Journal of Trauma & Orthopaedics - Vol 7 / Iss 2 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 07 | Issue 02 | June 2019 | The Journal of the British Orthopaedic Association | boa.ac.uk

How the Global Surgery Agenda is changing p50

International Sport and a Surgical Career p26

Striving for excellence in surgical training p46

Orthopaedic Curriculum Development in Guyana p54

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3 5

From the Editor

Bob Handley

From the President: Core Values

Phil Turner

6-7 Latest News 8-19 News 16 News: National Back Pain Pathway

Lee Breakwell

18 News: Conference listing 20 The Development of a Medical

Device (CasterpillarTM)

Don McBride

a Surgical Career

Richard Dodds

28 UK Peri-Prosthetic Joint

Arthroscopic Lateral Release of the Knee

34 Operations I no longer do...

Infection Meeting (UK-PJI)

Nick Kalson, Johnny Mathews, Andrew Toms

Richard Parkinson

36 How I do... High Tibial Osteotomy

Chris Wilson

websites can let you down in court

38 How notes, records, letters and

Bob Handley

Training, Examination

Learning in the Orthopaedic Operating Theatre: Educational Strategies for Surgeons

Adam Hexter and Alistair Hunter

26 International Sport and

24 The Future of Casting: Education,

David Ross

22 GIRFT Orthopaedic Trauma

30 Medical Student

Giles Eyre

40 Book Review: Clinical Practice

and the Law. A Legal Primer for Clinicians by Giles Eyre

Review by David Warwick

42 An introduction to Simulation

Lisa Hadfield-Law

Duncan Tennent

44 What is Simulation? 46 Trainee Section: Striving for

excellence in surgical training: Reassessing the Trainee-Trainer relationship

Matthew Brown

50 Subspecialty Section: How the Global

Surgery Agenda is changing and the increasing role of WOC UK in the development of training and trauma service development in low and middle income countries

Tony Clayson

54 Subspecialty Section: Orthopaedic

Curriculum Development in Guyana

Deepa Bose

56 Subspecialty Section: The Northwest

Orthopaedic Trauma Alliance for Africa (NOTAA): Approaching sustainable development through international collaboration and the Ethiopian and UK Residents Research Day

Kohila Vani Sigamoney, Henry Wynn Jones and Tony Clayson

62 In Memoriam: Sue Miles,

Dr. Yves Cotrel, Dr. Henry Mankin

Download the App The Journal of Trauma and Orthopaedics (JTO) is the official publication of the British Orthopaedic Association (BOA). It is the only publication that reaches T&O surgeons throughout the UK and every BOA member worldwide. The journal is also now available to everyone around the world via the JTO App. Read the latest issue and past issues on the go, with an advanced search function to enable easy access to all content. Available at the Apple App Store and GooglePlay â&#x20AC;&#x201C; search for JTO @ BOA.

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. Wymondley

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

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

Principles Course - Degeneration

and musculoskeletal disorders

Principles Course - Pedicle Screw Placement

www.aofoundation.org

Mar 29-30, 2019. Birmingham Nov 11, 2019. TBC

Credits JTO Editorial Team Bob Handley (Executive Editor) Rhidian Morgan-Jones (Editor) David Warrick (Medico-Legal Editor) Matthew Brown (Trainee Section Editor) Tony Clayson (Guest Editor)

l l l l l

BOA Executive

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

l Phil Turner (President) l Ananda Nanu (Immediate Past President) l Don McBride (Vice President) l Bob Handley (Vice President Elect) l John Skinner (Honorary Treasurer) l Deborah Eastwood (Honorary Secretary)

Policy & Programmes

BOA Elected Trustees

Interim Director of Communications and Marketing

Director of Policy and Programmes

- Julia Trusler

Policy and Programmes Administrator

- Megan Pugliese

Programmes and Committees Officer

- Harriet Wollaston

Communications & Operations Director of Communications and Operations

- Emma Storey

l l l l l l l l l l l l l l l l l l l

Phil Turner (President) Ananda Nanu (Immediate Past President) Don McBride (Vice President) Bob Handley (Vice President Elect) John Skinner (Honorary Treasurer) Deborah Eastwood (Honorary Secretary) Ian Winson Mark Bowditch Lee Breakwell Simon Hodkinson Richard Parkinson Peter Giannoudis Rhidian Morgan-Jones Hamish Simpson Duncan Tennent Grey Giddins Robert Gregory Fergal Monsell Arthur Stephen

- Annette Heninger

Membership and Governance Officer

- Natasha Wainwright

Online Examination Operations Project Manager

- May Elphinstone

Publications and Web Officer

- Komal Gorasia

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

Events & Specialist Societies Head of Events - Charlie Silva Events Administrator - Venease Morgan Exhibitions and Sponsorship Coordinator

- Emily Farman

UKSSB Executive Assistant - Henry Dodds

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C, Regent Court, 68 Caroline Street, Birmingham B3 1UG Email: inside@ob-mc.co.uk | Telephone: +44 (0)121 200 7820

Disclaimer

The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication.

BOA contact details

The British Orthopaedic Association, 35-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507

From the editor... Bob Handley

ords. In many respects I am not cut out to be an Editor, as a left-handed spatially based thinker I was always attracted to books with more pictures than words. However, this editorial role involves actually reading the words and that I find has its rewards; rather like revising for an exam and finding for the first time that the subject matter is genuinely interesting. The headline words on the front cover relating sport to surgery may lead the unwary to visualise a particular stereotype of a surgeon. The reality described in Richard Dodds’ article (page 26) guides us away from this assumption. To achieve expertise in sport or surgery requires effort as well as ability; and progress in each field is often the result of attention to detail and marginal gains. Words can obscure or illuminate. Strangely, it sometimes seems that excellence is not our objective; we train, examine and practice to a level of competence. It is quoted to us in lectures that not everyone can be above average; this creates an image of a bland, mediocre profession. This belies the objective in our training and working which is to achieve a level of general professional excellence, this is highlighted in the Trainee section (page 46). We expect more of ourselves as each year passes, just as in sport today’s average is yesterday’s excellent. Phil Turner in his President’s notes (page 5) speaks of ‘Core values’ and the how the BOA and others are involved in setting and advancing standards. He then cautions that individual pressures may ensue and that we have then to be prepared to honour the second half of the Association’s mission ‘Supporting Surgeons’. The sporting analogy now becomes rather stretched; this is not just a game. Words can conjure a reality and ‘What if’ scenarios are common in teaching. In a practical specialty simulation is now becoming more sophisticated and Duncan Tennent in the first in a series on simulation (page 43) explores how this should benefit both patient and surgeon. Caring for patients, supporting surgeons are words that are easy to say, and indeed define our job. What is more impressive is when they are played out not for direct reward but when it is just the right thing to do. The specialty section on the involvement of UK Orthopaedics abroad describes this (page 50). Whilst providing direct individual patient care has its appeal and benefits, it is the considered contribution to the development and maintenance of a system of training others to deliver that care which has the greater potential. When we mix surgery with the law, words are not just describing the issues, they are often the very essence of the issue itself. They are tools we must learn to use. The medicolegal section (page 38) is a reminder that effective communication is based on clarity, lack of ambiguity and consistency. That communication then needs to be recorded. The initial action and its record not only define the caring clinical interaction but are also key to ensuring fair consideration if there should be later problems. We must care for ourselves to best support patients. n

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From the President

Core Values Phil Turner

Our mission statement ‘Caring for patients, supporting surgeons’ has served us well for many years. It reflects the core values of our organisation. Many of our activities are clearly aimed at getting the very best outcomes for patients suffering from musculoskeletal disease or trauma.

he production of guidelines in the form of BOASTs has defined the standards of best care in trauma and these are now being extended to elective BOASTs with a change in terminology to ‘British Orthopaedic Association Standards’. We will be working closely with the specialist societies to look at the process for developing the new ‘elective BOASTs’ and also discussing how we continue to make best use of BOA ‘Blue Books’. On the subject of BOASTs, I am pleased to relay some other important developments. Firstly, our first new-style ‘trauma BOAST’ was published in May on the important topic of elderly and frail trauma patients (see page 6). It has been well-received both at its launch at the inaugural Fragility Fracture Network UK meeting in Oxford and on social media. Secondly, we are delighted to announce that we have established a relationship with the journal Injury whereby all trauma BOASTs will feature in that publication in future, along with a BOA-led editorial – look out for those coming soon! Finally, I can report that since the launch of the BOA website, the BOASTs have continued to be one of the most frequently accessed documents (and if you haven’t yet reviewed

the new site and the latest BOASTs, could I encourage you to do so at www.boa.ac.uk). For the BOA, publishing high quality BOASTs and other documents are central to our role in ensuring patients receive the right care at the right time. We cannot ignore the pressure on our members that comes from detailed scrutiny of surgeon performance. The fear of becoming a ‘NJR outlier’ is real, particularly for newly appointed consultants who do not have many years of established results to cushion them. The review of unit performance from Getting It Right First Time (GIRFT) should facilitate significant changes in practice and is a key quality improvement process but can be seen as a threat where the data fall below acceptable standards. The BOA has played a central role in the development of registries and GIRFT on the basis that they are powerful leavers to improve patient care, but we also have to step up to the plate and deliver on the second part of our statement. I would hope that the majority of us work in units with a culture where learning from substandard outcomes is positively encouraged and mentoring of new colleagues is the norm. However, I am not so naïve as to believe this is

“We cannot ignore the pressure on our members that comes from detailed scrutiny of surgeon performance. The fear of becoming a ‘NJR outlier’ is real, particularly for newly appointed consultants who do not have many years of established results to cushion them.”

the case for all. The Executive and Council are now actively considering the steps we must take to engage with those members who feel they need somewhere to turn for help and advice. We must provide the support we have promised to them. n

Latest News

Changes announced to BOA’s leadership programme From autumn 2019, the BOA will be commencing a new 12-month ‘Future Leaders Programme’, which has evolved out of the BOA Clinical Leaders Programme run for the past five years by Karen Picking and Associates. The new scheme will be led by Hiro Tanaka (BOA Ed Comm Chair) and Lisa Hadfield-Law (BOA Education Advisor), and aims to support 20 surgeons (post-CCT, SAS or in the first years of consultancy) with the passion to be future leaders within T&O and equip them with the advanced leadership skills needed to excel in their career. Enrolment is already well underway via the specialist societies and Trustsponsored participants, and at the time of writing some final self-funded places remain available. The structure of the programme will comprise four two-day residential forums over a 12-month period with Action Learning Sets that will be self-directed. The programme will be structured around four core domains: personal leadership, technical leadership, relational leadership and contextual leadership. For more information and how to apply visit www.boa.ac.uk/FLP.

Training Orthopaedic Clinical & Educational Supervisors (TOCS & TOES) Upcoming dates:

9th July (BOA London) Do you want to help trainees be the very best they can? Recognising and Approving Trainers (GMC) requires T&O trainers to be ‘trained and calibrated’ in workplace based assessments (WBA). More importantly, our trainees deserve the best training we can manage. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. For any queries, please contact policy@boa.ac.uk. If you would like to sign up, please visit our website.

Fracture Liaison Service Database: Commissioner’s report 2019 now published The report provides CCGs with a summary of the audit’s national key findings, recommendations and results for fracture liaison services (FLSs) within their locality. The report also explains how FLSs could help CCGs not only to reduce the number and cost of unplanned admissions but make a significant reduction in morbidity and mortality for older people. The full report can be found online at www.rcplondon.ac.uk.

Tackling Undermining and Bullying in the NHS The BOA is now part of a collective call to action and an alliance of over 25 healthcare organisations to improve the culture within the workplace and to tackle undermining and bullying within the NHS. On 4th April 2019, key stakeholders met at a conference hosted by the Royal College of Obstetricians and Gynaecologists and the Royal College of Surgeons of Edinburgh to share learning and to create a clear path towards the vision of a better, safer NHS. The impact of bullying within the NHS is profound. One in four staff within the NHS reports being bullied by managers or colleagues within the last 12 months with an estimated financial burden of £2.2 billion in sickness, employee turnover, reduced productivity and litigation costs. Ultimately, it is the patients who suffer the consequences as a result of its impact upon patient safety. Bullying is not necessarily about the individual. The solution therefore must not become a witch hunt but rather a collective understanding of what creates a positive workplace culture and what can damage it. In a stressful environment such as the operating theatre, we should be aware that a single episode of incivility or rudeness will reduce the cognitive ability of the recipient by 61% which may last days. What is more surprising is that all those who witness that event similarly experience a decline in performance of 20%. Is it any wonder that patient safety is severely compromised under those circumstances? How we behave towards each other is the single greatest factor in how well competent teams perform. A change in behaviour is neither difficult nor costly. With insight and self-awareness we can ensure that Trauma and Orthopaedic surgery is best able to care for patients and support fellow surgeons.

News

BOA Annual Congress 2019 10th-13th September, ACC Liverpool boa.ac.uk/congress #BOAAC

Guest Lecturers Presidents Guest Lecture Professor Per KjærsgaardAndersen, MD, Ass. Professor KjærsgaardAndersen is currently a Senior Consultant Orthopaedic Surgeon and the Head of Section for Hip and Knee Replacement in the Department of Orthopaedics at Vejle Hospital in Denmark. He is also an Assistant Professor of Orthopaedic Surgery and regularly lectures medical students at Vejle Hospital and at South Danish University. Professor Kjærsgaard-Andersen is the current president of EFORT.

he theme for Congress 2019 is New Horizons in Research, Education and Clinical Leadership. This year’s programme will include plenary keynote sessions, hot topics including Global Health, and revalidation sessions on specialist topics.

• • • • • •

Programme Update

Also invited to attend this year are the: • Asia Pacific Orthopaedic Association • Hong Kong Orthopaedic Association • Indian Orthopaedic Association • Irish Orthopaedic Association.

There will be revalidation sessions across each day of the congress programme including Trauma, Hips, Knees, Foot and Ankle, Elbow and Shoulder, Hand and Spines. Hot topics this year will include Research: Trauma and Orthopaedics Now and in the Future, Digital Tech and Machine Learning, Global Health and The Ageing Surgeon. Friday will once again see the return of the popular training courses Good Clinical Practice, Non-Technical Skills, TOCS and TOES and the clinical examination course. The medical student sessions which run for a full day will also be on the Friday.

Carousel and Visiting International Presidents We are delighted that the President of each of the following international orthopaedic associations will be attending Congress 2019: • American Academy of Orthopaedic Surgeons

American Orthopaedic Association Australian Orthopaedic Association Canadian Orthopaedic Association Chinese Orthopaedic Association New Zealand Orthopaedic Association South African Orthopaedic Association.

Exhibition The exhibition will run from Tuesday 10th to Thursday 12th September in Hall 2 at the ACC Liverpool. Each year over 80 companies exhibit at the event which is attended by over 2000 medical students, trainees, consultants and allied health professionals.

Accommodation TSC Hotel and Venues is the official hotel booking agency for Congress 2019. Please note that the exclusive rates are guaranteed until the 13th August 2019 and are subject to availability. Visit our accommodation page at boa.ac.uk/annual-congress/travel-andaccommodation.html for hotel options.

Robert Jones Lecture Professor John Skinner John Skinner is Professor of Orthopaedic Surgery at RNOH Stanmore with a special interest in hip and knee replacement surgery. He is on the Editorial Board of the BJJ. John is the Treasurer of the BOA and has represented the Association at high level discussions with NHS England and other stakeholders on elective care.

Howard Steel Lecture Nicky Moffat CBE Nicky Moffat was Britain’s highest ranking female Army officer, retiring as a Brigadier. In almost 30 years of service she held a range of personnel, administration and leadership roles.

News

A BOA ZimmerBiomet Travelling Fellowship to Malawi Andrew Walls Adolescent clubfoot Ilizarov correction with the Ilizarov method

Meeting Review - OTS

y time in Malawi was divided equally between Beit Cure International Hospital and Queen Elizabeth Central Hospital Orthopaedic Department and I cannot recommend my experience highly enough in both departments. All staff were incredibly welcoming and the environment was always friendly and supportive. The surgical and educational opportunities available for learning are vast and I wholeheartedly encourage any medical student or doctor who is considering time away to go and enjoy this beautiful, safe and welcoming country. It was an eye opener to experience first-hand the burden of trauma facing much of the world in a resource depleted setting of a lowincome country. The experience has developed my decision making and management of surgical problems not commonly encountered in the UK. Many factors such as cultural preferences, financial hardship and availability of resources would be an almost daily encounter, and would positively stretch and develop clinical judgement. During my time away, I logged 284 operations. My confidence operatively, as well as ability to think outside the box, has developed considerably due to the various challenges I was presented with in this environment. One of the most enjoyable and rewarding aspects was the ability to give something back to the units I worked in. Regular teaching of the medical students and interns on the ward gave a well-earned rest for the consultant body and also made the ward run more efficiently and safely. The time away has been life changing and I intend to go back! n

Alex Trompeter

he 2019 OTS annual meeting was held at St George’s Park, home of the English Football Association. This year over 170 delegates mainly consultants and senior trainees enjoyed two days of stimulating debate, case controversies and research updates, focussing on trauma care in the UK. The meeting has a reputation for vigorous delegate debate and this year was no different. Topics included the challenges of managing segmental fractures in upper lower limbs, complex wrist fractures, pilon fractures and strategies for removing incarcerated hardware (everyone’s favourite operation). Research updates complemented the OTS NIHR Trials day, which preceded the main meeting. We had updates on national policy and the political side of trauma care in the UK. The OTS was proud to have the President of the BOA, the Chair of the SAC, and the National Clinical Director for Trauma together to discuss orthopaedic trauma training and succession. International guest speakers; Martiz Laubscher (South Africa), and Jan Erik Madsen (Norway) added their enormous experience in orthopaedic trauma, and also their willingness to join in the debates. The OTS AGM was held during the course of the meeting and saw the new OTS constitution endorsed. The 2020 Meeting will be held at the Hilton Hotel in Gateshead. Once again the OTS NIHR trauma trials day will precede the main meeting. Information and registration will soon be on the OTS website at: www.orthopaedictrauma.org.uk. We hope to see as many of you there as possible. n

St George’s Park, Burton upon Trent

News

A group photo during the conference. From left to right, Mr Anish Sanghrajka (local host), Mr Tim Theologis (BSCOS President), Miss Helen Chase (local host), Mr Robert Hill, Dr Melita Irving, Dr John Herzenberg (all invited guest speakers) and Mr James Fernandes (BSCOS secretary)

Meeting Review - BSCOS T he annual meeting of the British Society for Children’s Orthopaedic Surgery was held at the Assembly House in Norwich on the 7th and 8th March 2019. The theme of the conference was ‘Deformity: Science and Surgery’ and it was attended by over 250 delegates with multidisciplinary presentations on a wide variety of fascinating topics. We were delighted to have a number of presentations from Dr John Herzenberg, from Baltimore, with his wealth of experience and engaging presentation style. He lectured on the new paradigm for limb lengthening and the use of internal lengthening devices and fixator assisted nails moving away from external fixators. Dr Herzenberg also talked about the challenges of Congenital Pseudarthrosis of the Tibia describing his multimodal approach including the ‘cortical plate sandwich’. His presentation about the treatment of clubfoot and his technique learned from Ponseti himself was instructional and encouraging. Mr Keith Tucker (a founding member of BSCOS) provided a very informative presentation giving visitors an insight into Norfolk and Norwich. An enlightening and entertaining summary of history, current practice and a look to the future was provided by Robert Hill, whilst Rajiv Hanspal’s lecture about advances in prosthetic reconstruction particularly the issues around osseointegrated prostheses was very well received.

