion we have simply had to roll up our sleeves and get on with the realities of protecting our patients’ interests. Sometimes that has been almost surreal; the posture of the CCGs to commissioning MSK services has been extraordinary. The constant assumption that surgery is a form of failure and is the only dangerous option out there has been a theme that is based on the reality that the costs of surgery can be measured fairly accurately. The cost of any other treatment is rarely if ever measured to the equivalent level. The consequences to the individual and to society as a whole of not sticking to a progressive and logical care plan, which is evidence-based, is not recognised. Keeping a patient population as fit as possible has to impact positively on the reality of an aging population.

The response has to be to produce better and better evidence, and that evidence

should not be looking to stand still but to improve what we do for patients. Nonetheless, the ongoing trend to regard MSK patients as a low priority, whose problems can be solved by prevention and lifestyle changes, needs to be knocked back by contemporary and logical argument. The BOA has involved itself actively in pushing this forward. The solution is consistently to promote the best treatment available. The Elective Care Reviews are now up and running, the aim being to give units and their hospitals an opportunity to have an impartial look at where things are inconsistent with what is achievable nationally.

We have been looking at how surgeons are supported throughout their careers and the obvious need to support education for the full period of a professional life. This will move forward over the next year.

So let’s look forward while continuing to learn from the lessons of the past. n

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Volume 06 / Issue 03 / September 2018

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JTO News and Updates

BOA Membership Update Membership Benefits BOA membership entitles you to a range of benefits including: free attendance at our annual Congress, free subscription to the Journal of Trauma and Orthopaedics (JTO), orthopaedic Fellowships, Awards and Prizes, access to UKITE and discounts on services.

Make the most of your BOA membership benefits and find the full list at www.boa.ac.uk/membership/benefits.

Free Membership Subscription Prize Draw Congratulations to the recent monthly winners, who were 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.

Joint Action Challenge Events We would like to offer huge congratulations to our BOA staff members Emily Farman, Hayley Oliver and Venease Morgan (pictured right) for participating in the 2018 British 10K on Sunday 15th July. We are extremely proud of our three runners, who showed motivation, dedication and focus – smiling until the very end!

A very big thank you and congratulations to Andrew Cranmer, Ricardo Morgan and James Tomlinson for taking part in the Prudential RideLondon-Surrey sportive on Sunday 29th July. We would like to thank these wonderful individuals for taking on this challenge and raising donations for Joint Action, the only UK charity that specialises in raising and distributing funds to the entire musculoskeletal spectrum. Keep an eye on the BOA website for the cyclists’ photos soon to follow.

Also, a huge thanks to all who donated and cheered!

We truly appreciate the support you have given us.

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

Royal College of Surgeons Update With the site of the Barry building now unrecognisable from this time last year, work will shortly be starting on the construction phase, following the breaking of ground at the end of September. Once ground has been broken, there will be two years of construction and fit-out to enable us all to get in and accustomed to our new, modern and prestigious home.

Barry Library temporary floorboard removal works commenced.

During the next 18 months, we will be refining and realising the designs of the interior of the building including the new teaching

and examinations areas, the new Hunterian Museum, the new conferencing suite with views over Lincoln’s Inn Fields, and the offices where we will all work. We will also be carrying out sympathetic restoration of the main library, and retained frontage.

The layout of the new building will be much more open and welcoming to visitors and everyone who will be working in it, and will bring our visitors closer to the work that everyone does in the building, bringing them closer to surgery.

To watch the progress of the rebuild, the College has installed a time-lapse camera with a view over the Barry site.

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Barry Library proposed upcoming interior.

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Experience of the BOA Clinical Leadership Fellowship in Lower Limb Arthoplasty Marshall Sangster I have just completed the BOA Clinical Leadership Fellowship with a specialist interest in lower limb arthoplasty at Northumbria Healthcare NHS Foundation Trust, with a team of five revision surgeons. This is one of three routes into the programme that include recruitment by Trusts hosting National Clinical Leaders Fellowship (such as this), individual applications and Specialist Society Sponsored Fellows such as BSCOS and BOFAS. The Clinical Leadership programme aims to develop future orthopaedic consultant leadership with a focus on service transformation and quality improvement. This is provided for by formal leadership training delivered over four twoday modules, alongside a quality improvement project where you are significantly supported and guided. The results are presented at the BOA Congress.

The areas I found most stimulating included sessions on coaching and mentorship, leadership styles, motivation and negotiation. During the programme there is a focus on self-awareness and personal leadership style and how you become a more effective leader in the NHS. All of these qualities are beneficial for the pre-Consultant transition and those already in a Consultant

post wishing to gain a greater understanding of higherlevel NHS management and strategic thinking.

Professor Mike Reed founded the Clinical Leaders Programme and as a consequence, he understands the development needs to further your leadership and management skills, providing tailored opportunities within new and existing projects within the trust. Northumbria is recognised as one of the leading units with regards to infection rates and length of stay for total hip and knee replacements nationally. As part of the team that continually strives to improve patient outcomes you get first-hand experience of the processes in action that deliver these outstanding results.

This is an operatively rich fellowship with extensive experience gained. In a 12-month period you would expect to achieve approximately 100 revision cases and 150 primary arthroplasty cases. In particular for lower limb arthroplasty this high caseload of primary and revision work includes infection, periprosthetic fracture and complex revision in both hip and knee.

There is a weekly infection MDT and a monthly revision MDT and as the Fellow, you are responsible for the organisation and presentation of these meetings. This provides excellent learning opportunities and post-operative feedback.

The fellowship would help develop your CV and personal qualities to be competitive in

applying for a Consultant post.

These include audit, MDT, presentations at both regional and national level, and research opportunities alongside the QI project as part of the Clinical Leaders Programme.

It has been a pleasure to work in one of the most forwardthinking units in the UK that provides a wide experience in developing the skill set necessary to undertake a Consultant post. It has been an exciting and enjoyable fellowship that encourages innovation and improvement in your own future Consultant career. I would actively encourage senior trainees to apply for this post as a platform to becoming a top-performing orthopaedic surgeon incorporating the NHS values of excellence. n

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The National Joint Registry Update On the 31st of March 2018 the NJR celebrated 15 years of collecting data when 2,520,000 procedures had been registered.

Quite an achievement!

Our audit on completeness and accuracy of data has been a key focus for the NJR this year. At April 2018, our data quality audit showed that overall approximately 95% of all primary operations (hip and knee only) had been registered in 2014/15, and over 90% of all revisions.

The minimum dataset has been updated this year, now enabling the registration of Debridement and Implant Retention (DAIR) procedures, which will allow more accurate and detailed assessment of these procedures in relation to later revision surgery.

The NJR component database is in the process of being redesigned to enable a more detailed analysis of the types of components that are

implanted. This should lead to a better understanding of how the attributes of devices may affect performance.

An NJR ‘risk calculator’ is being developed by Mark Wilkinson and his research team and should be available for clinical testing later this year. It is envisaged that these tools will be used in the outpatient setting by the surgeon and patient to facilitate ‘shared decision-making’.

These will all be presented at the BOA Congress in our session ‘How to use NJR data responsibly to improve care’ or at our lunchtime updates on our stand in the exhibition hall each day. New enhancements to the consultant level report, available from the clinician feedback portal, will also be covered here. n

Trauma symposium 2019 Tuesday 12 February 2019 to Thursday 14 February 2019 CPD accredited Learn how to manage complications in everyday practice and debate common issues. Network with experts in the field, and understand how their experiences have shaped the opinions and techniques of leading surgeons.

Early bird rates start from £30 (expiring Monday 14 January 2019) Find out more and register today at: www.rsm.ac.uk/events/orm05 Venue: Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE

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The Inaugural BOA Bootcamp: A Delegate’s Review Matt Gray

Bootcamp group taking in a simulated conflict resolution scenario.

Background The first BOA bootcamp took place in Newcastle in June, publicised as an “exciting new course to prepare new orthopaedic trainees with knowledge and skills to excel during training”. Twenty trainees (ST2-ST4) were put through their paces during the four-day course, comprising human factors training alongside a two-day cadaveric surgical approaches program (Figure 1).

Speaking as a delegate, here I outline the highlights of this landmark course and explain why the ‘boot camp’ model offers a sound foundation to a sustainable career for surgeons at the start of specialist training.

Day 1

Day 2

Human factors/non-technical skills Introduction Team-building Leadership Conflict

Resilience Self-awareness Conflict resolution Mentor review

Day 1 and 2: Focused Human Factors Training Days one and two covered orthopaedic-specific ‘human factors’ training including resilience, conflict resolution, teamworking and leadership. Rather than a traditional didactic overview of topics, the unconventional but successful delivery through small-group tutorial (four trainees/group) and team-based exercises was adopted. Lego®, pandas, spaghetti, jigsaws and stand-up comedy all made an appearance, facilitated by insightful senior consultants and industry facilitators.

Trainees were encouraged to share personal accounts of human factors at play in their own practice, which although initially daunting, were ultimately Day 3

Day 4

Cadaveric surgical approaches Upper Limb Key approaches and external fixation

Lower Limb Key approaches and external fixation

Figure 1: Broad themes covered over the course of BOA bootcamp.

instrumental in distilling an individualised understanding of these often generically understood ‘non-technical skills’.

(1:2). An outstanding learning experience ensued, serving as an ideal practical foundation to early years registrar training.

One-on-one named mentors were a particularly important component of the course, on hand for discussion, debate and consolidation of learning throughout. Perhaps most impressive was the offer for ongoing mentorship into the future for each trainee. Aspects like this not only boost trainee morale but set this course apart from others.

Overall

Although full-on, the first two days of the bootcamp were both rewarding and insightful. Well worth the effort!

Days 3 and 4: Cadaveric Training: Surgical Approaches for Trauma The second half of the course was based at the Newcastle Surgical Training Centre (NSTC), a bespoke cadaveric surgical training facility contained within the Freeman Hospital, Newcastle.

Focusing on case-based common approaches used in trauma, each was performed in a simulated theatre environment using fresh frozen cadaveric material.

Attention to detail meant that discussion around each approach covered theatre layout, draping/ positioning of the ‘patient’ in addition to technical aspects.

A particularly impressive feature of the cadaveric program was a strikingly low tutor:delegate ratio

The feeling from fellow delegates was that the inaugural BOA bootcamp was a resounding success. Yes, the course fulfilled its stated aims, but perhaps the most valuable feature was an individualised action plan to achieve a fulfilling and sustainable career that each delegate took away with them.

The more unique aspects of this course such as tailored mentorship, candour amongst trainees during small group teaching and quality of cadaveric training all contributed to feeling of renewed enthusiasm and preparedness amongst delegates. This is a testament to the solid foundation offered by the ‘bootcamp’ model.

As a specialty, we should feel buoyed that such an innovative program has been backed by our professional association. With a further bootcamp scheduled for October, I am sure the program will thrive to become a gold standard for early years training (and probably the envy of other specialty programs!). n

Bootcamp group at the end of the cadaveric sessions.

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EFORT-APOA Fellowship 2018 Kar Hao Teoh I was selected by EFORT to represent Europe along with Michiel Siebelt (Netherlands) as an exchange fellow to the 20th Congress of the Asia Pacific Orthopaedic Association (APOA) in Antalya, Turkey. We joined nine APOA Young Ambassadors (YA) and two SICOT exchange fellows for a week-long fellowship

on 7th April 2018. This was the first time EFORT and SICOT participated as exchange fellows.

We were put up in a five-star all-inclusive full board beach resort hotel. The first day was a get together introductory dinner at the hotel. The thirteen YA had different sub-specialty interests

The young ambassadors’ dinner with Council Members of APOA and the Presidents of various international societies.

and came from different cultural backgrounds which made the experience very enriching. The second day was a series of interesting lectures and difficult cases chaired by Prof Dr Alpay Merter Özenci. We then spent the next two days at Antalya Education and Research Hospital, which is the biggest public university hospital and a level one trauma centre. We observed many surgeries over the two days, some of us even scrubbing up.

The Congress took place from 11th to 14th April 2018. The scientific quality of the Congress was very strong, with keynote and plenary lectures given by distinguished speakers from across the world. I bumped into our own BOA President, Ananda Nanu, at the conference who delivered an excellent plenary lecture and managed to discuss with him the current issues facing British orthopaedics.

One of the sessions at the Congress was dedicated to the Young Surgeons Forum.

This gave rise to interesting discussions on the different experiences in the young surgeons programme in EFORT, SICOT and APOA, how we could learn from each other and possibly integrate the programmes. This was followed by talks from each YA on their research project of choice and the YA dinner with Council Members of APOA and Presidents of various international orthopaedic societies, e.g.

EFFORT and SICOT. The fellowship concluded with the presentation of certificates by the President of APOA during the congress dinner. This was an invaluable experience for me as not only have I met today’s leaders of orthopaedics, I have also forged links with tomorrow’s leaders in the field. It was also a great honour to be representing British and European orthopaedics. n

Never Event Involving Wrong Prosthesis – BOA Response to Healthcare Safety Investigation Branch The HSIB (Healthcare Safety Investigation Branch), a relatively new health body for England, has as its purpose “to improve safety through effective and independent investigations that don’t apportion blame or liability”.

In June 2018, they released their first investigation report about a Never Event from 2017 in which a wrong prosthesis was implanted during a joint replacement. In this incident the wrong implant was a mismatch of different manufacturers, which was

picked up when entered into the National Joint Registry (NJR) after the procedure. The report covers system-wide issues identified by the investigation, recommendations for improvements and highlights the role of human factors such as fatigue and distractions for the occurrence of never events. Recommendations included possible methods for detecting prosthesis errors prior to being used and enhancements to the NJR system for flagging of mismatched prostheses.

By implementing these recommendations, the hope is to decrease the likelihood of Never Events from occurring and identifying the issue as soon as possible if it does occur. The report highlights that the number of Never Events involving a wrong implant has not declined since reporting began in 2011, with an average of 52 per year across all surgical procedure types.

In response to the HSIB report, the BOA released a statement supporting efforts

to improve patient safety and to encourage development of further mechanisms for detecting and flagging issues with wrong implants. Read the full report on the HSIB website at www.hsib.org. uk/investigations-cases/ implantation-wrong-prosthesesduring-joint-replacementsurgery/final-report. n

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Volume 06 / Issue 03 / September 2018

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JTO News and Updates

PHIN Update: Improving Reporting and Transparency in Private Healthcare By now, most orthopaedic consultants who treat private patients will be aware of the Private Healthcare Information Network (PHIN). PHIN is required (by the Competition and Markets Authority) to publish up to eleven performance measures for all hospitals and individual consultants who treat private patients in the UK.

At the time of going to print with this issue of the JTO, PHIN is nearing the point of publishing the first two metrics (patient numbers and average length of stay) for the first 1,000 or more consultants who have reviewed and approved their private practice data and populated their online profile.

We are aware that more consultants are also working towards this, by reviewing their private practice data and working with hospitals to correct any errors. (From a BOA perspective, we are aware that there have been some significant data issues and we encourage members encountering particular difficulties to let us know by email to policy@boa.ac.uk.)

There are three things that PHIN are asking consultants to do. Anne Coyne, PHIN Consultant Relationship Manager, explains:

1. Review your practice data, and report any inaccuracies to the hospitals where you work

committed to working with you and the hospitals to achieve this objective.

