Journal of Trauma & Orthopaedics - Vol 8 / Iss 4 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 08 | Issue 04 | December 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

2020 NICE Guidelines: Virtual Learning â&#x20AC;&#x201C; key recommendations p22 Moving Forward p38

Amputation in the context of tumour or infection p57

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Promoting excellence in patient care and treatment outcomes in trauma and musculosketal disorders www.aouk.org | www.aofoundation.org

Journal of Trauma and Orthopaedics

Contents

In this issue...

From the Executive Editor

Deborah Eastwood

5 From the President Bob Handley 6- 7 Latest News 8- 19 News 8 News: BOA Virtual Congress 2020 18 News: New BOA Trustees 20 BOA Council 22 The 2020 NICE guidelines for

primary hip, knee and shoulder replacement: key recommendations and the ongoing need for better quality evidence in orthopaedics

Paul Baker, Ananth Ebinesan, John Skinner, Andrew Metcalfe and Jonathan Rees

Contact Practitioner and Advanced Practitioner in primary care

26 The MSK training pathway to First

Amanda Hensman-Crook

Our response to Cumberlege, the MDR and the UKCA... making UK plc a good place for safe innovation of implants

28 ODEP and Beyond Compliance: Keith Tucker and Peter Kay

31 Double pandemic, Dr Forte

and the fork in our road

Ben Caesar

34 Major Alexander William

Lipmann-Kessel MBE MC: Surgeon, paratrooper, prisoner of war, and orthopaedic innovator

Simon Hurst, Dylan Griffiths and Roger Emery

Usman Ahmed

38 Virtual learning - moving forward 40 Zambia, FlySpec & the Rotary

Doctor Bank

Rhidian Morgan-Jones

COVID-19: second round legal issues

42 Medico-Legal Section:

Henry F Charles

46 Trainee Section:

The future of orthopaedic training: diversity and education

Ran Wei, Kathryn Dayananda and Oliver Adebayo

Pre-amputation: the first step in amputee rehabilitation

50 Subspecialty Section:

54 Subspecialty Section:

Amputation after trauma

Jowan Penn-Barwell

57 Subspecialty Section:

Amputation in the context of tumour or infection

Martina Faimali and Will Aston

60 In Memoriam:

John Ireland, Kyle Martin McDonald

Jennifer Fulton

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.

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 04 | December 2020 | boa.ac.uk | 01

69%

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

Bone cement with gentamicin and clindamycin * Sprowson AP et al. Bone Joint J 2016; 98-B: 1534â&#x20AC;&#x201C;1541

www.heraeus-medical.com

Credits JTO Editorial Team Deborah Eastwood (Executive Editor) Rhidian Morgan-Jones (Editor) David Warwick (Medico-Legal Editor) Tricia Campbell (Trainee Section Editor) Will Aston (Guest Editor) Jowan Penn-Barwell (Guest Editor)

l l l l l l

BOA Executive

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

l Bob Handley (President)

Policy and Programmes

l Don McBride (Immediate Past President)

Director of Policy and Programmes

l John Skinner (Vice President) (Honorary Treasurer)

Programmes and Committees Officer

l Deborah Eastwood (Vice President Elect)

- Julia Trusler

- Harriet Wollaston

Educational Programmes Assistant

- Eliza Khalid

l Simon Hodkinson (Honorary Secretary)

Communications and Operations

l Phil Turner

Director of Communications and Operations

- Emma Storey

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

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

Interim Director of Communications and Marketing

- Annette Heninger

Marketing and Communications Officer

- Sabrina Nicholson

Membership and Governance Officer

- Natasha Wainwright

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

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 Deborah Eastwood

ell, fancy that... I find myself the Editor of a prestigious journal – one of the many surprises that 2020 has dealt me and us! I admit I am looking forward to carrying on where Bob left off under the expert guidance of Nick, Annette and my colleagues Hiro Tanaka and Rhidian Morgan Jones. We will continue to try and play nicely with the new kid on the block – the Transient Journal where Fergal Monsell helps us curate the content! For all this tumultuous year has taught us, I for one will be glad to welcome in the new year – I am not naïve enough to think that ‘all will be well’ in 2021 with COVID-19 merely a distant memory but I do believe I will approach it with renewed optimism and determination. This year has taught us to pull together in a way that has been unique to me in my career-time and perhaps in yours too. Our front cover echoes all our thoughts when we say thank you to our colleagues, our patients, our families and friends who have helped us through… One high spot of 2020 was the BOA medical student essay prize which attracted a record number of entries and a worthy winner in Silvia Allikmets (page 17). The BOA Council is now much more knowledgeable about the benefits of social media and as a result, several of us are now active twitterers! Never let it be said that we don’t move with the times. If these students are the future of orthopaedics, I am very impressed. Whilst on the subject of ‘youngsters’, I was glad to hear that a past president of BOTA enjoyed his BOA supported fellowship to France (page 10). 2021 sees four new recruits joining Council, bringing some welcome diversity, as well as huge knowledge and experience, to the leadership of our Association. You can read about them on page 18. It is clear too from the articles on NICE Guidelines including the call for involvement from our members, our response to Cumberledge and the future of UK plc, and on the role of the first contact practitioners (FCPs) in the delivery of MSK services that the future is looking bright. We must ensure that it lives up to its promise. The subspecialty section on amputation shows how far this quintessential original surgical procedure has moved with the times and rightly highlights the value of prehabilitation when possible. Innovation has always been a key aspect of our profession as illustrated in the short biography of Lipmann-Kessel. The fields of war may have taught us much but he felt that ‘exciting and wonderous enterprise is more profitably to be found in peacetime’. This year during our war against the virus, significant and rapid scientific progress has been made in the field of vaccine development with perhaps wider implications for the management of other infectious diseases too, another reason for hope for 2021. Despite my hopes for 2021, the past year has been difficult and Ben Caesar’s article (page 31) about the Double Pandemic we have been facing reminds us to be kind to ourselves and to others. On behalf of the BOA and all of us at the JTO, I thank you all for your support and I wish you all some fun and relaxation over the festive season... n

From the President

Too many tactics and not enough strategy? Bob Handley

Being President of the BOA is not quite as I had anticipated. The coronavirus, caring for patients, supporting surgeons and Zoom are now the ingredients to produce a fare of tactics and strategy for the 2020-21 Presidential year. As the pressure of events drives us into a corner we could easily become consumed by developing tactics to resolve immediate issues, just firefighting. However, the bigger the problem the greater the long term effects and the consequent need for strategy.