Michael Pullinger and Anish Sanghrajka

Dr Melita Irving gave an excellent presentation about genetics, next generation sequencing and bioinformatics and the importance of this work for children with skeletal dysplasia and their families as well as discussion of the genetics of club foot and alerts and red flags for referral. An insight into the psychological services available and the potential for wider use of clinical psychology in paediatric orthopaedic practice was Questions to Dr John Hernzenberg given by Dr Bridget Coleman. She advocated use of the Smiling Mind App to reduce the impact of the power difference in interactions with our patients. Workshops about assessment of limb deformity and the use of the Bone Ninja App as well as management of fixed flexion deformity of the knee in Cerebral Palsy were well attended and provoked a lot of interesting debate. There were a number of descriptions of fellowships and bursaries that have facilitated travel to the USA

and updates on current research topics and education in the society. Free paper sessions covered limb lengthening, slipped upper femoral epiphysis, patient reported outcome measures, developmental dysplasia of the hip, neonatal fractures, and tibial fractures. There were presentations describing work around the world including Afghanistan and Pakistan. Interesting and informative debates followed a number of the presentations. The prize for the best presentation was awarded to Charlotte Broadhurst for her presentation from Southampton about the incidence of late diagnosed DDH in a 26-year national study. This year’s dinner was held at The Halls which are the most complete medieval friary complex in the UK and raised a substantial amount of money for the charity STEPs. Next year’s BSCOS meeting will be a combined meeting of the British and Israeli Paediatric Orthopaedic Societies in Manchester on 12th and 13th March 2020. n

News

Meeting Review – BHS Andrew Manktelow

Presidential guest speaker, Prof Clive Duncan with BHS President Andrew Manktelow and local dignitaries at the BHS dinner in Nottingham, March 2019

The presidential line of the BHS. From left: Jonathan Howell (Exeter) President elect Andrew Manktelow (Nottingham) Immediate Past President Steve Jones (Cardiff) President of the BHS Andy Hamer (Sheffield) Vice President

he Annual Scientific Meeting of the British Hip Society was held on 27th February - 1st March 2019. The meeting was hosted in Nottingham by 2018-19 BHS President, Mr Andrew Manktelow. The meeting was held at the Royal Concert Hall and was attended by 350 orthopaedic surgeons alongside a number of medical students and guests. The conference was held in association with the Arthroplasty Care Practitioners Association, and the BHS was joined by 40 ACPA members. In the three day programme, over 40 scientific podium presentations were heard alongside 80 poster presentations. A Hot Topics session looked at new developments in orthopaedics including robotics, custom implants, the significance of spino-pelvic alignment and an update on the recent Philadelphia Infection Consensus. There were five Topics in Focus chosen, including clinical assessment and the role of non-arthroplasty hip surgery, clinically effective ‘follow-up’ post hip surgery, the 15-year anniversary of the National Joint Registry, its role at present and into the future with a final session on what high demand activities are acceptable following hip surgery in 2019. There was a more political session, co-chaired by the BHS and BOA and attended by BOA president Professor Phil Turner, in which the recent Best Practice Tariff consultation document was presented and discussed. In addition, to the academic presentations, there were clinical discussion sessions, industry-sponsored seminars and workshops. It was a huge privilege for the BHS to welcome Professor Clive Duncan from Vancouver to deliver the Presidential Guest Lecture. Clive, who has contributed so much to the world of primary and revision hip surgery, chose to give a 30-year review of his practice surrounding periprosthetic fractures. The Society Annual Dinner was hosted in St Mary’s Church, with the President choosing the occasion to give a more humorous review of the year and of the political turmoil and challenges the British Hip Society has faced in 2019. With the British Hip Society flag lowered outside the Concert Hall in Nottingham, the BHS meeting in 2020 will be on the 4th-6th March at the ICC Wales, home of BHS President Steve Jones. n

Meeting Review - AAOS Rhidian Morgan-Jones

he American Academy of Orthopaedic Surgeons once again pitched its all-encompassing tent at the Venetian/Sands Expo. Las Vegas had its usual charms. An impressive venue and the usual military organisation behind the scenes make it an enjoyable, if at times overwhelming meeting. This year featured over 1000 posters, 800 faculty, 725 industry exhibits and 25 symposia. The theme, ‘Focused on You’ highlighted the desire to offer a customised educational experience ‘to appeal to your practice area or career stage’. Customisation was definitely helped by the meeting My Academy app and the multiple attendees always willing to advise when you got off at the wrong level (again!). Time constraints meant that I couldn’t stay for the whole meeting but the highlight of the first couple of days for me was the session on Career Development which had real insight from all speakers. Starting with ‘The Aging Surgeon’ and how to recognise in yourself, and colleagues, the deterioration of physical and cognitive function with age and the importance of developing an exit strategy. Next followed ‘Surgeon Well Being for the Benefit of the Patient’. Recognising the demands of our profession and the threat of burnout, overuse injuries and operating theatre hazards shortening careers. The need for career long coaching, mentoring, team building and leadership to help sustain productive and safe careers benefiting everyone. The session was neatly summed up by paraphrasing an airline safety message...... ‘put the oxygen mask on yourself before you help others’! n

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Meeting Review: BASK

or the 2019 BASK Annual Spring Meeting on March 26th and March 27th, delegates were welcomed to The Hilton Metropole Hotel, Brighton, by BASK President Professor Andrew Price and the BASK executive team. There were five free paper sessions at this year’s meeting, which were interesting, well attended, and of a very high standard. Papers on total knee arthroplasty, ACL and meniscus, cartilage, polyethylene and revision surgery, and the painful knee arthroplasty were attended by many lively discussions. The short poster presentation session was excellent and gave some poster presenters the opportunity to expand on their work. Attendees had the opportunity to attend several registry update sessions, including the NJR, and emerging registries such as NLR, UKKOR, and ICRS. Another useful update was provided by Andrew Toms from Exeter, who reported on his recent trip to the second International Consensus on Peri-

Prosthetic Joint Infection in Philadelphia. The five year results of the TOPKAT study were presented by Professor David Beard, and an NIHR update by Caroline Hing. Johnny Matthews gave details of the work he has been able to carry out in conjunction with the James Lind Alliance as the result of a BASK Research Fellowship. Instructional sessions included lectures on fixation or replacement in fragility peri-articular fractures around the knee, and an articular cartilage salvage session, in which Jo Banks presented an interesting and educational journey through the trials and pitfalls of managing articular cartilage loss in the knee secondary to trauma. The patellofemoral joint session was also very informative and discussed PFJ instability replacement and infection. Kriti Sharma, the invited guest speaker, gave a very interesting lecture on the progress of artificial intelligence over the past few years, and how this may affect all

“The BJJ award was presented to Simon Abrams for his oral presentation; ‘Long-term risk of knee arthroplasty in Anterior Cruciate Ligament injured patients undergoing reconstruction: a review of 120,285 ACL reconstruction procedures’.”

Juliet Clutton of our lives in the future, with particular respect to surgery. The Lorden Trickey lecture was presented this year by Professor Anders Troelsen from Copenhagen, who gave an insight into the way an arthroplasty service works in Denmark, and provided food for thought for many on how to manage their practice in this time of everincreasing demand. As usual, at the close of the conference, prizes were presented. Best Oral Presentation was won by Simon Abram for ‘Long-term risk of knee arthroplasty in Anterior Cruciate Ligament injured patients undergoing reconstruction: A review of 120,285 ACL reconstruction procedures’. Arianna Cerquiglini won the best poster prize for ‘Analysis of the Attune knee system: a comparative retrieval study’, and the best ePoster prize went to Amy Garner for ‘Medial bi-compartmental arthroplasty retains the functional advantages of unicompartmental arthroplasty with a higher functioning gait compared to total knee arthroplasty’. The President’s Medal was awarded to Tom Kurien by Colin Esler, for his podium presentation at the 2017 BASK meeting; ‘The structural, psychological, functional and pain sensitization characteristics of preoperative knee osteoarthritis patients with evidence of neuropathic pain. A prospective observational study’. We look forward to the 2020 meeting in Oxford. n

News

Update from PHIN (Private Healthcare Information Network) Jonathan Finney

HIN’s focus over the last six months, and particularly that of my team, has been on bringing greater transparency over the costs of private healthcare by publishing the typical fees charged by consultants working in private practice for consultations and procedures. This is an important part of the CMA’s Order and we are delighted that so many consultants have taken part and submitted their fees. There are 15,000 consultants that appear in the data collected from private hospitals, so this has been a major endeavour. I’d like to thank the many orthopaedic surgeons who have been proactive in this process. I’m sure you won’t be surprised to hear that orthopaedic surgeons are among the most prominent specialties appearing on our website. Of course, there are some who experienced issues – none more so than what to do about your packaged prices? Although the CMA Order only requires PHIN to publish

consultants’ fees, we know that many have inclusive package agreements with their hospitals and providing a fee purely for undertaking the procedure is therefore difficult. We also believe that patients should have clear and simple information on the total costs they can expect to pay, so we have asked hospitals to publish the package fees too. Our work on publishing fee information will be ongoing. There is a legal requirement on all consultants with private practice to publishing their typical fees. If you haven’t yet done so, our team are always here to support. The next measure at consultant level will be patient satisfaction. Several larger hospital groups and independent hospitals have implemented the standard set of questions as part of their overall patient feedback programmes and data is coming in. As more data is submitted we will look to show consultants their satisfaction scores in the PHIN portal and then publish the

information for patients. We believe this will help patients positively choose a consultant who suits their needs. As I read back through this article, there is clearly a lot going on. We are beginning to see that the CMA’s Order and PHIN’s work is having an impact on the private healthcare sector. While we’ve not actively promoted the website, visits have doubled over the last 12 months and will continue to grow as more information is published and insurers point the clients to the website when authorising treatment. It will take time to get the data right, but many hospitals are steadily responding to the queries they receive from consultants. Data and reporting on private healthcare is steadily improving, and we welcome your continued support on this journey. n ____________________________________

Jonathan Finney is Member Services Director at the Private Healthcare Information Network.

BOA Membership Update New BOA Members Portal and Website We hope you like the look of the new BOA website which launched in March and has a range of useful features including booking courses and events. Through the website, members can access the My BOA Portal, which allows them to update their membership details, pay for membership and review previous invoices and payments. Members can also access the Members Directory, which replaces the printed Handbook. The online Members Directory enables us to help members keep their contact details up-to-date and also allows us to meet requirements under the new data protection regulations (GDPR) and help reduce costs. Make sure to have a look, you can find us at the same website address: boa.ac.uk.

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National Back Pain Pathway Lee Breakwell

Back pain is one of the major scourges of modern humankind, accounting for 11% of all disability amongst the UK population1. NHS England spends £200 million per year on spinal surgery, with over 10,000 patients per year undergoing elective surgery.

he recent GIRFT spine report has embarrassingly highlighted the huge variation across the country in its delivery. It does not compute that these variabilities are good for patients or for that matter the economy. The latest NICE back pain guidance, NG59, which had a significant input from relevant parties, has clearly shown that many of the modalities offered are of poor efficacy and safety, and as such should not be routinely commissioned. Whilst spinal surgery for many pathologies is extremely effective, and often life-changing, it is recognised that fusion for low-back pain in many patients is of poor efficacy. It is further estimated that £9 million alone will be saved by non-commissioning of ineffective injections for back pain. A working party, the Improving Spinal Care Project2, ably led by Professor Charles

“Whilst spinal surgery for many pathologies is extremely effective, and often life-changing, it is recognised that fusion for low-back pain in many patients is of poor efficacy. It is further estimated that £9 million alone will be saved by non-commissioning of ineffective injections for back pain.” 16 | JTO | Volume 07 | Issue 02 | June 2019 | boa.ac.uk

Greenough sought to design a model of care that offered quality, evidence-based treatment for all those in need. The result, the National Back Pain Pathway was launched in September 2017 with the associated Clinical Network (NBP-CN) to aid in the rollout and implementation. The stated aim is to deliver a locally managed National Back Pain Pathway assessment and treatment map. pathway seamlessly linking primary and secondary care ensuring the patient sees and treat practitioners, which will be vital the right person at the right time, in the right to the wide scale delivery of this model. All place, and is offered the right approach. This those involved in the day to day management can be achieved with appropriate system design, of back pain stand to benefit by ensuring this and implementation. Good, reliable results structured evidence-based approach to the care however are wholly reliant upon buy-in from of these patients. n the clinicians involved, high level training of the initial triage and treat practitioners, and a References single point of access into secondary care for those deemed in need of referral. A functioning 1. www.england.nhs.uk/blog/charlessystem also requires the regional spinal network greenough to have agreed systems to fully utilise and 2. www.ukssb.com/improving-spinal-caresupport the acute care trusts as well as the project independent AQP providers. 3. www.flipsnack.com/Cynergy/necsu-back Pilot studies in the North East3 and pain-programme-ftjezeelu.html Sheffield4 have already shown that this 4. Withers S, Cole A, Athanassacopoulos methodology can be practically implemented, M, Breakwell L, Chiverton N, Ivanov M, efficient, and scalable, with measurable Michael A, Tomlinson J, Lachlan S, Wilson outcomes whilst offering significant cost H. (2017). Triage and treat service for back savings at CCG level. The NBP-CN is working and radicular pain: 3 year results. The Spine to develop the roles of first contact and triage Journal. 17. S9. 10.1016/j.spinee.2016.12.026

News

Conference listing: EFORT (European Federation of National Associations of Orthopaedics and Traumatology)

www.efort.org 5-7 June 2019, Lisbon

SBPR (Society for Back Pain Research)

www.sbpr.info 5-6 September 2019, Sheffield

BOA (British Orthopaedic Association)

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

Lisbon, Portugal ACC, Liverpool

WOC (World Orthopaedic Concern)

www.wocuk.org 8 June 2019, Glasgow

BESS (British Elbow and Shoulder Society)

www.bess.org.uk 18-21 June 2019, Leeds

BTS (British Trauma Society)

www.bts-org.co.uk 6-7 November 2019, Nottingham

BOFAS (British Orthopaedic Foot and Ankle Society)

www.bofas.org.uk 13-15 November 2019, Nottingham

CAOS (Computer Assisted Orthopaedic Surgery (International))

BSS (British Scoliosis Society)

BIOS (British Indian Orthopaedic Society)

BOTA (British Orthopaedic Trainee Association)

BLRS (British Limb Reconstruction Society)

OTS (Orthopaedic Trauma Society)

BORS (British Orthopaedic Research Society)

BritSpine

www.caos-international.org 19-22 June 2019, New York

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

www.blrs.org.uk 27-30 August 2019, Liverpool

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

www.britscoliosissoc.org.uk 21-22 November 2019, Cardiff

www.bota.org.uk 27-29 November 2019, Edinburgh

www.orthopaedictrauma.org.uk 15-17 January 2020, Newcastle

www.ukssb.com 1-3 April 2020, London

News

Virgin Money London Marathon 2019 C ongratulations to Paul Banaszkiewicz, Alan Cooney, Paul Harnett, Robert Jordan, Ann Oldroyd, Peter Thompson, Jonathan Waite and Caesar Wek for running the London Marathon on Sunday 28th April. We would like to especially congratulate Paul Harnett on his finishing time of 5 hours 30 minutes whilst running in ski boots, this was also a New World Record! So far the Joint Action runners have raised over £12,000, if you would like to show your support for these amazing runners please donate to the London Marathon Team page: www.justgiving.com/ campaigns/charity/boa/londonmarathon2019. We’d like to thank our runners for participating to raise the much-needed funds for Joint Action, the only UK charity that specialises in raising and distributing funds to the entire musculoskeletal spectrum. If you are interested in taking part in the Virgin Money London Marathon 2020 please contact us at jointaction@boa.ac.uk.