While it would be easier for PHIN to simply amend the data following feedback from consultants, ultimately the data must be corrected at source – by the hospitals. PHIN normally receives data from hospitals on a monthly basis with another three months allowed for improvements to the data, including amendments requested by consultants. As such, we ask consultants to login to the secure online portal at www.phin.org.uk and check the data submitted about their practice each quarter.

2. Preview your performance measures, and approve for publication once you are confident in the data

We have already seen that where consultants have engaged with their hospitals and provided feedback on data inaccuracies, steadily errors in the data are disappearing and the quality of new data submitted by hospitals is improving. PHIN remains

While consultants can view the latest status in the portal at any time, they are only required to approve the measures once every year, after first approval. However, we will prompt consultants to login and preview their performance

In PHIN’s secure online portal consultants can also preview their performance measures, benchmarked against the average among your peers for each procedure. When consultants are confident in the data submitted by hospitals, they can see how they will appear on the website and sign-off their measures for publication.

measures before each quarterly update to the website. If the measures for the upcoming period are incorrect, consultants can choose to remove from the information to be published on PHIN’s website.

3. Populate your online profile PHIN also allows consultants to populate their profile with photos, biographies and information about their clinical specialties. Patients using PHIN’s website are keen to know more about their consultants and their specialist interests, and the profile is a great way to provide this.

While some consultants have viewed the PHIN project with some scepticism, for many it is an opportunity. Working together can demonstrate improvements in the standard of clinical data, promote innovations in healthcare achieved through data sharing and showcase the breadth and quality of care that consultants deliver to patients.

There will be frustrations along the way, be these data/technical challenges, but the PHIN team wants to support consultants through the process and hear how we can improve. If you have any questions or concerns, or would like access to your data, please contact us at consultants@phin.org.uk. n

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Volume 06 / Issue 03 / September 2018

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JTO Features

Rationing and Barriers to Access in Orthopaedic Surgery John Skinner Rationing is the controlled distribution of scarce resources or an artificial restriction of demand. A barrier is something that gets in the way. The National Health Service was born in 1948 from the National Health Services Act (1946), which mandated a comprehensive health service and that the services should be provided free of charge at the point of delivery.

The NHS was launched at a time of post war austerity with rationing of petrol, cheese and meat continuing until 1954. The NHS was an instant success as 30 million people immediately registered with NHS doctors and it had a budget of £438 million.

Today, the annual cost of delivering the NHS has risen to £127.2 billion for 2018-2019 with an anticipated shortfall £20 billion by 2020. The UK population is 66.6 million and we are ageing. By 2007, there were more pensioners than children in the UK; by 2015, 27% of the population was obese (BMI ≥ 30Kg/m2) and by 2017 there were three million diabetic patients in the UK. While patients are living longer they still expect to remain active and it is in everyone’s interest that they do.

John Skinner

In 1979, Harold Wilson’s Government set up a Royal Commission in order to consider the best use of financial and

manpower resources in the NHS. This observed that “whatever the expenditure on healthcare, the demand is likely to meet and exceed it.” Today the NHS is one of the world’s largest employers, along with the Chinese Peoples Liberation Army, the Indian Railways and Wal-Mart supermarkets. It treats 1.4 million patients every 24 hours and with this scale of healthcare delivery, there will always be pressures on capacity and finances.

Symptomatic arthritis is common affecting 10 million people in the UK. It is a chronic painful deteriorating condition, leading to joint stiffness and disability. Arthritis is invisible, not well understood in the general population and is easily dismissed. For patients, it threatens independence and ability to earn. Arthritis Research UK found that 70% of patients with arthritis feel a burden to family, friends, carers and even their doctors1. Musculoskeletal

conditions are the reason for 20% of all consultations in primary care. Arthritis Research UK’s latest awareness campaign aims to make ignoring the impact of arthritis unacceptable.

The clinical and cost effectiveness of hip and knee replacement on health quality of life is well established. These are operations with high levels of patient satisfaction and confidence. Some studies have shown that total hip and total knee replacement are more effective than many other healthcare interventions2,11.

Recently we have seen arbitrary barriers to patients accessing orthopaedic care introduced.

It seems that many Clinical Commissioning Groups (CCGs) are seeking to limit patient access by establishing BMI thresholds, symptom severity triage using Oxford scores and withholding treatment from smokers. This is in clear contradiction to NICE guidelines and the wishes of NHS England. These arbitrary barriers to treatment will inevitably lead to delays. The impact of these delays is clear, patients will have worse outcomes and it will add to the cost of procedures. The King’s Fund has shown that painful chronic conditions impact on patient’s mental health; sufferers are two to three times more likely to experience mental health problems and depression, than the general population3.’

Approximately 14% of the NHS budget is spent on treating mental health conditions4.

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is 31Kg/m2 and the NJR shows high satisfaction levels in these patients. High BMI is a risk factor for developing arthritis, so the effort to treat obesity should surely be initiated long before patients get the end stage disabling effects of arthritis and start to go off their legs.

Table 1: Giori’s table showing how setting various BMI thresholds affects access to joint replacement surgery and its ability to prevent complications. Reproduced with permission of JBJS, Incorporated.

Currently, care is commissioned by 197 CCGs, each managing a finite budget for a small geographical area. On this scale, orthopaedic operations may appear expensive, as there is an implant cost associated with the procedure. However, NHS Improvement data, for an average cost and lifetime of a hip replacement has been costed at £7.50 per week, which represents excellent value for the pain relief and high-level function. Economic studies repeatedly show that THR and TKR are good value when assessed by QALYs (Quality Adjusted Life Years).

In 2018, 55% of the 197 CCGs have a mandatory threshold limiting patient access to joint replacement based on BMI or smoking. The commonest BMI threshold is 35 Kg/m2 but 26 CCGs have a threshold of 30 Kg/ m2 and 10 have a BMI threshold of 25 Kg/m2. The situation seems to be intensifying, with a 10% increase in the number of CCGs publishing BMI thresholds for referral in the last 12 months.

If BMI predicted complications that could then be avoided, then this may have benefit. Giori et al found that a BMI threshold of 30 kg/m2 for total joint replacement referral, is only marginally

better than tossing a coin in identifying patients who would have had a complication5. While this strategy seems ineffective at preventing complications, it is highly effective at rationing access. It has the effect of preventing access to surgery for 52% of patients who would have had complication free joint replacement surgery (Table 1).

Commissioners deciding whether patients are suitable for hip or knee replacement should not use Oxford scores for triage.

Some CCGs mandate that Oxford score as low as 20 (out of 48) are used as a threshold for referral for surgery. Oxford scores are not validated as a triage tool for individuals. They are heavily influenced by comorbidities, particularly back pain and depression. It seems unlikely that their use enables the best possible decisions to be

taken for patients. Preoperative Oxford hip and knee scores do not predict which patients will be satisfied or dissatisfied with the results of joint replacement surgery. There is clear evidence that the lower the Oxford score prior to joint replacement then the lower the function achieved post surgery. Patients still benefit from the pain relief but are not optimised with respect to achievable potential postoperative function. A patient’s symptoms of pain in an arthritic joint, and not an Oxford score, should be used to decide whether joint replacement surgery is appropriate.

Patients with high body mass index (BMI) are eight times more likely to need total joint arthroplasty when compared with patients with a normal BMI. The average BMI of UK patients undergoing Knee replacement

NICE: Osteoarthritis Care and Management Clinical Guideline 177 (Feb 2014 updated 2017) l Refer for consideration of joint surgery before there is prolonged

and established functional limitation and severe pain l Patient – specific factors (including age, sex, smoking, obesity

& comorbidities) should not be barriers to referral for joint surgery

Surgeons do not operate on morbidly obese patients lightly.

It is technically more difficult and a decision to operate is a commitment to care for complications. Some surgeons have advocated a BMI-based eligibility criterion for total joint arthroplasty above, which the surgical procedure is delayed or is denied6-7. However, total joint replacement surgery provides such good pain relief and functional benefit to obese patients that these are similar to those achieved by nonobese patients8-10. Currently, the most appropriate way to assess which individual patients will benefit from joint replacement surgery, is in the outpatient setting with risks, benefits and timings being agreed between the patient and the consulting surgeon.

While the BOA remains committed to promoting active and healthy lifestyles, it is imperative that patients can access the most effective healthcare solutions at their time of need. n John Skinner is Professor of Orthopaedic Surgery at the RNOH Stanmore with a special interest in hip and knee replacement surgery. He is on the Editorial Board of the BJJ. John is the Treasurer of the BOA and has represented the Association at high level discussions with NHS England and other stakeholders on elective care.

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

PLCV: Purchasers Likely Commissioning Victory?

An insight into spinal rationing Lee Breakwell A lot of recent press1 has been directed at the notion of restriction of certain procedures considered to be of low efficacy, and as such poor value for money for the NHS. Terms such as “Procedures of Limited Clinical Value (PLCV)” are being wielded against us and our patients. It has been suggested that up to 20% of what we offer as clinicians is of poor value!

Whilst all but the hardiest of protectionists would accept that we should not offer any treatment that cannot demonstrate improved outcomes for patients, there is increasing concern about the means by which this “value” is being measured.

For the first time in recent history, the purchasers are interested in what happens at the sharp end of secondary care, and it is clear that in many cases PLCV are being used as rationing tools.

Whilst it is fair and appropriate to only perform treatments that do have clinical value, it’s ludicrous to suggest that one of the best operations invented in modern times, i.e. the total hip replacement, is ever of limited clinical value in someone with painful osteoarthritis of the hip.

Lee Breakwell

Increased funding into the NHS has been promised, but we all expect the associated increased scrutiny. We in orthopaedics

have been at the vanguard of procedure based data through our registries. Time and again the National Joint Registry proves its worth when identifying the best and the least performing procedures.

Albeit with a later start, and a slow one at that, the British Spine Registry has over 125,000 patients, and is beginning to have meaningful data on the most common procedures.

Getting It Right First Time (GIRFT) has identified huge variation in practice across England with regard to spinal surgery interventions. The rates and relative cost of

such interventions are also hugely variable. It has been a rather surprising finding that procurement costs are widely inequitable across the country.

The most recent assessment by NICE of back pain management NG592 has shown that a number of our widely used interventions are of relative low efficacy. Many spinal surgeons have realised for years that facet joint injections for mechanical backpain offer limited, short-term benefit and poor reproducibility, and yet they have continued to be performed in their thousands.

Whilst potentially giving some benefit to a number of patients, they do not offer a long-term solution to a condition that is essentially lifelong and as such do not offer value for money for the cash strapped National Health Service. NICE has recommended that they no longer be performed. It is recognised however that another widely used form of injection, nerve root injection, can be a valuable resource at avoiding costly and risky surgery in the presence of predominantly selflimiting radicular leg pain and as such are still available for use.

Perhaps the most striking finding of this guidance is that fusion for non-specific mechanical low back pain is no longer acceptable in the

>>

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JTO Features

PERHAPS THE MOST STRIKING FINDING OF THIS GUIDANCE IS THAT FUSION FOR NON-SPECIFIC MECHANICAL LOW BACK PAIN IS NO LONGER ACCEPTABLE IN THE NHS. SUPPORTING EVIDENCE FOR FUSION IS POOR AND WITH RELATIVELY HIGH COST, REVISION RATES, AND COMPLICATIONS, THE OUTCOMES THAT CAN BE ACHIEVED ARE NOT JUSTIFIABLE ACROSS THE POPULATION.

NHS. Supporting evidence for fusion is poor and with relatively high cost, revision rates, and complications, the outcomes that can be achieved are not justifiable across the population. It was recommended therefore that low back fusion only be available as part of a randomised controlled trial.

Not surprisingly, purchasers have seized upon this guidance and have de-commissioned fusions forthwith. This has been something of a wakeup call for the spinal surgery fraternity as this was a mainstay of many people’s practice. In many ways, we only have ourselves to blame. Before the advent of registries, most surgeons continue to offer procedures based on oftmisguided anecdotal based outcomes. Many surgeons still tell me that spinal fusion works...

Well, where is the evidence?

A session was held at our most recent national meeting, BritSpine in Leeds, reviewing the potential for an RCT across the nation for low back fusion.

An excellent multidisciplinary working group looking at various aspects and logistics was successfully chaired by Prof Nadine Foster of Keele University. Recommendations for a funding bid are being

drawn up by the British Association of Spinal Surgery research committee for a prospective trial seeking to identify in whom fusion offers benefit. In this way, it is hoped that we are able to design and complete a quality study that gives some clarity on the place for fusion in low back pain management.

Clinicians across the spine world have recently created the National Back Pain Pathway3 which seeks to streamline assessment and treatment for spinal conditions, using the best available manpower and evidence. This is now superbly supported by the clinical network of highly experienced and dedicated spine care professionals. Whilst weight loss, self-help and exercise are never likely to cure or significantly affect the natural history or symptoms of severe osteoarthritis of the hip, they can make notable improvement in mechanical back pain. By applying the appropriate triage assessment by the correct individual at the clinically relevant time, it has repeatably been shown that surgical conversion rates increase, waiting times decrease, and money can be saved, all at the same time as managing a wider number of affected individuals.

As the national burden of back pain continues to rise, along with the incidence of serious spinal pathology associated with an aging population, surely the time has come to recognise that team-working and evidence based practice offer all of us a brighter future. Expectation management, self-help and patient re-education are seen as major priorities across the NHS, and perhaps apply more to the common spinal pathologies than other areas of orthopaedic management. n Lee Breakwell is a full-time spinal surgeon at Sheffield Children’s and Teaching Hospitals. He is a current Trustee of the BOA and past President of BOTA. He co-designed the British Spine Registry and represents the BSS. Lee is Secretary of the UK Spine Societies Board, as well as Chairman of Sheffield Orthopaedics Ltd.

References 1. www.bbc.co.uk/news/ health-44665560.

2. www.nice.org.uk/ guidance/ng59/chapter/ Recommendations.

3. www.ukssb.com/improvingspinal-care-project.

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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Taking care of your medical indemnity not only helps to reduce your fixed costs, but also provides contract-certain cover that protects you and your family. Bespoke Medical Indemnity can offer medical indemnity insurance advice and solutions to consultants whatever your speciality or workload, with a personalised approach to help you find the best deal for your practice.

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Volume 06 / Issue 03 / September 2018

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JTO Features

Trauma Networks – Where Next for Orthopaedic Trauma?

Paul Dixon Co-authors: Nigel Rossiter, Tim Chesser and Chris Moran Since the trauma networks went live in April 2012 the quality of care given to people suffering life threatening injury has improved measurably. Mortality data from the Trauma Audit and Research Network (TARN) demonstrates a 20% improvement in the probability of survival following major trauma in England and this equates to more than 500 additional survivors per year.

TARN data also provides evidence of changes in the process of care with significant improvements in consultant-led care, access to CT scan plus the use of massive transfusion protocols and Tranexamic acid to reduce bleeding.

Paul Dixon

Major trauma centres (MTCs) are now established as network hubs and ambulance services have adapted well to changes in triage criteria and bypass protocols. As a result, the landscape of trauma management in England has changed with an 80% increase in the number of patients being taken directly to an MTC. This,

together with the development of Emergency Department (ED) major trauma protocols, means that in 2011, 4,000 patients with severe trauma were received by a consultant-led trauma team whilst 16,000 patients received this standard of care in 2016, a fourfold increase.

