Journal of Trauma & Orthopaedics – Vol 6 / Iss 4

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 06 / Issue 04 / December 2018 boa.ac.uk

E Muirhead Little 1918-1919

A S B Bankart 1932-1933

Sir Harry Platt 1934-1935

1954-1955

Philip Wiles 1956-1957

Norman Capener 1958-1959

Sir Robert Jones Sir Thomas Fairbank E W Hey Groves 1926-1927 1928-1929 1920-1925

R C Elmslie 1930-1931

1952-1953

Naughton Dunn 1938-1939

T P McMurrary 1940-1941

G R Girdlestone 1942-1943

St J D Buxton

1960-1961

1962-1963

1964-1965

1966-1967

Roland Barnes 1968-1969

W J W Sharrard 1979

D L Evans 1980

A Ratliff 1981

G Mitchell 1982-1983

R Duthie 1984

Sir Rodney Sweetnam 1985

D L Hamblen 1991

G Bentley 1992

M A R Freeman 1993

A W F Lettin 1994

C L Colton 1995

A Catterall 1996

T Duckworth 1997

M F Macnicol 2002

P J Gregg 2003

D H A Jones 2004

M K d’A Benson 2005

I J Leslie 2006

C J M Getty 2007

S R Cannon 2008

C L Marx 2009

T W R Briggs 2014

C R Howie 2015

T J Wilton 2016

I G Winson 2017

A Nanu 2018

G Perkins 1946-1947

S A S Malkin 1948-1949

S L Higgs 1950-1951

J S Batchelor 1970-1971

A L Eyre-Brook 1972-1973

T J Fairbank 1974-1975

P H Newman 1976

J I P James 1977

G C Lloyd-Roberts 1978

D K Evans 1986

R Ling 1987

B McKibbin 1988

John Goodfellow 1989

J Chalmers 1990

P J Mulligan 1998

D J Dandy 1999

H Phillips 2000

C S B Galasko 2001

M J Bell 2010

P R Kay 2011

J Dias 2012

M Porter 2013

Inside

W Rowley Bristow 1936-1937

Sir Reginald Watson-Jones Bryan McFarland

Sir Herbert Seddon Sir Frank Holdsworth Sir Henry Osmond-Clarke H Jackson Burrows

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 the Effects of ‘Winter Pressures’ on T&O Training, Use of Interpreters in Orthopaedics; our regular features and some festive fun for you and your family

Read the latest update on our clinical issues, the focus of this issue is research methodology

News & Updates ––– Pages 02-22

Features ––– Pages 24-51

Subspecialty Section ––– Pages 52-61

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From the Executive Editor

Contents

Bob Handley Having been honoured with task of Executive Editor, I sought a guiding principle. The positive route of aiming for a commendable objective “Caring for patients, supporting surgeons” was already in use. An alternative was to choose something to avoid; the surgeon’s stereotype of “Often wrong but never in doubt” seemed appropriate.

Our Medico-Legal Feature article – ‘Evolution of the objectivesubjective test for material risk in consent’ by Simon Britten explores an area of importance to us all, both in our clinical duties and medico-legal work.

Our duties and responsibilities have evolved as consequence of legal judgements relating to consent, which have presented some answers but also some problems. I would also like to thank Mike Foy, for whom this is the last appearance as MedicLegal Editor of the JTO. Having stated the objective of dispelling a negative stereotype it may seem strange to include ‘Life Outside of the Ring’ by Tom Carter describing his parallel interests Trauma and Orthopaedic surgery and Boxing.

However, the article does just that, exploring the positive side of a medically maligned sport.

The article is a theme we aim to pursue, and we would welcome further submissions on interests away from the operating theatre.

News and Updates

02–22

Custom, opinion and preference are clearly factors important in guiding our practice, particularly as we approach an individual patient. These may be challenged by research, standardisation and cost. The Subspecialty section provocatively pursues these points in looking at how we respond to data, research and health economics, particularly when our prejudices are challenged.

Features

The Effects of ‘Winter Pressures’ on Trauma and Orthopaedic Training

24–51

There are some external pressures we cannot avoid, and as this issue comes out, Winter will no doubt be manifesting itself not just as a picture postcard backdrop but as coverall term for lack of resource in health provision. The “pressures” do not only affect patient care but training too; the BOTA collaborative describe both the nature of this problem and goes further to suggest ways of mitigating the adverse effects.

As the 100th year of the BOA draws to a close, we can reflect on past glories by gazing at the sepia-toned faces on the front cover of a lineage to be proud of. The alternative is write submissions and suggestions for future editions. As the new Executive Editor I would encourage you to do both.

24

An Update on the British Orthopaedic Surgery Research Centre (BOSRC)

26

Using NJR Data for Reflection

28

The Fate of Abstracts Presented at the Welsh Orthopaedic Registrars Day Orthopaedic Meetings

30

How I do... management of a young person with anterior knee pain and a normal MRI

32

JTO Festive Fun

34

Use of Interpreters in Orthopaedics

36

We are O&T: the German Society for Orthopaedics and Trauma

40

Life Outside of the Ring – Combining a Career in Orthopaedics with Amateur Boxing

42

Evolution of the objective-subjective test for material risk in consent

44

It’s Showtime! #ActItOut Lights, Camera, Action!

48

Subspecialty Features

Big data – what it does, and what it doesn’t...

52–61

52

Orthopaedic surgeons must be ignorant, biased or immoral if research doesn’t change their practice

54

The Price to Pay...

60

In Memoriam

62

General information and instructions for authors

64

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JTO News and Updates

From the President Phil Turner The BOA Congress in Birmingham was the best attended in the history of the Association. The event undoubtedly benefited from our overseas input, particularly those who came to represent the guest nation of India and the Carousel presidents.

The separation of trauma and orthopaedic surgery from the generality of surgery was born out of conflict but progress now relies on international collaboration. Those who read the articles on the history of the BOA will recognise how quickly we established close relationships with similar associations in America and across Europe.

Since Congress, I have been to Australia, New Zealand and Germany to attend their annual scientific meetings.

It is easy to be sceptical of the benefits that come from these exchanges, much time is lost from clinical practice and the jet-lag doesn’t get any easier to cope with as you age. However, there are untold benefits that arise from the interchange of ideas, cultures, systems and practices.

Phil Turner

The pressures on elective orthopaedics are present in varying degree in the countries

I have visited, but nowhere do they seem as severe as those we are under in the UK. New Zealand continues with a system of surgeon “self-regulation� where they themselves decide on prioritisation of need utilising written information from the GP. Restrictions were present but less evident in Australia and there was no overt impact on German practice. Morale amongst all surgeons still seemed remarkably high in spite of their problems.

One common theme in all the meetings was the combination of an ageing population with high expectations of surgical treatment. Efforts to improve outcomes varied from selection and optimisation to the use of some very high-tech surgical procedures requiring X-ray, CT and MR scanning for planning before arthroplasty. It is interesting to ponder the likely cost effectiveness of these very different approaches.

Another common theme is concern over surgeon health and wellbeing, for trainees and consultants at all stages of their careers. Surveys on bullying and undermining in the workplace and the impact on day-to-day life demonstrated a similar prevalence. They also demonstrated a clear negative effect on choosing a career in orthopaedics with persisting but hopefully false perceptions amongst students and juniors that success went with being male and good at sport. There is still a clear need to change the culture in all medical specialties but we also seem to have a particular problem in ours arising from the difficulty in admitting to ourselves and others that we may be struggling and need help when the pressure gets too much.

Perhaps this is not unrelated to those perceptions of toughness and resilience.

To finish on a more positive note, the presentations from the trainees were uniformly professional and delivered with confidence and enthusiasm.

The vast majority of projects were well planned and designed to have an impact on scientific or clinical practice.

Whilst we are all under pressure, the trainees still inspire me to think that trauma and orthopaedics will continue to develop as a vibrant and exciting specialty. n

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JTO News and Updates

The New BOA Trustees (2019-2021) Grey Giddins

Rob Gregory and closed fusions. I run a specialist practice in obstetric brachial plexus injuries, wrist and DRUJ pathology, and rheumatoid arthritis. I have an interest in surgical error and its avoidance.

Grey Giddins

I trained in Oxford and at the RNOH. I have since worked as an orthopaedic and hand surgeon in Bath since 1995.

I am privileged to work in a very supportive team of three hand surgeons and four hand therapists with a wide range of practice, including a full range of elbow, wrist and hand trauma and elective conditions.

I have particular interests in the management of common hand injuries, the mechanism and outcome of falls on the wrist, and minimal access surgery for many common elective hand conditions such as finger ganglia, corrective osteotomies

I am a visiting professor in the Mechanical Engineering department at the University of Bath, where I run a research programme looking at tendon injuries, mechanisms of falling and joint replacement failures. I have recently been awarded an NIHR grant to develop a novel drill guide system. I have developed a novel jig to measure DRUJ instability and am developing jigs to measure instability in other joints.

I was honoured to be President of the British Society for Surgery of the Hand (BSSH) in 2017 and Editor-in-Chief of the Journal of Hand Surgery (European) from 2012-2016.

I am married with two daughters in their 20’s, a son who has just left school and a cat and dog. When not at work I enjoy playing tennis, golf, skiing and swimming. I cycle most places to work, not least as parking is increasingly difficult.

I hope to be able to contribute further to the already strong programmes of the BOA. n

particularly honoured to be awarded Trainer of the Year two years ago.

I have held senior departmental management roles for over ten years and as a result am familiar with the constant conflict between service and training, but am always aware of our duty to ensure that investment in the future of our profession is given the highest priority.

Rob Gregory

Having graduated from Newcastle University in 1981, I remained in the North of England to train in orthopaedics and after spending a highly rewarding fellowship year in Adelaide, returned to take up my current post in Durham where I have remained for the last 25 years.

My clinical interest relates to surgery of the knee but I have always had a strong interest in orthopaedic training. I am currently a member of both the SAC and Selection Design Group, hold QA Lead roles in my School of Surgery and SAC. I’m an examiner at both MRCS and FRCS (Orth) level and was

I am a firm advocate of performance improvement being driven by the publication of accurate, relevant outcomes data and believe that we can only achieve the highest standards of both training and clinical care if we are prepared to accept that we have areas of weakness. Alongside this, we have to be proud of our considerable achievements and defend these strongly in the prevailing political climate.

I am fortunate to have what I believe is the best job in the world and am also fortunate to have been supported throughout my career by a wonderful wife, Nicola, and three wonderful children. I am looking forward to the next three years, I appreciate the professional support that I have been given and hope that I can help ensure that our profession remains the very best for the next generation. n

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Fergal Patrick Monsell

Arthur Stephen

My clinical practice is broad based with a special interest in the management of patients with limb deformity. I have experience in surgical and prosthetic management of this patient group and lead a multi-disciplinary team. I’m involved in all aspects of paediatric trauma and the treatment of children with cerebral palsy using a spectrum of contemporary techniques.

Executive Medical Director of the Royal Derby Hospital before becoming the Divisional Medical Director for Surgery of the newly formed Trust. I am also a member of the BOA Professional Practice Committee.

I have an active research portfolio and have published on surgical innovation, outcomes in limb reconstruction and paediatric orthopaedic surgery. I’m involved in the provision of global healthcare and run an international visiting surgeons programme.

Fergal Patrick Monsell

I was born in Dublin and emigrated shortly before England won the World Cup. After attending Sir Joseph Williamson’s Mathematical School, Rochester I graduated without distinction from the Welsh National School of Medicine. I completed higher surgical training at the University of Manchester and fellowship training at the Royal Alexandra Hospital for Children, Sydney. I was appointed to the Consultant staff at the Hospital for Sick Children, Great Ormond Street and the Royal National Orthopaedic Hospital, Stanmore in 1997 and have been a Consultant at the Royal Hospital for Children, Bristol since 2005.

I was awarded degrees at Masters and Doctorate level, and am visiting Professor at Cardiff University and King James IV Professor for 2018.

Arthur Stephen

I’m General Editor for AO Surgery Reference (Paediatric Trauma), a Member of the Board of the Society for Children’s Orthopaedic Surgery, the Education Committee of the BOA, Council of Management of Bone and Joint Journal and Specialty Editor for paediatrics. I’m also Past President of the British Limb Reconstruction Society (BLRS) and was an ABC Travelling Fellow in 2000.

I trained at the University College and Middlesex Hospital School of Medicine, London graduating in 1993. My higher surgical training was in the Mid Trent region and Brisbane, Australia before taking up my consultancy at the Royal Derby Hospital in 2004. This has recently merged becoming the University Hospitals of Derby and Burton, housing over 50 surgical theatre suites and has become one of the largest orthopaedic units in the country, second only to dedicated elective orthopaedic units.

I’m married to Ros, whom I met at school, have three grown-up children and to my credit am a lifelong Spurs supporter. n

Clinically, I specialise primarily in hip and knee arthroplasty. My interest in clinical management covered a spell as the interim

During this time of change within the health service, particularly in the way services are commissioned and delivered, I am eager to see actively practicing clinicians at the forefront of the key decision making bodies. Whilst everyone appreciates financial concerns are unavoidable, I am keen to keep a patient-centred focus within these difficult discussions. As orthopaedics accounts for a huge part of the NHS budget, it frequently has the ‘spotlight of financial austerity’ firmly trained upon it. It is part of the BOA’s responsibility to inform and sometimes reform how these budgets are spent to the maximum benefit of patients whilst maintaining a quality agenda.

A keen educator, I have taught extensively on many courses (national and international) including hip arthroplasty courses, FRCS(Orth) for SpR courses, chairing AO fracture courses and was the co-founder of the AO periprosthetic fracture course.

I am married, with two teenage children, and outside of work, I enjoy road cycling and training my gun dog. n

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JTO News and Updates

BOA Congress Reviews Nima Razii, Specialty Trainee The BOA Congress in its Centenary year, was held at the International Convention Centre in Birmingham, with over 2,000 delegates in attendance.

Mark Ormrod delivering the Howard Steel Lecture on ‘You Can’t Spell Disability Without Ability’.

The theme of this celebratory year was ‘Taking Stock: Planning for the Future’, and indeed it was a chance for us to reflect on the development of orthopaedics over the last century. An archive of documents, photographs, and materials was displayed at the Congress, and was complemented by the ‘100 years of the BOA’ session on the opening day. It was fascinating to hear how the specialty originated in a family of bone-setters from Anglesey, whose descendants included Hugh Owen Thomas and Robert Jones.

The archive itself presented the original ‘document’ signed by the founding members of the BOA, a menu card from the Café Royal in London, where a meeting was held on 28th November 1917 to discuss the establishment of the association.

Another highlight from the opening day was the Howard Steel Lecture, delivered by Mark Ormrod. A former Royal Marine who became a triple amputee whilst on duty in Afghanistan in 2007, he went on to win two silver medals at the inaugural Invictus Games just two years later. His inspiring message from such a remarkable achievement was to ‘embrace your situation and push the boundaries’.

Dr Mathew Varghese delivered the Presidential Guest Lecture on the second day of the Congress. He has treated thousands of patients with deformities from poliomyelitis over three decades, whilst also developing the largest clubfoot treatment programme in India, training other surgeons across the country in the Ponseti technique. He reminded us that the importance of recognising the needs of any society is a ‘journey from knowledge to understanding’.

The BOTA ‘Act It Out’ session was both entertaining and thoughtprovoking, with several role-play scenarios that were based on real experiences.

Dr Mathew Varghese delivering the Presidential Guest Lecture on ‘Orthopaedics in an Equal World’.

As always, the Congress was a great opportunity to meet with both colleagues and industry, and the educational content was very impressive. Many thanks to everyone who has worked so hard in making the Centenary a success and we look forward to Liverpool next year. n

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Sandeep Kohli, Associate Specialist It was September 2018 and the time of the year for the British Annual Orthopaedic Congress again. I now really look forward to this time of the year. I have three full days to myself with all my old colleagues and friends as company for the evenings and at times late into the night! It is becoming a bit difficult not to feel under the weather after a late night and some drinks (with advancing age I guess!).

educational benefit at the same time. I thoroughly enjoyed the session ‘Tips and Tricks in Nailing’. Intra-medullary Nailing can always be relied upon to surprise you and humble the surgeon’s ego! This session provided great tips for Nailing of long bones and with a fantastic humour to go with it.

My favourite time is really the social side of the meeting.

Meeting my friends and colleagues whom I have not seen for a number of years and the friendships come back to life.

Another favourite is the evening reception on Tuesday, which provides great opportunity to catch up with colleagues.

I greatly enjoyed the SAS session.

Professor Briggs gave a great insight into the role of cementing Hip Replacement by providing the evidence from the National Joint Registries around the world. Ananda Nanu and Martyn Porter shared their thoughts and provided great advice on a number of fronts. Mamdouh Morgan provided a sound structure for the career progress model for SAS Surgeons.

The best part of the Congress is that it provides a great

The experience was great and I look forward to September 2019. n

Sandeep Kohli (second from left) with friends (from left) Mufe Al-Shoaibi, Manju Koti and Mohamad Alam.

Sanjay Anand, Consultant Knee Surgeon, Manchester Birmingham was the host city for the 2018 BOA Congress, an apt choice given the theme of ‘Taking Stock: Planning the Future’.

The city is undergoing massive redevelopment, particularly around the ICC, in preparation for the Commonwealth Games in 2022 and beyond.

Phil Turner, BOA President delivering his acceptance speech.

Multiple parallel sessions covered every aspect of specialty revalidation, along with excellent plenary speakers in the formal lecture sessions. As a knee surgeon, I enjoyed the BASK revalidation sessions that covered hot topics centred around arthroscopic meniscectomy and knee replacement.

Andrew Price provided a wellbalanced overview of the literature surrounding arthroscopic meniscectomy, including some of the difficulties faced getting this work published.