Paul Harnett - New World Record Holder “I’m a Consultant Orthopaedic Surgeon in Pelvis and Acetabular Reconstruction at King’s College Hospital, London. At the London Marathon I broke the Guinness Book of World Records for running a marathon in ski boots, with a time of 5 hours 30 minutes 27 seconds. I raised over £7000, via my fundraising website, skibootmarathon.com. On the day of the big race, I had a technical glitch with the timing tracker strapped to the side of my ski boots, so it didn’t work, this meant I had to wait an agonising three days until the official result was announced. Thank you so much to all those who sponsored me. I was really worried about getting a femoral neck stress fracture, most of my colleagues including me have a seen one or two patients over the years with a femoral neck stress fracture running the London marathon, so it’s not that rare, but luckily my hips held up just fine, I’d run a few more miles each week in the boots, up to 20 miles three weeks before the race. A couple of times I ran eight miles to work in my ski boots through Hyde Park and past Buckingham Palace, I certainly got a few weird looks, but sometimes people didn’t bat an eyelid, ‘just another weird thing in London’. The race was mostly fun, towards the end, my proximal medial tibial plateau was hurting a lot, and I was imagining the bone stress reaction on the T2 MRI while I was running. A few miles later, I was sure I had a second metatarsal stress fracture (a Marchers’ fracture!), I thought to myself ‘if that’s the only injury I get, I’ll take that in exchange for a world record’. In the end, I just had few blisters, killer thigh pains for a few days, and one very proud eight year old son.”

Robert Jordan “Running the London Marathon has been a great experience and I am grateful to Joint Action for the opportunity. The chance to set personal goals, experience the supportive London crowds whilst raising money for a good cause made me return for a second year and I would recommend it to others!” Alan Cooney “The London Marathon is an iconic sporting event and I’d encourage anyone to take part. The winter training can be gruelling but having something to aim for makes getting out of bed on a cold, dark morning all the easier. And it’ll all be worth it as you come down The Mall at the end. Pain is temporary but glory is forever!” Peter Thompson and Jon Waite “We completed the 2019 London Marathon which turned out to be the biggest ever with over 42,000 competitors. It’s a truly memorable and spectacular event with a route that takes in many of the famous sights of London. However the most impressive part is the crowd support. At times it’s deafening with cheering, singing and music including steel drums and DJs. Despite being in a world of pain from 20 miles you don’t dare to stop running! It’s an emotional day that will stay with you for ever so suggest you get signed up for next year.”

Paul Banaszkiewicz “Running the London marathon has to be one of the achievements to look back on in later life. One of the world’s best marathons, fantastic crowds, fantastic atmosphere, running through historic iconic landmarks of London. Joint Action is a really worthwhile cause it’s what we ideally should be aligned with as orthopaedic surgeons treating arthritis on a daily basis. Don’t think too much or worry about whether you will manage it to complete it just sign up for next year’s run and get going. You will have a fantastic experience.” Ann Oldroyd “My two daughters have scoliosis so have worn braces to control the curvatures of their spines. To run the London Marathon for the British Orthopaedic Association was an opportunity

to give something back. I thoroughly enjoyed my whole London Marathon experience. I can’t say the training wasn’t hard at times but it was all worth it on the day to run with the crowds behind you and for a worthy cause.” Caesar Wek “Completing the London Marathon was one of the most rewarding experiences in my life and I will be forever grateful to the BOA for allowing me to represent Joint Action. The support throughout the run was fantastic with crowds cheering from start to finish. There were lots of sweets, jelly babies and even ice lollies on offer from the passers-by! There were many emotional highs and lows, especially when my headphone battery died, however the support from the crowds helped carry me to the finish line. Thanks again for giving me the opportunity to support such a worthy charity!”

Features

The Development of a Medical Device (CasterpillarTM) David Ross

Cast saws are noisy, produce dust and can injure the skin. Plaster-cutting shears are unable to cut synthetic casting tape and industrial cutting techniques are not appropriate for clinical use. About 20 years ago, I suggested to several large orthopaedic product manufacturers that a new device could be developed. These approaches were unsuccessful.

David Ross had initial surgical training in Glasgow, was an orthopaedic registrar in Bristol then a hand surgery fellow in Edinburgh. Having completed higher surgical training in Aberdeen he was appointed as a consultant orthopaedic surgeon in Stirling in 1988, with special interests in trauma and hand surgery. He retired from clinical practice in 2014.

hrough Scottish Enterprise, I was introduced to George Miller, a development engineer, and in 2003 we formed Ross Wark Medical Ltd., to design, develop and market a safer device. We were accepted on to the Scottish Enterprise ‘Pipeline’ and given a ‘By Design’ award. We received advice on Intellectual Property, Medical Device Approval and international marketing and sales. We have also had financial assistance from Scottish Enterprise, but this has been a small proportion of the substantial investment required. We approached several design houses but they were unable to produce a practical cast cutting system. We realised that we would have to design the cutting system and we studied conventional hard material-cutting shears and identified the key features. We then reproduced these key features and added novel design components to produce a safe and efficient cast cutter. We obtained British, American, and Canadian patents, with a German patent pending. The United

States patent was only granted after our patent attorney took a prototype to the United States Patent Agent in Washington and demonstrated our novel design features. ‘Casterpillar’ is registered as a trade mark in the U.K. We moved into an industrial unit at Stirling Enterprise Park: this allowed us to build workshop, testing and administrative facilities. The power, drive and control systems were developed to BS 60601 (Medical electrical equipment safety and performance standard), and the design and build processes were closely aligned to ISO 13485 (international quality management standards for medical devices). Good relationships were established with our component suppliers. We obtained MHRA (Medical and Health Regulatory Authority) registration as manufacturers of a class 1 medical device. Product liability insurance was arranged. Once satisfactory performance had been achieved on test casts, made from combinations of different types of stockinet, under-cast padding and casting tape, we progressed to removing casts from adult volunteers. By 2015 our initial device had been evaluated in a major orthopaedic teaching hospital by an expert casting course tutor and was in clinical use in four other hospitals. The feedback indicated safe and satisfactory cutting performance, but weight and control complexity issues. The use of ‘Rapid Prototyping’ including 3D printing, and CAD/CAM (computer assisted design/computer assisted manufacture) allowed design changes to accommodate clinician feedback and technical advances. The second generation device is lighter, easier to use and is now in clinical use. It has been demonstrated successfully at exhibitions in England, at a large international trade fair, Medica, in Dusseldorf, and in Atlanta, Georgia. We have expanded our facility in Stirling and will continue to manufacture our device in the UK. Possible options are being explored for production under licence in the USA and Germany and for our UK made products to be distributed in the UK, Ireland and Scandinavia. A study is planned comparing the operator vibration exposure of our device with that of a cast saw. There have been discussions on producing a child and parent information video of cast removal. n

33rd EDINBURGH INTERNATIONAL TRAUMA SYMPOSIUM AND TRAUMA INSTRUCTIONAL COURSE 12TH - 16TH AUGUST 2019 BOOK EARLY TO SECURE VIVA AND CADAVERIC BREAKOUT PLACES. TRAUMA SYMPOSIUM 14TH-16TH AUGUST 2019 Annual meeting for established orthopaedic surgeons with renowned international faculty. Three day meeting focused on revalidation and update through a combination of short interactive lectures and case based discussions Breakout sessions include cadaveric surgery focusing on surgical approaches and modern fixation techniques TRAUMA INSTRUCTIONAL COURSE 12TH-16TH AUGUST 2019 Five day orthopaedic trauma course suitable for established surgeons, trainees and AHPs Comprehensive lectures and case based discussions on the assessment and management of paediatric, adult and fragility fractures. Breakout sessions including cadaveric anatomy teaching and FRCS viva practice Venue: Sheraton Hotel and Edinburgh Medical School Visit us during one of the most exciting times of the year with the world famous Edinburgh International Festival and Fringe.

Further information and a detailed programme are available on our website: www.trauma.co.uk or by email: symposium@trauma.co.uk. SPONSORED BY www.trauma.co.uk symposium@trauma.co.uk.

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Features

GIRFT Orthopaedic Trauma Bob Handley

GIRFT (Getting It Right First Time), a project initiated by Tim Briggs, has grown progressively. Elective orthopaedics was its first home but it is now active in 35 specialities. I took up the role of National Clinical Lead for GIRFT Orthopaedic Trauma in January of this year. An initial period of wondering what I had let myself in for, has to some extent continued.

Bob Handley is a Consultant on the Trauma Service at the John Radcliffe Hospital in Oxford. Bob is Vice-President Elect of the BOA, and is a Past President of the Orthopaedic Trauma Society and AOUK. Bob co-chaired two NICE guideline development groups related to fractures, and is National Clinical Lead for GIRFT Orthopaedic Trauma.

IRFT can be regarded as a process, but is better seen as an opportunity or lever to effect beneficial change. Central themes have been the analysis of and reflection on available data, avoiding unnecessary variation and promoting the dissemination of good practice. At this early stage in the development in the Orthopaedic Trauma GIRFT there are aspirations which may not pass the test of practicality but I will set out my general approach.

HES data is used for much of the GIRFT analysis but Orthopaedic Trauma also has the advantage of some other well established sources notably TARN and the NHFD. Another advantage is that the process does not start in a vacuum, there is the background of the recently produced NICE guidelines for Complex and Non-Complex Fractures and the BOASTs, all providing an accepted basis for good practice. The GIRFT dataset

and the questionnaire will naturally include these areas on which standards have already been set. Visiting every acute trust will allow assessment of the uptake and implementation of such guidance. The overall picture gained should shed light on variation, difficulties with implementation, the need for update of the standards and examples of good practice. An early objective is to disseminate examples of practice so that we do not need to constantly re-invent solutions. As the elective orthopaedic GIRFT has been running for five years, it seem wise to seek areas where Trauma is different. Apart from the specifics of individual injuries, the major difference between Orthopaedic Trauma and our elective work is time. We cannot control the time of initial presentation, when required interventions often need to be prompt and the patient has little time to prepare or be prepared. The variable route and time of initial presentation make it difficult to manage the front of house and the first contact. Setting reasonable and appropriate expectations at that first contact increases the chance of a smooth, efficient and co-operative relationship with patient and carers. In elective practice the patient generally knows only too well what it is like to live with their problem, whereas with an injury we the clinicians have to inform the patient of both the natural history and the likely results of intervention. We have to initiate a pathway of treatment when it is necessary and provide reassurance when it is not. Whilst prompt treatment may be vital, many injuries have a benign course so

Features

avoiding ‘medicalisation’ and over treatment is an important part of an effective service. This management of front of house and first contact with a patient is genuinely an example of the need to Get It Right First Time. The concept of Red and Green days (or time) helps draw attention to where improvement is possible. Red representing the time that a patient is in hospital or using a resource without anything productive actually happening. The use of day case surgery is common in elective work but more difficult when the procedure cannot be preplanned. Whilst waiting lists can be a burden, they do bring the advantage of the flexibility of a having a reservoir of cases to smooth peaks and troughs of acute presentation. It will be interesting to find how much variation there is in the provision of trauma day case surgery and how the good systems work. It seems likely that many patients are either held

at home and repeatedly cancelled or occupy a hospital bed when they could have been managed as a day case. Not all trauma practice is self-contained within individual units. The arrangement of the hub and spoke of the major traumas centres is familiar to us all. The NICE guidelines also recognised this in separating complex form noncomplex fractures. More recently the notion of a genuine network has been emerging; within the footprint of the MTC there is communication and co-operation not just as hub and spoke but in many directions more along the lines of a spider’s web. This allows for conscious consideration of the development of protocols and consideration of unnecessary variation within a network; this may have benefits for trainees, procurement, agency staff and consequently patients. To encourage this my aim is that in addition to the normal deep dive visit to an individual trust

“Setting reasonable and appropriate expectations at that first contact increases the chance of a smooth, efficient and co-operative relationship with patient and carers.”

there will also be a network visit to discuss matters best addressed in that forum. Orthopaedic Trauma may sound self-contained but there are many interfaces. The list is daunting; we work with ED, anaesthetics, radiology, orthogeriatrics and many more, we may have patients with chest injuries, head injuries, hand injuries, soft tissue injuries under our name. Whilst GIRFT cannot address all of these issues it will be an objective to form a picture of how practice varies and to identify where groups of patients may be disadvantaged by falling between spheres of influence. In summary, at this stage I remain naively optimistic with regard to my stamina and the objectives. GIRFT Orthopaedic Trauma is without doubt an opportunity to effect beneficial change. I suspect that most frequently any change will not be directly my doing, but more often the result of in-house effort precipitated by the preparation, open discussion and deadline of a GIRFT visit. My travelling as a benevolent vector should make it easier to spread good practice. Where general policy change is needed then this can form part of the GIRFT final report but may also be used to inform the future content of guidelines such as BOASTs. n

Features

The Future of Casting: Education, Training, Examination Don McBride

Plastering techniques and splintage are a skill and art form that have been in practice for thousands of years1. In general terms, the principles have remained the same but the education, training and certification have developed and expanded.

Don McBride is VicePresident of the BOA and a Consultant Orthopaedic Surgeon at the University Hospital of North Midlands specialising in foot and ankle surgery. Don has previously been Chairman of the Scientific Committee and President of BOFAS, and is a co-opted Council Member acting as liaison with EFAS where he is now President Elect (President 2020-22) and Chairman of their Certification Board.

owever, in recent years there has been a concern that some of these skills have been lost amongst junior doctors including specialist trainees in trauma and orthopaedics and indeed their more senior colleagues. For example, the application of balanced traction for a femoral fracture is rarely practised (it was my last duty as an SHO to check it on patients at the end of each day) and there is minimal use of even simple techniques such as the application of a Thomas Splint, most commonly utilised as temporary pain relief prior to surgery and when transferring from the emergency department to the trauma ward. There has been a response with short, often day courses, being run in a number of hospitals and other institutions by a variety of providers including junior doctors, nurses and plaster technicians variously supported by industrial partners. Inclusion in the training curriculum as a required skill has clearly helped and should continue to do so.

The BOA has had a Casting Committee and Casting Certificate since 1982 and this has fulfilled a necessary role for education, training and examination in casting techniques for nurses working in plaster rooms and plaster technicians. The exam is currently overseen by the Glasgow Caledonian University and it takes place at Stanmore three times per year. The courses to sit the examination are run at Stanmore (five weeks), Bradford (day release) and in the Royal Gwent Hospital, Newport (day release). Scotland has a day release course at the Glasgow Caledonian University and Northern Ireland has no current course but should hopefully be included. The courses involve suitable training in anatomy and physiology relevant to trauma and orthopaedics, cast application using different materials including plaster of Paris and resin-based materials with their special properties for specific techniques. The use of splints and their particular applications are also covered, for example, the Pavlik harness. The examination involves a viva provided by Trauma and Orthopaedic Consultant Casting Examiners

â&#x20AC;&#x153;The BOA has had a Casting Committee and Casting Certificate since 1982 and this has fulfilled a necessary role for education, training and examination in casting techniques for nurses working in plaster rooms and plaster technicians.â&#x20AC;?

However, more coordinated education is required with appropriate standardisation and examination uniformity, principally for our nurses and plaster technicians who would like

to develop their skills. The clear advantages of this relate to the correct application of plasters and splintage, the early recognition of complications such as compartment syndrome and the appropriate early management of these complications while contacting others for assistance in dealing with them, for example, surgical decompression. In addition, it is logical to assume that there would also be a reduction in complaints about cast and splint application, for example, to individual trusts and to the Health Services Ombudsman2 or indeed in cases involving alleged medical negligence, for example, pressure sores and superior mesenteric artery syndrome following the application of hip spicas in children3.

Features

England with a separate northern group, the OTA (Orthopaedic and Trauma Alliance), run from Bradford. Recently there has been a consideration to amalgamate the two groups and they now run joint meetings on alternating years. Although there are obvious hurdles, an element of unification would be highly desirable to move things forward across the UK and would be welcomed by the industrial partners who kindly sponsor the meetings and provide workshops. In this regard the BOA would be more than happy to facilitate any discussions, which may enable this process to be progressed. n

and assessment at practical stations provided by the National Casting Adviser assisted by nurses and plaster technicians who are in possession of the Casting Certificate.

of time, the main leaders in the provision of education, training and the examination for casting have been sadly lost. They will be sadly missed. However, although their past achievements should be suitably praised it is clearly time to take stock and move things forward in a manner that they would both appreciate. The BOA shall soon be advertising for a replacement National Casting Adviser and are expecting high quality applicants. This is an important position.

With the sad passing of Sue Miles (National Casting Adviser, RNOH) and Anne Petty (past chairman Orthopaedic Trauma Alliance, Bradford) within a short period

The Casting Committee and indeed the BOA are currently affiliated to the AOP (Association of Orthopaedic Practitioners) mainly but not exclusively recruiting from the south of

3. Tisherman RT, Hoellwarth JS, Mendelson SA. Systematic Review of Spica Casting for the Treatment of Paediatric Diaphyseal Femur Fractures, J Child Orthop. 2018 Apr;12(2):136-44

References 1. Szostakowski B, Smitham P, Khan WS. Plaster of Paris-Short History of Casting and Injured Limb Immobilisation. Open Orthop. J.2017;11:291-96 2. Report of Selected Summaries of Investigations by PHSO, 2018

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Features

International Sport and a Surgical Career Richard Dodds

I had no idea I wanted to be a doctor let alone a surgeon. I went to Kingston Grammar School, played a lot of sport, passed some exams and applied to Cambridge University to do medical sciences as my older brother’s best mate, who had done the same four years earlier, thought I would be good at it and it looked like a place I could play some good sport. Serendipitous that I should choose a career in which I could use so many lessons learnt playing sport.

B Richard Dodds was born in York in 1959 and moved south aged five. He attended Kingston Grammar School, St. Catharine’s College Cambridge and St. Thomas’ Hospital Medical School. He completed orthopaedic training in Reading and Oxford as a Registrar and at St. Mary’s Rotation as a Senior Registrar. He gained a fellowship in Brisbane. He was appointed as a consultant at the Royal Berkshire Hospital in Reading in 1994 with a special interest in Knee Surgery and Children’s Orthopaedics. He has been a Regional Adviser in Oxford Orthopaedic Training Programme and Director of Medical Education at Royal Berks. He was Chairman of the Great Britain Men’s Hockey Board and a member of the Executive Committee at the British Olympic Association. He is currently a RCS Tutor at Royal Berks.

etween the summer of 1979 (aged 20) and 1st October 1988, I was lucky enough to play 144 hockey internationals (79 England, 65 Great Britain), winning Olympic Bronze, World and European Silver and ultimately the Olympic Gold medal in my final match. Summer 1979 was the end of my first year in Cambridge. So, during my international hockey career I got a degree, transferred to St. Thomas’ Hospital Medical School, qualifying in 1984, did house jobs (missing the first two weeks of my first job for the Los Angeles Olympics), casualty and anatomy demonstrating at The Middlesex and a basic surgical training programme in Chertsey at St. Peter’s. I owe big thanks to the surgical staff (most notably Martin Thomas, Douglas Donaldson and Pete Surtees) and management there who allowed me to work part-time in the last three months of that job in the build up to Seoul in 1988. Whilst I could manage my full time job (one in three on call) and train and play hockey, I had no rest time – consequently, I found I was beginning to do both badly. Here’s the first lesson – all work and no rest leads to poor performance. I suspect a few surgeons reading this have learnt this lesson the hard way!