Despite the evidence that an extra 500 patients a year are surviving since 2012, clinicians in Trauma Units (TUs) have expressed concerns relating to their reduction of exposure to victims of polytrauma. Many network ambulance bypass protocols advise that patients in extremis should be taken to

the nearest hospital rather than the MTC. Thus, on occasion the sickest patients may arrive in an ED where trauma resuscitation is a rare event, leaving staff unprepared and feeling vulnerable to criticism.

Surgeons and theatre teams also fear becoming deskilled as their exposure to complex trauma cases decreases and some previously common procedures, such as IM nailing or fixation of complex periarticular fractures are become increasingly rare in the TU. From another perspective, these teams have a wealth of experience and skills in trauma management that are not being utilised as effectively as they could be. This has a knock on effect for training in trauma and how this should be organised to maximise exposure to the whole range of the specialty and the opportunities available.

It has also become apparent within T&O that the emphasis on the treatment of the relatively rare group of patients who have sustained life-threatening injury and the development of MTCs has created a feeling of disconnect in some regions between clinicians working in the MTCs and those in TUs. The best practice tariff incentive that was developed

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Volume 06 / Issue 03 / September 2018

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JTO Features

THE KEY TO BEING ABLE TO DEVELOP EFFECTIVE SYSTEMS IS GOOD LOCAL LEADERSHIP AND COMMUNICATION COUPLED WITH ACCURATE DATA WHICH CAN BE USED AS A BASIS FOR RESOURCE ALLOCATION AND AS A FOUNDATION FOR CHANGE.

for MTCs to finance the capital and workforce developments needed to provide a 24/7 service may have contributed to the feeling of disillusionment in some clinicians, with the perception that TUs are not rewarded for the vital role they play and that they are regarded as “the poor relations in the networks”. In addition, the absence of clear channels of communication regarding repatriation and follow up or on-going responsibility for care issues remain a problem in some networks. This can result in clinical issues when complications occur and coordinated, multidisciplinary care is necessary.

With this apparent de-skilling, there has been an increasing trend for orthopaedic trauma which doesn’t hit the triage criteria (e.g. complex periarticular fractures including tibial plateau, pilon and foot fractures) to be referred to MTCs as there is a concern about maintaining the necessary skill levels.

Another issue reported is the increasing surgical subspecialisation leading to inappropriate requests for transfer to a MTC e.g., a patient with an isolated, simple clavicle fracture transferred because the upper limb surgeon was on holiday that week!

Table 1: 2017 Trauma Audit and Research Network (TARN) data, unpublished.

Despite this perception, an analysis of TARN data shows that TU’s remain integral to the management of major trauma: the majority (56%) of patients with an Injury Severity Score (ISS) >15 are still initially treated in a TU albeit with 40% of these patients now transferred rapidly and safely to an MTC. Overall, two thirds of ISS>15 patients are now treated in an MTC (Table 1) meaning a third remain in a TU for definitive care, these tending to be older with head, chest or musculoskeletal injuries plus potentially complex medical, rehabilitation and social needs. Many of these patients are frail and have similar comorbidities to hip fracture patients and need to be treated near to home in order to allow access to social and community care. Thus, the TUs remain an essential part of the trauma system in England and networks have a duty to recognise this and try to develop in a way that optimises all the resources available.

Building on this concept, some MTCs report issues related to the system change which stretch their ability to provide an appropriate service to all patients. As an example, some have seen the number of open fractures presenting increase by a factor of 5,

impacting on their ability to treat local patients with less severe injuries in a timely fashion. On occasion, these patients may benefit from transfer of care to local TUs especially if they are waiting at home and are able to mobilise independently with the potential to be treated as a day case. A network that can function in a collaborative manner, with good communication pathways and robust governance systems should be able to facilitate appropriate treatment for all patient subgroups and respond to fluctuations in demand and availability of resource. To this end major trauma networks shouldn’t be regarded as pyramidal but more as a twoway hub and spoke model with the potential for additional cross links (Figure 1).

Thus, despite the gains made since 2012 there is room for improvement in trauma network functioning throughout the country and potential to further improve the outcome of patients, not just in terms of mortality but with timely return to function and a reduction in disability. T&O surgeons have a key role to play in this and need to take the lead in improving the way networks work so that we can provide our patients with better and more timely care.

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trauma conference at the MTC, including how this advice will be recorded and communicated.

5. Define referral pathways for isolated open fractures to allow orthoplastic care as defined in the NICE Clinical Guide (NG37). In some Major Trauma Networks, orthoplastic services are available in TUs and the best way to use these resources should be considered.

Figure 1: Illustration of a Trauma Network.

National directives may be useful in establishing a framework and standards by which systems can develop but each of the trauma networks faces different challenges due to variation in geography, infrastructure and skill mix.

Thus, network development and solutions must be addressed at a local and regional level, rather than nationally. The key to being able to develop effective systems is good local leadership and communication coupled with accurate data which can be used as a basis for resource allocation and as a foundation for change.

TARN and NHFD data can give a snapshot of subgroups of trauma patients and can be extrapolated to a certain degree but more detailed information is sometimes needed to inform specific change and this is probably best collected at network level after a regional consensus on measurable parameters is reached.

Communication within and between networks would seem to be the key to achieving this and the Trauma Group at the BOA, the Orthopaedic Trauma Society (OTS) and NHS-England would suggest the following framework as a potential way forward. We would like to work together to promote the development of orthopaedic

trauma networks within each of the major trauma networks.

The group would have a T&O consultant representative from each TU and also the local MTC. The aims would be to: 1. Improve communication regarding patients sustaining musculoskeletal trauma within the networks.

2. Provide training/support for TUs where patients in extremis have been/are likely to be taken and concerns are raised regarding the capacity to resuscitate these patients effectively.

3. Identify groups of surgeons with specific expertise in trauma who would be willing to provide a tertiary referral service for complex, isolated injuries and draw up referral guidelines and pathways within the network.

Examples might include isolated, specific periarticular fractures such as the pilon, tibial plateau, complex elbow injuries, complex children’s fractures, pelvic and acetabular fractures, calcaneal fractures, knee dislocations without vascular injury and periprosthetic fractures.

4. Delineate clear pathways and systems for obtaining expert advice from the daily

6. Provide a clear and network agreed referral plan for when key local experts in certain injuries are not available due to holidays, sickness, etc.

7. Develop a system that allows feedback of key learning points and clinical governance issues from any point in the Network to all members and build on this to create more robust systems for the future.

8. Consider repatriation pathways, communication and responsibilities for ongoing care. A national template for the rehabilitation prescription has been developed and has just been released. As part of best practice tariff, MTCs will be expected to use this to facilitate transfers and communication.

9. Ensure that when ongoing treatment of orthopaedic trauma injuries is required, this is clearly documented and all relevant medical notes and imaging are transferred with the patient.

We hope to be able to provide representation from one of the supporting organisations at each of these meetings as they are convened, collect information on problems and potential solutions and then feedback data and themes at the BOA Congress network sessions as they become available. In addition to facilitating the development of these orthopaedic trauma networks, NHS-England is also

working on a Best Practice Tariff for TU’s to incentivise both care pathways and TARN data collection within these hospitals.

Ideally, this network approach shouldn’t be limited to T&O surgeons but as the largest trauma specialty and the group most often taking the lead in treating these patients, it is imperative that we drive the process and enable major trauma networks to develop so that they remain patient centred and also make best use of a wealth of experience in trauma management and education that is available in Trauma Units. n Paul Dixon is a Consultant Trauma and Orthopaedic surgeon working in Sunderland.

He trained in the Northern Deanery and completed fellowships in knee surgery and trauma in Sydney and Denver respectively. He has been a member of the BOA Trauma Group for the past five years and has acted as Chair for the last two. His particular interests are in the multidisciplinary care of patients who have sustained a fragility fracture and the development of wellfunctioning, patient centred trauma networks.

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JTO Features

The Use of the Internet by Orthopaedic Out-patients in 2015 compared to 2001 AurĂŠlie GC Hay-David Co-authors: Wright JED, Caine A, Chadwick C, Seyoum D, Bassett P and Brown RR results of the earlier study. The 95% confidence intervals was reported and calculated using the exact binomial method.

In 2001, 33.5% of adults in the UK used the internet on a regular basis1. At that time, our baseline study reported that 8% of orthopaedic patients consulted the internet before their consultation2. In 2015, 86% of UK adults regularly used the internet3. This study aims to quantify this increase and discern any changes in the factors that influence internet usage by orthopaedic outpatients.

Methods

AurĂŠlie GC Hay-David

The methodology and questionnaire of our 2001 study was used so that any change over time could be evaluated 14 years later1.

There were 350 consecutive outpatients (200 elective, 150 fracture) in the same settings (a district general hospital, two regional teaching hospitals, a tertiary referral centre, Thames and Trent Health Regions, UK). Information collected from internet users included: device/s used; website/s visited; priority of trust in the information; alternative sources of information. Usage was analysed by: age; sex; geographic region; initial/ follow up consultation.

Results There was a six-fold increase in the percentage of patients consulting the internet about their current orthopaedic condition (2001, 8% vs 2015, 48.3%, 95% C.I. 42.9%, 53.7%) and 6% within the first four hours of their appointment.

Patients frequently used more than one device: 48.4% laptop; 48.4% tablet; 46.4% mobile phone; 29.4% desktop. The majority of websites used were non-medically reviewed sites (Table 1, Figure 1).

Statistical analysis was done using chi-squared tests for categorical variables, such as internet usage, and the unpaired Student’s t-test for continuous variables, such as age.

Statistical significance was set at 5% for comparison with the

Age significantly influenced whether a patient consulted

Type of Website

Number

% of Patients using the internet (95% CI)

Medically Reviewed

104

61.5% (53.8%, 68.9%)

Non-medically reviewed

142

84.0% (77.6%, 89.2%)

Patients support website

1

5.9% (2.9%, 10.6%)

Table 1: Summary of the type of websites accessed for information about orthopaedic conditions.

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the internet (mean age 46.1, s.d 16.2) compared to those that did not (52.8, s.d. 19.5, p<0.001). The 30-49 group (62.5%) was most likely to consult the internet; the over 65’s least likely (28.2%, p <0.001), see Table 2. Gender had no influence on whether a patient consulted the internet, except in females over 65 (p= 0.27), see Table 3.

Figure 1: The change in sources of information used by orthopaedic patients (*Patient support leaflets were not reviewed in 2001).

Figure 2: Which source of information do orthopaedic patients trust the most.

Variable Age category

Gender

Consultation Number

Category

Internet use (%)

No internet use (%)

P-value <0.001

< 30 yrs

32 (49.2%)

33 (50.8%)

30 – 49 yrs

60 (62.5%)

36 (37.5%)

50 – 64 yrs

52 (50.5%)

51 (49.5%)

65+ yrs

24 (28.2%)

61(71.8%)

Female

105 (51%)

101 (49%)

Male

63 (45%)

78 (55%)

First

22 (37%)

38 (63%)

Second

39 (46%)

47(55%)

Further

88 (54%)

75(46%)

0.28

0.06

Table 2: Factors associated with the use of the internet by orthopaedic patients.

Age Category

Females consulted n/N (%)

Males Consulted n/N (%)

Age x Sex interaction P-value

< 35 yrs

25/46 (54.4%)

16/35 (45.7%)

0.9

35 – 49 yrs

28/42 (66.7%)

23/38 (60.5%)

50 – 64 yrs

36/70 (51.4%)

16/32 (50.0%)

65+ yrs

16/48 (33.3%)

8/36 (22.2%)

Table 3: Internet usage by orthopaedic patients by age and gender.

0.27

Internet usage increased with each visit but was not statistically significant (p=0.06). There was no geographical difference between the Thames vs Trent Regions (50.7% vs 46.5%, p=0.44); nor the level of health care (46.7% of patients at a secondary level vs 58% at a tertiary hospital, p=0.14).

The internet was accessed at similar rates by patients at elective vs fracture clinics (53% vs 51%, p>0.05). The majority of patients 91% (C.I 87.8%, 94.2%) trust the information supplied by their surgeon over information from the internet (Figure 2).

Conclusion This is the first study to repeat the same methodology to examine internet usage by patients within the same population and to describe changes over time (a sixfold increase)2. In common with other studies, we have demonstrated that patients access non-medically reviewed websites and wonder if we have a responsibility to provide / direct them to medically reviewed sites?4-10.

Decreasing internet usage by the older population suggests an emerging digital divide associated with low health literacy and no access 2, 11, 12.

In spite of this, we feel reassured that our patients overwhelmingly maintain their trust in the information received from their surgeon. n

Aurélie G.C. Hay-David graduated from Barts & The London and is a Trauma & Orthopaedic Registrar, West of Scotland Rotation. Honorary Clinical Lecturer, University of Glasgow. Interests include pre-hospital care that takes her trackside to motorsports, horseracing and horse trials.

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

BOA “Cut it Out” Survey 2018 Fergal Monsell and Lisa Hadfield-Law The purpose of this summary is to draw attention to the results of the recent BOA survey on bullying in its many forms. This is not intended to be an in-depth analysis of the data, but a straightforward attempt to create a narrative on which to frame future discussion.

President Truman reflected that “...there is nothing new in the world except the history you do not know...” and in the 2008 NHS staff survey, 12% of respondents reported bullying, harassment or abuse at work by colleagues in the previous year. This survey was repeated in 2016 with 24% reporting bullying and 30% reporting psychological stress due to bullying.

Attempting to redecorate an important issue such as this with statistics, one of Disraeli’s three kinds of lies, is in danger of missing the detail and the aim of this undertaking was to collect authentic stories of bullying in clinical practice.

Two questions were included, encouraging an open narrative response: Have you experienced bullying or undermining behaviour in the workplace?

Have you witnessed bullying or undermining behaviour in the workplace?

Responses were received from 126 members and whilst a low return is perhaps to be expected, if this represents the tip of an uncomfortable metaphorical iceberg, we have a professional and personal obligation to listen to them.

The replies have been grouped by the BOA Education advisor and includes an example from each:

Surgeons by medical managers; “...They (Trust Medical Directors) have instigated serious investigations into my practice, with threats of criminal proceedings, without ever speaking to me - before, during or after the investigation...”

Surgeons by managers; “...I have several consultant colleagues who have been told by management that there are allegations against them from a trainee, secretary, junior manager or nurse, but they never get to see the allegations...”

Women by men; “...The trainee returned, pinned me up against the wall, threatened me and told me never to tell him off again...”

Trainees by consultants, nurses and theatre staff; “...A consultant publicly shared personal examination performance results in a busy meeting and proceeded to later mock my performance further with peers and other trainees...”

Female consultants by secretarial staff; “...My secretary announced in front of the whole department that she didn’t believe women should be orthopaedic consultants...”

Fergal Monsell

Lisa Hadfield-Law

SAS surgeons by consultants; “...My work is always scrutinised more than trainees and consultants.

Senior staff always look for the

small “mistake” to point out and to show in front of everyone...”

Medical students by trainees; “...I saw an orthopaedic trainee telling female medical students they didn’t need to know what he was about to teach as they were going to be GPs...”

This affords a simple opportunity to recognise that all is not well without attempting to provide the detail required to formulate policy.

It is not the beginning of a truth and reconciliation agenda but an acknowledgement that there are issues, which are damaging. It is intended to encourage engagement by all of our members on behalf of their invisible colleagues who have been humiliated.