Roman Seil provided a current ESSKA overview of the controversies

facing knee surgeons in the management of paediatric ACL injuries, a controversial topic in the UK. A special mention must be given to Lisa Hadfield-Law, whose ‘TOCS and TOES’ session on the Friday was fantastic. I learnt a great deal on how to help train and get the best out of our trainees. I would highly recommend these courses to any trainer/trainee if they have not yet been.

Finally, it was an honour to see my mentor, colleague and good friend Phil Turner formally accept his Presidential handover. Phil has worked tirelessly over the years as a surgeon and trainer, as an educator in steering development of training curriculum, as well as roles in the SAC, JCST and BOA. He will no doubt steer the ship on to ‘New Horizons’ for the BOA Congress at Liverpool next year. n

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BOA Timeline: The first 100 years 1887

American Orthopaedic Association (AOA) founded

1940

Harry Platt becomes a Council Member of the RCSEng

1894

British Orthopaedic Society formed: final meeting four years later

1942

Publication of BOA Memorandum on Fracture and Accident Services

1913

Orthopaedic Section at the International Congress of Medicine in London, with Robert Jones as President

1942/43

1913

Orthopaedic Sub-Section formed at the Royal Society of Medicine, with E Muirhead Little as President

1914 - 1918

First World War stimulates growth of orthopaedic surgery as a discrete discipline

1917

Robert Jones knighted for services to military orthopaedics

1917

28 November: 15 surgeons attend a dinner at the Café Royal, London, and approve a proposal to form a British Orthopaedic Association

1918

1 February: Temporary Executive Committee formed, and approve a formal proposal to form the British Orthopaedic Association

First concerns over chiropodist activities, and definition of chiropody

1943

400 Members of the BOA

1944

Rent for BOA offices at 45 Lincoln’s Inn Fields raised to £100 p.a.

1944

Foundation of the Institute of Orthopaedics

1945

Reginald Watson-Jones knighted for his contribution to the RAF orthopaedic service

1945

Formation of Surgical Appliances Subcommittee

1947

Membership fees set at 7 guineas for Fellows, 5 guineas for Members

1948

First publication of Journal of Bone and Joint Surgery (British Volume), under editorship of Sir Reginald Watson-Jones

2 February: First BOA meeting, Roehampton, with E Muirhead Little as Chairman, Robert Jones as vice-Chairman, and Harry Platt as Secretary

1948

Category of Associate Members introduced for surgeons in training

1948

Second joint meeting of AOA, BOA and COA in Quebec

1918

20 members of the BOA

1948

1918

Journal of Orthopaedic Surgery becomes official organ of BOA and AOA

First ABC Fellows visit the USA and Canada, followed by first US and Canadian Fellows return visit to the UK

1919

Proposal for a National Orthopaedic Scheme for the Cure of Crippled Children published in the BMJ by Robert Jones and G R Girdlestone

1948

Introduction of National Health Service

1949

Royal Cripples’ Hospital, Birmingham becomes Royal Orthopaedic Hospital

1919

Orthopaedic Club founded: last meeting 1925

1949

Chairman and Editor of JBJS(B) appointed to BOA Executive Committee

1921

Opening of Shropshire Orthopaedic Hospital, Oswestry

1952

Orthopaedic Unit opened at the Royal Sea Bathing Hospital in Margate

1923

First BOA overseas meeting in Leiden

1952

1924

Introduction of fees for exhibiting companies at annual meetings; £20 for larger companies, £10 for smaller

Robert Jones Gold Medal and Association Prize inaugurated, with award to George Perkins

1924

First MChOrth awarded in Liverpool

1924

BOA Meeting in Bologna

Third combined meeting of the Orthopaedic Associations of the EnglishSpeaking World held in London, including for the first time the Associations of Australia, New Zealand and South Africa: Presidents of the Associations presented with Jewels of Office

1924

100 Members of the BOA

1952

BOA Constitution limits no. of Fellows to 150, elected from the Membership

1927

Biddulph Grange Orthopaedic Hospital opened as the first orthopaedic hospital for children provided by a public authority

1953

BOA is granted a Royal Coat of Arms

1927

Princess Elizabeth Orthopaedic Hospital opened in Exeter

1953

Henry Osmond-Clarke grows his beard

1928

BOA visit to the Hôpital des Enfants-Malades in Paris

1953

Formation of British Editorial Society to manage JBJS(B) affairs

1928

Robert Jones Dining Club founded

1954

Harry Platt becomes President of the RCSEng

1928

200 Members of the BOA

1955

The Wingfield-Morris Orthopaedic Hospital, Oxford becomes the Nuffield Orthopaedic Centre

1929

First joint meeting with American Orthopaedic Association, in London and Liverpool

1956

BOA offices move to the third floor of the Royal College of Surgeons

1929

Harlow Wood Orthopaedic Hospital opened

1958

Wrightington Hip Centre established by John Charnley

1930

1959

Publication of BOA Memorandum on Accident Services

Foundation of Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)

1959

Establishment of BOA Subcommittee on Specialist Orthopaedic Hospitals

1930

Rowley Bristow produces first BOA seal

1959

Publication of Platt Report on ‘Arrangements for the Welfare of Ill Children in Hospital’

1959

Her Majesty Queen Elizabeth the Queen Mother becomes BOA Royal Patron

1959

Roland Barnes appointed first professor of orthopaedics in Glasgow

1960

Abstracts first published in the annual meeting programme

1960

Introduction of the Professions Supplementary to Medicine Act

1962

The BOA is recognised as a registered charity by the Inland Revenue

1963

Foundation of the Naughton Dunn Orthopaedic Club Honorary Secretary becomes a four-year tenure, with one year as Assistant Secretary followed by two years in post and a further year as Deputy Secretary

1918

1952

1930

Winford Orthopaedic Hospital, Bristol opened

1933

Mount Gold Orthopaedic Hospital, Plymouth opened

1934

Orthopaedic Department opened at Manchester Royal Infirmary

1937

First Gold Cup competition [Post-war, became Robert Jones Golf Cup]

1937

G R Girdlestone appointed first Professor in Orthopaedics in the UK, at Oxford

1938

H A T Fairbank delivers the first Robert Jones Lecture

1938

BOA Benevolent Fund established

1963

1939

H A T Fairbank appointed Orthopaedic Adviser to the Ministry of Health in connection with the Emergency Medical Service

1940

Publication of ‘Fractures and Joint Injuries’ by Reginald Watson-Jones

1963

British Orthopaedic Research Society (BORS) founded, with John Sharrard as President

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1964

Herbert Seddon knighted

1964

Inauguration of Department of Orthopaedics, Sheffield

1965

Presidents’ Council of the Combined Associations formed

1967

Introduction of a £1 registration fee for the annual meeting

1967

Margaret Bennet becomes Senior Administrator of the BOA

1968

Frank Holdsworth knighted

1968

Surgical Appliances Subcommittee stress importance of performance specifications of implants, including bone cements

1993

BOA 75th Anniversary: Publication of ‘The History of the British Orthopaedic Association’ by William Waugh

1993

Introduction of Certificate of Orthopaedic Medical Technology

1993

Establishment and first meeting in Paris of the European Federation of National Associations of Orthopaedics and Trauma (EFORT), at the instigation of Jacques Duparc (Paris) and Michael Freeman (London)

1993

Foundation of The Senate of Royal Surgical Colleges of Great Britain and Ireland

1993

2,600 Members of the BOA

1968

1,200 Members of the BOA

1994

Introduction of annual BOA census

1969

Henry Osmond-Clarke knighted, KCVO

1994

BOA moves into offices in Nuffield College, refurbished with money from the Cutner Bequest

1969

Surgical Appliances Subcommittee recommends performance specifications for implants

1972

Introduction of an annual instructional course for trainees

1972

Union Européenne de Médecins Spécialistes (UEMS) established: The BOA has two representatives

1974

Foundation of RCS England Advisory Bureau for Overseas Trainees

1976

John Fairbank begins first one-year BOA presidency

1976

Joint Secretariat (BOA, BAPS & BSSH) moves to new offices in the RCSEng

1976

Establishment of Trade Liaison Committee

1977

World Orthopaedic Concern (WOC) established

1977- 1992

1978

BOA representation on the Coordinating Committee of Orthopaedic Associations of the Common Market (COCOMAC)

Inaugural meeting of the Association of Professors of Orthopaedic Surgery (APOS)

1980

Executive Committee re-titled ‘Council of the BOA’

1981

Establishment of the Working Party on Plaster Technicians (subsequently Casting Techniques)

1984

First sub-specialty societies affiliate to the BOA: the British Scoliosis Society (BSS), the British Association for Surgery of the Knee (BASK), and the British Orthopaedic Foot Surgery Society (BOFSS)

1984

Foundation of British Society for Children’s Orthopaedic Surgery (BSCOS)

1986

RCS(Eng) appoints an Orthopaedic Regional Adviser in each region

1986

Orthopaedic Linkmen appointed in many hospitals to assist in data collection

1986

Founding of British Orthopaedics Trainees Association (BOTA)

1986

First Advanced Instructional Course for Consultants

1989

First publication of British Orthopaedic News (BON), with Christopher Ackroyd as editor

1989

1989

David Adams becomes Senior Administrative Officer (subsequently CEO) of the BOA

1996

1996

1997

Introduction of Continuing Professional Development by Senate of Royal Surgical Colleges Sir Rodney Sweetnam becomes first orthopaedic President of the RCSEng since Sir Harry Platt in 1954

BOA becomes a Company Limited by Liability, with publication of new Constitution and Rules

1997

Howard Steel Lecture inaugurated: first lecture delivered in Dublin 1998

1998

50th anniversary of the JBJS(B)

1998

First BOA website goes online

1999

Introduction of the European Working Time Directive

2000

Inauguration of the Bone and Joint Decade 2000-2010

2002

National Joint Registry comes into force

2002

DoH Initiatives ‘Action on Orthopaedics’ and ‘Treatment of Patients Abroad’

2003

Wishbone Trust goes into administration, succeeded by British Orthopaedic Foundation

2003

British Orthopaedic Specialists Association (BOSA) founded

2003

MSeC Portal Project Launched at Birmingham Congress

2004

Hugh Phillips becomes President of the RCSEng

2004

Ian Ritchie becomes first orthopaedic surgeon President of the RCSEdin

2004

George Bentley becomes President of EFORT

2004

South West London Elective Orthopaedic Centre (SWLEOC) opens

2005

Formation of British Orthopaedic Directors Society (BODS)

2006

ASEAN Travelling Fellowship introduced

2006

Frances & Augustus Newman Foundation project begins

2006

Ian Learmonth organises Bristol meeting on metal-on-metal hip resurfacing issues

2007

Joint Action adopted as formal fundraising arm of the BOA

2007

Senate of Surgery becomes Surgical Forum of Royal Colleges and Specialist Associations of Great Britain and Ireland

2008

Claire Marx becomes the first female President of the BOA

2009

Appointment of first National Clinical Director for Trauma Care

2010

BOA hosts 12th Combined Meeting of the Orthopaedic Associations in Glasgow

Establishment of the Wishbone Appeal (subsequently Trust) to raise funds for orthopaedic research

1989

First Great Hip Walk of the Wishbone Appeal

1989

‘The Management of Trauma in Great Britain’ and ‘Advisory Booklet on Consultant Orthopaedic and Trauma Services’ published

1990

Establishment of the Board of Affiliated (subsequently Specialist) Societies

2010

JBJS(B) splits from the parent body and becomes The Bone and Joint Journal

1990

Publication of ‘The Management of Trauma in Great Britain’

2011

Keith Willett appointed National Clinical Director for Trauma Care

1990

Publication of Blue Book, ‘Advisory Booklet on Consultant Orthopaedic and Trauma Services’

1990

2012

Final publication of BON, replaced by The Journal of Trauma and Orthopaedics

2013

‘Getting It Right First Time’ initiative launched by Tim Briggs

BOA representation on BMA Central Consultants’ & Specialists’ Committee

2013

1991

Appointment of a professional exhibition organiser, Event Presentations

Revised version of ‘Advisory Booklet for Trauma and Orthopaedic Services’ published

1991

Foundation of Federation of Surgical Speciality Associations (FSSA)

2014

Claire Marx becomes the first female President of the RCSEng

1992

Publication of ‘The Management of Skeletal Trauma in the United Kingdom’

2014

EFORT Annual Congress held in London for the first time

1992

First census of orthopaedic manpower in the UK

2017

4,700 Members of the BOA

1992

Spring and Autumn meetings of BOA replaced by a single Congress

2018

BOA celebrates its 100th anniversary and 5,000 members

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JTO News and Updates

BOA Latest News Instructional Course 2019

Travelling Fellowships

Saturday 12th January – Final Places remaining!

The BOA is pleased to offer numerous Travelling Fellowship opportunities to members.

The 2019 BOA Instructional Course will take place on Saturday 12th January at the Macdonald Hotel Manchester. The new 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.

Travelling Fellowships offer BOA trainees a unique opportunity to visit centres of excellence overseas, sharing best practice, gaining invaluable knowledge and experience different cultural perspectives within trauma and orthopaedic surgery.

Stream One will give the trainees an opportunity to gain Clinical Based Discussions (CBDs) in diabetic foot; necrotising fasciitis; spinal infection and metastatic spinal compression. While Stream Two will cover foot and ankle; shoulder and elbow; hand and wrist; hip and knee, spine and paediatrics.

Further details are available at www.boa.ac.uk/trainingeducation/boa-travelling-fellowships.

In addition, the BOA Instructional Course provides an excellent platform for trainees to network and attend lectures delivered by expert clinicians. Plenary lectures this year includes BOA President Phil Turner, David Warwick, Fergal Monsell, Dave Cloke, Mike Reed, Niall Eames and Hiro Tanaka.

Clinical Leaders Programme 2019/20

For the final programme and further information, including how to register, please visit the BOA website www.boa.ac.uk/events/ instructional-course.

Medical Student Essay Prize Winner The BOA would like to congratulate George Pickering for winning the 2018 Medical Student Essay Prize. It was fantastic to hear him present his essay as part of the Medical Student Day at the BOA Centenary Congress this year. We look forward to working alongside George as he takes his seat as the newest member of the BOA Education Committee.

Medical Student Essay Prize 2019 - Question Announced Medical students are invited to submit an essay (no longer than 1,000 words) answering the following question, ‘Using an example to illustrate your essay, such as the metal on metal hip problem or any other examples you wish, how can orthopaedics learn from the mistakes of the past as it moves into the future?’ Submissions open in December and close on Tuesday 30th April 2019.

For more information on the prize, please visit the BOA website www.boa.ac.uk/latest-news/medical-student-essay-prize-2019.

The BOA National Clinical Leaders Programme (CLP) is now in its sixth year. The programme is delivered through a combination of master classes, tutorials and coaching sessions with experts. The legacy of this one-year development programme is a significant innovation and improvement project delivered by each clinical leader to either their Trusts or Specialist Societies strategic change agenda and improvement of T&O services across the board.

To apply for the Clinical Leaders Programme 2019-20, please visit www.boa.ac.uk/training-education/boa-clinical-leadersprogramme-201819.

Training Orthopaedic Clinical and Educational Supervisors (TOCS and TOES) 15th January 2018 (BOA, London) 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. 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-supervisorstocs-toes.

Volume 06 / Issue 04 / December 2018

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Training Orthopaedic Trainers (TOTs) Course

Hip and Knee Replacement – BOA media coverage

16th-17th January 2019 (BOA, London)

The BOA has recently drawn headlines in the Health Services Journal by criticising the proposed rationing policies for hip replacements by clinical commissioning groups (CCGs) in Sussex. Ananda Nanu (then President of the BOA) was quoted: “The BOA is concerned that opiates are being championed for the management of a chronic condition such as arthritis where the treatment and solution is clearly surgical. These are strong, highly addictive controlled drugs that are intended for acute pain of short duration.” For full details, visit www.boa.ac.uk/latestnews/boa-responds-to-restrictive-ccg-proposals-in-sussex.

The TOTs course was established to improve the standard of teaching for those in trauma and orthopaedic (T&O) training and practice. The basic premise of the course is that if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. If you would like to sign up, please visit www.boa.ac.uk/events/ training-orthopaedic-trainers. For any queries, please contact policy@boa.ac.uk.

Evidence Based Interventions – BOA Response The BOA’s response to the Evidence Based Interventions consultation from NHS England in collaboration with BSSH, BASS, BASK and BESS was submitted September 2018 and is available at www.boa.ac.uk/ latest-news/evidence-based-interventions-boa-response-submitted.

Following this, we were invited to participate at a roundtable event to provide further input. John Skinner (BOA Treasurer) and two BOA staff attended, along with representatives from BESS and BSSH. Members will be kept informed via our email updates.

Waiting Times and Access to Care across the UK Last year’s winter months saw cessations of elective surgery that were unprecedented in recent years. As we continue to monitor and engage on these issues, recent developments include: l Scotland announced a new action plan to cut NHS waiting times, although the 12-week treatment time guarantee is not expected to be fully met until 2021. l In Plymouth, an 18-month arrangement has been put in place whereby all planned T&O surgery will be relocated to a Care UK private facility with the aim of reducing waiting times and improving resilience against winter pressures. l In Northern Ireland, where orthopaedic surgery has exceptionally long waits, we arranged a teleconference in November with the Chief Medical Officer in Northern Ireland to discuss this situation.

Further to this, the BOA responded to the Telegraph article ‘Antibiotic-resistant superbugs creating deadly risks for hip and knee operations’ (23rd October). The response from BOA President Phil Turner, along with John Skinner, Andrew Maktelow and Andrew Price states, “Antimicrobial resistance is a real healthcare risk, but patients can be confident that joint replacement remains the best form of pain relief for endstage arthritis.” Full response at www.boa.ac.uk/latest-news/ boa-bhs-and-bask-respond-to-daily-telegraph-article-onantimicrobial-resistance-affecting-routine-operations.

