Journal of Trauma & Orthopaedics – Vol 7 / Iss 4 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 07 | Issue 04 | December 2019 | The Journal of the British Orthopaedic Association | boa.ac.uk

Winter Bed Is day case hip and knee replacement Pressures p26 surgery achievable in the NHS? p32

Litigation, regulation and the cost of indemnity p36

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3 5

From the Editor

27 Intra-Deanery Transfer

From the President: Fresh faces and ideas

Bob Handley

Don McBride

6- 7 Latest News 8- 19 News 8 New BOA Trustees (2020–2022) 10 Best Practice Tariff (BPT) changes

in 2020: Fractures of the Femur

16 Conference listing 18 BOA Research 20 Robert Jones Lecture

John Skinner

24 BASK Revision Knee Working

Group Update

Johnny Mathews, Nick Kalson, Jonathan Phillips and Andrew Toms

Matthew Brown

During Winter Bed Pressure Months: A Trainee’s Perspective

Ryan Hillier-Smith

28 The impact of webinar-based

teaching programme on FRCS (Tr&Orth) exam performance of SAS Orthopaedic Surgeons

Firas Arnaout and Shwan Henari

30 Operations I no longer do... Open

reduction of supracondylar fracture

Fergal Monsell

32 Is day case hip and knee replacement

surgery achievable in the NHS?

Sam Jain, Sarah E Paice, Mike R Reed and Paul F Partington

36 Medico-Legal: Litigation, regulation

and the cost of indemnity

Mike Devlin

40 Simulation Section: Cognitive

Simulation - A novel method to improve operative skills

Uttam Shiralkar

26 Winter Pressures and effects on training 44 Trainee Section: BOTA at the BOA

Matthew Brown

48 Subspecialty Section: Pelvic Ring

Injuries – An overview

Ian Pallister

52 Subspecialty Section: Blast injuries to

the pelvis - essential lessons learned

Iain A. Rankin, Arul Ramasamy and Julian Cooper

56 Subspecialty Section: The hidden

side of pelvic fractures - Urological and sexual dysfunction following injury

Alasdair Bott, Graeme Nicol and Tim Chesser

60 Products, Courses and Events

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 – search for JTO @ BOA.

2020

UK & IRELAND EDUCATION

Introductory Course for Undergraduates Jan 19, 2020. Dublin

Basic Principles of Fracture Management Jan 20-23, 2020. Dublin

Basic Principles of Fracture Management for ORP

Small Animal Fracture Management for ORP Jun 12-13, 2020. Oxford

Principles in Small Animal Fracture Management

Jan 21-23, 2020. Dublin

Jun 14-16, 2020. Oxford

Paediatric Course

Advanced Techniques in Small Animal Fracture Management

Feb 5-6, 2020. Leeds

Introductory Course for Undergraduates

Jun 14-16, 2020. Oxford

Mar 1, 2020. Edinburgh

Basic Principles of Fracture Management Mar 2-5, 2020. Edinburgh

Foot & Ankle Reconstruction with Anatomical Specimens Mar 31-Apr 1, 2020. London

Current Concepts Course with Anatomical Specimens Apr 22-24, 2020. Coventry

Introductory Course for Undergraduates Jun 21, 2020. Leeds

Basic Principles of Fracture Management for Surgeons Jun 22-25, 2020. Leeds

Advanced Principles of Fracture Management

Jun 23-26, 2020. Leeds

Advanced Principles of Fracture Management for ORP

Management of Facial Trauma (Undergraduates) May 3, 2020. Leeds

Management of Facial Trauma (Principles Course for Surgeons) May 5-6, 2020. Leeds

Management of Facial Trauma (Principles Course for ORP) May 6-7, 2020. Leeds

Jun 24-26, 2020. Leeds

Basic Principles of Fracture Management for ORP Jun 22-23, 2020. Leeds

Pelvic Masters Sep 7-9, 2020. Bristol

Principles Course - Degeneration

Management of Fractures of the Hand

Mar 20-21, 2020. Cambridge

Oct 5-7, 2020. Leeds

Principles Masters - MIS & Navigation

Wrist Course

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Oct 8-9, 2020. Leeds

Introductory Course for Undergraduates Nov 8, 2020. Wymondley

Basic Principles of Fracture Management

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

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

l l l l l

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

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

BOA Elected Trustees l l l l l l l l l l l l l l l l l

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

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Programmes and Committees Officer

- Harriet Wollaston

Communications and Operations Director of Communications and Operations

- Emma Storey

Interim Director of Communications and Marketing

- Annette Heninger

Marketing and Communications Officer

- Sabrina Nicholson

Membership and Governance Officer

- Natasha Wainwright

Online Examination Operations Project Manager

- May Elphinstone

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

Events and 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

From the Editor... Bob Handley

‘W

inter drawers on’, one of the oldest of schoolboy jokes, with its novelty lost in years of repetition. The same is true of winter bed pressure. Instead of an unpredicted crisis, it seems a necessary ritual on the road to spring; so we must be ready and prepare. One way to avoid the grip of the bed managers is to push the boundaries of daycase surgery to include a greater proportion of our work. Hip and knee replacement surgery with discharge on the same calendar day is shown to be possible in an NHS setting (page 32). This practice is not yet widespread and so there continues to be a loss of training opportunities when ‘winter pressures’ lead to cancellations or movement of patients. Moving the trainee to follow the training opportunity is shown to be achievable (page 27), but naturally requires forethought.

“No man is an island entire in itself”; this sentiment of John Donne applies to surgeons too. We may realise that we should communicate, discuss, refer and transfer but we also need the structure and funding to achieve it. Networks, be they hub & spoke or more web-like, already exist for some areas of practice, but will become more common. The article relating knee revision surgery (page 24) outlines the proposals in this area. Continuing to demonstrate the changing and more broad-minded image of the Orthopaedic Surgeon we have now officially gone holistic and will recognise the ‘whole of the femur’ in new changes to Best Practice Tariff previously restricted to hip fracture. It is my earnest hope that this will be seen as a broadening of an index of performance and not an end in itself, and that we should treat patients on merit and not on tariff. The specialty section on pelvic trauma also includes a broadening of our vision. Whilst naturally referring to the time-critical, lifesaving aspects of pelvic injury that both scare and enthral us, it also explores the less glamorous side. There is hidden morbidity in patients with frailty or the higher energy fractures. The pelvic fragility fracture so often consigned to being swept under the carpet of a different hospital service is now being studied to establish whether there are indications to be when we should be more interventional to improve quality of life. The higher energy injury also has a hidden burden of urological and sexual dysfunction.

Disclaimer

A newcomer to our regular features is now to ask the Robert Jones Lecturer from the BOA Congress to provide a precis of their presentation. It had seemed that we did not make the most of the time and effort put not only into the presentation itself but the professional life underpinning it. A worthy first is provided by John Skinner (page 20).

BOA contact details

Increasingly in this world, we not only have to do the right thing but prove we that have done it; this is even the case with the reading of the JTO. So I would ask that in addition to cherishing and studying your paper copy of JTO please do some of your reading on line via the App (see bottom page 1) or the BOA website; this helps our relationship with advertisers! n

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.

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

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From the President

Fresh faces and ideas Don McBride

With the dust settling on yet another excellent and highly successful Congress, closely followed by my first Executive and Council meetings, I barely had time to reflect before catching the plane to Dunedin for the NZOA Annual Scientific Meeting followed by the Australian ASM a week later in Canberra. Summaries are available elsewhere in this edition of the Journal.

owever, I can happily reiterate that they were excellent examples of how Trauma and Orthopaedic Association Congresses should be organised with good core subspecialty teaching and diverse general topics of interest including a variety of non-orthopaedic but thought-provoking lectures. A good example was a presentation on ‘Climate Change and the Effect on our Future’ by Professor James Renwick, Victoria University of Wellington at the NZOA ASM. It was based on current and excellent scientific evidence unravelling the background of climate change, which inevitably occurs, and the adverse human contribution, particularly in the last century, causing additional unwelcome effects over and above these natural processes. Thankfully, solutions are possible and these were explained in some detail. In addition, both Congresses had several speakers from the UK. We should be proud of this and the fact that British Trauma and Orthopaedics is held in high regard by our international colleagues. The day after returning to the UK I attended a reception at the Houses of Parliament regarding MSK care and reorganisation. This was interesting but I was struck by the immediately adjacent debate on Brexit just a few yards away. As I write this article there remains much uncertainty in UK politics because of Brexit and although this is a

problem there are still European Parliament decisions and policies that may affect us. I have previously outlined the new Medical Device Regulations (MDR) taking effect in 2020. The BOA remains actively engaged with colleagues across Europe on issues raised by these Regulations and I am pleased to be advised that our members are applying for the Expert Working Panels in some numbers. This is definitely a process we need to be involved in providing common sense clinical advice. Nearer to home reorganisation of the BOA committee structure is complete and shall ‘go live’ from January 2020. We recently invited members to apply for several positions across these committees and I am pleased to report that there has been an excellent and diverse response. Short listing is complete and interviews will have occurred at the end of November with successful candidates being informed prior to the start date in January. Fresh faces and ideas will be heartily welcomed. This is the start of a very busy but rewarding year. Everything has so far been very positive and I look forward to meeting

“Both Congresses had several speakers from the UK. We should be proud of this and the fact that British Trauma and Orthopaedics is held in high regard by our international colleagues.”

as many of you as possible over the next nine months culminating with our Annual Congress in Birmingham. More details of this will follow over the coming weeks and months. n

Latest News

Training Orthopaedic Educational Supervisors (TOES) Upcoming dates: 24th March (London) Our trainees need to learn professional judgement, insight, leadership, and the ability to work with others, alongside the operative skills required to be a safe surgeon. The new updated curriculum should help us do this more effectively. This one day course is designed to help Educational Supervisors make the changes, scheduled for October 2020, work for them and their trainees. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. For any queries, please contact policy@boa.ac.uk.

New Orthopodcast The BOA has recently released a new Orthopodcast, about chronic pain and the T&O patient. There can be a reluctance to talk about pain because it isn’t as visible or tangible as other T&O conditions. With an ageing population, we will need to do more to meet the needs of people with chronic pain. It might not be life threatening, but it can have a devastating impact on quality of life. David Ring shares invaluable insights into how we might help. To view the podcast, please see boa.ac.uk/orthopodcast.

If you would like to sign up, please visit boa.ac.uk/toes.

BOA Position statement on Medical Devices Regulation from 2020

Medical Student Essay Prize

On 26th May 2017 the Medical Devices Regulation (MDR 2017/745) was published, with the aim of replacing the current Medical Devices Directive (MDD 93/43/EC). Following a transition period of three years, this regulation will be applied in full from 26th May 2020.

Medical students are invited to submit an essay (no longer than 1,000 words) answering the following question: ‘Discuss your ideas on how the BOA can utilise social media and new forms of communication to improve engagement across the profession including students’.

The BOA has recently published its position statement on the MDR. We welcome the drive to improve the rigour and regulation of novel devices and procedures for the benefit of patients. However, we raise some particular concerns with regard to legacy devices, regulation of different types of device, value of registry data in evaluating devices and long term monitoring.

Submissions open on Wednesday 1st April 2020 and close Thursday 30th April 2020. For more information on the competition and to see our FAQs, please visit boa.ac.uk/medical-student-essay.

The position statement is available on the BOA website at boa.ac.uk.

News

New BOA Trustees (2020â&#x20AC;&#x201C;2022)

Colin Esler

Anthony Hui

I was born in Northern Ireland and graduated from the University of Nottingham in 1985. My determination to pursue a career in trauma and orthopaedics followed a year as SHO in Nottingham. I was a Registrar on the Exeter rotation and Senior Registrar in Leicester. I was a Junior Fellow in Knee Surgery in Bournemouth and Fellow at UCLA, Los Angeles before being appointed Senior Lecturer at the University of Leicester in 1999.

I was born in Hong Kong and educated at Greshamâ&#x20AC;&#x2122;s School, Cambridge University and the London Hospital Medical College. My orthopaedic training was based in Leicester and I went on a travelling fellowship in Shock Trauma Center, Baltimore and the Brigham and Women Hospital in Boston, USA.

My main clinical interest relates to surgery of the knee, from sports knee surgery through to knee revision, but I also maintain a practice in hip arthroplasty surgery. My research interest relates to the outcomes of knee and hip surgery. Throughout my career I have been involved in the management of registers (Trent, NJR and NHFD) and the interpretation of registry data. I was awarded an MD in 2014 from the University of Leicester and have been Associate Professor there since 2017. I have been honoured to be BOTA President (1996 - 1997), Elected Member of BOA Council (2007 - 2009) and BASK President (2016 - 2018). I am a member of the NJR Editorial Board and Data Quality Committee and ODEP and Beyond Compliance Panels. I am married to Claire, a Clinical Oncologist, and have boys aged 2 and 8 years old. I try to keep fit running, swimming and cycling. I am looking forward to the next three years on Council and hope to be able contribute in furthering orthopaedics and trauma in these challenging times. n

I have been a consultant orthopaedic surgeon in Middlesbrough since 1997 and I specialise in knee surgery. I was the Clinical Director for my department for over 10 years and was Secretary and subsequently Chairman of BODS. I have been a Clinical Co-ordinator for NJR, clinical adviser for the Healthcare Commission (now CQC), specialty advisor to NCEPOD, steering committee member of the Falls and Fragility Fractures Audit Project and Honarary Lecturer to Teesside University. I was elected to the BOA council 2011 - 2014 and this will be my second stint in council. I was secretary for BASK 2016 - 2019 and I am a member of Beyond Compliance and ODEP for knees. I went to Kurdistan with the Newcastle Gateshead Medical Volunteers last year under the leadership of Professor Deiry Kader and had a most enjoyable week working with the dedicated staff in their hospitals. I have recently retired from the NHS but am still working in the private sector. My interests are football, golf, walking and gardening. n

News

Andrew Manktelow

Ian McNab

Trained at the Royal Free and the RNOH, I headed to the East Midlands and to Nottingham in 1999. Part of our busy trauma group for many years, my practice is now based around hip surgery. My clinical interest started in London and developed during a year in Boston, at MGH. Away from my hips, the scope of our unit has allowed me a continued understanding of the issues that excite and confront other areas of orthopaedic practice.

I trained in Medicine at the London Hospital Medical College and in orthopaedic surgery on the St Bartholomew’s Rotation. My hand fellowship training was in Oxford and Melbourne. I was appointed as a Consultant Hand Surgeon at the Nuffield Orthopaedic Centre and John Radcliffe Hospital in 2000.

My clinical work provides research opportunities and forms the basis of my educational activities. I travel widely to lecture and demonstrate my practice and set up the Nottingham Revision Course in 2007. Recent work with our Revision Surgery Network, which provides a weekly framework for surgeons from different hospitals to meet ‘virtually’ to discuss complex cases, has received attention nationally and internationally. On the Executive of the British Hip Society for a number of years, I became President in March 2018. My year gave me a better appreciation of the challenges of today’s health economic environment. I saw how the BOA facilitates discussion, providing a cohesive response to support what good orthopaedics achieves for our patients. Married to Claire, a GP and with four beautiful and tolerant daughters aged between 21 and 14, I have little time to spare away from my work. When quiet, I enjoy travelling, music, gardening, (watching) sport and planning future revisions. Passionate about orthopaedics, I look forward to a further opportunity to contribute to our speciality. n

My clinical interests include wrist surgery and arthroscopy, complex wrist problems, scaphoid fracture non-unions, vascularised bone flaps, small joint arthroplasty, minimally invasive surgery for Dupuytren’s contracture and hand trauma and fracture fixation. My academic appointments include Honorary Senior Clinical Lecturer, University of Oxford, and Honorary Lecturer in Clinical Medicine at Wadham College. In 2007, I undertook the British Society for Surgery of the Hand (BSSH) Stack Travelling Fellowship in New Zealand, Australia, Singapore and USA. I have held many professional positions including Supervisor/ Training Head, Oxford Hand Fellowships, Council member BSSH, BOA and BMA UK Council, UK Hand Surgery Diploma Examiner, Chair BMA South Central Regional Council, member BMA Consultants Committee, past Chair AOUK Hand & Wrist Courses. I am a keen supporter of training and of multidisciplinary team working. I was honoured to be elected as President of British Association of Hand Therapists (BAHT) for 2017 - 2019 and continue to promote further close working between therapists and hand surgeons at all levels. n

News

Best Practice Tariff (BPT) changes in 2020: Fractures of the Femur Dominic Inman and Antony Johansen, NHFD Orthopaedic and Orthogeriatric Clinical Leads, Royal College of Physicians

ip fracture care in England has been financially incentivised since 2011, with NHS England offering an additional payment of £1,330 each time the National Hip Fracture Database (NHFD) records that a patient has received eight key interventions: • Surgery within 36 hours from admission to hospital • Assessment by an orthogeriatrician within 72 hours of presentation • Pre-operative cognitive testing using the Abbreviated Mental Test (AMT) score • Screening for malnutrition on admission • Physiotherapist support in getting out of bed by the next day • Screening for post-operative delirium using the 4AT screening tool • Specialist falls assessment • Assessment for bone protection The impact of this incentive structure is now clear. An academic assessment of national clinical audit data (Metcalfe et al, Bone Joint J 2019; 101-B: 1015-1023) recently concluded that interventions driven by pay-forperformance in England led to 7,600 fewer deaths within 30 days of hip fracture between 2010 and 2016. The National Hip Fracture

Database (NHFD Annual Report; RCP London 2018) has demonstrated a steady reduction in mortality for patients in England (from 8.4% at the start of 2012, to just 7.1% in 2017), but no such improvement in Wales where in the absence of Best Practice Tariff 30day mortality was 7.9% at the start of 2012, and remained unchanged at 7.8% at the end of 2017. The success of NHS England’s approach has led to the consideration of similar incentive models in a number of countries, including the recent introduction of payments for best practice in Ireland.