If you are dismayed by the responses, pay attention and calculate how you can make a difference.

The widespread adoption of campaigns to call out this unacceptable behavior in the UK and abroad shows that the wind is clearly changing.

For further support and information, please visit www.rcsed.ac.uk/professionalsupport-development-resources/ bullying-and-underminingcampaign. n Fergal Monsell is a consultant at Bristol Children’s Hospital where he is involved in the management of limb deformity and trauma.

He is Visiting Professor at Cardiff University and Projector at The Grand Academy of Lagado.

He has an active clinical and basic science research portfolio and is widely published.

Lisa Hadfield-Law, RGN, MSc, FAcadMEd and Education Advisor to the BOA.

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JTO Features - Manufacturer’s Perspective

Are Technology Advances in Orthopaedic Implants at an End? Mike Tuke I am 70 years old, just six months older than the NHS but thankfully in better health. As patients, we expect a full service but as it is we can all recognise the stresses and strains in the Health Service. Sustaining a supply business to the NHS that can predict its income and cash flow is a real nightmare. To add to this, we patients are living longer, we are more expectant, more active and more interested in outcomes.

Mike Tuke FREng

MatOrtho is recognised for delivering pioneering orthopaedic solutions. In our Finsbury days, we managed to get Hip Resurfacing to work and are duly recognised as ‘The Home of Hip Resurfacing’.

Before that, we created the Medial Stabilised knee and introduced it to the world; both revolutionary products with sound design principles and supporting clinical data.

Many companies now focus on ‘me-too’ implants and more so on fancy delivery systems with budget-breaking trickery – it would seem that implant innovation and improved patient outcomes are not a top priority.

Implant innovation globally has almost reached stagnation.

MatOrtho remains bent on continuing to create and introduce innovative implant devices that improve outcomes for patients. Implants designed to be more like the normal anatomy should improve patient satisfaction and have consistently had the low revision rates for many years.

The majority of knee implants today are either Cruciate Retaining or Posterior Stabilised type, these are relatively unstable A-P compared to the normal knee for the majority of activities. A Medially Stabilised knee has better outcomes and remains A-P stable for a full range of motion and for ALL activities; however, around 30% of surgeons are still using

PS Knees with an invasive stabilising mechanism that has no effect for more than 80% of everyday activity, walking around! It is a challenge to persuade a surgeon to change his implant; they are rarely willing or able to do so, often due to administrative burdens.

I may be an implant patient myself one day, but luckily, after working at a desk for 40 years and only occasionally popping home for a sleep, my joints have been preserved quite well. I now walk hundreds of miles when I can, and for those who have not had chance to do that yet I cannot recommend it highly enough. Exercise extends our lives; twenty-five percent of us

ReCerf® Hip Resurfacing Arthroplasty.

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MATORTHO REMAINS BENT ON CONTINUING TO CREATE AND INTRODUCE INNOVATIVE IMPLANT DEVICES THAT IMPROVE OUTCOMES FOR PATIENTS. IMPLANTS DESIGNED TO BE MORE LIKE THE NORMAL ANATOMY SHOULD IMPROVE PATIENT SATISFACTION AND HAVE CONSISTENTLY HAD THE LOW REVISION RATES FOR MANY YEARS.

alive now are supposed to live to be 100 and I intend to be one of them. I don’t want a cheap metal-on-poly hip or poorly A-P stable knee because I am over 65 or for any other reason, better implants can easily be researched and generally are not more expensive. What I want is the best, a large diameter all-ceramic hip bearing (crosslink poly has NOT solved wear), or a full time A-P stable knee with lateral patella sulcus; I do not want a revision operation in the next 30 years, that itself is a big risk. I want proven advanced technology that might last my natural lifetime and I want a say in that as should every patient who needs an implant!

Technology advancement can and does improve the operation, we must reduce infection as the number one priority. We can work further to remove implant position and limb alignment outliers but we have yet to establish if some of the outliers are the ones that are correct, so getting better grouping by using an expensive robot is a bit silly compared with the shotgun approach that at least gets some in the right place.

In the meantime, many hospitals find the extra million or so to buy a robot or get a free robot by committing to a particular implant brand for years. Many

companies now prefer to supply such systems with great marketing, and change marketing angles on ‘me-too’ implants but avoid real implant innovation.

As a small company we cannot afford to make mistakes. The consequence of mistakes is that innovation is now almost impossible. Notified bodies rule on innovation itself so they are more inclined to stop everything unless the risks can be shown to be zero, which of course is impossible. They are really only happy to certify exact copies.

Thankfully, some wise people in this country realised that innovation would be stifled and introduced ‘Beyond Compliance’ which provides a glimmer of a route for CE approved devices to be carefully monitored just as MatOrtho did voluntarily with the SAIPH knee, the only designedfor-purpose Medially Stabilised knee system. The SAIPH had eight years of careful follow-up prior to full launch this year.

It demonstrates much better ‘forgotten knee’ scores than the best competitor knees with surgeons who have been brave enough to directly compare it with their current practice.

So, can our last little remnant of an orthopaedic company continue to innovate? We are in any event the last remaining

The SAIPH® Knee System.

independent orthopaedic company in the UK; the UK has led with most of the successful innovations in orthopaedics.

Some would say we are crazy to continue to innovate implants, I am determined we should, but there is a limit to it making business sense.

Whether patients will get a chance to benefit if we do is much more difficult to answer.

It is up to regulators to allow it to happen, no longer up to me as the innovator, it is really up to us all as patients who want long active lives to fight for better implants and their own choices or they, WE, will be the ultimate casualties. n

Mike Tuke FREng co-founded Finsbury Instruments in 1978.

Mike launched MatOrtho® in 2010 following re-acquisition and continues to deliver pioneering orthopaedic devices.

Mike’s passion is to improve the quality and longevity of active life for patients with a MatOrtho® implant.

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JTO Features

How I do...

Emergency Care of the Diabetic Foot Fred Robinson Around 6,000 people with diabetes undergo leg, foot or toe amputations each year in England, with 61,000 patients with diabetes having foot ulcers at any point in time. This, and the fact that only 56% of patients with diabetic foot ulceration survive for five years, confirms the importance of diabetic foot care.

Nevertheless, the diabetic foot rarely impacts on the practice of the non-foot and ankle surgeon.

The care of a diabetic patient with a Charcot neuroarthropathy, chronic osteomyelitis or ulceration has become the remit of the orthopaedic foot and ankle surgeon.

There is one situation in which everybody who deals with emergencies needs to

Fred Robinson

be competent. The diabetic foot abscess is a surgical emergency. The patient presents with an acutely red, hot and swollen foot. There are three principal causes for such a presentation - Charcot neuroarthropathy, cellulitis or an abscess. Apart from the fever and obvious markers of infection the most important clinical feature is whether the patient has ever had a break of the skin on their foot, whether that break be surgical or ulceration (Figure 1). A break in the skin makes infection likely, and Charcot neuroarthropathy unlikely.

Therefore, if you come across a septic patient with a swinging fever and a foot abscess please drain it. Delaying for an MRI scan, a vascular opinion, or even the return of your foot and ankle colleague on Monday morning, whilst attractive, is inappropriate.

Pus needs draining. Failure to drain the collection at best delays recovery, and at worst can lead to sepsis and death.

Most commonly, delay leads to gangrene and loss of a toe or two.

It is important to establish the vascular status of the limb. If the pulses are not present a vascular opinion should be obtained. Often the foot is swollen and palpation of the pulses is difficult. In my opinion, it is safer to drain an abscess in a poorly vascularised foot, than delay a day or two for advice.

How do I drain the abscess?

This is not surgical wizadry!

The incision is centred over the fluctuant area. I only have two technical tips: 1. Webspaces are often involved, and incision may need to allow access to more than a single webspace (Figure 2). If the dead and necrotic tissue necessitates do not be timid about extending the incision to the plantar aspect, essentially creating a split between the metatarsals.

Figure 1: A foot abscess, note the ulcer over the hallux.

2. The infection usually tracks along the tendon sheaths, and therefore the incision should align with the long tendons of the toes (Figure 3).

Post operatively a VAC dressing can be helpful, but if there is ischaemia is best avoided. I usually rest the foot in a plaster back slab. Antibiotics are adjusted according to the biopsies taken at the time of surgery.

Figure 2: Decompression and drainage of two webspaces.

I encourage you to make a decision, drain the pus, save lives and feet if you admit a patient with a diabetic foot. n Fred Robinson is a Consultant orthopaedic surgeon at Addenbrookeâ&#x20AC;&#x2122;s Hospital, Cambridge. He has run the foot and ankle service for 17 years. He is past President of BOFAS and is former Trustee of the BOA.

Figure 3: Drainage of the abscess in Figure 1. Note the generous extension of the incision along the line of the long flexor tendons.

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JTO Features

Operations I no longer do...

MACI for Chondral Grafting Chris Wilson

When I became a consultant in 1997, I had an interest in knee joint preserving surgery and the regenerative approach to knee injuries and early knee arthritis. Regarding Autologous Chondrocyte Implantation (ACI), whilst I could envisage stem cells working in areas where the surrounding matrix was not crucial to function (for example, Islet cell transplantation) it was harder to see how simply putting chondrocyte cells into a damaged area would necessarily result in mechanically functional articular cartilage. I performed some ACI procedures but with the advent of MACI it was easier to envisage viable tissue regeneration, as the cells would be held in the grafted area.

Over the next five years, I did 12 MACI procedures in both femoral condyle and patellofemoral joint lesions in patients aged 17-43 years. I even had a MACI procedure performed on my own knee, although crucially this was also combined with a tibial tubercle osteotomy.

In most cases, I was able to get one and two year MRI scans. In

Chris Wilson

terms of pain and functional scores, they yielded reasonable results, but no better than the patients upon whom I had performed either microfracture or, in some later cases, isolated osteotomy.

I saw no real evidence of the areas grafted turning into tissue resembling articular cartilage, and I stopped doing these procedures, having read Knutson’s paper1, which suggested that ACI was not superior to microfracture.

I also became aware of Scott Dye’s concept of joint homeostasis2 which pointed me in the direction of alignment and stabilisation as primary goals.

Since then, there have been a great number of publications and variations on the theme of putting chondrocytes or stem cells into a cartilage defect (Table 1). Some papers have been encouraging, but with only marginal gains in terms of function and pain3.

It is fair to say that the topic remains a controversial one4 and this is reflected in the variety of procedures on offer. And what’s often forgotten is the large placebo effect of these interventions5. There remains no real evidence that articular cartilage can, at this point, be successfully regenerated to the point where osteoarthritic change might be mitigated.

It has also become clear to me that osteotomy around the knee has powerful biological as well as functional effects6. There is evidence that it is the osteotomy rather than the chondrocyte implantation that provides the benefit7, 8, and there has been a slow trend in this direction.

Dr Jacob, a past President of the ICRS stated at their 2016 meeting, “There is solid evidence in literature that osteotomy is the real workhorse in the cartilage repair setting... Osteotomy is like

doing cartilage repair without cartilage repair... ...the conclusion would be to first, before talking cartilage repair, learn to plan and perform a safe osteotomy technique.”

The general view on MACI now is that it is best in the larger lesions which have not been treated before and that the regenerate takes a long time to fully mature. I accept that these differences in approach mean that in time it may become the procedure of choice, although personally I think the future will lie with MDSC-seeded allografts.

In any case, I think that these various approaches to articular cartilage replacement should be tested in a controlled research setting, as, in my humble opinion, and contrary to that of NICE9, the cost effectiveness of MACI and similar techniques as a standard and widely available treatment in a cashstrapped NHS is not established. n Chris Wilson is a Consultant orthopaedic surgeon in University Health Board, Cardiff.

He has a special interest in knee surgery, with an interest in joint preservation, having been appointed in 1997. He trained at UCL, Nottingham, Cardiff and Sydney.

Table 1: Evolution of Autologous Chondrocyte Repair and Comparison to other Cartilage Repair Techniques10.

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

Did you know?

Straighter

More Curved

The T2 Alpha femoral nail is anatomically designed based on SOMA and has a length-dependent radius of curvature.

1

2

This document is intended solely for the use of healthcare professionals. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient.

Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery.

The information presented is intended to demonstrate a Stryker product. A surgeon must always refer to the package insert, product label and/or instructions for use, including the instructions for cleaning and sterilization (if applicable), before using any Stryker product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area.

Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker, T2 Alpha. All other trademarks are trademarks of their respective owners or holders.

Content ID: T2-PO-4, 08-2018 Copyright Š 2018 Stryker 1 2

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JTO Features

Historical Canvas of Orthopaedics in Pakistan: From Trauma to the era of Subspecialties, a Paradigm Shift Syed Shahid Noor Pakistan is a country of vast proportions. Its own history dates back to over 3000 BC with the earliest inhabitants making it as a cradle of civilization that the world learnt from in many ways.

This Indus Valley civilization taught us the art of developing cities and societies. With the Current Pakistan being declared as a sovereign state in 1947 after the end of the British Empire rule, the country has been weaving its own social fabric and has made commendable initiatives in the fields of education and science. In medicine, Pakistan forms the second highest exporter of trained medical doctors to the world.

Syed Shahid Noor

Like many other countries, orthopaedics in Pakistan was in its infancy stages in the middle of the 20th century. This was the era of composite surgical training and general surgeons would carry out virtually all socalled orthopaedic procedures.

This was the time when most of orthopaedic surgery was related to trauma. Most orthopaedic surgeons in this era were trained in trauma orthopaedic surgery from Europe, especially Austria, and they came back after attaining an MS in Orthopaedics and Trauma. It was 1962 when three British trained orthopaedic surgeons, namely the Late Prof Z K Kazi, Late Prof A Raheem and

Prof Ali M Ansari, experimented with the idea of developing a professional body that would represent orthopaedic surgeons in Pakistan. As a result, Pakistan Orthopaedic Association (POA) came into existence in the historical city of Hyderabad.

It was in the 1980s, when UK trained surgeons started to return to Pakistan in large numbers.

They established the concept of a separate operation theatre for orthopaedic, principles of open reduction and internal fixation as well as hip and knee arthroplasty. By the late 1990s, the EU health policies in the UK had already started affecting

opportunities for the training of orthopaedic surgeons in the UK. In addition to this, the twin towers incident in 2001, followed by global geopolitical scenarios, meant overseas training for Pakistani citizens became a mere dream as many were refused jobs and visas. In the face of rising demands for good quality training, the existing faculty who had attained their higher surgical training abroad endeavours to train aspiring young surgeons who could not travel and equipped them with the same level of training they had received abroad. This led to a renewed interest in developing subspecialties and the need to establish these subspecialties becomes imperative at that particular point in time.

Pakistan Orthopaedic Association has been instrumental in the indigenous development of orthopaedic subspecialties.

Initially, subspecialty forums were established, among which most of them have matured into subspecialty societies subsequently. The objectives of these societies are to promote orthopaedic subspecialties by conducting seminars, hands on workshops as well as arranging fellowships both nationally and internationally. Following are established independent societies working in close collaboration with POA:

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1. Pakistan Arthroplasty Society (PAS) 2. Pakistan Society for Surgery of Hand (PSSH) 3. Paediatric Orthopaedic Society of Pakistan (POSP) 4. Society of Spine Surgery Pakistan (SSSP) 5. ASAMI Pakistan 6. AO Trauma Pakistan 7. AO Spine Pakistan Moreover, the Journal of Pakistan Orthopaedic Association (JPOA), published quarterly, is the official journal of the society, established in 1967. The Journal is indexed in SCOPE MED, recognised by higher education commission of Pakistan as well as Pakistan Medical and Dental Council.