Robert Jones Golf Tournament The 2018 Robert Jones Golf Tournament was held on Tuesday on 25th September at Harborne Golf Club. We would like to thank John Ireland for hosting and organising the day.

After a brilliant day of golfing, the winner of the tournament was Paul Murphy. Paul was presented with the Robert Jones Trophy by then BOA President Ananda Nanu at the BOA Centenary Congress during the Medal and Awards ceremony.

Other notable mentions are David Woods in second place and Raghunanda Kanvinde in third place.

The 2019 Robert Jones Gold Tournament will take place on Monday 9th September in Liverpool.

Paul Murphy awarded the Robert Jones Trophy

by Immediate Past President Ananda Nanu.

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

Volume 06 / Issue 04 / December 2018

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JTO News and Updates

BOA Travelling Fellowship Nick Furness I undertook a two-week BOA Travelling Fellowship at the Alfred Hospital in Melbourne to experience how trauma is managed in the busiest trauma centre in Australasia. The Alfred is renowned for its excellent outcomes in treating the most

severely injured patients and for leading the way in trauma education in the developing world. Despite the relatively short time-frame, I was exposed to a variety of cases and most importantly, a whole different way of managing major trauma.

The Alfred Hospital: Australasia’s busiest trauma centre.

The Alfred operates a separate Trauma Team, staffed by emergency physicians and general surgeons who admit all major trauma patients and coordinate the involvement of other specialties as required. This not only benefits the patients, who receive an unbridled

The purpose built Trauma Centre with heli-pad.

CT scanner and operating theatre in the department.

continuity of care, but also provides a fantastic educational opportunity as the daily trauma meeting is attended by consultants from all trauma related specialties. There are also daily clinics, weekly pelvic and spinal radiology meetings and an audit review meeting every week, all of which are excellent opportunities for learning.

The clinical exposure offered by the Alfred is very broad with general trauma, spinal and pelvic lists, as well as the usual range of elective lists running throughout the week.

The Fellow can tailor his or her experience by selecting preferred lists and supervision is always present. This is a busy job as the trauma burden is understandably high; hence, the Alfred Fellows work hard and are rewarded with a wide clinical exposure and a very extensive logbook. n

BORS Annual Meeting 2018, Leeds The two-day British Orthopaedic Research Society annual meeting was attended by 120 orthopaedic researchers, and attracted delegates from engineering, biological and clinical backgrounds. Professor Rullkoetter (University of Denver) gave an opening keynote address, talking about modelling knee mechanics for THR design and patient monitoring. This was followed by a session for poster presenters to briefly highlight the work they were presenting.

Sessions covered a diverse range of topics; from translation and manufacturing in orthopaedics to outcomes; and trauma to orthopaedics research outreach.

Preeminent speakers from a range of backgrounds started each session; they included, Dr Wilkinson (MHRA), Professors Wilcox and Ingham (Leeds), Shelton (QMUL), Blom (Bristol) and Pallister (Swansea). These keynotes were followed by

key papers from orthopaedic researchers. The OATech Network led a session highlighting future perspectives on osteoarthritis.

BORS President Mark Wilkinson was delighted to present the ‘BORS Presidential Medal’ to Paul Gregg, who shared his experiences of a career in clinical orthopaedics and research and its legacy. In the society’s public lecture, we heard about how the microstructure of bone provides a signature for human experience from Robson-Brown (University of Bristol). Leeds has a rich heritage in orthopaedics, and delegates were able to learn more about this at the Thackray Medical Museum, the venue for the conference dinner.

Details of the BORS 2019 meeting (Cardiff, 4th-6th Sept 2019) and a full meeting report (including 2018 prize winners) will be available in due course at https://borsoc.org.uk. n

Questions from delegates.

Public lecture from Robson-Brown.

Delegates exploring science fair activities.

Mark Wilkinson presenting Paul Gregg with the Presidential Award.

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JTO News and Updates

AOA Annual Scientific Meeting, Perth 2018 Rhidian Morgan-Jones The Australian Orthopaedic Association’s Annual Scientific Meeting was held in Perth between the 7th-11th October 2018, the theme ‘Better Patient Outcomes’. In total 1,200

delegates attended from over 30 countries, belying the thought that Australia is isolated. This was a high quality meeting but retained the typical Australian hospitality and friendship to all.

For me, it was an interesting meeting of contrasts. On the one hand, we had advanced patient care illustrated by multiple robotic surgical platforms, an emphasis on outcome measures, ‘big data’ and patient orientated healthcare. On the other, there were multiple sessions dedicated to social orthopaedics, The Australian Orthopaedic Association’s ASM 2018 at the Crown Convention Centre, Perth. collaboration

with regional orthopaedic associations and the work of Orthopaedic Outreach. The latter is the charitable arm of the AOA and works with other countries in the region (Nepal, Cambodia, Fiji and the Solomon Islands to name but a few) to advance orthopaedic healthcare, training and organisation.

As someone who had previously undertaken a fellowship in Sydney, I caught up with old friends and new, learnt much, and would recommend attending to anyone if the opportunity arose. n

NZOA Annual Scientific Meeting, Rotorura 2018 Matt Costa The 2018 New Zealand Orthopaedic Association Annual Scientific Meeting was held in Rotorua, a beautiful town in the centre of the North Island.

Rotorua (big lake in Maori) sits next to a tranquil expanse of water surrounded by picturesque mountains. However, the ubiquitous bubbling mud and hot springs are a constant reminder that this town sits atop an active volcano!

The meeting began with an Instructional Course during

which well-known surgeons gave excellent, concise updates related to their sub-specialty areas of interest. Highlights included a fantastic review of the rapid changes in the management of metastatic disease of the spine, and a practical guide to extracting broken hip implants presented by our own Colin Howie. This was followed by the official NZOA Sports Afternoon, where the whole meeting takes to boats, bikes and walking shoes in traditional Kiwi style. I am embarrassed to have won the Annual Mountain Biker prize – presented because I was the only rider to be bleeding from “all four limbs” at the end of the ride...

Great relief, having survived the world’s largest commercially rafted waterfall at Rotorua.

The main Congress was an excellent demonstration of the latest research and educational activities from New Zealand, including the current findings from their unique arthroplasty

register and some fascinating new trial data. The meeting was very wide-ranging with notable contributions from invited surgeons from the Pacific Islands and the Asia-Pacific region more Matt Costa (right) stands next to NZOA Convenor broadly, as well Vaughn Poutawera and colleagues, plus special guest as the Carousel Ngahihi o t era Bidois who gave an excellent talk on Presidents. I Mental Resilience for Surgeons. was honoured to talk about the development of the Major training coaches, nutritionists Trauma Networks in England and primary care physicians. as well as to contribute to a lively session around the I am very grateful to have been development of national invited to the NZOA. It was clinical research networks. an outstanding meeting and a Our own President Phil Turner great chance to catch up with created great interest with old friends on the other side of a talk about the Getting it the world. Particular thanks to Right First Time initiative.

Richard Street, the President The meeting ended with a of the NZOA, and Vaughn fascinating session about Poutawera, Congress Convenor, the well-being of surgeons: for making all of us from the UK including talks from personal feel so welcome. n

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DKOU, Berlin 2018 Phil Turner The German Congress for Orthopaedic and Traumatology (DKOU) was held in Berlin from 23rd-26th October 2018. The meeting was hosted by Professor Werner Seibert, Professor Joachim Windolf and Dr Gerd Rauch representing the three societies that came together to arrange DKOU2018. The societies represent elective orthopaedics, trauma and nonoperative orthopaedics.

The venue in Messe Berlin was huge and a bit soulless but provided the number and range of halls and lecture theatres needed to run up

to 15 parallel sessions for over 10,000 attendees over the four days. The industry exhibition required two large halls and were arranged so that participants had to pass through them as they moved location. The organisation was superb with punctuality being key – as expected!

The UK were the guest nation and several of our specialty societies organised English speaking sessions which showcased our clinical and scientific research with input from other international presenters giving a very stimulating overview of

THE NJR-RCS FELLOWSHIP For orthopaedic trainees who wish to contribute to the analysis of data from the National Joint Registry and undertake a period of independent research into arthroplasty.

DKOU 2018 hosted at Messe Berlin.

topics as diverse as basic research in bone healing, the development of trauma systems and protocols, revision hip surgery and foot and ankle surgery. I was pleased to be able to thank the DKOU for the invitation at the opening ceremony and welcome the

international speakers to the British Embassy in Berlin where the reception was held.

Several of the UK speakers were rewarded by election as corresponding members, which was a true honour for all concerned.

Under the patronage of

Complex Spine SymposiumZürich Spinal Deformity

World-renowned spine surgeons will cover the complexity of spinal deformities with interactive lectures, live surgery, handson workshop and case discussions.

Thursday, May 23rd, 2019 Balgrist University Hospital, Zurich International faculty Behrooz A. Akbarnia, MD, Professor University of California, San Diego

One Fellowship is available with the successful candidate to be appointed in early 2019, for a start 2019/20. The Fellowship is worth up to £60,000 per annum for a maximum two-year period.

Visit www.rcseng.ac.uk/fellowships to find out more including the terms of the Fellowship programme and the application form Closing date for applications: 28 February 2019

Oheneba Boachie-Adjei, MD, Professor Foundation of Orthopedics and Complex Spine Mazda Farshad, MD, Professor Balgrist University Hospital, Zurich

Carol C. Hasler, MD, Professor University Children’s Hospital Basel Jürgen Harms, MD, Professor Ethianum Heidelberg Han Jo Kim, MD Hospital for Special Surgery New York Roger F. Widmann, MD Hospital for Special Surgery New York

Visit www.balgrist.ch/spinesymposium for more information.

Balgrist University Hospital

Volume 06 / Issue 04 / December 2018

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JTO News and Updates

Conference Listing: OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk 10-11 January 2019, Burton upon Trent

BHS (British Hip Society) www.britishhipsociety.com 27 February-1 March 2019, Nottingham

BSCOS (British Society for Children’s Orthopaedic Surgery)

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

BLRS (British Limb Reconstruction Society) www.blrs.org.uk 27-30 August 2019, Liverpool

BIOS (British Indian Orthopaedic Society)

www.bscos.org.uk 7-8 March 2019, Norfolk and Norwich

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

BASK (British Association for Surgery of the Knee)

BORS (British Orthopaedic Research Society)

www.baskonline.com 26-27 March 2019, Brighton

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

www.borsoc.org.uk 4-6 September 2019, Cardiff

SBPR (Society for Back Pain Research) www.sbpr.info 5-6 September 2019, Sheffield

BOOS (British Orthopaedic Oncology Society) www.boos.org.uk 5 April 2019, Leiden

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

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org 5-7 June 2019, Lisbon

BOA (British Orthopaedic Association) www.boa.ac.uk 10-13 September 2019, Liverpool

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Volume 06 / Issue 04 / December 2018

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JTO News and Updates

Royal College of Surgeons Update

The new entrance on to Portugal Street.

As the structure of the new RCS building starts to rise from the ground, we look back on where we have come from, where we are currently, and where we will be in a couple of years’ time.

The whole project started following a recognition from the RCS College Council at the time, that if the College was to continue being at the forefront of surgery, then its home and base of operations would need to be reviewed to make sure that it could fulfil its aims and objectives for years to come. As a result, it was decided to demolish and rebuild the rear section of the Barry building, which itself was rebuilt in the early 1950s following a direct strike from a WWII bomb. In order to enable the works, everyone from across the Barry and Nuffield buildings needed to move in the Nuffield Building which started late 2017.

For the RCS at present, we are halfway through the demolition

and rebuild phase of the Barry buildng, having moved everyone and everything into the Nuffield building, into offsite storage, or both. While the building project progresses, we are also carrying out a wide reaching transformation programme to ensure that the organisation is ready to move into our new home.

When it is all finished, we will have a building fit to take the RCS forward for the next 100 years, with new office space, new teaching and examinations spaces, a new museum, and new public and conferencing spaces available for everyone to make use.

We have our time-lapse camera running to follow the journey of the building project at: URL: www.lobstervision.tv Username: BarryBuilding Password: kJhAGL36

The new central atrium providing natural light through the building.

Wisepress Book of the Quarter Illustrated Tips and Tricks in Sports Medicine Surgery Author: Dr. Frederick M. Azar, M.D. ISBN: 9781496375414 Published: 20th July 2018 Price: £133.00 BOA Members are entitled to 15% off the cost.

Email membership@boa.ac.uk for the discount code.

The sympathetically renovated, original front entrance.

This new quick-reference is the latest volume in the Illustrated Tips and Tricks series. You’ll find succinct, precise information from a wide range of experts and prestigious institutions on tackling technical problems in sports medicine surgery.

Drawings, operative photos, and videos are used liberally throughout the book to illustrate surgical techniques and provide a handy visual complement to the text. It features the latest surgical techniques, presented in a crisp, step-by-step style, and provides brief overviews of equipment, anaesthesia, patient positioning, and other procedural elements. Designed for residents, fellows, and practicing orthopaedists – those in training or anyone who needs to brush up on the latest techniques.

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Volume 06 / Issue 04 / December 2018

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JTO News and Updates

BOA Membership Update New Member Benefit

BOA Reaches 5,000 Members!

The BOA is pleased to announce that we have secured a new member benefit with OrthOracle, an independent, surgeon developed online resource full of practical surgical techniques for both experienced surgeons as well as those in training.

We are delighted to announce that the BOA has welcomed the 5,000th member during our Centenary year!

OrthOracle publish new techniques across the whole orthopaedic spectrum every month and currently has over 200 procedures in hip, knee, hand, upper limp, foot and ankle, spine, shoulder and bone tumour.

BOA members will receive free access to the platform for an introductory six month period. For more information contact membership@boa.ac.uk.

In addition to our three core objectives of Excellence in Professional Practice, Training and Education, and Trauma and Orthopaedic Research, membership of the British Orthopaedic Association also entitles members to a range of benefits including: free attendance at our Congress, access to UKITE and discounts on services. Join today and complete the application at www.boa.ac.uk/contact-us.

Download the free JTO App!

Search for JTO @ BOA

Volume 06 / Issue 04 / December 2018

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33rd Edinburgh International Trauma Symposium and Trauma Instructional Course 12th - 16th August 2019

SAVE THE DATE

Early Bird Discount Registration Fee www.trauma.co.uk symposium@trauma.co.uk.

Volume 06 / Issue 04 / December 2018

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JTO News and Updates

Leaving behind a Legacy Rhidian Morgan-Jones [‘lɛɡəsi] NOUN: an amount of money or property left to someone in a will. “my grandmother died and unexpectedly left me a small legacy” synonyms: bequest · inheritance · heritage · bequeathal · bestowal · benefaction ·

The origin of the term ‘legacy’ comes from late Middle English (also denoting the function or office of a deputy, especially a papal legate): from Old French legacie, from medieval Latin legatia ‘legateship’, from legatus ‘person delegated’.

I had only ever given scant thought to legacy and even then through the prism of my own, occasionally huge, ego. It was all about me! However, age and life have a way of changing you.

Although in moments of hubris I feel I have achieved more than I ever expected and that my ‘legacy’ is assured, there are times to re-evaluate, question and be honest with yourself.

Such a moment occurred recently.

Death, as we are all aware, is always with us. My mother, who had been ill for some time passed away a few months back. A time

of reflection. Although Dementia had robbed her and the family in recent years, her passing has allowed time to pause and assess her legacy. She was an artist. Her home, my childhood home, is full of her paintings and they will be a physical legacy of her humanity, creativity and personality.

So what then will I leave? A few publications and lectures that will amuse future surgeons of what I once thought was ‘cutting edge’. Hopefully, one or two trainees whom I’ve inspired, or at least not put off arthroplasty surgery? The fading memory of a once feisty Welshman?

Aristotle is credited as saying: “Excellence is not an art. It is a habit.” We all strive for excellence daily in our professional lives.

This individual dedication is important and cannot be

underestimated; however, working together as an Orthopaedic community, our Association can achieve so much more. We do that through our membership, serving on committees and council. We could also do this through leaving a financial legacy. We are naturally altruistic in our professional lives, as clinicians and teachers. So much more can be achieved by pooling resource and leaving a financial legacy to the charities that the

BOA support, such as Joint Action, the orthopaedic research appeal of the BOA. Leaving a financial legacy is straightforward but takes some thought. Many of us will already have Wills in place, many will not. A short meeting with a solicitor or professional Will writer can mean your family, loved ones and charities of your choice can benefit from a professional life and be part of your lasting legacy. n

How do I leave a legacy?

Thinking of the future? Leave a legacy through a lifechanging gift to Joint Action. Learn more on everything you need to know about leaving a legacy by visiting www.boa.ac.uk/research/leaving-a-legacy.

IF YOU WOULD NOT BE FORGOTTEN AS SOON AS YOU ARE DEAD, EITHER WRITE SOMETHING WORTH READING OR DO SOMETHING WORTH WRITING.” ~ Benjamin Franklin

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Volume 06 / Issue 04 / December 2018

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JTO Features

The Effects of ‘Winter Pressures’ on Trauma and Orthopaedic Training Togay Koç, Mark Bowditch and Vittoria Bucknall on behalf of the BOTA collaborative The winter of 2017/2018 was one of the most frustrating times that trainees have recently experienced. There is unlikely to be a trainee who was not affected by ‘winter pressures’, at least to some degree. Some trainees have even been informed that they will require additional training time through no fault of their own. The demands on the NHS are rising and cancellations of elective cases due to bed shortages have had an effect unseasonably early year upon year.

Of course, these frustrations are not limited to trainees.