his dilemma is reflected in efforts to prioritise care and the difficulty recognising when the short-term morphs into the long-term. Many of us have been brought up with an ATLS approach to immediate and pressing problems; which is to have a ranking of potential issues, to seek them out and to deal with each as soon as it is found. We are equally familiar with the NICE process for assessing treatment pathways depending upon a balance of cost and outcome distilled into QALYs. In general even though we have worked in a resource limited environment these conceptual approaches to prioritisation have not competed too much, but we should not assume this will continue. The relief of pain and restoration of function with a long life expectancy make many of our procedures remarkably cost effective. However, they are vulnerable to side-lining as a consequence of terminology; elective often being interpreted as synonymous with optional, and the stereotypic perception that many are lifestyle procedures. The balance we have to strike is our full co-operation with the necessary tactics to tackle the immediate crisis along with a resolute strategy to maintain the status of and capability to deliver pain relief and restoration of function. We can achieve some of this with the application of a ‘Keep calm and carry on’ philosophy and a re-affirmation of evidence. However, the hearts and minds argument for appropriate recognition and resource will be more resonant if we learn from our logo and present it shoulder to shoulder with our patients. Thus far the BOA has responded well to COVID-19. Phil Turner and Julia Trusler have been vigilant and proactive to keep us informed and involved. Having independent eyes on the evolving situation around the UK would in the past have been difficult, but the hard work of Julian Owen and his PA Helen Davies in resurrecting the BODS network has given the T&O community an easy and regular way of communicating at the level of Clinical Directors. The tactics and strategy of training are also a significant problem. The short-term crisis tactics for service delivery should not be allowed to derail training. There should be a strategic aim to allow every NHS funded case to be a training opportunity and targeted tactics for those areas where this is not occurring. This is not just a burden that will be borne by the individual trainees but will affect the whole system if there are delays to CCT. The centrepiece of a BOA year is the Congress. This year it could have fizzled out, but with the efforts of many and the particular efforts of a few it was a great success. Simon Hodkinson, Charlie Silva, Venease Morgan and “next slide please” Emily Farman kept the show on the road. Next year we are hedging our bets by planning for each of a full, hybrid and virtual Congress. It would be an honour to be a virtual BOA President, I will do my best to be a real one. n JTO | Volume 08 | Issue 04 | December 2020 | boa.ac.uk | 05

Latest News

BOA Virtual Training Orthopaedic Trainers (V-TOTs) With the cancellation of face-to-face educational courses, the BOA have developed a Virtual Training Orthopaedic Trainers (V-TOTs) course facilitated by the BOA Educational Advisor Lisa Hadfield-Law. The V-TOTs course is currently being delivered primarily for those concerned about meeting CCT requirements, but anyone who wishes to register their interest should email policy@boa.ac.uk to be added to a waiting list. Please see further information, along with detail on the structure, assessment and cost of the V-TOTs course here: www.boa.ac.uk/vtots.

BOASTs • New ACL BOAST The BOA has recently published a Specialty BOAST, led by BASK and BOSTAA on the Best Practice for Management of ACL injuries, as well as an accompanying guideline. The BOA is pleased to be able to publish this Specialty BOAST as part of a development of the wellknown BOAST ‘branding’, to enable a wider range of standards documents to be created in collaboration with Specialist Societies. • Supracondylar Fractures BOAST Updated The BOA Trauma Committee has also recently published an updated BOAST ‘Supracondylar Fractures in the Humerus in Children’. This BOAST will be the next to feature in Injury, so keep an eye out for this too! All new Specialty BOASTs, as well as Trauma BOASTs, can be found on the BOA website at www.boa.ac.uk/boasts.

BOA Virtual Training Orthopaedic Education Supervisors (V-TOES) V-TOES will be offered through two routes: you can join a small cohort on a paid-for course (‘Regular V-TOES’) or in many regions we are holding a ‘regional V-TOES’ at the request of the TPD: • Regular V-TOES courses will have lower numbers of participants compared to regional courses and will be given greater moderation by faculty, and tailored interactions between faculty and participants based on the needs of the cohort. • Regional courses will cover high numbers of participants on each programme, with TPDs and College tutors joining as faculty. The new curriculum will require more collaboration between departments within deaneries and the BOA Regional V-TOES courses will be supporting this. These courses are being delivered as part of a BOA-led national strategy to support implementation of the new curriculum – this commenced in December 2019 and will be delivered in those regions where requested and organised by the TPD (check with the TPD for your region if you aren’t sure).

BOA ‘Coping with COVID’ webinar series

2021 Medical Student Essay Prize

At the end of October we held a webinar entitled ‘Coping with COVID: Elective operating and the second wave of COVID-19’, in partnership with BODS, BHS and BASK, which provided several different perspectives on how elective surgery was going and what data was available. We’ve had great feedback from this, with one participant describing it as “a sobering, pragmatic and informative session with erudite speakers offering guidance and support for our local challenges.” Further webinars in our ‘Coping with COVID’ series are due to be announced shortly, so keep an eye on our website and news emails.

The 2021 Medical Student Essay Prize title is ‘As a medical student, what would encourage you to consider a career in T&O and what are the perceived barriers to such a career?’ Applications for the 2021 Medical Student Essay Prize are scheduled to open 1st April 2021 and essays should be no longer than 1,000 words. Further information on the 2021 Medical Student Essay Prize can be found here: www.boa.ac.uk/medical-student-essay.

Latest BOA guidance

Further information on V-TOES is available here: www.boa.ac.uk/v-toes. If you are interested in V-TOES please email policy@boa.ac.uk to be added to the V-TOES waiting list.

New edition of ‘Standards for the Management of Open Fractures’ published The BOA and BAPRAS collaborated on this publication, which includes 21 fully updated chapters as well as the latest version of the associated BOAST. The book is available both online and in print, and can be found for free on Oxford Medicine Online thanks to funding from BAPRAS, the BOA and the OTS. We are very grateful to all who helped with this publication.

The BOA continues to support our members with guidance and support on COVID-19 related issues. At the time of going to press with this JTO issue, we have just launched with BESS and BSSH a document called ‘Information for patients having steroid injections in the upper limb or hand during the Coronavirus pandemic’, available at: www.boa.ac.uk/steroid-injections.

