Journal of Trauma & Orthopaedics - Vol 8 / Iss 3

BOA Journal of Trauma & Orthopaedics

Journal of Trauma and Orthopaedics Volume 08 | Issue 03 | September 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

Volume 08 / Issue 03

Don’t let a fracture obscure the bigger picture

boa.ac.uk

Reflections of a Training Programme Director p28

FFN UK Orthogeriatric medicine p52

Rib fracture management in the older adult p54

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3

From the Executive Editor

Bob Handley

5 From the President Don McBride 6- 7 Latest News 8- 20 News Honorary Fellowships and 8 News:

Presidential Merit Award 10 News: Get involved at the BOA! 12 News: BOA Virtual congress 2020 22 Carousel President perspectives:

leadership lessons learned at the time of a world pandemic

Christopher D Harner

26 Evolution of UK and Ireland

In-Training Examination (UKITE)

Ajay Malviya

28 Reflections of a Training

Programme Director

Donald Campbell

negative perceptions that deter female medical graduates from pursuing orthopaedic surgery

32 A networking event can reduce

Anh T V Nguyen, May Al-Shawk, Scarlett McNally, Caroline B Hing

35 Commentary on: Inequality,

discrimination and regulatory failure in surgical training during pregnancy

54

Sara Dorman

36 100 years of BOA nerve repair

Matthew Wilcox, Ian Stephen, Deborah Eastwood, Tom Quick

Learning from UK orthopaedic cases

40 Medico-Legal Section:

Heidi Mounsey

42 Simulation Section:

52 FFN UK - Orthogeriatric medicine

Opinder Sahota

44 Trainee Section: It’s time to

Rib fracture management in the older adult; an opportunity for multidisciplinary working

Ran Wei, Jenny Clements

Lauren Richardson, Shvaita Ralhan

Fracture Network UK

Fragility fractures, frailty and fragmented care

Simulation and the UK trauma and orthopaedics curriculum

Catherine Kellett

think about... Fellowships

48 Why we need the Fragility

Matt Costa

49 Anaesthetic management

of hip fracture

Stuart M White

50 Nursing standards and

fragility fracture outcomes

Julie Santy-Tomlinson, Karen Hertz

54 Subspecialty Section:

58 Subspecialty Section:

Shvaita Ralhan, Lauren Richardson

61 Subspecialty Section: Workforce

challenges in orthogeriatrics

Faye Wilson, Shvaita Ralhan

64 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.

We are committed to sustainable forest management and this publication is printed by Buxton Press who are certified to ISO14001:2015 Standards (Environmental Management System).

Buxton prints only with 100% vegetable based inks and uses alcohol free printing solutions, eliminating volatile organic compounds as well as ozone damaging emissions.

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 01

Credits JTO Editorial Team Bob Handley (Executive Editor) Rhidian Morgan-Jones (Editor) David Warwick (Medico-Legal Editor) Tricia Campbell (Trainee Section Editor) Duncan Tennent (Simulation Section Editor) Shvaita Ralhan (Guest Editor) Faye Wilson (Guest Editor)

l l l l l l l

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 Simon Hodkinson (Honorary Secretary) l Deborah Eastwood

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Programmes and Committees Officer

- Harriet Wollaston

Educational Programmes Assistant

- Eliza Khalid

Communications and Operations Director of Communications and Operations

- Emma Storey

Interim Director of Communications and Marketing

BOA Elected Trustees

- Annette Heninger

Don McBride (President) Phil Turner (Immediate Past President) Bob Handley (Vice President) John Skinner (Vice President Elect) (Honorary Treasurer) Simon Hodkinson (Honorary Secretary) Deborah Eastwood Colin Esler Peter Giannoudis Grey Giddins Robert Gregory Anthony Hui Andrew Manktelow Ian McNab Fergal Monsell Rhidian Morgan-Jones Hamish Simpson Arthur Stephen Duncan Tennent

- Sabrina Nicholson

l l

l l

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

Marketing and Communications Officer Membership and Governance Officer

- Natasha Wainwright

Education and Online Exam Project Manager

- May Elphinstone

Publications and Web Officer

- Nick Dunwell

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

Copyright

Copyright© 2020 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

Advertising

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

Disclaimer

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

BOA contact details

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

From the Executive Editor Bob Handley

B

ehind every fragility fracture is a bigger picture. Behind the hip fracture on the cover of this JTO the bigger picture is that of my Mum and Dad on their 60th wedding anniversary standing in the steam of the Orient Express. In their late eighties they bowled, argued, had a various ailments and a pushy son; in fact they were ‘people’. However, should one of them have fallen over they may well have become a ‘NOF’. The labels, generalisations and preconceptions of our daily practice may be a route to an efficient pathway but are often a veneer that conceals or even promotes prejudice. Curiously, there was a time when being labelled a ‘NOF’ was a disadvantage as it led to delayed treatment delivered by juniors at the wrong time of day. Then there was a time when the ‘hip fracture’ label got you better treatment than your contemporaries with less lucrative fractures; you would be seen by a physician and put first on the list. We long for a utopia where the bigger picture is sought and recognised and the injured frail are treated on the basis of their individual needs. This issue explores various aspects of this large component of our trauma work.

The Fragility Fracture Network (FFN) UK is introduced by Matt Costa page 48. He describes it as being not a new Society but rather a network of activists to collate and share best practice. The articles that follow explore the problems and potential solutions of the injured frail. Hip fractures are readily accepted as being squarely in the province of the T&O surgeon but rib fractures are more of a Cinderella condition, with the potential to be admitted under the care of any of a number of specialities; always a risky situation for the patient. A constructive approach is to co-operate as is described in ‘Rib fracture management in the older adult; an opportunity for multidisciplinary working’, page 54. Once you have read the articles relating to the care of the injured frail you will likely be fully convinced of the need for constructive co-operative care. Now read ‘Workforce challenges in orthogeriatrics’. The demand far outstrips the supply of orthogeriatricians. Whilst this shortfall continues we must use the skills of those orthogeriatricians that we do have to their best effect. I suspect this will be by way of specialist nurse support and collaborative use of junior staff. We then need to play our part in making orthogeriatrics an attractive career choice. Ironically it ticks many of the boxes that we all considered before and then spouted out in our medical student interview ‘caring, diverse, holistic etc’ but does not have the kudos it deserves and has the significant barrier of years as the RMO.

If we are to change perceptions and adverse labels then we must consider what we can and cannot influence; idle pontification may be therapeutic for the speaker but is otherwise unproductive. ‘A networking event can reduce negative perceptions that deter female medical graduates from pursuing orthopaedic surgery’, page 32 describes how we may help repaint the landscape. The implication is that the white older male should accept that whilst they can support diversity it really does help to have role models. What an ideal time to hand the baton of the JTO Editorship to such a role model and wish Deborah Eastwood well. n

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 03

69%

reduction of deep infections in hip hemiarthroplasty after * fractured neck of femur

69

Bone cement with gentamicin and clindamycin * Sprowson AP et al. Bone Joint J 2016; 98-B: 1534–1541

www.heraeus-medical.com

From the President

Unity is the best way forward Don McBride

Traditionally, this column presents the exciting things to look forward to at the imminent BOA Congress, contemplates the social interaction and networking that our members are looking forward to during the event and provides some guidance on highlights from the past year and future activities of our organisation.

Despite it all I am still going to do that.

W

hat an ‘interesting’ year we have had. The ‘background’ work in Events Organisation, Finance, Membership, Communications and Policy and Programmes has continued without any great issues from an office to a home-based environment. I thank all of the BOA staff who have managed this seemingly effortlessly but clearly with great endeavour on their part.

So, what has been occupying most of our thoughts this past few months? Strangely enough a virus that is apparently 120-140nm in size but large enough to cause a major pandemic.

The BOA has produced or has assisted in the production of a plethora of documents at the forefront of our knowledge at each applicable time with constant updates throughout the pandemic for trauma and orthopaedic surgeons and our patients. As I write this article the currently available BOA literature is yet again being evaluated and consolidated. This is likely to be available around the time the JTO reaches your letterboxes. (And in this edition I should like to refer you to the excellent article written by the Carousel Presidents about their own experiences of COVID-19 across the English speaking nations.

This is enlightening and informative.)

During the pandemic, trauma care saw an initial dip in those patients presenting but we are well aware that numbers are back to ‘normal’ and our units dealing with trauma are as busy as ever, and that throughput for surgery is typically less than normal due to COVID-19 precautions. The elective orthopaedic restart has been generally governed by local decision making and has been full steam ahead in some areas but slower in others. The reasons are clearly multifactorial.

Of course, we should not forget the people at the heart of this are our patients whose lives have been badly affected by the inevitable delays that have occurred in their orthopaedic management. Inpatient and outpatient waiting lists were very significant prior to lockdown but are now significantly worse across the country. We are liaising with patient groups

and other associations to help as much as we possibly can. Good communication is the key as always. Unfortunately, there remains concern about potential second or third waves of viral infection and as we head towards autumn and winter the likelihood of additional effects on winter pressures or seasonal variation is higher than it would normally be and should be considered in our planning.

On a positive note a number of societies have organised alternatives to their Annual Meetings including webinars, instructional lectures and educational events. We ourselves are providing a combination of pre-recorded sessions, live webinars and virtual AGM and Presidential handover over a two-week period instead of the BOA Congress. The second week is mainly made up of SPR presentations, since trainees have been denied other opportunities because of the cancellation of so many meetings. I am also particularly looking forward to the Carousel session on Diversity, Equality and Inclusion, giving international perspectives on this important topic.

The theme for the Congress is ‘Working Together – the Way Forward’ never more important at any other point in our history.

As this is my last Presidential JTO article I should like to thank the BOA Executive, BOA Council, the BOA staff and our members and patients who have supported me during what has been a very difficult year. We have managed to make something out of a very hard time confirming the overall strength of this association. Unity is as always the best way forward. n

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Latest News

Medical student essay prize The BOA received a record number of essays for the 2020 BOA Medical Student Essay Prize, and the winner will be announced this month. Keep an eye out for the announcement of the winner on social media and email news bulletin. We will also launch the 2021 competition, with a new essay title for medical students to begin working on!

Last chance to apply for the BOA Future Leaders Programme Applications for the 2020/21 Future Leaders Programme (FLP) will close 06 September 2020 at 23:59pm.

There are four main application routes to gain a place on the FLP: • Trust-sponsored Fellows • Specialist Society Sponsored Fellows • NEW FOR 2020: BOA-sponsored fellow as part of our commitment to diversity and inclusion • Individual applications (self-funded).

More information on the FLP, the different application routes and how to apply can be found at www.boa.ac.uk/flp.

Virtual TOTs and TOES courses The BOA has made the decision to cancel all face-to-face TOTs (Training Orthopaedic Trainers) and TOES (Training Orthopaedic Education Supervisors) courses for the rest of the year due to continued uncertainties about travel, meetings and social distancing.

We have, however, developed Virtual TOTs and Virtual TOES courses, both facilitated by the BOA Educational Advisor Lisa Hadfield-Law. Anyone who wishes to find out more or register their interest should email policy@boa.ac.uk.

UK and Ireland In-Training Examination (UKITE) UKITE 2020 will take place from 4th – 11th December 2020. Registrations will open later in the year and all participants should register by the 30th November 2020 in order to be given access.

BOA trainee members should ensure that their membership subscriptions are up to date to enable them to register for UKITE free of charge.

Subscription payments should be made by no later than 31st October 2020.

Non-BOA members can register for UKITE for a fee of £150. Non-members wishing to join BOA should apply for membership by the 30th September 2020 in order to be eligible for free UKITE registration in 2020.

Any participant who wishes to register for UKITE 2020 after the registration deadline will be required to pay an additional fee of £50.

For more see www.boa.ac.uk/ukite or email ukite@boa.ac.uk.

BOA support regarding COVID-19 The BOA has continued to be active in recent months on a range of COVID-19 issues, such as restarting elective surgery, use of PPE, and infection prevention and control across different patient pathways. The pace of change with COVID-19 developments means that several updates are expected during the printing process that we therefore cannot cover in any detail in this edition.

All the latest updates can be found on our website at: www.boa.ac.uk/COVID.

Free BOA membership during parental leave As part of our efforts to support members during all stages of their career, from 1st July 2020 membership fees are now free for BOA members during Maternity, Paternity, Adoption or Shared Parental Leave. This means we will waive your subscription fee for this period while you retain all the benefits of BOA membership such as access to Congress, regular updates, and your subscription to the BJJ or Bone and Joint 360 if part of your current membership package. For more information please email membership@boa.ac.uk.

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New specialty BOASTs published Following the success of Trauma BOASTs, the BOA has decided to expand the guidelines to incorporate elective care, as well as inviting Specialist Societies to come up with their own BOASTs relevant to their subspecialty and publish them in this format. The BOA – along with BASK and BOSTAA – have recently published the first Specialty BOASTs, which can be found on the BOA website. The Specialty BOASTs published include: • Assessment of Patients with Recurrent Patellar Instability • Surgical Management of Patients with Recurrent Patellar Instability • Best Practice Management for ACL Injuries More BOASTs are on the way, and all of them can be found at: www.boa.ac.uk/boasts.

Latest News

New appointment to BOA Presidential line – Deborah Eastwood

“If you change the way you look at things, the things you look at change.” – Wayne Dyer

What a year this has been and we are only two thirds through…

We have all had to change our work and social lives, work harder, work differently or perhaps feel we were not working hard enough and now, well now, we are trying to get back to a new normal.

This new normal will include new ways of delivering clinical care but our role must be to ensure that we keep the ‘good’ changes such as some aspects of virtual care and MDT meetings over the airwaves whilst ensuring we get back to face-to-face work safely and effectively.

During 2020, the BOA has worked hard at helping both surgeons and the patients we treat and we have been delighted by the active participation and support from many of our members – drafting guidance and setting standards is hard work and we could not have done it without you!

Amidst all of this, I was proud to be elected to the Presidential line and very touched by all the supportive messages I received in the aftermath. I am hoping that we can continue to work together in a process of active engagement and inclusion that I am sure will increase our diversity and enrich our association and our profession.

BOA Ortho Update 2021 Saturday 9th January - Manchester We are pleased to announce the launch of the new BOA Ortho Update Course previously the BOA Instructional Course. The improved course gives delegates the opportunity to access new understanding and support preparation for the FRCS exam. We provide the facility for delegates to participate in Case Based Discussions (CBDs) across a range of critical condition topics, which are essential to their training, and join lectures delivered by expert clinicians.

Registration for this course has now opened!

The one-day programme will run in two parallel streams and provide curriculum driven clinical updates and critical condition assessment opportunities aimed at all levels within Trauma and Orthopaedics.

Stream 1: Case Based Discussions (CBDs) on critical conditions including compartment syndrome, neurovascular injuries, painful spine in child and spinal trauma.

Stream 2: Plenary update sessions including foot and ankle, hands, hip and knee, paediatrics, shoulder and elbow and spine.

Further information can be found on the BOA website, www.boa.ac.uk/OrthoUpdate.

BOA Election Results Deborah Eastwood – President 2022-2023 Mark Bowditch – Honorary Treasurer 2021-2023 Amar Rangan – Trustee 2021-2023 Fares Haddad – Trustee 2021-2023 Hiro Tanaka – Trustee 2021-2023 Sarah Stapley – Trustee 2021-2023

BOA Diversity Strategy In June 2020 we launched our Diversity and Inclusion Strategy and action plan.

This was the result of six months’ work with contributions from across the membership to address underrepresentation in the BOA and Trauma and Orthopaedics and create a more diverse and inclusive profession. We are committed to better understanding the demographics of our workforce, translating this into action and championing change in the profession to eradicate racism and discrimination in all forms.

Work started with an initial action plan which is being fleshed out through our Diversity and Inclusion Forum and will form the basis of a number of projects over the coming years.

We will regularly monitor and review progress and provide updates both here, and through member newsletters and social media.

We believe that a more diverse BOA better serves our patients and best supports our colleagues. We will be working closely with members and Specialist Societies to achieve our aims. If you are interested in being involved, please contact us at secretary@boa.ac.uk.

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News

Honorary Fellowships

The BOA is pleased to announce the recipients of the 2020 Honorary Fellowship, which will also be announced at BOA 2020 Virtual Congress and presented at BOA 2021 Congress.

Chris Lavy Chris Lavy did not follow a conventional route into orthopaedics.

He was an undergraduate at University College London and St Bartholomew’s Medical College.

After house jobs he took a six month break and cycled to the source of the Nile, starting a life-long interest in healthcare in Africa. He then did GP training in Norwich before seeing the light and moving to orthopaedics in 1987.

He was orthopaedic registrar in Bath, with an exchange year in Cape Town, then senior registrar at the Royal National Orthopaedic Hospital with a fellowship in hand surgery in Paris where he was nicknamed ‘C’est La Vie’.

His first consultant post was at The Middlesex and University College Hospital where he was appointed in 1992 with an interest in trauma and hand surgery.

Robert Grimer Robert Grimer qualified from the Middlesex Hospital Medical School London in 1976 and immediately worked for Sir Rodney Sweetnam who was PRCS, Past President of the BOA and the main sarcoma surgeon in the country at that time – an inspirational introduction to bone tumour diagnosis and management. Appointed to the Royal Orthopaedic Birmingham Hospital training programme he worked with Rodney Sneath, again specialising in bone tumours. He obtained his FRCS Orth in 1986 and was appointed the first Consultant Orthopaedic Oncologist in the country in 1988 at the Royal Orthopaedic Hospital in Birmingham.

Professor Grimer took a year out of training to establish a tumour database in 1986 to inform the long term results of treatment, and his specialist interest in outcomes and pelvic sarcomas, creating an ‘electronic patient record’ years before the term was invented. The database became a gold mine of information – in no small part contributing to the 380+

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In 1996 he heard that Malawi had no orthopaedic surgeons so took his pregnant wife Vicky to Blantyre, where they stayed 10 years.

In Malawi he was challenged by the thousands of children who could not walk for want of reconstructive surgery so he set up a children’s orthopaedic hospital in 2002, which is now visited by many UK trainees. His work with the charity CURE led to the setting up of a sister hospital in Zambia in 2006.

Chris’s passion is surgical training in Africa and his greatest honour was to have been part of the small team who dreamed of a regional college of surgeons, then raised the funding to start it in 1999. Now 20 years old, the College of Surgeons of East Central and Southern Africa (COSECSA) has 600 trainees and covers 14 countries. For this he was awarded the OBE.

He has raised many millions of pounds for children’s hospital building, surgical training and research, with current research interests being clubfoot, spine and trauma care in Africa. He is currently working on opening a children’s orthopaedic hospital and training centre in Bulawayo Zimbabwe in late 2020. (www.bohz.org).

Chris describes his motivation in life as serving the many people in the world less fortunate than us and showing God’s love in practice to the many children who need reconstructive surgery.

Outside of surgery Chris loves art, and sport – and like too many weekend warriors is currently rehabilitating after an Achilles tendon rupture. n

publications and 34 book chapters from the Royal Orthopaedic Hospital Oncology Service over the following years and his own DSc thesis ‘Improving outcomes for patients with musculoskeletal tumours’ published in 2011. This was also the subject of his Hunterian lecture to the BOA.

He has served on the council of the BOA 2009-2012, on the editorial board of the BJJ/JBJS and Bone and Joint 360, the NICE guideline development group for Sarcoma as well as developing NICE Guidelines for early diagnosis of sarcomas.

He has been President of the European Musculoskeletal Society and was the founder and Secretary of the British Sarcoma multidisciplinary group. Together with Steve Cannon, Simon Carter and John Healy he was a founding member of the British Orthopaedic Oncological Society set up in 1989 following a meeting in St Malo France, a touch of decadence which still surrounds this sociable and august group to this day, inspiring an active group of surgeons around the country who work as a virtual team supporting each other clinically and socially.

Inevitably he became president of this group as well. He has been on the board of trustees of Sarcoma UK a leading patient orientated UK Charity.

Professor Grimer spent his career dedicated to the care and scientific management of patients with sarcoma.

He realised the benefits of massive endoprostheses, multidisciplinary working, electronic databases, and research.

Sharing his skills and experiences has inspired generations of surgeons around the world to follow his example. n

News

Joseph Dias Joe Dias graduated from Bombay University in 1981 and moved to the UK obtaining accreditation in the UK 1987. He trained on the Leicester training programme under Paul Greig where he obtained his MD and was appointed consultant in general orthopaedics specialising in upper limb surgery.