Ultimately, our patients who are at the centre of our care meet delays to operations that they desperately need.

Cancellations are distressing to patients, with prolonged delays potentially resulting in more complex procedures and poorer outcomes.

Furthermore, consultant orthopaedic surgeons face a real-time reduction in operative volume leading to conceivable deskilling, a decrease in a unit’s productivity and its results. It is hard to ‘Get It Right First Time’ when one is hardly doing ‘It’ in the first place, even for a few months.

BOTA Winter Pressure Survey The BOTA Winter Pressures Survey, supported by the BOA, has given us some insight into trainees’ experiences during the 2017/2018 winter period and brought to light some potential strategies to help reduce the training impact of winters to come.

The survey was conducted in May-June 2018 on trainees’ placements between October 2017 and March 2018. Ninetyfive (10%) trainees from 27 deaneries in the UK responded to the survey. Ninety percent of respondents were on elective placements during this period and are likely to be a self-selected group of trainees who were most

heavily affected. Cancellations of cases due to a lack of beds were reported by 76%, while nearly half reported lists that were cancelled in full. Elective cases were affected 91% of the time. Nearly half of trainees reported that four or more lists were affected each month.

With case and list cancellations, trainees needed to find other activities. Fifty percent undertook trauma operations, 5% participated in non-training lists while just over 10% went to clinic. A third of trainees, however, did not perform another activity. In over 90% of cases, no changes were made to the placement or training programme during this time. In the remaining 10% of cases, trainees were reassigned to another hospital that could provide the required operative experience.

The survey revealed 80% of respondents felt negatively affected by cancellations. Half of trainees worried that they would need to have additional training time while two trainees had already been informed that they would have training time added. Training time extension and repetition of placements are likely to effect training opportunities for themselves and others, access to time out of programme, fellowship plans, leave and career planning. Trainee commitment

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to getting the required operative experience appears steadfast.

However, some trainees are resorting to taking annual leave to attend NHS lists in the private sector or cancelling summer leave to make up the training shortfall. These BOTA Survey results are in line with the results of surgical trainees in general (Halkias et al, 2017).

October 2017 to March 2018.

They found that total trainee operating fell by a third with a 25% reduction in performance of index cases. Additionally, they found no variation between winter and summer seasons suggesting that ‘winter pressures’ are becoming more constant as demand on hospital beds made by acute admissions increases.

Total Operations and Indicative Procedures

Are there solutions to the problem?

In an eLogbook analysis, A Norrish, M Bowditch and D Large (2018, in review) compared indicative operations and total operating amongst trainees in 20 NHS training hospitals across the UK between September to December 2017 and December 2017 to March 2018. Between these time periods, there was a 37% reduction in elective in-patient operations (largely the hip/knee arthroplasty cases) and only a 7% increase in trauma cases; with an overall reduction in operations of 20%. There was considerable variation between hospitals suggesting some were much better at protecting elective orthopaedic beds. Based on their data, it was predicted that up to 6.5 months of extra training might be required to meet the minimum total/indicative operative numbers.

With winter fast approaching and the prospects of further cancellations and suspension of elective operating very real, it appears imperative to do all we can to lessen the impact of the ‘winter pressures’ on patients, surgeons and trainees as well as the health service as a whole. Some solutions will not be applicable to every region but could include:

In another comparison of operative data from 2015/2016 to 2017/2018, Kilbane et al (2018, in review) reported the results from Queen Alexandra Hospital in Portsmouth, a hospital that had been hit hard by the winter acute admission crisis and closed its doors to elective inpatient operations from

- Hospital level interventions: l ‘Ring fenced’ beds for elective surgery l Short stay wards l Annualisation of elective services (e.g. increased inpatient elective operating during Spring and Summer months) l Utilisation of private patient beds within NHS hospitals for NHS patients l Splitting elective and trauma services between neighbouring hospitals.

- Deanery level interventions:

l Avoid trainees (especially senior

trainees in need of indicative numbers) rotating into affected placements during winter months l Assign one trainee to two consultants during affected months, (current best practice) l Low threshold for transferring

trainees out of heavily affected placements/hospitals to unaffected teams/units l Low threshold for transfer into a trauma placement mid-rotation l Formally roster trainees to operate in private/independent sector lists (NHS patients).

- Trainee level interventions (when cases or lists are cancelled): l Proactively seek trauma operating cases l Organise study and annual leave during cancellation season l Simulation training - industry led cadaveric workshops l Double up Junior and Senior Registrars on cases to benefit both l Non-Operative Work Based Assessments with Trainer l Proactively organise FRCS revision sessions with affected trainers l Research l Quality improvement and audit l Service improvement and management.

‘Perfect’ would not be a descriptor for these solutions and, depending on the unit, deanery or trainee, ‘feasible’ may not be either. Although some of these potential solutions may appear unpalatable, the effects of the ‘Winter Pressures’ are even more so. Therefore, it is incumbent upon hospital units and training programmes, with the involvement of trainees, to find novel ways in which to combat the reduction in elective operating that is occurring. With creativity and flexibility, as well as a realistic understanding of resources and capabilities, we may be able to survive the famine of elective operating we face ahead of us.

Winter is coming... n

BOTA Collaborative Authors: Emily Barnard (BOTA Junior) James Berwin (BOTA WOC) Mark Bowditch (SAC Chair) Matthew Brown (BOTA Vice President)

Vittoria Bucknall (BOTA President) Bec Critchley (BOTA WIS) Pete Davies (BOTA Treasurer) Beth Dominguez (BOTA Medical Student) Darren Ebreo (BOTA Wales) Alastair Faulkner (BOTA Secretary) Graham Finlayson (BOTA Northern Ireland) Simon Fleming (BOTA Past President) Togay Koç (BOTA SAC) Rory Morrison (BOTA Academic) Oliver Pearce (BOTA Web) Louise Robiati (BOTA Scotland) Zubair Saeed (BOTA Publicity) Tricia Walker (BOTA BMA) Patrick Williams (BOTA Education)

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

An Update on the British Orthopaedic Surgery Research Centre (BOSRC) Amar Rangan The BOA Orthopaedic Surgery Research Centre (BOSRC) at the University of York became functional in July 2014 and has already demonstrated how the new BOA research strategy is bringing big benefits to our specialty. This feature outlines how the BOSRC has evolved to become the BOA’s hub to provide research methods support for clinical trials and what this means for BOA members.

The focus of the BOSRC in the first four years has been on engagement; defining processes for BOA members accessing research support; supporting high quality research grant applications led by BOA member surgeons; and increasing the number of centres and surgeons involved in clinical research, by increasing the UK pool of Principal Investigators and Chief investigators in Trauma and Orthopaedic Surgery. There has been further consolidation of these activities over the last two years with increasing support by the BOSRC to T&O trainees for promoting trainee involvement in clinical research.

Attracting funding for T&O research

Amar Rangan

Embedded within the UKCRC accredited York Trials Unit, the BOSRC has over the last four years, helped BOA surgeons

as Chief Investigators to attract nearly £10 million into T&O research. For a modest ‘investment’ we made from the BOA research committee of £230K over these four years to access support from the York Trials Unit by establishing the BOSRC, the ‘returns’ have been substantial. This in itself clearly justifies the new strategy of accessing methodological support to help T&O research.

The number of BOA member surgeons accessing support from the BOSRC is increasing and consequently the number of research grant applications is also increasing. The BOA research committee has supported a number of James Lind Alliance priority setting partnerships; and more recently, an NIHR led survey, which have both identified key priority areas for research within the various subspecialties of orthopaedics.

It is likely that these will lead

to NIHR and other research funders commissioning research on a number of these topics.

The BOSRC, along with other trials units interested in this line of work, will help increase our capacity to run these future trials to answer key questions in T&O.

Accessing support from the BOSRC The purpose of the BOSRC is to provide methodological support for research grant applications to run clinical trials in T&O. Some surgeons already have access to trials support locally, but for other BOA members who do not have such access, the BOSRC is an excellent resource. The only essential pre-requisite to access support is for the surgeon to be a BOA member. If a surgeon is interested in designing a clinical trial to answer a key clinical question, the BOSRC website has a form that needs to be completed to apply for consideration of support. It is important to provide as much background information as possible within the form in order to allow the experts in BOSRC to determine whether the research question can be ‘sold’ to the funding bodies as being important; and whether a clinical trial is the best way to answer that research question.

Once the information in the form has been assessed and deemed suitable, the BOSRC will help the surgeon develop a research grant application to secure external funding for a clinical trial.

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Table 1: Growth in research income over two years.

The application for support will be assessed using the following key criteria: l Does the work address an important question to patients and clinicians? l Does it address a clear gap in knowledge? l What is the feasibility of the proposed clinical trial? l What is the potential to secure funding?

The application form for accessing BOSRC support can be found at www.york.ac.uk/ healthsciences/research/trials/ research/bosrc/#tab-2.

Developing new investigators There are currently eight new NIHR funded multi-centre clinical trials that are active within the BOSRC, with surgeons from Barts, Leicester, Hull, Northumbria and Middlesbrough acting as Chief Investigators leading these trials. Several other surgeons from across the UK have contacted the BOSRC for support and their applications are at different stages of development.

Surgeons from up to 40 centres are collaborating on each of these trials, with a sequential increase of the pool of site Principal Investigators and over 100 surgeon collaborators over the last four years. In addition to the opportunities this brings to surgeons, there is emerging evidence that patient experience and outcomes are improved within research active centres.

The Collaborative Orthopaedic Research Network (CORNET) is a trainee research collaborative established in the North East of England. CORNET has successfully led recruitment to the WHITE-3 (Hemi) trial, completing recruitment eight months ahead of time and target! The BOSRC has recently hosted a meeting of Leads from regional trainee research networks to facilitate linking up the regional collaboratives and help them evolve into a national trainee research collaborative.

The recently introduced trainee ‘Associate PI’ scheme promotes structured involvement of trainees in clinical trials to gain practical research experience.

Future plans Having identified key research priorities within our subspecialties via the BOA research committee supported priority setting; it is

Supporting T&O trainees There is wellestablished support and training for postgraduate Doctoral students within the Department of Health Sciences and the Medical School at the University of York. The BOSRC has supported five T&O trainees with their OOPR over the last four years to complete their MD or PhD using the clinical trials activity as the vehicle for their Doctoral training.

Figure 1: Achievements of the BOSRC.

evident that a number of these topics would need clinical trials to answer these questions. The BOSRC provides additional capacity and support for BOA members to run high quality rigorous clinical trials. It is likely that the NIHR will remain the largest source of funding for this type of research. Our T&O clinical trials activity in the UK is attracting increasing international attention and the BOSRC is likely to play an important role in enhancing our global presence by generating high quality evidence to guide clinical practice. n Amar Rangan is Professor of Orthopaedic Surgery at the Department of Health Sciences, University of York; and at Faculty of Medical Sciences & NDORMS, University of Oxford. He leads a programme of clinical effectiveness research, particularly multi-centre clinical trials. He maintains his clinical base in Middlesbrough as a specialist shoulder surgeon.

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JTO Features

Using NJR Data for Reflection Martyn Porter NJR Data

This short article supplements an earlier report published in the June edition of JTO entitled ‘Using NJR Data in Appriasal’.1

Reflection An excellent guide on reflection has been produced by the Academy of Medical Royal Colleges, the UK Conference of Postgraduate Medical Deans (COPMeD), the General Medical Council (GMC), and the Medical Schools Council.2 In the guide, reflective practice is described as “the process whereby an individual thinks analytically about anything relating to their professional practice with the intention of gaining insight and using the lessons learned to maintain good practice or make improvements where possible”.

Martyn Porter

In addition to the guidance, there is a toolkit that contains several templates that can be used to support documentation of reflection.3

There are many different styles of professional reflection but a common one is the “What, So what, Now what” approach.

Reflective notes used in appraisal should not contain patient identifiable information and does not need to contain full details but should contain learning and how future practice may change.

It is worth bearing in mind that the GMC will not request to see a reflective note in the event of an investigation. However, it is not a privileged document and a court of law could require a note to be disclosed.

Although reflective entries from Dr Bawa-Garba’s ePortfolio were not used as evidence against her, notes made by her consultant at a meeting after the incident formed part of his witness statement.4

The Consultant Level Report can be downloaded from the Clinician feedback portal.

Within the report is a list of primary cases that have subsequently been revised.

This is labeled as “Linked / Attributable Hip or Knee Revisions from xyz linkable primary procedures” (Figure 1).

It is important to validate this list by using locally available data. The number of cases on this list will depend on the volume of primary activity and as such, consultants within early years of appointment or low volume surgeons are unlikely to have many cases to validate. Over the years and with increasing volume this list will grow. New cases are identified in bold in the report and can readily be updated on an annual basis. Adding a ‘sticky note’ containing details to the report list can do this but it is useful to add to a separate spreadsheet. The spreadsheet can be valuable in identifying patterns of practice and reasons for revision in more detail. It is important to consider if any learning can be made from any revision or if any adverse patterns of performance are emerging.

These may include dislocation, infection, periprostheic fracture, instability and secondary patella resurfacing in particular.

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REFLECTIVE NOTES USED IN APPRAISAL SHOULD NOT CONTAIN PATIENT IDENTIFIABLE INFORMATION AND DOES NOT NEED TO CONTAIN FULL DETAILS BUT SHOULD CONTAIN LEARNING AND HOW FUTURE PRACTICE MAY CHANGE.

revision surgery. The evidence on volumes is still emerging with guidance coming from the BOA, specialist societies and the GIRFT team.

Team Working

Figure 1: Linked/Attributable Hip or Knee Revisions from 1706 linkable primary procedures.

Patient Selection

Implant Selection

Surgeons do not in reality ‘select the patient’ but they do play a key part in advising patients and listing patients for surgery. In the vast majority of cases this process is relatively straightforward but in others dealing with patient expectations can be demanding. Be aware and do not feel pressurised to list a patient for surgery if you genuinely feel that an operation is unlikely to result in the patient’s expected outcome.

A second opinion from a senior colleague or discussion at the MDT meeting can be invaluable.

Detailed documentation is very important in these circumstances. When surgery is technically demanding, consider operating with a colleague.

Be careful in terms of using new and ‘innovative’ products.

Select devices with good outcome data (ODEP rating), where possible. Hopefully, you will work in a unit that has a structured and consistent approach to implant selection.

If you work at variance with any protocol, ensure that you have endorsement from the governance team and document this.

Clinical Practice Be aware of advice or recommendations regarding volume of procedures and outcomes. This may have particular relevance in relation to partial knee replacement and

Establishing and maintaining good relationships with other consultants and staff within your department is very important. Discuss complex cases within the MDT meeting and work within established policies.

There should be a consultant meeting at least every year to discuss unit NJR data and individual outcomes within a confidential environment.

Variation in implant selection and outcomes should be discussed and changes instigated if necessary. n Martyn Porter is the National Joint Registry’s Medical Director and Vice Chairman, appointed by the Department of Health from 1 February 2014.

He is a consultant orthopaedic surgeon based at Wrightington Hospital, Lancashire, a past-President of the British Orthopaedic Association (BOA) and immediate past-President of the International Society of Arthroplasty Registers (ISAR).

References 1. Using NJR Data in Appraisal.

JTO volume 6/issue/2/June 2018.

2. The reflective practitioner - Academy of Medical Royal Colleges https://www.aomrc.org.uk/ wp.../the_reflective_practioner_ guidance_single_page.pdf.

3. Academy of Medical Royal Colleges/COPMeD. Reflective practice toolkit, 2018. http:// www.aomrc.org.uk/wp-content/ uploads/2018/09/Reflective_ Practice_Toolkit_AoMRC_ CoPMED_0818.pdf.

4. BMA - Reflective practice https://www.bma.org.uk › ... › The Bawa-Garba case and its wider implications 25 Apr 2018 -.

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JTO Features

The Fate of Abstracts Presented at the Welsh Orthopaedic Registrars Day Orthopaedic Meetings Konrad S Wronka Co-authors: Clare Carpenter, Declan O’Doherty and Khitish Mohanty Background Clinical audit and research are mandatory components of higher surgical training and, ideally, result in publication in peer-review journals.

Commonly, prior to writing up their research, trainees first present their work at a national or regional meeting, either orally or as a poster.

Experience has shown that, disappointingly, much work never progresses beyond this stage. Sahu et al1 reported the abstract to publication rate (APR) of presentations made at the British Association for Surgery of the Knee (BASK) as 38% (years 2000-2005).

Whitehouse et al2 reported the APR for British Hip Society (BHS) meetings at 23% (years 2003-2006). Collier et al3 in a recent paper demonstrated

Type

n

Published

%

Presentation

130

36

27.7%

Poster

93

24

25.8%

Total

223

60

26.9%

Figure 1: APR of research papers presented by Trainees on Welsh Registrars’ Day 2011-2016.

Results There were a total of 130 podium and 93 poster presentations over the six -year period (Figures 1 and 2). No duplicates were identified.

Thirty six out of 130 podium presentations (27.7%) were published, as were 24 out of 93 posters (25.8%). The overall rate of conversion was 26.9%, at a mean time of two years after presentation (range 0-4).

Figure 2: APR of research papers presented by Trainees on Welsh Registrars’ Day, shown for each year.

an APR of 23.7% for papers presented at BASK and BHS meetings over four years period. There are, however, a paucity of data on the APR at trainee meetings.

Konrad S Wronka

and 2016 were analysed.

A thorough search using the computerised databases PubMed, Ovid, Embase, Medline and Google Scholar was conducted.

Articles that matched the author’s name and had similar content to the abstract were classified as successful conversion from presentation to publication.

All Trauma and Orthopaedic Specialist Registrars within the Wales Deanery are expected to present their ongoing research at the annual Welsh Orthopaedic Registrars’ Day. Trainees decide what they wish to present and there is no peer pre-selection.