Latest News BOA Ortho Update 2021 - Saturday 9th January (AM), Online (Zoom) BOA Ortho Update Course, previously the BOA Instructional Course, will give delegates the opportunity to access new understanding and support preparation for the FRCS exam. Given the current rise in COVID-19 cases across the UK we have taken the decision to make this course fully virtual. The course will run for half a day on the morning of Saturday 9th January. Simon Hodkinson, BOA Honorary Secretary, Lisa Hadfield-Law, BOA Education Advisor and Hiro Tanaka, BOA Education Committee Chair have come to the decision that we will not be providing CBDs in 2021. The course will include the plenary update lectures from our guest faculty in a number of specialist areas which will be followed by Q&A. Programme, presentation speakers and further registration information can be found at: www.boa.ac.uk/orthoupdate.

Membership Update AGM Results We are pleased to announce that all resolutions at the AGM have passed. The main points to note are below: • Membership subscription rates for 2021 have been frozen at the 2020 level, so there will be no increase next year. • Eligibility to vote has been expanded and now includes all Home Fellows, Home Members, SAS Surgeons in the 16 years+ membership category and Post-CCT members. • We have amended our voting process to allow online voting in future for election to Council and Officer positions, and at the AGM. • The timeline for payment has been reduced from nine months to three months from the renewal date. Notice of the renewal will still be given 1-2 months in advance of the start of the year.

New Membership Benefit

Joint Action (www.boa.ac.uk/joint-action) We’d like to thank our runners who took part in the first ever Virtual Virgin Money London Marathon on Sunday 4th October, the platform is still open to donations if you would like to show your support, www.justgiving.com/campaign/JAlondonmarathon2020. Joint Action Christmas Appeal 2020! General 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 this Christmas in helping to make a difference through donating to Joint Action, www.justgiving.com/campaign/joint-action-christmas-appeal-2020. We raise funds to support the development of clinical trials in trauma and orthopaedics. In 2019 we awarded funding for the appointment of three Surgical Specialty Leads to facilitate clinical trials in our specialty and in early 2021 we will be announcing new funding for two clinical trial units. Find out more about Joint Action, The Orthopaedic Research Appeal of the BOA online and the clinical trials we are currently funding, www.boa.ac.uk/bosrc-research.

As part of our efforts to support members during all stages of their career, membership fees are now free for BOA members during Maternity, Paternity, Adoption or Shared Parental Leave. For more information and to apply email membership@boa.ac.uk.

Coming Soon – Paperless Direct Debit We will soon be offering paperless direct debit and are hoping to have this up and running by the end of December 2020. If you any queries please email accounts@boa.ac.uk.

Are your details up to date? Please log into the MyBOA area of the website and check your details are up to date, including memberships of any specialist societies. If you have not logged in yet, you can create your account at www.boa.ac.uk/set-up using your primary email that we have on record.

New Orthohub podcast with Prof Tim Briggs Orthohub have put out a ‘see one / do one’ podcast with former BOA President Tim Briggs where they discuss his time as Medical Director, the BOA Presidency, and his transition from orthopaedic surgeon to one of the most influential people in UK healthcare. This wide-ranging conversation covers the development and principles of GIRFT (Getting It Right the First Time), what are Integrated Care Systems (ICS), the role and input of the BOA, and what this all means for our profession. Access the podcast at www.orthohub.xyz/episode-11-tim-briggs-girftthe-future-of-orthopaedics.

News

BOA Virtual Congress 2020

his year’s BOA Annual Congress ‘Working Together’ – the first in a virtual format – was a great success with almost 6,000 live session registrations in total. Together with the pre-recorded content, there are more than 80 hours of video content, with over 6,500 views of these recordings to date. COVID-19 was a key topic at this year’s event. The most popular and key sessions included: • T&O and COVID-19; the Good, the Bad and the Future • Elective Orthopaedics Re-Start After COVID-19 • The Future of Orthopaedic Training: Diversity and Education • Changing Clinical Practice 2020 In case you missed them (or want to view again) all sessions are available to BOA members through the website at: www.boa.ac.uk/live-recordings. Over 1,500 abstracts were received across 19 abstract categories. All Virtual Podium and Accepted Abstracts along with the announcement of our 2020 Abstract Winners can be viewed at: www.boa.ac.uk/abstracts2020. We would like to thank every BOA member, Executive, Council, TPDs, presenters and speakers who took part in this year’s BOA Congress including, Depuy Synthes, Heraeus, Link Orthopaedics, Pfizer and Smith & Nephew for supporting the event. Work is already underway in planning for our 2021 event, whatever format this may take, but we of course hope we will see you in Aberdeen!

Please note: only those who have presented in a live session will receive a certificate, we will not be sending out certificates of attendance for the BOA Virtual Congress 2020. The Royal College of Surgeons of England has awarded up to 50.5 CPD points.

“We would like to thank every BOA member, Executive, Council, TPDs, presenters and speakers who took part in this year’s BOA Congress including, Depuy Synthes, Heraeus, Link Orthopaedics, Pfizer and Smith & Nephew for supporting the event.”

News

Honorary secretary, Simon Hodkinson, on Virtual Congress 2020 and the future

n January I started as Honorary Secretary of the BOA and preparation for the Annual Congress was in full swing. However, it rapidly became clear a face to face event was not going to happen. The decision was made to cancel Congress and after some masterful negotiation from the Treasurer we retained the contractually obligated costs for a future year.

I think the vast majority of us hope that we can hold a face to face conference in 2021 in Aberdeen. Whilst we and many others this year have shown that educational content can be delivered perfectly well via the internet, we cannot, online, replicate the human interaction element of Congress which we all recognise is important and a major reason for attending such events.

And there we sat until in June we decided we had to produce something, so the idea of a virtual Congress was suggested and rapidly agreed.

At a recent catch up meeting with the Specialist Societies it was felt that many elements of the pre-recorded material had gone down well, especially the ability to review the material on the web site very soon after the presentation.

The original idea was to keep it relatively small but as planning progressed the event expanded. It was decided to reopen abstract submission for two weeks expecting a few more submissions and to give trainees in particular, a chance to present work in 2020 given the near complete cancellation of events the year. 1,500 submissions later we had them all marked and sorted, and the second week was born!

We are also fully aware of the risk of ‘Zoom’ burn out! However, we have learnt a lot from this year and there seems an appetite to incorporate some of what was done this year into next.

Next year therefore we will look at prerecording some of the free paper sessions and making them available during Congress at various points for attendees to dip into, when and how they wish. The number of free papers in a session could also be reduced to allow more questions to be asked.