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POA also offers fellowships to its members as well as international applicants in the following specialties: 1. Fellowship in hip and knee arthroplasty 2. Fellowship in spine surgery 3. Fellowship in trauma 4. Fellowship in paediatric surgery 5. Fellowship in hand surgery 6. Fellowship in deformity correction and Ilizarov.

With the ever growing membership of POA (currently more 1,000 members), we represent a very large heterogeneous group unified on common grounds for the benefit of the society by promoting education and training. Our

commitment to improve quality of training for our members has enabled us to progress through the realms of time with continuous improvement. We also aim to advance the culture of education and research in all possible ways and to encourage highest standards of practice. We have established liaisons with international societies and are currently partnering or in the process of establishing bilateral ties with American Academy of Orthopaedic Surgeons (AAOS), British Orthopaedic Association (BOA), Asia Pacific Orthopaedic Association (APOA), Singapore Orthopaedic Association and Turkish Orthopaedic Association (TOTBID).

We envision Pakistan Orthopaedic Association as a truly global organisation that is mutually beneficial to its local and international partners. n Professor Syed Shahid Noor is the current President of Pakistan Orthopaedic Association. He is also President of Pakistan Arthroplasty Society, the Director of Pakistan National Joint Registry and the Founder Principal of Liaquat National Medical College.

BASK ANNUAL SPRING MEETING

26th – 27th March 2019

Hilton Brighton Metropole, Brighton

“CALL FOR PAPERS” Online submission opens: 24th September until 18th November 2018 REGISTRATION for both BASK Members & Non-Members will OPEN Online on 16th November BASK Members may register for FREE until 13th January 2019 (after this date a Member registration fee will apply) Further meeting information will be posted on the BASK website as it becomes available If you specialise in Knee Surgery and would like to become a member of BASK apply online Website: www.baskonline.com Email: admin@baskonline.com

Volume 06 / Issue 03 / September 2018

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JTO Medico-Legal Features

High Court Rejects Claims on Metal on Metal (MoM) Implants Michael A Foy The judgement on Gee and others v DePuy International Ltd was published on the 21st May 2018 by the Honourable Mrs Justice Andrews DBE and runs to 170 pages. The hearing ran from 16th October 2017 until 26th January 2018. Over 40 witnesses were called. In 2016, the Daily Telegraph published an article headlined, “I used to swim and run and then a metal hip crucified me.”

Michael A Foy

In the article one of the claimants in this case said that the MoM hip had “blighted” his life. It recorded that in another patient the MoM implant had caused “such a mess to flesh” in his hip and he later developed “pseudotumours and part of his hip socket had been eaten away.” It is interesting to note, in light of comments such as these, that in her judgment, Mrs Andrews referred to, “the panic about MoM hips that was engendered in consequence of the increasingly hysterical media reporting”, which typically contained no scientific research to support it, together with “alarmist contentions” which may have led patients to seek revision surgery and may have influenced surgeons’ willingness to revise.

She also described, “increasingly hysterical” reporting on BBCs Newsnight and the BMJ who described, “poorly regulated and potentially dangerous” hip devices and also suggested that the wear debris may be carcinogenic.

The claim involved a Group Litigation by 312 individual patients (claimants) in respect of 341 MoM hip replacements carried out using the Pinnacle/ Ultamet System manufactured

by DePuy (the Defendant).

There was no allegation of substandard practice brought against any of the orthopaedic surgeons involved in the management of these patients.

The Pinnacle system was introduced into the UK in 2002.

The acetabular liner could be cross-linked polyethylene, ceramic or metal. All the claims related to MoM (Ultamet) procedures. All of the claimants alleged that they had suffered an adverse reaction to metal wear debris (ARMD) generated by the MoM articulation leading to a requirement for revision arthroplasty. Six lead claims were selected, three by the claimants’ legal representatives and three by DePuys legal representatives.

The claims were brought under Part 1 of the Consumer Protection Act (1987). The primary allegation was that the Pinnacle/Ultamet MoM system was defective because it had a tendency to produce ARMD which caused them personal injury for which DePuy should provide compensation. Under the Act a product is “defective” when it fails to meet the standard of safety that the public is generally entitled to expect at the time that it was introduced to the market.

An additional argument was also introduced by the claimants’ legal representatives that the Pinnacle system had an “abnormal propensity” to produce ARMD. At the trial it was argued that: The Pinnacle MoMs tendency to cause ARMD was itself the defect under the 1987 Act despite the fact that ARMD is a recognised risk of such procedures and that particulate debris from polyethylene is recognised to cause osteolysis in metal on polyethylene articulations.

The failure rate of the Pinnacle MoM system was higher because of the above alleged defect.

Statistics from the National Joint Registry (NJR) were used in support of this allegation.

The court heard a wide range of expert evidence in disciplines ranging from orthopaedics, mechanical engineering, statistics and histopathology.

Five of the six lead claimants >>

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JTO Medico-Legal Features

gave evidence either directly or via video link. Four of the orthopaedic surgeons carrying out the revision procedures gave evidence. Initially there was expert engineering evidence criticising various design features of components within the Pinnacle/Ultamet system. Many of these criticisms were made on the basis of incorrect factual evidence and were withdrawn.

Those that were persisted with did not help or advance the claimants case. At the time that the Pinnacle/Ultamet system was introduced there were many other companies that had introduced MoM systems.

Legal proceedings had been commenced against most if not all of these companies. All these other actions were stayed pending the outcome of this case. Mrs Justice Andrews indicated that although her Judgement was not binding she hoped that her interpretation and reasoning would provide suitable guidance in deciding the way forward in the other claims.

Although the case was brought under the Consumer Protection Act, there was rigorous analysis through expert evidence and statistical analysis on the data contained in the NJR and its use in support of the claimants pleaded cases. The claimants’ representatives argued that the cumulative revision rate (CRR) for the Ultamet MoM liner was materially higher than for comparable implants. The evidence presented led the Court to take the view that when it was introduced in 2002 the CRR for the existing generation of hip implants was 10-14% at 10 years. The NICE guidelines from 2000 were said to suggest that better performing prostheses would have a revision rate of around 10% at 10 years. The Court decided that at the time of its introduction the public was entitled to expect that the Pinnacle/Ultamet MoM system (irrespective of which stem was used) would not have a greater risk of failure in the first 10 years after implantation than

the expected failure rate of the product that it was intended to improve upon, i.e. metal on polyethylene. As far as the need for an actual comparator was concerned, that is the implant they would have received had they not received Pinnacle/ Ultamet, the Court decided that this would be metal on polyethylene and not other bearing surfaces within the Pinnacle system.

After careful consideration of the NJR statistics, Mrs Justice Andrews drew the following conclusions: l The NJR did not record data

on levels of post-surgery activity which she believed was a major variable affecting implant survival

l The data relied upon had a

systemic bias in the reporting of body mass index which had the potential to be a confounding factor l The Pinnacle/Ultamet data

had a small number of outlying surgeons with a very high revision rate who had a significant effect on the overall statistics

l The NJR data on the Pinnacle/

Ultamet (and in general) was incomplete which affected the reliability of the statistics

l The NJR data combined results

from older polyethylene bearing surfaces with newer cross linked polyethylene liners

l A different type of MoM implant

(ASR) had been withdrawn in 2010 following which guidance was given by the Medicines and Healthcare products Regulatory Agency (MHRA) leading to enhanced surveillance of MoM hips compared to other bearing surfaces l A panic fuelled by

sensationalist media reporting had an impact on revision rates.

On the basis of her interpretation of the NJR statistical data, she decided that she could not safely rely on the CRR of 13.98% as being representative

of the performance of the Pinnacle/Ultamet system over 10 years. She believed that there were too many potentially confounding factors, arguing that the outlier effect alone would suggest that a CRR of 10/11% was more accurate.

The preliminary issues were tried with the six lead cases.

In two of these cases, DePuy admitted that the claimant had suffered ARMD while denying that this was because their implants were defective. In the other four cases, they disputed the diagnosis of ARMD. The Court took evidence from the claimants themselves and the revision surgeons to matters of fact and from experts in the fields of orthopaedics, radiology and histopathology. In each of the four disputed cases the Court found in DePuys’ favour.

Mrs Justice Andrews concluded that the claimants pleaded case was untenable because the “inherent propensity” of MoM hips to shed metal debris through normal use, to which some patients may suffer an adverse immunological reaction is not a defect in the product within the meaning of the CPA. She did not believe that it subsequently became a defect because of the recorded incidence of such adverse reactions or the calculated risk of revision caused by such reactions. On the alternative case she opined that the claimants had failed to prove that the Pinnacle/ Ultamet MoM prosthesis did not meet the level of safety that the public were entitled to expect at the time of its introduction to the market in 2002. On this basis she found that DePuy were not liable to the claimants.

The team at Crown Office Chambers who represented DePuy were obviously delighted at and supportive of the decision reporting that, “The Court’s discussion of the factors to be taken into account when deciding whether or not a product is defective under

the CPA is likely to become the definitive judgment in the field of Product Liability law.

Producers are likely to welcome the Court’s acknowledgment that factors such as risk-benefit and avoidability are relevant in deciding whether or not a product met the level of safety that the public generally is entitled to expect. The judge’s endorsement of “a flexible approach to the assessment of the appropriate level of safety” is expected to give producers greater scope for defending product liability actions.

Producers will also appreciate the court’s endorsement of DePuy’s submission that where a product includes a feature which gives it a potential functional advantage, or eliminates a perceived deficiency in design, but by doing so necessarily introduces a risk, the Court should not be prevented from considering the actual or potential benefit when assessing whether the product is defective.

The safety risk may be one that, objectively, the public would be expected to accept, bearing in mind the benefits that the product would confer.”

The claimants’ solicitors were not (as one might expect) so supportive of the Judgement with the Association of Personal Injury Lawyers (APIL) describing in its June 2018 issue of PI Focus how the four firms representing the claimants (Corries, Leigh Day, Hugh James and Irwin Mitchell) had issued a joint statement to express their concerns that “a product group that the orthopaedic profession has rejected for the serious harm that it can cause has been deemed safe by the Judgement.” It is not clear at the present time whether there will be any appeal against this Judgement. The claimants were particularly surprised that Mrs Justice Andrews found the NJR data unreliable as it is, “the largest and one of the most respected registries in the world.”

They were also concerned by comments in the Judgement relating to the National Institute for Clinical Excellence (NICE),

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accepting that whilst NICE guidelines were relevant, they did not determine what level of safety patients were entitled to expect.

The claimants solicitors felt that the judgment was a retrograde step for consumer protection, and therefore were not surprised that the manufacturers and their legal teams were happy with it.

Whilst this judgement is not directly applicable to our day to day clinical practice we do have a certain amount of input and responsibility in the decision making process for selection of the type of implants that we use in a great variety of operative procedures. Against the background of this case, it is interesting to reflect how the interpretation of the CPA by the MITA Recon advert.pdf Courts has metamorphosed

1

boa.ac.uk

over the last 20 years. In 2001, in the case of A v National Blood Authority a patient contracted Hepatitis C after blood transfusion following which the Court found in the claimants favour. In 2016, in the case of Wilkes v DePuy where there was a femoral stem fracture three years after a total hip replacement the Court found in favour of DePuy. While these cases are very different they were held as landmark judgements in medical product liability litigation in 2001 and 2016 until the case of Gee v DePuy. The Judges in the NBA and Wilkes cases used very different methods to analyse and define the meaning of “defect”.

Under the CPA there is a defect in a product if its safety is, “not 08/05/2018 17:20 such as persons are generally

entitled to expect” taking into account “all the circumstances”.

In the 2001 case, the claimant had described this as a requirement for a “legitimate expectation” of safety from a product. However, the judge in the 2016 case described this as “unnecessary and unhelpful”.

He went on to emphasise that safety is “inherently and necessarily” a relative concept and there cannot be a “sensible expectation that any medicine or medicinal product is entirely risk free.” In the Pinnacle/Ultamet case, Mrs Justice Andrews adopted the more flexible approach to the interpretation of the CPA (in similar fashion to the Wilkes case) concerning the definition of defect and what in the circumstances a patient is entitled to expect. It will be

interesting to see if the case goes to appeal and how the situation evolves in the future. n 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.

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

Heroes in Disguise: How the best trainers make the greatest differences and longest lasting impressions Vittoria Bucknall Co-authors: Lawrence Moulton, Fraser Harrold and Alastair W Murray The time in which we are training is considered one of the most enjoyable but equally challenging times in our career, made easier by the support and influence of a few exceptional trainers. If asked to reflect upon our training, most of us would picture with great ease and the utmost fondness, a principle trainer who stood out as truly making a personal difference during our training years.

We all know and recognise these training heroes either through the privilege of working with them or through their guidance as programme directors. In the midst of our day-to-day toils, we often forget to celebrate these trainers and learn from their triumphs. More often, we focus on enhancing training by highlighting only those aspects which we believe require improvement, rather than building upon and learning from those which outstanding trainers already practice.

Vittoria Bucknall

In the UK, the British Orthopaedic Trainees Association (BOTA) recognises these outstanding orthopaedic trainers through the presentation of the highly prestigious Trainer of the Year

and Training Programme Director (TPD) Awards. Each region puts forward their locally selected best trainer, and then following a blinded scoring process, the top three in each category are interviewed to select an overall UK winner. During the 2017 interviews, it became immediately clear why these trainers and TPDs had been nominated, recounting some of the best examples of exceptional training with the most brilliant uplifting quotes. This wealth of material offered by these trainers is invaluable and could not be kept locked away, but should be shared and celebrated with the wider orthopaedic community.

So, what does great training look and sound like?

Creating an Effective Training Environment “Every situation is a training situation.” – Fraser Harrold Regardless if it is day or night, no teaching opportunity is ever wasted. The best trainers distil from every clinical situation, a learning point for their trainees.

The clinical environment is a busy one but it is recognised that trainees need to be invested in and “it is important to set aside time for teaching” – Andrew MacDonald. The best trainers take reward in seeing their trainees succeed and will selflessly put their heart and soul into them, following the mantra that “Every generation should be better than the last.”– F Harrold.

Giving trainees the time and opportunity to explore and practice those aspects of training which they find challenging in a supportive environment encourages skill progression. Furthermore, to get the best from trainees, good trainers know that “setting a safe learning environment” is highly important, allowing trainees the room to learn and reflect on those cases which could have been improved – John

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JTO Features - Trainee Section

MORE OFTEN, WE FOCUS ON ENHANCING TRAINING BY HIGHLIGHTING ONLY THOSE ASPECTS WHICH WE BELIEVE REQUIRE IMPROVEMENT, RATHER THAN BUILDING UPON AND LEARNING FROM THOSE WHICH OUTSTANDING TRAINERS ALREADY PRACTICE.

McArthur. As surgeons, we strive to do the very best for our patients but it is important to also “teach our trainees to cope with the difficult fact that we do not always do a brilliant job” - A Macdonald.

Outstanding trainers invariably become the role models of tomorrow’s surgeons. However, it should be recognised that they also set an example to the wider surgical team. Good trainers and TPDs should “Encourage other trainers to be the very best that they can be” – Richard Spencer-Jones.