Aim The aim of this study was to look at the APR of research presented during Welsh Registrars’ Day over a six-year period and to compare it to the APR of national orthopaedic meetings within the UK.

Methods All podium and poster presentations on Welsh Registrars Days between 2011

Comparison of APR of Welsh Registrars’ Day presentations and of research presented during BASK and BHS meetings are presented in Figure 3.

Discussion The uniqueness of this study is that it relates to presentations given at a local trainees meeting, where there was no formal peer review process and no competitive selection. Despite this, the conversion rate of 26.9% was comparable to that of two national subspecialist meetings. For both of these societies it can be assumed that only those abstracts perceived as being the best will be selected for presentation.

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Figure 3: Comparison of APR of Welsh Registrars’ Day presentations with APR of BASK and BHS meetings.

BESS 2019 18-21 June 2019

Join us for Leeds @Harrogate 2019 at the Harrogate Convention Centre for our 31st Annual Scientific Meeting and 3rd Instructional Course Instructional course - 18 June 2019 Instability and Sports Injuries of the Shoulder & Elbow Annual scientific meeting - 19-21 June 2018 Presidential guest speaker: Brian Busconi Organisers guest speaker: Bassem Elhassan Abstract submission is now open - closes midnight 31 January 2019 Submissions must be via bess.org.uk.

We expect to accept the top 42 submissions for podium presentations and the next 20 best submissions for poster presentation. Further guidance can be found at bess.org.uk Online registration opens December 2018 Sign up to our newsletter at bess.org.uk

It is reassuring that our trainees’ publication rates compares favourably with that of the specialist societies, and reflects well on their motivation and hard work.

However, reviewing the original abstracts we would have expected a significantly higher publication rate. We think it likely that trainees find the process of being published as being daunting and, in consequence, either the paper never is written or the trainee gives up at the first rejection. This is where the support of the trainer is paramount because they can help the trainee navigate through the process. n

Konrad S Wronka is currently working in St George’s Hospital in London as part of Travelling Fellowship awarded by British Hip Society. He completed All Wales Deanery Specialist Training in Trauma and Orthopaedic and obtained his CCT in August 2018.

His special interest is in complex hip and knee reconstructive surgery.

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

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JTO Features

How I do... management of a young person with anterior knee pain and a normal MRI Karen Daly A 14-year-old female has a ninemonth history of bilateral anterior knee pain, the left side being worse. She was a participant in sport at county level but has not done any significant activity for six months. On examination, she has weakness of the quadriceps on the left and short hamstrings bilaterally. Examination of the patellofemoral joint and hips is normal and pain free. Her XRs show normal knees including the patellofemoral articulation.

A detailed history is important to: l exclude a history of trauma or illness l exclude referred pain caused by, for instance, Slipped Capital Femoral Epiphysis l identify “red flag” symptoms that may indicate serious pathology l establish the current impact of the symptoms to enable monitoring of improvements with treatment.

Karen Daly

The knee pain comes on during and after activity and rarely persists until the next day. She has no night pain. It emerges that she is not participating in sport because she was advised not to by her GP. She has actually been trying do some running but stops because it makes her knees hurt.

The traditional medical paradigm is that a good history establishes a diagnosis which is confirmed by the examination and specific testing. This will dictate the treatment. Doctors are trained to that model and it is a foundation of orthopaedic practice, which has been aided by the advent of MRI. The general public have the same expectation.

However, a significant proportion of symptoms at this age group are not associated with pathology. It is likely here that the MRI will be normal. In my experience, this scenario may lead to disappointment on the part of the patient, confusion on the part of the orthopaedic surgeon and anxiety in the parents. This can contribute to a disabling cycle of avoidance of exercise, concern about an undiagnosed serious and long-lasting problem and often further opinions and testing.

Often treatment (physio) is not started because of the lack of progress through the testing part of the traditional diagnostic algorithm. A prolonged period of inactivity during a period of rapid skeletal growth will compound the problem.

My approach is to explain beforehand that I am expecting the MRI to be normal. I suggest this will be a good outcome; we will no longer need to be concerned about the diagnosis just about improving the symptoms. The patient may still be disappointed because they may believe that normal tests mean the symptoms are “in their head”. I will reassure them that the majority of young people do not have abnormal tests and quite severe pain can be associated with normal scans – cramp, for instance. Parents are pleased to be reassured it is safe to allow their child to participate in activity and that is not causing any harm even if they have symptoms. Physiotherapists are entirely familiar with the concept of the management of mechanical symptoms on their own merit but will be additionally reassured by the normal MRI. An MRI report suggesting pathological change needs to be correlated with the symptoms and signs and discussed with the radiologist. The finding of high signal in the medial meniscus (Figure 1), for instance, is actually a normal variant and not relevant to the presentation of anterior knee pain. The reporting radiologist may not be alerted to the significance of the patient’s age or indeed not even aware of the MRI differences between adult and adolescent knees.

Is there a lesson here for adult orthopaedics, where changes on MRI are so much more common

Figure 1: T2 weighted coronal image showing high signal contained within medial meniscus. Normal variant in the adolescent knee.

than they are in children?

How much that we see in our imaging is directly relevant to the presentation? For instance, 37% of 20-year-old to 96% of 80-year-old asymptomatic individuals have “degenerative disc disease” in their spine (Brinjikji 2015) – is that pathology or a normal change with age? n Karen Daly is a paediatric orthopaedic surgeon and Associate Medical Director at St Georges University Foundation Trust in South West London.

She has been a core TPD and Associate Head of School with a QA portfolio. She is Vice Chair of the SAC in T&O and an elected member of BOA council.

References 1. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.

2. W. Brinjikji et al. American Journal of Neuroradiology 2015 Apr;36(4):811-6.

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Festive Fun

JTO Festive Fun How Much Do You Actually Know About The Festive Season?

Christmas trees, mince pies and carols... all spell out Christmas. Do you know where these traditions actually came from? Test your festive knowledge with this JTO Christmas quiz. We guarantee you will not get full marks!

Christmas Quiz 1. Which well-known figure is believed to be one of the first people to eat turkey on Christmas Day?

6. Who was the real Wenceslaus, made famous by the carol ‘Good King Wenceslaus’? a) Tim Wilton b) The builder of the tallest stone tower in Croatia c) An advisor to the Queen of Germany d) A Czech duke

a) Queen Victoria b) Henry VIII c) William Shakespeare d) Ananda Nanu

2. Which royal spouse is credited with bringing the Christmas tree to Britain? a) Ian Winson b) Prince Albert c) Anne Boleyn d) Prince Philip

7. What was the carol now known as ‘Hark! The Herald Angels Sing’ originally known as? a) Hark! How All The Welkins Rings b) Hark! The Smallish Smizers Bring c) Hark! We Have No Dreary Trings d) Hark! The Paltry Orchard Pings

3. There is actually no reference to three kings ever visiting the baby Jesus in any of the gospel tellings of the Nativity story. a) True b) False

4. When is the first recorded reference to Christmas being celebrated on 25 December? a) 354 b) 812 c) 1082 d) 2018

5. The first mince pies contained real meat, tofu or chocolate chips? a) Meat b) Tofu c) Chocolate Chips

8. In 1588, Elizabeth I ordered the whole of England to eat goose for their Christmas dinner. a) True b) False

9. The song ‘Silent Night’ was written about the 1914 Christmas Truce. a) True b) False

10. Archaeological evidence has actually been found that the Tudors were the first to wear Christmas jumpers. a) True b) False

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Names of Presidents Past

Unscramble the letters to reveal names of past BOA Presidents.

a) NINA OSWIN

f) ROMAN RETTPRY

b) WILT MONTI

g) PERKY ETA

c) CHEW NOILOI

h) RELAX MARC

d) NADA NAN UNA

i) JADE IOS

e) BRIM STIGG

j) LIMB KEEL

How well do you know the BOA?

Test your wisdom and draw a line to match to the correct answer!

1. First meeting of the BOA

a) 1959

2. Her Majesty Queen Elizabeth the Queen Mother becomes BOA Royal Patron

b) Clare Marx

3. The fundraising arm of the BOA

c) Liverpool

4. The first female President of the RCSEng

d) 1918

5. ‘Getting It Right First Time’ was launched by the BOA past President

e) 1998

6. First BOA website goes live

f) Birmingham

7. The BOA Annual Congress was held here in 2017

g) Tim Briggs

8. The BOA Centenary Congress was held here in 2018

h) Joint Action Answers on page 71

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JTO Features

Use of Interpreters in Orthopaedics Grey Giddins I am writing this as an ‘interested amateur’ without claiming great expertise. I have, however, discussed this with other clinicians and interpreters. There are also published papers available which give some guidance. This is not the definitive article on the topic but the beginning of a discussion about the best way to use interpreters. Interpreters may be for patients who do not speak much or any English, or for deaf people requiring sign language interpretation.

NHS obligations There is an NHS directive entitled “principals for high quality interpreting and translation services”. The key principals are as follows: 1

a) Translation is free b) Additional time will be needed in a consultation, typically double the regular appointment c) There should be a visible alert on the notes warning of the need for an interpreter and the relevant language d) The interpreter should be registered and will, amongst others, need up to date Information Governance training e) The use of an interpreter should not unduly delay clinical care Grey Giddins

f) Patients should be able to have an interpreter of the gender of their choice

g) “The use of family, friends or unqualified interpreters is strongly discouraged in national and international guidance and would not be considered good practice” (note this does not mean it is barred, but strongly discouraged). If a family member is used, the patient should ideally be consented for this in their own language by someone else. h) “The use of anyone under the age of 16 for ‘interpretation’ or language broking is not acceptable under any circumstances other than when immediate and necessary treatment is required. In this case safeguarding and competency must be a consideration” i) “Professionals and primary care staff may use their language and communication skills to assist patients making appointments or identifying communication requirements (language broking),

but should not, other than where immediate and necessary treatment is required, take on the role of interpreter unless it is part of the defined job role and they are qualified to do so. Staff use of interpreters this way must be covered by indemnity insurance”.

Advice in practice The use of professional interpreters improves patient satisfaction2,3 but in practice patients often attend without an interpreter. Currently systems to identify patients needing an interpreter are not well developed in most hospitals.

If the clinical problem can wait then it would be reasonable to review the patient in a short time period with an interpreter, although it is always a shame to bring patients back without offering anything in the first appointment. If the clinical problem cannot wait, it is a matter of doing the best possible but acknowledging that it is sub-optimal. In particular, any critical decision such as proceeding with surgery or not should ‘always’ be performed with a professional interpreter to avoid family bias influencing the patient inappropriately or inadequate interpretation, meaning that consent is poor or invalid.

Phone interpreter services are encouraged by hospitals but experience with these is variable. In time, video >>

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JTO Features

PHONE INTERPRETER SERVICES ARE ENCOURAGED BY HOSPITALS BUT EXPERIENCE WITH THESE IS VARIABLE. IN TIME, VIDEO INTERPRETING PERHAPS THROUGH SKYPE OR ANOTHER MEDIUM MAY BE A COMPROMISE BETWEEN A MORE PERSONAL FACE-TO-FACE SERVICE AND A CONVENIENT INSTANTLY AVAILABLE SERVICE.

interpreting perhaps through Skype or another medium may be a compromise between a more personal face-to-face service and a convenient instantly available service.

You should try to speak to the interpreter beforehand as an introduction, find out their name, which needs to be recorded in the notes, and make sure that they have similar expectations of the consultation as you do.

In the room there are a number of possible set ups, the chairs either as an equilateral triangle, the three primary individuals (patient, clinician and interpreter) on chairs similar distances apart but with the clinician mainly facing the patient rather than the interpreter or with the interpreter just sitting slightly behind the patient. The consultation should be performed primarily looking at the patient, not least to try to assess non-verbal cues.

Try to use simple short sentences mainly containing one idea, thus if you are explaining a number of possible options, they are best explained one at a time rather than as a series, as you might do in conversation with most patients. The interpreter should translate sentence by sentence. The use of short sentences makes it easier for the translator to translate the concepts for the patient and for the patient

to understand them. These steps make the consultation appreciably longer and a double length consultation may not be enough, particularly for any complex problems. During the conversation, it is important to try not to make ‘asides’ assuming that the patient will not understand. They may have some understanding of English and so may misinterpret or be upset by an aside. Unsurprisingly, it has been shown that even with a professional interpreter, patients are less satisfied with a consultation not in their own language. This is even worse with a non-professional interpreter. In an effort to mitigate these factors, it would be advisable to send the patient a copy of the clinic note, as is recommended in NHS practice.

Not every consultation works well in clinical practice and even more so with use of a translator. If you feel that the consultation is not going well, it is worth curtailing and rescheduling it, possibly with an alternative translator. In addition to the language barrier, there may be cultural differences you are not aware of, making communication even more difficult. In my experience, most patients who do not speak much English are either very ‘accepting/trusting’ of the doctor and happy with

whatever is recommended.

There is a minority who are plainly frustrated with the indirect communication. This may be due to my inexperience in communicating through an interpreter; I am also much more wary of making decisions and typically order more tests and see the patient more times before making a final decision.

Conclusion With a more complex ethnic mix in the UK, there will be more patients for whom English is not a language they speak or understand well. The use of interpreters is likely to become more common. The most important step is to give adequate time, which requires planning rather than just fitting into an already overbooked clinic. Always try to use a professional interpreter, especially if there are any crucial decisions such as a plan to go ahead with surgery. Ultimately, it must be recognised that consultation with a translator will be less satisfactory combined with cultural differences, which can be hard to recognise. There should be a low threshold for multiple consultations in patients where the decisions are difficult or a second opinion.

Documentation needs to be as good as possible. n

Grey Giddins is an orthopaedic hand surgeon. He has particular interests in the non-operative management of hand fractures and minimally invasive techniques for managing hand trauma and elective and post-traumatic hand problems. He runs a research programme in the Centre for Orthopaedic Biomechanics at the University of Bath and is a Trustee of the BOA.

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

20TH EFORT Congress 2019 www.efort.org/lisbon2019

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Congress Highlights | Main Theme: Registries & Impact On Practice Patient selection

Revision rate

Implant selection

Patient safety

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Quality improvement

Prediction of outcome

Patient reported outcome

Value based healthcare

Patient involvement

Key dates Registration opens: January 2019 Abstract status notification: 01 February 2019

Advanced Programme online: 15 March 2019

Volume 06 / Issue 04 / December 2018

Page 40

boa.ac.uk

JTO Features

We are O&T: the German Society for Orthopaedics and Trauma Werner Siebert The German Orthopaedic and Trauma Society is based on two societies, the German Orthopaedic Society and the German Trauma Society. Both have a long history and have been very specialised in their fields, but over time we have learnt that we need to combine our efforts and form a stronger joint society.

Starting in the 1990´s, leading orthopaedic and trauma surgeons started to set sail for a stronger orthopaedic and trauma society. This was our topic for many years as we were sure that we could better serve our patients, get a better education for our young residents and have more political influence in all fields of the health care system of our nation.

Werner Siebert

Of course, there were a lot of concerns and very emotional discussions, but in the end, the majority of the board members of both societies agreed to form a new conjoint society on 8th July 2008 and to also have a combined annual meeting, the so-called “DKOU” (German Congress of Orthopaedic and Traumatology) in Berlin every year. The society and the Congress have since then grown enormously. The DKOU is the largest Congress in this field in Europe. We see more than 11,000 participants. We have

the biggest industry exhibition in this field in Europe and in that one week we have a national, but also international programme with many sessions in English for our international guests. At this meeting, we expect to see up to 3,000 international medical professionals from more than 50 countries worldwide.

It is our great pleasure that the British Orthopaedic Association (BOA) and its specialist societies accepted our invitation to be our Guest Nation and to be an important part of our Berlin meeting held on 23rd-26th October 2018. We were very honoured that the BOA took part in our meeting in Berlin in the 10th year of our foundation. We, the German Orthopaedic and Trauma Society (DGOU) cordially congratulate the BOA on its impressive history. We are very thankful that our colleagues from the UK enriched our meeting with a lot of international sessions, posters and workshops.

The main topics of our Congress and the things that are discussed most in our orthopaedic and trauma society are numerous.

One of the most important things is digitalisation in orthopaedics and traumatology and in our whole society. Smart implants, wearables and big data applications may revolutionise our therapeutic options and are a major opportunity, but also a risk for our field of science. On the one side, we may have advantages from process optimisation and more successful procedures, on the other side we must be careful to protect the personal patient data that are given to us and our hospitals. Of course, we cover all the fields that are important in our combined big society from conservative orthopaedics, which is a part of our field in Germany, including all the patients with rheumatology and chronic diseases through traumatology and the whole field of orthopaedic joint arthroplasty, revisions and spine surgery. This year we had a ‘Specialty Day’ at the meeting with all our sections of the special societies. We had a whole day focusing on spine with the German Spine Society. There is a focus on sports traumatology and return to sports and on hand surgery. The German speaking Arthroscopy Society, which is a society formed from three nations (Austria, Switzerland and Germany) gave a whole day on the wide field of arthroscopy in orthopaedics

Volume 06 / Issue 04 / December 2018

Page 41

and traumatology. You will find details in our international programme on the DKOU website at https://dkou.org/en.

Our main topics were: Digitalisation in Orthopaedics and Traumatology, Implantassociated Infections, Arthroplasty and Revision Arthroplasty, Fractures and Joint Injuries, Hand and Wrist, Spine, Arthroscopic Surgery, Sports Medicine and Rehabilitation, and so we covered a wide field of topics on this meeting and in our society.