“Specialist Societies rose to the challenge and produced a huge amount of excellent material, both live and recorded, over 80 hours of which remain on the website.”

Specialist Societies rose to the challenge and produced a huge amount of excellent material, both live and recorded, over 80 hours of which remain on the website.

The Events team, Charlie, Venease and Emily, worked like Trojans to facilitate the event and we owe them a huge vote of thanks for making it work. So, did the Phoenix arise from the ashes? That is for others to decide but an educational Congress was produced and delivered, hopefully to members satisfaction. So, what of the future? As we are now, I don’t think any of us have any idea of what we will be able to do this time next year.

Some of the educational talks could well be prerecorded and then have live webinars to discuss the content of the talk.

Online presentations may well be better for international presentations which may well suit not only invited speakers but industry sponsored speakers which again could be delivered at times to suit members and repeated throughout Congress to increase exposure. As we head towards next year several societies have planned online meetings and it will be interesting to see how they approach the issue and we will learn from them. Therefore, as we are now, we will plan for three versions next year, virtual, hybrid and the real thing. Let’s hope it’s the latter. Bring on Aberdeen 2021!

News

BOA Travelling Fellowship Report: Institut de la Main, Paris, France

spent two weeks at the Institut de la Main in Paris, a private centre of excellence for hand and wrist surgery. I visited in the final months of my specialist training and I was hosted by Professor Christophe Mathoulin and Doctors Caroline Leclercq, Christophe Gras and Ahlam Arnaout. Professor Mathoulin has pioneered many arthroscopic wrist operations and Dr. Leclercq is an expert on the management of Dupuytren’s disease and upper limb spasticity. I was fortunate to assist with the following arthroscopic procedures: scaphoid non-union grafting and fixation, TFCC and scapholunate ligament repairs, ganglion excisions and arthroscopic interposition tendon arthroplasty for stage 2 SNAC. Most cases of carpal tunnel syndrome were decompressed endoscopically, with open decompression (‘classique’) reserved for severe or recurrent cases.

Matthew Brown

The team highlighted patient satisfaction with smaller scars and reduced scar pain. The minimally invasive operations were associated with steep learning curves, perhaps explaining their scarcity in specialist practice. Open operations included De Quervain’s and cubital tunnel decompressions, thumb collateral ligament repairs and a midcarpal fusion for hemiplegia. I am interested to explore the lateral digital rotation flap for use in my future practice. Theatre efficiency was optimised through a selection of lists being delivered across two operating theatres. All cases underwent regional blockade and supplementary general anaesthesia proved a rare exception. France is often overlooked as a fellowship destination; however, the institute’s dedication to minimally invasive surgery was an inspiration. I am grateful to the team for their hospitality (despite my terrible French!), to the BOA for their support and Professor Singhal who sponsored this fellowship. n

News

British Limb Reconstruction Society (BLRS) update Om Lahoti and Simon Britten

he British Limb Reconstruction Society (BLRS) was established in 1997 and current membership is approximately 220, comprising surgeons and Allied Health Professionals (AHPs). In August 2019 the BLRS hosted the 4th World Congress of combined ASAMIBR & ILLRS, essentially the world limb reconstruction community. This was the most successful World Congress to date, with over 600 delegates from 52 countries, and from delegate feedback, a very high standard of presentations and educational content. After this success, we were looking forward to our annual conference in Manchester in April 2020, but sadly the COVID-19 crisis supervened at exactly that time, leading to cancellation – similar to many other societies. We have now scheduled it for 15th and 16th April 2021 in Manchester, with both face to face and on-line options under consideration. While the pandemic has thwarted us in some respects, we have taken the opportunity to use our time in improving the overall

structure, organisation, and ethos of our society. During 2020 the BLRS has been accepted by the Charity Commission as a registered charity, necessitating an overhaul of our constitution. We have undertaken a survey of our entire membership on the issue of diversity and inclusion within the society, looking not only at gender, but also at other protected characteristics including ethnicity, religion, sexual orientation, ableness, and gender transformation. Over 100 responses are currently undergoing analysis. We are delighted by the level of member participation, and we are looking forward to developing a greater understanding of what we can do to foster participation in limb reconstruction by surgeons and other healthcare professionals from all backgrounds. The BLRS is very active in education and research. We conduct regular workshops and teaching programmes to promote the surgical techniques to deal with complex trauma, adult and paediatric deformity

correction and limb lengthening. We fund a candidate each year for the BOA Future Leaders Programme, and we generously fund annual travel bursaries for young consultants, senior trainees and AHPs. The BLRS is currently collaborating with the BOA Medico-legal Committee and Orthopaedic Trauma Society to provide practical guidelines for consent in trauma. With our new-found charity status, we are working hard to develop our academic research programme and enhance our funding of members to pursue training and visiting opportunities at centres of excellence in the UK and abroad. n

British Association for Surgery of the Knee (BASK) update Alexander Dodds, Andrew Price and Andrew Porteous

he last 12 months have proved a busy and challenging time for BASK. The spring scientific meeting was to be held in Oxford jointly with the combined knee societies of Australia, New Zealand and South Africa, but unfortunately was cancelled due to the pandemic. BASK ran three evening webinars, supported by our industry partners, to provide the membership with educational content. The free paper abstracts that were due to be presented have been collated into a supplementary edition of ‘The Knee’ and have been recently published online. BASK also contributed three revalidation sessions to the virtual BOA, with updates of soft tissue knee, arthroplasty and revision knee. BASK continues to build on its strong research portfolio, with the development of a BASK research steering group. The BASK research fellows continue to make an active contribution. Research work is supported with the work of the meniscus, revision and patellofemoral working groups. The working groups have now published a number of BOAST documents which can be found on the BOA website. Working groups for arthroplasty and ACL injury prevention have recently been set up. The BASK research survey will be circulated later in the year and be an important method of forming future research questions. Andrew Porteous has taken on the Presidency from September 2020, taking over from Andrew Price, who has come to the end of his term. Alasdair Santini takes on the role of Treasurer. This comes at a time that the organisation is likely to need to undergo major structural changes following similar changes to other BOA subspecialty societies. We continue to plan for the Spring Meeting of 2021 which is planned as a hybrid meeting and is likely to be held in May 2021. BASK welcomes membership applicants from registrars who are prospective knee surgeons and who would like to be involved in our busy research and education programme. n

Soft Impact Mallet with Weidman Silicone Handle PRODUCT NO:

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News

British Elbow and Shoulder Society (BESS) update Amar Rangan, Steve Drew and Mark Falworth

he British Elbow and Shoulder Society (BESS) remains at the forefront in guiding clinical practice driven by science and evidence. Surgeons and therapists, working together, have built a thriving and successful society. We would like to share a few of our successes and examples of good practice achieved over the last year. Our BESS annual meeting, launched on 14th October 2020, is a large scale international virtual meeting. Joined by our affiliated societies from Australia, New Zealand, India, South Africa and Europe, the resultant programme is a comprehensive showcase of the largest educational meeting ever staged by BESS, with major contributions from international opinion leaders. Most content was pre-recorded and has been available for delegates to view at their convenience until 31st December 2020. As with other specialties, the challenges to our professional practice imposed by COVID-19 have been immense. To help our patients and members, we have posted patient resources on our website providing guidance to patients on self-care during the lockdown. Additional BESS videos, covering advice and home exercise programmes on key topics, have augmented this patient resource section. These resources should prove useful to signpost during virtual clinic consultations and post-operative rehabilitation.

We are developing a formal accreditation process in partnership with the Royal College of Surgeons, for UK fellowships in shoulder and elbow surgery, enabling future trainees to secure high-quality UK fellowships. BESS has consistently promoted high quality research, particularly publicly funded national clinical trials. There are currently 10 commissioned trials within BESS. Despite the challenges posed by COVID-19 to research the UK Frozen Shoulder Trial (UKFROST) was recently published in The Lancet: www.thelancet.com/journals/lancet/ article/PIIS0140-6736(20)31965-6/fulltext. BESS continues to grow and we are proud to be aligned with the BOA and RCS equality and diversity strategy. Further details on our activities and membership can be found at: https://bess.ac.uk. n

British Orthopaedic Research Society (BORS) update - A symbiotic relationship

Wasim Khan

he British Orthopaedic Research Society (BORS) is a multidisciplinary association founded in 1961 and devoted to pursuing research relevant to orthopaedic and musculoskeletal surgery. Unlike most of the 22 BOA affiliated Specialist Societies, it benefits from a more diverse membership including surgeons, scientists, engineers and vets as well as allied health care professionals. The research interests of its membership are varied and include: Biological Science, Biomechanics, Osteo-articular Pathology, Biotribology, Molecular Biology, Bioengineering, Medical Imaging, and Patient Management. Like most specialist societies, the COVID-19 restrictions meant a change to the 2020 Annual Meeting format and for the first time in our history the meeting was held virtually on 7th - 8th September with 180 attendees. High profile international speakers described the effects of space flight on skeletal biology (Professor Mary Bouxsien, Harvard) and cutting edge

technology that is advancing tissue engineering opportunities in orthopaedics (Professor Farshid Guilak, Washington). The diverse programme has become highly clinically orientated in the last few years encouraged by affiliation with the British Orthopaedic Trainees’ Association, and this is reflected by an increasing number of surgeons attending. The Presidential Lecture was delivered by Professor Sally Roberts entitled ‘Scientists and clinicians in research – a symbiotic relationship?’. Professor Roberts is a biological scientist who has worked at the interface of clinical medicine for many years at Oswestry. She is well known for her work with the late Professor James Richardson in Autologous Chondrocyte Implantation that received NICE approval in 2017. The lecture highlighted how important developments in the history of orthopaedics have only come about through this symbiotic relationship between scientists and clinicians. The current COVID-19 pandemic and the resulting impact on healthcare delivery has highlighted

that clinical services can easily become overwhelmed and there is an ever-increasing need for innovation and research to identify better ways of doing what surgeons do. With the number of patients waiting for hip and knee replacements increasing, only trying to increase surgical capacity by doing more operations is surely not the answer. We need to also think ahead, and continue to develop and deliver therapies that would prevent the progression of focal chondral defects to more extensive degenerative changes. The next International Combined Orthopaedic Research Societies (ICORS) Meeting is being held in Edinburgh from 7th – 10th September 2022, and we look forward to hopefully meeting more of you face-to-face then. n

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Submit your abstract!

EBJIS 2021 39th Annual Meeting of the European Bone and Joint Infection Society

SAVE THE DATE 7 â&#x20AC;&#x201C; 9 October 2021 Ljubljana, Slovenia

Main topics ]

Optimising antibiotic treatment of bone & joint infections

]

Optimal bone infection sampling and microbiological processing

]

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

]

Musculoskeletal infections in children

]

Infections of arthroscopic implants, osteotomies and tendon reconstructions

]

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

]

Spinal infections

]

Fracture-related infections

Important dates

www.ebjis2021.org

Abstract Submission Deadline: 7 April 2021 Early Registration Deadline: 7 July 2021

News

British Society for Surgery of the Hand (BSSH) update David Warwick

he BSSH has shown its resilience and has risen to the challenge of responding to COVID-19 and an office reorganisation. As both BSSH and BAPRAS have grown, it has become apparent that the two organisations were diverging in their structures and workload. BSSH has now separated from BAPRAS and we are now finalising the new staffing and office arrangements.

Left: The new BSSH lapel badge designed by Terouz Pasha. Above: Alistair Platt designed and procured a washable BSSH theatre cap.

BOA Future Leaders programme: BSSH has sponsored two people for the BOA FLP in a competitive process - congratulations to Ben Dean and Adeline Clement. Modernisation: This year we have developed a Code of Conduct, a Diversity Review and a Green Agenda. We are developing a mentoring programme and more opportunities for SAS doctors. Our Constitution is also being overhauled. Hat and Badges: Zaf Naqui organised a competition for the new BSSH lapel badge and the stunning winner was designed by Terouz Pasha. Alistair Platt has designed and procured a washable BSSH theatre cap. COVID-19: The BSSH has been involved in two documents which helped the resumption of clinical services. Firstly we published the paper in Bone and Joint Open which presented the case for judicious use of steroid and secondly a BSSH working group contributed to the new BOA-BSSH-BOFAS guidelines which address the time required for isolation prior to local anaesthetic surgery and which informed the new NHSE rules. Meetings: The spring meeting, which would have had a display by the world famous sculptor Lorenzo Quinn was cancelled, we hope to have Lorenzo back for IFSSH in June 2022. The autumn meeting in Winchester was also cancelled and it was decided that a full virtual meeting was not really what was needed - we have all had the opportunity to view the outstanding webinars which Carlos Heras-Palou and the Derby team generously co-badged with the BSSH. However we did run an online Virtual Paper Competition. I am grateful to all those involved in organising this, and the generous sponsorship from Medartis and Acumed.