“NHS England have confirmed that from April 2020 the current BPT scheme for hip fracture will be extended to include all patients aged 60 and over presenting with fractures of the femoral shaft and fractures of the distal femur.”

NHS England have confirmed that from April 2020 the current BPT scheme for hip fracture will be extended to include all patients aged 60 and over presenting with fractures of the femoral shaft and fractures of the distal femur. In future years we hope the same approach can be used to improve the care offered to frail and older people with a variety of other fractures. The existing BPT criteria will be applied to this relatively small additional number of patients, but this extension of BPT means that the care these frail people receive will no longer be affected by where in their femur their fracture occurs.

We are currently redesigning the NHFD dataset and the data collection pages on our website www.nhfd. co.uk so that from January 2020 the database can collect data on all patients in England, Wales and Northern Ireland who present with hip, shaft and distal fractures of the femur.

The dataset redesign will also allow patients with any form of periprosthetic femoral fractures to be recorded, in the expectation that in future years BPT will also be extended to these cases. We would encourage hospital teams to start including these injuries in their data collection but, for 2020 at least, patients with peri-prosthetic fractures will continue to be excluded from the new BPT scheme. The existing BPT reporting for hip fracture patients, available when hospital NHFD clinical leads and data inputters log in to the database, will also include patients with femoral shaft and distal femoral fractures (but exclude patients with peri-prosthetic femoral fractures this year). This change in BPT will not lead to any other changes in the outputs of the NHFD website: the existing publicly available charts, benchmarking tables, dashboards, outlier analyses and annual reports will continue to focus on patients with hip fracture. Further information can be found on the NHFD website at www.nhfd.co.uk where all the latest hospital run charts, benchmarking tables and hospital dashboards are available to view and analyse without requiring login details. The NHFD 2019 annual report will be published and is available to view and download this month (December 2019). n

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News

Meeting Review - NZOA

Don McBride

he 2019 New Zealand Orthopaedic Association Annual Scientific Meeting was held in Dunedin between the 29th of September and 2nd of October, a beautiful town on the South Island (derived from Edinburgh – the burgh of Edin), surrounded by many Scottish place names and a statue of Rabbie Burns on the main street making me feel quite at home. The meeting had originally been scheduled for Christchurch but the convention centre had not been completed following recent earthquake damage. The theme was ‘Challenging Dogma’.

As is traditional the first day was a series of Instructional Course Lectures for Registrars and Surgeons. This covered a variety of topics and sub-specialty interests and preceded the Sports Afternoon, including golf, mountain biking and fishing for those inclined. The main Congress was underway on the Monday and included a variety of talks of general interest. Of Professor James Renwick particular note were ‘Climate Change and the Effect on Our Future’ by Professor Renwick , Victoria University, Wellington, ‘Preflight Routine, Operating Systems and Comparisons to the Operating Theatre Environment’ by Marc Studer, Surgeon and Fighter Pilot, Swiss Air Force and ‘Developing Organisational Resilience to Cyber

Threats’ by Tom Moore, Aura Information Security. Professor Chris Harner (President AOA, Carousel Member) gave the John Sullivan Memorial Lecture on ‘How I Manage the Multiple Ligament Injured Knee’ followed by our very own Professor David Murray as RACS speaker on ‘UKA: The Current State of Play’. The afternoon was completed with work force planning, training and selection issues. Day two started with the International President Carousel Symposium on the ‘Two Papers That Have Affected My Practice the Most’. This was a very well received session including my own talk entitled ‘Rise of the Machines versus Hands on Orthopaedics’. The morning was completed with a talk by Professor Fares Haddad on ‘Managing Infected Arthroplasty’ and an excellent debate presented by Professors Haddad and Murray on ‘UKR: Robotic Versus Conventional’. The day was completed with free paper sessions. The final day comprised mainly free paper sessions but included an excellent talk by John Quinn, Director, Performance Wellbeing on ‘Well-being and Leadership’. All in all this was an excellent meeting with many learning points to take back to the UK. My congratulations and thanks to Rod Maxwell, President NZOA, Conference Convenors Jonny Sharr and Nicholas Lash and the supporting CEO and Staff of the NZOA, in particular, Phillippa Shierlaw who made our visit run very smoothly. n

Meeting Review – SAOA Phil Turner

he 65th Annual Congress of the South African Orthopaedic Association was held at the International Congress Centre in Durban from 2nd to 6th September 2019. The theme was ‘Unity in Diversity’ reflecting the continuing problems of health delivery in a complex multi-racial society.

This Congress is unusual in that it is both the national association’s meeting and the combined meeting of the specialty associations. The number of overseas faculty was remarkable with 11 speakers from the UK and one from an apparently independent Scotland – Colin Howie. The guest speakers were certainly engaged with the event – many delivering more than five presentations or chairing sessions. There was little time to see the city or surrounding country even though the weather was

perfect. The breadth of the instructional courses and quality of research was remarkable. The disease profile was quite different from experience elsewhere. In paediatrics, Blount’s was seen as a common problem. HIV and tuberculosis were the subjects of several projects and the overwhelming incidence of major trauma was very clear. The provision of a government-based service was problematic. As elsewhere, funding and resources were major issues. Despite this, surgery of sports injuries is a burgeoning sub-specialty and robotic surgery was surprisingly commonplace.

The organisation of a complicated and packed schedule was a triumph for the secretariat with regular 7:30am starts. Despite this, all sessions were well attended by consultants and trainees. Time was taken to acknowledge the success of training programmes and those undertaking fellowships as well as honouring the dedication of the trainers and academics. At least there was no jet-lag to recover from before our own Congress in Liverpool which started three days later. n

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News

Meeting Review – AOA

he 2019 Australian Orthopaedic Association Annual Scientific Meeting was held in the National Convention Centre, Canberra, the Australian capital between the 6th and 10th of October, with the President David Martin and the theme ‘Teamwork and Engagement’. The city was built as a result of a dispute between Sydney and Melbourne over the issue of ‘Capital City’.

The meeting was preceded by the Presidents Reception held at the National Museum of Australia, an inspiring modern building.

the Carousel Presidents and included team work presentations by Peter FitzSimons, retired Australian rugby union player, journalist and author and John Newton, headmaster of Scotch College in Adelaide. Immediately after lunch there was an excellent plenary session on ethics including a lecture by Tracy Martin, a high flier in the Australian army. There was a separate presentation by ANZORS, a collaborative group with NZOA promoting and inspiring trauma and orthopaedic research.

“Day two included parallel sessions on arthroplasty (hip), trauma and shoulder and elbow with separate general presentations. The day was completed by another excellent plenary entitled ‘Overtreatment and Undertreatment’. This was compelling and thought provoking.”

The morning and afternoon of day one included parallel sessions on arthroplasty (knee), hand and wrist and spine including two excellent talks in the hand and wrist section from our very own past President, Professor Joe Dias. This was followed by the Opening Ceremony attended by

Don McBride

Day two included parallel sessions on arthroplasty (hip), trauma and shoulder and elbow with separate general presentations. The day was completed by another excellent plenary entitled ‘Overtreatment and Undertreatment’. This was compelling and thought provoking. I would not normally mention the social programme in detail but we attended a wonderful dinner at the Australian War Memorial, very inspiring and the only time we saw kangaroos.

Day three started with a plenary session on research followed by registry updates across Australia and New Zealand including an interesting talk on the knee osteotomy registry. This was followed by a further plenary centred around the Congress theme on Teamwork and Engagement. Each presentation was inspirational and provided the smiles, tears and knowledge advised by the speakers beforehand. The afternoon included further sessions on arthroplasty, medicolegal, trauma and tumour surgery. The final business included the AOA AGM but this was followed by the AOA awards and fellowship ceremony. The latter included formal awards to the registrars who had passed the AOA fellowship attended by their friends and family. I was asked to talk on ‘Why I became an Orthopaedic Surgeon’. This was an enjoyable end to the day and well received by those in attendance. The final day concluded with parallel meetings on arthroplasty, knee, trauma and tumour with a knee plenary session on ‘ACL update’. This was an excellent meeting against the backdrop of a beautiful city. My congratulations and thanks to David Martin, President AOA, Conference Convenors Ian Harris, Nicole and Maurizio Damiani and the supporting CEO and Staff of the AOA, in particular, Alison Fallon who made our visit very rewarding. n

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Conference listing: OTS (Orthopaedic Trauma Society)

EFORT (European Federation of National Associations

www.orthopaedictrauma.org.uk of Orthopaedics and Traumatology) 15-17 January 2020, Newcastle www.efort.org 10-12 June 2020, Vienna

BHS (British Hip Society)

www.britishhipsociety.com 4-6 March 2020, Wales

BSCOS (British Society for Childrenâ&#x20AC;&#x2122;s Orthopaedic Surgery) www.bscos.org.uk 19-20 March 2020, Manchester

BRITSPINE

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

BASK (British Association for Surgery of the Knee) www.baskonline.com 16-17 April 2020, Oxford

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk 30 April - 1 May 2020, London

WOC (World Orthopaedic Concern) www.wocuk.org 6 June 2020, Chester

CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org 10-13 June 2020, Brest - France

BESS (British Elbow and Shoulder Society) www.bess.org.uk 24-26 June 2020, Brighton

BIOS (British Indian Orthopaedic Society)

www.britishindianorthopaedicsociety.org.uk 10-11 July 2020, Cardiff

BORS (British Orthopaedic Research Society) www.borsoc.org.uk 7-8 September 2020, Bath

BOA (British Orthopaedic Association) www.boa.ac.uk 15-18 September 2020, Birmingham

News

UKITE (UK and Ireland In-Training Examination) UKITE is taking place this month from 6th - 13th December. The UKITE schedule and general information is available on the BOA website at www.boa.ac.uk/ukite. We want to wish everyone well who is sitting the UKITE this month. For those unaware of UKITE, the exam is intended as a tool for trainees to practice for section 1 of the FRCS Tr and Orth. The BOA currently delivers the exam annually in December. It is an online examination hosted on the BOA e-Learning site (BOA Learning Hub), which allows delivery to be managed locally within individual training programmes. This year the BOA have been looking in more detail at the UKITE offering and have set up a working group to consider ways to develop UKITE as a tool in preparing trainees for FRCS. This includes considering ways to align the exam in content and structure as closely as possible to Section 1 of the FRCS, provision of increased feedback on exam performance, and post examination statistical analysis. More information on this work will be available during the coming year.

Internationally renowned speakers will deliver state-of-the-art talks, including the prestigious Cierny-Mader lecture which is invited each year to honour ‘excellence and innovation in the multidisciplinary management of bone and joint infection’. The programme will include:

Online registration is now open at www.hartleytaylor.co.uk

For anyone interested in being involved in UKITE editorial process, please contact the UKITE Team (ukite@boa.ac.uk) for more information.

NHS England waiting times for September 2019 were published and showed the worst performance this decade for several metrics. It is now a full 5 years since the waiting time targets were last met for the T&O specialty, and over 90,000 people had been waiting over 18 weeks for treatment. We published a statement highlighting our concerns at the growing problem which can be found on the BOA website.

Thursday 26th & Friday 27th March 2020 Examination Schools, High Street, Oxford

• Do’s and don’ts. An (evidence-based) approach to … • DFI models of care • Prosthetic joint infection • Rehabilitation – managing expectations • Trials and big data • Engaging the research agenda • New horizons • Making the most of what we know .... and much more

The BOA wants to thank all those that contribute their time to the annual production of UKITE. A considerable amount of time is given by Ajay Malviya, the UKITE Clinical Lead, and editorial team to ensure on going delivery of UKITE.

Policy news round-up

The Oxford Bone Infection Unit 9th Annual Oxford Bone Infection Conference (OBIC)

Enquiries: anne@hartleytaylor.co.uk

Young Ambassador Congratulations to Nicola Fine who represented the BOA as the Young Ambassador at the Hong Kong Orthopaedic Association in November and presented on ‘Dupuytrens disease above the wrist’.

The NHS pension scheme was the subject of a Royal College of Surgeons of England survey recently. 1,890 RCSEng members responded (22% of them T&O surgeons), and in total: 92% of consultant surgeons were very concerned about the current tapered annual allowance and pension taxation rules; 69% had reduced the amount of time they work in the NHS; and 68% were considering early retirement. RCSEng has raised concerns, shared by the BOA, about severe impacts on waiting lists and training of future surgeons. A NICE consultation about hip, knee and shoulder replacement guidelines is currently open, and the BOA is working with BASK, BHS and BESS to prepare a response; the final guidance is due for publication in March 2020.

News

BOA Research

2019 has been a busy year on the research front for the BOA. This feature is designed to keep you up to date with all developments.

T&O has historically received a disproportionately small proportion of trial funding compared to the significant burden of musculoskeletal conditions on NHS expenditure. We are keen to do all we can to change that and hope you will be encouraged to hear of the BOA’s work in this area. Over recent years through our support to the BOSRC, alongside initiatives from other bodies such as the RCSEngland, we have already seen a large increase in the number of clinical trials for T&O. We are pleased to be providing additional investment, and hope to see a further step-change in improving the landscape for clinical trials in the UK. This work is only possible thanks to all those who donate to our research fund, and if you would like to contribute, please visit: www.boa.ac.uk/donate

Daniel Perry is Associate Professor of Children’s Trauma and Orthopaedic Surgery at the University of Oxford, an NIHR Clinician Scientist and a Consultant Children’s Orthopaedic Surgeon Alder Hey Children’s Hospital in Liverpool. Dan has united surgeons throughout the UK, such that they are now working together to change the face of children’s research worth about £7m. Dan’s love is to make clinical trials accessible – both to children, parents and surgeons. He keenly integrates cartoons, animations, videos and text message communication to make trials easy for everyone! Dan is a member of the NIHR HTA Commissioning Board, is an Editor of the Bone and Joint Journal and is the clinical lead for hip screening within Public Health England.

BOA-Sponsored Surgical Specialty Leads for clinical trials commence their work The BOA is, for the first time, sponsoring ‘Surgical Specialty Leads’ for trauma and orthopaedics and three excellent candidates have been appointed to these roles and take up these positions from 1st November 2019. These positions will cost £62,500 over three years and have been funded as a result of our research fundraising. The Surgical Specialty Leads are positions coordinated through the RCSEngland and the aim is for them to act as a conduit for clinicians interested in developing trials and to provide a forum for discussion of proposals that can be processed through appropriate funding bodies. They will each chair a clinical research group to help develop new trials in their field. The three appointees will work collaborative with the BOA, with our funded clinical trials unit and with other stakeholders to make progress in supporting development of research and trials. We are very pleased to introduce the newly appointed members taking up these roles:

Paul Baker is a clinical academic at the South Tees Hospital NHS Foundation Trust and has undertaken a significant amount of research in to the outcomes of patients undergoing hip and knee replacement procedures. He was the NJR’s first research fellow, and founded the CORNET orthopaedic trainee research collaborative whilst a trainee in the Northern Deanery. Paul is the current director of research and innovation for the South Tees Hospitals and an executive director for the Durham Tees Valley Research Alliance with responsibility for a portfolio of over 200 clinical studies. He is a NIHR grant holder and chief investigator for the OPAL study that completed in early 2019. He is currently developing the next phase of the OPAL study which will involve a multicentre clinical trial.

Xavier Griffin is an Associate Professor of Trauma Surgery at the University of Oxford and Honorary Consultant Trauma Surgeon at the John Radcliffe Hospital. His clinical interests are in the care of the multiply injured patient and those with pelvic and acetabulum fractures. He is currently an NIHR Clinician Scientist, with research interests in clinical and cost effectiveness of treatments for patients sustaining injuries, and is the Chief Investigator for several NIHR randomised clinical trials. Current studies include those related to broken hips, broken ankles and pelvic fractures. Xavier has several research committee appointments including, but not limited to: Cochrane Bone Joint and Muscle Trauma Group, Arthritis UK and British Orthopaedic Trauma Society.

News

BOA has launched a call for applications for clinical trial support to develop new trials Another arm of the BOA research strategy is funding of Clinical Trial Unit (CTU) infrastructure to provide methodological support needed to develop clinical trial ideas and competitive funding proposals. After five successful years working with the BOA Orthopaedic Surgical Research Centre (BOSRC) in York, the BOA is keen to build on the successes of this project. We have published a call for applications for CTUs to receive grant funding to work on this from 2020 to 2023. We are seeking proposals from CTUs experienced in delivering surgical trials either already covering trauma and orthopaedic surgery or otherwise who can demonstrate a significant interest in expanding their portfolio in T&O. We are particularly looking to ensure that support is provided to first-time PIs and CIs in order to build capacity and capabilities. BOA Council have approved funding for up to two CTUs to receive support, and we will keep members updated in 2020 as to who is successful. If you are involved in a CTU that would be interested in applying, please check our website for more information. You can also read more about the BOSRC and their work on our website at www.boa.ac.uk/research.

And finally... We are pleased to report other good news related to our work and members: • Prof Amar Rangan, BOA Member and past Chair of BOA Research Committee, has been appointed to The Mary Kinross Trust & RCSEngland Chair in Surgical Trials and Health Sciences at the University of York. This is one of seven RCSEngland Professorial Chairs that have been recently appointed in partnership with UK Universities to drive surgical research. Another of these Chairs, Prof David Beard, who is a physiotherapist by background, has a substantial interest in T&O trials. • The BOA contributed towards a James Lind Alliance Priority Setting Partnership on ‘Upper limb fragility fractures’, which started at the beginning of 2018. The results of this piece of work have been accepted for publication in the BMJ Open and will be available soon.