Joe is Professor in Hand and Orthopaedic Surgery and Head of Academic Team of Musculoskeletal Surgery (AToMS) at the University Hospitals of Leicester. He is a Consultant Hand and Orthopaedic Surgeon for the University Hospitals of Leicester.

He has published over 180 scientific articles, over 20 other publications and over 30 chapters in books most on hand surgery and epidemiology. He has 24 publications on scaphoid fractures. He has authored multiple national reports and NICE accredited clinical pathways.

Professor Dias has received many substantial grants including from the HTA and NIHR looking at scaphoid fractures (SWIFFTpublished in Lancet) and Dupuytrens contracture (DISC). He was co-applicant on DRAFFT2, UK FROST and SOFFT. He has been commissioned and has implemented the Leicester Remote Arthroplasty Clinic (LARC) with senior arthroplasty surgeons.

He has been Editor-in-Chief of the Journal of Hand Surgery (Europe edition) and on the Editorial Board for the Journal of Bone and Joint Surgery.

Professor Dias was President of the British Society for Surgery of the Hand (BSSH) in 2008 and was President of the British Orthopaedic Association in 2012.

He was Head of School of Surgery at the East Midlands Healthcare Workforce Deanery (South) and currently leads an orthopaedic research team (AToMS) at Leicester, with 5 MD/PhD students and two BSc students. He has maintained close links with Orthopaedic surgery in India visiting and lecturing regularly.

He lectures internationally and has given several eponymous lectures including the Harold Bolton Lecture, the Douglas Lamb Lecture and the Robert Jones Lecture for the BOA.

He chaired the PBR Tariff for Trauma and Orthopaedic Surgery, the EWG on T&O HRGs, the Clinical Commissioning Guidance development group and on the boards of the UK Department of Health Enhanced Recovery and Shared Decision-Making programmes. He has worked with MONITOR for many years.

He is currently Chair of the University Hospitals of Leicester NHS Trust clinical senate. n

Presidential Merit Award

The BOA is pleased to announce the recipients of the 2020 Presidential Merit Awards, which will also be announced at BOA 2020 Virtual Congress and presented at BOA 2021 Congress.

Mamdouh Morgan Mamadoh Morgan is a senior orthopaedic surgeon in Birmingham, working at University Hospitals Birmingham.

He graduated in Egypt 1984 and started his orthopaedic career in the Army in 1986, then joined the four-year High Residency Programme in an Orthopaedic surgery in Cairo. He obtained an MSc in Orthopaedic Surgery at the end of his training.

Mr Morgan moved to the UK in 1993. He has a passion for education, which led him to obtain the FRCS from the Royal College of Surgeons (Glasgow) in 1996, the MSc (Surgery of Trauma) from the University of Birmingham in 1998, the MSc (Orthopaedic Engineer) from Cardiff University in 2002, the MCh (Orthopaedics) from the University of Liverpool in 2003, the PG Cert (Leadership & Management) from Keele University in 2012, the PG Diploma (Medical Education) from University of Birmingham in 2012 and the PG Diploma (Sports

& Exercise Medicine) from University of Bath in 2013.

Mr Morgan has been on the Specialist Register for Trauma & Orthopaedics Surgery since 2008; he has a passion and commitment to the SAS Grade and strongly believes that SAS doctors have potential to contribute more within their grade and participate in leading change in the NHS for better patient care.

Mr Morgan as Associate Postgraduate Dean for SAS Doctors in the West Midlands is leading the region’s Staff Grade, Associate Specialist and Specialty Doctors’ professional development and career progression. He has a passion for the developmental needs of SAS doctors. His mission is ‘To promote a Strategic and Professional Approach to ensure all postgraduate education results in better patient care and service’. He has a clear strategic vision for the training, educational and developmental needs of SAS doctors. He continues to work with other stakeholders to ensure that educational activity for SAS doctors is incorporated into the assessment of Royal Colleges and the CESR application process.

Mr Morgan has been nominated by the British Orthopaedic Association (BOA) President to join the BOA Council, the BOA Education Committee and the BOA Training Standards Committee as a national SAS surgeon’s representative.

His role involves strategic development of the SAS doctors in trauma and orthopaedics with the view of restructuring this grade for better patient care in the UK. He is keen in ensuring a suitable environment of ‘training for all’ with SAS surgeons receiving similar resources for training, education, and CPD as other training surgeons. n

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News

Get involved at the BOA! Following the success of last year’s Committee restructuring, the BOA is now holding another recruitment round for a variety of different roles. Last year we had an unprecedented number of applications to all positions, and we are very excited to be able to broaden the membership of our Committees once again.

T

his is your chance to use your skills and expertise to influence and input into the work of the BOA. If you have an interest in trauma and orthopaedics that you’d like to pursue further as part of your national specialty body, the BOA needs you! We have exciting opportunities for BOA members who are Home Fellows or SAS surgeons to represent, lead and effect change across the trauma and orthopaedic profession.

The BOA is committed to equality of access to a T&O career and to the services of the Association. As per our Diversity Strategy we would particularly invite applications from underrepresented groups within the BOA.

• Committees Would you like to be involved in the BOA with writing new BOAST guidance? Or help to review how our research funding is used? We are recruiting for posts in the following committees: Education and Careers, Orthopaedic and Research.

• RSPA Regional Roles There are opportunities to improve local standards and shape service delivery through RSPA roles available in the following regions: South Central (North), South East Coast, South Central (South), South West, Yorkshire and The Humber (South), East Midlands (South) and the East of England.

• UKITE Editorial Roles There are vacancies for UKITE Editors across all sub-specialty areas. Editors play a key role in the creation of UKITE through contributing questions for the examination. This is an opportunity to gain experience in question authoring, editing and validation processes.

Best practice guidance is available for those new to this.

For all vacancies see www.boa.ac.uk/getinvolved for more information and how to apply.

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Three of last year’s recruits gave the following feedback on their experiences so far:

Caroline Hing, Education and Careers Committee: “I have really enjoyed the last six months in the committee, as I have been able to work with committee members and BOA operational staff, working on draft documents and putting together strategies for change and seeing this in action.

Initially I had thought applicants were more senior members of the profession but decided to throw my hat into the ring. The BOA needs to represent its membership and applying to a committee at whatever stage you are currently at in your career gives you a voice to influence change.”

Nick Aresti, Orthopaedic Committee: “An intriguing insight into how elective orthopaedics is run, its direction, levers and policy. It has been a great opportunity to share my experiences and knowledge and to give something back to our governing body.”

Alex Trompeter, Trauma Committee: “It has been an incredibly rewarding and enlightening experience. Shortly after joining, COVID-19 struck, and I was immediately involved in helping produce the emergency COVID-19 BOASTs. The ability to understand how trauma care is planned and delivered on a national scale is fascinating, and the opportunities that have come about as a result of being part of the committee are plentiful.”

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News

BOA Virtual Congress 2020 15th – 25th September, Online (Member Only Event) www.boa.ac.uk/congress

W

e will be running a virtual Congress during 15th – 18th September. Apart from the traditional four day event, the BOA has also decided to extend the event into the following week 21st – 25th September with the primary focus on abstracts and trainees.

The theme for the BOA Virtual Congress 2020 is ‘Working Together’, with an exciting programme comprising of live and pre-recorded content. Members can access the content across the two weeks and throughout the year by logging in to the BOA website, www.boa.ac.uk/login, if you are having problems with log in please contact events@boa.ac.uk.

Programme Update We will be offering a number of live sessions each day on current topics and are delighted to confirm that a number of high calibre speakers have been secured. Aside from the live sessions, the specialist societies will be providing pre-recorded hot topic and revalidation sessions. Societies who will be providing sessions include OTS, BHS, BASK, BSCOS and BSSH. This content can be accessed at any time once it has been released on to the BOA website so can be viewed at your convenience.

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• T&O and COVID-19; the Good, the Bad and the Future This session will offer a current update on COVID-19 and T&O from key national figures.

- Professor Keith Willett, National Strategic Incident Director, COVID-19 - Professor Chris Moran, Deputy National Strategic Incident Director, COVID-19 - Andrew Bennett, National Clinical Director, MSK - Professor Tim Briggs, National Clinical Director for Clinical Quality and Efficiency Tim Briggs - Professor Phil Turner, Immediate Past President, BOA As the COVID-19 situation remains volatile the listed speakers may not be available consequent upon other National commitment.

• Life Beyond Survival: From Orthopaedic Trauma to Pathogen Epidemics, What do Endings Really Mean?

As we wait for the current pandemic to be declared at an end, how can we be sure that all the necessary surveillance is in place to ensure that we are being both rigorous and sensitive enough to all the factors that allow

us to make a confident, effective evaluation?

What lessons should we be taking from other outbreaks, and also beyond epidemiology?

What do the long-term effects of blast injury on our current patient cohort tell us about whether declaring an end to the threat of suffering is ever a realistic prospect?

Dr Emily Mayhew, Historian in Residence, Dept of Bioengineering, Imperial Internal Lead, Paediatric Blast Injury Research, Convenor, The Potato Project, Imperial College London.

Dr Emily Mayhew is a military medical historian specialising in the study of severe casualty, its infliction, treatment and long-term outcomes in 20th and 21st century warfare. She is historian in residence in the Department of Bioengineering, working primarily with the researchers and staff of The Royal British Legion Centre for Blast Injury Studies, and a Research Fellow in the Division of Surgery within the Department of Surgery and Emily Mayhew Cancer. She is based

News

jointly in the Department of Bioengineering and at the Chelsea and Westminster campus of the Imperial College School of Medicine.

She is the co-editor of the Paediatric Blast Injury Field Manual, and the author of the ‘Wounded’ trilogy. Her forthcoming book War, Pestilence, Famine and Death: the Four Horsemen and the Hope for a New Age, will be published by riverrun in February 2021.

Please note: This session is available to both members and non-members and not solely aimed at medical students.

• Capturing Positive Change - the NHS Change Challenge The NHS Change Challenge is a project supported by NHSE & I, which strives to capture the positive changes in our way of working that have come about during the COVID-19 pandemic. Using a novel crowdsourcing technique, and covering all Chris Moran facets of musculoskeletal care, we have identified several unique and novel ways of delivering our services. The session will provide an outline of how the process works, and an update on some of your suggestions and ideas and what will happen next.

• Changing Clinical Practice 2020 This session will review the evidence that will change your clinical practice in 2020!

This year, we will cover Achilles tendon rupture with Professor Matt Costa, scaphoid fracture with Professor Joe Dias and frozen shoulder with Professor Amar Rangan. The session will be interactive, so bring your experience, bring your questions and bring your challenges.

Matt Costa

Abstracts With congress running virtually this year, abstract sessions will take place in the week following the core congress week from Monday 21st September to Thursday 24th September. Each day will see various topics covered and the full timetable for the session can be found on the BOA website www.boa.ac.uk/abstracts.

How to Register To register for the live sessions please log in to the BOA members portal and head to the BOA Annual Congress page, www.boa.ac.uk/congress.

Here you will also find information regarding the programme, speakers, sponsors and much more which will be updated regularly.

Pre-recorded sessions will also be made available, within the member’s area of the website, throughout the two week period of Virtual Congress, please login to the BOA website to access this content, www.boa.ac.uk/login.

Congress App We are delighted to announce that the BOA Congress App is now ready to download for members! Download the BOA Congress App now to your smartphones and tablets through the Apple App Store and GooglePlay - search for BOA Annual Congress and make the most of your experience before, during and after the Virtual Congress.

If you have any questions regarding this event please contact the BOA Events Team, events@boa.ac.uk.

Industry We would like to thank industry who have supported the BOA Virtual Congress 2020 through sponsorship and advertising, Bone and Joint Publishing, Heraeus Medical and Link Orthopaedics, further information can be found on the website.

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 13

News

Orthopaedic Trauma Society (OTS) update Paul Dixon

T

he Orthopaedic Trauma Society is now in its eighth year and has become established as a society that represents both the trauma interested orthopaedic surgeon working in a trauma unit and the MTC full time trauma specialist.

The membership now stands at over 250 which is an indicator of the increasingly high profile the society has built.

The OTS was fortunate to hold its annual meeting in Newcastle upon Tyne in January over two days preceded by the NIHR trauma trials day. This was attended by 200 delegates and feedback has been excellent

due in no small part to our international guests Ken Egol and Olof Wolf.

The society is delighted to be contributing a virtual session to the BOA congress this year which we hope will be as well received as the live sessions last year.

The education committee is also actively involved with BOTA and is working with ‘Orthopaedics and Trauma’ on a major trauma issue of the journal.

The research committee goes from strength to strength and is now offering

British Society I for Children’s Orthopaedic Surgery (BSCOS) update Colin Bruce

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n common with so many meetings the BSCOS 2020 annual conference was cancelled in the face of the advancing COVID-19 lockdown. The meeting has been re-scheduled for 1st – 2nd February 2021 at the Lowry theatre in Manchester and we keep our fingers crossed that the meeting can go ahead as the virus slowly exits stage right.

The last five years has seen a revolution in BSCOS, with formal research programmes moving from concept in the theatre wings, to centre stage. GIRFT tells us that unnecessary treatment variation is unacceptable, and our patients often tell us that this only adds to their confusion and anxiety. Through two rigorous consensus exercises the society identified key areas of research uncertainty - both in trauma and elective care. In these areas there is significant variation in practice, and the society called for robust randomised trials.

It is these trials that will both enthuse and protect surgeons. The protection comes from trials offering strong documented evidence that all reasonable treatments were considered by the surgeon (i.e. proof of Montgomery consent), irrespective of whether the family chose to participate in the trial or otherwise.

The National Institute for Health Research have been instrumental in working

research grants for trauma related projects and collaborating with the James Lind Alliance on priorities for research in complex trauma. In addition, the society has been able to offer assistance for trauma fellowships in the US through its alliance with IOTA which it hopes to continue next year.

Looking forward the society is planning its 2021 meeting and is keen to continue working with the BOA and other specialist societies in promoting all aspects of orthopaedic trauma management.

New members are always welcome and I would encourage you to visit www.orthopaedictrauma.org.uk for more information and contact details. n

with the society. We are pleased that the investment in our research is now over £10 million. Ongoing trials include surgery or non-surgery for medial epicondyle fractures (www.SCIENCEStudy.org) and whether wrist fractures need to be reduced in younger children, which is particularly relevant in the post-COVID age, when operating space is at a premium (www.CRAFFTStudy.org).

Beyond this, the ambitious nationwide BOSS Study will identify variation in practice for SCFE and Perthes’ Disease – and may have now led to the first national RCT in SCFE being funded (though we aren’t allowed to reveal this yet!).

BSCOS encourage you to participate in the national children’s studies if you treat the conditions being investigated. We support the paediatric orthopaedic GIRFT to monitor hospital involvement in NIHR research, because hospitals involved in research are known to have better outcomes.

BSCOS will continue to identify and reduce unnecessary practice variation. Our next target is common elective conditions – infant DDH treatment, infection and clubfoot. We know that there is significant variation, and we seek to identify this, and work to address it through consensus and research. We hope that we can all take our seats in February 2021 to get our show ‘The New Normal’ back on the road. n

News

The burden of neglected trauma in the developing world: Update from World Orthopaedic Concern UK

Neglected distal humeral fracture.

Deepa Bose

I

Neglected bilateral club feet.

Delayed presentation of open segmental tibial fracture resulting from a crocodile attack.

Innovative use of Kuntscher nails as an external fixator.

n most high income countries, patients who have suffered physical trauma present within the first twenty-four hours. In low and middle income countries, on the other hand, several problems collude to prevent immediate presentation of trauma. These include lack of access to medical facilities, lack of transportation, the services of traditional healers, and undiagnosed or missed injuries. Consequently, neglected trauma and its sequelae, such as osteomyelitis and non-union, are commonplace.

Such conditions would be challenging in the best of circumstances, with the latest equipment and resources to hand. Imagine trying to manage an infected gap non-union without the benefit of microbiology, plastic surgeons, or even simple implants such as external fixators!

The surgeon in such a situation is forced to draw upon the basic principles; anatomy, physiology, pathology, biomechanics, in order to formulate and execute a management plan.

Thorough surgical debridement of infected and devitalised tissue, correction of alignment, stable internal or external fixation, and robust soft tissue cover are all essential measures in the management of neglected trauma.

Lateral thinking, innovation and cognitive flexibility are required in addition to clinical acumen and technical skills. As always, the planning and effort which goes into these cases is liberally rewarded by the clinical outcomes and the gratitude of the patients.

If this has piqued your interest please do consider joining World Orthopaedic Concern UK: www.wocuk.org. n

British Hip Society (BHS) update: Research in response to COVID-19 Jonathan Howell, Vikas Khanduja and Ajay Malviya

T

he COVID-19 pandemic posed an unprecedented challenge to medical services in the UK, diverting resources away from elective surgery, thereby adding to the delays faced by patients. Furthermore, the presence of the disease in the community, and the results of patients who contracted COVID-19 in the perioperative period, have created uncertainty regarding the risks of elective surgery.

The BHS has responded to the uncertainty created by COVID-19 through involvement in three research streams.

In the last few months the surgical Royal Colleges have produced broad-spectrum advice on Surgical Prioritisation during COVID-19. The BHS has sought to expand on this advice, adding detail to the list of conditions and procedures pertinent to

the hip, and creating a scientifically-robust clinical guide through engagement in a Delphi consensus process. The results of this work have been sent to BHS members but non-members may also access them by emailing our secretary, Matt Wilson, at brithipsocsec@gmail.com.

To address concerns over the safety of elective lower limb arthroplasty in the current environment, the BHS has combined with the British Association for Surgery of the Knee (BASK) to establish a new research project; Restarting Elective orthopaedic JOINnt surgery after COVID-19 (The REJOIN Study). The aim is to collect data on elective knee and hip arthroplasty without exclusion and the results, most significantly the risk of mortality to patients, will be fed back to

each unit faster through this project than through any other route, helping to inform decision-making for the recipients and providers of elective orthopaedic services.

Arthroplasty units wishing to join the project can send an expression of interest by email to rejoin@ndorms.ox.ac.uk.

Finally, the Non-Arthroplasty Hip Registry (NAHR) has launched a COVID-19 audit for all patients being operated on from 1st June 2020, with 30 and 90 days follow-up to look at COVID-19 related complications. The registry will analyse the data later in the year, surgeons will be fed back their confidential results, and a public report will be published. Surgeons are encouraged to join, avail themselves of the benefits of the NAHR, and to encourage their patients to participate. n

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 15

News

T The Combined Services Trauma and Orthopaedic Society (CSOS) update

he Combined Services Trauma and Orthopaedic Society held a recent successful virtual conference. As ever a wide range of papers were presented, many which had implications for both military and civilian life. There were two particularly strong examples, the first from Maj Tim Packer on lessons learned during COVID-19 and the second from Surg Lt Cdr Tom Stevenson’s PhD work was of military and civilian interest.

Louise McMenemy

• COVID-19 has had a dramatic effect on the working patterns of the Military T&O Cadre at all grades. Translation of acquired skills to deployed military roles has been highlighted as a potential positive outcome. Comparison was made across different UK trusts. Lessons learned included the establishment of minor injury units to ease clinical burden, and increased use of conservative treatment; both suiting lowresource deployed military environments. These new skills will allow us to be flexible when deployed in isolated teams. The increased use of telemedicine translates into the remote deployed setting with innovative technology solutions helping to mitigate clinical risk. It is imperative to assimilate these lessons into doctrine to prevent a ‘Walker Dip’. Equally, the role of military trainees in rapidly changing civilian structures is intrinsic to military responsiveness and organisation.

• Surg Lt Cdr Stevenson’s PhD work has resolutely explored the effect of gunshot wounds. The effect of UK military clothing on GSW patterns within a cadaveric animal limb model was the latest thing examined. Two ammunition types found in recent conflicts, 7.62x39mm and 5.45x39mm were used in the study which used fallow deer hind limbs as a model. They were shot by either ammunition type, an additional variable being how much clothing was present. Limbs were analysed using contrast CT scanning to measure damage. Results showed greater damage within limbs with full military equivalent clothing as compared to light clothing or no clothing for both ammunition types. The effects included greater size in the entry wound and greater cavitation in the limbs. These findings suggest these wounds would likely necessitate more extensive surgical management. With growing numbers of civilian gunshot wounds the role of what the victim was wearing should be appreciated. n

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

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

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

Your generous donations are helping us to advance Trauma and Orthopaedic research. Thank you very much!