Expanding our reach: The BSSH is extending its central aim of education and better patient care and there have been three initiatives this year: • The Education Committee under Jill Arrowsmith’s leadership is looking at a wider educational programme for GPSI, AHP etc. • Arranged by Steve Hodgson, we have signed on behalf of BSSH a Memorandum of Understanding with the President of the West African College of Surgeons with the first webinars between WACS and BSSH held in September and October. This is in addition to a huge overseas programme run by our Overseas Chair Jonathon Jones. • The chair of BAHT, Hayley Smith, has accepted an invitation to attend our Council meeting. It has been an honour to serve the BSSH in 2020 and our Society will be very capably led by my successor Sue Fullilove in 2021. n

News

Results of the 2020 Medical Student Essay Prize

ilvia Allikmets is the winner of the 2019 BOA Medical Student Essay Prize. She completed medical school at King’s College London and, amidst the global pandemic, has started working as a Foundation Doctor in the South Thames Foundation Trust. Silvia has had a keen interest in surgery for many years and has won prizes from both the Royal Colleges of Surgeons of England and of Edinburgh, as well as the Royal Society of Medicine, in recognition of surgical projects. She continues to participate actively in teaching, including organising and carrying out surgical teaching for medical students and foundation doctors. The topic of this year’s essay aimed to discuss maximising the productive use of social media to improve engagement across orthopaedics. A majority of internet users use the web to search for a doctor, treatment, or medical problem. However, doctors and surgeons are thought to be held back by lack and inefficiency of media skills, and concerns over ethics and professionalism. As such, there is a large population of professionals, students and patients that remain to benefit from a variety of education, insight and advice via social media. The winning essay evaluates the efficiency of BOA’s current use of social media across multiple large platforms (notably Facebook, Instagram, LinkedIn, Twitter and YouTube) and makes recommendations for improving their use in orthopaedics. These recommendations are based on published research regarding engagement with social media for surgical purposes and take into account potential pitfalls and how to avoid them. Silvia’s essay is available to view online at: www.boa.ac.uk/medical-student-essay. n

Conference listing 2021: OTS (Orthopaedic Trauma Society)

CAOS (Computer Assisted Orthopaedic Surgery (International))

BSCOS (British Society for Children’s Orthopaedic Surgery)

EFORT (European Federation of National Associations of

www.orthopaedictrauma.org.uk 14-15 January 2021 www.bscos.org.uk 1 February 2021, Virtual

BRITSPINE

www.ukssb.com 10-12 March 2021, Virtual

BOFAS (British Orthopaedic Foot and Ankle Society) www.bofas.org.uk 11 March, Virtual

BLRS (British Limb Reconstruction Society) www.blrs.org.uk April 2021, Online

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk 14-16 April 2021, Exeter

BASK (British Association for Surgery of the Knee) www.baskonline.com May 2021, Bristol

WOC (World Orthopaedic Concern)

www.wocuk.org 5 June 2021, Chester

BHS (British Hip Society)

www.caos-international.org 9-12 June 2021, France

Orthopaedics and Traumatology)

www.efort.org 30 June - 2 July 2021, Vienna

BIOS (British Indian Orthopaedic Society)

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

BOSTAA (British Orthopaedic Sports Trauma & Arthroscopy Association) www.bostaa.ac.uk 14 July 2021, London

BOA (British Orthopaedic Association)

www.boa.ac.uk 21-24 September 2021, Aberdeen

BTS (British Trauma Society)

www.bts-org.co.uk 24-25 November 2021, Oxford

BSS (British Scoliosis Society)

www.britishscoliosissoc.org.uk November 2021, Edinburgh

CSOS (Combined Services Orthopaedic Society) www.csos.co.uk 2021, Portsmouth

www.britishhipsociety.com 9-11 June 2021, Torquay

News

New BOA Trustees (2021–2023)

Fares Haddad Amar Rangan I am a Shoulder & Elbow Surgeon at South Tees Hospitals NHS Trust in Middlesbrough and I’m Professor of Orthopaedic Surgery, holding the Mary Kinross Trust & Royal College of Surgeons Chair at Department of Health Sciences and Hull York Medical School, University of York. I also hold a full Professorship with the Faculty of Medical Sciences & NDORMS, University of Oxford. I am current President of the British Elbow and Shoulder Society. I was Chair of the BOA Research Committee from 2013-2018; the Academic / APOS representative on the T&O SAC from 2013 to 2016; and have been FRCS (Tr& Orth) examiner for the Intercollegiate Specialty Boards for 10 years. I lead a programme of clinical and translational research, including NIHR funded multi-centre clinical trials. I have been published widely in Trauma & Orthopaedic Surgery, particularly in the field of Shoulder & Elbow surgery, where my work has influenced clinical practice, national guidelines and policy. I am a member of the NIHR i4i Challenge Awards Committee and am a surgeon member of the Steering Committee of the National Joint Registry. There are obvious challenges ahead to our professional practice during the pandemic and beyond, but also some exciting opportunities for us to become innovative with our services, education and research. I look forward to contributing to the BOA’s work in these areas. We have come a long way in the last decade in world leading, practice changing research. I will work to build on our strengths to attract further investment into T&O research to benefit our patients and our services. n

I am a Hip and Knee Reconstructive Orthopaedic and Sports Surgeon at University College Hospitals, Divisional Clinical Director of Surgical Specialties at UCH, and Director of the Institute of Sport, Exercise and Health at University College London. I graduated from the University College London Hospitals with a First Class BSc and MB BS. I was the gold medallist in the FRCS (Orth) exam and have gained a large number of prizes and prestigious academic awards. I have been an EFORT Travelling Fellow, British Hip Society Travelling Fellow and ABC Travelling Fellow in 2004. I was a Hunterian Professor in 2005. I am Editor-in-Chief of the Bone and Joint Journal. My clinical and research endeavours have centred on hip and knee reconstruction. I have presented and published widely on key aspects of hip, knee and sports surgery and continue to lead a clinical research group with interests in hip and knee joint preservation after injury, prosthetic design and performance and outcomes measurement after hip / knee surgery and sports injuries. I was the musculoskeletal lead at the 2012 London Olympics and run the IOC research centre at ISEH. I am Chief Medical Officer for the NFL in the UK. I am really pleased to have the opportunity to contribute to the challenges facing the BOA and our profession. We face an era of mounting service pressures, lengthening waiting lists, limited opportunities for trainees and trainers, and difficulty with pension and finances and premature burn out. The need for strong BOA Council has never been greater. NHS and professional pressures adversely affecting surgical practice require decisive action. I am organised, hardworking, and vocal when needed, and will stand up for our colleagues, our trainees, our researchers, our profession and our patients. n