I do not think that nine year period is reproducible these days as the time requirements of the sports are much more demanding – only some part-time work is really possible, but in those days much training was on your own. That period of time required close time management for me and indeed some sacrifice, especially of social life. I missed all seven of my cousins’ weddings due to either hockey or work. My training time needed to be put to good use. Matthew Syed states that it takes 10,000 hours of meaningful practice to become an expert in anything. Thus, the second lesson is that practice needs to be ‘meaningful’ be it hockey training or surgical training unless you want to take longer than that to become an expert. Back in 1979, when I first played, I thought sport was all about ability and I wondered why the top sides always seemed to get the lucky breaks. As a cocky youth, it was a hard lesson to learn that experience does matter. You make your own luck in sport. Gary

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Player said, “The more I practise, the luckier I get”. He wasn’t wrong. Good pre-match planning, having a different plan if the first plan isn’t working and knowing when to change tack, post-match debriefing and reflection on what worked and what didn’t are all integral parts of success in sport. Does that ring any bells with surgery? Attention to detail and marginal gains were the hallmark of the success seen in British Cycling. This sounds a bit like Getting it Right First Time.

different characters from full backs. Midfielders can be hard-workers you never hear of, or star players who score great goals too. As for goalkeepers…weird lot! A great striker will only score if he gets the ball in the right place – would Eric Cantona have been as good without David Beckham’s passing? I doubt it. The team is as strong as the sum of its parts and in fact is probably only as strong as its weakest part. The art of captaincy is to unite the players on the pitch and get the best out of each and every one. For me, the lesson here is that as a consultant surgeon you are captain of your team and have just the same responsibility. You are not just the striker waiting for the ball to be served where you want it so you can take the glory.

“During my international hockey career I got a degree, transferred to St. Thomas’ Hospital Medical School, qualifying in 1984, did house jobs (missing the first two weeks of my first job for the Los Angeles Olympics), casualty and anatomy demonstrating at The Middlesex and a basic surgical training programme in Chertsey at St. Peter’s.”

I was made captain of England in 1986 for the World Cup and then of GB for the Olympic programme. This brings an increased responsibility to the team and makes you look more closely at the characters that make it a team. Strikers are

On some days hockey was easy, on some days surgery is easy. On some days form deserts you and yet you still have to perform. When I was out of form in sport, going back to getting the basic skills right and patiently waiting for form to return seemed the best and perhaps only option. Patience with your poor form in surgery is a necessary skill. It is said that form is temporary but class is permanent – believe it. Of course, having an Olympic Gold medal on your CV sets you apart from most of the other applicants for a registrar and consultant job. I only did not get short-listed for a job I applied for once – I didn’t want to be a neurosurgeon anyway! In my Senior Registrar interview I was asked about the state of hockey coaching in this country. It’s not often you get a question in these interviews where you definitely know more than the interviewers – I made the answer long and detailed! However, as I reflect on reaching 25 years as a Consultant Orthopaedic Surgeon, I think it is the other lessons I learnt from playing top level team sport that have helped me the most in what I hope will be regarded as a successful surgical career. Thank you for allowing me to indulge in my memories of the 80s and the lessons my sporting career taught me that have benefitted my surgical career – I’ve enjoyed it, I hope you have too. n

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Nick Kalson is an NIHR Academic Clinical Lecturer in Orthopaedics (ST5) in Newcastle and is the BASK research fellow for 2019-20.

UK Peri-Prosthetic Joint Infection Meeting (UK-PJI) Nick Kalson, Johnny Mathews, Andrew Toms

Johnny Matthews is a specialist trainee in orthopaedics on the Bristol rotation currently undertaking a PhD, and was the British Association for Surgery of the Knee (BASK) Research Fellow 2018-19.

Prof Andy Toms is a consultant knee surgeon at the Exeter Knee Reconstruction Unit and BASK Research lead. He undertook orthopaedic training on the Oswestry/ Stoke rotation and fellowship training in Adult Reconstruction at the University of British Columbia in Vancouver.

Peri-prosthetic joint infection (PJI) is one of the most challenging clinical problems in orthopaedics. It is expensive to treat, achieving good outcomes is difficult and best practice is not well-defined. This uncertainty and variation in treatment was reflected at the International Consensus Meeting (ICM) on Musculoskeletal Infection (July 2018, Philadelphia, USA), which attempted to produce guidelines covering the entirety of orthopaedic infection not just PJI.

lthough the ICM was hugely successful, several areas produced considerable debate. To tackle these challenges and develop guidelines for UK clinical practice, a UK-PJI group was formed. The first meeting, convened by Rhidian Morgan-Jones and Andrew Toms, brought together 62 clinicians from more than 30 centres; surgeons, microbiologists and infectious disease physicians reflecting the contemporary importance of the multidisciplinary team (MDT). Sessions were held on diagnosis, MDT working, antibiotic cement, fungal infection, as well as subspecialist meetings in hips, knees and microbiology. The key points from these sessions are presented (boxes). Three areas were the focus of discussion: • Diagnostic criteria and culture negative joint infection (CNJI) • Antibiotic loaded cement (ABLC) • Surgical technique (one or two-stage revision) and use of spacers

A number of diagnostic criteria currently exist (e.g. MSIS, ICM 2018), but tests such as synovial fluid cell counts and leukocyte esterase are not routinely available, hence have not been widely adopted in UK practice. However, widespread adoption would guide management and improve standards. It is hoped the British Joint Infection Register (BAJIR) will improve usage of these diagnostic criteria.

“The overriding theme of the meeting was recognition that PJI is difficult to manage, and best results are obtained with multi-disciplinary working and collaboration. This will likely extend to the development of regional infection centres, to manage more complex cases.”

Regarding CNJI, it was agreed this diagnosis should only be reached after five intra-operative samples have been cultured, and additional tests such as molecular work (PCR), fungal culture or liquid culture for mycobacterium have been considered. Sending samples to a second regional laboratory was also recommended. Antibiotic-loaded cement has been shown in both trial and registry data to reduce the rate of PJI. However, the ICM failed to recommend its routine use on cost grounds.

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The literature was presented and agreement reached that routine use of ABLC is supported unless contraindicated in primary joint replacement in the UK. Both knee and hip groups recognised there is insufficient evidence to recommend one or two-stage revision, although clinical comparison trials are currently underway.

Diagnosis: • If there is concern over infection cases should be discussed by the MDT and aspiration considered • Synovial fluid aspirate and biopsy should be performed for diagnosis pre-operatively • Five intra-operative samples are recommended, one of which can include synovial fluid MDT: • All PJI should be managed by an MDT comprising infection specialists, surgeons and specialist nurses with access to allied specialists e.g. plastic surgeons Fungal infection: • Should not be treated by DAIR; two stage revision is recommended • Should be managed in a specialist centre Antibiotic delivery: • ABLC does reduce incidence of PJI • If there is no contra-indication then use of ABLC is recommended

In the knee session, discussion was held on choice of surgery. Similar results have been reported for one and two-stage revision, making absolute contraindications to either technique difficult to define. It was broadly agreed that caution should be exercised when considering a one-stage procedure in a fungal, atypical or resistant organism or culture negative case, and it should not be performed in a previous failed revision for infection or when there is inability to achieve soft tissue coverage. The hip session focused on the use of articulating/non-articulating spacers in staged management of PJI. There was agreement that that when articulating spacers are used the two-component custom-made type is preferable, and that non-articulating spacers should only be used in limited situations (septic patients, damage control surgery). Importantly, the UK BAJIR (http://bajir.edendrite.com/) is now running, collecting comprehensive clinical data (surgical treatment, antibiotic therapy, pathogenic organism etc.) aiming to understand and improve management and outcomes of infected bone and joint conditions. Units are encouraged to register by emailing nhc-tr.bajir@nhs.net. The overriding theme of the meeting was recognition that PJI is difficult to manage, and best results are obtained with multidisciplinary working and collaboration. This will likely extend to the development of regional infection centres, to manage more complex cases. There will be a UK-PJI session at the BOA meeting on Tuesday 10th September, alongside other specialist sessions. The next UK PJI forum will be held in Birmingham (March 2020). Thanks to Dominic Meek, Vanya Grant, Pedro Foguet, Jason Webb, Sam Oussedik, Martin Sarungi, Amir Sandiford, Lee Jeys, Rob Townsend, Rob Porter, Neil Jenkins, Matthew Wilson, Michael Whitehouse, James Murray, Ian Mcnamara and Abtin Alvand for running the sessions and Helen Vint for information on BAJIR. n

Microbiology: • Pre-operatively patients should be off antimicrobials for at least two weeks, longer if clinically safe • CNJI should only be diagnosed after processing an appropriate number of intra-operative samples • Histology should be available. Second opinion should be sought.

Knees: • Debridement and implant retention (DAIR) is an urgent but planned procedure that should be performed/supervised by an experienced arthroplasty surgeon involving exchange of all modular components plus radical debridement and lavage. (Arthroscopic washout or debridement has no place other than in the acutely septic patient.) • DAIR indications: early and late-acute haematogenous infections in a well-fixed, wellpositioned implant in a joint functioning well prior to the infection • Cautions to DAIR; loose implants, chronic infection, inability to close the wound, resistant organism (fungal / multi-resistant / atypical) • Single-stage revision indications: positive preoperative culture with antibiotic sensitivity, not a resistant organism • Contraindications for single stage; sepsis, previous failed revision for infection, inability to close soft tissues • Cautions for single stage revision; CNJI, resistant organisms, immunosupression or significant comorbidities • Two-stage indications: negative preoperative culture, resistant organism, staged soft tissue reconstruction required, significant immunocompromise, sepsis • Contraindication to two-stage; inability to achieve adequate temporary stability of the joint

Hips: • Excision arthroplasty and non-articulating spacers should be limited to septic/unstable patients for ‘damage-control’ surgery or short interval (around two weeks) two-stage revision • Once stabilised early conversion to articulating spacer or second-stage should be considered • When articulating spacers are used the twocomponent cemented spacer with both femoral and acetabular components may be optimal interval treatment and preferable to hemiarthroplasty type spacers

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Medical Student Learning in the Orthopaedic Operating Theatre: Educational Strategies for Surgeons Adam Hexter and Alistair Hunter Attending the operating theatre (OT) is one of the hallmarks of undergraduate teaching in orthopaedic surgery1. ‘Theatre-based learning’ offers a unique resource with exposure to orthopaedic pathology and technical aspects of orthopedic procedures, whilst providing opportunities to observe ‘softer’ non-technical skills, such as teamwork, communication and decision making2. Adam Hexter is a NIHR-funded Academic Clinical Fellow in Trauma and Orthopaedics on the North East Thames (UCH) Rotation. Adam is now a ST4level registrar taking time out of training to complete a PhD at UCL. Adam has a passion for medical education and completed his post-graduate certificate which led to this piece of work.

Alistair Hunter is Consultant Hand, Wrist and Elbow Surgeon and Surgical Tutor at University College London Hospitals. He holds a Masters in Medical Education and has a strong interest in surgical training at all levels, running a number of local and national courses. He is senior author on this systematic review.

owever, the OT is a dynamic, high-pressure setting with unique challenges for students, and it represents an unfamiliar environment for students to acquire knowledge3. Theatre-based learning receives mixed feedback, with fear and anxiety common emotions owing to the traditional surgical stereotype of ‘learning by humiliation’4. Students can feel like a hindrance owing to hostility from members of theatre staff, arising due to the apparent conflict between teaching and service provision5. This has implications on recruitment into orthopaedic surgery, with student experiences ‘in theatre’ known to influence future career decisions6. Therefore to promote the orthopaedic profession to students it is important for them to have positive learning experiences in the operating theatre. This article summarises the pertinent findings from a systematic review into medical student learning in the OR7. This article highlights the main factors that influence medical student learning in the OT, and identifies five educational strategies that orthopaedic surgeons should use in their teaching practice to address these.

Emotions Emotions in the clinical setting are known to influence student learning8. To be effective learners in the operating theatre students must cope with the emotions generated by entering an unfamiliar learning environment. The emotional response reported by students typically includes negative emotions such as apprehension, fear and anxiety. Prior to their first theatre attendance 96% students report feeling nervous, with 89% concerned that they will appear incompetent9.

Socio-environmental Theatre-based learning has been described as a dynamic, social interaction where students and surgeons are constantly ‘sizing up’ each other10. Teamwork and a sense of feeling socially included are powerful determinants that positively influence learning11. When students were asked about factors that affect learning, the friendliness and approachability of staff was most important factor, reported by 74% of students12. OT attendance is increased when students perceive the environment as welcoming and where they can actively participate13.

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Educational

finding the operating theatres, getting access to theatre attire, and seeing the surgery once in theatre. Students are often uncertain over whom to address and in understanding the different staff members and their roles. Many students are unclear of general theatre etiquette, such as which doors to enter through and where to stand16.

Setting clear objectives for learning in the OT is beneficial to medical students, but is most often not performed. Students report feeling insecure when the learning objectives were unclear14. A survey of 209 newly qualified graduates found that 13% had clear learning objectives set for their time in the OT, despite the presence of learning objectives being positively correlated with attendance in the OT13. Learning objectives are not always apparent to students and even when they are, they might be overlooked by the surgical educator, with surgeons focusing on technical processes15.

“When students were asked about factors that affect learning, the friendliness and approachability of staff was most important factor, reported by 74% of students.”

Educators

The behaviour of surgical faculty strongly influences how conductive the operating theatre is to learning. Six behaviours of surgeons appreciated by students include: clarifying who the teacher is; signposting so the theatre staff know when teaching is happening and applying time frames; acknowledging when critical incidents are happening; clarifying expectations of students; and providing a continuous commentary and asking questions of the students14. Students also like it when

Organisational Students often express a perceived lack of preparation for learning in the OT, which has been attributed to insufficient organisational support. Students report challenges such as

QIST 2019

DAY CASE HIP & KNEE ARTHROPLASTY DATE: Tuesday 15 October 2019 th

VENUE: Grand Hotel Gosforth Newcastle DELEGATE CHARGE: £55 INCLUDES REFRESHMENT AND LUNCH

QIST in collaboration with the British Association of Day Case Surgery (BADS) presents the above meeting to provide information and shared experience on how to set up a day case hip and knee athroplasty services and how to overcome the challenges. The meeting will be suitable for Orthopaedic Surgeons, Anaesthetists, Physiotherapists, Nurses, Managers, Pharmacists & Allied Health Professional.

To register please go to eventbrite via link below:

www.eventbrite.co.uk

surgeons ‘think out loud’, provide continuous commentary and question students, which makes them feel validated as learners17.

Strategies to enhance student learning in orthopaedic operating theatre The following educational strategies have been shown to improve theatre-based learning: 1. Induction. A session should be carried out that provides teaching on OT etiquette and basics skills such as scrubbing. The expectations of students in the OR should be outlined and emotions acknowledged. Teaching of basic information or learning of scrubbing, gowning and gloving for theatre led to students feeling significantly more confident in theatre etiquette skills and having an improved experience in the operating theatre18. 2. Physical orientation. Students should be familiarised with the workspace and be introduced to OT interdisciplinary team. An introductory session reduces negative emotions and should include details such as the nature of the procedure to be seen, the amount of blood loss expected and necessity for lead gowns in advance14. >>

Overview of the topics: •

The challenges to overcome

•

Results and safety of day case hip and knee replacement

Faculty: •

Professor Mike Reed, Clinical Director, Trauma and Orthopaedics, Northumbria Healthcare NHS FT

•

Mr Paul Partington, Consultant T&O Surgeon, Northumbria Healthcare NHS FT

•

Dr Kim Russon, Consultant Anaesthetist, Rotherham Foundation Trust, President Elect British Association of Day Surgery (BADS)

•

Dr Mary Stocker, Consultant Anaesthetist, Director of Day Surgery, South Devon Healthcare NHS FT

•

Mr Michael Kent, Consultant Orthopaedic Surgeon, Torbay & South Devon NHS FT

•

Tracey Hepworth, Senior Physiotherapist, Rotheram NHS FT

•

Mr Tom Wainwright, Associate Professor of Orthopaedics, Bournmouth University

•

Mr Phil Walmsley, Consultant Orthopaedic Surgeon at Fife NHS Board

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3. Clear learning objectives. Expectations and learning objectives should be present in curricular documents. For the surgical educator, ensuring clarity of the learning objectives prior to or in the OT, and ensuring the content aligns with the needs of the students are important in maximising the educational relevance of the teaching. 4. Simulation. There is increasing evidence that simulation can prepare trainees to overcome barriers within training and develop skills within in a safe environment19. Where facilities are available, medical students should benefit from simulated operation suite (SOS) and inclusion of interdisciplinary team members will increase the theatre staff appreciation of medical students as learners and improve the socioenvironmental factors20.

5. Educator feedback. An institutional commitment to delivering constructive formative feedback to surgical educators would be of benefit in the continued development and improvements in theatre-based learning.

“Six behaviours of surgeons appreciated by students include: clarifying who the teacher is; signposting to the theatre staff know when teaching is happening and applying time frames; acknowledging when critical incidents are happening; clarifying expectations of students; and providing a continuous commentary and asking questions of the students.”