Knowing Your Trainee “Be interested in trainees as people.” – A MacDonald Taking the time to learn a little about a trainee as an individual helps to build a robust and productive working relationship. If a trainer knows their trainee, they will have better understanding where training needs lie and the potential barriers and solutions to learning. “A chat over coffee can be the most invaluable tool to knowing your trainees and their needs.” – Alastair W Murray. Some trainers make a special effort to meet with their trainee before a rotation even starts. “This is usually over dinner at my house both with my

current trainee to check how things are going, and with my future trainee to welcome them to the team” – F Harrold.

Trainees appreciate and engage with their trainers taking an active interest but some trainees are naturally more reserved and can therefore miss out on these opportunities.

“Knowing people personally is important… it is almost more important to make a special effort with the quieter trainees” – AW Murray.

Creating a Supportive Working Environment: “If a trainee loses faith in you or feels that you are not someone they can confide in, you are on a losing wicket.” – AW Murray During surgical training, trainees may occasionally need a little extra support. This could be for a number of reasons including personal problems, ill health or pressures in the working environment. It can sometimes be difficult to encourage trainees to speak about these challenges that can impact on training progression, as surgical trainees can see these challenges as weaknesses.

Excellent trainers tend to be those in whom trainees confide in during difficult times in their

career, offering pastoral care by presenting themselves as accessible, non-judgemental and as an equal. “Never present yourself as the Colonel as trainees will never be honest about their difficulties.”

– Simon Hodkinson.

The opportunity for trainees to discuss their problems rarely just happens, but instead it is created, often through open door policies and “regularly making contact with trainees to let them know you are there to support them” – J McArthur.

“Make an effort to touch base with those trainees who go quiet and begin to disengage. It is more often than not a red flag…

Be prepared to go through a series of meetings to get to the point that your trainee will disclose” – AW Murray.

Occasionally, problems can relate to interpersonal difficulties at work. During the 2017 interviews, a common theme, strongly presented by those nominated as the top trainers and TPDs, was an absolute ‘no tolerance policy’ to bullying and harassment behaviours in the workplace. The best trainers recognise that such cultures are detrimental to patient care and training overall. “Undermining a trainee in any situation isn’t any good for anyone.” – A MacDonald. These trainers felt a personal responsibility to ensure that a safe working

environment is maintained at all times. “Trainers need to do everything possible to ensure that trainees do not come to work worried or threatened” – R Spencer-Jones. If concerns relate to an individual trainer’s behaviour, actions should be taken to safeguard the trainee and their training needs.

“Trainees should simply be relieved of their duties for that trainer, and be provided with a better training opportunity” – S Hodkinson.

Top trainers who visibly stand against such behaviours lead by setting the example that these cultures are not tolerated. The best trainers however, recognise that fellow trainers can also need support from time to time.

These trainers in need of guidance are key to creating the best working and learning environment possible. “You have a responsibility to your trainers as well as your trainees. You are an advocate to your trainees first, and then support your trainers to see if you can get them back to being a good trainer again” – AW Murray.

Final Thoughts Excellent trainers are often the most humble of people in a team, rarely realising

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their widespread influence or how valued they are by their trainees and colleagues. We are privileged to capture in words some of their incredible attributes that make them unmistakably remarkable trainers.

There is something that each of us can take away from their insight and experience.

During our day-to-day work, it is important that we learn from the good examples of training around us as much as we learn from that which we feel is lacking.

We hope that this article has inspired you to be the best trainers that you can be.

Perhaps it has made you reflect on how would you like to be remembered by your trainees and what lasting impressions you would like to make. BOTA would like to wholeheartedly congratulate the trainers in this article as your guidance and influence mean that to your trainees, you are each heroes in disguise. n Vittoria Bucknall is the President of the British Orthopaedic Trainees Association (BOTA) and a specialist registrar in trauma and orthopaedic surgery in the South East of Scotland. Vittoria represents UK orthopaedic trainees at a national level at the BOA and the Intercollegiate Royal Colleges of Surgeons in addition to other key training boards.

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“I am no better than any of my trainees. I am just a colleague at a different stage in my career.”

Fraser Harrold, East of Scotland

Winner: Trainer of The Year 2017

“It is always better to build people up than knock them down.”

Andrew MacDonald, West of Scotland

Runner Up: Trainer of The Year 2017

“Take an interest in what your trainees are interested in.”

John McArthur, Warwick and Coventry

Runner Up: Trainer of The Year 2017

“Dipping performance is multifactorial which needs time and an open mind without judgement to address.”

Alastair Murray, South East Scotland

Winner: Training Programme Director Award 2017

“Being a TPD is a privilege not a chore.”

Simon Hodkinson, Wessex

Runner up: Training Programme Director Award 2017

“Trainees need to have trust in you.”

Richard SpencerJones, Oswestry

Runner up: Training Programme Director Award 2017

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JTO Subspecialty Section

The Introduction of an Electronic Inpatient Referral System (EIRS) Andrew Wilkinson, AurĂŠlie GC Hay-David and Paul Jenkins Inpatient referrals are usually received by junior clinicians on-call by telephone. These referrals often lack structure and can omit important information1,2. The junior doctors receiving these referrals are often not experienced in dealing with calls and important information might not be relayed efficiently2. Furthermore, it is difficult to audit the demand and efficacy of this process1.

Our orthopaedic department is a high-volume unit within a large metropolitan teaching hospital, which houses over 1,000 beds and covers an area of high socio-economic deprivation. We make extensive use of electronic patient record (EPR) systems.

This has led to the development of an electronic inpatient referral system (EIRS) that enables clinicians to refer patients internally within our hospital.

Functionality was developed to allow other teams to request inpatient review of patients with orthopaedic problems. These

internal referrals are completed by clinicians and associated healthcare professionals (AHPs) using a standardised template: situation, background, assessment and response (SBAR). The SBAR system was originally used in military and aviation, but has since been adapted for use in the medical profession3,4.

Improvements in technology are leading to paperless systems and for the purposes of quality control, it is imperative that our EIRS is regularly reviewed.

Our investigation of the pattern of referrals aimed to assess whether the system is being used appropriately and whether adjustments could be made for the future.

How we collected our data

Andrew Wilkinson

Paul Jenkins

We conducted a retrospective analysis of the electronic referrals made to the orthopaedic department, from February 2016 to January 2017.

Several aspects of the referrals were analysed including; site/ ward the patient was being referred from and the referring clinician. The SBAR was analysed to inform of the type of orthopaedic problem being referred and the anatomical area(s) affected.

The EIRS enabled the referrer to request specific interventions which included; inpatient review, outpatient review or telephone advice. They could select whether a routine or urgent review from the on-call team was required.

What our results indicated There were 766 patients referred using the EIRS and the majority were female at 56% (429/766).

Overall, 70% (536/766) of this patient cohort were over the age of 65. Our results indicated that 82% (627/766) of the referrals were routine, with the remaining requests being urgent.

Clinicians utilising the EIRS were mainly doctors, but a small proportion came from nurses and physiotherapists (Figure 1).

The EIRS is useful as it enabled us to map the demand for our services throughout the hospital.

Care of the Elderly and medical wards accounted for the majority of departments the patients were being referred from, at 85.3%. Surgical wards referred less patients to the on-call trauma team, however a higher proportion of these were urgent (Table 1).

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Most referrals were made by doctors and the majority were routine. There were fewer referrals made by nurses and they were all routine requests. Physiotherapists also utilised the system less than doctors and they only requested inpatient assessments and telephone advice (Table 2).

The SBAR template was an essential component of the EIRS because it enabled the referring clinician to provide information on the orthopaedic problem. Overall, 40% of our referrals were suspected fracture and 16% were suspected infection. Other reasons for EIRS requests included; interpretation of radiology and assessment of neurovascular status following trauma. The most common anatomical areas affected were the hip and pelvis and the upper limb, both accounting for 28.3% of referrals Figure 1: Visual representation of referrals by profession. respectively.

Table 1: Breakdown of the referrals.

Table 2: Interventions requested by different clinicians.

A small proportion of referrals contained inadequate amounts of information and did not detail reasons for wanting assessment by the orthopaedic on-call team. This could be related to the presenting complaint, the background history or the site of injury.

Significance of our findings The group of individuals most frequently referred were females aged over 65, who had sustained a hip, pelvic or upper limb injury. This is consistent with the literature that suggests the ageing population are at risk of developing musculoskeletal pathology. Hip fractures are the most common presenting complaint requiring hospitalisation in the elderly population over the age of 65 in developed countries, with women being at especially high risk5, 6.

The most frequently requested intervention in this group was for inpatient assessment. It was apparent that a higher percentage of telephone requests were routine, compared to inpatient and outpatient requests.

Our results suggest that doctors are more likely to request an inpatient assessment if they believe the referral to be more urgent. Reasons for this could be that telephone consultations may not provide enough reassurance to less experienced clinicians, who are not specialised in dealing with orthopaedic problems.

The use of the template for referrals allows a more standardised format that enabled us to collate the data we needed for this study.

However, as previous studies have documented, the use of a free-text referral system means that there are variable amounts of information the department receives7. This was observed when data was being collected for patients in this study, as some referrals did not accurately document the location of injury and did not provide adequate information for the receiver.

Implications for future practice The advantage of the electronic system is that it allows instant transmission, storage and retrieval of referrals in a structured form.

It means the junior on call is not deluged with “bleeps” and telephone referrals; electronic requests can be viewed in a more ordered fashion and triaged accordingly. The disadvantage is that the free-text SBAR system occasionally lacks information, which can make it difficult for the department to triage these referrals.

In these cases, the referring clinician was contacted to allow the referral to be correctly managed.

Feedback from staff outwith and within our department suggests that the EIRS has streamlined the referral process. There is potential to expand the EIRS in the future and share this method of referral to other specialties within our hospital and indeed other sites as well. Education must be provided to users of the referral system to improve the efficiency of this service and to continue to ensure safe handover. n Andrew Wilkinson is a fifth year medical student, studying at the University of Glasgow. He has a keen interest in pursuing Orthopaedic Surgery as a career in the future.

Paul Jenkins is a Consultant Orthopaedic surgeon at Glasgow Royal Infirmary. He has a subspecialty interest in upper limb surgery. He has been involved in the redesign of several clinical pathways, including the successful “Fracture Clinic Redesign” programme.

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

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JTO Subspecialty Section

Survey of Senior Frontline Clinicians on Information Technology Quality in Trauma and Orthopaedic Departments across the UK Sunny Deo The quality of Information and Communication Technology (ICT) is frequently cited as a key area of service improvement by senior executives and health ministers. Its increased use is seen as important in improving health care efficiency and care quality. The UK healthcare sector has struggled with large IT infrastructure projects over the past three decades, exemplified by the National Programme for Information Technology which resulted in an estimated £8-10 billion loss and abandonment of the main project 1-4.

The aims driving the adoption of computerised services are absolutely valid and are not in doubt. The problems lie with the tools which some frontline clinicians are provided with to achieve them.

Sunny Deo

It is difficult to gauge how bad one’s IT infrastructure is in a given Trust. Reassurance that the frequency of complaints has declined, may be due of improvements but may be because the lack of response from IT departments or Trust Executives mean that clinicians “put up and shut up”. A simple reflection of mundane ward tasks, suggests that out-dated IT programmes will increase rather than decrease the time taken to complete such tasks.

The advent and evolution of smartphones and tablet computers in the late 2000’s, has significantly increased the perception of slow IT. We now all have access to highpowered hand-held computers,

that switch on instantly, have easily navigable apps which run simultaneously without problem and are securely activated using a swipe, key code, fingerprint or iris scan. For many working in healthcare, such functionality is a pipe-dream.

Methods and participants In order to work out my key question: ‘How good (or bad) is your IT?’ I created a simple questionnaire with five questions, two with 5-grade Likert scale responses, one question aiming to relate the hospital IT to a contemporary smartphone or Mac which were rated as 100%, one Yes/No question relating whether there had been recent discussion with the IT department and why and a request for three issue suggestions about IT from the responding clinician.

The questionnaire is shown in Table 1.

Q1

How would you rate you IT infrastructure and speed? very poor: active contributor to clinical risk; poor; adequate; good; excellent: really enhances our care delivery

Q2

How would you rate your IT helpdesk? (as per Q1)

Q3

If your smartphone or mac were 100%, what % score would you give your IT

Q4

In the past year have you as a department raised concerns with your IT?

4a

If yes, please specify:

Q5

If you had 3 thoughts on your IT what would they be:

Table 1: Study Questionnaire: Survey of IT quality within T&O departments in the UK.

>>

Together, we will enhance patient care.

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Bring your team on board: www.rcseng.ac.uk/surgicalcareteam

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JTO Subspecialty Section

THE ADVENT AND EVOLUTION OF SMARTPHONES AND TABLET COMPUTERS IN THE LATE 2000â&#x20AC;&#x2122;S, HAS SIGNIFICANTLY INCREASED THE PERCEPTION OF SLOW IT. WE NOW ALL HAVE ACCESS TO HIGH-POWERED HAND-HELD COMPUTERS, THAT SWITCH ON INSTANTLY, HAVE EASILY NAVIGABLE APPS WHICH RUN SIMULTANEOUSLY WITHOUT PROBLEM.

This questionnaire was sent by secure email to the web forum of the British Orthopaedic Directors Society, who represent all Trauma and Orthopaedic Clinical Leads in the UK, a body of 125 senior orthopaedic clinicians, and responses collated.

orthopaedic hospitals, with the remaining 20 being from district hospitals of varying size.

Results

Based on the Likert ratings, 4/31 (13%) thought their IT was so poor it posed a direct clinical risk to their department, and overall 14/31 (45%) felt their IT to be poor or very poor.

A high proportion 8/31 (26%) placed the function of the IT at less than 20% of a smartphone or mac. The excellent groupings were smaller in both question responses at 2/31 and 1/31 respectively, but the top two quintiles representing good and excellent together were 9/31 (29%) and 10/31 (32%) respectively.

There were 31 responses, which form the basis of this study. The locations of the respondents are shown in Figure 1; the majority were from the southern half of England. There were responses from eight major trauma centres and two specialist elective

Questions 1 and 3 are most reflective of IT infrastructure and perceived quality, and the results are graphically represented in Figures 2 and 3.

Figure 2: Response to Question 1, rating of IT quality (Likert Scale).

The personnel running the IT helpdesks are almost universally praised, and their scores are much higher than the measures of IT infrastructure, as shown in Figure 4. They were rated as good or excellent by 74% (23/31)

Figure 1: Location of responding hospitals.

Figure 3: IT quality rated as a percentage of a smartphone device.

For Question 4, 79% (24/31) of clinical leads had raised concerns with their IT departments in the previous 12 months, but there were no narrative comments given after this.

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Volume 06 / Issue 03 / September 2018

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JTO Subspecialty Section

WE NOTED WIDE DISPARITIES IN QUALITY OF IT RANGING FROM 13% WHO FELT THE IT POSED AN ACTIVE CLINICAL RISK, AND 45% WHO RATED IT POOR OR VERY POOR, TO 29% WHO FELT IT WAS GOOD OR EXCELLENT; ONLY TWO TRUSTS (6%) RATED THEIR IT QUALITY AS EXCELLENT. Question 5 responses were divided into positive, neutral and negative based the content, some examples of which are shown in Table 2.