Remembering a charity in your Will is simple. For an easy step-by-step guide to everything you need to know about leaving a legacy to Joint Action, please visit https://www.boa.ac.uk/research/joint-actionthe-orthopaedic-research-appeal.html.

16 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk

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Join the British Trauma Society Benefits of Membership of the British Trauma Society ♦ Discounted rates for the British Trauma Society Annual Meeting. ♦ Vote on AGMs and EGMs. ♦ Eligibility to Apply for Grants. ♦ Eligibility to be voted onto the Executive Committee. ♦ Networking opportunities with luminaries from both UK and International Trauma fields. ♦ Discounted prices on Expert delivered Trauma Current Concepts courses and Workshops throughout the U.K. ♦ Monthly subscription to ‘Injury’ The International Journal of Care of the Injured.

BECOME A BTS MEMBER TODAY

www.bts-org.uk

News

Royal College of Surgeons of England – Building Update

C

onstruction work on the new building continued to plan during 2019 and early 2020.

On the 23rd January 2020 the ‘Topping Out’ Ceremony took place. This is a traditional builders’ rite to mark the last beam being placed on a finished structure.

As part of the response to the COVID-19 pandemic Wates, the main building contractor, paused their site activities for a brief period in the run up to 27th March 2020. This was to review and assess ways of keeping the site operational whilst working strictly in accordance with the Government guidelines.

The site re-opened on the 30th March and since then Wates have continued their construction activities with a reduced number of operatives.

Topping out plaque.

Building façade from Portugal Street.

Items reviewed in the run up to resuming work included implementing social distancing and putting additional site protocols in place.

The builder’s completion, originally scheduled for 30th November 2020, has been revised and is now expected in March 2021, with the College occupying in mid-May 2021.

The project team has been impressed with how Wates has handled the situation and continues to constantly assess the situation whilst working to reduce the impact on the project timeline. n New atrium roof with scaffolding removal commenced.

Pictures and words courtesy of Royal College of Surgeons of England.

Joint Action - The Orthopaedic Research Appeal of the BOA

G

eneral fundraising has been hit very hard by the COVID-19 pandemic.

Thousands of fundraising events have been cancelled and many charities, particularly smaller ones, are struggling to maintain services because of this huge reduction in income.

Musculoskeletal problems impact all sectors of society from children to the elderly; please support us in helping to make a difference through donating to Joint Action, www.boa.ac.uk/make-a-donation.

The London Marathon Team announced the cancellation of ‘The 40th Race’, the Virgin Money London Marathon 2020, as a mass-participation event on Thursday 6th August. However, the elite race is still taking place as scheduled on 4th October and a virtual race will take place on the same day for all other runners who were scheduled to run the marathon this year. We wish the best of luck to all the runners who are registered for the Virtual Virgin Money London Marathon to raise funds for Joint Action. Your efforts are most appreciated! Please donate and support our runners through JustGiving, www.justgiving.com/campaign/JAlondonmarathon2020 or Virgin Money Giving, www.virginmoneygiving.com/fund/JAlondonmarathon.

Save Your Place Today!

• British 10K London Run - Date to be confirmed 2021 • Prudential RideLondon 100 - Date to be confirmed 2021 • Virgin Money London Marathon - Sunday 3rd October 2021 If you would like to get involved and help to raise money orthopaedic research please visit the BOA website or email jointaction@boa.ac.uk to find out more and to register for a fundraising event. n

18 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk

In Memorium ––- Marjorie Durrance Neal The BOA are extremely thankful for the legacy to Joint Action from Mrs Neal.

Remembering a charity in your Will is simple. For an easy step-by-step guide to everything you need to know about leaving a legacy to Joint Action, please contact jointaction@boa.ac.uk.

HIP DEMO-STATION

• Replaceable dry bone acetabular cup left and right • Replaceable dry bone proximal femur left and right • Replaceable dry bone left and right hemi pelvis • Supine or Lateral decubitus orientation • Adjustable/Lockable muscle groups Patent pending

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

News

Conference listing: BORS (British Orthopaedic Research Society)

www.borsoc.org.uk 7-8 September 2020, Virtual

BOA (British Orthopaedic Association)

www.boa.ac.uk 15-25 September 2020, Virtual

BOFAS (British Orthopaedic Foot and Ankle Society) www.bofas.org.uk 17-19 March 2021, Torquay

WOC (World Orthopaedic Concern)

www.wocuk.org 5 June 2021, Chester

CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org June 2021, Brest

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org 30 June - 2 July 2021, Vienna

BIOS (British Indian Orthopaedic Society)

BESS (British Elbow and Shoulder Society)

www.britishindianorthopaedicsociety.org.uk 2-3 July 2021, Cardiff

BOOS (British Orthopaedic Oncology Society)

BOSTAA British Orthopaedic Sports Trauma & Arthroscopy Association

BSCOS (British Society for Children’s Orthopaedic Surgery)

BOA (British Orthopaedic Association)

BRITSPINE

BTS (British Trauma Society)

BHS (British Hip Society)

BSS (British Scoliosis Society)

www.bess.org.uk 14 October 2020, Virtual

www.boos.org.uk 13 November 2020, London

www.bscos.org.uk 1-2 February 2021, Manchester www.ukssb.com 17-19 February 2021, Glasgow

www.britishhipsociety.com 3-5 March 2021, Torquay

20 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk

www.bostaa.ac.uk 14 July 2021, London

www.boa.ac.uk 21-23 September 2021, Aberdeen www.bts-org.co.uk 24-25 November 2021, Oxford www.britishscoliosissoc.org.uk November 2021, Edinburgh

Features

Carousel President perspectives: leadership lessons learned at the time of a world pandemic Christopher D Harner

As we approach the end of the 2019-2020 academic year, I am at a loss to find words to express my feelings. It has been a great honour to serve as President of our organisation during this unprecedented time. By definition the COVID-19 pandemic involves the entire world and I thought it would be of great interest to share some of the challenges our leaders of English speaking orthopaedic associations have experienced. As organisations across the globe contend with the pandemic, we can take advantage of our participation in the Carousel group to share knowledge and experiences.

W

hat follows are insights on the effects of the global pandemic on Graduate Medical Education (GME)/ educational programming, surgical caseloads, clinical office practice, and professional meetings.

Christopher Harner is Professor in the Department of Orthopaedic Surgery, vice chair of Academic Affairs and director of the Sports Medicine Fellowship Program at McGovern Medical School at The University of Texas Health Science Center, Houston, USA. He is President of The American Orthopaedic Association.

Educational Programming The Impact on USA Resident and Fellow Education

• Virtual Learning

“We, as leaders, are creating new and innovative ways to train our residents/ fellows to be competent and compassionate orthopaedic surgeons.”

Like our fellow Carousel countries, the USA orthopaedic training programmes have been significantly disrupted and forever changed by the COVID-19 pandemic. The AOA is uniquely positioned to address the new challenges to our GME programmes through our CORD/Academics Committee (CAC).

Despite unprecedented alterations to our traditional CME pathways, we, as leaders,

22 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk

are creating new and innovative ways to train our residents/fellows to be competent and compassionate orthopaedic surgeons.

Some of these adaptations we anticipate will be solutions to temporary conditions, while others have post-pandemic implications:

It is here to stay. It has been well received by residents, fellows, and faculty. We learned early on that the traditional lecture styles (‘death by podium’) needed to change to allow more interaction with the learners.

It has been especially successful for case-based presentations, journal clubs, surgical demonstrations and small group research meetings.

• Surgical Simulation

Historically, orthopaedic surgical simulation has received mixed reviews from the faculty, residents, and fellows. Regardless of decreased surgical case volumes, however, one of our major goals should be improved technology, and more importantly, defining better ways to reliably assess our trainees’ surgical performance on simulators and cadavers.

Features

• Resident and Fellow Well-being As leaders, we are responsible for ensuring that residents and fellows feel safe, protected, and heard. Fortunately, we benefited from the welltimed virtual Spring CORD Conference. Hearing from programmes such as Columbia University (Bill Levine) in NYC (the USA’s pandemic ‘epicenter’), we gained from their experience including to ‘call your residents’. This resonated loudly with our programme directors.

• Collaborations with Surgical Subspecialty Societies The Subspecialty Societies have excellent educational programmes/lectures/symposia

that have not been easily accessible to trainees. The AOA, through CORD, is assisting with increasing awareness of these products to our programme directors and division chiefs for use in their teaching conferences.

• Visiting Students AOA’s CORD Programme, in collaboration with other key stakeholders, developed a consensus statement to address this complex issue. On 19th May, the AOA sponsored a webinar entitled ‘CORD Town Hall: Student Movement Best Practices’.

A recording is available for CORD Affiliates and registrants at www.aoassn.org.

Throughout history, our specialty has evolved during and following periods of intense upheaval, uncertainty, and challenges. The COVID-19 pandemic will prove likewise. Once it has resolved, exceptional reorganisations and approaches will result in beneficial changes for resident/fellow education (GME), continuing medical education (CME), surgical case handling, the adoption of telemedicine, and changes to traditional meeting formats.

Occurrences and Adaptations – By Don McBride, President, British Orthopaedic Association In February 2020, we were still organising our ‘normal’ day-to-day activity and preparing for our own meetings across the globe. What transpired since then has had no precedent, not even across the Great Wars.

One of the greatest impacts has been on education, training, and national selection. Within our hospitals, the registrar rotations have been put on hold, the morning trauma meetings and ward rounds have become virtual, elective clinics and operating have been cancelled, and our trainees have been redeployed. Consultants lead and provide the trauma and emergency service, with only occasional senior trainee involvement. Some Consultants have also been redeployed to provide assistance in Intensive Care Units, either permanent or temporary.

All educational courses have been postponed, replaced with virtual courses and webinars. The use of current technology has ensured that this will become an established method of education. The exit examination for our trainees (FRCSOrth/Tr) has been delayed until November 2020, but is more likely to restart in early 2021. The BOA, our Specialist Advisory Committee, and Health Education England have facilitated the continuation of new trainee national selection, with a virtual assessment based on well-established criteria developed from the most recently validated tools.

Finally, the BOA has remained in close communications with our trainees and their faculty through the British Orthopaedic Trainees Association (BOTA). All trainees and their faculty who are BOA members have been in contact via e-mail or virtual meetings on current and future educational issues effected by the pandemic. >>

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 23

Features

Surgical Caseloads The Australian Perspective – By Andrew Ellis, President, Australian Orthopaedic Association Australia has had a very fortunate experience relating to the COVID-19 pandemic compared with peer nations. All elective surgery was cancelled by the National Government across both private and public hospitals on 25th March. Trauma and injury surgery, the management of infection and oncology surgery, continued with little restriction. Naturally, appropriate operating room precautions were put in place, which did not alter treatment choices.

Surgical caseloads for trainees are measured in real time within the AOA (AUS) by a centralised reporting system and have fallen by ~30% in March. Further data analysis will allow us to assess effects as the situation develops, and the effect will near 40% in April. Australian trainees (residents/ fellows) usually have high numbers of surgical cases, and work on a competencybased system. With an expected catch up after return to planned surgery, the effect is expected to be compensated.

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Elective surgery began again on 27th April, but in a graded and safe sense. Hospitals were running at about 25% capacity. Then the national government allowed a further increase of 25%, bringing capacity to about 50%. AOA (AUS) provided guidance that cases should be prioritised on pain and disability, giving preference to low risk and high value cases. It is likely there will be continued relaxation regarding surgical lists, and trainees will still participate in surgical training as this occurs.

South Africa COVID-19 Experience – By Phillip Webster, President, South African Orthopaedic Association South Africa has experienced a unique path through the COVID-19 crisis. We entered the pandemic six weeks after the USA. With the aggressive lock down protocol enforced by the government, South Africa has, for now, achieved flattening of the curve with COVID-19 infections—in spite of the challenges of poverty, unemployment, and over-crowding.

We’ve had time to prepare our hospitals, acquire PPE, and build temporary (‘isolation facilities’) hospitals (Johannesburg 6,000

beds). This has resulted in a unique situation where our hospitals are nearly empty. Even the public hospitals are running occupancies of less than 30%.

We’ve seen a significant reduction in trauma cases due to a decrease in motor vehicle accidents and interpersonal trauma. In fact, South Africa is probably the only country in the world to have a decreased overall death rate during the COVID-19 pandemic.

As of this writing on 1st May, we keep waiting for the COVID-19 surge, but it has not yet happened. We expect an increased case load after lockdown, but apart from a few local controlled outbreaks, we still have fewer than 200 patients with active infection in the whole country and 103 deaths.

A phased easing of the lock down is slated for 1st May. Up until now, we have only operated on emergent and urgent cases. We are now starting to open up the hospitals for medically-necessary, timesensitive operations—with the requirement that the whole surgical team agrees to the procedure. We have had to develop new surgical and anaesthetic protocols for COVID-19 negative test and screen, patients under investigation (awaiting test result or suspicion on screening), and COVID-19 positive patients.

Features

Clinical Office Practice Canadian Clinical Office Practice Adaptations for Orthopaedic Consultants and Residents – By Mark Glazebrook, President, Canadian Orthopaedic Association Canadians are known to be friendly, patient, diverse, and tolerant. While COVID-19 has tested our resolve, we did not blink. During these unprecedented pandemic times, Canada’s medical officers—including Chief Medical Officer Dr. Theresa Tam—have led Canadians though an extended period of social isolation doing what they do best: Fall in Line and use their inborn skills to ‘flatten the curve’.

This behaviour was translated to most, if not all, orthopaedic surgeons across Canada. Clinical office practices evolved from standing room only waiting rooms for all types of patient assessments to socially distanced waiting rooms for patients requiring urgent or emergency care only. Institutions divided their orthopaedic consultants and residents into teams, insulated from each other avoiding concurrent exposure. These teams were deployed in a scheduled fashion to provide in-person care for urgent ongoing postoperative care needs and new emergency care only. In many institutions, resident teams were temporarily restricted from clinic and office practice to avoid exposure and allow continued high-quality emergency and surgical care.

Patients with non-urgent or emergency orthopaedic care needs were cared for in a novel pandemicfriendly way, with orthopaedic surgeons diving into the waters of virtual care. This essential telemedicine experiment satisfied most patients’ needs for ongoing care, and it is likely to evolve and to be part of future orthopaedic care patterns in Canada.

Virtual technology also has made an impact on education for residents across Canada. Residents ‘go to’ their own personal pandemic protected spaces to be educated by ‘Zoom’ sessions with consultants who have more time to teach, given reduced emergency care needs.

Office Orthopaedic Practice – By Peter Robertson, President, New Zealand Orthopaedic Association As the most remote and isolated island nation on the planet, New Zealand aims for elimination, rather than submission, of COVID-19. An extensive shut down of the country driven by Northern Hemisphere experience resulted in near elimination with low mortality, thereby as The Washington Post noted, ‘smashing the curve’. The result, however, has huge economic impact.

With overseas tourism a major income earner, a future with a COVID-19 naive population and extensive travel restrictions, will be questionable until a vaccine arrives.

electives, although clinics are still a little quiet, running at about 75% of normal flow.

Only two new cases in the country in the last five days so we have flattened the curve—but alas, also our economy!

Beyond emergency and some trauma follow up, face-to-face consultation ceased.

Virtual consultation and deferment replaced clinic work. Understanding unnecessary duplication and over-servicing will improve efficiency in the future. Office based training for registrars reduced dramatically, offset by markedly increased consultant availability and enthusiasm for teaching.

“As the most remote and isolated island nation on the planet, New Zealand aims for elimination, rather than submission, of COVID-19. An extensive shut down of the country driven by Northern Hemisphere experience resulted in near elimination with low mortality, thereby as The Washington Post noted, ‘smashing the curve’.”

Our hospitals have avoided the full crisis: we closed almost all elective orthopaedic surgery and consulting over five weeks. This extends already long waits in our public sector, and similarly delays private practice where the majority of elective surgery occurs. As of mid-May, we are out of lock down now—back to playing golf at last!

Surgery is pretty much back to normal with

The NZOA leadership deferred major examinations, CME, Specialty Society meetings, training weekends, trainee selection, and conferences for a 12-month period— essentially putting activity into hibernation. Direction to our membership has been prompt and decisive, driven

by Government Guidelines.

What have we learned?

That alert, responsive, evidence-based changes well-articulated to the orthopaedic community are more important than ever. We also learned not to be limited by viewpoints articulated only a few days ago, as the world changes faster than we could have ever imagined! n

2019-2020 Carousel Presidents of English speaking orthopaedic associations and partners.

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Evolution of UK and Ireland In-Training Examination (UKITE) Ajay Malviya

As we enter into the 14th year of UKITE, it is perhaps time to reflect and acknowledge how the perseverance of the editorial team and all the contributors has helped shape UKITE into its present format. I am sure the current generation of trainees would be interested to know how it has evolved over time and in fact it seems surreal and certainly a matter of pride that we are at a stage when I am able to appraise everyone of the journey.

U Ajay Malviya is Consultant Orthopaedic Surgeon and Academic and Quality lead for T&O Northumbria Healthcare.

He is Senior Lecturer for Translational and Clinical Research at Newcastle University, Chair for the UK Non Arthroplasty Hip Registry and UKITE National Lead for the BOA. He is Deputy Editor of the Journal of Hip Preservation Surgery.

KITE was the brainchild of Mike Reed, my esteemed colleague at Northumbria Healthcare and Ashwin Kulkarni, who at that time was a trainee at Northern Deanery, and is now based at Leicester. If ever there was an appropriate use of the phrase ‘burning the midnight candle’, it would certainly be true for this endeavour. We’ve had a change of the team over time but most of the senior editors would recognise the long hours we spent, late into the night, discussing and debating the questions that should be selected and constantly striving for quality. My special thanks goes to Rob Clayton, Gavin Henderson, Ashish Khurana and Rajesh Kakwani who have moved on and would certainly relate to this. I am grateful to the team that have decided to stay and continue to contribute.

In terms of the question bank for a long time we relied on the trainees submitting questions but with the cushion provided by having a large question bank (almost 14,000 MCQ and EMQs), we now have editors who write questions under the supervision of specialty editors. The focus is on delivery of an examination that stimulates higher order thinking and requires more cognitive processing than factual recall, which on reflection perhaps the initial exams could be accused of. Over the last few years feedback has suggested that the quality of questions has improved.

It is currently delivered and administered by the BOA but has evolved from a regional examination developed in the Northern Deanery in 2006. It was introduced nationally

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in 2007 and has since been a part of the annual diary of all the Orthopaedic Training Programmes. The examination is now available internationally and continues to be delivered online annually every December for UK and Ireland trainees and SAS surgeons.

We’ve had some issues with exam delivery in the past, but May Elphinstone from the BOA office has ensured one of the smoothest run examinations in 2019. Over the last three years approximately 150 South Africa trainees have also been sitting annually.

UKITE is intended as a ‘self-assessment’ tool, a practice for those approaching FRCS section 1 and as a vehicle to assist with learning. Aspects of the UKITE mirror as closely as possible the FRCS section 1 exam with the inclusion of both single best answer or multiple choice questions (MCQs) and extended matching questions/ items (EMQ/Is) and the exam content is broadly aimed to cover the curriculum with a similar level of difficulty. The UKITE is not intended to be an exact replication and there are key areas of difference, in particular in how the exams are delivered. No standard setting is applied as there is no pass/fail in UKITE. Each annual UKITE is created through the contributions of the Clinical Lead and Editorial team (www.boa.ac.uk/ukite-editors). New questions authored by UKITE Editors are reviewed and edited by the Specialty Lead Editors and if suitable are recommended for inclusion in the exam. Review processes aim to ensure not only accuracy of the questions but that the question is a suitable level of difficulty. The editorial team are crucial to the process of creating an exam with sub specialty

Features

area coverage and containing questions that are not purely testing recall of factual knowledge, but clinical judgement and application of knowledge.

Whilst the exam has evolved over the years, its development continues. A UKITE Working Group was set up to consider aspects of quality assurance.

The group comprised of myself as the UKITE Clinical Lead, Deborah Eastwood, Hiro Tanaka and Lisa Hadfield-Law. The focus of the group has been to build on the existing good practices and look for ways to ‘evidence’ and assure what was already believed to be the case (that the UKITE is a good quality assessment).

Through this work the group spent some time reconfirming the purpose of UKITE to ensure processes in place support the intention. Considerations of which aspects of UKITE could or should be aligned with the FRCS T&O were important.