Summary The OT is traditional learning environment for students and theatre-based learning is gaining greater attention. Attending the OT allows students to observe real clinical problems and their surgical management and develop a clinical memory of surgery through tactile, visual and auditory mechanisms. However students face many challenges in the OT and orthopaedic surgeons must be aware of the factors that influence student learning.

Behaviours that orthopaedic surgeons should adopt in the Operating Room: • Clarify who the teacher is • Introduce the theatre staff • Signpost so the theatre staff know when teaching is happening and applying time frames • Acknowledge when critical incidents are happening • Clarify expectations of students • Provide a continuous commentary • ‘Think out loud’ • Ask questions to the students • Discuss learning objectives and address teaching accordingly • Seek real-time feedback for your teaching

Orthopaedic surgeons should incorporate the educational strategies discussed in this article into their daily teaching practice to maximise their students’ learning experiences. This will lead to better undergraduate teaching of orthopaedics, and promote the profession to students considering orthopaedics as their chosen career. n

References References can be found online at www.boa.ac.uk/publications/JTO

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Operations I no longer do...

Arthroscopic Lateral Release of the Knee Richard Parkinson

I am senior enough to remember that during my early training years in the early 1980s knee arthroscopy was a rarely performed operation and open meniscectomy was considered the standard treatment for a torn meniscus.

Richard Parkinson works on Merseyside at Wirral University Teaching Hospital. He is a past president of BASK. Currently he is a BOA trustee and a committee member of ODEP and Beyond Compliance.

efore the days of MRI scanning in the late 1980s, knee arthroscopy became a commonly performed operation. There was a long slow learning curve in those halcyon days, and it was a procedure that was often performed for diagnostic purposes. The diagnosis of chondromalacia patellae was a common one. Following failure of conservative treatment, this condition was often treated surgically with a lateral retinacular release. The lateral release became to be performed arthroscopically, quite often with a Smillie knife or a pair of scissors. The procedure appeared to be supported by peer reviewed publication and expert opinion. It was my observation from an early stage that very often the operation failed miserably to relieve the patient’s symptoms. Continuing pain was common; indeed, many patients got worse. Haemarthrosis, complex regional pain syndrome (called reflex sympathetic dystrophy in those days) and even medial dislocation of the patella were all notable and observed complications. Lateral release also became a recommended treatment for patella instability as reported Dandy and Griffiths. In my hands it never seemed to work. As an isolated procedure it has drifted into obsolescence, to be replaced by procedures such as medial patello-femoral ligament reconstruction, tibial tubercle osteotomy, patellar tendon transfer or femoral trochlearplasty. The description of chondromalacia patellae has largely given way to the more modern terminology anterior knee pain syndrome. This is a catch-all term for patello-femoral pain in the presence of normal radiology and healthy joint surfaces in the young patient. The rationale for performing lateral release was to relieve pressure on the lateral patella facet due to a supposedly tight lateral retinaculum. Patella tilt and lateral maltracking could also, in theory at least, be surgically corrected.

Still with an open mind about this procedure, I did my knee fellowship with John Bartlett in Melbourne Australia in 1993. He performed arthroscopic lateral release very sparingly. He told me that of all the knee procedures that he did, lateral release was the one most likely to generate a phone call to his secretary with the patient claiming to be ‘in extremis’ and demanding an urgent clinical assessment. With advancing age, the diagnosis of chondromalacia merges into patello-femoral arthritis with the result that lateral release has often been supplemented with a synovectomy or abrasion chondroplasty. One of my previous mentors, Jonathan Noble, observed in a classic JBJS editorial as long ago as 1992 that “shaving is at its most effective on the chin and not in the knee”. How right he was! This is another example of a procedure which now becoming confined to the history books. Many patients who present with severe and intractable patello-femoral pain appear to have a disproportionally high level of symptoms which often fail to respond to the usual conservative treatments of physiotherapy, analgesics, NSAIDS, cortisone injections and watchful waiting. Not infrequently there are coexisting psycho-social problems in addition to physical symptoms, perhaps at least partly explaining why there is such a poor response to surgery. It has also been my observation over 25 years in consultant practise that arthroscopic lateral release, performed in isolation for any patello-femoral disorder, rarely produces any worthwhile benefit. Very often it resulted in a surgical complication or worsening symptoms. It is an age-old mantra that a physician should ‘do no harm’. Anterior knee pain syndrome is a commonly seen disorder, but hardly ever is the solution a surgical one. n

References 1. Anterior Knee Pain: Diagnosis and Treatment. Post RJ. J Am Acad Orthop Surg 2005;13:534- 543 2. Unnecessary Arthroscopy (Editorial). Noble J. JBJS(Br) 1992 74-B 797-8 3. Lateral Release for Recurrent Dislocation of the Patella. Dandy DJ Griffiths D. JBJS(Br) 1989 71-B 121-5

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How I do... High Tibial Osteotomy Chris Wilson

t is, in selected patients, at least as good as arthroplasty for pain relief and better for function, and is, of course, knee preserving. There are many indications, including regenerative surgery and in association with knee ligament reconstruction, but the main workhorse procedure is the correction of the arthritic varus knee with a proximal tibial osteotomy.

I am describing the technique of open-wedge osteotomy performed for medial compartment DJD associated with varus deformity, for both advanced and given the evidence that deformity in association with arthritic change generally progresses early disease. It is helpful to think of exclusions rather than indications. Exclusions include severe fixed deformity, limitation of movement, tricompartmental disease, but not age. Preparation should include analysis of the deformity and the desired angle of correction. It is important to have appropriate longleg x-rays taken in bipodal weight bearing stance with the patellae directly anterior to the distal femur. Mistakes of rotation in the long-leg views can lead to substantial errors in calculating the angle of correction. There are several methods of calculating the angle of correction from the long-leg views. I use the Miniaci method (image 1). It is important to avoid overcorrection and better to slightly under correct than over correct.

I prefer a paramedial longitudinal incision, extending for 10cm just below the level of the pes anserinus tendon insertion. An oblique incision is also an option (image 2). The medial collateral ligament is released below the joint line (i.e. not releasing the deep portion). Release of the pes anserinus is optional.

Osteotomy around the knee is a powerful procedure, widely practised in continental Europe but only to a degree in certain UK centres.

Chris Wilson is a consultant in Cardiff University Hospital. He has a mixed knee and trauma practice, and is interested in the biological approach to knee reconstruction, although he retains healthy scepticism over the present use of stem cells in knee surgery.

The surgeon should know opening distance in the proximal tibial osteotomy. It is very difficult in practice to measure angles on the table. The set-up is with the leg initially at 90Â° held by a bolster and side support. A tourniquet is optional.

Once the release is performed a retractor or swab should be inserted into the space in the tibia behind the level of the osteotomy to protect the neurovascular bundle. I use a fixed angle plate. Firstly using x-ray screening, I place the plate alongside the tibia and confirm that the starting point of the osteotomy lies at an appropriate point, which is generally just in the crook of the axilla of the medial side of the tibia. I then place a guidewire posteriorly at that level, and aim for the area of tibia just superior to and lateral to the head of the fibula. I then place a second wire exactly parallel. I then draw a line between these wires, but then three-quarters the way anteriorly, take my line proximally and design a coronal osteotomy. This is known as a biplanar osteotomy. I first of all use a saw to complete the coronal osteotomy behind the tibial tubercle. If the osteotomy is over 15mm it is better to make an inferior biplane. I then use the saw on the guidewires to make a cut three-quarters of the way across. A low-excursion saw such as the Stryker Precision saw is better. It is important to ensure that the posterior cortex cut is complete. I then complete the osteotomy to within 1cm of the far cortex with an osteotome.

â&#x20AC;&#x153;I use a fixed angle plate. Firstly using x-ray screening, I place the plate alongside the tibia and confirm that the starting point of the osteotomy lies at an appropriate point, which is generally just in the crook of the axilla of the medial side of the tibia.â&#x20AC;?

At this point, the osteotomy should appear mobile. If it is not, the cuts need to be revisited. Then insert sequential osteotomes as a stacked technique. Then a widener. The opening should be measured at the posterior cortex. The anterior width should be twothirds of the posterior width in order to preserve the tibial slope. If the anterior width is increased, the tibial slope will increase. I then insert a laminar spreader (image 3). If the osteotomy is less than 10mm, I would use simple allograft chips in order to capture the blood clot in the osteotomy, but it is quite permissible to put nothing in the gap and has been demonstrated to give reliable healing.

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If the osteotomy is over 10mm then there would be a case for putting in some form of graft. An allograft wedge reduces pain and bleeding. I personally would not favour a synthetic wedge. Having confirmed the correction, I then remove the protective swab, put the medial ligament back in place as far as possible (although some surgeons leave the medial ligament) and place the plate, anchor it with a wire then place the four proximal locking screws.

At this point, the osteotomy can still be adjusted. Once the final correction is achieved, I insert a compression screw. The compression screw is aimed in the most proximal of the distal holes and orientated perpendicular to the plane of the osteotomy to compress the hinge (image 4). Once the plate is compressed, I put in three distal locking screws, the most distal being unicortical. I then remove the compression screw and put in another locking screw. It is important to fill all the screw holes and not leave any empty. At that point, the layers can be closed. No drain is required. I allow full range of motion, with no brace (unless there has been a problem with fixation or clear lateral hinge fracture) and 10kg weight bearing for six weeks.

I warn the patients about severe bruising and pain for three weeks, and ask them to come back early if they have severe lateral pain, which can be a sign of lateral hinge instability. I am very happy with the results of this technique. It deserves wider attention and uptake in the UK. There are very good UK courses now run by my colleagues which you can find here: http://clockwork-medical.com/. n

Acknowledgements to Ronald Van Heerwaarden, Philipp Lobenhoffer, Alex Staubli and Roland Jakob for permission to use these illustrations.

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Medico-Legal

How notes, records, letters and websites can let you down in court Giles Eyre Background: Mrs Hassell had a C5/6 decompression

and disc replacement operation performed by a spinal orthopaedic surgeon. She suffered a spinal cord injury during the operation which caused tetraparesis and rendered her permanently disabled.

M Giles Eyre is a recently retired barrister and an Associate Member of Chambers at 9 Gough Square, London, having practised for many years in the field of injury claims and at the interface of law and medicine. He continues giving training and presenting workshops for experts on providing effective expert reports and evidence, and on medico-legal issues. He is co-author of Writing Medico-Legal Reports in Civil Claims – an essential guide (2nd edition 2015), and author of Clinical Practice and the Law – a legal primer for clinicians (October 2018) both published and sold by Professional Solutions Publishing (www.prosols.uk.com), and regularly writes articles on these subjects.

rs Hassell complained that the surgeon did not warn her that the operation might leave her paralysed and did not discuss other conservative treatments before the decision to have the operation was made. The Trust asserted that the surgeon warned Mrs Hassell about the risks of paralysis and discussed other conservative treatment options. Allegations were also made about the standard of care but this aspect of the claim failed at trial. However, in relation to the failure to obtain informed consent, the claim succeeded, entitling Mrs Hassell to substantial damages.

The judgment

1. The surgeon showed a misunderstanding about the patient’s history which was inconsistent with having had a proper discussion about treatment options. While he claimed in evidence to have discussed conservative treatment options including physiotherapy with Mrs Hassell he understood that Mrs Hassell had already had physiotherapy for her neck. However, the judge held that he could not have had this misunderstanding if there had been a proper discussion with her about other treatment options because she had not had physiotherapy for her neck and upper arm problems and that would have become clear in any discussion. 2. The surgeon was ‘not a good communicator’ about operation risks because when he gave evidence in chief about the risks of the operation he did not include DVT or PE, which in his witness statement he said he would have mentioned, claiming that it was his ‘invariable practice’ to mention them for the cervical discectomy. There was no obvious reason why he should have failed to do so. Although he believed that it was his invariable practice the judge concluded that in fact what he said sometimes differed.

“The judge’s analysis of the evidence demonstrates the lawyer’s approach to evidence, in which accuracy and consistency are crucial. Predominantly the decision was based on inconsistencies (or what appeared to the judge to be inconsistencies) in the surgeon’s evidence.”

In Hassell v Hillingdon Hospitals NHS Foundation Trust1 the judge had to decide whether the surgeon had given the patient a warning of possible cord injury in consenting her for spinal surgery and the possibility of alternative treatments. Having heard the evidence of both the surgeon and the patient the judge decided, on the balance of probabilities, that the warning was not given and alternative treatments were not discussed. He relied on seven reasons for coming to that conclusion which give an insight into the way a judge’s mind works in establishing probable (and therefore, for court purposes, proved) facts:

3. The patient’s recollection was clear and carried weight. She recalled discussion about a less serious risk – a hoarse voice - but not the more serious risk of paralysis, which would have been of very real concern for her as the mother of three children and in full time work. She confirmed that situation in a letter of complaint that she wrote.

4. The surgeon asserted in a letter following the surgery that the operation could result in paralysis, adding that the risks were similar to those explained to Mrs Hassell for previous

Medico-Legal

unreliable, as to whether he mentioned the possibility of further injections as an alternative treatment. In his witness statement he made no mention of mentioning injections although in his oral evidence at court he did.

spinal surgery. However, the earlier letter in relation to the previous surgery said nothing of the risk of paralysis. Therefore, if he had explained the risks to Mrs Hassell as he had for the previous low back surgery he would have failed to mention paralysis. 5. The surgeon’s evidence was inconsistent, and therefore regarded by the judge as

6. The surgeon asserted that he referred patients to his website to understand better the risks and benefits of the surgery, but the website omitted reference to paralysis, again raising doubt that he in fact did warn of this risk. 7. The risk of paralysis was not expressly referred to in a letter dictated in front of the patient prior to the surgery.

Learning points The judge’s analysis of the evidence demonstrates the lawyer’s approach to evidence, in which accuracy and consistency are crucial. Predominantly the decision was based on inconsistencies (or what appeared to the judge to be inconsistencies) in the surgeon’s evidence. It might be assumed that knowledge of the import and effect of the decision in Montgomery on consent would equip a surgeon to provide proper information in consenting a patient. However, there can be no doubt from this judgment the importance of accuracy both in giving evidence and in any underlying documents relied upon in evidence, and of consistency between oral and other evidence, and of being able to communicate well, both in this case to the patient and to the court. It is also essential to make and maintain clear contemporaneous records and notes to describe and explain what has taken place. n

References 1. [2018] EWHC 164, http://www.bailii.org/ ew/cases/EWHC/QB/2018/164.html

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Features

Book Review: Clinical Practice and the Law. A Legal Primer for Clinicians by Giles Eyre Review by: David Warwick

I am privileged to be asked to review this book by the author, Giles Eyre. He has recently retired as a Barrister, having become a leading educator for doctors and others in becoming Expert Witnesses, based on a long and illustrious career in the field of personal injury and clinical negligence.

David Warwick has been a Consultant Hand Surgeon at University Hospital Southampton since 1998 as well as visiting Hand Surgeon to the States of Jersey and Bailiwick of Guernsey. He is involved daily in the clinical management of complex hand and wrist problems with a particular interest in the DRUJ, Dupuytren’s, joint replacement and orthopaedic hand trauma.

he book is remarkably short – just 135 pages – and can be read within three or four hours. It is beautifully laid out with clear chapters each with a brief introduction followed by logically arranged headings and subheadings. Key points are highlighted in concise text boxes. Reading this book would benefit all doctors both junior and senior. Why? Because the work of all doctors is inextricably linked with the law. Every time we meet a patient we have a Duty of Care. Every interaction with a patient (whether in person or in writing) might one day be scrutinised in a negligence claim. We have to interact with police enquiries and coroners’ inquests. Some of our patients have issues with mental capacity for which clear legal laws apply. We face issues of consent for transfusion and unconscious patients. General Data Protection Rules are the latest threat to our peace of mind. Many doctors probably feel threatened or even hostile to the legal profession. Perhaps the doctor fears unfair scrutiny of his work, more for the gain of the lawyer than the patient. This book goes a long way to dispelling this misconception. By reading the book, a doctor will understand the legal context of clinical practice. The book starts with an explanation of how lawyers and the Court examine evidence (be it oral or written) in a tidy, logical and forensic way. By understanding this, a doctor’s record keeping will inevitably improve and will provide a robust defence at a later date were his clinical practice to be questioned. Having read this book, there is no doubt that I will spend more time recording all key clinical findings, more fully explaining consent and to explain explicitly my clinical reasoning for any particular decision or recommendation. The book also talks the reader through the process followed when things go wrong in clinical

practice. Genuine mistakes rather than negligent errors are common; the obligation for Duty of Candour is emphasised-; it does not mean an admission of negligence. If things go properly awry, then the Author explains how to engage with the potential clinical negligence process, Fitness to Practice assessment or disciplinary proceeding. The book briefly and clearly explains long-standing and also more recent legal judgements such as Bolam, Bolitho, Montgomery, Thefaut and more recently Hassell. With each judgement, a doctors’ obligation to provide clear, logical patient-orientated advice has become more and more established. Whilst this might on the face of it make a doctor feel more insecure, in reality by understanding the simple principles outlined in this book, the doctor should become more immune to legal scrutiny. Another strength of this book is the repeated emphasis on how established good medical practice as defined by the GMC merely reflects the expectation of the law. Simply by following good medical practice much of the perceived threat of litigation will just fall away. Even though I have been in consultant practice for over 20 years and an Expert to the Court on medical negligence cases for several years, I found countless wise tips which I will integrate into my practice. These will include routinely recording my logic on every decision, making sure that informed consent is viewed entirely from the patient’s perspective, and writing to the patient in clear non-medical terms rather than to the GP in medical terms after a clinical consultation. This really is an excellent practical guide and I would recommend it wholeheartedly to all doctors. It is a gentle, easy read and yet so apposite to current practice. n

“Many doctors probably feel threatened or even hostile to the legal profession. Perhaps the doctor fears unfair scrutiny of his work, more for the gain of the lawyer than the patient. This book goes a long way to dispelling this misconception.”