This year’s Congress motto ‘We are O&T’ addresses the variety and the wide range of our shared field. Ten years after

boa.ac.uk

the foundation of the German Society of Orthopaedics and Trauma (DGOU), the Congress is the signature feature of the successful growing-together of orthopaedics and traumatology in Germany. Today we can say it is a successful project and the efficiency of our work can be seen on the nationwide projects like the Trauma Network, certification systems for total joint arthroplasty, the German arthroplasty registry (EPRD) and so many other joint efforts. We have 35 specialty societies, a special residency programme and a programme for students and young members in the new society.

The society is growing and we have already more than 11,000

3rd Annual

members and we try to keep the high specialisation and even improve it in the new society.

Last but not least, we have also founded an academy of orthopaedics and traumatology of all kinds of education courses and workshop where you find a wide range of advanced training possibilities as a member. Maybe in this way a combined orthopaedic and trauma society can be an example for other societies, not to lose energy in conflicts, but to gain energy for our great specialty of orthopaedics and traumatology. As the UK has been our Guest Nation, I hope like us, you can also say: ‘We are O&T’. n

Werner Siebert is the President of the German Society for Orthopaedics and Orthopaedic Surgery (DGOOC) and of the German Society for Orthopaedics Trauma (DGOU).

A specialist of orthopaedics and trauma surgery, he has been the Medical Director of the Vitos Orthopaedic Center Kassel since 1994 and is Professor of Orthopaedics and Orthopaedic Surgery at the Philipps University in Marburg.

He is a founding member of the German Endoprosthesis Register (EPRD) and also a member of the Academy of Endoprosthetics (AE).

7th Annual

UCH Basic Shoulder Arthroscopy Course

UCH Basic Knee Arthroscopy Course

Wednesday 08th May 2019

Thursday 09th May 2019

Course Convenor: Mr Abbas Rashid UCLH

Practical Skills for Orthopaedic ST3 Interviews Wednesday 13th February 2019

Course Convenor: Mr Sam Oussedik UCLH

Course Convenor: Mr Alistair Hunter UCLH For course information and booking

For more information email: uclh.simulationcentre@nhs.net

uclh.simulationcentre.nhs.net

Volume 06 / Issue 04 / December 2018

Page 42

boa.ac.uk

JTO Features

Life Outside of the Ring – Combining a Career in Orthopaedics with Amateur Boxing Tom Carter The British Medical Association has strong views on boxing, having campaigned to ban it on multiple occasions.

However, amateur boxing is very different to the professional game, which despite being entertaining, I agree is hazardous.

Doctors are cautious when asked to help, with their views influenced by the media and medical associations. Shows around the country unfortunately come under threat when medical cover falls through.

Having boxed for many years, including winning a national light-heavy weight (81kg) title in 2008 and fortunately sustaining few injuries along the way I continue to partake, this time on the other side of the ring.

By sharing my experience, I hope I can dispel a few myths and encourage more support from members of the orthopaedic community.

Tom Carter

Is amateur boxing safe?

In a nutshell, yes. Boxers are a self-selected group of young, fit individuals. They train religiously, monitor their weight and generally don’t smoke or drink alcohol, making them a refreshing change to the general public. All boxers require a preliminary medical

witnessed a significant head injury. Injuries I have dealt with in the last season (255 bouts) are summarised in Table 1.

What equipment do you need?

Kit is easy to acquire through colleagues and medical supply companies. I subscribe to British Oxygen Company (BOC), who supply and service personal oxygen cylinders, which I take to every competition. Basic airway adjuncts and a bag-valvemask are crucial, although I have never had to use to date.

A stethoscope, pen torch, gloves and swabs are the

assessment when registering, including cardiovascular, respiratory and neurological exam. Visual acuity, blood pressure and urinalysis are checked.

Abnormal findings are infrequently picked up, such as a murmur (yes you need a stethoscope!).

I simply refer to their GP for investigation.

Competition injuries are mainly soft-tissue, Scottish National Elite Championships in 2008 (left) receiving gold medal (despite the black eye) from including nose Dick McTaggart MBE, Scotland’s most famous bleeds and cuts. amateur boxer winning medals in two Olympic games In the last seven (1956 and 1960) and winning 610 of his 634 contests. years, I have not

Volume 06 / Issue 04 / December 2018

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boa.ac.uk

ALL BOXERS REQUIRE A PRELIMINARY MEDICAL ASSESSMENT WHEN REGISTERING, INCLUDING CARDIOVASCULAR, RESPIRATORY AND NEUROLOGICAL EXAM. VISUAL ACUITY, BLOOD PRESSURE AND URINALYSIS ARE CHECKED.

Injury

Number (%)

Outcome

Total bouts

255

Total injuries

14 (5%)

Epistaxis

7 (3%)

1 bout stopped early, 6 allowed to continue.

Superficial laceration

2 (1%)

1 bout stopped early.

Both closed with steri-strips.

Deep laceration

2 (1%)

Both bouts stopped.

Cleaned and sutured post-bout.

Mild traumatic brain injury (concussion)

2 (1%)

Both bouts stopped. Head injury advice and 30-day medical suspension (concussion guidelines).

Distal biceps tendon rupture

1 (<1%)

Surgical repair at local Orthopaedic unit.

Tom Carter representing Scotland in 2009 (second boxer from the left) at the national boxing stadium, Dublin.

Table 1: Breakdown of injuries seen in one season.

go-to essentials. I steri-strip or glue superficial lacerations where possible. For deeper lacerations I suture, but do not use local anaesthetic.

Always take a sharps bin and clinical waste bag. Refer complex lacerations to the local emergency department, as changing room lighting and equipment can be challenging.

A ringside defibrillator must always be present and provided by the boxing board.

Update your medical indemnity appropriately.

Immediate Care in Sport (ICS), covering generic principles.

We are currently setting up a specific amateur boxing course in Scotland.

How to get involved

What experience do you need?

Approaching your local amateur boxing club is a good starting point. Doctors are encouraged to become delegates of a local club, although not obligatory.

Contact the national boxing board, including Boxing Scotland (www.boxingscotland.org) or Amateur Boxing Association England (www.abae.co.uk) for more information. n

Prior boxing knowledge is not mandatory, but makes the job more enjoyable. Shadowing a medical officer is the best way to get experience with shows and competitions occurring at the weekend. Advanced Life Support qualification is mandatory. There are a number of sport-specific courses out there including

Tom Carter is an orthopaedic registrar in the South-East Scotland deanery, currently out of programme as a trauma research fellow completing an MD with the University of Edinburgh. He is passionate about sport, holding active medical officer positions with both Boxing Scotland and Scottish Rugby Union (SRU).

Tom Carter attending to a boxer as part of routine post-bout examination in an international between England and Scotland in 2017.

Life inside the ring.

Volume 06 / Issue 04 / December 2018

Page 44

boa.ac.uk

JTO Medico-Legal Features

Evolution of the objectivesubjective test for material risk in consent Simon Britten The Supreme Court’s unanimous judgment in Montgomery recognised the importance of respect for patient autonomy and consigned to history the Bolam test when assessing standards of risk disclosure1. The judgment emphasised the importance of time and dialogue between patient and doctor in the consent process to discuss all material risks, and provided some clarity to the objective-subjective test for materiality of risk.

The case has been prominent in the medical press and journals, commentators noting that Montgomery has aligned the legal and ethical standards in risk disclosure. This article considers the development of the concept of the objectivesubjective test for material risk from Bolam to the present day.

In cases of risk disclosure, surgeons will be judged by the court on the basis of whether they identified and communicated the material risks of a procedure, rather than behaving as a reasonable group of their peers would have done by application of the Bolam test.

Simon Britten

Recent case law discussed

by Mike Foy in this journal2 demonstrates how themes of autonomy, material risk, and dialogue are important

in the consenting process as opposed to information transmission alone as was highlighted in Montgomery.

Interpretation of the decisions and reasoning in this Judgement continue to evolve. In applying Montgomery, the courts are increasingly emphasising the need to provide an accurate risk-benefit profile in the consent process, and to allow adequate time and space for the necessary dialogue.

Surgeons are professional takers of risk and also bearers of responsibility. Lord Denning stated – “Every surgical operation is attended by risks.

We cannot take the benefits without taking the risks.”3 An individual’s autonomy includes their right to make choices and decisions for themselves,

free from control or interference from others4. Taking or rejecting such choices in terms of medical treatment manifests itself in the weighing up of potential risks and benefits as noted by Lord Denning, and as a result giving or withholding consent to surgical or other treatment.

So what constitutes ‘material risk’?

At the time of Bolam in 1957 the concept of risk disclosure was rudimentary at best. A psychiatric patient sustained acetabular fractures as a complication of ECT. They had not been warned prior to the procedure of the small risk of such a significant complication.

With regard to risk disclosure, the expert instructed by the plaintiff (claimant) said – “I think it is not right to give no warning of the risks to a patient who can understand the import of the warning.” 5 He qualified his evidence with the concern that at times warnings of the potential risks may not be of benefit to the patient.

The experts instructed by the defendants were clear – ordinarily they would not disclose risks of treatment which might deter a patient from accepting treatment from which they were likely to benefit. There was a caveat, that in circumstances where the patient enquired of any risks, then the treating doctors would provide a truthful explanation. >>

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Volume 06 / Issue 04 / December 2018

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boa.ac.uk

JTO Medico-Legal Features

THE TEST COMBINES A GENERAL OBJECTIVE ARM – WHAT THE REASONABLE PATIENT IN THAT POSITION WOULD NEED TO KNOW, WITH A SUBJECTIVE ARM TAILORED TO THE INDIVIDUAL – WHAT RISKS IN THE DOCTOR’S VIEW THE PARTICULAR PATIENT WOULD CONSIDER IMPORTANT.

By the early 1970s in the United States a prototype description of material risk was set out in Canterbury v Spence6. The court’s view was that a risk should be disclosed “when a reasonable person, in what the physician knows, or should know to be the patient’s position would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forgo the proposed therapy.”

In 1985 in the case of Sidaway, Lord Scarman set out the concept of ‘material risk’ which doctors must disclose and defined it as – “The test of materiality is whether in the circumstances of the particular case the court is satisfied that a reasonable person would be likely to attach significance to the risk …”7 Other judges in considering the case referred to the concept of “substantial” and “grave” risks, but at that time it was ambiguous as to who decided whether a particular risk was ‘substantial’ and ‘grave’ – the treating surgeon, expert medical evidence, the court or the patient.

At that time, Lord Scarman recognised the need for a duty of disclosure for the objective or reasonable patient, but he did not take into account the individualities of patients, only finally catered for by the endorsement of a subjective arm for the test of materiality in Montgomery8.

By 1993, the emphasis in defining material risk shifted

away from any quantitative considerations, towards purely qualitative considerations in the Australian case of Rogers v Whitaker9. A patient blind in one eye was not warned of the possible 1:14,000 risk of surgery on her bad eye causing sympathetic ophthalmitis, which in turn might cause blindness in her good eye, which unfortunately developed.

In this case, material risk was defined as – “a reasonable person in the patient’s position, if warned of the risk would be likely to attach significance to it.” Even if a risk is extremely rare, it may be of sufficient severity – e.g. going blind – that a reasonable person would most certainly want to know this to assist them in deciding whether to opt for surgery or not. Numerical percentage point risks are of no relevance in defining material risk.

By 2003, in Wyatt v Curtis, increasing consideration was made of the specific patient’s view of what constituted material risk – “… what is substantial and what is grave are questions on which the doctor’s and patient’s perception may differ, and in relation to which the doctor must therefore have regard to what may be the patient’s perception …”10 In Chester in 2004 Lord Steyn stated – “…In modern law medical paternalism no longer rules and a patient has a prima facie right to be informed by a surgeon of a small, but well established, risk of serious injury

as a result of surgery”11. Lord Steyn left it open as to whether appreciation of seriousness of risk was from the point of view of the doctor or patient, although given his ‘end to medical paternalism’ approach, it can be presumed that he felt it was the patient’s perception that was important.

By the time of Montgomery in 2015, the Supreme Court noted that the most recent GMC guidance had treated Chester as the standard in risk disclosure12.

Lord Kerr and Lord Reed set out the two-armed test for materiality in risk disclosure as follows – “The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”13 The test is not ‘what the patient thinks is important plus what the doctor thinks is important to the patient’. It is more subtle than that. The test combines a general objective arm – what the reasonable patient in that position would need to know, with a subjective arm tailored to the individual – what risks in the doctor’s view the particular patient would consider important.

It can be argued that the second arm of the test is doubly subjective, given that it relies on what the treating doctor thinks (subjective) the particular patient (subjective) would wish to know.

Material risk is not simply an objective matter of a percentage risk or severity of a given potential complication which would concern the reasonable patient, it is also a subjective test which at its simplest is anything which the particular patient thinks is important.

This subjective component of the test of materiality will vary from individual to individual and the doctor is obliged through discourse with the patient to ascertain their concerns.

The subjective arm was considered by Badenoch (Mrs Montgomery’s counsel) as the need to personalise the dialogue with the particular patient during the consent process to include consideration of factors such as “age, intellectual ability, nature and demands of employment, family and other responsibilities, social and other problems, prospects if untreated.”14 I suggest adding the individual patient’s personal views, hopes and fears, eccentricities and religious views.

The need to satisfy the subjective arm of the test is the reason why providing a Patient Information Leaflet [PIL] alone will never be sufficient to ensure adequate consent.

A standardised leaflet cannot make provision for the concerns of the particular patient.

Recent work by Seewoonarain, reviewing the readability of PILs from leading UK orthopaedic institutions, concluded that orthopaedic-related PILs do not comply with recommended

Volume 06 / Issue 04 / December 2018

Page 47

reading ages, with some requiring graduate-level reading ability.15 On this basis, PILs do not appear to satisfy the objective arm of the test either, as in many instances the reasonable patient will be unable to comprehend the literature provided.

The subjective arm of the test can be seen to be very propatient rights, well-illustrated in FM v Ipswich Hospital NHS Trust, like Montgomery a shoulder dystocia case, in which the judge noted that while the disclosure of risk may not have altered the final decision made by the majority of patients, it would have affected what the specific mother would have done.16 Wheeler has expressed several practical concerns in risk disclosure. A difficulty for clinicians to know when to draw the line, identifying the point at which the foreseeability of risks becomes too theoretical while navigating the “branches and twigs of complications that arborise from only one of several alternatives”.17 Wheeler also touched on the subject of emergency surgery, with the scenario of a patient in significant pain, fearful both of receiving a grave diagnosis and of impending surgery. He argued that in such a circumstance a full and detailed discussion may be impractical and unreasonable and may have to be slimmed down to a simple nugget which the patient is able to

boa.ac.uk

comprehend. With regard to deciding what to say to the patient he notes – “Plainly this is an exercise in clinical judgement, no different from choosing the relevant investigations and antibiotics that the patient requires.” Are risk disclosure, diagnosis and treatment all part of exercising clinical judgement?

Bring back Bolam! Perhaps the surgeon should decide what to tell the patient after all?

In Jones v Royal Devon and Exeter NHS Foundation Trust it was argued successfully that when applying the subjective arm of the test for materiality, the identity of the operating surgeon was of importance to the patient – the experienced consultant rather than the less experienced fellow. This despite the fact that six days prior to surgery she had signed a consent form which stated “I understand that you cannot give me a guarantee that a particular person will perform the procedure.

The person will, however, have appropriate experience”.

When a recognised complication arose, the court found that while surgery had not been performed negligently, on balance the claimant had been led to understand that her operation would be performed by the more experienced surgeon. Expert evidence given was that the seniority and experience of the operating surgeon had an effect on the likely rate of complications.

The judge concluded that the claimant’s “right to make an informed choice as to who

would operate on her” had been infringed, thereby denying her autonomy and dignity. On the basis of Montgomery, being informed of the change in surgeon virtually as she was being wheeled to theatre did not give her time to consider whether to proceed or not.

If the floodgates open on a proliferation of cases in which surgery is performed in non-negligent fashion, a non-negligent complication arises, and yet the patient successfully sues in negligence on the basis that they would not have had surgery had the consent process been adequate, it remains to be seen whether the NHS will be able to afford the spiralling negligence bills.18 The evolution of the objectivesubjective test for materiality in consent has been described.

While carefully written PILs may satisfy the objective arm of the test – what the reasonable patient needs to know – careful dialogue with the particular patient during the consent process is necessary to try to identify any subjective concerns specific to the individual. Consultant orthopaedic surgeons will still have a role to play giving expert medical evidence in clinical negligence cases involving consent, but it will not be to give their opinion on whether the standard of risk disclosure was reasonable or not. Rather it will be to advise the court on the potential

benefits and known risks of the specific procedure under consideration, and any alternative treatments of which the court should be aware. It will then be for the court to determine which of the known risks pass the test of materiality, and to determine whether all material risks and alternative treatments were satisfactorily disclosed. n Simon Britten is a Consultant Trauma and Orthopaedic Surgeon in Leeds specialising in lower limb reconstruction. He is the current Secretary of the British Limb Reconstruction Society, and he was recently awarded the taught degree of Master of Laws with Distinction in Medical Law and Ethics by De Montfort University Leicester.

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

We would like to offer our sincere thanks to Mike Foy for his skill, knowledge and support as Medico-Legal Editor of the JTO over the last five years, as he now hands over his role on the JTO Editorial team.

Volume 06 / Issue 04 / December 2018

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boa.ac.uk

JTO Features - Trainee Section

It’s Showtime! #ActItOut Lights, Camera, Action!

Vittoria Bucknall and Alastair Faulkner Co-authors: Matthew Brown, Graham Finlayson, Tricia Walker, David Finlayson, Fraser Harrold, Pete Bates and Sarah Stapley At the 2018 British Orthopaedic Association (BOA) Centenary Congress, the British Orthopaedic Trainees Association (BOTA) took to the stage. As the curtains lifted, trainees, trainers and programme directors stepped into the shoes of the modern day trainee, to wittily explore the often fine line between banter and worrisome workplace behaviours.