Fundraising Events on behalf of Joint Ac�on

Join our 2020 fundraising events and help raise much needed funding for trauma and orthopaedic research! We are always looking for new fundraising opportuni�es so please share your ideas with us at jointac�on@boa.ac.uk. You can now also donate directly through the BOA website at www.boa.ac.uk/donate

Pruden�al RideLondon 100

July 2020 - Date TBC Places available

@BritOrthopaedic

Sunday 16th August 2020 Places Available

Bri�sh Orthopaedic Associa�on

BritOrthopaedic

Features

Robert Jones Lecture John Skinner

The Robert Jones Lecture is one of the highest honours bestowed by The Royal College of Surgeons of England. This year the lecture was given by Professor John Skinner at the British Orthopaedic Association Annual Congress in Liverpool. The lecture title was ‘Hip Resurfacing and metal bearings: what did we learn?’.

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

idespread awareness of the latest iteration of hip resurfacing in the United Kingdom began when the Sunday Times published an article on 2nd June 1996. This was entitled ‘Everlasting hip removes the pain of replacements’, and suggested “the new hips would last forever”. It summarised some of the early work of Derek McMinn, with metal on metal hip resurfacing.

With the advent of bone cement and the discovery of high-density polyethylene (HDP), along with concerns regarding the carcinogenic potential of cobalt-chromium debris, metal on polyethylene bearings became the norm. By the mid-1990s hip replacement was so successful that it was increasingly performed on younger, more active patients and failures were more commonly from the effects of wear debris and osteolysis. This was McMinn’s driver to revisit metal bearings and resurfacing designs, as a bone conserving wear resistant operation for highly active younger patients.

“The world’s first total hip replacement was performed by Sir Phillip Wiles in 1938 and was a resurfacing device made initially of stainless steel and then a Vitallium alloy of cobalt and chromium.”

The world’s first total hip replacement was performed by Sir Phillip Wiles in 1938 and was a resurfacing device made initially of stainless steel and then a Vitallium alloy of cobalt and chromium. In 1958 Sir John Charnley also designed a hip resurfacing device made from Teflon (Polytetrofluoroethylene). These devices taught us that materials in hip surgery really matter, with the Charnley device failing with bone destruction but the failure mechanism being ascribed to avascular change in the femoral neck. The first generation of metal on metal total hip replacements were pioneered by Ken McKee in Norwich, Peter Ring in Surrey and also a Stanmore design. All of these devices were monobloc,

without modular junctions and although their success was determined in part by machining tolerances, most failed by loosening. The ones that survived did so with minimal wear. The Ring device was interesting in that it had an acetabular stem that was inserted into the Ilium, via a posterior approach. When this was correctly seated, it effectively mandated that the acetabular cup was in a closed position and edge loading would be extremely unlikely. Hence, many of the things that we learned and relearned in the early part of this century had been alluded to in early hip designs. Materials matter, modular junctions can be problematic, component orientation is critical and that the Press plays an important part in communicating both success and failure.

It is quite likely that if McMinn had had access to highly cross-linked polyethylene in the 1990s, this line of development may not have been required. Hip resurfacing is technically more difficult than total replacement and surgeons went to Birmingham to learn the technique, much as Charnley had insisted on for his total hip replacement in the 1960’s. In the early stages, the biggest concern with hip resurfacing was the risk of femoral neck

Features

The Birmingham Hip Resurfacing Implant

fracture which represented 55% of all of the early complications. At this stage we still hadn’t heard of ALVAL, ARMD and pseudo tumours. If a fracture occurred, the solution was to revise to a total hip replacement, retaining the acetabular component and inserting a large diameter resurfacingtype head onto a modular stem. This unfortunately was the advent of the least successful total hip replacement design of all time: namely the large diameter metal on metal total hip replacement which failed largely from wear and corrosion creating debris, at the head-stem junction. This debris seemed to be highly biologically active and in relatively small volumes could produce significant soft tissue response. In some circumstances these large diameter bearings became high friction, effectively ‘torture testing’ the taper junction. Early this century, we started to see patients with metal on metal hips (MOM) who seemed to have unexplained pain when conventional criteria and testing were applied. In 2007 Alister Hart and I set up the London Implant Retrieval Centre (LIRC) with the aim of understanding why these metal hips may be causing problems. Ultimately one million metal on metal bearing hips were performed worldwide. In 2006, hip resurfacing was the most common type of hip used in men under 50 years and represented 10% of all hip bearings in the UK. By 2009 35% of all hip bearings were metal on metal in the USA. We believed that analysing the retrieved implant would show why these implants were failing and how the metal ions were generated. We published our methods and David Langton and Tony Nargol in North Tees published similar findings at the same time.

At this time, with teams in London, North Tees, Birmingham and Oxford the UK was leading the world in the analysis and understanding of the problems leading to revision of metal bearing hips. We all described edge loading and Langton’s work on the contact patch to rim distance elegantly described the problem of component design and position and its relevance to failure. Measuring blood cobalt and chromium ions rapidly became a new orthopaedic investigation that may act as a biomarker of problems at the bearing or taper junction. Our work first suggested a level of 7ppb that seemed to be a figure that was behaving differently in a cohort of 100 hip resurfacing patients. The MHRA adopted 7ppb as a level

that warranted further investigation in hip resurfacing patients. This level had high specificity but a lower sensitivity for detecting problems. Others suggested that 5ppb may be better, but it soon became clear that no metal ion level was ever likely to be a threshold that mandated revision surgery. Lower levels of metal ions had higher sensitivity to detect problems with lower specificity and higher ion levels were more specific but less sensitive. MRI scanning also became a primary investigation for hip implant problems for the first time. Previously MRI had been relatively contra-indicated in orthopaedic implant surgery as the metal artefact was considered to be too great to allow useful interpretation. We further developed the work from Norwich, of Toms, Tucker and Nolan and working with MRI Physicists and Radiologists developed MRI protocols that allowed excellent definition of muscles and soft tissues around metal hips. This was helpful as it was the damage and necrosis to muscles around the hips as a result of ALVAL that created the most disabling and difficult to reconstruct sequelae of the worst ARMD reactions. Our work with the National Synchotron allowed us to perform speciation and to identify the ions and active agents in periprosthetic tissue. This produced the first ever nano-sized physical and chemical >>

A coordinate measuring machine showing wear and the contact patch on an acetabular component

A high resolution MRI of a hip implant, left, and an axial section of the same, right

Features

In summary, there may still be a place for epidemiological hip resurfacing where some results still show study linking NJR excellent function and safe performance out data to HES and to 21 years. Newer materials are being tried CPRD databases for resurfacing with ceramic on ceramic to look at the heart resurfacing trials underway in London and failure incidence. Nottingham. Derek McMinn has designed a With 53,000 metal on highly cross-linked polyethylene hip patents with MOM resurfacing which is also being trialled with bearing hips and promising early results. We have learned over 482,000 with nonthe last 20 years that Registries can tell us MOM bearings, how successful an implant is, but it is analysis there was again no of retrieved implants that helps us explain the increased incidence mechanism of failure. Both are invaluable. in the risk adjusted We have set up the Beyond Compliance hazard rate of heart system in the UK to safeguard and increase failure in patients A wear map showing the effects of edge loading on an acetabular component the safety of introducing new implants into with MOM bearings clinical use. Patient safety must always be compared to those paramount and new implants in patients with alternative demand closer follow up and assessment. n maps of metal particles inside cells. This bearings. This was maintained after revealed chromium (III) phosphate, Chromium propensity matching in this UK population (III) oxide and Cobalt (II) and metallic cobalt of patients who were under surveillance as species were present. No hexavalent chromium recommended by the MHRA. References (a known carcinogen) was identified. Another concern at this time was that the young References can be found online at www.boa.ac.uk/publications/JTO. There has always been anxiety as to whether population having hip resurfacing was largely metallic debris from orthopaedic implants female patients with dysplasia may be associated with increased rates and many were of child bearing of cancer. Studies by Visuri and others age. Was it safe to have a family have always shown that patients with hip and go through pregnancy with a replacements live longer than age matched MOM bearing hip replacement? controls. The question arose again with metal Hena Ziaee in Birmingham on metal hips when a cohort of patients in performed an excellent study South Wales under follow up for their hips and followed up over 100 women were found to have lymphoma. This appeared through pregnancy to birth. She compared a cohort of women to be a random cluster and the excellent with average age 30 years (18work of Alison Smith and the NJR team 39) who had Birmingham Hip linked the NJR to national cancer Registries. Resurfacings, mean time from This showed that the observed incidence of operation 64 months, (range 11cancers was lower than the expected incidence 144 months) with a control group rate for all hip replacement patients, those who had no metal implants in with stemmed MOM total hip replacements situ. Measuring maternal and and for those with MOM hip resurfacings, foetal cord blood at delivery she using a multivariate competing risks flexible assessed blood ions and whether parametric survival model. This was found they crossed the placenta. Ziaee at seven years post-surgery and has been found no change in Cobalt repeated with the same findings at 12 years levels in the control group but a post-surgery. It would seem sensible for 60% reduction of Cobalt levels this study to be repeated every five years to from maternal to cord blood in confirm that it endures. patients with raised ions and hip resurfacing. Only 23% of In 2016 the Australian regulator the Sir Robert Jones the maternal Chromium blood Therapeutic Goods Administration issued ion level crossed the placenta an alert suggesting a potential association into the foetal circulation. The between the ASR XL large diameter MOM differences between maternal hip replacement and cardiac failure. We and cord blood metal ions in investigated this in detail with a study the control group was small, looking at patients with MOM hips and indicating that under these low ions (mean 2.5ppb range 0.7â&#x20AC;&#x201C;6.9ppb), circumstances the placenta raised ions (mean 30ppb range 7.5-118ppb) shows almost free passage of and non-mom bearings (mean 0.2ppb these metal ions. However, when range 0.1-0.5ppb). With 30 patients in maternal levels are increased each group, left ventricular function was the placenta exerts a modulatory assessed using cardiac MRI, echocardiogram effect on metal transfer, and the heart failure biomarkers BNP and A nano-sized physical and chemical map of metal particles inside cells from around a hip in keeping with placental Troponin. No difference was found between prosthesis. Chromium (III) species predominate and hexavalent chromium is absent. physiology for other substances. the three groups. We then performed an

Features

Johnny Mathews is a specialist trainee in orthopaedics on the Severn rotation currently undertaking a PhD, and was the BASK Research Fellow 2018 - 2019.

Nick Kalson is an NIHR Academic Clinical Lecturer in Orthopaedics (ST6) in Newcastle and is the BASK Research Fellow for 2019 - 2020.

BASK Revision Knee Working Group Update Johnny Mathews, Nick Kalson, Jonathan Phillips and Andrew Toms

Modern orthopaedic practice is increasingly specialised, outcomes are more closely monitored, and the finite pool of available resources are more carefully allocated. Reflecting these pressures, the British Association for Surgery of the Knee (BASK) has set up working groups in sub-speciality areas such as meniscal surgery, biological therapy and revision knee surgery tasked with tackling the challenges faced by knee surgeons.

evision knee surgery presents particular challenges in that decision making can be difficult, the operations themselves can be long and complicated, and may involve a huge array of instrumentation1. It is expensive, there are significant surgical risks and there is wide variation in outcomes with large numbers of low volume centres currently performing such surgery2. Over 100,000 knee replacement procedures are performed each year in the UK, with patient dissatisfaction a factor in up to 20% of cases. There is also considerable variation in the approach to investigating and treating this difficult patient group. Complications, such as Prosthetic Joint Infection, are challenging to treat with high complication rates and poor outcomes that we need to improve.

Jonathan Phillips is a consultant knee surgeon at the Exeter Knee Reconstruction Unit. He undertook orthopaedic training in the East Midlands and fellowship training in reconstructive knee surgery in Nottingham and Exeter.

Recognising these challenges the Revision Knee Working Group (RKWG) was set up in November 2018 with five principle aims: 1. Determine the organisational structure of how Revision KR (knee replacement) care is delivered in the NHS 2. Analyse and influence how best practice Revision KR is supported and incentivised 3. Develop guidelines and standards for best practice in Revision KR 4. Identify key clinical uncertainties and drive Revision KR research 5. Set an agenda for education and training of Revision KR surgeons

Surgeons were selected to be members of the RKWG after analysis of NJR data. The most active surgeons and centres in revision knee surgery were invited to participate.

Organisation of revision KR Services • The National Joint Registry (NJR) for

England and Wales recorded over 6,000 revision KR procedures in 2017, performed by over 1,300 surgeons at approximately 200 NHS sites. • A large volume of revision knee surgery is currently undertaken in low volume units, by surgeons performing a very small number of Revision KR procedures3. The most common number of such operations performed by UK surgeons is one per year, whilst next most common is two per year.

“Our patients require more postoperative support services and coordination than we currently deliver, and we need to reinvigorate revision knee leadership to improve care for this often disparate group of patients”

Features

to develop multi-centre clinical studies to bridge the evidence gap in these challenging patients.

Training Revision KR surgeons • The development of high-

volume Revision KR centres will be supported through specific subspecialist training. • The intention is to develop BASK-recognised Revision KR post-CCT training fellowships and the introduction of observer placements. • It is recognised that new Consultant Surgeons who are building their skills require support, and dual consultant operating will be encouraged. • There is currently a lack of a recognised, high-quality principlebased training course in revision KR; RKWG will develop this and deliver this, aimed at consultants and peri/post-CCT trainees, in autumn 2020.

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

•

It is becoming increasingly recognised that surgeons regularly undertaking a procedure achieve improved outcomes4. Challenging this low volume practice has been a primary pillar of the national GIRFT project and work in this area has already been done by the Scottish Arthroplasty project. The RKWG has undertaken a national analysis to design regional revision KR hub and spoke networks. This has been modelled on the successful Major Trauma hub and spoke network, and the recognition that specialist MDTs deliver optimised care for challenging, complex cases such as prosthetic joint infection. Such networks already exist in several regions, and these have been used as an example of best practice. Regional hubs, with the infrastructure to deliver care for complex Revision KR cases (such as re-revision, major bone loss, requiring plastic surgery or specialist microbiology input), will support spoke units that are regularly undertaking Revision KR surgery. Consolidation of service into the hubs and spokes will improve the cost-effectiveness of care delivery as well as consistency across the UK. This will also enable specialist Revision KR surgeons to achieve greater surgical volumes.

Revision KR Practice Guidelines • The success of the BOA’s trauma

guidelines (BOAST) has led to the development of further standards for elective orthopaedics (BOASt). To

support clinicians treating Revision KR patients, a series of these BOASts are being drafted to provide auditable guidelines for practice in knee surgery. • These BOASTs will focus on the investigation of the problematic knee replacement patient and investigation and management of prosthetic infection. As well as a surgical practice guideline document. • These will be supported by a BOA-BASK Blue Book for Revision Knee Surgery, which will outline the evidencebase for these clinical guidelines.

Research Priorities • Significant gaps exist

By working across these key domains, the RKWG aims to improve the care of Revision KR patients in the UK. This effort has stemmed from the recognition that the burden of work will increase, that current financial mechanisms are unsustainable, and that optimising care requires us to work in multidisciplinary teams within networks in a manner that was developed by cancer services years ago. Our patients require more postoperative support services and coordination than we currently deliver, and we need to reinvigorate revision knee leadership to improve care for this often disparate group of patients.

“Over 100,000 knee replacement procedures are performed each year in the UK, with patient dissatisfaction a factor in up to 20% of cases. There is also considerable variation in the approach to investigating and treating this difficult patient group.”

in our understanding of care of Revision KR patients. • Given this uncertainty, BASK and the RKWG have undertaken a James Lind Alliance Priority Setting Partnership to identify key research questions. The process is now complete and these research priorities, identified through a patient centred process, will guide the research agenda in Revision KR. • Using these priorities, the RKWG aim

The RKWG thanks BASK and the BOA for their support; the Blue Book on Care in Revision TKR and new BOASt clinical standards will be launched at BASK’s meeting in Spring 2020. n

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

Features

Winter Pressures and effects on training Matthew Brown Providing a high standard of care at all times is the absolute priority of all trainees. In recent years, NHS hospitals have struggled to cope with high numbers of acutely unwell patients presenting during the colder months, often termed the â&#x20AC;&#x2DC;winter pressuresâ&#x20AC;&#x2122; effect. We are living longer and with multiple and more complex chronic co-morbidities.

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

n late 2018 winter pressure guidance was issued by multiple organisations, including Higher Education England (HEE)1, the Academy of Medical Royal Colleges (AoMRC)2, the BMA and AoMRC Trainee Doctor Group3, and the RCS England4, amongst others. In response to trainees potentially being moved between hospital departments and a concern that surgical training would be disrupted, BOTA and the Association of Surgeons in Training (ASiT) issued a joint winter pressures statement in December 20185. We highlighted the need for improved long-term workforce planning and we withheld support for the movement of trainees away from their surgical training. The seasonal variation in acute admissions is here to stay; however, stretching the current workforce thinner is not a long-term solution. Surgeons in training have a duty of care to patients and will always provide emergency care when circumstances demand. Elective surgical training is often affected early and as a result of the 2017/18 winter pressures, 62,000 fewer operations were performed, compared to the previous year6. Elective operative numbers reduced significantly for some trainees, with significant variation between Trusts and regions. In such circumstances, Training Programme Directors (TPDs) face the difficult choice of moving trainees from poorly performing orthopaedic departments to those able to offer the necessary level of surgical exposure. Despite the great inconvenience, not least for the surgical trainee, such a move is often the only solution. Although Higher Surgical Training lasts six years, a poor six-month placement can have a

significant effect on total operative numbers and trainee progression7. An eLogbook analysis by Norrish, Bowditch and Large (2018, in review) at 20 NHS hospitals demonstrated a net 20% reduction in T&O operations, with the greatest decrease affecting lower limb arthroplasty8. They predicted that up to 6.5 months of extra training may be required for trainees to achieve minimum/indicative operative numbers. Improved workforce planning, in-patient bed capacity, discharge pathways and social care provision are required to avoid a worsening of the problem observed in recent years. The NHS Long Term Plan, published in January 2019, outlined the need to reduce the winter pressure burden through supporting those with pulmonary disease and expediting patient discharge9. This approach contrasts with the comments of Simon Stevens, Chief Executive of the NHS in England, who in June highlighted that more acute and general medical hospital beds were required after decades of capacity reductions10. The positive trainee experience detailed in the accompanying article demonstrates that efforts can be made to support and protect orthopaedic training when required. Trainees and TPDs should be empowered to seek and facilitate the highest quality training in order to deliver safe surgical care for the patients of today and tomorrow. n

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

Features

Intra-Deanery Transfer During Winter Bed Pressure Months: A Trainee’s Perspective Ryan Hillier-Smith In the December 2018 edition of the JTO Koç et al described the effects of ‘Winter Pressures’ on Orthopaedic training1. They suggested that a potential deanery level intervention could involve having a low threshold for transferring trainees out of heavily affected placements to other unaffected teams. During the winter of 2017/2018 the Wessex Deanery employed this intervention and I was transferred to another hospital as a result of the pressures.