News

Sarah Stapley Hiro Tanaka I have two passions as a Foot and Ankle surgeon in Wales. The first is a belief that if we improve the way we train future surgeons at all levels from medical students to fellows, we can guarantee the future of our profession as an inclusive and diverse speciality. By daring to innovate and testing new educational tools, we will nurture more resilient and capable surgeons. I have applied this ethos to the educational strategy of BOFAS for over 10 years and as Chairman of the Education Committee for the BOA. I continue my work for BOFAS as Honorary Treasurer. The second, is promoting clinical leadership and quality improvement across the NHS. I was one of the first people to complete the Generation Q programme with the Health Foundation and I am the co-director of the BOA Future Leaderâ&#x20AC;&#x2122;s Programme. In the midst of chaos, there is also opportunity. I believe we are at a critical moment in our profession. Change is inevitable both for us as surgeons and patients. The BOA is the most effective instrument by which the right changes are adopted because it is the combined voice of our consultants, SAS surgeons, trainees and patients. As JTO Editor, I will seek to ensure that our members are kept up to date with the most topical, useful and sometimes challenging content. n

A consultant since 2004, I have been fortunate enough to have experienced trauma and orthopaedic delivery in a number of settings, although based in the Portsmouth area for the whole of my consultant career. Serving with the Royal Navy for 33 years, I have lead health care delivery in isolated and extreme locations with limited resources. Understanding how education, and the effect a good mentor has on an individual, has continually driven me to encourage trainees of all levels to seek their potential, and I have demonstrated this as a Training Programme Director at both core and higher specialty level, and as Defence Professor of Trauma and Orthopaedics, where I have expanded the influence of military orthopaedics into several academic institutions. I have undertaken several unusual leadership roles, as a Deployed Medical Director (Camp Bastian Hospital) in Afghanistan, Consultant Advisor in Trauma and Orthopaedics to the Royal Navy and as the UK Representative on the NATO COMEDS futures advisory panel, which recently developed a military research strategy for the 47 Countries of NATO. I have been a member of the BOA since I was a trainee and sit on the Education Committee as the representative for Medical Student engagement. As my military career closes, I wish to utilise my broad leadership skills and experience to support and enhance the national development of Trauma and Orthopaedics as the outstanding specialty it is now. n

Features

BOA Council Who are the Council?

The full BOA Council comprises a minimum of, 18 elected trustees, and up to 12 Ex-Officio members representing key areas of interest including training and SAS. The Trustee body have the legal responsibility for the governance of the Association and is made up of the six Officers (the President, Immediate-Past President, Vice President and Vice President Elect, Honorary Secretary and Honorary Treasurer), 12 further elected trustees and for 2020/2021 an additional appointed trustee. What is the Council for? The Council has overall responsibility for leadership of the profession, setting the vision and strategic direction for the Association and being accountable to the members for its action and decisions. The BOA aims to make Trauma and Orthopaedics an inclusive surgical profession that inspires, attracts and retains the best talent from a wide variety of backgrounds. In doing so, we strive for Council to reflect this diversity and we are working hard to encourage wider engagement and involvement in the running of the Association.

What do Council members do? Council is incredibly important in the running of the BOA and, through the trustees, has responsibility for the governance, financial integrity and reputation of the Association. Meeting up to five times a year, the full Council considers matters of strategic importance to trauma and orthopaedics and delegates activities for delivery through the committee structure. While activities may be delegated to the committees, overall responsibility for decision making remains with the trustees. Last year we restructured our committees to better align our activity with our strategic priorities. Having committees that are efficient and effective with defined outcomes is key in the delivery of the BOA Mission: ‘Caring for patients, Supporting surgeons.’ All committees now have robust

governance, a high level of accountability and a clear remit. The main committees are Education and Careers, Orthopaedic, Trauma, Research, Medico-legal, and Casting but we also deliver work through short life working groups on key or ‘hot’ topics, often requiring a faster turn round. The committees are constituted in the following ways: • Allocation of Council members either by specialty or interest area • Through open competition from the membership, including a number of dedicated roles representing key areas of importance, such as SAS and trainee representation • By position, The President, Vice President and Honorary Secretary are Ex-Officio members of committees.

are allocated areas of responsibility and are required to lead on initiatives and report back to Council on progress. Ex-Officio Council members will also contribute to discussions and report back on matters of relevance to their specific area of responsibility, this includes reflecting activity in the devolved nations. All Council members are encouraged to bring matters for consideration to the wider body and to tackle issues of importance. Council and committee meetings are usually held during the working week but the role can also involve evening and weekend commitments, and – in non COVID times – travel in the UK and occasionally internationally.

“The Council has overall responsibility for leadership of the profession, setting the vision and strategic direction for the Association and being accountable to the members for its action and decisions. The BOA aims to make Trauma and Orthopaedics an inclusive surgical profession that inspires, attracts and retains the best talent from a wide variety of backgrounds.”

Being on Council gives members a chance to use their skills and expertise to influence and input into the work of the BOA, to drive the direction of the Association and to support the development of the profession. Trustees

The work of the Council is communicated through regular updates to members via the website, newsmail and social media. We welcome suggestions for developing and improving how we communicate and any issues that you would like to hear more about.

Features

A personal reflection Two Council members who are finishing their term reflect on their time on Council and what they achieved during their time. Peter Giannoudis: It has been a great honour and enjoyment to serve as a trustee of the BOA. It became clear to me within a short period of time that the daily challenges facing our Association, its members and our patients are enormous and require prompt evaluation, analysis and decision making. Working closely with the executive committee, the other trustees and the Council to provide a timely response to every matter rising has been a great personal experience. The opportunity

to engage and to express your views working as a team with the rest of the trustees and the Council allowed me to appreciate the degree of responsibility, accountability and the leadership required for BOA to deliver its objectives. A great personal thank you to the fellows that voted me to become a trustee and to everyone else for giving me the opportunity to serve BOA. Rhidian Morgan-Jones: I was elected BOA trustee in 2017 and am now coming to the end of my three-year term. Without doubt it has been one of the most enjoyable, informative and collegiate experience I have ever had. During my time I was

given responsibility of working as Deputy Editor of the Journal of Trauma & Orthopaedics (JTO) and latterly, in addition, the Transient Journal. Both of these posts suited my skill set but also kept a steady stream of meetings, e-mails and work coming my way, all of which was worthwhile. The BOA staff, behind the scenes, are a constant source of help and advice for which I remain grateful. On a broader view, sitting in Council, debating decisions that in one way or another affect us all, was a learning curve and I can be clear that the BOA is being led by many good, hard working members who have and continue to invest a great amount of time and effort for the benefit of the profession. The BOA is a great professional institution which genuinely cares for, supports and promotes its members. I certainly will consider standing for Council election again and would urge others to do the same. n

Features

The 2020 NICE guidelines for primary hip, knee and shoulder replacement: key recommendations and the ongoing need for better quality evidence in orthopaedics Paul Baker, Ananth Ebinesan, John Skinner, Andrew Metcalfe and Jonathan Rees Why should orthopaedic surgeons engage in the development of NICE Guidelines?