Consensus being that to meet the intended aims, an exact replication of the FRCS T&O is unnecessary but that similarity is beneficial in regard to curriculum representation, question styles, and level of difficulty.

where relevant. Following guidance from a psychometrician, measures to analyse and monitor the validity and reliability of the examination were implemented in 2019 for the first time. Based on analysis of the results of the 790 UK and Ireland participants for UKITE 2019, calculating a KR20 score demonstrated a high level of examination reliability (KR20 score of 0.928). Analysis of item discrimination as a point biserial correlation showed a positive correlation of 0.2 or higher in the majority of questions which had been the intended and expected outcome. The mean score for 2019 was 54.2% with a standard error of measurement of 5.83. These results have been reassuring and analysis will continue to be used to inform practices for question development and exam composition.

“UKITE is intended as a ‘self-assessment’ tool, a practice for those approaching FRCS section 1 and as a vehicle to assist with learning.”

Whilst not a ‘high stakes’ examination, in order to ensure a quality assessment, best practice approaches should be followed

Feedback from those who took the UKITE in 2019 was gathered in a different way with just open questions posed. The intention has been to capture more in depth thoughts on the UKITE as a tool or process. Based on analysis of the responses, these were categorised into themes with 95% of respondents giving a positive response to the question of ‘what

value the UKITE process had been to them’.

Broadly these themes were: as a preparation for FRCS (46%); as a self-assessment or benchmarking tool (17%); to identify gaps in learning (14%); and as a tool for learning (9%). 5% of the respondents suggested they felt there to be little or no value to the UKITE process. When asked to suggest ways for increasing the value of the UKITE process, the most common theme was a request to provide additional material in the form of either further practice questions or previous UKITE question sets freely available (11% of respondents). 32% of respondents indicated they had no suggested improvements. In response to requests for additional UKITE material outside of the annual examination, work is underway to review existing questions for suitability in order to have a selection of questions available online.

As part of the on-going work to support UKITE the quality assurance measures will be continued. Learning from the data analysis will help refine the question authoring process and improve guidance to authors. If you have any suggestions for improvement the UKITE team is always interested and available.

There will always be a need to recruit new editors to join the team. For those unfamiliar with question authoring or multiple choice examinations this is an opportunity to learn and a ‘stepping stone’ for those interested in this area. For those interested in joining the UKITE editorial team or have any feedback please contact ukite@boa.ac.uk. n

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Reflections of a Training Programme Director Donald Campbell

Being a surgeon is difficult. The public expects it to be. Occasionally, this fact can come as a surprise to one or two trainees who throughout their young lives have never failed at anything. There is no shortcut to learn the broad range of competencies that permits the privilege to alter peoples’ bodies, when they are at their most vulnerable.

T Donald Campbell is Consultant Orthopaedic Surgeon at Ninewells Hospital and Medical School, Dundee. He is also Training Programme Director Forum Chair and SAC Liaison Member for JCST.

here are increasing demands on the trainee. Within a busy day in the NHS there seems little time to record training episodes and get feedback from trainers. The ePortfolio, to date, is the best way to record our surgical competence. Love it or hate it, it is here to stay.

It is hoped the new multiple consultant reports starting next year will give a more complete picture of the trainee. Having an accountable record of trainee competence to treat the public is mandatory.

Trainees who hope they will be relieved of the ‘burden’ of keeping a contemporaneous portfolio when they finally become a consultant will be sorely disappointed.

The GMC understands the importance of training. Its survey on teaching and training are still a useful way to listen to the beating heart of a healthy functioning unit - or one that is failing…

“Within our discipline are many roles, and the time to do them in seems to be shrinking.

Most of us feel pulled in many different directions at the same time. It can be hard to dedicate the time needed to all the different responsibilities placed on the surgeon in the modern day.”

Within our discipline are many roles, and the time to do them in seems to be shrinking. Most of us feel pulled in many different directions at the same time. It can be hard to dedicate the time needed to all the different responsibilities placed on the surgeon in the modern day.

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Sadly, our role as teacher and trainer today is becoming the most challenged. However, I believe it is also the most important, interesting and rewarding. We must fight to keep its primacy each and every day in our busy clinical practice.

The importance of training was recognised by the ‘old masters’ throughout the history of surgery. They knew that a single surgeon would only make a tiny difference to the massive burden of disease in society. In those times they remembered that the word ‘Doctor’ comes from the Latin ‘docere’ – ‘to teach’.

It is easy to think our role in the operating theatre is the most important thing we do, and of course this is what distinguishes our role from other doctors. But a single surgeon in his or her lifetime is a tiny ship passing through a great ocean, here today and gone the next. We need to train an ever-producing Armada to fight the burden of disease and push back the frontiers of what we know.

If you are reading this, the chances are that you too feel that T&O is a fascinating and

Features

rewarding career that will keep us all challenged and interested until the day we retire. The saying “The person that finds the job they love…never has to work again” certainly rings true with me. But what does the future hold..?

The numbers of UK female T&O consultants is just 5%. This is the lowest of all the surgical specialties. Female medical students are the majority in every medical school. So where are the T&O surgeons of tomorrow? If we do not reverse this embarrassing fact now and show there is a place for women in T&O surgery there will be unfilled posts at recruitment. Numbers are already perilously close to the appointable cut off in ST3

application. We need to work with medical student societies and schools to encourage women that T&O is for them.

We all have a role at work to publicly stamp out comments like ‘women can’t do revision hip surgery and polytrauma’. What nonsense. This negative stereotyping needs to be called out by all of us, but in particular by the leaders and most senior people in our ranks. I would argue that the prefix ‘Doctor (teacher)’ is much more apposite of what we are trying to achieve as surgeons than the confusing Mr/Miss/Mrs/Ms. This would definitely be more inclusive and a step forward for women considering a career in surgery.

I firmly believe that in diversity lies our greatest strength. We have to make these changes if we want the best in our specialty. It is heartening to see the BOA taking a lead on this with its diversity and inclusion strategy.

I have spent the last six years as T&O training programme director in the East of Scotland.

It has been my privilege to put something back in the specialty that has been so rewarding to me. It is important too, that trainees don’t forget what an enormous privilege it is to be in their position.

So what responsibilities do they have? They must put something back into training too.

They have to enthusiastically support their training programme by contributing to (not just attending) postgraduate teaching. They need to teach other trainees, AHPs, students - and their bosses something too!

The senior trainee must always remember to show the patience and kindness to a junior, that they were once shown when they first held a knife in their trembling hands…and become ‘Doctors’.

The aim at the end of training is to be a respected autonomous clinician delivering quality care for your patients. Ex BOA President David Jones told me, not long before I started my consultant post, “If you are good - the work will come”. Also, as it turns out, if you are good trainer, the trainees will come, but only if supported and facilitated by a good TPD. There is occasionally pressure by a few consultants on a TPD to allocate ‘my registrar’. For some having a trainee is a status symbol, not the privilege it really is, and the loss of ‘my registrar’ can be received with some disappointment. At the beginning of my tenure as TPD I was frustrated by the lack of feedback on our ability as trainers. Along with two trainees (Sarah Gill and Amar Malhas) the trainer feedback model1 was created. The famous quote “In god we trust… all others must bring data” was as true as ever. Anonymous data after three years collection of trainees’ feedback on our trainers gave me the confidence to match the trainees to the best trainers.

To my surprise, the feedback, although not always positive, was well received by the majority of trainers. An unexpected benefit of the feedback form was each trainer received individualised data on their training role. This gave useful information for trainers to reflect on and evidence to support recognition of trainer status. It also shifted the focus towards quality and competitive surgeons always like to be better than the next trainer…

One of the biggest issues of working in an under resourced NHS is the daily pressures we face, a major factor in workplace stress, >>

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aggressive behaviour and burn out. We must never forget that how we behave towards each other is the single most important factor in how competent teams perform. I would recommend reading more on how incivility in work can have a disastrous effect on us, teams and our patients at www. civilitysaveslives.com.

I think however we must go further than mere civility – by being kind.

Kindness towards each other is vital for the survival of the NHS but also for us to survive within the NHS. We need to fight a war on disease and suffering and not with each other. This does not mean that the responsibility to show kindness falls only to doctors, but we do need to lead by example.

become a force for good…the car that let you out on the busy road on the way to work, so you let the next one out. It simply makes people feel better. Kindness makes people work harder as part of a valued team and just like incivility, can be contagious.

“Be kind. Take time to know people, take an interest in their lives.

It will pay dividends.

Although weekends and evenings are precious personal time, ‘getting out’ together for social events can be vital in cementing team bonds.”

So, how do you smile on a cold dark rainy morning, dog tired when every muscle in your body aches as you step across the hospital threshold met by a barrage of requests…? You try. You fail some times. You try again and you ‘fake it till you make it.’ Kindness can

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A nurse at work once asked me how I was one morning. Rather than grunting my usual “OK thanks”, I tried smiling saying “fine thanks…BUT... how are YOU?”. Once I got over the shocked look on her face that a consultant had actually taken interest in her welfare, I also learnt it made my life better and work easier too.

It was a revelation.

Life can be hard, and everyone is walking the hardest road they will ever know.

Some may be experiencing much harder personal tragedies than you could possibly imagine, that you probably are oblivious to. Be kind. Take time to know people, take an interest in their lives. It will pay

dividends. Although weekends and evenings are precious personal time, ‘getting out’ together for social events can be vital in cementing team bonds.

This all may be obvious to you.

Embarrassingly, I must admit, it took me far too long to realise the best way to oil the wheels of the NHS, is to take a personal interest in the lives of all the staff around you. It’s hard to overstate how much taking that little bit of extra time with staff can make to help build a happy team. Try it.

Or at least ‘fake it till you make it’.

The 85/15 rule of Edward Demings says that 85% of problems in the workplace are with the system, 15% with the workforce.

Give the workforce a chance to work with pride, and the minority that apparently don’t care will erode itself by peer pressure.

He also said, “If you destroy the people of a company, you do not have much left”.

Be kind. Build happy teams. Focus on quality. Restore pride. Teach. n

References 1. Gill SL, Campbell DM. Promoting quality training and improving morale through a trainer-trainee dialogue and partnership.

Journal of Trauma and Orthopaedics.

2018;6(1):76-7.

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A networking event can reduce negative perceptions that deter female medical graduates from pursuing orthopaedic surgery Anh T V Nguyen, May Al-Shawk, Scarlett McNally and Caroline B Hing

Women have consistently made up half of medical school entrants in the United Kingdom (UK) for 25 years1. However, this rising trend is not reflected in the orthopaedic workforce2. As the future success of orthopaedics relies on attracting the best and brightest trainees into the field, it is a concern that the specialty fails to recruit from the talent pool of female medical graduates.

Anh Nguyen is an Orthopaedic Registrar and a Black, Asian, Minority and Ethnic (BAME) recruitment panel representative at St George’s University Hospitals NHS Foundation Trust.

She is a Clinical Teaching Fellow and Post graduate student representative for the St George’s University of London.

T

he under-representation of women in orthopaedic surgery can be partly attributed to female graduates having a lower tendency to pursue orthopaedics as a career compared to their male counterparts3. Various negative perceptions of orthopaedic surgery have been reported by women as deterrents from aspiring to orthopaedics in the last decade4. This study aims to explore whether these negative perceptions still exist amongst our medical students and junior doctors in the UK today and if so, whether a networking event hosted by senior women orthopaedic surgeons could change these perceptions.

Methods

May Al-Shawk is a final year medical student at St George’s University of London. She is the former President of the St George’s Student Athena SWAN Society and a Jean Shanks Foundation Intercalated Grant Recipient.

Junior doctors and medical students were invited to attend a women orthopaedic surgery networking event held at St George’s University of London on the 25th November 2019. Details regarding the event were published in JTO Volume 8 Issue 1. Attendees were invited to take a voluntary, confidential online survey before and after the event. The surveys (see Appendix 1) included questions related to demographic information and perceived barriers to women thriving in orthopaedic surgery. Data was anonymised and kept on a secure password

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protected drive. Data analysis was performed using descriptive methods via Microsoft ® Excel (version 16.16.17).

Results 50 pre-event and 42 post-event surveys were available for analysis (Table 1). After the event, there was a substantial reduction in the number of participants reporting five common negative perceptions related to women in orthopaedics, including sexism and the ‘old boys club’ culture, lack of work-life balance, absence of women role models and women lacking physical strength to do orthopaedic work (Table 2). Table 2 demonstrated a substantial reduction in participants’ perception of the negative stereotype, by around three-quarters across all key statements. In addition, participants listed the following factors as most encouraging to motivate them to pursue orthopaedic surgery: the possibility of balancing work with family life (66%), increased visibility of women role models (56%), availability of women focused leadership opportunities (46%) and a cultural shift away from gender bias and discrimination (36%). Most participants reported that the event had provided helpful suggestions to break down personal barriers to pursuing orthopaedics (93% of participants) and encouragement towards pursuing orthopaedics as a career (95%).

Features

Discussion This study suggests that several negative perceptions related to women in orthopaedic surgery still exist amongst medical students and junior doctors in the UK today. The results are discussed in the following themes, in conjunction with relevant interventions carried out at our ‘Future women of orthopaedics’ event.

Scarlett McNally is a Consultant Orthopaedic surgeon at East Sussex Healthcare NHS Trust. She is an elected Council member of the Royal College of Surgeons of England and collated resources at www.rcseng.ac.uk/study. She is Deputy Director of the Centre for Peri-Operative Care.

Caroline Hing is an Orthopaedic Surgeon and Honorary Reader at St George’s University Hospitals NHS Foundation Trust. She is a member of the BOA Equality and Diversity working group and BOA Education and Careers Committee.

Stereotype

Total

50

Female : Male

39 : 11

Age 20 to 25 years

29 (58%)

25 to 30 years

15 (30%)

30 to 35 years

6 (12%)

Grade Medical student

24 (48%)

A common perception is that women do not fit the stereotype of orthopaedic surgeons and are not physically strong enough to perform orthopaedic work, reported by 54% and 28% of participants respectively. Several participants stated that they felt ‘not belonging in Trauma and Orthopaedics’ and pressured to ‘compensate in order to fit in’. These statements have been reported in other studies in the UK4, 5. The stereotype of an orthopaedic surgeon is a heavy built macho male, ‘strong as an ox’ as depicted in a study restricted to men published in the British Medical Journal in 20116. This stereotype can create a lack of occupational identity amongst women in orthopaedics, leading to mal-adaptive coping mechanisms such as ‘exclusion’ (feeling that one does not belong in their chosen field) and ‘adaptation’ (attempt to downplay their feminine characteristics in order to avoid exclusion)7. Not only women are affected, such stereotype also deters men from entering the specialty as some feel that they are not ‘man’ enough8. To female medical students and junior doctors aspiring to an orthopaedic career, the experience of such stereotype can make them feel uncertain about their future success and self-select out of the training pathway9. Our women orthopaedics event reduced the above negative perceptions amongst the participating students and junior doctors (Table 2).

Foundation year doctor

13 (26%)

Core trainee/ SHO

11 (22%)

Registrar

2 (4%)

Responses

Before event

After event

Ultimately the task of challenging the masculine stereotype in orthopaedics and forming an inclusive group identity is a responsibility of the leading members of the specialty. Peters and colleagues, who studied women in surgery in the UK5, reported that a critical determinant of a team’s drive to succeed is having a sense of fit and similarity with the leader, as team members’ motivation is “not only malleable but also acutely sensitive to the image of the group that the leader establishes and represents”.

Number of responses

50

42

The surgical culture of orthopaedics is that of an "old boys club" and women do not fit into that culture well

27 (54%)

5 (12%)

Sexist and discriminatory attitude observed in orthopaedics can make life of a woman in this field very hard at times

18 (36%)

6 (14%)

Generally speaking, women are not as physically strong as men. Yet orthopaedics is a physically demanding specialty

14 (28%)

2 (5%)

Orthopaedic surgeons' lifestyle and training does not accommodate a family life very well

21 (42%)

5 (12%)

There are not enough women in orthopaedics currently so it can feel lonely, isolated and quite hard being a woman in this specialty

24 (48%)

4 (10%)

Lack of visibility of female role models The negative impact of the masculine stereotype in orthopaedics is further perpetuated by the scarcity of female role models, as perceived by 46% of our participants. Again, this finding is similar to previous studies in the UK4,10,11.

As women are more likely than men to cite the importance of having a role model of the same gender in influencing their career choice, visibility of women orthopaedic surgeons has been shown to increase the number of female orthopaedic surgery applicants12,13. After our event, a large reduction from 46% to 10% >>

Highschool type State

31 (62%)

Private

11 (22%)

Not reported

8 (16%)

Parental occupation Doctors

9 (18%)

Professional

24 (48%)

Labourer and traders

10 (20%)

Business

2 (4%)

Services workers

2 (4%)

Not working

1 (2%)

Aspired career Orthopaedics only

21 (42%)

Orthopaedics or others

27 (54%)

Not yet decided

2 (4%)

Table 1: Demographic data of participants.

Table 2: Perception of barriers to women pursuing orthopaedic surgery.

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was noted amongst the percentage of our participants who perceived orthopaedics as an isolating career for women. A figure of 30% of the workforce being female has been proposed as the critical mass for feminine traits to no longer be considered atypical in a scientific field, to mitigate homogenous group think and result in gender inclusive organisational changes14. As of July 2019, 6.7% of orthopaedic surgeons in the UK are women2, this number needs to be increased five-fold to reach the above gender balanced ‘critical mass’.

Unconscious bias and gender-based discrimination To result in sustainable and significant changes, diversity must be coupled with inclusion, meaning valuing all workers including those from hitherto minority groups15. 35% of our pre-event survey responses reported a perception that genderbased discrimination against women was

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prevalent in orthopaedics. This perception is consistent with results from a 2019 survey in the UK16. Gender bias and discrimination can lower job satisfaction, damage collegial relationships and lead to burn out and drop out amongst female surgeons5,7. For junior doctors and medical students, gender based discrimination can portray a hostile work environment that discourages them from pursuing an orthopaedic career4. At our St George’s event, participants learned various strategies to tackle these behaviours, resulting in a positive change in their perception of the sexism in the current orthopaedic culture (Table 2). Anti-bullying initiatives in the UK health services may need to focus more on targeting sexism and gender based unconscious bias.

Work-life balance Lastly, 42% of our participants reported their perception that the orthopaedic work and training is not compatible with family life. At our St George’s event, participants are reassured that worklife balance tends to improve after training, with consultants having more flexibility in their schedule than trainees.

This is consistent with findings from a study in the US reporting that orthopaedic surgeons have higher satisfaction with overall work-life balance than their trainees17. Even

during training, changes in work conditions as a result of the European Working Time Directive and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report have reduced the amount of unsociable work hours for surgeons18,19.

After our event, the perception that orthopaedic surgery is not compatible with a family life dropped to 12%.

In the long-term, the issue of balancing work and family life reflects the challenges faced by women in all sectors of society5. Despite increasing participation in the workforce in the last few decades, many women still carry the majority of child bearing and home management responsibilities, leaving them with less time and energy for work than men20. Policy changes to enable men to increase their involvement in childcare and family life will be necessary before a true work-life balance can be achieved for women, including orthopaedic surgeons.

Conclusion Our study demonstrated that current negative perceptions that deter female doctors from pursuing orthopaedic surgery could be reduced substantially by a networking event led by senior women orthopaedic surgeons.

Established surgeons should realise their impact in offering respect, current information and opportunities to individual future surgeons. n

Appendices and References Appendix 1 and References can be found online at www.boa.ac.uk/publications/JTO.

Features

Commentary on: Inequality, discrimination and regulatory failure in surgical training during pregnancy Sara Dorman

Full article was published in the TJTO&C 1st September 2020 and can be viewed at: https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journal-of-traumaorthopaedics-and-coronavirus/inequality-discrimination-and-regulatory-failure.html.

I Sara Dorman is an ST7 trainee on the Mersey rotation. Sara has previously been the honorary secretary for BOTA. Her interests include paediatric orthopaedics, sustainable healthcare and work in low income countries.

n recent years there has been an increasing number of publications reporting the difficulties experienced by women working in surgical specialities. The World Health Organisation recent gender equality analysis report, ‘Delivered by women, led by men’ highlights that although women account for 70% of the health and social care workforce worldwide, female healthcare workers face barriers at work not experienced by their male colleagues. This can impact well-being, prevent further progress on gender equality and negatively impact healthcare systems and the delivery of quality care1.