Q Ryan Hillier-Smith is an ST5 Orthopaedic Registrar in the Wessex Deanery currently working at Salisbury District Hospital.

ueen Alexandra Hospital, Portsmouth, closed its doors to elective orthopaedic in-patient admissions from October 2017 until March 2018. At the time, I was an ST3 registrar due to start a four month elective knee rotation in January 2018. There were concerns that given the lack of elective operating, my opportunities for learning would be limited. My Training Programme Director (TPD) was proactive and organised for me to be transferred. I was transferred to the Royal Bournemouth Hospital to join the knee team there. Their department continued to perform elective operations and I was able to add 66 operations to my logbook over two months. I returned to Portsmouth as soon as elective operating had restarted. Whilst at Bournemouth I continued to fulfil my weekend on call trauma commitments at Portsmouth. This meant that the trauma service at Portsmouth was unaffected by my transfer and I was able to have access to both trauma and elective learning experiences across two hospitals. There were a number of additional advantages beyond my operative numbers. Bournemouth was chosen because my TPD knew that I would be rotating there the following year. Therefore my two months spent here were extremely valuable as I learned the layout of the hospital and also worked with many people I would then work with the following year. I definitely found that this made my transition into ST4 much easier and I feel that I had more training

opportunities because I already knew many of my colleagues and consultants. In fact the consultant I worked for during my two months was then my educational supervisor the following year. On a more practical note I was also able to complete my mandatory training, organise car parking and identification/access badges in those two months which meant I did not have to do this when I started ST4. During my time in Bournemouth I was effectively supernumerary. This meant that I could design my rota to be as useful as possible. This included clinic time where, as an extra pair of hands, I could see patients which took the workload off my colleagues. I found that this meant they had more time to train me and complete my work based assessments. Winter bed pressures can have a significant impact on the experience of orthopaedic trainees. It is likely that we will be faced with these pressures again and from my positive experience I would recommend that deaneries and trainees consider transfers as a potential solution. I found it to be a very useful experience in the early stages of my career and I am grateful to my TPD and colleagues at both Portsmouth and Bournemouth for helping me make the most out of the opportunity. n

References 1. Koç T, Bowditch M and Bucknall V. The Effects of “Winter Pressures” on Trauma and Orthopaedic Training. 2018. Journal of Trauma & Orthopaedics. Vol 6 Issue 4

Features

The impact of webinar-based teaching programme on FRCS (Tr&Orth) exam performance of SAS Orthopaedic Surgeons Firas Arnaout and Shwan Henari

Intercollegiate Fellowship of the Royal Colleges of Surgeons, Trauma and Orthopaedics (FRCS Tr&Orth) is a prestigious qualification and is a prerequisite for all the trauma and orthopaedic surgeons working in the UK and looking to accomplish recognition and career progression. Firas Arnaout is a member of the BOA and a Fellow of the Royal College of Surgeons, he has a special interest in trauma and lower limb arthroplasty. He has been nominated for the Innovation in Surgical Education award at the Royal College for his work in founding and managing this education programme.

Shwan Henari FRCS, MCh, MB/BCH/BAO qualified from University College Dublin, presently working within the Oxford Trust. He is one of the founding members of the FRCS Mentor Group.

he FRCS exam is composed of oral and clinical components which require significant presentation skills and ability to perform focused clinical examination under time constraints.

The surgeons who are not in a formal training programme face additional challenges due to lack of support, deficient career advice and lack of focused clinical training. Historically, there has been a significant gap between the pass rate of training and career grades in the UK1. It is hypothesised that lack of access to structured teaching programmes and the absence of exam-oriented teaching contribute towards the relatively poor outcomes. In this study, our objective was to evaluate the pass rate of career-grade surgeons undertaking the FRCS exit examination who participated, in a peer-assisted and problem-based teaching, which is designed by a group of career-grade surgeons who have been successful in completing the exit exam. The results are compared with the pass rate of trainees in a national training programme.

Methods Initially, we extracted exam results for trainee and career-grade surgeons published on the JCIE website for February 2016 and May 20162. These two exam sittings were prior to the start of the educational system for career-grade surgeons.

Data collected included the total number of career-grade and trainees who appeared in the exam, and the total number of career-grades and trainees who passed the exam. We then introduced the teaching platform and re-evaluated the pass rate in Nov 2017, Feb 2018 and April 2018. We then compared the results after the introduction of our problem-based teaching programme. Our problem-based teaching system includes several constituents: 1 - A communication platform using TelegramÂŽ app. This became the largest community of career-grade orthopaedic surgeons in the UK preparing for the FRCS exam, with over 400 members at various stages of exam preparation, from people preparing for part 1 to people who have already passed (image 1). This allowed prospective exam candidates to correspond directly with previous successful candidates who have been through the same experience. The successful candidates were able to give valuable advice on how to prepare for the exam, practical tips, sharing of educational materials, the recommendation of courses to attend as well as coaching.

Features Discussion The non-consultant, career-grade doctors are a diverse and large part of the medical workforce. Significant numbers want to train and progress to a more senior responsibility and productivity within the profession. This would not only benefit the individuals concerned but would also help with the current medical workforce challenges. The data strongly suggests that if the careergrades are given structured mentoring and teaching but allowed to learn at their own pace and with the use of multiple platforms, the pass rate gap will be significantly narrowed.

Image 1

Image 2

2 - Weekly webinars that are modulated and delivered by senior members of the above group who have passed the exam and have shown relevant skills and interest to teach. Candidates were invited to attend and were given the opportunity to interact with the presenters. Appropriate sessions have been recorded, edited and shared with the wider audience via a YouTube channel (image 2). This teaching programme has achieved the required standard to be CPD accredited by RCSEd and attracts an average weekly attendance from 50 to 60 participants. Following the introduction of the above teaching methods, we re-audited the FRCS exam results. We collected the same data about trainees from the JCIE website and compared those to the results of the members of our group who took part in the above teaching scheme. The results were collected by asking each member who attempted the exam to declare if they passed or failed. We also compared results with other career-grade surgeons who were not members of the coaching group. Their results were obtained from the JCIE website.

Results The initial exam results are demonstrated in the table below: Career-grade

Trainees

Total number sitting exam

116

158

Total number who passed

132

Exam pass percentage

29.3 %

83.5%

Table 1: Passing results of the FRCS exam comparing career-grade to trainees in Feb and May 2016, i.e. prior to the implementation of the new teaching method.

These results show a significant difference in the pass rate between trainees and career grades.

We then re-evaluated the pass rate in Nov 2017, Feb 2018 and April 2018, after the introduction of the teaching programme. The results are summarised in the table below: Careergrades (in the group)

Careergrades (out of the group)

Trainees

Total number sitting exam

142

Total number who passed

129

Percentage

56.2 %

32.6 %

90.8%

Table 2: Passing results of the FRCS exam comparing career grades to trainees on Nov 2017, Feb 2018 and April 2018, i.e. after the implementation of the new teaching method.

These results show significant improvement in the pass rates of non-trainee surgeons undertaking the FRCS (Tr&Orth) exam after being supported by a mentoring programme, with an impressive increase from 29.3% to 56.2%. Chi square test on the pass rates among career-grades in and outside the group shows a statistically significant positive outcome for those is the group (p value 0.006). This study shows a narrowing of the gap between trainees and career-grades. It also shows that career-grades who followed the mentoring scheme have much better chance of being successful than those who didnâ&#x20AC;&#x2122;t. Feedback collected from candidates after the interactive webinar sessions emphasised the fact that problem-based learning curriculum and access to the support provided have facilitated their learning and their eventual success, even those who had not passed felt supported and felt their performance had improved.

This study provides a review of exam performance of career-grades versus trainee orthopaedic surgeons. It focuses on current challenges and attempts to find some solutions. These findings lend support to the notion that provision of guidance, peer support and problem-based interactive sessions help careergrade surgeons to improve their likelihood of passing the exit exam and hence allow them more opportunities to advance their career should they wish to. Another advantage of this comprehensive online mentoring approach is the low cost involved, such as saving on booking lecture rooms and providing catering, and the time saved by not having to travel long distances to attend teaching. Thus, it was possible to deliver this teaching to candidates who were geographically spread all over UK, and in fact the world. This smart use of technology has ensured better attendance as the location of the candidate is not a hindrance.

Conclusion The Intercollegiate Specialty Examination in Trauma & Orthopaedics FRCS (Tr&Orth) is a challenging examination for orthopaedic surgeons not in a formal training programme. However, with focused energy, sufficient support and supervision, and good forward planning, improvement has been achieved in the pass rate. We will continue to introduce new components to this teaching programme and will re-audit again, including a larger sample size.

Acknowledgements Acknowledgment to members of the teaching faculty: Fouad Chaudhry, Athar Siddiquie, David Hughes, Husam El-Banna and Kashif Memon. n

References 1. Examination Results [Internet]. JCIE. 2018 [cited 2018 Feb 5]. Available from: https:// www.jcie.org.uk/content/content.aspx?ID=9 2. GMC data on doctors working in the UK [internet].2015. Available from: https:// www.gmc-uk.org/Chapter_1_SOMEP_2015. pdf_63501394.pdf For further information please visit: Orthopaedic Fellowship Preparation Course on YouTube.

Features

Operations I no longer do...

Open reduction of supracondylar fracture Fergal Monsell

Children with this injury will make a guest appearance at centres throughout the United Kingdom during any otherwise unremarkable weekend and cause anxiety in treating surgeons of all ranks. A subliminal desire to avoid deformity at any cost leads to subversion of sensible decision making but restoration of normal function should have primacy over normal radiological anatomy.

Fergal Monsell is a consultant at Bristol Childrenâ&#x20AC;&#x2122;s Hospital where he is involved in the management of limb deformity and trauma. He is Visiting Professor at Cardiff University and Projector at The Grand Academy of Lagado. He has an active clinical and basic science research portfolio and is widely published.

pening these fractures does not necessarily improve the immediate management or eventual outcome and if a logical approach is taken to closed reduction, the need to consider surgery should be infrequent. Patients with vascular injury and evolving ischaemia or deteriorating neurological signs are completely different and mandate aggressive surgical intervention1-3. The deforming forces have been understood since the time of Hippocrates and this is crucial for successful manipulative reduction. This was elegantly described by Sir John Charnley4 and more recently codified by Dr Richard Reynolds5, to whom I am very grateful for clarifying the nuances of the technique. It must be understood that this is a two-surgeon operation and should not be undertaken without an informed accomplice. Initially, length is restored with prolonged longitudinal traction and if this is unsuccessful, subsequent manoeuvres are doomed to fail. Speculative attempts at reduction will cause further soft tissue injury and make relatively stable fractures substantially more difficult to manage. Length is corrected when space between

proximal and distal fragments is demonstrated radiologically. Medial or lateral translation is identified and corrected by pushing in the appropriate direction. If imperfect alignment persists, there is a rotational component, which is corrected with the elbow flexed to 20o degrees, using the forearm as a rotation bar. There is perennial, heated debate about the position of the forearm during correction of extension and my view is the position that results in perfect radiological alignment of the supracondylar ridges should be used. Extension is corrected by placing a thumb over the olecranon, flexing the elbow with the forearm in this position and a block to flexion invariably means that reduction has been unsuccessful. If these simple steps are followed, the need to consider open reduction of these fractures is obviated in the majority and only a very small proportion require further scrutiny.

Attempted manipulation

Patient

Features

Unwelcome traction images

Four weeks

Three months

I appreciate that the proud orthopaedic surgeon will be somewhat irritated by such a facile description but watching vainglorious attempts at reduction over what is now protracted period, leads me to the uncomfortable conclusion that a lot of people have simply no idea what they are doing. I estimate that I find myself in a position in which the fracture is irreducible approximately once every 2-3 years whether due to intrinsic difficulties associated with some injury patterns or technical deficiencies on my part. Before I was in independent practice, I remember being instructed to simply “get along and open it” and this created significant personal misery, from which I have only partially recovered. I now believe, without evidence, that there is no shame in managing these fractures expectantly and will routinely obtain prior permission from the family to treat the injury with traction. I appreciate that this has resource implications for the National Health Service and practical implications for the family, which make it a potentially unattractive option but in the postMontgomery era, I recommend that this is part of the consenting process.

I make sensible attempts to reduce the fracture and if unsuccessful, use the smallest available Thomas splint to apply straight-arm skin traction with the injured arm in symmetrical coronal alignment. This requires no more than tactically applied padding to ensure that the carrying angle is identical to the uninjured arm and reassurance to the incredulous junior ranks that I have not completely lost my mind. It is a visual exercise, radiographs are not required and my written instructions specify that imaging prior to discharge is not necessary. This is universally misinterpreted as an error and the inevitable radiographs produce a predictable emotional response from nonbelievers. It is possible to squeeze the fracture site without pain after approximately one day per year of age and at this point, a cast is applied with the patient awake. The elbow is flexed to 20o to stop the cast from falling off and it is worn until radiological evidence of union 2-4 weeks later. The parents are advised that the elbow will be very stiff in the immediate period following plaster removal and that physiotherapy will not accelerate recovery, which occurs gradually for 3- 6 months. In extension injures, there will invariably be a bump at the site of the unreduced humeral metaphysis, which will impinge and limit elbow flexion. After 6-9 months of normal longitudinal growth this will be sufficiently distant from the radial head and coronoid for full movement and the child will have returned to normal function several months earlier. I can report, from the 9th circle of evidence, that the fracture will heal, the radiographic appearance will improve and function will normalise provided this simple algorithm is followed.

2. Early versus delayed surgery for paediatric supracondylar humeral fractures in the absence of vascular compromise; A systematic review and meta-analysis (2018). Farrow L, Ablett A, Mills L, Barker S. Bone Joint J;100-B:1535–41. 3. Comparison between a multicentre, collaborative, closed-loop audit assessing management of supracondylar fractures and the British Orthopaedic Association Standard for Trauma 11 (BOAST 11) guidelines (2018). Goodall R, Claireaux H, Hill J, Wilson E, Monsell F, Boast 11 Collaborative, Tarassoli P. Bone Joint J;100-B:346–51. 4. The Closed Treatment of Common Fractures 4th Edition (2003). Charnley J. Cambridge University Press. ISBN-0521682878. 5. A Technique to Determine Proper Pin Placement of Crossed Pins in Supracondylar Fractures of the Elbow (2000). Reynolds R.; Mirzayan, R. J Pediatr Orth;20:4;485-489.

One year

The purpose of the article is to describe an operation that, in the absence of ischaemic vascular or deteriorating neurological injury, I have not performed for 15 years. I have been able to reduce the majority closed, and when this was not possible, I have managed the patients with traction. All five have had a perfect clinical and functional result and apart from an irrelevant bump, do not have any consistent radiological abnormality. I cannot think of a reason why I would want to perform open reduction of this fracture. It is a deeply unsatisfactory undertaking and probably creates more problems than it solves. It is recognised as a mistake as soon as the skin is opened and requires nothing more than blind faith, an extra few days in hospital and complete disregard for the conventional wisdom and propaganda that clouds this subject. n

Two years

References 1. Nerve injuries associated with supracondylar fractures of the humerus in children: our experience in a specialist peripheral nerve injury unit (2016). Kwok I, Silk Z, Quick T, Sinisi M, MacQuillan A, Fox M. Bone Joint J; 98-B:851-856.

Three years

Features

Is day case hip and knee replacement surgery achievable in the NHS? Sam Jain, Sarah E Paice, Mike R Reed and Paul F Partington All affiliated to Northumbria Healthcare NHS Foundation Trust Prof MR Reed also affiliated to University of York

Sam Jain MSc, FRCS (Tr&Orth) is currently working as BOA Clinical Leadership Fellow and Revision Arthroplasty Fellow at Northumbria Healthcare NHS Foundation Trust. His subspecialty and academic interests include enhanced recovery and periprosthetic joint infection.

Sarah E Paice BN (hons) is a Nurse Practitioner at Northumbria Healthcare NHS Foundation Trust.

Day case total hip replacement (THR) and total knee replacement (TKR) surgery is proven to be safe and effective across several different healthcare systems1, yet it is not commonly performed in the NHS. Continuing improvements in enhanced recovery protocols have led to significant reductions in length of stay to the point where patients can now be safely discharged on the day of surgery. Advantages may include greater patient satisfaction, reduced cost, improved operational efficiency and lower demand on inpatient beds. In this article, we review the evidence and present the results of our first hundred day case THR and TKR procedures.

Definition

Literature review

The definition of ‘day case’ surgery varies across the literature and its terminology appears to have evolved over time. ‘Inpatient’ surgery typically involves a patient staying at least one night in hospital whilst the term ‘day case’ usually implies admission and discharge on the same calendar day. However, the term ‘outpatient’ surgery has also been applied and may be misleading as in some reports, these patients stay in hospital overnight but for less than 24 hours.2 More recently there has been a shift towards reporting on genuine ‘day case’ surgery where patients are discharged on the same day as their surgery, often in ambulatory care settings.3 It is therefore important for researchers to accurately quantify their length of stay in hours and minutes and equally for the reader to be alert to these discrepancies. This article focuses on day case patients admitted and discharged on the same calendar day.