The chief study weakness is the relatively low proportion of all departments responding nationally, although the 31 responses does reflect about at least 50% of the active participants on the BODS web forum who regularly corresponded as of 2016. Further analysis shows no significant differences between hospital size, i.e. tertiary centre or district general hospitals.

Interestingly, only one hospital at the time was widely using iPads, and this was one of the two respondents who gave excellent scores and comments.

Conclusions 1. A short form survey has been created to assess quality of information technology within a hospital trust 2. We noted wide disparities in quality of IT ranging from 13% who felt the IT posed an active clinical risk, and 45% who rated it poor or very poor, to 29% who felt it was good or excellent; only two Trusts (6%) rated their IT quality as excellent 3. A qualitative question response when offered the opportunity to comment using free text, showed that only 8% of all comments were positive, 30% were neutral, and 62% were negative 4. This survey format could and should be used more widely and should be used to track current quality and improvements

Figure 5: Demonstrates the frequency of the various types of comment.

Figure 4: Rating of IT support.

Positives: l We’re making progress, now starting to enhance clinical care... also contributes

to the management of the Directorate

l The usefulness of IT systems, especially ECR, has transformed clinical care

in the last five years

l Our PACS provider, have created a very user friendly system

Neutral: l Get someone who actually uses it to be involved in design l Invest in good hardware, invest in good clinically led/vetted software, have IT

support that can mould biometric logins

l Previous good practice into modern systems

Negative: l Frustrated, angry as hell, I want to take a baseball bat to it l Systems don’t integrate, totally non clinician oriented, no upgrade or

maintaining contract

l Not repeatable in polite company l Out of touch with clinicians requirements

Table 2: Examples of responses given to Question 5, “If you had 3 thoughts on your IT what would they be?”.

5. This information should be disseminated to NHS Digital and Department of Health, with a robust discussion as to what “good” looks like and how we achieve this. n Sunny Deo is a Trauma and Orthopaedic Consultant at the Great Western Hospital Swindon.

He has been a consultant since 2001, qualified in 1989 and trained mainly in the Oxford region. He specialises in elective knee surgery and lower limb trauma. His specific research interests are related to diagnostic and clinical complexity, and clinical outcomes.

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

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JTO Subspecialty Section

The Future of Orthopaedic Surgery Axel Sylvan As the 21st century comes of age and the global burden of disease shifts increasingly towards musculoskeletal conditions, orthopaedic surgeons will be called upon to rise to the challenge.

Orthopaedic surgery is on a path towards less invasive and more precise operations, with a greater proportion of outpatient and overnight procedures1. This trajectory is likely to continue and will be further facilitated by new technologies, making surgery more selective and the orthopaedic surgeon an increasingly proactive specialist in the management of injuries and conditions.

As the saying goes: “Predictions are difficult, especially about the future.” It would be remiss

to presume too much about how orthopaedic surgery will look tomorrow, but there are a few key trends that are becoming apparent. This is occurring against a backdrop of increasing demand for orthopaedic services worldwide and the rising threat of antibiotic resistance2,3,4. Clinical expertise and experience will be needed to inform appropriate responses.

Technology is reshaping the world and, with it, orthopaedic surgery. Whilst many recent advances have occurred inside the operating theatre, much of what is set to change will take place outside of the hospital, beyond the clinic room, in the time before and after surgery.

Measuring quality: Tomorrow’s questions

Axel Sylvan

As new tools and techniques enter orthopaedic practice, accurate and comparable approaches to assess quality of care and outcomes will be paramount. The future success of orthopaedic surgery will be assessed using digitallyenhanced Patient-Reported Outcome Measures (PROMs).

By applying Item Response Theory and Computer Adaptive Testing

(CAT), which shapes remaining survey questions based on those already answered, patients can be asked more relevant questions whilst giving fewer responses.

CAT can make patients’ survey responses more efficient, of higher quality and more easily comparable. Cambridge University’s open-source adaptive testing platform Concerto (concertoplatform.com) and the Patient-Reported Outcomes Measurement Information System (PROMIS) (www.healthmeasures. net) are leading exponents of this approach, with the latter comprising the world’s largest item bank of CAT measures currently being translated, implemented and validated across the word.

PROMIS surveys measure generic, commonly relevant outcomes such as pain and physical function that can be used and correlated across and within different patient populations. Increasingly, orthopaedic patients have more than one condition and combining generic scores with disease or procedure-specific measures provides opportunities for more comprehensive assessments with relevance across different groups5. PROMIS CAT surveys can also avoid the ceiling effects seen with other musculoskeletal function scores6.

Beyond surveys: Smartphones and sensors As existing models of measuring pre-intervention function, treatment progress and outcomes are being refined, smartphones, wearables and sensors are adding new layers of objective, real-world data, informing a deeper and more nuanced understanding of musculoskeletal treatments and results. Specialised sensors able to provide continuous, real-time information will increasingly enhance decision-making before, during and after surgery.

Smartphones are rapidly becoming ubiquitous across the world and, with their in-built recording of steps and activity, offer a convenient and scalable means of measuring the physical activity of both individuals and large populations7. Automatically collected patient-specific data will reveal new insights into recovery patterns and enhance pre- and post-intervention planning.

Research using smartphone data in orthopaedics is in its infancy, yet its use has been demonstrated

Future of Orthopaedics.

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handled with respect. As costs fall and evidence builds, roboticassisted approaches will become increasingly common across the orthopaedic subspecialties.

Rather than replacing clinical skills, however, these new technologies will assist and enhance decision-making intraoperatively, as they will do too in the planning and recovery stages.

In time, computer-assistance is likely to also enable new techniques and procedures11.

The Tree of Andry digitised.

in predicting outcomes including Parkinson’s-related gait progression and recovery from shoulder injuries8,9. Improved tools to estimate recovery progress against activity-related baselines and procedure-specific points of reference may also aid conversations with patients about treatment goals and expectations.

Remote support and day-case surgery Improved capabilities for accurate remote monitoring and self-care will further enable day-case surgery. Retrospective activity data with clear baselines and tools to estimate outcomes will help to identify patients appropriate for outpatient procedures. Patients will be able to take more active roles in their treatment and improved capabilities for remote support can help to ensure that the potential savings of shorter hospital stays are not offset by increased follow-up appointments or readmissions10.

Machine Learning and Artificial Intelligence: Making sense of more information Arguably, the uptake of robotic surgery may not have been as rapid as expected, yet its transformative potential is clear. Robotic surgery and Artificial Intelligence, as with any powerful force, must be

Currently recognised as the best-in-class approach within AI, Machine Learning techniques combine computer science and mathematics to improve predictive accuracy and translate large datasets into useful insights12. Long before autonomously operating robots become credible competitors, AI systems will revolutionise orthopaedics by working in partnership with surgeons, applying their superior capacity of drawing conclusions from large datasets, to enable surgeons to do more, better.

Recent successful examples include algorithms helping to organise operation lists, prioritise workflow and predict in-hospital mortality, unplanned readmissions and prolonged length of stay13,14. Indeed, an appealing vision of the future is one where emerging technologies increasingly shoulder administrative duties, meaning healthcare becomes safer and more efficient, whilst surgeons are freed up to spend more time on clinical work.

New tools of the trade Biologic treatments comprise a wide field of techniques, including stem cell therapies and platelet-rich plasma injections, which aim to encourage regeneration and repair. Whilst the current evidence for these techniques is variable, biologic approaches hold great potential and will likely play a role in the future evolution of the orthopaedic surgeon as injected therapies become more common.15,16

3D imaging, navigation and printing will enable surgeons to be increasingly precise and personalised. Implants themselves will become increasingly ‘smart’ with personspecific design, dynamic materials and incorporated sensors providing further data and direct feedback on progress and performance. Smart implants will be able to highlight the need for further review and may even be self-protective by automatically responding to changes in the local environment17.

Virtual and augmented reality will enhance pre-operative planning, training and procedural precision, further supporting safer surgery18.

Telemedicine tools are enabling surgeons to share expertise in real-time during cases, adding a new dimension of collaboration to surgical practice, which may evolve further as surgeons become increasingly able to virtually ‘scrub in’ and join cases remotely19.

Coming together As orthopaedic practice is changing, so too is the fabric of the profession, increasingly matching the diversity of its patients. The current and widely acclaimed online campaign #ILookLikeASurgeon is challenging the white, male surgeon stereotype and helping to redefine ideas about who surgeons are20.

The ability to share ideas and experience is a core promise of a more interconnected and informed world. As highlighted by The Lancet Commission on Global Surgery, five billion people are currently unable to benefit from surgical care and, whilst many new technologies are vying for a place in the orthopaedic toolkit, perhaps the most significant achievements of tomorrow will lie in replicating current successes and increasing access to high quality surgery.21 To echo the author William Gibson: “The future is already here – it’s just not evenly distributed”22.

Communities of orthopaedic surgeons are forming to discuss and define the changing landscape. To find out more and join these conversations, see the links below to Stefano Bini’s Digital Orthopaedic Conference in San Francisco; the upcoming Digital Orthopaedics meeting at The Royal Society of Medicine and, for more general discourse on the impact of AI in medicine, AIMed Europe. n

Find out more: AIMed Europe Shoreditch Town Hall, 11-13th Sep 2018 aimed.events/aimed-europe Digital Orthopaedics: Measuring quality in orthopaedic healthcare The Royal Society of Medicine, Monday 17th Sep 2018 tinyurl.com/rsmortho Digital Orthopaedics Conference San Francisco InterContinental San Francisco, Jan 5-6th 2019 www.docsf.health Axel Sylvan trained in surgery before co-founding the London-based orthopaedic start-up myrecovery.ai with fellow surgical trainee and patient Tom Harte. Aiming to improve patient experience and clinical insight, www. myrecovery.ai enables surgeons to create tailor-made treatment companion Apps and, with a growing team of software engineers and PhDs, is developing the next generation of AI-enabled digital tools for musculoskeletal care.

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

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JTO Subspecialty Section

The Role of Simulation Catherine Kellett Simulation is recognised and accepted as an important part of education and training in all areas of medicine and in particular surgical specialties such as Trauma and Orthopaedics by the surgical Colleges, the Academy of the Medical Royal Colleges and Health Education England.

Simulation is an essential part of training and a requirement for patient safety. The public also perceives simulation as safer training (Akhtar et al 2015). We are now required to map simulation to the UK T&O postgraduate curriculum. This has been done in consultation with the Specialty Advisory Committee (SAC) and Specialist Societies. In the new curriculum, simulation is marked as essential for some skills and mapped to the suggested year of training.

It is appreciated that not all training programmes will have the same facilities and resources so the emphasis is on simple, low fidelity simulation, which has been shown to be very effective.

A typical example is practicing arthroscopy of a dry model which transfers to improved skills on a cadaveric specimen (Butler et al 2013).

Catherine Kellett

the cuts and cocktail sticks in place of screws to fix it. The idea is to create some form of deliberate practice, which might be mental rehearsal or talking through a procedure with the trainer. We should not forget the value of reading operative techniques (many of which are online) before any procedure and this should be considered the bare minimum for any trainee. Certain simulations can be used for all procedures and skills, such as reading the technique, cognitive simulation, eLearning and Apps.

So what types of simulation should we select?

Cognitive simulation is an effective evidence-based approach for shortening learning curves and enhancing the quality of surgical performance. It is a type of mental rehearsal, which has a structured and specific technique. It can be used to help learning and with simulation training in a skills laboratory, allowing transfer of a skill to an operating theatre.

Often simple low-tech simulations are very effective, such as practicing breaking bad news with a peer or practicing an osteotomy for hallux valgus using a banana, with a knife to make

Dry bone workshops are useful during early years training, whereas cadaveric surgery in a simulated theatre may be more helpful at consultant or senior trainee level. However, cadaveric

workshops to learn surgical approaches benefit early years trainees and any surgeon learning a specific new technique.

Although, the availability of cadaveric material and facilities may be limiting.

We should not forget to integrate human factors with technical skills simulation training (as recommended by RCSI) and we should take every opportunity to measure improvement in skills using assessment tools and keep this in our portfolios.

The Future Arthroscopy simulators are becoming popular (although expensive) with increasing research showing their validity as a simulation tool. These simulators are able to capture data on the speed and accuracy of movements, which can help to show progression of skill acquisition. This data may also provide data for simulation research and allow us to predict how much deliberate practice an individual surgeon requires to reach a certain skill level. Many arthroscopy simulators now come with training packages to take surgeons from basic through to advanced skills.

Simulators for open surgery are also available with research evidence to show their effectiveness.

New technology such as augmented reality (AR) and virtual reality (VR) is rapidly developing and becoming cheaper, with evidence that it improves skills (Aim 2015) and that these are transferable to the operating theatre (Howells et al 2008).

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Virtual reality simulation can be very simple and easy to maintain, such as a PC-based simulation using the keys to place screws across a fracture.

Other VR simulators have a haptic stylus, which simulates the drill for placement of a dynamic hip screw with simulated fluoroscopic images. The task can be practiced many times with no exposure to radiation and can be updated remotely and maintained easily with no consumable parts (Akhtar 2014).

The latest VR simulators emerging use VR goggles and allow the surgeon to use their hands to practice a procedure in full. This promises to be a highly versatile, portable and easy to assemble form of simulation.

Programmes can be developed

boa.ac.uk

to allow simulation of different sub specialty procedures.

Augmented reality uses the addition of artificial information, such as sound, vision or feel, to the real time image to assist with the task. It allows for a “see through” display rather than the “heads up” display we see on the stack in arthroscopy. For instance, using a VR head set, the anatomy can be projected onto the surgical field to help the surgeon orientate themselves during surgery.

In the future VR and AR may become more cost effective and easier to maintain than other types of simulation as no consumables are required and software updates can add procedures or variations to a

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procedure. However, the literature lags behind other types of simulation and so we must interpret this carefully.

In summary, there is a range of types of simulation available from very low cost, low tech to high cost and high tech.

New technologies such as VR and AR look promising and may prove to be more cost effective. Further research will be required on how to map new simulation technologies to the curriculum and indeed whether different learners require different technologies. n Catherine Kellett is a Consultant Orthopaedic Surgeon, currently Director of Medical Education and Policies at Tree Top Hospital in Maldives, and specialises

in primary and revision hip and knee arthroplasty. She trained in Oxford, Geneva and Toronto.

At postgraduate level, Catherine has been Lead for Simulation on both the BOA Training Standards Committee and the T&O SAC. She co-authored the 2014 Post Graduate Trauma and Orthopaedic Curriculum. She is also Honorary Senior Lecturer at St George’s University of London.

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

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JTO Subspecialty Section

Optimising Surgeons’ Education to Optimise Patients’ Outcomes Mark Herron OrthOracle is a comprehensive resource demonstrating orthopaedic operative technique. We are a collective of 30 UK based orthopaedic surgeons, working collaboratively through a co-owned digital publishing company to produce and continually update our educational platform.

We are currently, however, far from complete in our scope, having launched just over 12 months ago. We are well on course to illustrate 400 techniques by the end of this our second year and the 600 we have planned by the end of year three, completing our first edition.

their career-long learning of operative techniques.

Though there are many significant technological developments in the pipeline with the potential to transform surgical education such as augmented reality (AR) and

virtual reality (VR), the need for such a fit for purpose resource is immediate.