In the UK, female surgical trainees commonly report dissatisfaction with lack of support and available guidance during pregnancy and maternity leave. Trauma and orthopaedics presents a unique risk profile to pregnant trainees with many potential hazards to both mother and child, including ionising radiation and exposure to teratogenic chemicals in bone cement and some scrub solutions. Some professional bodies have made steps towards improving guidance, however the information is difficult to access, fragmented and not specific to T&O. Moreover, there is a lack of awareness and signposting amongst trainees and trainers of the resources that are currently available.

Anecdotally, guidance and risk assessment currently available for pregnant trainees is perceived as a ‘tick box’ exercise rather than providing useful, practical or safe advice.

Editors note: This article raises a number of interesting issues and the importance of clear and comprehensive guidance for trainers and trainees alike. The BOA are working on developing T&O specific guidance to address this and hope to have it available later this year.

A recent UK wide study published in the TJTO&C uncovered evidence of inequality, discrimination and regulatory failure in pregnancy Trauma and Orthopaedic trainees. The majority of highlighted issues stemmed from overarching themes of inflexible training infrastructure, lack of communication and clear guidance on what is reasonably expected from the employer, trainer and trainee during pregnancy.

There is currently wide variation in management of pregnant T&O trainees with many women reporting negative experiences during pregnancy and when returning to work after a period of maternity leave. Occupational risk assessment is a statutory responsibility of every employer, which is not currently adequate. The majority of women

reported either no risk assessment, or an assessment completed by an inappropriate staff member.

Anxiety was reported from both trainees and trainers regarding risks of operating whilst pregnant and how to support a returning trainee after maternity leave.

A lack of clear practical guidance combined with an inability of trainers who have never experienced pregnancy or maternity leave to understand the impact of this on one’s training often lead to wellintentioned but ineffectual support.

There are issues to be addressed with regards to practical aspects of job planning, workplace bias, effective loss of training time towards CCT, lack of engagement with KIT days and lack of awareness of guidance from key trainers. In response to these findings the JCST have released updated guidance, ‘Pregnancy - A guide for surgical trainees and trainers’, to provide current and consistent ‘user friendly’ recommendations.

Pregnant T&O trainees are no longer a rare occurrence and it is important to consider the changing trends in the workforce population. In the UK, 55% of current medical students and 59% of doctors in training are female. Whilst surgical specialties have traditionally been a male dominated field, the number of female trainees continues to rise and currently one in three surgical trainees are female2.

It is therefore likely that managing pregnant surgical trainees will become increasingly commonplace in the future. Should surgical specialties wish to continue attract highly-skilled, competitive female trainees, these issues need to be addressed. n

References 1. World Health Organisation (2019). Delivered by Women, Led by Men: A Gender and Equity Analysis of the Global Health and Social Workforce. Human Resources for Health Observer [Internet cited 2020 Feb 10]. Available at: https://www.who.int/hrh/ resources/health-observer24/en/.

2. General Medical Council (2017). Our data on medical students and doctors in training in the UK [Internet cited 2020 Feb 10]. Available at: https://www.gmcuk.org/static/documents/content/SoMEP_2017_ chapter_2.pdf .

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 35

Features

100 years of BOA nerve repair Matthew Wilcox, Ian Stephen, Deborah Eastwood and Tom Quick

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Matthew Wilcox is integrating a PhD at the UCL Centre for Nerve Engineering and Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital with his UCL MBBS degree. His collaborative research is focused on advancing outcome measures following peripheral nerve repair.

Ian Stephen is a Consultant Orthopaedic Surgeon in East Kent since 1983, eventually specialising in Foot and Ankle Surgery, and retired from practice in 2007. Past President of the British Orthopaedic Foot and Ankle Society, and of the Orthopaedic Section of the Royal Society of Medicine. Presently Honorary Treasurer of both the History of Medicine Society and the Retired Fellows Society at the Royal Society of Medicine, and Honorary Archivist for the British Orthopaedic Association.

he British Orthopaedic Association (BOA) was founded in 1918 as the world was coming to terms with the end of the first global conflict and the interlinked devastation of the influenza pandemic. In the decades leading up to the foundation of the BOA, there had been a tide of basic science and isolated clinical reports which had started to challenge the accepted wisdom that nerve injury was not amenable to surgical repair1-3.

World War I (WWI) created an environment which hastened and focused the dissemination of this conceptual shift. In 1918 a large cohort of injured servicemen requiring rehabilitation started to return home, as did a significant number of clinicians with knowledge of acute nerve injury treatment acquired in the theatre of battle. The lessons learnt by these clinicians are perhaps best demonstrated by the volume of clinical papers published relating to nerve injury, many of which remain central to clinical practice today4-8. Jules Tinel (1879-1952) famously described the Tinel sign in 1915 where it is possible to elicit a paraesthesia by tapping on a recently injured nerve9. Some of the first experiments that investigated the effectiveness of sciatic nerve grafts also took place during this era10,11.

The significant patient demand and resultant specialist clinical interest presented a critical mass that necessitated the development of a network of specialised military orthopaedic hospitals12.

This served as a stimulus for surgical enquiry and exploration by general surgeons, representing the first steps towards

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the establishment of peripheral nerve surgery as a speciality in its own right. This period of transition was largely led by the founder of BOA, Sir Robert Jones (Figure 1) widely regarded as one of the earliest pioneers of peripheral nerve surgery at a time when the specialty of orthopaedics was coming to recognise its own individuality12. The fascination with nerve injuries is seen in published statements from the then leaders of clinical opinion: “The re-growth of a severed nerve is a romance.

It is, perhaps the most beautiful example of Nature’s power of repair….”13.

Figure 1: Sir Robert Jones. 1857-1933.

Features

Deborah Eastwood is UCL Professor of Paediatric Orthopaedic Surgery at Great Ormond Street and the Royal National Orthopaedic Hospitals. Deborah is a former council member of BSCOS (British Society for Children’s Orthopaedic Surgery) and current Board Member for EPOS (European Paediatric Orthopaedic Society).

Figure 2: Sir Reginald Watson-Jones, BOA President 1952-53.

Tom Quick is a Consultant Surgeon in the peripheral nerve injury unit at the Royal National Orthopaedic Hospital where he treats adults’ and childrens’ nerve injuries. He is a clinical academic and honorary associate Professor in the Institute for Orthopaedics and Musculoskeletal science and also lead for peripheral nerve at the UCL Centre for Nerve Engineering.

The teachings of Jones are best portrayed in his book entitled ‘Orthopaedic Surgery of Injuries’ published in 1921, the second edition of which included six chapters dedicated to addressing the diagnosis and treatment of nerve injuries14.

This literature encouraged the input of multiple medical specialties on an ‘as needed’ basis, recognising nerve injuries as a complex and heterogeneous pathology14. Jones would go on to mentor many young surgeons who went on to be at the forefront of orthopaedics such as 1936-1937 BOA President Walter Rowley Bristow (1882-1947).

Between 1916 and 1918, Bristow worked under the supervision of Jones as an assistant inspector of military orthopaedics whilst also leading the electro-therapeutic department at the Military Orthopaedic Centre in Shepherds Bush, London15.

Under the guidance and mentorship of Jones, Bristow fostered an interest and extensive expertise in the treatment of nerve injuries.

It was these experiences which culminated in Bristow’s appointment as a Committee member of the Peripheral Nerve Injuries council founded by the Medical Research Council15.

This introduced him to other notable clinicians such as neurologist Henry Head and pioneering neurosurgeon Wilfred Trotter15. The breadth and depth of expertise that grew from these relationships allowed Bristow to develop some of the most effective rehabilitation programmes for nerve injured patients which advocated the

collaboration of physiotherapists, neurosurgeons and orthopaedic surgeons in order to maximise functional recovery15. These programmes were vital in encouraging the wider adoption of this approach which was largely overseen by 1952 BOA President Reginald Watson-Jones (1902-1972).

As a consultant orthopaedist to the Royal Air Force, Watson-Jones (Figure 2) was credited with the plan to set up a network of 10 multidisciplinary units across the country with a specific focus on functional rehabilitation16. It was an approach that demonstrated considerable success; 77% of personnel returned to full combat duty and only 4.8% were invalided or discharged out of the services15. It was this work that was largely responsible for his appointment as a Knight Bachelor in 1945 and these triumphs that empowered Watson-Jones to co-ordinate the purchasing of Headley Court and the establishment of the Defence Military Rehabilitation Centre (DMRC). The DMRC continues to drive academic publication in nerve injury outcome from conflict injury to this day.

The unification and coalition of multiple specialities incited by Jones, Bristow and WatsonJones has been an approach that has become intrinsic to the management of PNI patients.

Today, patients benefit from cross-disciplinary collaborations between orthopaedic surgeons, neurologists, neurophysiologists, physiotherapists, neurosurgeons and plastic surgeons. >>

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Features

Clinical research by Birch began to focus civilian care onto optimising the timing of surgical nerve repair in order to optimise functional outcomes. Contrary to the historical paradigm of early surgical repair of all injured nerves, clinical experiences and biological studies documented by Birch and colleagues present arguments for early or delayed nerve repair dependent on the type of injury encountered. This work culminated in the publication of the ‘Blue Book’ in 2011, a BOA guide for the management of nerve injuries. This publication led to the condensed BOAST5 published in 2012, representing a tripartite agreement from the British Association of Plastic and Reconstructive Surgeons, BOA and the British Society for Surgery of the Hand.

Evolution in the weapons of war used in recent conflicts such as in Afghanistan and the Falklands afforded new challenges within the military arena of trauma and orthopaedic surgery. Similarly, increases in terrorist attacks and knife crime lead to changes in injury patterns in civilians and improvements in road safety have changed the characteristics of the closed traction injuries of the brachial plexus. This evolving environment provides novel challenges and acts as a stimulus for the continued study and understanding of peripheral nerve injuries.

The history of peripheral nerve repair has shown that these challenges are best met by a combined approach of clinicians and scientists partnered with patients.

The speciality has now moved from the proof of concept phase into a time of great advances. Tissue, cellular and genetic engineering are likely to represent key strategies in order to improve peripheral nerve repair. There are also many advances in neurophysiology and imaging techniques which will facilitate the development of new outcome measures of nerve regeneration and the clinical translation of new therapeutics for nerve injury.

Figure 3: Sir Herbert Seddon, BOA President 1960-61

During the post-war period, the incidence of nerve injuries began to fall but it was not long before a new stimulus for the orthopaedic centred study of the peripheral nervous system would emerge. The polio outbreak in the UK in the 1950s reaffirmed the focus on neuromuscular function held by the early leaders of the BOA. This led to pioneering work by BOA members such as Sir Herbert Seddon and Rolfe Birch who transformed peripheral nerve surgery during the 20th Century.

Sir Herbert Seddon was appointed as the first Nuffield Professor of Orthopaedic Surgery at Oxford University where he established a PNI unit at the Wingfield-Morris Orthopaedic Hospital (now the Nuffield Orthopaedic Centre), between 1940 and 1960. Famously, Seddon went on to publish his classification

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of nerve injury with ‘Surgical Disorders of the Peripheral Nerves’ first published in 1971. He was elected President of the British Orthopaedic Association in 1960 and served in that position for two years.

Rolfe Birch followed Seddon in leading the PNI unit initially from its relocated base in St Marys Hospital and then bringing it to the Royal National Orthopaedic Hospital (RNOH). The PNI unit grew over this period with close links to UCL academics such as Shelagh Smith, Praveen Anand and Susan Standring. The third Edition of ‘Surgical Disorders of Peripheral Nerves’ brought further advances in clinical experience especially from the Defence Military Research Centre. Specifically, this publication provided insight into traumatically induced neuropathic pain states from the conflict in Afghanistan.

Such changes will improve the clinical management of this heterogeneous pathology but in order to maximise these benefits we must remember the lessons of the past. The story of nerve surgery in the UK confirms the benefit of cross-disciplinary teams and a central organised structure to provide quality care and the data to constantly improve treatments. This evolution of clinical governance in nerve injuries mirrors that of other rare and specialist orthopaedic conditions. The development of bone tumours and bone infection units attests to this as does the establishment of the UK Trauma network. n

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

Medico-Legal

Learning from UK orthopaedic cases Heidi Mounsey

Orthopaedic surgery is a specialty dealing with a wide range of musculoskeletal conditions. Serious complications following surgery are rare, but medico-legal cases may arise due to the life-changing impact they can have on mobility and function.

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edical Protection analysed more than 1,800 cases including claims, pre-claims complaints, General Medical Council investigations, local disciplinary procedures and inquests. The value of our highest case payment was over £3.6 million.

Claims Heidi Mounsey is a medicolegal consultant and provides healthcare professionals with advice and support on a variety of medico-legal matters including claims, complaints, disciplinaries and regulatory proceedings. She is a former anaesthetic registrar and is a Fellow of the Royal College of Anaesthetists. She joined the Medical Protection Society in 2016.

The below are the most common types of procedures leading to a claim: • Knee surgery: including total knee replacement, knee arthroscopy, and anterior cruciate ligament reconstruction. Common themes included failure to offer conservative management or to explain the limitations of the proposed procedure. The highest payment was over £550,000.

• Hip surgery: the majority of claims were brought in relation to elective hip replacements and revision surgery.

Common factors included selection of the wrong sized components, malposition of components and failure to perform or correctly interpret postoperative x-rays. Alleged negligent outcomes included leg length discrepancy, restriction of mobility, nerve damage, infection or dislocation. Many patients who claimed required correction surgery.

The highest payment was over £300,000.

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Figure 1: Cases opened by type.

• Metal on metal hips: in some cases a product liability claim was brought against the manufacturer. Allegations directed at Medical Protection members included ‘mixing and matching’ of components. This sometimes led to increased metallosis or accumulation of metal debris in soft tissues. Contributing factors included failing to review patients, failure to monitor metal levels in the blood, failure to perform imaging and failure to offer revision surgery.

• Spinal surgery: claims often related to lumbar nerve root decompression or spinal fusion.

Common factors included incorrect choice of procedure and allegations of poor surgical technique or misplacement of metalwork.

Consequences included pain and weakness, development of bladder and bowel incontinence.

The highest payment was over £3.6 million.

Medico-Legal • Hand surgery: in particular, procedures such as trigger finger release, Dupuytren’s contracture release, ganglion excision and carpal tunnel surgery when performed in a ‘one-stop’ setting. Common factors included failure to discuss the options and assuming that conservative management had been offered or trialled by the GP. Allegations were made in relation to poor surgical technique resulting in consequences such as nerve injury, leading to loss of function of the hand.

• Foot surgery: complications arising from hallux valgus correction surgery, including tendon and nerve damage resulting in complex regional pain syndrome and abnormal gait. Common factors included the risks of chronic pain and/or neuropathic pain not being discussed prior to surgery.

• Fractures: missed fractures around total hip prostheses. Common themes included not adequately examining the patient or arranging further imaging; and inadequate assessment.

Regulatory (GMC) and disciplinary investigations GMC cases have followed referral from patients, relatives or colleagues. The common themes were: • Allegations of poor surgical competence, including higher than expected complication rates, poor functional outcomes, or lack of experience for the operations performed.

• Patients’ or colleagues’ dissatisfaction with the manner or attitude of the surgeon.

• Inadequate communication when surgery was delayed or cancelled.

• Bullying, harassment or assault of colleagues.

• Failure to supervise junior staff in theatre.

• Poor postoperative management of complications.

• Allegations of theft of equipment from the hospital.

• Failure to attend when requested while on-call.

• Performing private work during NHS time or using NHS resources to do so.

• Alcohol and drug misuse.

• Probity issues, including fraudulent use of codes when billing in private practice or authorship of publications.

• Criminal convictions arising from personal life.

• Use of experimental joint replacement prostheses without adequate informed consent or governance.

Inquests The purpose of an inquest is to find out who died, when, where, how and in what circumstances.

We identified the following themes: • Postoperative deaths due to pulmonary embolism – in some cases where postoperative prophylactic anticoagulation had not been provided or had been stopped due to bleeding from the surgical incision.

• Other complications including sepsis, bowel ischaemia or obstruction and haemorrhage.

Complaints Similar themes to those outlined above were seen, but also included: • Inaccurate completion of medico-legal reports, for example in relation to personal injury compensation claims.

• Development of pressure sores postoperatively.

• Inappropriate examination of patients.

• Dismissive attitude during consultations.

• Delay in organising further care such as physiotherapy.

• Failure to inform patients of investigation results.

Top tips to minimise risk This is not an exhaustive list of recommendations, but some key learning points.

• Ensure your surgical technique is regularly updated and in line with current best practice such that it would be supported by your peers.

• Discuss the possible benefits and risks of all potential surgical or conservative treatment options. Consider what is most important to that individual.

• Listen to what your patient would consider to be a successful outcome. Understand concerns and expectations.

• Explain complications, including the possibility of chronic pain. Explain what can be done to manage complications.

Document these discussions.

• Never pressurise patients into giving consent to have surgery.

• For elective operations always leave sufficient time after the consultation before scheduling the procedure.

• Remember consent is a process and not simply a signature on a form.

• Do not assume that another practitioner has held an informed discussion with the patient about all the available options.

• Give patients clear information about all costs involved and what their rights are to refunds/return of deposits.

• Double-check that the information has been understood and decisions are informed.

• Ensure a perioperative management plan is in place, including assessment of venous thromboembolism risk.

• At discharge, review the requirement for ongoing anticoagulant.

• Ensure any postoperative deterioration, complication or falls are communicated, investigated and managed.

• Consider the Medicines and Healthcare products Regulatory Agency guidance when providing follow up of patients with metal on metal hip replacements: https://www. gov.uk/drug-device-alerts/all-metal-onmetal-mom-hip-replacements-updatedadvice-for-follow-up-of-patients.

• Demonstrate empathy in your consultations.

• Remember that accurate and clear documentation is the cornerstone of any medico-legal defence.

• Ensure you are fully indemnified to carry out the relevant procedure in the UK.

Additional resources • Medical Protection workshops and masterclasses: https://www. medicalprotection.org/uk/hub/workshopsmasterclasses.

• Getting It Right First Time (GIRFT) report on spinal services: https:// gettingitrightfirsttime.co.uk/surgicalspecialty/spinal-surgery/.

• British Association of Spinal Surgeons (BASS) guidance on consent: https:// spinesurgeons.ac.uk/patient-area/consent.

• Royal College of Surgeons of England standards and research: https://www. rcseng.ac.uk/standards-and-research/ standards-and-guidance/. n

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Simulation Section

Simulation and the UK trauma and orthopaedics curriculum Catherine Kellett Co-authors: Duncan Tennent and Robert Gregory

Simulation is recognised as an important part of education and training in all areas of medicine and in particular surgical specialties such as Trauma and Orthopaedics.

Many groups have embraced simulation including the JCST Simulation Working Group, Joint Royal Colleges of Physicians Training Board (JRCPTB), Health Education England (HEE) and ASPiH.

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ince 2013, simulation has been incorporated into all surgical curricula and the GMC has required a mapping exercise relating to simulation be included. With patient safety in mind, it is hoped that all surgical trainees would be given the opportunity to practice in a simulated environment before performing a procedure on a patient1.

Catherine Kellett is a Consultant Orthopaedic Surgeon specialising in primary and revision hip and knee arthroplasty.

She has extensive experience in undergraduate education and has been Lead for Simulation on both the BOA Training Standards Committee and the T&O SAC. She is a co-author of the 2014 Post Graduate Trauma & Orthopaedic Curriculum.

T&O have been keen to embrace simulation, a simulation lead sat on the Training Standards Committee from 2011-12 and there are currently simulation leads that sit on the SAC and on the BOA Education and Careers Committee.

fellow international orthopaedic associations were similarly challenged. There was little guidance available to show how a curriculum should be mapped or indeed evidence to show how it influenced patient safety. Other surgical specialties were further ahead with simulation research such as general surgery with the extensive research into laparoscopic surgical simulation by Sir Alfred Cuschieri.

Furthermore, T&O also has a very broad scope, with operations being undertaken on most parts of the body, and with numerous procedures being possible within even the smallest of parts. It would not be realistic to expect every possible orthopaedic operation to be the subject of simulation, so key (transferrable) skills need to be identified.

Additionally, financial constraints restricted the ability of local training bodies to deliver a comprehensive range of simulation, although this is slowly changing.

The 2014 Simulation Curriculum document was written by Cass Kellett, Lisa HadfieldLaw and the Training Standards Committee, and was submitted to the GMC with the 2014 T&O Curriculum. It is • There is good evidence that certain CMT practical procedures (central venous available on the ISCP catheterisation, thoracocentesis, abdominal paracentesis) and emergency and GMC websites. presentations (cardiorespiratory arrest) can improve patient outcomes if taught Simulation lying within the curriculum should promote learning in a safe environment and hopefully improve patient safety and learner enjoyment. The initial mapping exercise was challenging, as no such mapping had previously existed; our

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using Simulation Based Education. There is no obvious reason why additional CMT procedures should not also be taught using SBE, indeed the evidence points to it being desirable to do so.