Much of the published literature originates from USA where it is estimated that there will be a 77% growth in day case THR and TKR surgery over the next ten years.4 This is largely due to the introduction of bundled payment systems which provide financial incentives for hospital providers to reduce costs associated with length of stay. There is also a high prevalence of cementless implants in the USA and a drive towards the use of minimally invasive hip approaches, such as the direct anterior approach, but these factors remain unproven in facilitating early discharge.5 The advantages of day case THR and TKR surgery are well reported and include greater patient satisfaction3 and reduced costs of approximately 30% associated with the inpatient episode.6,7 This may have important benefits for NHS patients where there is

Features

Professor Mike R Reed MD FRCS (Tr&Orth) is a consultant Trauma & Orthopaedic Surgeon at Northumbria Healthcare NHS Foundation Trust and University of York.

an increasing focus on reducing length of stay, improving financial sustainability and relieving pressure on inpatient beds, particularly during winter pressures. Concerns about the safety of same day discharge are understandable but a review of the literature reports a similar, if not better, safety profile for day case compared to inpatient surgery when investigating readmission and complication rates.1 This is unsurprising given that well-implemented enhanced recovery protocols are known to decrease the risk of medical complications such as cardiopulmonary and thromboembolic events.8 Risk factors for failure of same day discharge include significant medical comorbidity, performing surgery late in the day, inadequate pain control, dizziness, general weakness, nausea and sedation.9 This highlights the need for careful patient selection, thorough preoperative medical evaluation and established regimens for analgesia, antiemetics and rehabilitation.

Before admission

Comprehensive preassessment Anaemia screening and optimisation Other screening tests (HbA1C, CRP, thyroid, albumin) MSSA and MRSA screening Ring fenced wards Staggered admissions Minimise fasting Carbohydrate loading Anaesthesia

Paul F Partington FRCS (Tr&Orth) is a consultant Trauma & Orthopaedic Surgeon and pioneer of UK day case hip and knee replacement surgery at Northumbria Healthcare NHS Foundation Trust.

Patients who wish to undergo day case surgery are counselled appropriately and are usually listed either first or second on a morning list to allow time for assessment and rehabilitation on an inpatient ward. There is no difference in our rehabilitation protocol for day case patients with no additional physiotherapy or nursing input at home. In other words, this does not use a â&#x20AC;&#x2DC;hospital at homeâ&#x20AC;&#x2122; model. Physiotherapy assessment begins approximately two hours after the patient has returned from recovery and involves mobilisation with a walking aid, range of movement exercises, strengthening exercises, transfer practice and stairs assessment, if required. Patients are dressed in normal clothes rather than pyjamas and achieve independent mobility for toileting. Routine hip precautions are no longer used and instead, we encourage patients to use their limbs normally but not to force their joint into extreme positions. Discharge criteria are listed in Table 2. >>

Patient pre-warming Low dose spinal anaesthetic (no opiates) No neuraxial blocks Prophylactic antiemetic agents Streamed music with specific artist as per patient preference

The Northumbria approach Over the past 11 years, we have refined our enhanced recovery protocol to allow early mobilisation, effective analgesia and same day discharge for primary THR and TKR. A standardised protocol for all THR and TKR patients has been developed with our surgical, anaesthetic and rehabilitation teams (Table 1). This is the same protocol for both preselected day case patients and routine inpatients with no difference in anaesthetic techniques, surgical approaches, implant choice, analgesic regimens and postoperative mobilisation. Selection criteria for day case surgery include satisfactory general health and uncomplicated surgery but mainly a desire to return home on the evening of surgery. Stable chronic medical conditions are not a barrier to same day discharge.

Patient education and counselling

Intravenous tranexamic acid Surgery

Chlorhexidine prewash Double prep with alcoholic povidoneiodine (10%) and chlorhexidine (2%) Assisted gloving Standardised implant inventory for THR and TKR No drains Preservation of patellar fat pad No patellar resurfacing Povidone-iodine wound lavage Topical tranexamic acid Triple skin closure (subcuticular absorbable monofilament, skin clips, glue) Aquacelâ&#x201E;˘ surgical dressing

Discharge and follow-up

Ward discharge criteria Discharge at 6 week follow-up appointment

Table 1: Enhanced recovery protocol

Reasonably pain free on regular analgesia Voiding urine without a catheter Satisfactory postoperative blood tests (full blood count, urea and electrolytes) Independently mobile with an appropriate aid Able to negotiate steps or stairs safely (if required) Table 2: Discharge criteria

Features

Patients

Follow-up (mean)

0.21 yrs (0.12 to 0.53)

Length of stay (mean)

11hrs 32min (8hrs 21min to 14hrs 37min)

Age (mean)

63.1 yrs (25.7 to 82.5)

Male

55 (55%)

Joint replacements

100 (6 staged bilateral)

THR

57 (57%)

Cemented

45 (78.9%)

Hybrid

12 (21.1%)

TKR

43 (42.2%)

Right sided

51 (51%)

THR approach

Prophylactic antiemetic agents

Posterior

48 (84.2%)

Lateral

9 (15.8%)

TKR approach Medial parapatellar

39 (90.7%)

Midvastus

4 (9.3%)

Surgeon grade Consultant

78 (78%)

Trainee

22 (22%)

ASA score (mean)

1.7 (1 to 3)

ASA 1

33 (33%)

ASA 2

64 (64%)

ASA 3

3 (3%)

BMI (mean)

29.7 (19.5 to 46.6)

Length of surgery (mean)

65.7 mins (31 to 156)

Table 3: Patient demographics

Comorbidity

Cases (%)

Hypertension

Atrial fibrillation

Ischaemic heart disease

Hyperthyroidism

Hypothyroidism

Diabetes mellitus

COPD

Hypercholesterolaemia

Smoker

Table 4: Comorbidities

Patients are allowed home if they have achieved these goals. A pre-discharge x-ray is not a routine requirement unless there has been an intraoperative or postoperative concern. Patients are given a surgical helpline number to contact in case of any concern and are followed up with a telephone call at 2200 hrs on day of discharge and again at 0800 hrs the next day. TKR patients are referred for an outpatient physiotherapy appointment at two weeks. A surgical outpatient clinic appointment is made at six weeks for all patients and most are discharged at this point.

Our experience

and knees, respectively. Mean Oxford score improvement was 24.4 (4 to 45) and 21.2 (12 to 32) points for hips and knees, respectively. This is compared to a national average improvement of 22.6 and 17.1 points for hips and knees, respectively. However, our day case patients are selected and therefore direct comparison of complications and outcomes should be interpreted with caution.

â&#x20AC;&#x153;Our results indicate that day case THR and TKR surgery is feasible within the NHS. Our approach relies on the standardisation of anaesthetic and surgical techniques including low dose spinal anaesthesia, avoiding neuraxial blocks, using established (not minimally invasive) surgical approaches and only using implants with a proven track record.â&#x20AC;?

We studied the outcomes of THR and TKR surgery with same day discharge in a consecutive series of 97 patients (100 joint replacements) with a mean follow-up of 0.21 yrs (0.12 to 0.53). This included 57 THRs and 43 TKRs. Patient demographics and comorbidities are presented in Tables 3 and 4, respectively. Mean length of stay was 11 hrs 32 mins (8 hrs 21 mins to 14 hrs 37 mins). Our 30-day readmission rate for any cause was 3% (three cases) due to dislocation, pulmonary embolism and wound leakage. This last case had a negative joint aspiration and the wound healed without further intervention. No patients were acutely readmitted for pain, nausea or hypotension. This is compared to a readmission rate of 5.5% in an unselected concurrent cohort of inpatients undergoing THR or TKR surgery. Our surgical complication rate was 2% (two cases) including dislocation and knee stiffness. Both of these cases required further surgery. A dislocated THR required stem revision at the third postoperative day and a stiff TKR underwent successful manipulation under anaesthesia at six months postoperative. Mean postoperative Oxford scores were 40.5 (23 to 48) and 41.7 (25 to 48) points for hips

Our results indicate that day case THR and TKR surgery is feasible within the NHS. Our approach relies on the standardisation of anaesthetic and surgical techniques including low dose spinal anaesthesia, avoiding neuraxial blocks, using established (not minimally invasive) surgical approaches and only using implants with a proven track record. Our readmission rate was lower than our routine inpatient cohort and we observed a low complication rate. These are similar observations to other published results on wellestablished enhanced recovery protocols.10,11 Our functional results are also higher than the national average as determined by Oxford score improvements.

Challenges to the wide-scale implementation of day case THR and TKR surgery in the NHS largely relate to cultural and organisational issues. With an increasing body of evidence supporting same day discharge, it may only be a matter of time before its adoption into routine clinical practice. Further research will help clearly define its role within the NHS and this should focus on patient selection criteria, preoperative pathways, safety and education.

Conclusion This is the first report of day case THR and TKR surgery in the UK and it confirms that it is achievable within the NHS. Appropriate patient selection, standardised enhanced recovery protocols and dedicated rehabilitation teams are essential to success. n

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

Autologous Bone Marrow Concentrate Prepared in the Operating Room

www.heraeus-regenerative-medicine.com

Heraeus Medical GmbH Philipp-Reis-Str. 8/13 61273 Wehrheim Germany

Medico-Legal

Litigation, regulation and the cost of indemnity Mike Devlin

Many will be familiar with the saying “if it ain’t broke, don’t fix it,” although I suspect fewer could attribute it to President Carter’s Director of the US Office of Management and Budget, Bert Lance1. What Lance also said is as true today as it was in 1977, “that’s the trouble with government: fixing things that aren’t broken and not fixing things that are broken”. When explaining to doctors why there is a sustained rise in their indemnity subscriptions, Lance’s sentiments have a certain resonance. Spiralling cost of damages - failing to fix what is broken in the market

Dr Mike Devlin is head of Professional Standards and Liaison at the MDU, having been a medicolegal adviser for over 15 years, latterly as Head of Advisory Services. He is the MDU’s Responsible Officer. He was a member of the Faculty of Forensic and Legal Medicine’s academic committee and was an examiner for the MFFLM until 2014. He is an international editorial board member of the Journal of Forensic and Legal Medicine. He was Treasurer of the FFLM from 2011 - 2015. He has published many articles on medico-legal matters in various medical journals and papers in UK and Ireland as well as a book chapter and has significant experience in teaching and assessing knowledge in medico-legal subjects.

They key driver impacting on indemnity subscriptions is the cost of damages. Figure 1 below graphically illustrates the stark comparison between clinical negligence claims inflation and other common measures of inflation over a ten year period. NHS Resolution, which indemnifies NHS Trusts in England, has seen its total liabilities grow at a rate that is plainly unsustainable, and in 2018 were reported as £77 billion2.

availability of NHS care. Future care costs (for example residential support) are also calculated on a private basis4 and can be a substantial component of a high-value claim. The trend is inexorably upward, but there is evidence from other countries, notably the US, is that reform of the laws governing clinical negligence claims is effective5 (so called ‘tort reform’) because it goes to the root of the problem, how damages are calculated.

“It is the size of individual compensation awards that lie behind the enormous total liabilities burden the NHS faces. The essential principle of compensation, where a patient is negligently harmed during treatment, is to put them in the position they would have been in had the injury not occurred.”

It is the size of individual compensation awards that lie behind the enormous total liabilities burden the NHS faces. The essential principle of compensation, where a patient is negligently harmed during treatment, is to put them in the position they would have been in had the injury not occurred. This includes amounts for future medical costs, social care costs and lost earnings. It may surprise many to know that future medical costs are calculated, in accordance with 1948 legislation3, on the basis that they will be provided on a private basis, despite the

The rise in total clinical negligence liabilities is not a reflection of increasing claims numbers. After a peak in 2013/14, there has been a levelling-off in numbers6, which are largely a reflection of civil litigation reforms7 that were brought in during 2013 and which resulted in an anticipatory ‘surge’ in personal injury claims. It is interesting to note that this levelling-off trend in claims numbers is occurring despite the increase in demand for clinical care and staff shortages. A key GMC report in 20188 described it in terms of the profession being at a ‘critical juncture’:

Medico-Legal

patient safety. It noted that the rises were more related to things outside the control of NHS staff and organisations, such as increasing life expectancy, more expensive treatments and legal reforms and market developments in legal services, which are referred to above. A key example of the type of external influence on the market the NAO report alluded to is the decision in February 2017 by the Lord Chancellor10 to cut the discount rate from 2.5% to minus 0.75%. The effect of the discount rate change is particularly pronounced in high-value claims (in which there are, characteristically, considerable and enduring future care costs), where damages were roughly doubled and in some cases trebled, at a stroke.

Figure 1: All values set to zero in 2005 and y-axis represents the relative increase in costs.

“Demand for care is increasing in volume and complexity. Combined with severe shortages of staff in some areas of the UK and in some parts of health and social care provision, this creates huge pressures on the medical workforce.”

Even with these pressures, the GMC notes that “doctors are still delivering good care in very trying circumstances”. An NAO report9 on managing the costs of litigation in the NHS also found that there was no evidence that the rise in litigation awards was related to poorer

In its response to the NAO report and subsequent review by the Public Accounts Committee11 the government accepted the PAC’s recommendation that the Department of Health, Ministry of Justice and NHS Resolution, “must take urgent and coordinated action to address the risking costs of clinical negligence”12. While the work to address the spiralling costs of claims by the bodies referred to is ongoing, unsustainable liabilities continue to accrue and action is needed now to bring about meaningful and effective legal change so that compensation is fair and affordable13. >>

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Medico-Legal

Spiralling cost of damages - fixing what is not broken in the market Lance’s prescient maxim can be neatly applied to the government’s consultation on appropriate clinical negligence cover14. The government identified the following four objectives that it believed should be addressed: • Patients harmed by the negligence of regulated healthcare professionals can access appropriate compensation; • Regulated healthcare professionals hold stable and sufficiently funded clinical negligence cover, thereby reducing potential risks of prohibitive costs to healthcare workforce and the patients they treat failing to access appropriate compensation; • Regulated healthcare professionals have greater clarity and confidence about the security and terms of their cover, as well as suitable patient protection in the event of a dispute with their indemnity provider; and • Patients have greater clarity and confidence of their recourse to any compensation.

What the consultation fails to do is provide evidence that the current indemnity arrangements in the UK are failing either doctors or patients. This is a paradox as doctors we are used to assiduously following and applying evidence; we would be reluctant to treat patients where there was no proof of clinical effectiveness. We should rightly be wary of accepting regulatory changes to the provision of medical indemnity, which has served doctors’ needs for over a century, in the absence of cogent evidence of the need for change or that suggested alternatives are better. The effect of the government’s policy objective, if successful, would be the requirement that future medical indemnity is either provided under a contract of insurance or would have to be subject to a regulator’s oversight, and both of these options are likely to increase the cost of indemnity for surgeons. In addition, insurance brings with it its own costs, such as profit for shareholders, Insurance Premium Tax, regulatory and brokers’ fees. Oversight by a regulator would have to be paid for, and ultimately this would likely fall to doctors and other healthcare professionals through increased insurance premiums.

“Most surgeons with some private practice are acutely aware that indemnity costs continue to rise, and understand that having appropriate indemnity in place for the whole scope of their practice is a GMC requirement. However, fewer will be familiar with the factors driving the inexorable rise in the cost indemnity, and this article aims to have tried to shed much needed light on the subject.”

Furthermore, the government has clearly indicated that its preferred option is to “change legislation to ensure that all regulated healthcare professionals in the UK not covered by a state-backed indemnity scheme hold appropriate clinical negligence cover that is subject to appropriate supervision, in the case of UK insurers, by the Financial Conduct Authority and Prudential Regulation Authority”. The implication in the consultation is that the objectives above are not provided by discretionary indemnity. This is plainly not the case, since long before the NHS existed, the medical defence organisations have been providing appropriate indemnity to doctors in England and the rest of the UK, and patients receive compensation where it is found that they have been negligently harmed.

There is also an important point to consider that relates to one of the characteristics of medical indemnity. Clinical negligence claims have what is described as a ‘long tail’, meaning that a claim may not be brought for many years, sometimes decades, after the event that gave rise to it. An illustrative example of this is where an MDU member reported a 1959 incident three decades later, in 1989, which was subsequently settled in 1998 for £866,00015. This has implications for caps that insurance policies may have in place. For example, an insurance policy in 1985 that had a cap of £1 million might have been adequate, as the MDU’s first claim

of that amount was not paid until 1988. Indeed, a £10 million cap might have been adequate until 2010, but with the sudden and dramatic cut to the discount rate in 2017 we now see high-value claims settled for sums that may exceed £30 million. Traditional occurrence indemnity, provided by the medical defence organisations, is not constrained by caps on indemnity. However, the government consultation does not properly address this point, an insured cap that might have been adequate in 2004 may be substantially less so if the claim is brought 15 years after the incident when the policy was taken out. A final point is that the consultation does not appear to acknowledge the limitations of regulation. Simply being an insurance company, and regulated by the FCA and PRA, does not stop it withdrawing from unprofitable lines of business, such as was seen with the St Paul withdrawing clinical negligence cover worldwide in 200116, leaving thousands of UK doctors to make arrangements for their tail cover. Nor does it eliminate the risk that an insurer may fail17, leaving policyholders without cover and needing to make urgent alternative arrangements.