Digital publishing tools together with an innovative IT and design team have allowed the design and execution of our solution without the need for traditional publishers. Using social networks to promote our platform worldwide is our next transformational step.

This opportunity has come about because medical publishers themselves haven’t innovated in this sort of meaningful way and it does beg the question ‘why?’.

They of course all dwarf our small enterprise but to quote Mark Twain, “It’s not about the size of the dog in the fight, it’s about the size of the fight in the dog”.

In this article I provide some insights into how we have developed and published our product.

The Idea OrthOracle was a concept borne of the inadequacies of existing educational resources that demonstrate orthopaedic operative techniques.

Mark Herron

Our core objective therefore became simply to provide surgeons and trainees worldwide with the most comprehensive educational resource available to support

OrthoOracle website: www.orthoracle.com

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JTO Subspecialty Section

one basis based on personal recommendation. Speaking as the managing editor it has been a pleasure to get to know so many motivated consultants at every stage of the career path and to be working with them week in week out. No one has produced anything similar so it has been a learning experience for us all.

OrthoOracle website: www.orthoracle.com

Understanding the requirement Famously, if you ask a designer to produce a bridge he’ll come up with a way of crossing a river and that’s how we looked at designing OrthOracle.

Our objective was that all the steps that need to be understood to perform an operation safely and appropriately were detailed and that a reader should be able to access the information intuitively.

Apart from that, we didn’t have any preconceptions about how the front end would look.

Of equal importance though was to couple this with an editorial suite that made remote production of new surgical techniques in a standardised fashion as simple and fulfilling as possible for individual editors.

An operation is a series of discreet steps that need to be understood and recalled before a knife is wielded. In surgery, these steps are inherently visual.

If an operation has 100 phases, then that’s what should be defined and demonstrated and online is the ideal medium for such a resource.

One of the key areas we cover, which has been a glaring gap in

orthopaedic education for too long, is specific orthopaedic implants. What we demonstrate is how a named surgeon uses a named implant and their insights into the practicalities of its use.

We are overt that any companies own technical instruction should be relied upon as the primary source of information but the information we provide is complimentary and independent.

Whether we think about it or not, orthopaedics is really a very aesthetic activity with approaches designed to exploit anatomical planes allowing us to reveal then adjust the anatomy and leave ideally with minimal trace. Far more than our colleagues in other branches of surgery orthopaedics can be far more Caravaggio than carvery.

The way we shoot and process our images therefore has been thought through to reflect that reality accurately by a talented photographic team who ensure a consistent style and quality for all our images.

Team Without a dedicated and talented team of editors producing continuous content OrthOracle wouldn’t be here. Assembling the team has been on a one by

The publishing schedule is full on with new techniques published twice a month every month, which is our trajectory for the next two years. For an editor this means it takes not only an aptitude but application and commitment so it isn’t for everyone.

The fact that as a group we have shared core objectives which are meaningful and a venture that is genuinely unique has meant that motivation is not an issue.

It is also key that the task for editors is proportionate, of fixed duration and technology is used to labour save throughout the creative process.

Non-academic aspects Taking the platform through to a functioning and commercial small business has taken a great deal of additional assistance from many others, some paid for and some provided on goodwill because they thought our idea worthy of support.

We have had to get to grips with terms like a business plan, income stream, investors and many legal and intellectual property issues. As a company, we’ve outsourced as much non-clinical work as we could to independent experts which has been the quickest and most cost-effective route.

Funding Our growth has been funded by our own investment and that

of a few enlightened industry supporters, whose numbers are now finally growing.

We had the good fortune to be supported by the executive of the West Midlands Academic Health Acience Network in the form of their director Dr Chris Parker CBE and business manager Tony Davis with a loan and an early contract to supply our product to the West Midlands NHS region at a key moment.

As soon as we had a minimum viable product towards the end of 2017, we sought outside investment and sold some of the company which is funding our activities as income grows.

I know we’ve all learnt a lot already but this continues week in and week out. The big lessons have been to get published as soon as we had something usable, ignore rejection, speak to anyone who may be able to help, communicate well with everyone, continually adapt and finally, if an email is worth sending once it’s worth resending until the restraining order is served. n Mark Herron is a consultant orthopaedic surgeon in Birmingham and London specialising in foot and ankle.

He is Managing Editor of OrthOracle and his research interests are in enhanced surgical education and medical innovation.

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In Memoriam

Adrian Flatt

26th August 1921 – 14th October 2017 Adrian Flatt was one of the greatest of the first generation of hand surgeons. He was born in Frinton-on-the-sea, but brought up initially in India where his father was in charge of the railways. He returned to the UK and later studied medicine in Cambridge.

Adrian Flatt

After qualifying he was in the RAF for two years before returning for orthopaedic training in and around London. He visited the USA on a Fulbright scholarship and was both impressed and made a strong impression.

He was appointed to start an academic hand unit in Iowa City but not before he helped set up

the Second Hand Club which became the BSSH. He published over 200 papers.

He was appointed the first nonAmerican born President of the American Society for Surgery of the Hand (ASSH). He started the Journal of Hand Surgery (American) and was the second Editor from 1981-1990. He also set up the renowned ASSH self-assessment exam and in 1983 anonymously gave a donation to fund a trainee day before their main meeting which now bears his name.

He left Iowa in 1978 to head up the Orthopaedic department in Norwalk, Connecticut and

then in 1982 to become Chief of Orthopaedics in Baylor hospital, Dallas. He continued teaching long after he gave up operating.

He found that making plaster casts of congenitally abnormal hands helped understand the problem and record the deformity. He managed to persuade Presidents Truman and Eisenhower to have their hands cast. His collection of 120 casts, including seven US Presidents is in a museum in Baylor.

Adrian Flatt made an enormous contribution to hand surgery whilst remaining a most generous educator throughout his career. n

Richard Geoffrey Burwell 1st July 1928 – 7th January 2018 Richard Geoffrey Burwell – known affectionately as Geoffrey – was born on July 1, 1928 in Leeds, England, the son of Arthur Reginald and Mabel Walker Burwell.

He qualified in medicine at Leeds in 1952 and was awarded Doctor of Medicine at the University Leeds in 1955.

Richard Geoffrey Burwell

Whilst in Leeds, he wrote a seminal dissertation on the fate of bone grafts, which should be compulsory reading for any aspiring orthopaedic surgeon, to this very day: accessible as a series of Studies in the Transplantation of Bone published in the British JBJS from 1963 onwards.

His academic achievements made him a perfect candidate for Professor of Orthopaedic Surgery at London University, 1968-1972, based at the Royal National Orthopaedic Hospital. Sadly, his clinical colleagues expected from him both maximal academic activity and a full clinical commitment.

He was unable to deliver this and, as he had been appointed on a research and education ticket, he delegated much of his clinical load to his senior Lecturer and his Lecturer.

He then left the RNOH for the position of Senior Medical Research Fellow, University Nottingham, in 1972 and then

Professor in Human Morphology and Experimental Orthopaedics in 1974. He developed a close liaison with Center for Spinal Studies & Surgery, Nottingham, and became Director of the British Scoliosis Research Foundation, 1990-2001.

He published prolifically and received many prestigious honours.

He married Helen Mary Petty in 1963, but sadly she predeceased him. Geoffrey died peacefully on 7th January 2018, aged 89. He is survived by his two children, Matthew and Jane.

British orthopaedics has lost one of its scientific giants. n

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Volume 06 / Issue 03 / September 2018

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In Memoriam

William Alexander Souter 11th May 1933 – 1st June 2018 Willie will be remembered as an exceptional orthopaedic surgeon, but also for the ever-present twinkle in his eyes!

Trained in Edinburgh, he left school as Dux in 1951 and Edinburgh University in 1957 Honours MB ChB. He came under the spell of Douglas Saville an eminent Rheumatoid Surgeon in Edinburgh and became fascinated by the challenge of managing rheumatoid arthritis.

He travelled to Derby working with Guy Pulvertaft then to Seattle as Associate Professor.

William Alexander Souter

Appointed Consultant and Senior Lecturer in T&O at Princess Mgt Rose in 1968 concentrating on

Nigel Cobb In 1982, Nigel Cobb achieved fame. Barry Sheen, two-time World Champion motorcyclist, careened into another bike during a warm-up for the British Grand Prix at Silverstone. Most people watching the fireball thought that, were Sheen to survive at all, he’d

joined, e.g. BSSH, BESS, RASS, ERASS and FESSH. President of most and Honorary member of all, he was a council member of the BOA twice and the RCSEd once.

He developed an elbow replacement based on his clinical experience and, together with Strathclyde University, sound biomechanical and anatomical principles; as ever pursued in detail. First released in 1978, presenting the first results at the BOA in Aviemore in 1984, the Souter Strathclyde elbow was widely used and reported.

Willie was a generous, caring and humble family man with three children and six grandchildren of whom he was immensely proud. His family life was as organised (usually by Kath, his wife) and hectic as his work life; he designed and built gardens, he was a patron of the arts attending opera and ballet.

Internationally respected, it was the pleasure of being with Willie and Kathleen which made them special. n

Willie took formal roles in the many societies he started or

5th March 1929 – 20th June 2018

likely never walk again. Nigel Cobb in nearby Northampton General Hospital set about reassembling the motorcyclist’s limbs, a task that was followed in some detail by press and television. Nine weeks after an accident that had left the champion’s legs like “crushed eggs”, Sheen was back on his bike, a contender once more.

Born 1929, qualifying from Bristol in 1952 and after completing his house jobs, Nigel joined the Navy as ship’s surgeon on a vessel surveying the Red Sea. Immortality of sorts was attained when a subterranean sea mountain was discovered and, as per naval custom, named after the ship’s doctor.

Nigel Cobb

his arthritis practice from 1981.

He was an ABC fellow in 1972, formally retiring from the NHS in 1997, continuing in private practice till 2001 and as an Honorary NHS consultant till 2003.

Nigel relocated to Canada, where he requalified with a Canadian MD and worked near Toronto.

On his return to the UK, he focused on orthopaedic surgery, a path that took him to the Royal

National Orthopaedic Hospital as a Senior Registrar. In 1967, he was appointed consultant in Northampton. Here, in 1969, an anaesthetist, Eileen, joined the team, and after a short romance the two married.

An ingenious method of repairing the tibialis posterior tendon became Nigel’s “signature” operation. He became a regular and popular member of the faculty of the RNOH’s annual course in foot and ankle surgery, illustrating his talks with beautiful, hand-drawn slides.

Nigel remained in Whiston, Northampton after his retirement in 1993, where his many and eclectic interests included beekeeping, embroidery, trumpet playing, cooking and gardening.

He is survived by Eileen. n Read the full obituaries on the BOA website at: www.boa.ac.uk/ publications/jto-vol-6-issue-3.

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.

- Roeland Leonard Raymakers - John Kenneth Oyston - John Glover Gill - Colin Holloway Hooker

A full obituary is available at www.surgeons.org/memberservices/in-memoriam/ colin-hooker.

- Henry Vernon Crock

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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

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.

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.

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.

The programme is suitable for consultants and senior trainees.

The format is informal and sessions

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

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).

Joint Preservation – TOP ICRS Events l ICRS Focus Meeting

“Not Ready for Metal” Milan, Italy – December 13-14, 2018 Advancing Science & Education of the Prevention & Treatment of Cartilage Disease Worldwide

l 5th ICRS Summit “Bio-Orthopaedics in Sports Medicine” San Diego, USA – January 17-18, 2019

www.cartilage.org email: office@cartilage.org l 3rd ICRS World Series Brazil “Treating

Cartilage Defects in South America” São Paulo, Brazil – February 7-9, 2019 l 15th ICRS World Congress – ICRS 2019

Vancouver, Canada – Oct 5-8, 2019

The Charnley Low Friction Society founded in 1974 All Fellows and Registrars who have worked at Wrightington for six months or more are now able to become Members of the L.F.S. The Inaugural Meeting will be held in the Wrightington Conference Centre on Saturday 29th September 2018 from 10.00am to 1.00pm.

If you wish to join the L.F.S. please complete the Membership form from our website at www.wrightington.com or contact Liz Newton at Wrightington Hospital, Tel: 01257 256293 Email: wrightingtoncourses@gmail.com

Wrightington Hospital, Hall Lane, Appley Bridge, Wigan WN6 9EP

Volume 06 / Issue 03 / September 2018

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Imprint

JTO: Information for readers, advertisers & potential authors

BOA Staff Executive Office Chief Operating Officer ....... Justine Clarke Personal Assistant to the Executive ........................ Celia Jones Education Advisor ........ Lisa Hadfield-Law

Policy & Programmes

JTO Editorial Team l l l l l

Phil Turner (Executive Editor) Rhidian Morgan-Jones (Editor) Michael Foy (Medico-Legal Editor) Vittoria Bucknall (Trainee Section Editor) Phil Turner (Guest Editor)

BOA Executive l Ananda Nanu (President) l Ian Winson

(Immediate Past President) l Phil Turner

(Vice President) l Don McBride

(Vice President Elect) l John Skinner

(Honorary Treasurer) l Deborah Eastwood (Honorary Secretary)

BOA Elected Trustees l Ananda Nanu (President) l Ian Winson

(Immediate Past President) l Phil Turner

(Vice President) l Don McBride

(Vice President Elect) l John Skinner

(Honorary Treasurer) l Deborah Eastwood (Honorary Secretary) l Stephen Bendall l Karen Daly l Bob Handley l John Skinner l Mark Bowditch l Lee Breakwell l Simon Hodkinson l Richard Parkinson l Peter Giannoudis l Rhidian Morgan-Jones l Hamish Simpson l Duncan Tennent

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

Programme Director ............... Julia Trusler Committee and Project Support Manager .................. Obaayaa Asantewaa Policy and Programmes Assistant .......................... Michaela Regan Policy and Programmes Assistant ...................... Katherine Hawkins eLearning Officer .................. Silvia Bianco

Communications & Operations Director of Communications & Operations ........................ Emma Storey Interim Director of Communications & Marketing .................... Annette Heninger Membership & Governance Officer ........................ Natasha Wainwright Marketing & Communications Officer ...................................... Emily Farman Publications Officer ................ Anami Kabir

Finance Director of Finance ���������������������������Liz Fry Deputy Finance Manager ...... Megan Gray Finance Assistant ������������������Hayley Oliver

Events & Specialist Societies 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.

Word Limit

News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 words and must include an image. We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 250 words and should include a photo. Feature articles and Subspecialty articles should be no longer than 1,500 words. Please be aware that the Editorial Team reserves the right to reduce the content where appropriate.

References are not included in the word count but will be included separately on the BOA website in the JTO section and will not be included in the print version of the journal. References should be supplied in the Oxford Referencing format.

Images

All articles should include images, illustrations, graphs, tables etc. where possible – this is strongly encouraged. These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title. An indication within the article should identify where the image should be inserted.

The article should state a short title/ caption for each image.

Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.

Important items to note

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.

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

Download the App Search for JTO@BOA to download the JTO App on App Store or Google Play.

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

Advertising All advertisements are subject to approval by the BOA Executive Board.

If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820

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: John Angel, Zine Beech, Deepa Bose, Gautam Chakrabarty, David Clark, Chris Colton, Tom Cosker, Kamal Deep, Grey Giddins, Colin Howie, David Limb, David Shewring, Ian Stephen and Wei Tian.

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