Needless to say, the packed auditorium was thoroughly entertained! But, what was the purpose of putting on a show?

The Background The importance of heightening awareness of bullying and harassment over the last few years has garnered traction. Following campaigns such as BOTA’s #HammerItOut and the Royal College of Surgeons of Edinburgh’s #LetsRemoveIt, the public and professional consciousness of unacceptable workplace behaviours has been elevated to an international audience.

Vittoria Bucknall

Alastair Faulkner

We all appreciate that considered communication and conduct is an important part of our daily activities, but to what extent do our behaviours really affect others?

Independent studies conducted by the Joint Committee for Surgical Training (JCST), the Association of Surgeons in Training (ASiT), the BOA and BOTA, demonstrate that approximately 40% of orthopaedic trainees have witnessed bullying1 and that surgical trainees in general have witnessed or experienced language that is sexist (42%), racist (21%) or homophobic (13%) in nature2. The vast majority of trainees report that these behaviours negatively affect their enjoyment at work, influencing 42% of these trainees’ decision to leave surgery2.

Whilst increasing awareness is a worthy objective, this alone will not achieve change. Lasting change requires us all to identify unacceptable behaviours and react to them, for example through improving one’s own communication with colleagues (leading by example) and calling out or challenging such behaviours when they occur.

With this in mind, BOTA took a gamble for this year’s BOA/ BOTA trainee’s session. To open the audiences’ hearts and minds to the idea that these behaviours do exist (and with potentially significant consequences), we developed #ActItOut – a >>

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Volume 06 / Issue 04 / December 2018

Page 50

boa.ac.uk

JTO Features - Trainee Section

INDEPENDENT STUDIES DEMONSTRATE THAT APPROXIMATELY 40% OF ORTHOPAEDIC TRAINEES HAVE WITNESSED BULLYING AND THAT SURGICAL TRAINEES IN GENERAL HAVE WITNESSED OR EXPERIENCED LANGUAGE THAT IS SEXIST (42%), RACIST (21%) OR HOMOPHOBIC (13%) IN NATURE.

The Plot Several scenarios were acted out, using real themes and quotes gathered directly from the BOTA 2016 and BOA 2018 surveys. The session started with a show-stopping performance by David Finlayson. What began as a very dry lecture soon escalated when a ringing smartphone repeatedly interrupted his talk; taking hold of it, he promptly submerged it into a jug of water! An extreme (but true) opener, which certainly focused audience attention.

What followed were three principle scenes set within ‘everyday’ workplace environments: a trauma meeting, a theatre session and an informal coffee room gathering. The scenes relied on the same collection of characters and explored themes of bullying, undermining and harassment, including sexism, homophobia, and malicious gossip. We aimed to create a dialogue that was realistic (albeit artificially quick fire) whilst having sufficient humour to maintain audience engagement.

A ‘laughometer’ crescendo

BOTA put on a show-stopping performance at the BOA Congress 2018.

production of multiple real life scenarios, with each short scene presenting several themes in a different clinical setting. Over 300 BOA members packed the auditorium, with discussions between acts proving both lively and frank. Workplace bullying can take many forms and confronting these issues requires us to ask ourselves “What does it look like?”, “Have I witnessed this?” and “What did I do about it?”.

Knowingly or unknowingly, we are all culpable and no one is immune. The purpose of this session was to hold up a mirror and view ourselves as others do. If we review our behaviours for a moment, much can be achieved.

Through wit and humour, we highlighted that what we say and do in the workplace can affect individuals in ways that we may not fully appreciate.

The Cast With a stellar cast assembled, including reigning Trainer of the Year (TOTY), Fraser Harrold, Pete Bates (TOTY 2014), Surgeon Captain Sarah Stapley (Wessex TPD) and David Finlayson (TOTY 2001) the show could go live! BOTA President, Vittoria Bucknall (who excelled in the director’s chair), encouraged audience participation despite the distraction of complimentary popcorn!

Surgeon Captain Sarah Stapley operates under pressure as her trainer questions her sexual orientation.

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occurred when Fraser Harrold referred to his registrar Pete Bates as a ‘snowflake’ and asked his senior registrar Surgeon Captain Sarah Stapley if she was a lesbian in light of her interest in orthopaedics! There was laughter, not least as a result of the fine comic performances, but serious discussion followed after the lights went up. The audience were invited to consider the effects of each scenario on the trainee, the wider MDT and, ultimately, the patients concerned.

We explored the reality that whilst it is great to have fun at work with humour affording us a degree of resilience, it is important to acknowledge that there are others around us and we may not necessarily know or appreciate their views, circumstances or struggles.

When humour becomes detrimental to the performance of others, it should no longer be considered funny.

The Sequel The question remains, what next?

It is our hope that through this engaging session we can highlight the relevance of workplace behaviours pertinent to the entire MDT, not just trainees and their trainers.

Unacceptable behaviours know few boundaries and problematic

boa.ac.uk

relationships can also exist between consultants, between managerial and clinical staff, and from trainees directed towards their trainers. The session was recorded and will be made available on the BOA website at congress. boa.ac.uk/birmingham-2018/.

Although humour was apparent throughout the session, serious messages were conveyed: problematic behaviours are not just caricatures but occur in many departments in different forms and guises. If this small production can help address the thankfully limited culture of workplace bullying, harassment and undermining, then a satisfactory first step will have been achieved.

Half of the battle is for us all to recognise poor behaviour, both in others and within ourselves. Some will accept these behaviours as the norm with the established status quo remaining unchallenged. As an orthopaedic family, the next step is to advance together and practice saying no; no to bullying, no to undermining and no to harassment for the protection of our colleagues, our friends and our patients. The majority of our orthopaedic family are fundamentally kind and brilliant people who together, can work towards making a better working environment. By looking out for each other, we are ultimately looking after our patients.

Tensions rise in the morning trauma meeting as Fraser Harrold calls his trainee Pete Bates a ‘snowflake’.

We hope that for those who attended the session, you took away something more than an empty box of popcorn. 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.

Alastair Faulkner is a trainee on the East of Scotland rotation at ST4 level and is the Secretary for

the British Orthopaedic Trainee Association. He previously attended the University of Edinburgh and is an artist whose illustrations have appeared in several orthopaedic publications.

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

Big data – what it does, and what it doesn’t...

Daniel Perry Data is everywhere in our lives – it’s GP records, hospital admission diagnoses, joint registry data, birth records, death registry data, and even the store-card data from your local super market! It’s not just text and numbers, data includes pictures (medical imaging), sounds, and even the bizarre squiggles collected by physicians (“ECGs”).

Everything that a computer can store is “data”.

‘Data is the New Oil’ is a phrase commonly used, attributed to Clive Humby, a British Mathematician and the man behind Tesco Clubcard. Data is big business bringing power and great wealth, and like oil, data needs to be good quality and to be extracted and refined before it has value. However, data is better than oil. Data is not finite – it’s growing – you are generating it every day, making it more valuable, increasing the utility and adding to its richness. Every time you do something recorded by a computer you add to it, and are making it (and probably someone, but almost certainly not you) richer!

Daniel Perry

In orthopaedics we’ve been ahead of the curve. We’ve used ‘Big Data’ to guide our practice for a number of years, with the National Joint Registry and National Hip Fracture Database making major contributions to the decisions that we make in our daily practice1,2. We’ve used Big Data to identify problems with metal-on-metal hip replacements

with international action2, and to identify disparities in the care of people with hip fractures leading to the revision of NICE guidelines1. Big Data using GP records has been used to map the epidemiology of rare orthopaedic diseases such as Perthes’ Disease3, and we’ve even linked sources of data to identify that metal-on-metal joints do not cause cancer4.

With the use of Big Data it has been possible to investigate the efficacy of health-service interventions such as the introduction of Major Trauma5,6, and an analysis to explore the efficacy of the ‘Best Practice Tariff’ in patients with hip fractures is eagerly awaited.

Big Data is great – Big Data can demonstrate things that no single hospital could identify on it’s own in a timely fashion.

Big Data can tell us about what is happening in the real world.

Big Data can tell us a lot about rare disease, uncommon events or small (but important) effects.

Big Data can do the studies

that are virtually impossible to do in so-called ‘gold-standard’ clinical trials.

However, ‘Big Data’ is only as good as the data. Big Data can only make sense of what data is already collected. Poor quality Big Data, yields really poor quality results. Poorly conducted Big Data studies can always find a statistically significant result – somewhere! Big Data can also demonstrate statistically significant differences that are of no clinical significance to anyone.

Big Data captures the inherent bias that exists in practice.

Whilst ‘the dream’ would appear to be to replace expensive, time-consuming and ‘poorly generalisable’ randomised clinical trials with analysis from Big Data sets, this isn’t always possible.

Patient-reported outcomes rarely form part of routine data; therefore, in orthopaedic surgery measures of patientreported-function (i.e. those that are most meaningful to patients and surgeons) are typically not available for analysis.

Furthermore, in instances where sufficient Big Data may be available, bias within clinical practice may mean that the result of a big data study will only yield a biased result to the question posed. For example, comparing the results of nails vs. sliding hip screws in Big Data is likely to be troublesome, as although similar fracture types may be chosen in which to make the comparison (i.e.

AO A2-type fractures), it is likely

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BIG DATA CAN TELL US A LOT ABOUT RARE DISEASE, UNCOMMON EVENTS OR SMALL (BUT IMPORTANT) EFFECTS. BIG DATA CAN DO THE STUDIES THAT ARE VIRTUALLY IMPOSSIBLE TO DO IN SO-CALLED ‘GOLD-STANDARD’ CLINICAL TRIALS.

that the A2 fractures in the nail group are more complicated than those in the sliding hip screw group. The Big Data analysis is likely to yield better outcomes in the ‘sliding hip screws’, simply because there is a selection bias within the treatments chosen.

The only way to address this question properly would be through randomized controlled clinical trials.

‘The dream’ (at least my dream) is to combine clinical trials and Big Data, to be able to simplify trials, and ensure many aspects of the trial process and study follow-up become routine. For example, amongst hip fracture patients, randomising between interventions routinely by patient (individual randomization), or by hospital (cluster randomization) at the point of admission to

hospital, using routine followup within the NHFD framework would mean that many of the ‘big questions’ in hip fractures could be answered within months. This isn’t too far away from reality, as the UK-led WHiTE study (World Hip Trauma Evaluation Study) already make clinical trials part of usual care, with many randomised trials running within a comprehensive cohort, all aligned to the core value set and outcomes collected within NHFD.

Similarly, a platform now exists in Children’s Orthopaedic Surgery to use surgeon reported-data, augmented by routine data, to collect patient and surgeonreported outcomes in rare children’s orthopaedic disease – British Orthopaedic Surgery Surveillance Study (BOSS) – with the first randomised trial being embedded into this network over the next few months; Surgery or Casts for Injuries of the Epidcondyle in Children’s Elbows (there is SCIENCE in BOSS!).

The WHiTE Collaborative along with the wider UK-traumatrials network, and the BOSS Collaborative, are making waves internationally in orthopaedic British Orthopaedic Surgery Surveillance (BOSS) website: www.BOSS.surgery; World Hip Trauma clinical research, Evaluation (WHiTE) website: www.ndorms.ox.ac.uk/ though rapid research-groups/oxford-trauma. recruitment to

studies making the UK the international leaders in clinical orthopaedic research – because we have a great network of surgeons and great big data.

In future, the use of Big Data will grow, and rather than resist it, as surgeons we need to embrace it. Algorithms can now rapidly interpret complex medical imaging, including the detection of stroke and detection of retinal pathology. It seems likely that soon the diagnosis, and prognosis relating to many orthopaedic injuries and diseases will be made with the use of Big Data – and this is likely to be the next ‘revolution’ to which we are exposed. This will undoubtedly change our role in the outpatient setting, and may challenge the treatments that we offer when computers don’t use ‘the eye of faith’ that we sometimes offer to imaging.

The future will undoubtedly cause us unease and will make the technology challenge our role – and will make us challenge the role of technology.

Ultimately, Big Data will offer more reliable diagnoses, unbiased outcome detection, better prognostication, better identification of patients eligible for clinical trials, simpler clinical trials, better surgical decisionmaking and better patient outcomes. Big Data is oil - we need to learn to extract and refine it to remain a strong surgical specialty – or else someone will extract and refine it for us. We need to be oil giants, rather than oil users! n

Daniel Perry is Associate Professor of Children’s Trauma and Orthopaedic Surgery at the University of Oxford and a Consultant Children’s Orthopaedic Surgeon at Alder Hey Children’s Hospital in Liverpool. He is chief investigator on the NIHR British Orthopaedic Surgery Surveillance Study, the NIHR FORCE Study and the NIHR SCIENCE Study amongst others. Dan sits on the research committee of the BOA and the research committee of British Society for Children’s Orthopaedic Surgery.

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

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JTO Subspecialty Section

Orthopaedic surgeons must be ignorant, biased or immoral if research doesn’t change their practice Steve Gwilym Variation in clinical practice is not surprising when we consider the practicalities. Differences in training, healthcareeconomics and societal expectations all influence what we do, and to whom. Whilst large variations exist in all clinical practice, surgical procedures are, in some ways, easiest to quantify. There is wide geographical variation between some orthopaedic procedures within the UK1, and worldwide variations of procedure-per-capita can be even greater, despite access to the same research evidence2. Why does this occur? Should we aim to reduce the variation? If so, how?

As clinician-scientists, we must always ask why do we perform research? The answer is so that you can give clinicians and patients clarity in their decision-making and provide evidence that the audit of individual practice can’t provide. However, even if you provide this information in an accessible way, then the work of ‘research’ is still only half-done. If practice doesn’t change, patients or the healthcare system do not benefit as much as they ought to.

Steve Gwilym

Wide variation is rarely desirable, but it appears almost inevitable in our current healthcare and scientific environment. Even common

conditions, for which much resource, scientific input and output has been appropriately dedicated remain the subject of wide practice variation. If we consider the management of a wrist fracture, we must implement the following evidence into our practice: Does the fracture need any reduction at all in order to affect long-term outcome? If it does require reduction, is this best done closed, or with surgical intervention? If surgical intervention, are wires or a plate best3? If plates are used, is it better to use a dorsal or volar approach? How long should I immobilise my patient? Should I refer my patient for postimmobilisation physiotherapy or give them an information sheet?

What about ankle fractures?

Clavicles? Proximal humeral fractures? All common conditions, and all within the scope of practice of the majority of orthopaedic surgeons who contribute to a general oncall service. In this review, we consider the barriers to utilising the evidence available to surgeons, and opportunities to improve the translation of theory to practice.

Ignorance (noun): Lack of knowledge or information The most prolific barrier to the implementation of evidence must be that the end-user is unaware of its existence, or is unable to interpret the research in relation to their practice.

The data available on all clinical problems is now almost endless.

Faced with an avalanche of information, how is the orthopaedic surgeon supposed to keep ‘up to date’ and still find time to treat patients? Besides, the literature can seem a waste of time; half of the papers published in medical journals are never cited by anybody, and it is hard to imagine that a paper can have any important impact if it is never mentioned after publication. This obscurity is often due to a postpublication recognition of its low value. What about conferences?

Unfortunately, most conferences still rely on the peer-review of abstracts alone, and most of the >>

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THE DATA AVAILABLE ON ALL CLINICAL PROBLEMS IS NOW ALMOST ENDLESS. FACED WITH AN AVALANCHE OF INFORMATION, HOW IS THE ORTHOPAEDIC SURGEON SUPPOSED TO KEEP ‘UP TO DATE’ AND STILL FIND TIME TO TREAT PATIENTS?

research presented at meetings is never seen as a published paper at all.

Another aspect to consider is whether the reader can understand the results of the study, which seem to be presented using increasingly complex statistical techniques. Is the orthopaedic research too complicated to understand? Or, are the researchers attempting to persuade the reader with obscure analysis that suits their purpose?

The combined effect of data volume, inaccessibility (journal) and complexity make it unsurprising that orthopaedic surgeons remain ignorant of much of the published research of relevance to their practice.

Bias (noun): inclination or prejudice for or against one person, group or thing Journals like controversial, counter-intuitive research findings that stimulate debate and increase their readership. This encourages researchers to focus on esoteric research questions and to ‘favour’ the publication of their more ‘interesting’ research.

This sort of publication bias may be promoted by some journals but, more commonly, it is researchers who select which of their findings are submitted for publication. This, of course, distorts the literature. It may

Situation

Individual factors

Solutions

Too many articles to read

Time

Encourage quality not quantity of research output: review ‘publish or perish’ mentality

Read journals but don’t digest

Reading only the abstract Burnout / disinterest

Ensure study designs are relevant, interesting and digestible

Looking in the wrong place

Specialty specific journals may not have published ‘high impact’ research

Encourage independent, cross-platform summary articles, e.g. BOAST guidelines or BJJ 360 reviews

Impenetrable statistics

In order to satisfy reviewers, statistics expert has chosen obscure or novel tests

Less common statistical approaches must be supported by descriptive prose for the educated, non-specialist reader

Table 1: The potential reasons for orthopaedic surgeon ignorance of the literature.

Situation

Individual factors

Solutions

Bias by researcher who writes the article

Easier to publish the more ‘interesting’ analysis of my data

Encourage quality not quantity of research output: review the ‘publish or perish’ mentality

Situational bias

Doctors who own, or have financial investment in technologies are more likely to use them6

Transparency to the patient, and to the publisher

Exceptional surgeons

The belief that ‘in their hands’ patients do better with treatment ‘x’ than ‘y’

It is beholden on surgeons to review this belief, or provide evidence to support their exceptional practice

Table 2: The potential reasons for orthopaedic surgeon bias in their interpretation of implementation of the literature.

stimulate some surgeons to adopt experimental techniques or interventions and, conversely, alienates other surgeons who cannot see how the published research reflects their practice.