• It also found that there is reasonable evidence that non- technical and human factors skills required by CMT can be effectively taught using SBE. • The teaching of CMT essential and desirable procedures and also non-technical skills using SBE is already widespread within the UK and CMT training programme directors (TPDs) support this training.

Box 1. Key findings in report from the JRCPTB/HEE Expert Group on Simulation in Core Medical Training2.

Simulation Section

The 2020 T&O Curriculum and Simulation Mapping is more extensive. The SAC and specialist societies have had input into the changes and a new paediatric orthopaedics section has been added.

The Applied Clinical Skills section maps the type of simulation with the stage of training and some procedures are now marked as essential for simulation as they are considered key skills. However trainers should feel free to use innovative methods of simulation, not necessarily just those suggested.

Simulation does not need to be expensive or high tech. Often simple low-tech simulations are surprisingly effective, such as practicing breaking bad news with a peer, or practicing an osteotomy for hallux valgus on a banana with a knife to make the cuts and cocktail sticks in place of screws to fix it. The idea is to create some form of deliberate practice, which might be mental rehearsal or talking through a procedure with the trainer. We should not forget the value of reading operative techniques (many of which exist online) before any procedure and this should be considered the bare minimum for any trainee.

Certain simulations can be used for all procedures and skills, such as reading the technique, cognitive simulation, e-Learning, and Apps.

“Simulation does not need to be expensive or high tech. Often simple low-tech simulations are surprisingly effective, such as practicing breaking bad news with a peer, or practicing an osteotomy for hallux valgus on a banana with a knife to make the cuts and cocktail sticks in place of screws to fix it.”

Simulation should be included as part of departmental induction programmes, perhaps in the form of an enhanced induction (the pastoral aspects of ‘boot camps’ should be noted). It should cross all phases of training but with the emphasis being on early years when it is thought to have most impact.

Integrating human factors with technical skills simulation training is essential, as recommended by RCSI and Joint Royal Colleges of Physicians Training Board (JRCPTB)/Health Education England (HEE) Expert Group report on enhancing UK Core Medical Training through simulation2.

The T&O curriculum simulation mapping will be a developing area and as a specialty we need to evaluate the role of different types of simulation. It is important we help each other and share our ideas.

The BOA has various fora to promote and facilitate simulation by providing sessions at Congress, including the annual ‘BOA Innovation in Simulation’ and ‘Simulation & Education Free Papers’ Prizes and the BOA Simulation Group. We would encourage you all to attend and contribute to these sessions.

The impact of COVID-19 on surgical training has been, and will continue to be significant. Optimal use will have to be made of the more limited time spent with patients and therefore more use will have to be made of other training opportunities. Simulation, both at the low-tech and high-tech ends of the spectrum will be a critical component of this and industry must be encouraged to work with us. The curriculum will continue to evolve and simulation should be seen, not as an adjunct but as a vital component of training. n

References 1. Rimmer A. Simulation training to become part of surgical curriculum.

BMJ. 2013;347:f6706.

2. NHS Health Education England (2016).

Enhancing UK Core Medical Training through simulation-based education: an evidence-based approach. A report from the joint JRCPTB/HEE Expert Group on Simulation in Core Medical Training. Available at: https://www. jrcptb.org.uk/sites/default/files/HEE_ Report_FINAL.pdf.

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Trainee Section

It’s time to think about…

Fellowships Ran Wei and Jenny Clements

In 2019, BOTA conducted a census of its members and found that 96% of the 590 trainees who completed the survey intended to undertake a subspecialty fellowship.

The majority (69%) of respondents planned on either an international only (13%) or combination of a UK and international (56%) fellowship.

Ran Wei is a ST8 in South West London. He is the BOTA Vice President and is currently acting up as President. He represents T&O trainees on a number of Committees and is tasked with leading all BOTA Regional Representatives across the UK. He is due to undertake a Knee Surgery fellowship in Sydney in 2021.

Jenny Clements is currently on a Hand Surgery fellowship in Auckland, New Zealand. She obtained her CCT this summer having trained in South West London. She is a past BOTA Regional Representative for South West London.

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any junior doctors take time out of training to work in Australasia after their Foundation and Core Surgical years in a bid to en-richen their CVs and life skills. They will have experienced the administrative headaches and financial heartache that precede the bounty of working abroad. In recent years, there has been an impressive conversion rate of core surgical trainees to T&O specialty trainees at national selection, such that fewer trainees experience ‘the overseas travel to work’ before getting their number.

Why do trainees go on fellowships?

In our 2019 census, BOTA sought to find out what motivates trainees to delay independent practice and undertake a post-CCT subspecialty fellowship. The most common answer to the question “what influences your decision to complete a fellowship?” was “competition for consultant posts / everyone else is doing one”.

97% of the trainees who responded to the BOTA census stated that they will be dedicating 6 to 24 months to attaining fellowship experience. Given that most trainees gravitate towards Australasia, it is not surprising that most will want to spend more than six months working there after a long-distance move.

Most UK consultant job advertisements stipulate the need for prospective applicants to have subspecialty fellowship experience. It is therefore unsurprising that trainees have responded by adopting post-CCT subspecialty fellowships as a mandatory stepping stone to consultant appointments. More recently, some consultant job adverts have also stipulated an additional requirement for a stand-alone trauma fellowship. It is important for trainees to bear this emerging trend in mind when planning their fellowship year(s).

The recent COVID-19 pandemic resulted in temporary cessation of all elective activity both domestically and internationally. This has no doubt had a profound impact for those who were in the midst of their fellowships.

Now that elective practice is starting to tentatively resume, the knock-on effect will undoubtedly be felt by those who are about to embark on their fellowships. In this article we aim to help trainees considering or planning on undertaking subspecialty fellowship experience in Australasia to tackle the common barriers.

A surprising finding of the BOTA 2019 census was that 42% of trainees intended on undertaking a fellowship as a result of insufficient training in their subspecialty area of interest during their specialty training. It is possible that this statistic may improve with the new framework set out by the new T&O curriculum, but we will have to wait a few years to evaluate this. In the meantime, surgical exposure (cited by 72% of trainees in the census) will continue to remain the most important factor for trainees when choosing a fellowship.

Trainee Section

It can be difficult to ascertain the likely surgical exposure (i.e. cutting time) of a fellowship job prior to an application. Apart from word of mouth, most trainees rely on either luck or an educated guess.

Whilst there are some fellowship schemes such as the RCSEng Senior Clinical Fellowship Scheme1 that publish the expected logbook numbers, there lacks a comprehensive and honest source of information when it comes to fellowship posts. BOTA are attempting to tackle this issue by investing in a new initiative that aims to help trainees become better informed prior to fellowship applications.

At the end of 2019, we started work on www. fellowshipfinder.org. uk. It will take some years to mature but it is our hope that trainees will contribute their anonymised and honest reviews and surgical logbooks to an ever-growing database of domestic and international fellowships. After all, logbooks do not lie!

Preparing for an international fellowship If you are considering an overseas fellowship it is essential that you start planning early. The need for this cannot be stressed enough. The latter part of your training will be fraught with exam pressures, acquiring CCT requirements and honing surgical skills. It would be prudent to note that competitive and even lesser known fellowships are often booked up two to three years in advance.

“Most UK consultant jobs stipulate the need for prospective applicants to have subspecialty fellowship experience. It is therefore unsurprising that trainees have responded by adopting post-CCT subspecialty fellowships as a mandatory stepping stone to consultant appointments. ”

If you are considering Australasia, then check out the Australian and New Zealand Orthopaedic Association websites where many fellowships are listed2,3.

There are often stipulations and a suggestion that local candidates will be preferred but don’t be put off. They do make exceptions and there may be last minute availability if prospective fellows pull out. Asides from the formal route, fellowships can also be arranged by word of mouth. State your intentions early and ask your consultant trainers, other registrars and use regional trainee meetings/websites to get ‘inside information’.

Be prepared for the 4am video interview (at least we are all now more experienced with video conferencing!). Do some research about the hospital and local region that you are applying for. If possible, ask if you can have the contact details of the person currently in the post to get some details on the day-to-day job, on-calls, expectations and locality. It is important to ensure that the fellowship will fit your needs and expectations.

Once the job has been secured, start the admin/ paperwork early. It will take the good part of eight months to work your way through the mountain of forms and the necessary but lengthy email trails. If you want to reduce your stress, then start this process 12 months before your fellowship.

Finance is also an important consideration.

You should ensure you set aside money for administrative costs as these are usually in the region of £1,500. The pay/income of fellowships can vary widely. If necessary, you will need to start saving early. After all, you will want to do more than just clinics and theatre lists when you are on the other side of the world.

Below are some important considerations if you intend on a fellowship in Australasia.

New Zealand or Australian Medical Council registration This requires registration with Electronic Portfolio of International Credentials (EPIC) which is a long process and being granted >>

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Trainee Section

Document/ Health Checks This can often be a lengthy process.

Ensure that you shop around for a Notary Public as the fees can vary widely. Most hospitals will also ask for a police certificate (different from a DRB certificate) which can be requested via ACRO (Criminal Records Office) and takes a few weeks. Mandatory training and occupational health checks will also apply. Most of this can also be done online before leaving the UK. It can be useful to contact your own OH department before leaving to ask for a summary of the relevant records.

Medical Indemnity

full registration will often require a face to face interview once you have arrived in the country.

They will also ask for a ‘letter of good standing’ from the GMC which can be obtained on the GMC website.

Work Visa This takes time to obtain and will need the involvement of the relevant immigration bodies. You will find it much easier to get this when the relevant medial council has issued an ‘invitation to complete the process’.

Bank Account It is highly recommended that you open an Australasian bank account and obtain a tax number before leaving the UK. This will ensure that there is no delay to your wages.

You will struggle to obtain a tax number until you have a bank account. It is also much easier to open a bank account once a work visa has been obtained.

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Unlike the UK, medical indemnity is not provided by the hospital but needs to be purchased independently. The cost can often be reclaimed from the health board you are working for. Again, a ‘letter of good standing’ will likely be needed from your current provider in the UK which takes a couple of weeks to organise.

All of the above are considerations surrounding the work aspect of your fellowship. You must also consider the ‘real life’ aspects as well. Single trip travel insurance should be considered as your normal travel insurance may not suffice and be sure to check what health care you are entitled to. In NZ, as a UK citizen with a work visa you should be entitled to full health care but be sure to check with your employer. You may need to organise accommodation, a form of transport and perhaps a school for your children prior to your arrival. It is therefore highly recommended that you get in touch with the incumbent fellow(s) as they are often a gold mine of advice. If you get lucky then you may be able to take over more than just

their fellowship job. It is possible to secure accommodation, a set of wheels and even the odd surfboard through this avenue!

The current COVID-19 pandemic means that you must make several considerations when thinking about an international fellowship.

From personal and family health, travel limitations and immigration restrictions through to government guidelines, quarantine requirements and the exposure of surgical procedures if a country has limitations on elective practice. Not only do these add a layer of logistical complexity but never has careful consideration and research of all risks and potential ‘spanners in the work’ been so critical.

Lastly, when you leave the UK for a prolonged period of time you will also need to consider what to do with your domestic baggage. Your GMC registration, UK medical indemnity and pensions will all be affected so make sure you don’t leave sorting these out until the last minute.

Prior to leaving for your fellowship contact your supervisor to get a project set up. This will help you hit the ground running and will be especially important for those who intend on undertaking a six months fellowship. You should also utilise the knowledge of past/present fellows to gauge your boss’ scope of practice, kit preference and hobbies. You may find that spending a few more hours on the golf course might benefit your surgical training after all!

In summary, overseas subspecialty fellowships can be a challenge to organise but remain highly desirable and rewarding. Most trainees start their applications for fellowships prior to the commencement of their FRCS exam year.

Preparations for fellowships in Australasia can take in excess of eight months so start early.

The current COVID-19 pandemic may render international fellowships more logistically challenging to prepare for. When considering fellowships, it is often difficult to gauge the quality of surgical exposure. BOTA are therefore launching www.fellowshipfinder.org.uk in a bid to help trainees with this conundrum.n

References 1. Royal College of Surgeons England (2020).

RCS Senior Clinical Fellowship Scheme.

Available at: https://www.rcseng.ac.uk/ education-and-exams/accreditation/rcssenior-clinical-fellowship-scheme.

2. New Zealand Orthopaedic Association (2020). Fellowship Opportunities. Available at: https://nzoa.org.nz/fellowshipopportunities.

3. Australian Orthopaedic Association (2020).

AOA Accredited Fellowships. Available at: https://www.aoa.org.au/orthopaedictraining/fellowshipsheader/aoa-accreditedfellowships.

Features

Why we need the Fragility Fracture Network UK Matt Costa

Matt Costa is Professor of Orthopaedic Trauma at University of Oxford and Honorary Consultant Trauma Surgeon at the John Radcliffe Hospital, Oxford. He is the current Chair of the BOA Research Committee and the immediate past President of the Global Fragility Fracture Network.

T

he burden of disease is massive. In the year 2000 there were an estimated nine million new fragility fractures worldwide and 50 million people living with the consequences of these injuries1. These figures are only going to increase, (see Figure 1). In the UK there are 70,000 hip fractures alone each year, causing a profound and long lasting effect on quality of life and costing an estimated £2 billion in health and social care costs2,3.

Figure 1: United Nations Population Prospects; Global population aged 60 years or over 2017-2100.

The Global Fragility Fracture Network (FFN) has coordinated a Call to Action to meet these challenges4. This call has been endorsed by over 130 international organisations and has led to the development of national Fragility Fracture Networks in over 20 countries, representing half the world’s population.

The express mission of the national FFN’s is to change policy in each of those countries, with the aim to improve the multidisciplinary acute management of patients with a fragility fracture, to improve rehabilitation services for these vulnerable patients and to implement effective secondary prevention strategies. You can join the global FFN for free: https://www.fragilityfracturenetwork.org/.

But why do we need a UK branch of the FFN? We already have the NICE guidance for hip fractures, the largest National Hip Fracture Database in the

world and, arguably, the best Fracture Liaison network in the world. Yet none of our hospitals meet all of the best practice criteria for hip fracture all of the time, rehabilitation in hospital is ‘variable’ at best and mostly non-existent after the patient leaves hospital, and many hospitals still do not have a Fracture Liaison Service at all. Oh, and what about all of the non-hip fragility fractures…

FFN UK brings together like-minded clinicians, managers and patients to address these problems.

It is not a new society. It is not seeking to replace any existing organisations or activities. FFN UK is a ‘network’ of activists whose goal is to collate and share best practice across all stakeholders to improve the care of patients with fragility fracture.

Find out more at http://www.ffnuk.org.uk/. n

References 1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726-33.

2. Griffin XL, Parsons N, Achten J, Fernandez M, Costa ML. Recovery of health-related quality of life in a United Kingdom hip fracture population: the Warwick Hip Trauma Evaluation - a prospective cohort study.

Bone Joint J. 2015;97-B(3):372-82.

3. National Institute for Health and Care Excellence (2018). NICE Impact: Falls and Fragility Fractures.

Available at: https://www.nice.org.uk/media/ default/about/what-we-do/into-practice/ measuring-uptake/nice-impact-falls-and-fragilityfractures.pdf. (Last accessed 6 March 2019).

4. Dreinhöfer KE, Mitchell PJ, Bégué T, Cooper C, Costa ML, Falaschi P, et al. A global call to action to improve the care of people with fragility fractures. Injury.

2018;49(8):1393-7.

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Features

Anaesthetic management of hip fracture Stuart M White

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he anaesthetic management of hip fracture has traditionally focused on whether spinal or general anaesthesia provides better outcomes for patients.

A number of RCTs and more recent large, observational studies have failed to resolve this issue, and it is unlikely that imminent results from several RCTs (REGAIN, REGARD, iHOPE, RAGAdelirium) will find any difference, if indeed one exists.

Stuart White is Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS Trust.

Instead, professional focus has shifted towards standardising anaesthetic management, to reduce the wide variation in practice recorded by the National Hip Fracture Database and bring anaesthesia in line with contemporary orthopaedic and orthogeriatric practice. To this end, the Association of Anaesthetists will shortly be publishing its updated 2020 guidance for UK anaesthetists on the management of hip fractures, endorsing the Fragility Fracture Network’s 2018 International Delphi consensus statement on the principles of anaesthesia for patients with hip fracture1.

Both documents emphasise the need for experienced anaesthetists’ participation in a standardised, multidisciplinary team approach to patient care. Also addressed in both documents are the fundamental aims of anaesthesia for hip fracture management, namely the facilitation of: early (< 36 hours) surgery, day one postoperative remobilisation, re-enablement (i.e. resuming activities of daily living), and rehabilitation (Figure 1)2.

Figure 1: A schematic timeline of what joint anaesthesia/orthogeriatric care should aim to achieve.

The blue line represents traditional anaesthesia care. The patient’s functional condition has been declining for some time, until they fall and break their hip (‘X’), at which point they become entirely dependent. They are taken to hospital but receive minimal care until surgery, and so experience no functional improvement. Intraoperatively, the fracture is fixed, analgesia, fluids/ blood are given, the blood pressure monitored, and the patients functional status improves, which continues into the immediate postoperative period. However, perhaps the patient develops delirium or feels too nauseous to remobilise for several days in the early postoperative period, as a result of reliance on postoperative opioid analgesia. They recover function over the next few days, but then develop pressure sores or suffer a pulmonary embolism related to their prolonged bedrest, and their functional recovery is delayed again. Eventually, they recover, not quite to their pre-fracture level of function but enough to be discharged from hospital. However, their relatives report that the patient ‘was never quite the same’ after this episode, with a slow ongoing decline in function after discharge (dotted lines).

Instead, proactive multidisciplinary care (red line) aims to return patients quickly to their pre-fracture functional status.

Simple resuscitation (analgesia, fluids, food) decreases the relative decline in function after fracture, and may indeed begin to improve function pre-operatively. The patient undergoes surgery sooner and for a shorter period, during which resuscitation and normalisation of function continues using standardised anaesthesia. The patient’s functional status rapidly returns to pre-fracture levels,

there are no immobilising complications, the patient is discharged from hospital sooner and remains ‘well’ after discharge.

The Association guidelines address controversies that commonly arise peri-operatively (potentially delaying surgery) and how to manage these, specifically concerning non-opioid analgesia/ nerve blockade, anaemia/blood transfusion, echocardiography, anticoagulant/antiplatelet therapy and the need for critical care facilities.

Anaesthetic research into hip fracture management has also undergone a process of standardisation, with the development of a core outcome set for comparisons of morbidity and mortality after anaesthesia3. This will allow for better reporting consistency and more meaningful results from future meta-analyses of anaesthesia interventions for hip fracture. Following on from the 2015 Anaesthesia Sprint Audit of Practice (ASAP)4,5 and other observational studies, research has started to focus on intra-operative hypotension and its association with mortality and end-organ ischaemia, particularly of the brain (possibly contributing to postoperative delirium). Research into spinal vs. general anaesthesia for hip fracture continues, but is set to become more nuanced in determining the best type of each modality and comparing these (e.g. lowdose spinal anaesthesia without opioids + minimal sedation + nerve block vs. depth-monitored general anaesthesia without opioids + nerve block). n

References 1. White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, et al. International Fragility Fracture Network consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018;73(7):863-74.

2. White SM. Orthogeriatric anaesthesia. In Falaschi P, Marsh DM (Eds). Orthogeriatrics. Springer, Switzerland, 2017. pp. 97-110.

3. O’Donnell CM, Black N, McCourt KC, McBrien MC, Clarke M, Patterson CC, et al. Development of a Core Outcome Set for studies evaluating the effects of anaesthesia on perioperative morbidity and mortality following hip fracture surgery. Br J of Anaesth.

2019;122(1):120-30.

4. Royal College of Physicians and the Association of Anaesthetists of Great Britain and Ireland (2014).

National Hip Fracture Database. Anaesthesia Sprint Audit of Practice. 2014. Available at: https://www.nhfd.co.uk/20/hipfractureR.nsf/ vwContent/asapReport/$file/onlineASAP.pdf.

5. White SM, Moppett IK, Griffiths R, Johansen A, Wakeman R, Boulton C, et al. Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP 2). Anaesthesia. 2016;71(5):506-14.