Conclusions Most surgeons with some private practice are acutely aware that indemnity costs continue to rise, and understand that having appropriate indemnity in place for the whole scope of their practice is a GMC requirement. However, fewer will be familiar with the factors driving the inexorable rise in the cost indemnity, and this article aims to have tried to shed much needed light on the subject. It is a reminder that the drivers of indemnity costs have to date not been addressed by government – if anything potentially new inflationary costs might result due to the regulation of indemnity consultation. And as the article is primarily to inform, rather than act as a call to arms, it is of course open to any interested party to find out more and take action to make their voice, and that of their profession, heard. n

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

Fashion Meets Science

HIGHLIGHT LECTURES

Ejnar Eriksson Lecture ACL Reconstruction from the Past to Present What Have I Learned from Ejnar? Matteo Denti (Italy/Switzerland)

Werner Müller Lecture The Anterolateral Soft Tissues – Fact and Fiction Andy Williams (United Kingdom)

Presidential Guest Lecture 2020 Leadership from Ferrari F1 to the Operating Room — Luigi Mazzola ∞ How to lead a team ∞ How to improve results through effective leadership ∞ Surgeon 4.0 - the evolution of the Surgeon

Scientific Programme

ACL: The Challenge of Treating Knee Injuries in Professional Alpine Skiing – A Journey from Arthroscopy to Total Knee Replacement Christian Fink (Austria) Cartilage Biomaterials and Innovative Tissue Technologies for Knee Repair Daniel Saris (United States) Knee Arthroplasty Fashion versus Science in Total Knee Arthroplasty Michael Mont (United States) Shoulder Stem Cells in Rotator Cuff Repair

Don‘t miss: • Instructional Course Lectures • Certified Team Physician Course • Radiology Sessions

Hip Femoroacetabular Impingement: the Pursuit of Evidence

New Session Formats:

Knee Functional Reconstruction of the Knee: from Sports Medicine to Joint Reconstruction

• How do I do it? • Lecture and Discussion • Battle, Debate and Discussion • Myth Busting – Science vs Fashion • Ask the Expert

Maurilio Marcacci (Italy)

Important Dates Early Registration Deadline 24 February 2020

Pietro Randelli (Italy)

Olufemi Ayeni (Canada)

Ankle from Sprain to TOPIC, Topcare for Ankle Cartilage Injuries in Sports Gino Kerkhoffs (The Netherlands) ESSKA PRESIDENT

SCIENTIFIC CHAIRS

David Dejour (France)

Michael T. Hirschmann (Switzerland) Kristian Samuelsson (Sweden) Elizaveta Kon (Italy)

CONGRESS PRESIDENT

Matteo Denti (Italy/Switzerland)

esska2020@kit-group.org

www.esska-congress.org

Simulation Section

Cognitive Simulation: A novel method to improve operative skills Uttam Shiralkar

Uttam Shiralkar qualified and worked as a surgeon for 15 years before entering the field of psychological medicine. While pursuing a career in psychological medicine, it became clear to him just how much impact surgeon’s psychology has on surgical performance. Since then, he has been creating an awareness of significance of psychological factors in surgery and remediable measures surgeons need to take. Currently, in addition to his role as a consultant psychiatrist, Uttam is actively involved in coaching surgeons at various levels of their careers on a range of performance issues. He has written awardwinning books, conducted masterclasses to improve surgical performance by cognitive techniques and has published research on this subject.

The traditional methods of surgical craft teaching have become non-viable for various reasons. After being employed for decades, flaws in the ‘see one, do one, teach one’ method became apparent over time. Additionally, expansion of surgical techniques and changing patterns of healthcare delivery made it difficult to continue the old system. Shortening of the working hours have reduced the skill learning opportunities even further.

ince the decline of the traditional methods of learning skills, several alternatives have been developed to compensate for the loss of ‘hands-on’ experience: from cadaveric dissection via synthetic material to the most expensive virtual reality simulators. However, all have limitations: availability of facilities, cost and fidelity. In contrast, the novel method of cognitive simulation is a unique approach for acquiring surgical experience that is free and accessible 24 hours a day. Mental techniques have been used to enhance psychomotor skills in sport. In many ways, surgical performance is similar to competitive sports performance. Given the similarities, surgeons would benefit from adopting techniques that have been shown to improve psychomotor performance in sports. In view of the current curriculum requirement for surgical trainees and trainers to engage with simulation, it is crucial to develop an understanding of this novel method and its role in surgical learning.

Cognition is a process by which sensory information is mentally assimilated and applied by the individual. We all know that simulation means imitation or re-creation of an event or activity. Thus, cognitive simulation is the creation of an experience of a surgical procedure, in your mind. This is not the same as just ‘thinking’ about the procedure since cognitive simulation requires the surgeon to use multiple senses to get the ‘feel’ the procedure. It is more than ‘mental practice’ as the mentally created experience vividly resembles the real experience of an operative procedure. In other words, it is a method to create a simulator in your mind. Unlike conventional simulator that simulates only few specific procedures, cognitive simulation can be applied to any procedure and it creates a quality experience that no conventional simulator can match. Cognitive simulation is not simply ‘seeing in the mind’s eye’ or ‘visualising’. The difference between them is same as watching a procedure on video and practicing on a simulator. Thus one of the differentiating point is the >>

Fact vs fiction in hip and knee arthroplasty today 6-7 February 2020 The Royal Society of Medicine 1 Wimpole Street | London

TOPICS INCLUDE: Chaired by

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An elite Faculty will Chair, Challenge and Debate hard evidence of progress across the world of arthroplasty.

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39th Annual Meeting of the European Bone and Joint Infection Society

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Optimising antibiotic treatment of bone & joint infections

]

Optimal bone infection sampling and microbiological processing

]

Low-grade PJI â&#x20AC;&#x201C; what is the best approach?

]

Musculoskeletal infections in children

]

Infections of arthroscopic implants, osteotomies and tendon reconstructions

]

Chronic osteomyelitis with good function. To treat or to live with?

]

Spinal infections

]

Fracture-related infections

Important dates

www.ebjis2020.org

Abstract Submission Deadline: 10 April 2020 Early Registration Deadline: 1 July 2020

Simulation Section

inclusion of kinesthetic or movement sensation. The other senses that are incorporated are tactile, auditory, olfactory and verbal. When you are able to practice a procedure incorporating all these senses, the effect will be the same as actually performing the procedure. Some people are able to generate these sensations easily but others require deliberate efforts and practice. The first step is to become aware of those senses while performing a procedure. After all, cognitive simulation is a skill and like any other skill it requires updated information and practice.

How does it work? It is now recognised that our mind cannot differentiate between a real and an imagined experience, provided the experience is imagined in a specific manner1. If conducted appropriately, the same building of neural pathways occurs, through imagined practice, as it does through actual practice. Thus, we have the potential to make mental practice almost, if not as effective as physical practice. Studies have shown that if carried out correctly, imagined muscle movement is observed on electromyography, imagined visual sensation affects the cerebral blood flow in the occipital cortex and imagination of auditory stimulus is recorded on the Positron Emission Tomogram (PET) of the temporal cortex2,3.

What is the evidence? As it is impossible to observe cognitive simulation directly, indirect methods must be used to assess the effect. This creates difficulties in the surgical context, as results are likely to be affected by a number of variables. It is therefore necessary first to extrapolate evidence from other disciplines. A review of literature reveals the paradigm of mental practice studies as:

In general, outcomes have been consistent across a number of studies. Physical practice has a greater effect on performance than imagery practice, which in turn is more effective than no practice at all4. Examining the effect of combining imagery and physical practice (initial physical practice followed by mental practice) is where results are particularly interesting when compared to physical or imagery practice alone. Those studies have shown that a combination achieves far better results than mental practice or physical practice alone5. Researchers suggest replacing some physical practice with cognitive simulation, which will save time and resources, without affecting performance enhancement6.

â&#x20AC;&#x153;It is now recognised that our mind cannot differentiate between a real and an imagined experience, provided the experience is imagined in a specific manner. If conducted appropriately, the same building of neural pathways occurs, through imagined practice, as it does through actual practice. Thus, we have the potential to make mental practice almost, if not as effective as physical practice.â&#x20AC;?

1. Physical practice, when subjects practice the task a fixed number of times 2. Imagery, when subjects mentally rehearse the task the same number of times 3. The control, when subjects do not practice

Studies in surgical literature have shown that cognitive simulation can be used to demonstrate and optimise the perceptual motor learning and skill decay in surgical skill training7. Results of the first randomised controlled trial of mental practice in surgery were published in 2007 in the Annals of Surgery8. In this study the effect of cognitive training on performance of a simulated surgical procedure was evaluated. A statistical analysis of the results showed that there was a significant improvement in performance in the mental training group, but not in the practical training group. Mental training accomplished superior results, compared to other groups, in the task specific checklist. Authors of this study recommended that mental and physical teaching should be blended, as in sport, and considered a critical part of training.

Simulation Section

A recent randomised controlled study determined whether mental practice really does improve surgical skills9. Participants were assigned randomly to an intervention arm or a control arm. Subjects from the intervention group were trained in mental practice. All participants practiced one procedure every day on a simulator for five days. Prior to each session, participants in the intervention group conducted mental practice for half an hour. Each participant from the control group spent the same amount of time with a faculty member, during which time they were asked to conduct an academic activity. Since all participants were engaged in some kind of activity, they were oblivious to the fact that they were either in the intervention or control group, ensuring blind control. Every subject from the intervention group was trained in MP using a mental practice script. The script depicted steps of the procedure, and also highlighted the related clues intended to improve the mental representation of the skill. The main outcome of the study concerned quality of performance during five surgical procedures. All the procedures were recorded and sent to experienced surgeons for assessment, adhering to blind protocols. When results were

evaluated, it showed that the intervention group performed considerably better than the control group during all sessions.

How can it be applied in surgery? Cognitive simulation, in a broad sense, is like computer software designed for the human mind. It is a technique that programs the mind to respond in a certain manner. No physical props or outside stimulus are necessary to engage in the activity in any position or situation. During intense and vivid imagery, the brain perceives and interprets images as being real. Cognitive simulation has immense potential and scope to add value to surgical learning, but its value is dependent on the quality of application. Cognitive simulation has a wide range of applications in surgical practice including: a) Acquisition of new surgical skills b) Shortening the surgical learning curve c) Maintenance of surgical performance d) A range of operative experience e) Transfer of surgical skills from an established technique f) Assessment of operative performance problems g) Management of unfamiliar operating theatre conditions h) Development of stress coping strategies

Since cognitive simulation is a new concept in surgery, trainees may need training to develop correct habits for remembering and creating a sensation and to apply them to day-to-day practice. Those who are involved in training will also need orientation programs to incorporate this concept in their training. Current experience indicates that few hours of training is sufficient to get the basic understanding of the concept. After the initial session, surgeons can develop it further by regular individual practice. Learning cognitive simulation is like learning a foreign language. Both require practice before attaining fluency. Proficient surgeons are often good at what they do because of their attention to small detail. Similar attention to detail is required from those wanting the best results from cognitive simulation. There is nothing to stop a motivated surgeon from taking the plunge into the emerging and splendid domain of cognitive simulation! n

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

Trainee Section

BOTA at the BOA Matthew Brown Co-authors: Alastair Faulkner and Ran Wei

BOTA hosted two sessions at the BOA Congress in Liverpool this year. Our flagship session, Ortho Family Fortunes, explored the important role played by our surgical trainers. Over 90 minutes, we examined the attributes and practices of our best orthopaedic trainers. A second session combined updates on CCT guidance, the new T&O curriculum for 2020, a role play demonstration of the Multiple Consultant Report (MCR) assessment and concluded with a forum for Training Programme Director questions.

O 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.

rtho Family Fortunes opened with an interactive gameshow format reviewing results from our triennial trainee survey, the BOTA Census 2019, and a Barriers to Training survey for consultant trainers. The BOTA Census explored T&O registrar opinion and experiences regarding their training and wellbeing. It ran for a period of six weeks during the summer and was completed voluntarily by over 600 trainees from all corners of the United Kingdom. Our session focused on consultant trainer attributes and support after the Census suggested that only 11% of trainees believe that all consultant trainers were capable of providing good surgical training. The perceived variability in trainer performance raises the question of how surgical trainers can be better supported to fulfil this important role. Although some question the validity of the apprenticeship model in contemporary surgical training, trainees remain dependent on consultant trainers for their professional development, training and assessment. A further finding of interest identified that just 49% of trainees believe that consultant surgeons have a duty to be a surgical trainer, perhaps identifying low levels of training interest among current trainees.

approachable. A third of trainees highlighted trainer willingness to supervise (34%) and an ability to develop trainee confidence and semi-independent practice (33%). 19% highlighted the ability to provide constructive feedback. Regarding training barriers, most consultants surveyed (70%) highlighted the loss of firm structure to be the most significant barrier (Figure 2). >>

Figure 1: Family Fortunes gameshow screen of the top five trainer characteristics (BOTA Census 2019).

Audience members were invited to guess the top five survey responses to the following questions: (1) the qualities most appreciated in orthopaedic trainers (BOTA Census 2019, n=612), and (2) the barriers facing surgical trainers (Barriers to Training survey, n=52). Regarding trainer qualities, most trainees (42% respondents) value trainers who treat them like a colleague (Figure 1). This finding supports educational theory that says we should prioritise adult-to-adult interactions and avoid a paternalistic or parent-child hierarchy. In second place, 38% trainees stated that they appreciated trainers who were friendly and

Figure 2: Family Fortunes gameshow screen of the top five barriers to training as identified by consultant trainers (Barriers to Training survey).

Trauma Symposium 2020

This popular annual course provides a comprehensive update on newconcepts and techniques in orthopaedic trauma for consultants and senior trainees. There are also dedicated orthopaedic trainee sessions for the Fellowship examination. Upon completion of the programme participants should be able to: • Discuss evidence-based treatment of common fractures • Revisit surgical techniques in elbow and shoulder injuries • Apply new concepts for fixation of foot and ankle fractures • Understand recent advances in proximal femoral fractures • Evaluate and apply new concepts for treatment of infected fractures • Gain understanding of spinal trauma for the non-spinal surgeon International faculty includes Professors W M Ricci and Stuart Gold of USA, and Mr R Handley of Oxford. Book now:

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Trainee Section

Figure 3: Nigel Rossiter, Morgan Bailey, James Berwin and Graham Finlayson in the theatre ActItOut sketch.

This was closely followed by excessive workload (65%) and service and management pressures (60%). Of interest, 55% of trainers stated that negative trainee attributes posed a training barrier. These included knowledge or skills below that expected, unrealistic trainee expectations, apathy and a lack of commitment. Training is clearly a two-way partnership with both parties having responsibilities. BOTA intends to explore the responsibilities of trainees in the coming months. Although not featured in the session, interesting findings regarding trainee opinion on the most frequent characteristics of poor surgical trainers highlighted the following: (1) doesn’t allow trainees to operate (73%), (2) disinterest in training (53%), (3) provides poor or no feedback (33%), (4) unfriendly or unapproachable (23%), and (5) tied between provides poor supervision and poor interpersonal skills (22% each). With rehearsal time squeezed into the lunch break, the light-hearted ‘ActItOut Part II’ outpatient and theatre sketches were delivered with enthusiasm by BOTA committee members Morgan Bailey, Ran Wei, Alison Kinghorn, Graham Finlayson, Alastair Faulkner and James Berwin (Figure 3). They were joined on stage by trainers Karen Daly, Nigel Rossiter and Deborah Eastwood. Ahead of each sketch we shared Census data highlighting high levels of trainee satisfaction regarding the quality of training in the outpatient and operating theatre environments.

When asked to rate the quality of the one-to-one training provided by their current consultant trainer, the average ratings for out-patient and theatre training were 7.7 and 8.4, respectively (0 non-existent, 10 outstanding; n=579). As reflected in a higher average score, the theatre environment may facilitate better training when compared to the relative isolation of out-patient consulting rooms. Each sketch was followed by lively discussion with personal insights, practices and experiences volunteered. Additionally, the stresses faced by trainers and the effect on their ability to train were explored. Professional or personal commitments, for example, attendance at meetings or collecting children from school, add external time pressures that are often overlooked. Service requirements, including the pressure to cram clinic and theatre lists with more cases, were demonstrated wonderfully through Deborah Eastwood’s cameo as the deliberately discourteous waiting list coordinator. Trainee responsibilities were also highlighted, with advance review of patient notes and radiology requirements often affording greater time for trainer-trainee interaction. Alison Kinghorn played the enthusiastic medical student who declared “I want to be a surgeon!” (Figure 4).

Both scenes highlighted that medical student engagement (including discussion and as an extra pair of hands in theatre) can encourage interest and facilitate improved registrar training, respectively. For example, during a mock-total hip replacement, Nigel Rossiter (playing Mr Bones) joined his trainee, Morgan Bailey, on the same side of the table whilst the medical student provided assistance and tissue retraction on the other, all whilst being asked questions. Additionally, it was seen in out-patients that limited trainer assistance from Karen Daly (playing Ms Traction) had a negative effect on her trainee, Ran Wei, who subsequently lacked the enthusiasm to engage the attending medical student.

Figure 4: Karen Daly, Alison Kinghorn and Ran Wei in the outpatients’ ActItOut sketch.

Trainee Section

Mr Fraser Harrold, a consultant in Dundee and the BOTA Trainer of the Year for 2017, presented his methods for maximising training opportunities and reflected on barriers to training (Figure 5). He emphasised the continuing need for trainees to be inspired by their consultant trainers. Using the Standards for Surgical Trainers framework of the Faculty of Surgical Trainers1, Mr Harrold detailed how clinics and theatre lists can be designed and run to facilitate improved learning. He highlighted his expectations of those trainees joining him, including the need to ‘own’ the patients they operate on and to paying special attention to small details during patient assessment and management. A summary of Fraser Harrold’s training methodology: - Consent clinics allow time for the examination of pathology requiring surgery and the opportunity for discussion. - Two new cases routinely start the follow-up clinics to facilitate trainee learning with the trainer observing. - Reviews of clinic cases in advance to identify those of greatest training value. - Continual trainer presence and hands-on activity in theatre (e.g. prepping the case whilst the trainee scrubs) aids theatre efficiency and permits maximal trainee engagement. - Providing immediate verbal feedback during training. - Treating trainees as colleagues rather than a junior or just another trainee. - Supporting informal meetings at his home, including journal clubs and new/old trainee handover dinners. - Providing emotional support when invited by the trainee. - Encouraging feedback from trainees: informal during placement (learning from his trainees is welcomed) and anonymised rotation-wide trainer feedback. Mr David O’Regan, a consultant cardiac surgeon and Director of the Faculty of Surgical Trainers, presented his remit to explore the ‘professionalisation’ of trainers across the surgical specialities. He highlighted the need for all stakeholders, from trainees and trainers to surgical societies and colleges, to work collectively to both review and stipulate the requirements for training. Trainers require additional support and recognition through training and workplace adaptation. For example, trainer Programmed Activities (PAs) must facilitate adequate time for constructive trainee-trainer interactions, such as teaching, feedback and assessment. Theatre and clinic lists should be designed to improve the balance between training and service provision. In addition, trainers should be expected to demonstrate proficiency in selfawareness, team-work, constructive feedback and other essential ‘people skills’ that are shown to improve training outcomes.