The effect of this, and other bias, is illustrated by further considering the model of wrist fractures. Research has shown that younger surgeons4, and hand surgeons5 perform more volar plating for distal radius fractures than older, or non-hand specialist surgeons.

There can be no scientific basis for this variation in practice unless information is only being made available to those groups, and other surgeons remain ignorant. There is no evidence for this position.

There, therefore, appears to be unsubstantiated bias in their practice, the sources of which may be summarised in Table 2.

Finally, but perhaps the most resonant reason for bias seems to be the perception by most surgeons that they are ‘exceptional’. In that awareness, we may believe that a piece of research does not reflect our own practice or outcomes. Through this, we feel empowered to ignore the evidence and offer treatments not supported by research data. Research data, by its very nature, aims to define the ‘average’ outcome for a

>>

SAVE THE DATE 12-14 September 2019 · Antwerp · Belgium Important deadlines Abstract submission: 12 April 2019 Early registration: 1 July 2019

EBJIS 2019 38th Annual Meeting of the European Bone and Joint Infection Society We look forward to seeing you in Antwerp!

www.ebjis19.org

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For more information: www.salford.ac.uk +44 (0)161 295 4545 enquiries@salford.ac.uk

Wrightington Hospital Course Venue: Hospital Conference Centre BASIC SCIENCE VIVA COURSE – 2 & 3 April 2019 FRCS (0rth) UPPER LIMB SURGERY MEETING – 4 & 5 April 2019 WRIGHTINGTON MASTERCLASS IN HAND SURGERY – 9 & 10 May 2019 UPPERLIMB SCANNING & GUIDED INJECTION MASTERCLASS – May/June 2019 For further details please contact Jackie Richardson on 01257 256413 WRIGHTINGTON ADVANCED TECHNIQUES IN ELBOW REHABILITATION & SURGERY – 18 & 19 November 2019 (Venue : Wrightington Hotel) WRIGHTINGTON TIPS & TRICKS IN HAND & WRIST SURGERY – 20 & 21 November 2019 (Venue : Wrightington Hotel) Further information: Upper Limb Education, Wrightington Hospital WN6 9EP. Mavis Luya – Elbow and Hand & Wrist Meetings Telephone: +44 (0) 1257 256248 Email: upperlimb@wrightington.org.uk Jackie Richardson - FRCS/Basic Science Telephone: +44 (0) 1257 256413 Email: jackie.richardson@wwl.nhs.uk Websites: www.wwl.nhs.uk (Our hospitals, Wrightington, Forthcoming Courses), www.wrightington.com (Courses)

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JTO Subspecialty Section

ANOTHER ASPECT TO CONSIDER IS WHETHER THE READER CAN UNDERSTAND THE RESULTS OF THE STUDY, WHICH SEEM TO BE PRESENTED USING INCREASINGLY COMPLEX STATISTICAL TECHNIQUES.

patient – “surely that does not apply to me or my patients?”

We all trained with individual surgeons who are technically gifted (although equally, half of our trainers were below average…)

We all like to believe that surgical skill influences outcome, but there remain a number of variables that should challenge the concept of “in my hands…” Firstly, it is almost certain that patient factors and patient selection are more influential than surgeon factors on outcomes7. It is important that research identifies patient characteristics that make them above- or below-average in terms of their likely outcomes, for a given intervention. This is likely to be more discriminatory than surgeonvariability. Secondly, the health and safety literature tells us clearly that systems and routine protect people from poor outcomes, not individual brilliance. Was your favorite surgical trainer technically gifted? Or, were they performing a procedure they had practiced under a strict routine?

harm the patient or healthcare system for a malevolent reason.

Thankfully, there is no evidence that this practice exists, but the prime theoretical driver for immoral are financial gain.

The promotion of surgical intervention over non-operative treatment for financial gain

(private practice) and the choice of a particular intervention because of direct or indirect gain (manufacturer relationships) are undeniable potential influences on personal practice. Surgeons should always remain mindful of the influences on their practice as it deviates from evidence-based medicine.

A consultation in a fracture clinic...

Surgeon “Good morning Madam, your X-rays confirm you have sustained a displaced extra-articular fracture of the distal radius. But fear not, for I am an orthopaedic surgeon and shall address your malady using internal fixation in the form of a locking plate.”

Patient “Hmmm, when I Googled wrist fracture, the evidence suggested that most such fractures can be treated with wire fixation. Isn’t that a quicker operation, and cheaper for the NHS?”

Option 1: Ignorance “Really? I’ve never seen or heard of that evidence – please educate me further.”

“Ah, I did hear that at a conference, but the statistics sounded complicated so I switched off.”

“Published where? – The BMJ, but that is a magazine for general practitioners, not specialist surgeons such as I.”

Option 2: Bias

Immoral (adjective): Not conforming to the principles of right and wrong behaviour In the final explanation, we must consider that surgeons know the evidence, but choose not to apply it through their own cognisant choice. This is to acknowledge patients will not benefit by their specific choice of actions but act anyway. It is, essentially, to

“Ah, yes, but in my hands…”

“I read the same thing, but note that there are many, smaller studies suggesting plates are better than wires and these are all published in the specialist journals that I read – it’s a witch-hunt.”

Option 3: Unethical “Ah, yes, but I have shares in the company that makes the locking plates and the CEO is my best friend.”

“Besides, the hospital makes more profit if I use a locking plate.”

Figure 1: . An example of a consultation in a fracture clinic.

Practicing evidence-based orthopaedics is hard work.

Thankfully, as a community there is good evidence that orthopaedic surgeons in the UK change their practice in light of research8. We should continue to make clinical research relevant, accessible and digestible. We should also continue to mitigate against predictable sources of ignorance and highlight potential areas of bias and unethical behavior. n Steve Gwilym is a Consultant in T&O in Oxford. He has a specific interest in injuries affecting the shoulder, arm and elbow. His current research areas are the conduct of intervention trials for upper limb trauma (fractures, tendon injuries, dislocations), the conduct of intervention trials for chronic conditions of the upper limb (impingement, arthritis) and exploring the non-surgical influences on patient outcomes after upper-limb injuries.

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 Price to Pay...

Matt Costa

Cost

Surgical quote: “I thought statistics was deliberately

complicated, but health economics is a real black art...”

Whenever you use an implant during surgery do you think about what it costs? Is the cost of an intervention a part of your decision-making when you are consulting with a patient? Is this question even relevant – is it even ‘your job’ to consider cost?

Many surgeons would answer ‘no’, ‘no’ and ‘definitely no’.

We are trained to consider which interventions work best (evidence) and to discuss these interventions in the context of the patient’s own experience and priorities (shared decisionmaking). Besides, each Trauma and Orthopaedic Department has a finance manager and it is surely their job to worry about the costs...

It is certainly easier not to think about cost; it complicates the decision-making process and – even if were responsible for the budget – health economics is surely too complicated for trauma and orthopaedic surgeons to understand. Right?

Matthew Costa

This article seeks to outline the basics of health economics, just in case the reader thinks that it is their job to consider cost…

What is Health Economics?

“Health economics is a branch of economics concerned with issues related to efficiency, effectiveness, value and behaviour in the production and consumption of health and healthcare.”

[Wikipedia Sep 2018] It is necessarily a very broad area so, for the purposes of this article we are going to concentrate on the area which is perhaps most pertinent to trauma and orthopaedic surgeons. Namely, cost-utility analysis. Why? Because this is the analysis that is used by National Institute for Health and Care Excellence (NICE) when creating their guidelines for the use of healthcare technologies, such as surgical interventions.

As the name would suggest, these analyses have two components.

Working out what an implant costs is pretty easy; you can just look in the manufacturers’ online catalogue. Although, beware that this may not be the price your hospital actually pays! However, the cost of the implant may not be the main cost associated with treating the patient.

NICE recommends that costs are calculated using the perspective of the United Kingdom National Health Service (NHS) and Personal Social Services (PSS). The NHS costs include not just the implant costs, but the costs of the patient’s whole ‘episode’ of care; length of hospital stay, medication, follow-up appointments, physiotherapy appointments etc., etc. The PSS costs include any social care costs paid by the state; home-carers, adaptations to the home such as stair-lifts, walking aids etc., etc. These costs are usually obtained from national databases such as the Department of Health’s National Schedule of Reference Costs and the Personal Social Services Research Unit; Costs of Health and Social Care Compendium. In large-scale research, such as multi-centre clinical trials, we often also collect Personal Costs, e.g. time off work, but for NICE it is the cost to the tax-payer which drives the attribution of cost and hence their analyses.

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Utility

Cost-Utility

A health utility is derived from a health-related quality of life measurement tool. Many readers will be familiar with the EuroQol (EQ-5D), but there are many other measurement tools available.

EQ-5D measures health-related quality of life across five domains: mobility, self-care, usual activities, pain/discomfort and anxiety/ depression. The patient rates their own health in each of these domains and their answers are used to create a single number – a ‘health utility’ where a score of ‘0’ is a health-related quality of life equivalent to death and ‘1’ which represents perfect health.

Working out cost-utility is then pretty straightforward.

You simply divide the cost of the intervention by the utility measured in QALYS:

Figure 1 shows how utility scores measured over a period of time can be plotted on a graph to show how quality of life changes in the first year after an intervention. The area under the curve represents the Quality of Life Adjusted Life Year (QALY).

Cost-Utility of intervention A = Cost A / QALY A If you want to compare two interventions A versus B you can create a simple ratio called an ‘Incremental Cost Effectiveness Ratio’ (ICER): ICER =

Cost A – Cost B QALY A – QALY B

The ICER therefore represents the additional cost of treatment required to gain a QALY. As a general rule, NICE considers interventions costing the tax-payer less than £20,000 per QALY gained to be ‘cost effective’, but the exact figure may vary at different times and certainly in different countries.

Figure 1: . Utility scores are used to calculate the Quality Adjusted Life Year.

Incremental CostEffectiveness Health economists often present their estimates of cost-effectiveness graphically, as in Figure 2.

An intervention which falls into area ‘a’ is more expensive than the alternative and less effective. The NHS is not going to pay for this treatment.

An intervention in area ‘d’ is less expensive and more effective, in which case the NHS would be crazy not to invest in this treatment.

Of course, more commonly, the ‘new’ treatment is either a little bit more effective but costs a bit more, or a bit cheaper but less effective. Then there is a decision to make.

Figure 2: An incremental cost effectiveness plane.

Summary Hopefully, this article has made it clear that health economics is not really a black art. The principles are actually very straightforward.

While the details of the modelling work which health economists use to assess the precision of their estimate of cost effectiveness can be much more involved, the basic information used to inform clinical decisions can certainly be understood by all trauma and orthopaedic surgeons.

Of course, some surgeons may still feel that their clinical decisionmaking should not be ‘tainted’ by issues of cost. They should certainly have an easier life than the rest of us. Good luck to them I say – keep your heads in the sand for as long as you can! n Matt Costa is Professor of Orthopaedic Trauma Surgery at the University of Oxford and Honorary Consultant Trauma Surgeon at the John Radcliffe Hospital, Oxford. He is Chief Investigator for a series of randomised trials and associated studies supported by grants from the UK NIHR, Musculoskeletal Charities and the Trauma Industry.

Matt is Chair of the NIHR Clinical Research Network Injuries and Emergencies Specialty Group and the NIHR Musculoskeletal Trauma Trials Network. He is also a member of the NIHR HTA Research Board.

He Chairs the BOA Research Committee and is the Specialty Lead in Orthopaedic Trauma for the Royal College of Surgeons of England. He is Associate Editor for Trauma and Research Methods at the Bone and Joint Journal.

Matt is the President of the Orthopaedic Trauma Society and President of the Global Fragility Fracture Network.

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In Memoriam

Murray Matthewson

17th September 1944 – 7th August 2018 Murray Matthewson, a consultant orthopaedic surgeon at Addenbrookes in Cambridge, died on 4th August 2018. He had a special interest in surgery of the spine and hand, having trained in the United States with

Murray Matthewson

Harrington and Green. His heavy clinical workload of hand surgery, scoliosis correction and spinal fracture management narrowed with time, culminating in his Presidency of the British Society for Surgery of the Hand in 2003.

Murray’s interests were broader than this; he was instrumental in the establishment of the East Anglian training program and was training program director between 1994 and 2001. He was a great trainer, exacting, fastidious, and whilst physically a presence, he was in fact gentle and empathetic. He thrived as a teacher, with a mischievous sense of inquisition he could intimidate, but it was the teaching and learning which were his passion. Fran and he were always hospitable, and attendance at their house for a digestif following the annual training programme dinner was mandatory.

Murray’s clinical acumen was legendary, his anatomical knowledge a passion. The two combined to ensure his surgical excellence.

Murray Matthewson was born in Wellington in 1944. His father was a barrister; his mother looked after Murray, his brother and sister.

He was educated at Wellington College and left New Zealand for England in 1971. He trained in Bristol and in Texas, becoming an orthopaedic consultant at Addenbrooke’s hospital. He was a keen sportsman, enjoying judo and rugby (like any good Kiwi).

Indeed, one of his great pleasures was looking after the Cambridge University rugby team.

Murray is survived by his wife Fran, whom he met at the age of 13 and married a decade later, and their four children, Scott, Mary, Kate and Jamie and his 11 grandchildren. n

Leave a Lasting Legacy Whether you’re someone who is suffering from a musculoskeletal disorder or whether your life’s work is helping those who are suffering; you can really make a difference.

Once you have considered your immediate friends and family; please consider leaving a life-changing gift to Joint Action to fund ground-breaking orthopaedic research.

Your donations support the BOA Orthopaedic Surgery Research Centre (BOSRC), based at York Trials Unit, which works with the BOA in expanding the number of trials in the UK related to

Trauma and Orthopaedics.

Your generous donations are helping us to advance Trauma and Orthopaedic research.

Thank you very much!

Remembering a charity in your Will is simple. For an easy stepby-step guide to everything you need to know about leaving a legacy to Joint Action, please visit www.boa.ac.uk/research/ leaving-a-legacy.

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.

- Professor Haim Stein - Jimmy Loudon - Desmond Cowan

A full obituary is available at www.mcphersonfh.com/ obituaries/DesmondCowan/#!/Obituary.

Volume 06 / Issue 04 / December 2018

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boa.ac.uk

Sponsored Content 13th Trauma & Orthopaedics Update

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The programme includes demonstrations of cadaveric prosection of the upper limb and the lower limb with presentations on the spine. The course is for all levels of orthopaedic trainees

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Cardiff Spinal Surgery Course for FRCS Orth & FRCS SN 10-11 January 2019

Cardiff Current Concepts in Spinal Surgery May 2019 (dates TBC)

Cardiff Revision VIVA Course for FRCS Orth 21-22 January 2019

Intermediate Cadaveric Knee Arthroscopy September 2019 (dates TBC)

Cardiff Cadaveric Spinal Injection Course 10 June 2019

Advanced Cadaveric Wrist Arthroscopy September 2019 (dates TBC)

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.

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www.wimat.org wimat@cardiff.ac.uk 02920 682131

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

Names of Presidents Past: a) Ian Winson; b) Tim Wilton; c) Colin Howie; d) Ananda Nanu; e) Tim Briggs f) Matryn Porter; g) Peter Kay; h) Clare Marx; i) Joe Dias; j) Mike Bell.

How well do you know the BOA?: 1) d; 2) a; 3) h; 4) b; 5) g; 6) e; 7) c; 8) f.

Volume 06 / Issue 04 / December 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

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BOA Executive l Phil Turner (President) l Ananda Nanu

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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.

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Copyright Copyright© 2018 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

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

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Fred Robinson and Sophie Williams

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

UK & IRELAND

EDUCATION

2019

Basic Principles of Fracture Management Jan 21-24, 2019. Dublin

Advanced Principles of Fracture Management for ORP Jan 22-24, 2019. Dublin

Introductory Course for Undergraduates Jan 25, 2019. Dublin

Paediatric Course Feb 6-7, 2019. Leeds

Introductory Course for Undergraduates Mar 3, 2019. Edinburgh

Basic Principles of Fracture Management Mar 4-7, 2019. Edinburgh

Shoulder & Elbow Course with Anatomical Specimens Mar 25-27, 2019. Newcastle

Foot & Ankle Reconstruction with Anatomical Specimens Apr 2-3, 2019. London

Current Concepts Course with Anatomical Specimens Apr 24-26, 2019. Coventry

Introductory Course for Undergraduates Jun 23, 2019. Leeds

Basic Principles of Fracture Management for Surgeons Jun 24-27, 2019. Leeds

Advanced Principles of Fracture Management Jun 25-28, 2019. Leeds

Advanced Principles of Fracture Management for ORP Jun 26-28, 2019. Leeds

Basic Principles of Fracture Management for ORP Jun 28-30, 2019. Leeds

Hand Fixation Course Oct 7-9, 2019. Leeds

Principles in Small Animal Fracture Management May 19-21, 2019. Oxford

Wrist Fixation Course Oct 10-11, 2019. Leeds

Introductory Course for Undergraduates Nov 10, 2019. Basingstoke

Basic Principles of Fracture Management Nov 11-14, 2019. Basingstoke

Management of Facial Trauma (Principles Course) May 1-2, 2019. Stratford-upon-Avon

Management of Facial Trauma (Principles Course for ORP) May 2-3, 2019. Stratford-upon-Avon

Promoting excellence in patient care and treatment outcomes in trauma and musculoskeletal disorders

Principles Course - Degeneration Mar 29-30, 2019. Birmingham

Principles Course - Pedicle Screw Placement Nov 11, 2019. TBC

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