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Simulation Section

An introduction to Simulation Lisa Hadfield-Law

The master-apprentice model of surgical training has endured for over a century, but today, our patients should not carry the sole burden of the learner’s learning curve. Simulation can help surgeons acquire capabilities across a wide spectrum of knowledge, skills, judgement and professionalism. Learners can develop, through trial and error without compromising patient safety. Driven by this philosophy, simulation-based training has been integrated into the T&O curriculum but implementation of effective and evidence based progress has vacillated.

Lisa Hadfield-Law, RGN, MSc,FAcadMEd and Education Advisor to the BOA. https://hadfield-law.co.uk

n the up side, there is a commitment to simulation and the focus on operative skills has been balanced more recently with non-technical skills learning. But on the down side, despite wellestablished principles of learning including deliberate practice and spaced learning, many simulation opportunities are provided through massed learning and a fixed number of repetitions. On top of that, too often, expensive simulation facilities lie fallow due to lack of technical or educational support or because trainers and trainees aren’t released from service. So, although simulator technologies continue to evolve and are attractive to surgeons with a technical focus, we must seek robust evaluation of impact and feasibility, to address questions around return on investment of time and money. Flawed research methods have plagued simulation initiatives, which may have led to inaccurate conclusions. Many of the procedural models still lack evidence for validity, which raises concerns about domination by technology rather than educational principles1.

Critics maintain that many simulation opportunities offer solutions without first identifying the problem. Whether simulated patients, virtual reality models, animal tissue, live anaesthetised animals, human cadavers, saw bones or a mix of all of them, the first step is to define learning need and evaluate options for achieving that need2. Although simulation has typically targeted more junior trainees, the more experienced and those requiring remediation could also benefit. Whoever the target audience, simulation opportunities should be dovetailed with relevant clinical opportunities. Deliberate practice3 around simulation should be focused, repetitive practice where the learner is continuously assessed with timely feedback and aiming for improved performance. Simulation has a valuable role in training, but it will not be the panacea. With this in mind, JTO will run a series of articles to help readers decide for themselves, how they might integrate simulation into their own teaching and learning. n

References 1. Palter VN, Grantcharov TP. Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial. Ann Surg. 2014 Mar;259(3):443-8 2. Bjerrum F et al Surgical simulation: Current practices and future perspectives for technical skills training. Med Teach. 2018 Jul;40(7):668-675 3. Ericsson KA (2011) The surgeon’s expertise in Fry H, Kneebone R, editors. Surgical education: theorising an emerging domain. London: Springer p107-121 4. Rivière, E et al (2018) Twelve tips for efficient procedural simulation, Medical Teacher, 40:7, 743-751

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Simulation Section

What is Simulation? Duncan Tennent

Much has been written about the change in surgical training with the reduction in surgical hours and length of training. A number of other factors have also added to the difficulty in obtaining adequate surgical experience including, but not limited to, joint registries and complication records, the increased technological complexity of many of the procedures and increased pressure to be ‘productive’.

lthough many surgeons are keen to teach these influences can produce a level of anxiety which results in a greater proportion of the cases being consultant delivered as opposed to the previous model of consultant supervised (occasionally at some distance!). All of this has spurred a desire for alternative teaching methods to compensate.

Duncan Tennent is Professor of Orthopaedic Education at St George’s Medical School and Director of Education for the South West London Elective Orthopaedic Centre as well as being a Consultant Shoulder and Elbow Surgeon at St. George’s NHS Trust. He is currently a BOA Council member, on the SAC and past Treasurer of BESS.

Surgery has long looked to the airline industry as a role model with checklists and safety being the main influences. The role of flight simulators in training is often discussed but, in reality, has not made any significant impacts on surgical training. Essentially this is due to the investment in both time and money to develop these simulators which has not, as yet been forthcoming. Over the last decade or so ‘simulation’ has been referenced as a means of teaching surgical skills but there is currently little structured approach to this. The orthopaedic curriculum now includes provision for simulation and this will be the subject of another article in this series. Evidence suggests that although there is enthusiasm for teaching and an orthopaedic willingness to embrace new technology the provision is patchy. One of the difficulties lies in understanding what is meant by ‘simulation’. For many this is all immersive reproducing the entire surgical experience, akin to the flight simulator mentioned previously. This is clearly an expensive option which would be difficult to develop for the multitude of procedures and, once this has been mentally discarded the subject is shelved. The next highest ‘fidelity’ which most of us are exposed to is that provided by the use of cadavers. These are immensely popular

amongst trainees and allow, in many cases, for a very realistic experience. There are however many drawbacks to their use including cost and availability, however the biggest drawback is the lack of measurable feedback and the ability to ‘reset and do it again’ which the pilots can do repeatedly in the flight simulators. To address the former, attempts have been made to produce devices which will measure activity, usually in terms of distance travelled and time taken, provide feedback and allow repeated attempts using a screen based/ haptic feedback construct. There is good evidence in general surgery and in one of the original studies of laparoscopic cholecystectomy a haptic feedback simulator was used to train a cohort of surgeons and demonstrated a 29% reduction in surgical time and a five-fold reduction in error rate1. Orthopaedics has lagged behind and most simulators have been based around arthroscopy as it lends itself to the instruments and screen, however the range of procedures available has been limited to fairly basic diagnostic procedures and, until recently, there was no evidence that performance in the simulator translated to performance in the operating room2. What is often forgotten in the drive to use ever more sophisticated technology is that most of us have been doing simulation for a very long time but have never appreciated it. The Cambridge Dictionary defines simulation thus “to produce a situation or event that seems real but is not real, especially in order to help people learn how to deal with such situations or events”. All of us have undertaken basic life support training using the Resusci Annie which has been around since the 1960s3 and, in its latest iterations is a highly sophisticated device. The sawbones session with the company rep is simulation. The only difference is that it is not dressed up as a teaching session with formal feedback,

Simulation Section

similarly the case based discussion which develops the ‘what if’ scenarios, enabling the trainee to make errors, receive feedback and ‘have another go’ is also a form of simulation. These scenarios should be embraced and recognised as opportunities. Scrutiny of surgical performance is going to increase. Currently there is only a National Joint Registry for arthroplasty but there are others and there is ongoing discussion of soft tissue registries. This not only makes the consultant more wary of allowing the trainee to possibly alter their own perceived performance but makes it very difficult for the newly minted consultant who may have very little experience and has their delayed learning curve recorded for the world to see.

to claim that simulation was all that was needed for the Blue Angels to perform in this manner, many hours of ‘real’ practice are also required. The same applies to surgery.

evidence that the time and money we spend is to the benefit of our trainees and, ultimately, our patients. n

Orthopaedic surgeons by their very nature are practical and many are enthusiastic teachers (certainly if you have read this far then you have an interest) and examples of this sort of innovative thinking are present in many locations around the country but are often only locally recognised.

References 1. Seymour, N.E., Gallagher, A.G., Roman, S.A., O’Brien, M.K., Bansal, V.K., Andersen, D.K. and Satava, R.M., 2002. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Annals of surgery, 236(4), p.458

“What is often forgotten in the drive to use ever more sophisticated technology is that most of us have been doing simulation for a very long time but have never appreciated it.”

What does this means for us as trainers and trainees? We need to start to ‘think outside the box’ when it comes to training. The Blue Angels flight display team practice as a team by ‘chair flying’, sitting in chairs going through the moves as a team4. This is a low tech, highly effective, flight simulator which, given the impressive high stakes, displays evidences that this sort of approach can be used effectively as an adjunct. Obviously it would be inaccurate and simplistic

As was indicated in the introductory piece we must be careful not to apply ‘simulation’ without first identifying the educational need and ensuring that whatever tool we use, be it all immersive ‘hi fi’ or case based discussion that it has a purpose. If this is done we can

2. Roberts, P.G., Alvand, A., Gallieri, M., Hargrove, C. and Rees, J., 2019. Objectively Assessing Intraoperative Arthroscopic Skills Performance and the Transfer of Simulation Training in Knee Arthroscopy: A Randomized Controlled Trial. Arthroscopy: The Journal of Arthroscopic & Related Surgery

3. Cooper, J.B. and Taqueti, V., 2004. A brief history of the development of mannequin simulators for clinical education and training. BMJ Quality & Safety, 13(suppl 1), pp.i11-i18 4. https://youtu.be/0wK3Wi3hoek

Trainee Section

Striving for excellence in surgical training: Reassessing the Trainee-Trainer relationship Matthew Brown Co-Authors: Vitty Bucknall and Alastair Faulkner

Much emphasis is placed on the expectations of today’s surgical trainees. 31 years after BOTA’s annual Trainer of the Year Award was established we review current initiatives to support, develop and ‘professionalise’ surgical trainers.

S Matthew Brown is an ST8 registrar on the North East Thames (Stanmore) T&O training rotation. He is the President of the British Orthopaedic Trainees Association and sits on the Councils of the BOA and the Royal College of Surgeons of England.

urgical trainees are familiar with the responsibilities required of them. Whilst demonstrating clinical competence through workplace-based assessments, logbook entries and annual reviews, we must satisfy the expanding requirements of the CCT, which has evolved to include everything from minimum operative numbers and passing the FRCS to demonstrating capabilities in leadership, teaching, quality improvement and research. The acronyms ISCP, WBA, FRCS, ARCP and CCT are never far from a trainee’s mind and they represent what a trainee must demonstrate or acquire during their training. Becoming a surgeon requires mastering technical skills, knowledge and professional attitudes, with on the job experience being fundamental to our learning. Although surgical trainees must take responsibility for their own professional development, an emphasis on what trainees must achieve has perhaps overshadowed the role played by our surgical trainers. With a decline in training hours, the dissolution of the traditional ‘surgical firm’, a focus on patient safety, and a move from time-based to competency-based training, a new conversation focusing on the quality of our training has begun. BOTA recognises, and celebrates, the principle attributes of our best trainers and often uses this journal as a conduit.

Bucknall et al. (2018) highlighted what great training looks like and explored the following qualities with input from our recent Trainer and TPD of the Year winners1: 1. Creating an effective learning environment – allowing trainees to learn through collective reflection on those cases that could have gone better. 2. Getting to know your trainee – helping to break down hierarchical barriers and encouraging a mutually beneficial training relationship. 3. Creating a supporting learning environment – encouraging trainees to discuss any professional or personal difficulties without judgement. The best trainers are often the humblest of trainers and their winning formulas may be difficult to quantify. Through recognising trainer excellence, we help demonstrate to all surgical educators what trainees appreciate most in this important training relationship. The Royal College of Surgeons of Edinburgh has taken a lead in the pursuit of surgical training excellence. The College established the Faculty of Surgical Trainers (FST) in 2013 to ‘promote and enhance’ the role of the surgical trainer. Until this time there had been no defined body devoted to supporting surgical trainers in the UK. The Faculty is open to all who demonstrate engagement with surgical training in the UK and beyond, with membership, available at three levels: Associate, Member or Fellow. In 2014, the FST published their ‘Standards for Surgical Trainers’ document (last updated in 2017), which highlighted the need for guidance and robust benchmarking for trainers across all the surgical disciplines2. Written by Mr Craig McIlhenny, chair of the FST and a consultant urological surgeon, the document highlights that surgical training had historically followed an apprenticeship model, with trainees expected to emulate and absorb

Trainee Section

Figure 1: Mr Fergal Monsell (left) and Mr Simon Paterson-Brown (right) during the ICOSET chamber debate at the RCS Edinburgh in April.

surgical skills and knowledge by osmosis. Time was the main indicator of competence. Using the seven training domains presented in the earlier framework of the Academy of Medical Educators (AoME), the FST presents seven domains that have been re-worked with a surgical emphasis. The seven domains are: excellence in training through safe patient care, maintaining an environment for learning, implementing learning and training, enhancing learning through assessment, appropriate goal setting, guiding personal and professional development, and personal continuous professional development as a trainer. The document also provides guidance on how these standards can be met and how the ISCP platform can be used effectively to meet these standards.

‘Excellence by Design’ outlined new standards which all postgraduate medical curricula should follow by 2020, including a move towards competency-based (rather than time-based) training and assessment3. Improving Surgical Training (IST) is a joint RCS England and Higher Education England (HEE) initiative to deliver the recommendations of Professor Greenaway’s 2013 ‘Shape of Training’ report4,5. Trainer professionalisation is a central tenet of the initiative, with enhanced trainer quality helping to facilitate a ‘modern’ surgical apprenticeship. An IST pilot is currently focused on the Core Surgical Training (CST) years but it is expected to cover Higher Surgical Training in the future. The first IST pilot commenced in late 2018 for 20 CST applicants with an interest general surgery. The urology and T&O CST pilots will start in 2019 and 2020, respectively. BOTA continues to work with ASiT, RCS England and other key national stakeholders to ensure that both pilot and non-pilot trainees are equally well supported and that independent and transparent review processes are utilised throughout.

“The best trainers are often the humblest of trainers and their winning formulas may be difficult to quantify. Through recognising trainer excellence, we help demonstrate to all surgical educators what trainees appreciate most in this important training relationship.”

In 2016, the GMC set out the first requirements for trainers to be calibrated and benchmarked, with regular reviews of their performance to drive trainer professionalisation. This framework was based on the work of the Academy of Medical Educators (AoME). Educational and clinical supervisors will be expected to map their activity to seven domains and five domains, respectively. The GMC’s 2017 publication

In 2010, Mr Chris Munsch, consultant cardiothoracic surgeon, and Lisa Hadfield-Law, BOA educational advisor, sought to determine the characteristics and behaviours of proven outstanding surgical trainers from across the spectrum of surgical subspecialties (personal communication). They reviewed winners and nominees for the Association of Surgeons in Training (ASiT) annual Silver Scalpel award through personality typing tools and a one-day workshop attended by occupational psychologists. Commonly observed behaviours included the ability of trainers to: • Adapt their own teaching style to suit different trainees • Provide honest feedback, including a willingness to be tough • Articulate clear expectations from the outset • Provide reflective dialogue and feedback • Be generous with their time and thought Munsch and Hadfield-Law concluded that great surgical trainers exhibit the following behaviours: 1. Make time 2. Adapt 3. Clarify expectations 4. Give feedback generously 5. Teach, mentor and coach appropriately 6. Confront problems 7. Seek continual improvement A recent systematic review of the attributes of successful surgical trainers by Dean et al. (2017) identified several recurring qualities under the themes of ‘character’ (approachability, patience, enthusiasm, willingness to train), >>

Trainee Section

‘procedural’ (willingness to let trainees operate, balance between supervision and independence), ‘teamwork and communication’ (setting educational aims and objectives, using feedback appropriately), and ‘clinical’ (capable, demonstrating good relationships with patients and the healthcare team)6. There is generally significant overlap in the findings of groups who review ideal trainer attributes. However, not all surgeons will demonstrate the full complement of these favourable characteristics. The International Conference on Surgical Education and Training (ICOSET) came to the Edinburgh College in March and welcomed the great and the good of surgical education from around the world. A chamber debate, organised jointly by BOTA and ASiT, debated the motion that ‘every surgeon has a duty to train’. Mr Simon Paterson-Brown, consultant general surgeon at Edinburgh’s Royal Infirmary and founder of the College’s Non-Technical Skills for Surgeons (NOTSS) programme, argued for the motion that every trainer has a duty to train. He stated that we owe it to our past trainers to pass on our knowledge and skills. Furthermore, Mr Paterson-Brown argued that unless trainers make a conscious effort to train they may not be allocated a NTN trainee to support them in their practice. Mr Fergal Monsell, consultant paediatric orthopaedic surgeon at Bristol’s Royal Hospital for Children and chair of the BSCOS education committee, argued against the motion. Mr Monsell put forwards a strong case that not every trainer has the skills or interest to train effectively. He argued that we should not leave the next generation of surgeons in the hands of the uninterested or unskilled. With a vote of 66% against the motion, Mr Monsell secured victory for his argument that not all trainers have a duty to train (see figure 1). This further supported the conference theme for greater support and professionalisation for surgical trainers. These admired trainers argued both for and against the motion using arguments that did not necessarily represent their personal views. However, one theme that they and the audience agree upon was that trainees should be protected from trainers who could not or did not wish to train. Furthermore, there was general agreement that training programme directors should be encouraged and empowered to remove trainees from trainers or training placements that fail to deliver the expected level of training. BOTA’s annual Trainer of the Year (TOTY) award has sought to identify the consultant trainers who go above and beyond in the provision of trauma and orthopaedic training. It is one of the most inspiring and reassuring processes that the BOTA committee has the pleasure of organising. Through celebrating excellence, we aim to recognise, encourage and congratulate trainers who may otherwise not receive recognition. We also aim to demonstrate to the wider trainer community which training methods and attributes are most appreciated by surgeons in training. The difference between

the best and the least best trainers can make or break a training partnership, in addition to influencing our future subspecialty choices and indeed our own training style. After all, we are the consultant trainers of the future. In 2018, TOTY nominations were received from all 29 UK training regions and we thank our network of Regional Representatives for coordinating their local nominations. Anonymised nominations are reviewed by our committee, with specific Figure 2: Trainer of the Year 2018 winner Mr Gavin Spence (centre) holds the new trophy alongside the then BOTA President, Miss Vitty Bucknall (left), and Vice President, Mr Matthew examples of exemplary Brown (right) at the 2018 Educational Congress. training attracting the highest marks. Three finalists were interviewed during the BOA Congress. The Year Trainer of the Year TOTY winner for 2018 was Mr Gavin Spence, who won for his outstanding teaching at Great 2018 Mr Gavin Spence Ormond Street Hospital in London (see figure 2). New trophies were purchased last year for both 2017 Mr Fraser Harrold our TOTY and Training Programme Director awards and the base of each will feature the 2016 Mr David Woods names of past and future winners. These impressive trophies reflect the magnitude of 2015 Mr Niall Eames each winner’s achievement and we hope for them to remain a symbol of orthopaedic training 2014 Mr Peter Bates excellence for decades to come. Nominations for the 32nd Trainer of the Year recently closed, 2013 Mr Stephen Bale however nominations for the TPD award (held every two years) will close at the end of June. 2012 Mr Stephen Cook Unfortunately, the nine TOTY winners between 1991-1999 cannot be identified with certainty despite the efforts of BOTA committee members and past winners. If you can confirm a past winner who is not included in the list provided (see table 1) please email Alastair, our awards lead: vicepresident@bota.org.uk. A new BOTA archive will help avoid this issue and future Past Presidents will help coordinate this endeavour. The Latin origin of the word ‘doctor’ (doceo) means ‘I teach’, however most doctors have little training in how to teach when compared to their expertise in what they teach. It is clear that the best surgical trainers share similar attributes, and although these may feature more naturally in some, all prospective trainers should be supported in developing these skills and characteristics if they so desire. This short article has presented current and future perspectives on the role and character of the surgical trainer and a drive to support and ‘professionalise’ their practice. The BOTA trainee session at the BOA Congress in Liverpool this year will focus on the role of the trainer and explore the topics discussed here. n

References References can be found online at www.boa.ac.uk/publications/JTO

2011

Mr Ian Braithwaite

2010

Prof Gordon Bannister

2009

Mr Tim Briggs

2008

Ms Cathy Lennox

2007

Mr John Shepperd

2006

Mr Tony Banks

2005

Mr Keith Tucker

2004

Mr David Jaffray

2003

Mr Paul Calvert

2002

Mr Chris Curwen

2001

Mr David Finlayson

2000

Mr Tony Banks

1991-1999

UNKNOWN

1990

Mr Hugh Phillips

1989

Mr Chris Colton

Table 1: Trainer of the Year (TOTY) winners since 1989. Winners for 1991-1999 cannot be identified and we seek your assistance. Please email vicepresident@bota.org.uk if you can help.