The Faculty of Surgical Trainers was established by the Royal College of Surgeons of Edinburgh and membership (as a member, associate or fellow) is achieved through application and peer assessment. Members can obtain formal training accreditation suitable for revalidation. The Faculty’s focus during Mr O’Regan’s chairmanship will be to work with all stakeholders to improve the training environment, particularly through engagement with national training bodies, including Health Education England (HEE) and NHS Education for Scotland (NES).

Figure 5: Fraser Harrold, Trainer of the Year 2017, delivering his talk on maximising training opportunities.

Trainer support is especially necessary when curricula and CCT requirements are updated. Following a summary of the new CCT requirements, the second BOTA session included an update on the new curriculum for 2020 from Mr Mark Bowditch, Chair of the T&O SAC. His talk can be summarised as follows: - New T&O curriculum undergoing final stages of GMC approval. - There are no intentions to alter the new indicative numbers at the current time. - New curriculum due to come into effect in August 2020. - New curriculum assessed using the Multiple Consultant Report (MCR) on the ISCP website. - MCR comprises two assessments – Generic Professional Capabilities (GPC) and Capabilities in Practice (CiPs). - MCR should be performed by a minimum of two consultants who have clinical contact with the trainee (i.e. Clinical Supervisors). A mock MCR assessment was demonstrated through role-play for the benefit of both trainees and trainers. Lisa Hadfield-Law (Educational Advisor to the BOA) completed the online MCR documentation on ISCP whilst Mark Bowditch (SAC Chair), Rob Gregory (SAC QA Lead), Bill Ryan (SAC Curriculum Lead) played the clinical supervisors to a mock trainee (played by James Tomlinson, South Yorkshire TPD for Education). The discussion that followed saw trainees and trainers voice their thoughts regarding the new assessment. The main issue highlighted by trainers was the additional administrative burden; however, it was highlighted that minimum numbers of WBAs and the Clinical Supervisor report will be removed. Trainees are not involved in the MCR process until after the MCR assessment is committed to ISCP. Trainee delegates highlighted concerns that the MCR process could support an element of ‘surprise feedback’, with some trainers saving difficult feedback for the relative anonymity provided by the MCR process. Regular and real-time trainer feedback enhances learning and our Census data suggests this is welcomed by most trainees. Trainees were also concerned regarding the potential for herd mentality, with one consultant’s negative impression unfairly influencing the overall MCR assessment. There

Example script - Script for the out-patient sketch.

was audience agreement that feedback should be continual and raised by trainers in a timely manner and not introduced for the first time during the MCR. It is intended that trainees will have the opportunity to document their thoughts when they review the MCR with their Educational Supervisor. Our first session recognised that we are all the product of our training environment. Enhanced trainer support and recognition regarding the fundamental importance of the trainer role will help drive improvements in surgical training, and ultimately patient care. Both trainees and trainers have a responsibility to engage with the updated CCT guidance and the forthcoming T&O curriculum. n

References 1. McIlhenny C. Standards for Surgical Trainers. Faculty of Surgical Trainers: Royal College of Surgeons of Edinburgh. Accessed on 1st October 2019: https://fst.rcsed.ac.uk/media/15968/ standards-for-surgical-trainers-version-2.pdf.

Subspecialty Section

Pelvic Ring Injuries – An overview Ian Pallister

The management of pelvic ring injuries is in a state of great flux. As a junior in Trauma and Orthopaedics I listened intently to stories of the emergency application of external fixators as part of the management of the exsanguinating patient in the Resusc. Room. Just as the management of the patient in extremis has changed beyond recognition, so the focus of interest in pelvic ring injuries has broadened enormously.

M Ian Pallister is a civilian orthopaedic trauma surgeon whose clinical and research interests include the management of and recovery from major trauma including pelvic ring injuries and open fractures. He also has a major commitment to simulation in training for time-critical emergencies and is co-director of the Damage Control in Orthopaedic Trauma Surgery (DCOTS) Course.

ulticentre studies in the UK aim to arm us with evidence on which to base decisions (with patients) about which injuries may or may not benefit from surgery. In particular low energy transfer insufficiency fractures and ‘new technologies’ are receiving structured evaluation in a manner never seen before. Foremost in our considerations are of course the patients, and the life they will lead after the injury has healed. Major gaps in our knowledge exist in truly determining the quality of life of our patients – gaps which will only be filled by recognising them and engaging with patients to determine how to record, measure and improve future outcomes.

The Exsanguinating Patient with a Pelvic Ring Injury Damage control resuscitation underpins the approach to managing exsanguinating trauma patients including those with pelvic ring injuries. The UK Defence Medical Services achieved unparalleled improvements in probability of survival for casualties in the recent Afghan conflict but applying a series of technique from the point-of-wounding to definitive care with the simple goals of minimising blood loss and restoring tissue perfusion1. The signature injury pattern of the conflict was massive blast trauma caused by improvised

explosive devices2, the pelvic element of which is described in the following article by Rankin et al. The establishment of major trauma networks has provided fertile ground for these philosophies to take root in the civilian setting. The liberal use of pelvic binders in the pre-hospital phase is a welcome development as the sooner the pelvic volume is reduced, with accompanying increase in intra-pelvic pressure3, the sooner venous bleeding may be brought under control (Figure 1 and 2). Military experience shows that clot stabilisation using tranexamic acid may be more effective in the most severely injured than indicated by the Crash 2 study4. The widespread use of massive haemorrhage protocols brings us closer to replacing lost blood appropriately, rather than making an attempt to stabilise an acidotic borderline coagulopathic patient using ‘balanced’ electrolyte solutions (which are themselves acidic) or synthetic starches (which interfere with clotting). Should these strategies fail to improve the patient’s condition and bleeding from the pelvic injury continues, further immediate action is required. Trauma CT scanning protocols include and angiographic phase which can be immensely helpful in identifying active arterial bleeding. The argument over whether to proceed to pelvic packing or interventional radiology for angio-embolisation misses the central point5. >>

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Subspecialty Section

The patient who is bleeding to death requires immediate intervention6. Extra-peritoneal pelvic packing is a systematic but simple technique which can be completed very rapidly. It is important to pack against the stability provided by a pelvic binder. If direct control of major vessels is required, this can be accomplished through the same exposure and the expertise of a vascular surgeon can be invaluable. Once in a position to allow the trauma anaesthetist to increase transfusion, perfusion and lastly blood pressure, consideration should be given to stabilising the pelvic ring injury either with a simple iliac crest external fixator or with a symphyseal plate. It may have proven necessary to do all of this before going to CT, in which case, once hypovolaemic shock is clearly being controlled, CT scan should be the next destination en route to ITU. Angio-embolisation can be very effective

but survival rates have been shown to be comparable in units which do not have the capability to deliver this technique7. A selective approach to the use of these techniques is logical and likely to be the most effective.

binder?” The answer can be found in an understanding of the purpose of the pelvic binder. Binders serve only to reduce pelvic displacement, increase intra-pelvic pressure and thus tamponade venous bleeding in injuries which have increased the pelvic volume. If the patient has not been in hypovolaemic shock, the binder can be safely removed. As a source of pain-relief skin traction is more comfortable and appears more effective, while it also helps stabilise the injured hemipelvis. A loose pelvic binder serves no purpose at all. The removal of a binder in a patient whose hypovolaemic shock has resolved should ideally be discussed with a local pelvic trauma surgeon. Once stable clot has formed, provided the patient is not moved carelessly, secondary haemorrhage is inherently unlikely. Catastrophic complications from continued binder use are rare but can and do occur8.

“Damage control resuscitation underpins the approach to managing exsanguinating trauma patients including those with pelvic ring injuries. The UK Defence Medical Services achieved unparalleled improvements in probability of survival for casualties in the recent Afghan conflict but applying a series of technique from the pointof-wounding to definitive care with the simple goals of minimising blood loss and restoring tissue perfusion.” The subject of definitive stabilisation of pelvic ring injuries is a specialised area beyond the scope of this paper. A much more common question that faces us is “when is it safe to remove the pelvic

Pelvic ring injuries associated with hypovolaemic shock and potentially delayed mobilisation have been shown to be at particular risk of thrombo-embolic problems9. Further evidence form combat casualties indicates that thromboembolic complications can occur very early after injury in those rescued from profound hypovolaemic shock10. The ideal regimen for thromboprophylaxis remains to be determined, but the potential use of caval filters should be borne in mind.

New Perspectives – How Can We Determine Which Injuries Benefit from Surgery?

Figure 1: Correct application of a pelvic binder can achieve excellent reduction and increase intra-pelvic pressure, helping to control potentially catastrophic venous bleeding.

As confidence in the range of operative techniques to stabilise pelvic injuries increases, so the indications for these to be used seems to broaden. The role of operative stabilisation in lateral compression fractures and

Subspecialty Section

standards of reporting trials) diagram reporting screening, recruitment, randomisation, compliance and include allocation proportions by centre. While generic healthrelated quality of life measures are undoubtably useful in largescale studies, the development of more injury specific metric has been proposed14. The development of such tools can be a lengthy process. Many questions remain unanswered in the recovery after pelvic trauma, and the more detailed the questions posed, the more intrusive and unwelcome they may be. However, in the following paper by Bott et al. the under-reported urological and sexual difficulties that post pelvic ring injury patients encounter are outlined. The clinic environment in which pelvic fracture patients are reviewed by the orthopaedic trauma team is usually deeply unsuitable to ask questions about sexual function and continence. The public nature of the consultation spaces Figure 2: Correct application of a pelvic binder can achieve excellent reduction and increase intra-pelvic pressure, helping to control potentially catastrophic venous bleeding. lends itself only to discussion along standard fracture clinic lines. It can be argued that these problems do not fall into the area in insufficiency fractures in particular has surgical management in lateral compression of responsibility of orthopaedic trauma always been an area of greater uncertainty type 1 injuries in patients over the age of 60 specialists. Direct physical injury to the than in other injury patterns. The adoption (ISRCTN16478561). The primary outcome is uro-genital tract is mercifully relatively and adaptation of spinal instrumentation in health related quality of life (EQ-5D-5L) over rare, but the findings of the following place of supra-acetabular external fixation the 12 months after injury. This study aims to study clearly show that a great many has heralded the development of INFIX recruit 600 patients over its course. patients have related problems which go techniques11. Although the insertion of the unreported and so unaddressed. supra-acetabular pin and tunnelled bar is Another is the Trial of sUrgical vs nonminimally invasive, it is not without potential surgical treatment of Lateral compression While the ideal means of describing the acute complications including major vessel Injuries of the Pelvis (TULIP) compares these nature of these problems for research occlusion, and metalwork removal can often treatment approaches in the non-fragility age purposes and also quantifying their be required12. group13 (ISRCTN10649958). As a feasibility severity for research purposes is yet to study, the primary aim is to determine be determined, the clinical imperative Fragility fractures seem to be ever more recruitment rates and enable the completion to recognise these problems and direct common despite effective treatments to of a produce a CONSORT (consolidated patients to appropriate help remains. address bone health13. While the surgical The results of current multi-centre studies management of proximal and the future development of new injury femoral fractures is specific patient centred outcomes will help accepted as a crucial us refine our management of the whole element in the care of such spectrum of pelvic ring injuries, enabling patients, the role of pelvic us to combine logical evolutions in surgical fracture stabilisation is yet practice with strong scientifically based to be fully determined. clinical evidence. n Major multi-centre randomised studies are References under way in the UK References can be found online at at present. The L1FE www.boa.ac.uk/publications/JTO. study compares anterior internal surgical fixation (i.e. INFIX) with non-

â&#x20AC;&#x153;Fragility fractures seem to be ever more common despite effective treatments to address bone health. While the surgical management of proximal femoral fractures is accepted as a crucial element in the care of such patients, the role of pelvic fracture stabilisation is yet to be fully determined.â&#x20AC;?

Subspecialty Section

Iain A. Rankin is a Specialist Registrar in Trauma and Orthopaedic Surgery at the North of Scotland Deanery and PhD candidate in Bioengineering at the Centre for Blast Injury Studies, Imperial College London. His thesis focuses on identifying the mechanisms of injury to the pelvis in blast and developing mitigation strategies.

Arul Ramasamy is is a Consultant Trauma and Orthopaedic Surgeon at Milton Keynes University Hospital and a Senior Lecturer in the Academic Department of Military Surgery and Trauma and the Royal Centre for Defence Medicine.

Julian Cooper is a Consultant Orthopaedic Trauma Surgeon at the Queen Elizabeth Hospital Birmingham, a Major Trauma Centre and UK receiving hospital for military casualties injured abroad. He has a special interest in pelvic injuries.

Blast injuries to the pelvis: essential lessons learned Iain A. Rankin, Arul Ramasamy and Julian Cooper

The most recent military conflicts have seen blast injury as the leading mechanism of wounding and death, with the Improvised Explosive Device (IED) as the signature weapon of choice.1 Outside the military setting, terrorists have increasingly used the IED globally over the last 40 years.2 One of the most challenging patterns of orthopaedic injury to emerge is that of blast injury to the pelvis.3

his involves pelvic instability, extensive tissue loss and heavily contaminated injuries.4,5 It is frequently associated with vascular injury, traumatic amputation of at least one lower extremity (typically proximal transfemoral amputations), a severe injury to another extremity, and abdominal, perineal or urogenital wounding (Figure 1).4–7 The associated mortality of all blast related pelvic fractures is 48%, rising to 73% when pelvic fractures are combined with open perineal injuries.8,9 This group of injuries is sustained by casualties who are wounded on foot patrol.6 In vehicle, injuries consist primarily of rami, sacral and spinal fractures – consistent with an upwards deformation of the seat.9 Causes of death in these circumstances are predominantly head or thoracic trauma, as the casualty is thrown upwards.9,10 On foot, pelvic fractures sustained consist principally of disruption to the pubic symphysis and sacroiliac joints.9 The fracture patterns are typically unstable injuries, classified as Tile type B or C.4 They do not fit clearly into mechanistic civilian classification systems (such as the Young-

Burgess classification).11,12 The mechanism of injury is not clearly understood, but has been hypothesised to occur secondary to axial load via the femoral head, outward flail of the lower extremities (with a resultant superolateral displacing force acting upon the pelvis), blast wind with fragmentation causing direct tissue damage and displacement, or combinations of the above.9,13 As in civilian pelvic fractures, blast related pelvic fractures are associated with injuries to other body regions. One military cohort described 29 survivors (of a total cohort of 89 casualties) of open pelvic blast injuries as having median new injury severity scores (NISS)14 of 41 (range 8 to 75), with significant injuries (defined as abbreviated injury severity score (AIS)15 ≥ 2) in a mean of 3.9 additional body regions. In 90% of cases, the pelvic injury was the most severely injured body region (based on the AIS score), followed by lower extremity and abdominal injury. As such, patients with blast injury to the pelvis represent the extreme end of the trauma spectrum – significant resources and multidisciplinary surgical input are required in

Subspecialty Section

major transfusion protocol should be initiated early. Haemorrhage from a pelvic vascular injury frequently requires surgical control with pelvic packing and/or direct pelvic vessel ligation.4 Vascular control should be achieved at the most distal level possible. Initial infra-renal control of the aorta through laparotomy, may then be moved distally to the internal and external iliac arteries.21

Figure 1: Intra-operative photograph showing a patient with blast injury to the pelvis (Tile C pelvic fractures) and open perineal injuries. The patient sustained bilateral proximal transfemoral amputations in addition to their pelvic blast injury. Image reproduced with permission.5

their management.5 Owing to ever increasing use of the IED in terrorist related incidents, the civilian surgeon may be expected to treat a patient with blast injury to the pelvis – knowledge of the immediate and ongoing management is essential.

Management of the blast pelvis

for patients with exsanguinating pelvic haemorrhage.18,19 Additionally, application of a pelvic binder is mandatory in lower extremity blast injury with suspected pelvic fracture, to aid stable clot formation from low pressure bleeding sites.20

As blast injury to the pelvis results in fracture patterns of a mechanically unstable nature (Figure 2), emergent operative management should include fracture stabilisation. Damage control orthopaedics, with external fixation techniques, form the standard treatment in the acute setting. Management includes provisional fracture stabilisation, debridement of contaminated and devitalised tissue, and limb preservation surgery of associated traumatic amputation (where possible). Conservation of maximal skeletal length and intervening joint levels may require fracture stabilisation proximal to the point of amputation.22 Provisional operative pelvic stabilisation is performed using iliac crest or supra-acetabular external fixation.8 In severely unstable pelvic fractures, the addition of a compact external fixator at the pubic tubercles, may aid stability across the pubic symphysis.23 With risk of concurrent colorectal injury, the input of a general surgeon should be sought early. Inspection of the perineum, buttock and perianal tissues is required, including digital rectal examination to assess for sphincter function, luminal compromise, haematochezia, or foreign bodies. Blast injury to the anus, rectum or sigmoid colon are strong indications for a diverting colostomy; abdominal perineal resection may be required in cases of massive pelviperineal wounds with rectal destruction and pelvic necrosis.24

“This group of injuries is sustained by casualties who are wounded on foot patrol. In vehicle, injuries consist primarily of rami, sacral and spinal fractures – consistent with an upwards deformation of the seat. Causes of death in these circumstances are predominantly head or thoracic trauma, as the casualty is thrown upwards. On foot, pelvic fractures sustained consist principally of disruption to the pubic symphysis and sacroiliac joints.”