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Features

Nursing standards and fragility fracture outcomes Julie Santy-Tomlinson and Karen Hertz

Julie Santy-Tomlinson is a UK based registered nurse with a clinical background in orthopaedic and trauma nursing and has worked in nursing education for the last 25 years. She is actively involved in the work of the Fragility Fracture Network and has co-authored several journal papers and book chapters on the subject. Julie has been Editor in Chief of the International Journal of Orthopaedic and Trauma Nursing and is Adjunct Associate Professor of Orthopaedic Nursing at Odense University Hospitals and the University of Southern Denmark.

Karen Hertz is a registered nurse, working in the NHS as an advanced nurse practitioner (ANP). She has worked for 33 years in a variety of roles in Trauma and orthopaedics, however her passion is for fragility fracture nursing and inter-disciplinary care. She has been actively involved in both the Global and National Fragility Fracture Network since their inception.

She has co-authored a number of Journal articles, book chapters and books on Fragility fracture management and allied subjects.

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Fragility fractures represent a significant challenge to health services and, while optimum fragility fracture care needs to take place in a person-centred and multidisciplinary culture, the contribution of nursing care to patient outcomes is central. Nurses are the largest workforce involved in the fragility fracture journey and patient contact is spread across the whole 24h, with significant influence on patient outcomes. Even so, the potential of nursing care to positively impact on outcomes has yet to be either fully tapped or demonstrated.

B

ecause of the breadth and mobilisation, malnutrition prevention, complexity of nursing care VTE prevention, UTI prevention, delirium, needs (Figure 1), it can be pneumonia prevention, constipation difficult to articulate its specific prevention and management, pressure ulcer role in the fragility fracture prevention, care transitions and preparing patient pathway, and to demonstrate the impact on patient outcomes.

Hip fracture audit in the UK, for example, currently focuses largely on admission screening and assessment (often carried out by nurses) and pressure ulcer incidence as measures of nursing care quality1; only a small part of the whole spectrum of nursing care activity.

MacDonald et al.2 and Meehan et al.3 have attempted to define this spectrum of activity and demonstrate its Figure 1: The complexity of nursing care needs for hospitalised patients with hip fracture (adapted from diversity in terms of: Hertz & Santy-Tomlinson 2017)4. pain management,

Features

for home and bone health improvement interventions. These are in addition to an abundance of fundamental nursing care activities such as comfort and hygiene, patient safety measures and patient and carer support and education.

Nursing activity is multifaceted and complexity is added because nurses must holistically care for patients who have not only sustained a fracture and, in the worst cases, require major orthopaedic surgery, but care must be provided in a manner that is agesensitive and takes account of frailty and other factors which significantly affect outcomes. In some localities, specialist and advanced practice nurses are leading the acute and postacute care of patients following hip fracture and expert nurses have become central in instigating and managing secondary fracture prevention. However, specialist education which brings together the skills of adult nurses with those of orthopaedic practitioners and geriatric nursing is only just beginning to emerge and dedicated time for post-qualifying nursing education is usually scarce or non-existent.

qualified nurses brought about by economic austerity, a mismatch of supply and demand for nurses and difficulties in recruitment and retention5. Optimum nursing care for a patient with a fragility hip fracture is difficult to define as it is unlikely that it has ever occurred. We do not know how many hours of nursing time with what kind of practitioner is needed to ensure outcomes and experiences are the best they can be because we have Without the nursing resource to do all not been able to study such a situation. The this effectively, patient experience and nursing community, however, is becoming outcomes suffer. The availability of enough more adept at demonstrating what happens appropriately educated and skilled nurses when nursing resources are insufficient. In to provide fundamental care is a constant a large international study6 an increase in a source of concern. This resource is under nurses’ workload by just one patient, from more pressure than it has ever been (Box 1). eight to nine per qualified nurse, increased There is currently a global shortage of the likelihood of a surgical inpatient dying within 30 days of admission by 7%. UnderThe global nursing shortage has resulted in additional workload and stress for resourcing nursing nurses. This results in missed nursing care with a detrimental impact on patient care outcomes. teams results in inability to Since 2010 there has been a 1% increase in nurses and health visitors working prevent morbidity in the NHS (1,653); however, the increase in nurses has not kept pace with the and mortality.

8 increase in doctors (12%), consultants (27%) or the population (5.7%) ; suggesting An association a mismatch between growing activity and the size of the nursing workforce. has also been demonstrated Aiken et al.6 demonstrated that an increase in a nurses’ workload by just one between ‘missed patient, from eight to nine per qualified nurse, increased the likelihood of a nursing care’ surgical inpatient dying within 30 days of admission by 7%. and adverse patient outcomes Box 1. Nursing resources issues. including;

medication errors, urinary-tract infections, falls, pressure injuries, critical incidents, low quality of care and patient readmissions7, highlighting failures in care quality.

As the work and influence of FFN UK gets underway it is important that exploring and developing the nursing contribution to patient outcomes is part of the direction of travel. Local and national lobbying for expansion of nursing resources and better, well-funded education for nursing teams working fragility fracture care is a collective responsibility for the whole multidisciplinary team. If outcomes for this vulnerable group of patients are to continue to improve, nurses must be able to provide optimum care, and this is predicated on a well-educated workforce with enough time to give that care to both their own and patients’ satisfaction and benefit.

Good quality nursing care is essential if we are to achieve the best outcomes for patients with fragility fractures. The whole multidisciplinary team needs to speak with one voice. Surgeons are key members of this team – we need the vocal support of orthopaedic surgeons to address the chronic shortage of nurses on the orthopaedic wards. n

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

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 51

Features

FFN UK - Orthogeriatric medicine Opinder Sahota

The subspecialty of orthogeriatric medicine has evolved as a response to the complex medical, rehabilitation, and social needs of older people presenting to hospital with musculoskeletal injuries.

S Opinder Sahota is a Consultant Physician and Honorary Professor of Ortho-Geriatrics Medicine, Nottingham University Hospitals. He is the Clinical Lead for the Ortho-Geriatric service in Nottingham, leading a team of six Ortho-Geriatricians providing care for Fragility Fractures in older people presenting across the Trauma and Orthopaedic Department, the Regional Spine Unit and the East Midlands Major Trauma unit. He has co-authored a number of national guidelines on the care of fragility fracture patients and currently Chairs of the Scientific Committee of the Fragility Fracture Network (FFN) UK, board member and scientific committee member of the Global FFN and Chairs the Global FFN Vertebral Fracture Specialist Interest Group.

ince the inception of orthogeriatric medicine, most of the published research in this field has examined its application to patients with a hip fracture, which is unsurprising given that hip fractures cause significant morbidity and mortality, along with substantial healthcare costs. However, other fragility fractures are common in older people admitted to hospital, such as vertebral, pubic rami and sacral insufficiency fractures, which also result in substantial patient morbidity and mortality. Furthermore, major trauma in frail older patients is also increasing, and the vulnerability of this subgroup is well recognised1.

First developed in the early 1960s2, the collaboration between geriatric medicine and orthopaedics was formalised in the UK in 20073 which formed the foundations for the National Clinical Guideline, National Quality Standards and the National Database for hip fracture care4-6.

As a result, the UK has led the way in defining the now accepted standards of early orthogeriatric medicine collaboration for hip fracture care, which is now part of routine clinical practice, through the introduction of the Best Practice financial tariff for Hip Fracture.

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This has led to an improvement in patient outcomes and reduction in 30 day mortality nationally7,8. More recently, England and Wales has seen the introduction for a Best Practice financial tariff for Major Trauma which includes a requirement for all patients aged 65 years or older to have a Clinical Frailty Scale completed within 72 hours of admission by a geriatrician (defined as a consultant, nonconsultant career grade (NCCG) or specialist trainee ST3 or above)9.

An orthogeriatrician is a pivotal part of the multidisciplinary team. A national survey has shown that increasing the time spent per patient from 1.5 to 4 hours, resulted in reduction in time to theatre, with an overall 3.4% decrease in 30-day mortality10.

The key roles of an orthogeriatrician are: â&#x20AC;˘ Perioperative medicine â&#x20AC;˘ Multidisciplinary working and targeted rehabilitation â&#x20AC;˘ Secondary falls prevention and bone health

Figure 1: Comprehensive Geriatric Assessment (CGA).

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Perioperative medical care Common perioperative problems include delirium, infection, acute kidney injury, pressure ulcers, thromboembolic disease and decompensation of co-morbidities such as diabetes, heart disease and respiratory conditions. Early orthogeriatric medical management is recommended in order to predict complications, prevent them where possible and manage them appropriately when they occur.

Multidisciplinary working and targeted rehabilitation Cornerstone to this is the Comprehensive Geriatric Assessment (CGA), which is an interdisciplinary diagnostic process to determine the medical, psychological and functional capability of someone who is frail and old. The aim is to develop a coordinated, integrated plan for treatment and long-term support, (see Figure 1).

supported discharge with environment review in a patient with dementia (modifiable risk factor). Routine assessment of vision, hearing and medication review should be undertaken in hospital, followed by a continued and more comprehensive falls risk assessment and individualised management in the community11.

Secondary falls prevention and bone health Secondary falls prevention begins in hospital and involves the identification of reversible falls risk factors, (those that can be treated), and modifiable risk factors, (those that can modified but not treated). Examples include postural hypotension secondary to medication (reversible risk factor) and

Metabolic conditions are prevalent in this population so an understanding of the identification and management of

the common conditions are important, which includes osteoporosis, osteomalacia, primary hyperparathyroidism and Paget’s disease. Given the poor compliance with oral bisphosphonates for the treatment of osteoporosis, earlier consideration should be given to the use of parenteral therapies. n

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

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For more information please contact us, Tel: 0845 607 6820 JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 53

Subspecialty Section

Rib fracture management in the older adult; an opportunity for multidisciplinary working Lauren Richardson and Shvaita Ralhan

Lauren Richardson is an ST7 Registrar in Geriatric and General Medicine working in the Thames Valley. Whilst undertaking a fellowship in Perioperative Medicine she helped to develop the Major Trauma Geriatric service at the John Radcliffe Hospital in Oxford.

The elderly will soon make up the largest number of patients sustaining major trauma; a fall from standing height is their most common mechanism of injury1. Rib fractures are a common consequence of blunt chest trauma and are important to recognise and diagnose as complications can be fatal. They can be considered a surrogate for major trauma as up to 90% of patients will go on to have additional injuries identified2. The older adult presents a unique challenge. Their injuries are often under-estimated and therefore under-triaged. Delays to diagnosis are not uncommon3.

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he mortality and thoracic morbidity in the elderly as a result of rib fractures is double that of their younger counterparts. In elderly patients, for each additional rib fracture, mortality increases by 19% and the risk of pneumonia increases by 27%4. It is therefore not surprising that older adults who sustain rib fractures have increased lengths of stay and more prolonged intensive care admissions5â&#x20AC;&#x201C;7.

Shvaita Ralhan trained in Geriatric and General Internal Medicine in London, and is now a Consultant in Perioperative Medicine at the John Radcliffe Hospital.

She is interested in major trauma in older patients and has set up the Major Trauma Geriatrics service in Oxford.

She is passionate about teaching, has completed a Masters in Clinical Education, and runs the Perioperative Medicine fellowship programme in Oxford.

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Elderly patients whose injuries are not recognised at the front door are usually spread across a number of different bed bases within the hospital. They are often on medical wards where staff have comparatively limited experience in managing traumatic injuries. Older adults who sustain rib fractures are often frail and comorbid. Their injuries cause decompensation of their medical problems and delirium which in turn leads to complex discharge planning; issues that surgical teams do not feel best placed to

deal with. Decisions regarding which team these patients should be admitted under can therefore be contentious. Nationally, there is significant variation, and even in institutions such as ours where pathways do exist, conflicts often arise as to where the patient should be managed and by whom.

This article aims to address the key issues that arise when managing older adults with rib fractures and highlights the importance of tailoring clinical care to their specific needs.

Imaging A plain chest radiograph will only detect 50% of rib fractures8 whereas computerised tomography (CT) is significantly more sensitive and is therefore the recommended imaging modality9. Due to underlying osteoporosis, the elderly can sustain lifethreatening injuries following what can be perceived as minor insults. Therefore, as clinicians, we should have a very low

Subspecialty Section

threshold for performing cross sectional imaging if chest injuries are suspected; particularly in this patient group. The presence of flail chest is associated with significant mortality (15-17%)10; paradoxical movement of the flail segment during inspiration restricts the underlying lung tissue, increases the likelihood of lung contusion and leads to ineffective ventilation.

Risk stratification There are a number of risk stratification scores that have been validated for use in rib fractures.

In our centre we use the Battle Score11 which comprises a number of factors that are known to influence outcomes (Table 1).

The final score is then converted to a percentage risk of developing complications (Table 2). Complications in this instance refers to mortality, morbidity (including all pulmonary complications), admission to intensive care and prolonged inpatient admission (greater than 7 days).

With a point given to each decade of life, the elderly automatically score highly. For example, an 80-year-old with a background of asthma and atrial fibrillation who is taking Apixaban will score 16 on the Battle Score without having even sustained a fracture.

Additionally, this scoring system does not make any adjustment for patients with lower baseline saturations; such as those with Chronic Obstructive Pulmonary Disease (COPD).

Other validated scores include the Rib Score (RS), Rib Fracture Score (RFS) and the Chest Trauma Score (CTS). In a recent comparison of these three scores12, the CTS was felt to be most useful in predicting outcomes in patients over the age of 65. A score of six or more was associated with an increased mortality, increased length of stay and increased rates of pneumonia. This scoring system puts less emphasis on patient specific characteristics but gives points for injury related factors including the number of ribs fractured, bilateral fractures and the presence of pulmonary contusions13.

Analgesia Morbidity and mortality from rib fractures occurs as a result of respiratory complications. Direct trauma, impaired gas exchange and paininduced hypoventilation predispose to atelectasis, retention of pulmonary secretions, pneumonia and respiratory failure.

Adequate analgesia is therefore the cornerstone of effective rib fracture management.

As a general rule, escalation of analgesia is guided by the risk stratification score although in our experience, individual patient requirements can vary hugely. Lower scores are treated with oral analgesia in the first instance whereas the highest scores should be referred for specialist pain team input and consideration of regional anaesthesia.

Locally, patients are grouped depending on their Battle Score (Table 3).

Risk factor

Score

Age

1

Score 1 for each additional 10-year increase after the age of 10

Number of rib fractures

3

Score 3 for each additional rib fracture

Chronic lung disease

5

Anticoagulant use pre-injury

4

Oxygen saturations

2

Score 2 per 5% reduction in oxygen saturations; starting at 94%

Table 1: Battle Score.

Final risk score

Probability of developing complications

0-10

13%

11-15

29%

16-20

52%

21-25

70%

26-30

80%

31+

88%

Table 2: Probability of complications.

Battle score

Recommendation

Conservative

0 -10

simple oral analgesia, may be safe for discharge home

Progressive

11-20

consider PCA

Aggressive

21-30

PCA and consideration of regional anaesthesia

It is vital that patients Emergent 31 or more urgent assessment for regional anaesthesia are able to cough and take a deep inspiration.

Table 3: Battle score and recommendations.

If pain is continuing to limit effective respiration or engagement with physiotherapy then analgesia must be upAnalgesia should therefore always be reviewed titrated as a priority. Elderly patients with in a patient who is newly confused. cognitive impairment may not always be able to articulate that they are in pain and so attention There are several factors that must be should be paid to non-verbal and observational taken into account when prescribing in the cues. These include autonomic changes, facial elderly. Non-steroidal anti-inflammatory expressions and drugs (NSAIDs) are often contra-indicated body language in the older adult due to pre-existing medical as well as conditions such as heart failure, renal failure inter-personal or risk of gastro-intestinal bleeding. Codeine interactions. and oral morphine are renally excreted and Tools such as should be used with extreme caution in renal The Abbey impairment due to the risk of accumulation.

Pain Scale14 or Oxycodone is therefore preferred. With Visual Analogue all routes, opioids can cause hypotension, Scales should sedation, falls and delirium. be considered.

Alongside many The use of Patient Controlled Analgesia (PCA) other causes, requires both cognitive ability and manual pain is also a dexterity. Patients who are confused, have well-recognised concurrent upper limbs injuries or those with trigger for severe arthritis are likely to have difficulties delirium. and this must be taken into consideration. >>

â&#x20AC;&#x153;Morbidity and mortality from rib fractures occurs as a result of respiratory complications.

Direct trauma, impaired gas exchange and pain-induced hypoventilation predispose to atelectasis, retention of pulmonary secretions, pneumonia and respiratory failure. Adequate analgesia is therefore the cornerstone of effective rib fracture management.â&#x20AC;?

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Subspecialty Section

Regional anaesthesia reduces the systemic opioid burden which is particularly important in the elderly who are more susceptible to side effects15. Conventional techniques to manage rib fractures include epidural analgesia, paravertebral and interpleural blocks. However, these are relatively contraindicated in those who are anti-coagulated16; which accounts for a moderately large proportion of older adults. Epidurals in particular also come with other added side effects including hypotension, urinary retention and the potential for motor block which can limit mobility17.

Serratus anterior and erector spinae blocks are comparatively newer techniques which have fewer side effects and very few contraindications; making them an ideal option for the elderly population.

Other considerations Chest physiotherapy is essential for all patients with rib fractures18. Evidence also supports the use of humidified oxygen and saline nebulisers to help with secretion clearance19. In patients

Rib fracture patients admitted under the care of Trauma and Orthopaedics (in contrast to General Medicine or Cardiothoracics) tend to be polytrauma patients who have additional injuries.

This adds an extra layer of complexity to their management.

In particular, patients with spinal injuries who require immobilisation or spinal precautions are at higher risk of deterioration from a chest point of view as their ability to comply with physiotherapy and clear secretions is limited. It is important that this increased risk is recognised from the outset as these patients usually require rapid escalation of analgesia; often irrespective of their risk stratification score.

â&#x20AC;&#x153;Rib fracture patients admitted under the care of Trauma and Orthopaedics (in contrast to General Medicine or Cardiothoracics) tend to be polytrauma patients who have additional injuries. This adds an extra layer of complexity to their management.â&#x20AC;? with lung contusions, clinicians should have a low threshold for starting antibiotics if infection is suspected; though to our knowledge, there is currently no evidence to support their use prophylactically.

Risk stratification tools such as the Battle score are useful to help communicate the severity of an injury to both patients and families. In turn, they can also be used to introduce discussions around escalation of treatment. Many patients who sustain rib fractures are elderly and frail with multiple comorbidities and ensuring that appropriate ceilings of care are put in place in a timely manner is essential.

Surgical fixation

Figure 1: 3D rib fracture reconstruction. Image courtesy of Dr Ed Sellon MRCS MSc(SEM) FRCR RAMC, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust.

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Surgical fixation aims to stabilise the chest wall to facilitate effective respiration but is a somewhat controversial area and consensus on management is required; particularly in the elderly population.

Several studies have proposed that fixation in patients with severe flail chest can lead to a reduction in the incidence of pneumonia, reduced length of intensive care admission, improved lung function and earlier return to work20â&#x20AC;&#x201C;22.

Subspecialty Section

However, the majority of trials have only included patients that are eligible for mechanical intubation and ventilation and therefore omit the frail elderly.

A study published earlier this year looking at non-flail injuries has suggested that surgical fixation can improve the primary outcome of pain control at two week followup23. However, patients aged over 80 were actively excluded.

There remains a paucity of robust evidence when it comes to surgical management in the older adult.

Our experience Whilst orthogeriatrics is a well-established model in hip fracture care, most geriatricians do not have experience in managing patients with rib fractures. Perioperative medicine is a rapidly emerging speciality and, in this context, we have recently become one of a few centres in the UK to launch a Major Trauma Geriatrics service. This has provided us with an insight into the challenges we face in caring for these patients.

It is clear that management of elderly patients with rib fractures requires a multidisciplinary approach from physicians, trauma and orthopaedic surgeons, thoracic surgeons and specialist pain teams including anaesthetists who are skilled at performing regional blocks. This however raises questions about where these patients should be managed and by whom.

Physicians are not traditionally trained to manage rib fractures and nursing staff on medical wards often not familiar with patient-controlled analgesia or epidural catheters. Conversely, surgeons are arguably not best placed to care for the complex elderly who do not require operative intervention. Inter-disciplinary learning and shared decision making is therefore key.