ISHA 2019

Annual Scientific Meeting Madrid, Spain 17 - 19 October 2019

Venue: Melia Castilla Hotel & Convention Centre, Madrid, Spain

Scientific Programme Theme: Teamwork in Hip Preservation

To book your place at a 5% discounted non-member early registration rate, use discount code BOAJUNE5 on your online registration form for the Annual Scientific Meeting at https://ishaconference.com/organise-your-attendance/registration Programme: Wednesday 16 October 2019 Principles of Hip Preservation Instructional Course – Iberian and Latin America programme (in Spanish) – English speaking programme – Asia regional programme (in English) – Physiotherapy programme (in English)

Thursday 17 – Friday 18th October 2019 ISHA 2019 Annual Scientific Meeting – Scientific sessions – Trade exhibition – Practical training sessions

This meeting is open to ISHA members and non-members. For latest information visit www.ishaconference.com

Saturday 19th October 2019 – Scientific sessions – Trade exhibition – Keynote speaker – ISHA Annual General Meeting – Programme end approx. 13:30

For ISHA membership information visit www.isha.net General information request contact info@ishaconference.com

Subspecialty Section

How the Global Surgery Agenda is changing and the increasing role of WOC UK in the development of training and trauma service development in low and middle income countries Tony Clayson

Since its formation as the Charitable Subspecialty Society of the BOA, WOC UK has been actively involved in supporting many colleagues working in low and middle income countries (LMICs) who have found themselves increasingly burdened with complex trauma to deal with. A well-trodden path documented in our own BOA history with Sir Robert Jones leading the establishment of a trauma system to respond to the large number of casualties produced during construction of the Manchester Ship Canal and later becoming an influential figure in the formation of the ‘British Orthopaedic Society’ later to become the BOA.

A Tony Clayson is a Consultant Orthopaedic and Trauma Surgeon at Wrightington Hospital, a member of the Executive Committee of WOC UK and Invited External Examiner of the Orthopaedic Residency Final Examination at Black Lion Hospital, Addis Ababa. He is a founder member and currently Executive Chairman of the Northwest Orthopaedic and Trauma Alliance for Africa (NOTAA) and a ‘Reverse Fellow’ for AO Alliance Foundation supporting the development of trauma services in Hawassa, Southern Ethiopia.

lthough a member of WOC UK for many years, I have only become actively involved in delivering overseas development work and training in orthopaedics since 2015 and have been in awe of the colleagues I have met both from the UK and throughout the world who I can now call friends and admire the commitment and dedication they have shown over long periods supporting their overseas colleagues. Listening to their experiences inspired me to contribute personally and by all accounts it is a good time for colleagues to actively get involved with the work of WOC as rapid change is taking place on the world economic stage and within the UK, as evidenced by developments at Health Education England, The Royal Colleges and within the specialty training committees of orthopaedics together with an increased desire from UK trainees in orthopaedics to engage in global health development opportunities.

The Global Stage Traditionally, surgical services have been regarded by many LMICs as an expensive burden on their economy and received little attention with governments directing resources towards treatment of communicable diseases such as AIDS, Malaria and TB along with maternal/child health services. This focus has been mirrored by economists and Dr Walt Johnson, WHO Lead for Emergency and Essential Surgical Care, reported at an RCS England Global Health Meeting in London in July 2018, that in previous years when the WHO has held summit meetings discussing trauma service, development members of The World Bank have not attended as they did not see it as an obstacle to a country’s development. However, statistics from the WHO have demonstrated that trauma and injury are now the cause of 32% more deaths in the developing world than HIV, tuberculosis and malaria combined and members of the World Bank did attend a WHO summit in Geneva in 2018 discussing challenges created for LMICs by such increases in trauma, hence the economic tide seems to be turning!

“Statistics from the WHO have demonstrated that trauma and injury are now the cause of 32% more deaths in the developing world than HIV, tuberculosis and malaria combined.”

In 2015, The Lancet Commission’s Report on Global Surgery1 highlighted the inequalities and population challenges caused by inadequate safe surgical services in LMICs and prompted the Global Surgery 2030 initiative. Also in 2015 the Ethiopian Ministry of >>

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Subspecialty Section

SAFE OR Course supported by WOC UK Jan 2018. Professor Vivien Lees, Chair RCS England International Development Committee training Ethiopian colleagues to deliver course material in Addis

Health, in its five year Health Sector Transformation Plan, mentioned trauma and injuries for the first time in the country’s history resulting as a consequence of the fact that it had spent 40% of its annual capital budget for that year on road development and suddenly observed a dramatic increase in injuries with high mortality and morbidity rates!

WOC UK Response to Evolving Global Challenges Building on its longstanding traditions and those of the BOA as a whole, of supporting training and education as the foundation of developing high quality trauma services for patients, WOC UK has been actively involved in supporting the Global Surgery 2030 initiative, its current flagship project

being WOC’s support for Ethiopia as a nation develop its orthopaedic training programmes and rehabilitation services, in collaboration with the AO Alliance Foundation (AOAF) and Australian Doctors for Africa (ADFA). The two WOC contributions for this edition of the JTO are examples of this transformational work being delivered by WOC both in Guyana and Ethiopia, both projects focussing on training programmes including the teaching of research and audit methods, so important in ensuring quality patient care. Members of WOC have also supported RCS England, The Association of Great Britain and Ireland (AAGBI) and LifeBox with their establishment of the ‘SAFE OR Course’, a multidisciplinary teaching programme aimed at enhancing teamwork and patient safety in an operating environment specifically aimed at being delivered and training competent local teachers of these principles in LMICs.

“Building on its longstanding traditions and those of the BOA as a whole, WOC UK has been actively involved in supporting the Global Surgery 2030 initiative, its current flagship project being WOC’s support for Ethiopia as a nation develop its orthopaedic training programmes and rehabilitation services.”

Multidisciplinary Ethiopian delegates SAFE OR Course Addis Ababa January 2018

WOC is extremely grateful for the financial support it has received from the BJJ which has facilitated regular WOC teaching visitors, both consultants and trainees, to Ethiopia thus enabling it to deliver its flagship project.

Future Challenges and Opportunities Looking ahead, as a relative newcomer to this area, I can vouch for my observation since 2015 that change seems to be occurring at a rapid pace. This is a consequence of widespread international collaborations between numerous organisations committed to developing trauma services within the global agenda of emergency surgical services as a whole and facilitating safe surgery, safe anaesthesia and critical care practices to put patient safety and good outcomes at the centre of service development. The next immediate challenge that WOC is being asked to support in Ethiopia is standardisation and consistency in its orthopaedic residency training programmes and final exams which are currently delivered in

Subspecialty Section

Tony Clayson representing WOC UK teaching on SAFE OR Course Addis, January 2018

Addis Ababa, Bahir Dar and Mekele, with further training centres identified. The Ethiopian Ministry of Health and the orthopaedic training programme leaders recognise the need for a national curriculum, some development and support for their examiners and consistency of exams between centres. This is not dissimilar to the challenges I recall encountering as a former BOTA President during the period when the Intercollegiate Examination Board and Subspecialty Examinations were being established in the early 90’s.

Tony Clayson observing Final Residency Clinical Examinations on behalf of WOC UK, Addis Ababa December 2018 Tony Clayson with Dr Biruk L.Wamisho, Head of Orthopaedic Dept. and Residency training programme Black Lion Hospital, Addis Ababa, March 2018 Orthopaedic Residency Final Exam Clinical viva Ethiopian style – Dr Geletaw Tessema and Dr Samuel Hailu leading

“The next immediate challenge that WOC is being asked to support in Ethiopia is standardisation and consistency in its orthopaedic residency training programmes and final exams which are currently delivered in Addis Ababa, Bahir Dar and Mekele, with further training centres identified.”

In December 2018, myself and Rick Gardner (Consultant Paediatric Orthopaedic Surgeon at Cure Childrens Hospital in Addis and WOC Country Representative in Ethiopia) on behalf of WOC, acted as the first ever invited external observers and examiners at the Final Orthopaedic Residency exams at The Black Lion Hospital in Addis, the largest training programme in the country. This was an extremely helpful experience for all parties and our constructive comments and feedback were well received to the extent that myself and Rick have recently been appointed as Invited External Examiners for the final orthopaedic residency examination by the University of Addis Ababa for the next five years and asked to support their curriculum development. We now intend calling on the assistance and advice of UK colleagues leading our own Intercollegiate Examinations Board for active support with this process. It is then our intention to report wider to BOA colleagues via the JTO later this year.

Want to get involved?

I hope readers will find these WOC UK contributions for the JTO of interest and I know, from conversations I have had with consultant colleagues, many trainees and collaborative international organisation leaders over the past four years, that the global surgical world, especially the development of trauma services is changing rapidly and is an exciting place to be in. As I mentioned earlier, I am a relative ‘newbie’ to this arena compared with some colleagues who have been delivering overseas

orthopaedic work for many years but what I can confirm is that is possible to get involved, continue working in the UK and make a real difference with WOC UK now having a number of opportunities available. n If any colleagues either Consultants or trainees would like to know more, please feel free to get in touch via email anthony.d.clayson@wwl.nhs.uk.

References 1. ‘Global Surgery 2030: evidence and solutions for achieving health, welfare and economic development’. The Lancet Commissions Vol.386, Issue 9993, pp569624, August 08, 2015

Subspecialty Section

Orthopaedic Curriculum Development in Guyana Deepa Bose

Guyana is a small country situated on the northern coast of South America. It was a British colony until 1966, and is the only English-speaking country in the continent. Culturally and historically it has more in common with the West Indies, and is a member of the Caribbean Community (Caricom). It has a population of approximately 780,000, mostly concentrated along the coast, although there are settlements in the interior of the country, linked to mining and forestry.

t is often referred to as the Land of Six Peoples because of the diverse ethnicity of its population; Europeans (mostly British), Africans, Indians, Chinese, descendants of Portuguese indentured labourers and native Amerindians. The word Guyana is derived from an Amerindian word meaning land of many waters.

Deepa Bose is a consultant in orthopaedic trauma and limb reconstruction in the Queen Elizabeth Hospital Birmingham. She is also the secretary to World Orthopaedic Concern UK, a specialist society of the BOA and a charity focused on orthopaedic training and education in low resource settings.

It is rather unfortunate that the few people outside the Caribbean who have heard of Guyana associate it with the mass suicide of Jonestown, involving members of an obscure cult called the Peoples Temple Agricultural Project, who had migrated from the USA. In fact, Guyana has many remarkable features, not least of which is its untouched Amazonian rainforest, complete with unique flora and fauna not found elsewhere. It also boasts Kaiteur Falls, the largest single drop waterfall in the world at 226

Kaiteur Falls

metres, and St Georgeâ&#x20AC;&#x2122;s Cathedral in the capital city of Georgetown, a wooden building reaching a height of 43.5 metres and constructed from a local hardwood called greenheart, prized for its durability and resistance to rot. Guyana currently has approximately 2.1 doctors per 10,000 people (compared to 2.8 per 1,000 people in the UK). Prior to the establishment of the School of Medicine in the University of Guyana in 1985, Guyanese who wished to study medicine did so abroad, in countries such as the UK, India, the Soviet Union and Cuba. The Guyana Public Hospital Corporation (GHPC), the large referral and teaching hospital in Georgetown, established a two year Diploma programme in Orthopaedics and Traumatology in 2009. Whilst this was a huge step forward, the specialists it produced were not necessarily prepared for independent practice without further training. Despite this, the programme was quite successful, producing ten graduates who are still working in the specialty in Guyana. I am Guyanese by birth, and since my involvement with World Orthopaedic Concern UK (WOC UK), I have had a desire to give something back to the country by offering assistance in orthopaedic training and education. In December 2016 WOC UK and the Institute of Health Science Education at GPHC signed a memorandum of understanding (MOU) concerning curriculum and faculty development for a new four year postgraduate Masterâ&#x20AC;&#x2122;s degree (MMed) programme in Orthopaedics and Traumatology. Our first task was to devise a curriculum which would be submitted to the University of Guyana for approval. I proposed to the British Orthopaedic Association Training Standards Committee that we could use the UK Trauma & Orthopaedic Curriculum as a template. Professor Philip Turner, current President of the BOA, kindly agreed to this. The current British curriculum was duly adapted to suit Guyanese requirements. In this endeavour I received enormous help from Dr Khan, a Senior Orthopaedic Surgeon at GPHC, and Lisa Hadfield-Law, Educational Advisor to the BOA.

Subspecialty Section

The knowledge and professional behaviours components of the curriculum remained largely intact, but the operative skills component was adapted to reflect local needs. The principle changes lay in the assessment tools to be used. The Procedure Based Assessments (PBAs) and Case Based Discussions (CBDs) from the British system were included, in addition to a Global Rating Form based on the six elements of the American College of Surgeons evaluation scheme; patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism and interpersonal and communication skills. Another difference from the UK curriculum is that residents are expected to complete an academic research project over the course of the four years, similar to a dissertation.

Open Kuntscher nailing of a femur in Guyana Signing the MOU in December 2016

Several iterations later, we had a curriculum we thought was fit for purpose, and ready for submission to the university. The university board approved this in May 2018, and the first resident started in July 2018.

The Global Rating Form

Many lessons have been learnt along the way. It was expected that the syllabus content would have to change to reflect local practice, but the assessment tools adopted by the Guyanese surgeons were also different, and demonstrated the need to allow flexibility for local content to develop. The chasm between aspiration and reality has also become apparent since the beginning of the programme. Guyanese residents and faculty both need time to acclimatise to a more rigorous system of assessment and documentation than they have been accustomed to using. An example of this is the surgical logbook, which has become second nature to UK registrars, but which is not routinely used in Guyana. Regular completion of PBAs and CBDs can be trying for UK registrars, so it may well be imagined how challenging it is to introduce these where nothing similar existed. Gentle encouragement and leading by example are the best antidotes in such situations, and are made easier by the obvious aptitude of the residents.

Guyanese orthopaedic surgeon Dr Ramcharran attending the TOTS course

Faculty development is also an important area to focus on when introducing a new curriculum. There are only a few senior surgeons at GPHC, who are all dedicated to the development of an excellent programme, and who are very forward thinking in their approach. However they already have very busy clinical commitments. Their workload has suddenly increased exponentially with the start of the MMed. In addition to supervision and assessment of residents in the clinical and academic arenas, they now also have to deal with a new system of recruitment and delivery of formal teaching sessions, not to mention the mountain of administration that goes hand in hand with such endeavours. Professor Turner kindly arranged a place for one of the Guyanese surgeons on a Training the Orthopaedic Trainers (TOTS) course in April 2019, and this proved to be enormously productive. Visits by UK consultants in various subspecialties would also be very beneficial in developing the capacity of the team at GHPC. Additionally, regular Skype teaching sessions from the UK will relieve some of the burden on local faculty. n I welcome correspondence from anyone interested in becoming involved in the project. Please email: deepa.bose@uhb.nhs.uk.

Subspecialty Section

Tony Clayson is a Consultant Orthopaedic and Trauma Surgeon at Wrightington Hospital, a member of the Executive Committee of WOC UK and invited External Examiner of the Orthopaedic Residency Final Examination at Black Lion Hospital, Addis Ababa. He is a founder member and currently Executive Chairman of NOTAA and a ‘Reverse Fellow’ for AO Alliance Foundation supporting Hawassa, Southern Ethiopia.

Henry Wynn Jones is a Consultant Orthopaedic and Trauma Surgeon at Wrightington Hospital, a member of WOC UK and a Co-Founder and Honorary Treasurer of NOTAA. He is also a ‘Reverse Fellow’ for AO Alliance Foundation supporting Hawassa in Southern Ethiopia.

Kohila Vani Sigamoney is a Specialty Trainee in Orthopaedics in the North Western Deanery. She is an Executive Committee Member of the Northwest Orthopaedic and Trauma Alliance for Africa (NOTAA) responsible for website management. She has been the lead developer of the Ethiopian Residents Day.

The Northwest Orthopaedic Trauma Alliance for Africa (NOTAA): Approaching sustainable development through international collaboration and the Ethiopian and UK Residents Research Day Kohila Vani Sigamoney, Henry Wynn Jones and Tony Clayson

The Northwest Orthopaedic and Trauma Alliance for Africa was established, as an approved subgroup of WOC UK, in September 2016 by Tony Clayson and Henry Wynn Jones, both Consultant Trauma and Orthopaedic Surgeons at the Northwest Pelvic Trauma Unit, Wrightington Hospital.