The principle priority in the management of blast injury to the pelvis is haemorrhage control, beginning on-scene prior to hospital intervention. Both pelvic vascular injury and associated traumatic amputation present sources of major haemorrhage from which exsanguination can occur. Pre-hospital haemorrhage control can be achieved in traumatic amputation with the use of tourniquets.16 For more proximal traumatic amputation where tourniquet application is not practical (such as the groin), advanced haemostatic products can help achieve haemostasis.17 For noncompressible haemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been shown to have a positive effect on mortality and has been used as a pre-hospital resuscitation treatment

Subsequent multidisciplinary operative management is required as soon as feasible to achieve vascular control and pelvic fracture stabilisation.4,5,8,21 On arrival in the emergency department, hypotensive patients warrant immediate transfer to theatre for damage control surgery with concurrent resuscitation. These patients require massive blood transfusion (mean 28 units of packed red cells within the first 24 hours)5 and the receiving facility’s

Urological review is required as the risk of urogenital trauma is increased three-fold in casualties of blast injury where a pelvic ring fracture is present, and partial or complete loss of genitalia has been observed in up to 25% of these patients8,25 Bladder or >>

Subspecialty Section

amputations.31 In cases of suspected fungal infection, intravenous antifungals should be administered in addition to repeated debridement of necrotic tissue – widespread debridement can be required.32

Figure 2: Anteroposterior radiograph of a patient with blast injury to the pelvis, taken on presentation, showing diastasis of the pubic symphysis and disruption of the right sacroiliac joint. Image reproduced with permission.5

urethral injuries should be suspected with the presence of blood at the urethral meatus or scrotal bruising. A retrograde urethrogram is advised to detect urethral injury, which may be followed by a CT cystourethrogram to identify bladder injury.26

Bacterial and invasive fungal infections are common and may cause late mortality29. Intravenous prophylactic antibiotics should be administered as soon as possible, ideally within three hours of injury. At initial debridement, antibiotic-impregnated beads

The principles of blast injury wound management emphasise extensive debridement, wound irrigation and negative pressure dressings. Repeated debridement over the initial days after injury are required, as blast effects on tissue viability are not always apparent at first. The zone of injury may be larger than initially apparent as tissues in close proximity to the primary blast region may die over time.27 The number of debridements required for patients with blast injury to the pelvis has ranged from two to thirty-two (median six).5 Subsequent soft tissue coverage and reconstruction is performed in a delayed fashion with split skin grafts or fasciocutaneous flaps.28

may be implanted in proximity to fracture sites. Prophylactic antibiotics should be continued for 24 – 72 hours. Antibiotic use beyond this is determined by the presence of an established infection or delayed wound closure.30 Invasive fungal infections are challenging to treat and outcomes remain poor. Risk factors identified from previously injured military personnel include (on foot) blast injury and above knee traumatic

Definitive fixation of complex open pelvic fractures can include iliosacral screws, with anterior disruption managed with internal fixation, external fixation, or a combination of techniques. In contrast to civilian open fractures, as a result of the high degree of soft-tissue disruption and environmental contamination, deep infection rates in pelvic blast patients reach 80%.5 The risk of infected indwelling metalwork is extremely high—one series reported a 57% removal of metalwork rate due to infection, subsequently requiring prolonged bed rest to achieve union.5 Owing to severe contamination, subsequent wound reconstructive problems and risk of metalwork infection in these patients, external fixation should be considered as a definitive treatment in preference to internal fixation. Blast injury is not limited to the battlefield and civilian orthopaedic surgeons may be required to manage these injuries following terrorist attack or similar mechanisms. These patients present with multiple life-threatening injuries and the most critical operative procedures should be prioritised — proximal haemorrhage control, pelvic stabilisation, contamination control, completion of amputations, bladder repair and colonic diversion.33 Whilst blast injury to the pelvis represents the extreme end of the trauma spectrum, pelvic stability and return to walking on native or prosthetic limbs has been achieved in up to 80% of casualties.5 Patients with blast injury to the pelvis require prior major incident planning, rapid surgical decision making, and prolonged multidisciplinary surgical and rehabilitation input in order to achieve optimal care and outcomes. n

“The principles of blast injury wound management emphasise extensive debridement, wound irrigation and negative pressure dressings. Repeated debridement over the initial days after injury are required, as blast effects on tissue viability are not always apparent at first. The zone of injury may be larger than initially apparent as tissues in close proximity to the primary blast region may die over time.”

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

Subspecialty Section

Alasdair Bott, MBBS, MSc, FRCSEd (Tr&Orth), Dip Hand Surg (Br) is an Orthopaedic Trauma Fellowship Trainee at North Bristol NHS Trust. His training in trauma and reconstructive surgery has been put to use in South Africa, Malawi, Cambodia and Myanmar. He has published research on long-term patient reported outcomes following pelvic fractures.

Graeme Nicol FRCS completed his Orthopaedic Surgical training in Dundee, Scotland in 2018. He then undertook sixmonths of arthroplasty training followed by a six-month trauma fellowship concentrating on pelvic and acetabular fractures fixation at Southmead Hospital, Bristol, England. Currently Graeme is in Ottawa, Canada completing an arthroplasty fellowship including hip preservation surgery.

Tim Chesser, MBBS, FRCS is a Trauma and Orthopaedic Surgeon at North Bristol NHS Trust with a subspecialty interest in Pelvic and Acetabular Surgery. He is Chair of the NICE clinical guideline and expert topic group for Hip Fractures, BOA representative for the National Hip Fracture Database and is the current President of the Orthopaedic Trauma Society.

The hidden side of pelvic fractures: Urological and sexual dysfunction following injury Alasdair Bott, Graeme Nicol and Tim Chesser

The anatomy of the pelvis dictates that the structure and function of the urogenital tract are at particular risk of injury in patients with pelvic fractures. Whilst impotence and incontinence are not life-threatening conditions, they have the potential to profoundly affect the psychosocial wellbeing of patients.1

he negative impact on quality of life extends into matters of relationships, sleep, travel, work, sport and hobbies. Both the recognition and optimal management of these injuries, is lacking. When there is not an obvious structural deficit, such as a bladder rupture, many go initially unrecognised and untreated. This, despite explicit national guidance emphasising the need to be vigilant and investigate early, with a BOAST guideline dedicated to the identification of the problem2, treatment occurs at an interface of orthopaedic and urological surgery and is often unfamiliar territory to both surgical specialties. When trying to improve outcomes in trauma, we need to recognise both early and late problems that arise as a result of injury. For polytraumatised patients cared for by orthopaedic surgeons, issues of urological or sexual nature may seem less important than pelvic ring stability and management of other musculoskeletal injuries. This is a developing research area, but we are recognising the incidence is significantly higher than previously thought and very little is known about the long-term impact of pelvic fracture on urinary and sexual outcomes.3,4

Anatomy of Injury The enormous energy required to disrupt the pelvis is usually transmitted via a blunt force,

meaning genitourinary injuries occur in up to a third of pelvic fractures.5 They are primarily classified according to the anatomy of bladder or urethra, but may also involve the rectum or lumbosacral plexus. Two thirds of patients with pelvic fractures suffer injuries to multiple body regions.6 Bladder ruptures occur in 9-16% of pelvic fractures and can be intraperitoneal (30%), extraperitoneal (60%) or combined (10%).7 Intraperitoneal injuries can result from massive energy transfer to a full bladder at the time of trauma, causing rupturing through the weakest point on the superior dome of bladder wall. Intraperitoneal injuries leak urine into the abdominal cavity, whereas extraperitoneal injuries can communicate with fracture haematoma leading to infection.7 (Figure 1)

Urethra Urethral patterns differ according to the anatomy of males and females and are considered separately. Pelvic Fractures with Urethral Injury (PFUI) occurs in 10% of all pelvic fractures, although injury to the male urethra occurs far more commonly than in females at a ratio of 28:1.8 The long male urethra is anchored at the prostatomembranous junction to the pubic

Subspecialty Section

bone, making this area particularly prone to injury at time of trauma. In the long term, urethral injuries can lead to urethral stricture causing poor flow, infection, incontinence and erectile dysfunction.7 Injury to the unanchored female urethra usually occurs anteriorly from direct bone damage. Urethral avulsion from the bladder neck can occur, leading to incontinence and voiding problems. Vaginal injuries and tears from bone fragments can be a missed source of open fracture.9

Urological and Sexual Dysfunction Urological and sexual dysfunction after pelvic fracture remains a sensitive topic that both doctors and patients find difficult to discuss, its complexity makes it harder to fully understand. Undoubtedly both physical and psychological factors play a role. Whilst

sexual and urological function deteriorates with age, the majority of patients with pelvic fractures occur in young adults and at the beginning of their sexual lives.10,11 Early identification of pelvic fractures with genitourinary injury (GUI) is critical to ensure appropriate care of the patient. But in the longer term associated GUI found to be a risk factor for more severe sexual dysfunction.12 However, not only those with GUI experience sexual dysfunction, up to 30% of patients without injury to the urogenital tract experience symptoms.4,13 In men, symptoms of sexual dysfunction are assessed by asking such question as do you have confidence in achieving erection? Are you able to achieve erections sufficiently hard to engage in penetrative intercourse? Can you maintain an erection? Are you able to complete intercourse achieve satisfaction?14,15 The description of complete erectile dysfunction

“Pain, or dyspareunia, is a common complaint in female patients with pelvic fractures. Mechanical causes such as misplaced metalwork and bone spikes may be responsible in some cases. Long term issues in lubrication and sexual satisfaction are reported in up to two thirds of patients.”

is defined ‘erection not sufficiently firm enough for sexual penetration’. For men with urethral injury approximately 42% experience persistent impotence, with a vascular cause thought to be responsible for around 80% of these cases, 20% due to neurological injury.3,16 Pain, or dyspareunia, is a common complaint in female patients with pelvic fractures. Mechanical causes such as misplaced metalwork and bone spikes may be responsible in some cases. Long term issues in lubrication and sexual satisfaction are reported in up to two thirds of patients.3,17 New urinary dysfunction occurs in up to 40% of patients after pelvic fractures, and appears to occur at equal rates in males and females.3 Two-thirds of patients with new sexual dysfunction also suffered from urinary dysfunction. Incontinence, the involuntary leaking of urine, causes intense distress and embarrassment to patients and is linked to depression and reduced quality of life.18,19 Other issues include increased frequency occurring both day and night, and voiding problems of reduced and painful flow or urinary retention.20

Outcome Measures The study of functional outcome and quality of life in patients with pelvic fractures is dauntingly complex and there is so much we are yet to learn. Through the influence of the Trauma Audit and Research Network (TARN), we have recognised the need to measure functional outcome following injury.21 This helps to evaluate the patient quality of care and influence trauma and rehabilitation services. It also helps to evaluate the cost effectiveness of such treatments as available such as medication, intracavernous injection, microvascular reconstruction to penile prosthetics.5 The TARN registry recommends several generic outcome measures to be used in trauma, these include the EQ-5D and the Glasgow Outcome Score Extended (GOS-E).21 These measures allow assessment of global function and quality of life; however, they have been shown to be insufficiently sensitive to identify urological or sexual dysfunction. So how best can we measure urological and sexual outcome? Disease-specific questionnaires have the potential for greater sensitivity and most validated tools are gender specific. Research into erectile dysfunction is a considerably more developed topic than urinary incontinence, perhaps this is a consequence of market forces regarding the treatments available for erectile dysfunction.

Figure 1: Direct trauma to the urogenital system can be very clear at the time of injury. However this paper shows that distressing long-term genitourinary dysfunction occurs frequently even without obvious direct injury.’

In outcome studies following pelvic fracture many researchers have designed their own >>

Subspecialty Section

X-ray of a male patient with pelvic ring injury before and after surgical fixation

questionnaires, probably the most commonly used validated measure for sexual function is International Index of Erectile Function (IIEF) for male patients and the Female Sexual Function Index (FSFI).4,22,23 This seems to be appropriate for use in pelvic fracture, in that it is gender specific, sufficient detail to make it useful, but at only 15 questions, it avoids the risk of questionnaire fatigue. There have been no reported trials in the literature of urinary outcomes after pelvic fracture using a validated urinary outcome PROMs. Many of the available urological questionnaires are focused on the performance of a certain urological conditions such as prostate cancer or female stress incontinence, and as such they are often not suitable for use in trauma patients.9,24-26 Our institution was instrumental in the development of the International Consultation on Incontinence (ICI) modular questionnaires and have found this to be the most appropriate tool for this purpose. With symptoms scored in three domains of frequency, urgency and incontinence it also contains a ‘Bothersomeness’ score, which can be used to judge overall patient perceived severity.24,27

years after pelvic fracture that there was no correlation between the generic EQ-5D measure and disease specific measures for urinary and sexual outcome. Furthermore, there was only poor correlation between sexual function and urological function. Whilst 19% of our patients had some form of neurological impairment, 70% reported sexual impairment, 37% of which was classified as severe. Only eight percent of patients reported no problems with their urinary function, and 70% some form of continence issues.

TARN, the national trauma registry, and perhaps it is time pelvic surgeons worked to find national accepted scoring tools as a way to develop further research. We can also work towards better collaboration between orthopaedic and urology surgical teams. Perhaps we will see joint pelvic and urological MDTs becoming the norm in trauma centres.

Conclusion Issues of a sexual or urological nature cause immense distress to patients, and are commonly encountered in pelvic fractures. Men and women can encounter different problems due to the differences in pelvic anatomy. If we are to develop our understanding of this topic, we recommend auditing functional outcome as part of patient care using gender and disease specific validated PROMS. The International Index of Erectile Function (IIEF) for male patients and the Female Sexual Function Index (FSFI) is the most commonly used tool for measuring sexual outcome.(4) Although no gold standard measures exist for measuring urological outcome, our institution regards the ICIQ – MLUTS and FLUTS as the most useful tool. n

“The BOAST guidelines, highlight the need to identify early, those patients with GUI to prevent unwanted complications such as missed open fractures, urethral injuries and abdominal contamination. However pelvic surgeons should be directly asking all their patients about sexual and urological symptoms as part of wholistic care.”

Long-Term Outcomes Study There is a problem with judging outcome. We found in a study of 56 male patients 15

Service Improvements As we move to a more integrated national trauma service in the UK, there is enormous scope to improve our management of patients with pelvic fracture. The BOAST guidelines, highlight the need to identify early, those patients with GUI to prevent unwanted complications such as missed open fractures, urethral injuries and abdominal contamination. However pelvic surgeons should be directly asking all their patients about sexual and urological symptoms as part of wholistic care. The measurement of functional outcome is recommended by

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

14th EDITION

EFAS CONGRESS 2020

European Foot & Ankle Society

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Products, Courses and Events 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, emergency medicine, radiology, plastic surgery, dermatology and general practice. We also invite speakers from other specialties like haematology, neurology, rheumatology to contribute to our education. The programme is suitable for consultants and senior trainees. The format is informal and sessions

include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees. Each day concludes with a lecture of general interest by an eminent guest speaker. We have an excellent orthopaedic faculty lined up and the programme when confirmed will be available at www.doctorsupdates.com.

Intensive Course in Basic Science in Orthopaedics 12-17 January 2020 Covering all the topics required for the basic science examination. It is for orthopaedic trainees who are seeking a strong foundation in basic orthopaedic sciences and for those trainees preparing for the FRCS (Tr & Orth) examinations. Course fee £940 (either a one-off fee or 4 instalment payments) inclusive of course book, course dinner and all refreshments.

Anatomy and Surgical Exposures for Orthopaedics 23-24 January 2020

Orthopaedic Institute at the Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire

The programme includes demonstrations of cadaveric prosection of the upper limb and the lower limb with presentations on the spine. The course is for all levels of orthopaedic trainees. Course fee £300 inclusive of all refreshments.

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www.orthopaedic-institute.org Email: sian.jones36@nhs.net Phone: 01691 404661

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iFuse Technology for Treating TM

Chronic Sacroiliac Joint Dysfunction as listed in the NICE Medical Technology Guidance1 as of August 2019

40,000+

1900+

70+

90%

procedures worldwide2

treating surgeons2

peer-reviewed articles3

patient satisfaction4

iFuse-3DTM Implant surface more “bone-like”5

Cancellous Bone

iFuse-3D

Porosity

Pore size

Porosity

Pore size

60-70%

200-400μm

65%

300μm

REFERENCES 1. NICE Medical Technologies Guidance [MTG39] - iFuse for Treating Chronic Sacroiliac Joint Pain. October 2018. 2. Data on file through August 2019, SI-BONE, Inc. 3. List of published studies is available at www.si-bone.com/results 4. Average satisfaction from 11 studies (Rudolf 2012, Sachs 2013, Cummings 2013, Gaetani 2013, Sachs 2014, Rudolf 2014, Vanaclocha 2014, Duhon 2016, Polly 2016, Darr 2018, Dengler 2019). 5. MacBarb RF, et al. Int J Spine Surg. 2017;11:105-15. [Part 1].

The iFuse Implant System is intended for sacroiliac joint fusion. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit www.si-bone.com/risks SI-BONE and iFuse Implant System are registered trademarks of SI-BONE, Inc. iFuse-3D is a trademark of SI-BONE, Inc. © 2019 SI-BONE, Inc. All rights reserved. Patents www.si-bone.com 10483.082219 GB

SI-BONE Ltd. 105-107 Monkswell House, Manse Lane, Knaresborough, North Yorkshire, HG5 8NQ, UK InfoUK@si-bone.com

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