In our experience, there are relatively few anaesthetists who are skilled in the newer regional anaesthetic techniques which may be more suited to the elderly population. This means that their availability can be limited; especially out of hours when increasing constraints on emergency operating theatre capacity means that these patients are often not seen as a priority.

Locally, we have developed a rib fracture working group and pathway; aiming to raise awareness of chest wall trauma in older adults and promote prompt recognition of injury through early CT. Appropriate analgesia is guided by the Battle Score and patient pathways through the hospital are facilitated by early senior clinical review. Through clear lines of communication and collaborative learning we are aiming to improve the quality of care for these patients.

The Future Many elderly patients admitted with rib fractures have their diagnosis delayed as their injuries are not immediately recognised.

Choice of analgesia is limited in the context of cognitive impairment, comorbidities and concurrent use of anticoagulation. As a result, these patients are at particularly high risk of deterioration and it is therefore vital that care is escalated early. Multi-disciplinary rib fracture working groups, clear clinical pathways, expansion of orthogeriatric/ perioperative medicine services and further research to help guide best practice are all required if we are to improve outcomes for this patient group. n

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

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Subspecialty Section

Fragility Fractures, Frailty and Fragmented Care Shvaita Ralhan and Lauren Richardson

Shvaita Ralhan trained in Geriatric and General Internal Medicine in London, and is now a Consultant in Perioperative Medicine at the John Radcliffe Hospital.

She is interested in major trauma in older patients and has set up the Major Trauma Geriatrics service in Oxford.

She is passionate about teaching, has completed a Masters in Clinical Education, and runs the Perioperative Medicine fellowship programme in Oxford.

Major trauma is traditionally viewed as a disease of young men that occurs due to high-energy mechanisms of injury. The ageing population in the UK means this demographic is rapidly changing. Trauma Audit and Research Network (TARN) data demonstrates this profound change; the elderly are soon set to represent the largest group of patients suffering major trauma with a fall from less than 2m as the causative event1.

F

railty and comorbidity in these patients may mean that they have poorer outcomes than their younger counterparts; but this data also highlights the considerable and unacceptable variation in care that older trauma patients receive.

These patients are more likely to be seen by a junior team member in the Emergency Department (ED), are more liable to delayed investigation and surgery, and are ultimately at an increased risk of death2.

as a distinctive health status that underpins how best to manage patients in later life.

There is no one accepted definition. Most simplistically, frailty can be viewed as decreased physiological reserve across multiple organ systems3. This decrease in reserve puts the person at risk of unpredictable deterioration in their health from what is a relatively minor stressor (Figure 1)4.

Frailty Lauren Richardson is an ST7 Registrar in Geriatric and General Medicine working in the Thames Valley. Whilst undertaking a fellowship in Perioperative Medicine she helped to develop the Major Trauma Geriatric service at the John Radcliffe Hospital in Oxford.

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Frailty is not a new concept and has been described in the literature for over three decades. It is now rightly being widely recognised

Figure 1: Frail people display low resilience to minor stressors and are less likely to return to independence.

Adapted from: Frailty in elderly people, Clegg et al. Lancet. 2013;381(9868):752-62.

Subspecialty Section

Frailty encompasses physical, cognitive and social domains and remains a complex syndrome that has overlap with sarcopenia, cachexia, disability and comorbidity (Figure 2).

There are several common misconceptions about frailty that deserve special mention.

Frailty is associated with ageing but is not synonymous with chronological age. Not all old people are frail; indeed frailty is observed in younger people. Frailty is not just a co-morbidity count; frail people are often co-morbid but fewer multi-morbid people are frail5. Furthermore, frailty varies in its severity and is not a static state and can therefore be modified.

Frailty is important in the surgical population and its prevalence is both high and increasing. In fact, frailty in the trauma population has been found to be highest out of all surgical specialties with studies reporting a prevalence of up to 53%6. It is essential to recognise as it is an independent risk factor for morbidity, mortality, protracted length of stay and institutional discharge. Once recognised, addressing and modifying the multisystem condition of frailty using comprehensive geriatric assessment (CGA) is increasingly supported in the literature7,8. CGA can be defined as a multi-dimensional interdisciplinary process to determine a frail older personâ&#x20AC;&#x2122;s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for their treatment9. It is an iterative, patient-centred, diagnostic, and therapeutic process that lies at the core of the practice of geriatricians, (Figure 3) and evidence has shown that older adults are more likely to be alive and living in their own home if they receive CGA on admission to hospital10.

Many measures of frailty exist and their utility depends on the clinical or research context in which they are used. The most common measure in primary care is the modified Frailty Index (mFI); an electronically calculated score derived from data routinely held in the patients GP record.

In the hospital setting the Rockwood Clinical Frailty Scale (CFS)11 and the Edmonton Frail Scale (EFS)12 are often used. The CFS has been advocated as a screening tool by several national organisations including The Specialist Clinical Frailty Network (SCFN), The Acute Frailty Network (AFN), The National Emergency Laparotomy Audit (NELA) and TARN. It has gained even greater recognition since its use was encouraged during the COVID-19 pandemic to aid decision making around appropriate ceilings of care during a time when unprecedented strain was predicted on health-care systems. A large study by Hewitt et al. in COVID-19 patients found that disease outcomes were better predicted

by frailty than either comorbidity or age alone13. The CFS is a simple, pictorial, valid frailty screening tool and is also available as an app (Figure 4).

The EFS is more time consuming but has the advantage of identifying domains in which interventions can be targeted to modify frailty and may be more suited to the outpatient setting.

Frailty Comorbidity

Sarcopenia

Cachexia

Disability

Figure 2: Frailty and its overlap with other geriatric syndromes. Adapted from: Frailty in the older surgical patient: a review, Partridge et al. Age and Ageing. 2012;41:142-7.

UK hip fracture care â&#x20AC;&#x201C; the frailty success story Hip fracture care in the UK is an outstanding example of how national initiatives, collaboration between trauma surgeons and geriatricians, continuous feedback through the National Hip Fracture Database (NHFD) and financial incentive via Best Practice Tariff (BPT), has transformed the care of a traditionally neglected group of frail patients. The last decade has seen huge improvements in the quality of care UK hip fracture patients receive.

Whilst other factors such as reduced time to surgery will have also contributed to improved outcomes, the rise of routine specialist multidisciplinary care for this vulnerable group is key to the reductions in mortality, length of stay and functional dependency that have been observed.

Many would like to see this fantastic progress expand into all fragility fracture care nationally. >>

psychological environment

cognitive

nutrition

Comprehensive Geriatric Asessment

quality of life

social

polypharmacy

functional status

comorbidities

Figure 3: Components of Comprehensive Geriatric Assessment.

Figure 4: Rockwood Clinical Frailty Score. Adapted from: A global clinical measure of fitness and frailty in elderly people, Rockwood et al. CMAJ. 2005;173(5):489-95.

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Subspecialty Section

energy fragility fractures. The older trauma population are often under triaged, with delays in imaging and additional injuries being identified late. Therefore, the initial ISS may be inaccurate and underscore the more severely injured who would benefit from the input of a geriatrician.

In our centre, we found that nearly half of our elderly trauma patients with lower injury severity scores would have benefitted from geriatrician review. Key themes identified were frailty, polypharmacy, falls and cognitive impairment. Increasing age was not surprisingly associated with an increasing need for geriatrician input15.

A subset of frail older trauma patients who lie outside the remit of the BPTs are only seen by a physician if they deteriorate acutely. In this context, review is reactive rather than preventative, is performed by different medical on call teams and often not by a trained geriatrician. Whilst these patients are deemed to have comparatively less severe injuries they are just as co-morbid and frail. We suggest that frailty assessment and CGA at the point of their index presentation is key in order to reduce falls risk, reduce perioperative risk, manage comorbidities and prevent repeated admissions.

We propose that orthogeriatric services will need to expand beyond the BPTs and adapt to meet the growing needs of this population.

Conclusions Recent changes in Best Practice Tariff In April 2019, new criteria were added to the Major Trauma BPT stating that all patients aged 65 or over with an Injury Severity Score (ISS) of >15 should have a CFS completed by a geriatrician within 72 hours of admission.

Although many would argue that a CFS alone in this subset of major trauma patients would add little to their outcomes, many geriatricians viewed this as a ‘foot in the door’, with the financial incentive providing some welcome impetus to develop services for trauma patients beyond those with hip fractures. In an MTC like ours we see approximately 300 patients above 65 years with an ISS >15 per year. The BPT uplift is £1,401 per patient, which would be an approximate income loss of up to £420,300 per annum, if geriatrician input had not been introduced when the BPT was amended.

Now that the CFS has been incorporated into the Major Trauma BPT we hope that it will evolve and develop over time to drive up quality of care in this patient cohort; much like we have seen in hip fractures.

Subsequent publication of the ‘Care of the older or frail orthopaedic trauma patient’ BOAST in May 2019 was a welcome addition14.

It advocated clear standards for all patients admitted with either a fragility fracture or

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major trauma with a CFS of five or more; suggesting CGA as well as orthopaedic, anaesthetic and orthogeriatric collaboration.

Amongst its 17 standards it highlighted the importance of clear pathways of care for elderly patients with blunt chest wall trauma including early access to regional analgesia (an important group of patients that are discussed in another article in this issue).

In April 2020, NHS England also extended the scope of the current hip fracture BPT to include fractures of the femoral shaft and distal femur. This is a long overdue addition that will hopefully mean that the specific part of the femur that is fractured will no longer dictate the quality of care that a patient receives.

Fragmented care The introduction of the new BPTs in trauma has facilitated geriatrician input for a group of patients with a high level of frailty, morbidity and mortality. Arguably, however, they may have created further divisions in care.

The major trauma BPT only includes patients with an ISS over 15. The ISS was developed in the 1980s based on information from young major trauma patients in high-energy transfer injuries. This puts into question its validity in an older trauma population sustaining low

Trauma in the elderly poses a significant and rapidly growing healthcare challenge.

Prevalence of frailty in this population is high and as geriatricians we welcome the new BPT changes that give the financial incentives to trusts to hopefully widen practice beyond hip fracture services. Unfortunately however, service development that is mapped to and driven by national tariffs means that further fragmentations in care are now becoming evident.

Management of the older trauma patient requires whole system changes. The combination of a cash strapped NHS postpandemic and workforce problems in geriatrics means that divisions in care are going to prove hard to overcome. However, changes are vital in ensuring that older trauma patients receive equivocal care regardless of the location of their fracture or the estimated severity of their injury.

Acknowledgement Trauma Data and Information Team, Oxford University Hospitals NHS Foundation Trust – for data collection used to support the business case for MTC Geriatrics. n

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

Subspecialty Section

Workforce challenges in orthogeriatrics Faye Wilson and Shvaita Ralhan

Faye Wilson has worked as a consultant orthogeriatrician in Sunderland since 2014. She completed both her undergraduate and postgraduate training in London and prior to taking up her consultant post completed a fellowship in orthogeriatric medicine at Imperial College London and a Masters degree in Cardiff.

Shvaita Ralhan trained in Geriatric and General Internal Medicine in London, and is now a Consultant in Perioperative Medicine at the John Radcliffe Hospital. She is interested in major trauma in older patients and has set up the Major Trauma Geriatrics service in Oxford. She is passionate about teaching, has completed a Masters in Clinical Education, and runs the Perioperative Medicine fellowship programme in Oxford.

The rapid expansion of orthogeriatric services in England and Wales over the past decade is remarkable. National benchmarking, real-time outcome feedback and linked financial incentives have led to specialist multidisciplinary care becoming routine and seen outcomes improve1.

T

he benefit of having embedded senior geriatric input on the trauma ward was highlighted during the peak of the COVID-19 pandemic. Risk factors conferring poor prognosis in SARS-CoV-2, such as increasing age and co-morbid burden, are common in those with fragility fractures, making early senior medical input and escalation decisions key2. Orthogeriatricians are uniquely well placed and experienced in both making and communicating these difficult decisions, yet in some units services were reduced or substituted.

and pastoral support to medical and ward staff.

These all help to change the culture of a trauma ward to one which is focussed on providing high quality care to older frail patients routinely.

Despite the many potential benefits, many trauma services have not been able to employ dedicated integrated geriatric support. So, why is that and what could we do to try to change it?

â&#x20AC;&#x153;The RCP has been trying to understand factors influencing traineesâ&#x20AC;&#x2122; career choices, and when surveyed, trainees consistently raise the same points. Geographical location of the post and the impact of this on family life, the perceived balance between speciality work and general medicine, and the pressures and stresses of being the medical registrar on-call were all deterrent features.â&#x20AC;?

As well as the obvious clinical roles orthogeriatricians fulfil, they can also provide other benefits to orthopaedic departments.

These include: providing consistent ward level leadership; promoting clear lines of communication between patients, relatives and staff; involvement in service development and quality improvement; helping to embed geriatric principles into routine ward care; and education

Medical workforce vacancies Surveys of junior doctors leaving Foundation training show declining numbers are choosing to progress directly into specialist training programmes. Despite this change to the traditional career pathway, fill rates for Core Medical Training (CMT) remain high nationwide, with 100% of posts filled in 20193.

Sufficient recruitment into ST3 posts, however, shows worrying trends in terms of long-term workforce planning across all medical specialities.

The number of trainees completing core training >>

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Subspecialty Section

and choosing to apply for Higher Specialist Training (HST) are currently insufficient to fill available ST3 posts. Geriatric medicine programmes filled 69% of their ST3 posts in 2019, with regional variation of between 25 and 100%4. However, even if all ST3 posts were full, this would not be enough to fill all current consultant vacancies. 2018 data from the Royal College of Physicians (RCP) shows that 43% of advertised consultant posts went unfilled across all specialities5.

The RCP has been trying to understand factors influencing traineesâ&#x20AC;&#x2122; career choices, and when surveyed, trainees consistently raise the same points. Geographical location of the post and the impact of this on family life, the perceived balance between speciality work and general medicine, and the pressures and stresses of being the medical registrar on-call were all deterrent features. The last of these, the difficulties of the medical registrar post, is especially important, with 44% of core medical trainees surveyed saying they felt poorly prepared for this role and that it put them off applying for HST6.

Work-life balance whilst a medical registrar is particularly relevant in geriatric medicine, as

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15% of trainees work less than full time (LTFT), around two thirds are female, and, unlike some other medical specialities, most trainees continue with acute general medical on-calls for their entire training period7.

Orthogeriatric recruitment On completion of training, geriatric trainees are in a strong position, with a surplus of available consultant posts. More geriatricians complete training every year than any other medical speciality and geriatric medicine has the highest fill rate of advertised consultant posts.

Despite this, over 50% go unfilled due to lack of a suitable candidate, with figures probably an underestimation due to unadvertised posts5.

In addition, more than half of advertised geriatric jobs are new posts, often in innovative sub-speciality areas such as acute frailty or perioperative medicine. These may have significant draw for trainees and orthogeriatrics may not always compare favourably7.

Poor on-call experiences on surgical wards as a medical registrar due to previously mismanaged clinical situations or difficult interactions with surgical staff can lead to the

misconception that working relationships will be challenging or clinical work will be unrewarding. There may also be concerns about being responsible for frail older patients on non-geriatric wards, with out of hours medical support provided by disinterested or inexperienced junior surgical trainees.

During specialist training, exposure to different models of orthogeriatric care will vary. Some trainees will experience only liaison services, attending the trauma ward infrequently to see new or unwell patients. For geriatricians, trained to provide individualised, multifaceted care as part of a multidisciplinary team, this model can seem unappealing or unsatisfactory. Conversely, some trainees will see an integrated service with daily early morning consultant input as less amenable to juggling childcare and working LTFT. Orthogeriatrics is a relatively new subspeciality, and for many more experienced geriatricians there will have been no specific orthopaedic training as a registrar. This may result in some highly skilled but not specialist geriatricians feeling uncomfortable working in this area.

Subspecialty Section

Potential solutions

Reshaping services

Improving recruitment and retention

Geriatricians learn to manage medically complex, frail patients during a lengthy and costly training period. Given the current deficit in orthogeriatric numbers and rapidly expanding older trauma population we are unlikely to solve workforce issues solely through employing geriatricians. However, by getting creative we can expand services without diluting the quality of care delivered.

CMT has now been redesigned into the longer three-year Internal Medicine Training (IMT) programme. This aims to provide a more structured preparation for taking on the role of medical registrar, with a more supportive transition period and a widening of clinical experience to include geriatric medicine and critical care.

Alongside this, the RCP has worked to support trainees by introducing a chief registrar scheme and flexible portfolio training8.

These aim to improve conditions on the acute take, increase support within acute hospitals for this grade and allow development of other professional skills such as management, research, medical education and quality improvement.

â&#x20AC;&#x153;If we want to encourage trainees, whether medical, anaesthetic or surgical, to return as our consultant colleagues it is up to all of us, whatever our own specialism, to showcase positive aspects.â&#x20AC;?

At consultant level, orthogeriatric job plans need to be flexible, with opportunities to job share, incorporate other interests and avoid excessive out of hours commitments given the number of LTFT and female geriatricians.

Promoting trauma geriatrics There is much in orthogeriatrics to generate enthusiasm. If we want to encourage trainees, whether medical, anaesthetic or surgical, to return as our consultant colleagues it is up to all of us, whatever our own specialism, to showcase positive aspects. Observing skilled professionals with mutual respect collaborating to deliver high quality care or education is a powerful incentive, and the opposite is also true.

By designing trauma services that have good geriatric care embedded within them (such as cognitive assessment, nutritional supplementation, early mobilisation and pressure area care) departments can allow busy geriatricians to focus on the more complex aspects of patient care. Ensuring reliable clinical ward support, adequate inpatient therapy provision and outpatient follow-up from a fracture liaison service also helps to relieve pressure on consultant time and make services more sustainable.

We need to look at who delivers routine daily care, much of which is straightforward, especially under direct supervision from a consultant geriatrician. Advanced nurse practitioners (ANPs), clinical nurse specialists (CNs) and physician associates (PAs) can successfully deliver some aspects of care with a model of training that is shorter and less costly. Furthermore, they can improve clinical continuity on the ward, provide mentoring

for less experienced team members, and help nursing retention by providing a rewarding role with an enhanced career path. In some hospitals support from anaesthetists with a specialist interest in perioperative medicine may also be available.

We are not proposing these individuals replace geriatricians, but act to redistribute the workload and complement the existing team.

Many centres already have success in this area in the form of hip fracture specialist nurses.

Understandably there are concerns that this reshape of the workforce could threaten quality of care with less experienced staff delivering care to a group of complex frail patients.

However, we feel the key to success of use of this extended workforce is underpinned by careful role design and expansion of practice that is jointly developed, supervised and appraised by senior nursing staff and orthogeriatricians.

Summary Orthogeriatric care has been shown to improve outcomes following hip fracture but services are variable in design and geriatric consultant input, at least in part due to the growing burden of workforce issues. Perceived challenges in the medical registrar role impact upon recruitment and are being addressed by medical colleges, but there is much that orthopaedic departments can do to attract geriatricians by extending roles and redesigning services. n

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

The wealth of data easily available from the NHFD, allowing individuals and services to audit outcomes following changes, is a significant positive not always appreciated amongst geriatric trainees. When highlighted this can provide the basis for interdisciplinary collaboration on quality improvement and research projects.

Regional trauma networks are well established to share orthopaedic best practice.

Orthogeriatric networks and specialist interest groups (SIG) are operational in some areas, but expanding trauma networks to encompass local geriatricians could provide the impetus needed for these to become more widespread. From geriatricians, the formation of a dedicated national orthogeriatrics SIG is perhaps long overdue.

JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk | 63

Products, Courses and Events 15th Trauma & Orthopaedics Update

Val dâ&#x20AC;&#x2122;Isere, 1-4 February 2021 www.doctorsupdates.com info@doctorsupdates.com +44 (0) 208 7151924 Doctorsupdates 2021, in their 32nd year will feature 15th 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

News from the Orthopaedic Institute We thank all our NHS colleagues for their amazing work and commitment over the past months. The continuing requirement for social distancing has had an effect on training and we are redesigning our courses either for face-to-face presentation with fewer delegates or as Webinars. at the Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire

Please keep checking our website for new courses we are offering for our clinical colleagues.

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.

Please visit:

www.orthopaedic-institute.org

CONTACT DETAILS:

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

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

TO ADVERTISE YOUR PRODUCT OR SERVICE IN THIS JOURNAL Call Rupinder on:

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64 | JTO | Volume 08 | Issue 03 | September 2020 | boa.ac.uk

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