OC UK had enlisted Tony’s help with its flagship project supporting development of orthopaedic trauma services in Ethiopia and AO Alliance Foundation had also sought their assistance acting as ‘reverse fellows’ to support two new Trauma and Orthopaedic Consultants establish an orthopaedic trauma department in Hawassa, destined to be a new major trauma hospital for Southern Ethiopia. Prior to this, basic first aid orthopaedic care was provided in Hawassa but when any specialised orthopaedic care was

needed, patients would have to be taken by their relatives elsewhere. Sometimes this could mean walking for days, the closest provider being Sodo Christian Hospital about 160km away. Although Ethiopia’s infrastructure is developing, health and safety measures are not resulting in an increased number of trauma victims. This usually affects young men of working age who are often the sole breadwinner for the family. Trauma burden is therefore a major public health issue for Ethiopia as it is in many developing countries.

Mr. Tony Clayson, Miss Kohila Vani Sigamoney and Mr. Henry Wynn Jones at the 2017 North West Registrar Day, Manchester UK, December 2017

With the support of WOC UK and AO Alliance Foundation, NOTAA was established as a charitable group to enable interested health professionals from the North West of England to utilise their varied skills for the improvement of trauma services in Africa, specifically Malawi and Ethiopia at the present time. This report focuses on NOTAA’s work in Ethiopia where its main emphasis is on education and team building, recognising the >>

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The Residents Day has been well supported by the Orthopaedic Training Programme Directors in Ethiopia, (Black Lion Hospital and St. Paul’s Hospital Millennium Medical College in Addis Ababa) and also Bahir Dar (Felege Hiwot Hospital) namely Dr. Biruk Lambisso, Dr. Zegene and Dr. Worku.

From left to right: Mr. Tony Clayson, Miss Sigamoney, Mr. Hughes, Dr. Samuel Hailu and the residents in the 2nd Residents Day, Addis Ababa June 2018

Ethiopian Residents Days to Date So far, three Ethiopan Residents Days have been held over a period of 18 months. The first Ethiopian Residents Day was held on 23rd November 2017 at Hawassa University Comprehensive Specialized Hospital (HUCSH) with the support of Dr. Ephrem Gebrehana, Head of the T&O Department in HUCSH. The day showcased seven projects (four oral presentations and three poster presentations). Fourteen Ethiopian residents and interns (12 from the BLH programme, one non-trainee from Hawassa and one general surgery trainee) and nine UK registrars were involved. importance of establishment of good audit and research methodology as a vital part of the development of surgical services. NOTAA have made six multidisciplinary team visits to Ethiopia since April 2016 and organised three Ethiopian Residents Research Days.

The Ethiopian Residents Research Day The Ethiopian Residents Day is a day held during a planned visit by a NOTAA team where the collaborative work of Ethiopian residents and UK registrars is showcased. This was an idea suggested by Ms Kohila Vani Sigamoney (UK Registrar, Northwest Deanery) in response to the multiple emails she received from Ethiopian residents, following her visit in May 2017, requesting education on how to carry out audits and research. It was evident that little audit and research work had been carried out in Ethiopia, it was not a part of the orthopaedic curriculum and there was little opportunity to perform such projects. The event was supported to realisation after further discussions with the NOTAA Executive Committee, the NW Deanery TPD, Jaysheel Mehta, the NW Trainee Research Coordinator, David Johnson, AO Alliance Foundation and The John Charnley Trust, with the latter two organisations providing financial support for prizes. The collaboration relies on international communication. It involves the T&O Registrars, from primarily the Northwest Deanery in the United Kingdom to date,

acting as mentors to Ethiopian residents, mostly working in T&O, for about one and a half to three months before the planned Residents Day. Projects (audits or research) are suggested by either party and then discussed via the internet using email, Whatsapp or Viber. The work is undertaken by an Ethiopian trainee or group of trainees, the findings collaboratively discussed between UK and Ethiopian colleagues and a presentation or poster is then put together jointly and presented at the Residents Day by an Ethiopian trainee. One or two UK trainees join the NOTAA team visit and coordinate the day. Although the parties may never meet in person they can continue to communicate throughout their careers. Ethiopia is a large country and if Ethiopian colleagues are unable to attend the day they submit a poster presentation. All presentations are judged on the day by the visiting NOTAA Consultants and the Ethiopian Consultants present at the event. Book prizes are awarded to first and second placed best presenters and the best poster. On the day all members of the winning teams receive a prize certificate and all participants receive a certificate of participation. The UK Registrars involved receive a certificate at their NW Annual Registrars Research Day.

The second Ethiopian Residents Day was held in the Black Lion Hospital (BLH) Addis Ababa 28th June 2018. Collaboration started two months ahead of the day. This event saw the involvement of 22 Ethiopian Residents (20 from the BLH programme, two from the Bahir Dar programme) and seven UK registrars. There were nine oral presentations and one poster presentation. Kohila Sigamoney worked together with Luke Hughes (UK registrar) to organise the day. The third Ethiopian Residents Day was held recently at HUCSH on 29th March 2019 and proved even more popular with 26 Ethiopian residents and 10 UK registrars participating. This included residents from Black Lion, St Paul’s and Bahir Dar and some Bioengineering students from Addis Ababa. UK trainees from the North West Deanery and West Midlands participated. Collaboration started three months ahead of the planned date. Sadia Afzal (UK registrar) was the visiting NOTAA trainee who helped organise the event.

“The first Ethiopian Residents Day was held on 23rd November 2017 at Hawassa University Comprehensive Specialized Hospital (HUCSH) with the support of Dr. Ephrem Gebrehana, Head of the T&O Department.”

Thus the event continues to grow in size and popularity throughout Ethiopia as trainees and trainers across the country are starting to embed audit and research methodology in their training curriculum and clinical practice. >>

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Subspecialty Section

Aims and Challenges of the Ethiopian Residents Day The aims of this collaboration have been to introduce audit, research and quality assurance methodology to Ethiopian Orthopaedic trainees and their trainers and demonstrate its role in enhancing patient care and clinical outcomes. The event allows trainees from Ethiopia and UK to work together even if they cannot travel due to time and financial constraints. This activity fosters mentorship and learning with trainees from both countries benefiting. It highlights areas that are good and those that need improvement in Ethiopian clinical practice and the UK registrars get an idea of healthcare in the developing world and global health issues. The event is fair and does not discriminate based on experience. It is a learning platform regardless of previous involvement in audit and research.

it has now been confirmed that audit and research methods will be incorporated into Ethiopian training programmes and is now on the agenda for change in designing a new nationally agreed Trauma and Orthopaedic training curriculum in Ethiopia. The political situation in Ethiopia has at times been a challenge with some occasional unrest and the second Ethiopian Residents Day was significantly affected by this as the location had to be changed a week before the planned event, although it has to be said that the political situation does seem to be rapidly changing and becoming more settled.

Benefits of the Ethiopian Residents Day While this event may be regarded by some as another extracurricular piece of work, it has been designed to have wide benefits for training and there is no doubt that Global Health challenges are starting to take centre stage as political issues with trauma in particular are becoming recognised as a major obstacle to economic development and a major humanitarian challenge. NOTAA remains committed to developing this project further and believe it is vital that all trainers recognise such importance as trainees do invest time into completing these projects.

â&#x20AC;&#x153;With the support of WOC UK and AO Alliance Foundation, NOTAA was established as a charitable group to enable interested health professionals from the North West of England to utilise their varied skills for the improvement of trauma services in Africa, specifically Malawi and Ethiopia at the present time.â&#x20AC;?

However, there have been challenges. The main challenge is that the internet connection can be unreliable although this has improved over time. There is also the issue of timing and considering when Ethiopian training examinations take place which is presently December each year. Although feedback revealed some communication difficulties on both sides there is keen interest in Ethiopia and the UK to continue this event on a yearly basis and

UK registrars who participated in the Residents Day and Mr. Tony Clayson at the NW Registrar Day in Manchester, UK, December 2017

The third Residents Day brought about more challenges, the biggest being our failure to promote adequately in the UK leading to a shortage of UK Registrars to mentor the growing number of Ethiopian Trainees. This will be addressed in the debrief of the event which will be held mid-year and we are looking to the newly formed Trainees Sub Committee of WOC UK to help NOTAA spread the word as we aim to support trainees and TPDs in other Deaneries to engage with this project.

For the Ethiopian trainees, they are able to learn how to carry out research and audit, some have been able to present their work at the Ethiopian Society of Orthopaedics and Traumatology annual meeting, and get opportunities for themselves to be involved in wider research and trials and our winning paper from June 2018 was presented at the COSECSA meeting in Rwanda in December. As this event is approved by their programme directors in Ethiopia, these projects will be of value as they may start to become approved towards their final completion of training as the training curriculum develops further.

Subspecialty Section

Miss Sigamoney with Ethiopian Residents, and visiting NOTAA Physiotherapists and Australian Doctors for Africa (ADFA) physiotherapists in November 2017 when first Ethiopian Residents Day was held in Hawassa

In the North Western deanery, the training programme director and specialist trainee research coordinator have supported and approved the projects carried out by UK trainees through this collaboration. Trainees have been able to treat these projects as they would projects in the UK. Therefore, these can be counted towards their certificate of completion of training (CCT). If trainees in the UK present it themselves at a national or international meeting or publish it, this also counts towards their CCT.

“Residents Day is an event where everyone ‘wins’ as both Ethiopian and UK trainees learn and have projects that they can take further. It fosters camaraderie and team work both locally and internationally and Residents in Ethiopia can look objectively at clinical outcomes and take this to their Consultants who can implement change.”

The benefits of the Residents Day is that it is an event where everyone ‘wins’ as both Ethiopian and UK trainees learn and have projects that they can take further. It fosters camaraderie and team work both locally and internationally and Residents in Ethiopia can look objectively at clinical outcomes and take this to their Consultants who can implement change to create improvement.

Future plans for the Residents Day and Research Methodology Training Despite all the challenges, the Ethiopian Residents Day has been looked upon as a successful project that has made a change to the practice of trauma and orthopaedics especially amongst trainees. The programme directors in Ethiopia have asked for this event to continue and AO Alliance Foundation are supporting the delivery of training courses on research methodology in Ethiopia in September 2019 and March 2020.

NOTAA and the Residents Day project has received a commended award in 2018 and 2019 from The University of Manchester for innovation in Global Health Development. The decision has now been taken to hold it once a year, at present alternating between the Black Lion Hospital and Hawassa University Comprehensive Specialized Hospital and there are discussions around

it possibly becoming part of their Annual Scientific meeting of the Ethiopian Society of Orthopaedics and Traumatology (ESOT). NOTAA is looking to establish more teams in the future for support with successfully organising the Residents day in Ethiopia and possibly in other countries. This would involve expanding the project to include the involvement of UK Registrars from other Deaneries outside the North West, subject of course to approval and support from their Training Programme Director.

Acknowledgements We would specifically like to express our thanks to Mr Jaysheel Mehta, Consultant Orthopaedic Surgeon Pennine Acute Hospitals/Training Programme Director NW Deanery and Professor David Johnson, Consultant Orthopaedic Surgeon Stockport Hospitals NHSFT and NW Deanery (Eastern) Trainee Research Coordinator for their belief and support in establishing this collaborative project.n Expressions of interest in NOTAA or participation in the Ethiopian Residents Day from trainees, trainers and TPDs throughout the UK are welcome by email to anthony.d.clayson@wwl.nhs.uk or nota4africa@gmail.com.

In Memoriam

Sue Miles

22nd August 1947 - 1st January 2019

ue Miles passed away on 1st January 2019. She will be greatly missed by everyone involved in UK and international casting. Orthopaedic Practitioners, nurses, students and colleagues, past and present members of the BOA casting committee as well many people across the world involved in modern day Trauma and Orthopaedics have benefitted from Sue’s wise teaching. Sue was the National Casting Training Advisor for the BOA, a role that she developed with the aim of promoting the safe application of casts through proper training and to ensure that all casting courses across the United Kingdom were taught to a consistent and high standard. Sue trained as a nurse at University College Hospital and then worked as an orthopaedic nurse at R.N.O.H Stanmore, where she was rapidly promoted. At that time in the late 1970’s, casts were applied by a variety of untrained hospital staff. With the encouragement from the orthopaedic consultants she was working with, she set up and then ran the Stanmore casting course. At about the same time, the importance of proper and safe casting was recognised by the BOA and so the Casting Committee was convened. Sue was dedicated to the casting committee and even though for her last year she had been unwell, she remained in contact and it was very good to see her when the committee met in November 2018. Sue is survived by her husband John, her daughter Anita, son-in-law James and two grandsons, Jack and Luke. n

Dr. Yves Cotrel

27th April 1925 – 29th January 2019

r. Yves Cotrel devoted his life to scoliosis. From 1948 onwards, as head of the orthopaedic department of the Institut Calot of Berck, France, he dedicated his expertise and empathy to serve his patients, who were often very young, and at the time were condemned to cumbersome, unsightly treatments, and long periods of immobilisation at the hospital. In 1975, he experienced three successive cardiac arrests forcing him to stop all professional activity. Unemployed, he discovered a vocation as a researcher. He could then put to use the sense of innovation he had acquired during a six-month fellowship in United States in 1958 when he became familiar with the American techniques of the time. Three years later, a whole new implantable metal instrumentation emerged from a modest DIY workshop in his house in Brittany. Although declared ‘permanently disabled’, nothing shook his passion, his curiosity, or his desire for action. He travelled the world to train surgeons in the new technique; he attended classes and lectures, one after another, and participated in exchanges of professional societies and welcomed fellows to Paris from all over the world. Yves revolutionised scoliosis surgery in 1983. Developed with Jean Dubousset, orthopaedic surgeon from Saint-Vincent de Paul in Paris, the CD instrumentation (Cotrel-Dubousset) makes it possible to correct the alignment of the vertebral column and to consolidate the straightened segment. To date, the CD devices have been implanted in more than two million patients worldwide. Today, the Cotrel Foundation supports more than 60 teams of researchers from around the world to take up Dr. Yves Cotrel’s challenge - to reveal the secrets of idiopathic scoliosis, its causes and mechanisms of evolution. n

In Memoriam

Dr. Henry Mankin

9th October 1928 – 22nd December 2018

enry Mankin passed away at his home in Brookline aged 90. He was predeceased by his beloved wife of 60 years, Carole Jane Mankin (nee Pinkney), and is survived by his three children, Allison Joan, David Phillip, and Keith Pinkney, and three grandchildren, Sam and Molly Carton (Allison’s), and Cameron Mankin (Keith’s). For forty years, Dr. Mankin was the chief of orthopaedics at the Massachusetts General Hospital and at Harvard Medical School. Born in Pittsburgh, he was the son of immigrants from Lithuania. Henry was a beloved member of the medical community both in Boston and around the entire world. As a dedicated and gifted teacher, he often said that his immortality was to be found in his students. In his home life, besides being a devoted husband, he was a watercolourist, a music enthusiast and above all things a lover of animals. 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 step-by-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.

Products and Courses 14th Trauma & Orthopaedics Update

Val d’Isere, 27-30 January 2020 www.doctorsupdates.com info@doctorsupdates.com +44 (0) 208 7151924 Doctorsupdates 2020, in their 31st year will feature 14th Trauma and Orthopaedics Update. This meeting is unique as it provides interaction between a number of

different specialities: orthopaedics, anaesthetics, critical care and pain, radiology, plastic surgery, dermatology and general practice. We also invite speakers from other specialties like haematology, neurology, rheumatology to contribute to our education. The programme is suitable for consultants and senior trainees. The format is informal and sessions

Wrightington Hospital

UPPERLIMB SCANNING & GUIDED INJECTION MASTERCLASS – 31 May 2019

FRCS (0rth) UPPER LIMB SURGERY MEETING – 26 & 27 September 2019

Course Venue: Hospital Conference Centre

WRIGHTINGTON CADAVERIC ELBOW TRAUMA COURSE – 27 & 28 June 2019

WRIGHTINGTON ADVANCED TECHNIQUES IN ELBOW REHABILITATION & SURGERY (WATERS) – 18 & 19 November 2019

(unless otherwise stated)

WRIGHTINGTON CADAVERIC HAND & WRIST TRAUMA COURSE – 8 & 9 July 2019 BASIC SCIENCE VIVA COURSE – 24 & 25 September 2019

TO ADVERTISE YOUR PRODUCT OR SERVICE IN THIS JOURNAL

Call Barbara or Rupinder on:

Venue: Wrightington Hotel

THE THUMB, THE WHOLE THUMB & NOTHING BUT THE THUMB – 20 & 21 November 2019 Venue: Wrightington Hotel

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.

Further information: Upper Limb Education, Wrightington Hospital WN6 9EP Mavis Luya - Elbow & Thumb meetings Telephone: +44 (0) 1257 256248 Email: upperlimb@wrightington.org.uk Jackie Richardson - FRCS/Basic Science, Upper Limb Scanning, Cadveric Courses 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)

IFUSE FOR TREATING CHRONIC SACROILIAC JOINT PAIN The Sacroiliac Joint... a unique and often overlooked, underdiagnosed and undertreated joint

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Greater than 34.000 procedures worldwide3 90% patient satisfaction4 Greater than 60 peer-reviewed articles5 REFERENCES 1. Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain Interventional procedures guidance Published: 5 April 2017 Minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain (IPG578) 2. iFuse for treating chronic sacroiliac joint pain. NICE Medical Technologies Guidance. MTG39. 2018Oct2. [nice.org.uk/guidance/mtg39] 3. Data on file through September 2018. SI-BONE, Inc. 4. Dengler JD, et al. Pain Physician. 2017 Sep;20(6):537-550. (iMIA 1-year, randomized controlled trial) 5. List of articles www.si-bone.com/results

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