Paul Baker is an Orthopaedic Surgeon specialising in primary and revision hip and knee replacement surgery. He is also the Director of Research and Innovation for the South Tees Hospitals NHS Foundation Trust. Paul is the current Royal College of Surgeons Speciality lead for Orthopaedics and a member of the BOA research committee.

Ananth Ebinesan is a Consultant Orthopaedic Surgeon at Manchester University Hospitals NHS Trust. He is an active BESS member and is currently the Clinical Lead for Orthopaedics at Manchester Royal Infirmary.

The development of a NICE guideline is viewed as rigorous and independent. As such published guidelines are supported and endorsed by NHS England and have a greater impact than guidelines from specialist societies. For this reason, when a new orthopaedic NICE guideline is proposed, it is critical we engage to ensure there is orthopaedic expertise on the guideline committee. However, this can be challenging as there are no â&#x20AC;&#x2DC;nominationsâ&#x20AC;&#x2122; and surgeons do not represent the BOA or their specialist society. The surgeon must apply independently, fulfil various criteria, pass an interview and be prepared for guideline commitments that take 2-3 years to compete. Despite these hurdles, we would encourage BOA members looking for new challenges and wishing to make a national contribution to patients and the health service to apply. In the instance of the new hip, knee and shoulder replacement guidelines, the sheer breadth of a combined guideline encouraged the authors to apply as we recognised the importance of the topic, and the need to ensure correct clinical interpretation of the evidence in making recommendations that could have profound effects on patients and joint replacement services. Once appointed to a NICE guideline committee, a detailed scope is first developed. Many will ask why this guideline complicates matters by combining all three joints. This topic was picked by NHS England, not NICE, and not the committee. Due to the large remit of this guideline, we structured it as a patient pathway from the point of offering joint replacement. The scope went out for public consultation in March 2018 and was finalised by NICE in April 2018.

Multiple systematic evidence reviews were then conducted for each question assessing clinical and cost effectiveness. It is worth noting that while some of us are involved in large joint registry data research, this is not considered in the NICE process even though many will consider registry data to be highly relevant to this topic. NICE deal with RCT evidence and the evidence reviews are detailed and of high quality. The meetings we attended were intense and long with many challenging discussions. In total it took 2.5 years to complete this guideline which has produced 24 final recommendations. Importantly for those of you active in high quality research, it has also produced 16 research recommendations. The full guidelines and committee discussions can be found at www.nice.org.uk/guidance/ ng157, but we present the main highlights for you by speciality.

How will these guidelines effect you and your Trust? For hip, knee, shoulder surgeons and hospital trusts Preventing infection in all patients: No evidence was identified to justify adding antiseptics or antibiotics to saline wash for wound washouts and so NICE guidance NG125 (www.nice.org.uk/guidance/ng125) on surgical site infection should be followed. A recommendation to use ultraclean air theatre ventilation systems for primary hip, knee and shoulder replacement surgery was also made. Avoiding implant selection errors in all patients: It is recommended that surgeons now use two intraoperative stop moments, one before implantation and one before wound closure to ensure correct implant details and compatibility. A recommendations was also

Features

given to consider intraoperative real time data entry before implantation using systems that provides an alert to any mismatch. A research recommendation was also made on the topic.

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

Post-operative rehabilitation: While an inpatient, a physiotherapist or occupational therapist should offer rehabilitation on the day of surgery if possible, and no more than 24 hours after surgery. Before patients leave hospital a physiotherapist or occupational therapist should give advice on self-directed rehab. For shoulder patients, additional advice on supervised group rehab or individual rehab should also be offered. Follow up and monitoring: No recommendations were made on this topic with no evidence identified during the review process. For hip surgeons and hospital trusts providing hip replacement surgery This current NICE guideline supplements the 2014 NICE technology appraisal for hips (TA 304), which produced ‘recommendations on artificial hips and hip resurfacing for treating end stage arthritis of the hip in adults.’ The 2020 guideline did not revisit the topics of this appraisal but instead expanded the recommendations related to hip replacement by exploring the following new topic areas.

Andrew Metcalfe is a Consultant Orthopaedic Surgeon at the University Hospital of Coventry and Warwickshire, and an Associate Professor at Warwick Clinical Trials Unit. His clinical practice is in knee surgery, both soft tissue and arthroplasty. His research focuses on the effectiveness of orthopaedic interventions, and randomised trials in particular.

Jonathan Rees is Professor of Orthopaedic Surgery and Musculoskeletal Science at the University of Oxford. He is President Elect of the British Elbow and Shoulder Society and holds a Fellowship with the National Institute for Health and Care Excellence.

Pre-operative rehabilitation: Evidence from non-NHS settings showed the value of pre-operative rehabilitation. It is important to recognise that pre-operative rehabilitation includes not only information about exercises to undertake prior to surgery but also information about lifestyle changes, health management, maintaining independence and maximising wellbeing after surgery. It reflects a holistic approach to patient care and an opportunity to grasp the ‘teachable moment’ around surgery when patients may be open to broader interventions that address their health needs. While the content of ‘prehabilitation’ was broadly defined, the format, timing and delivery of this intervention was not, allowing individual centres to introduce this intervention in a way that integrates with their current service. It also led to a research recommendation to best define how, when and where prehabilitation should be delivered. Tranexamic acid: There was an abundance of evidence supporting the use of tranexamic acid. This cheap intervention reduces blood loss and transfusion requirement and should be used both at induction of anaesthesia and topically during the procedure for maximal effect. Anaesthesia: NICE has recommended the use of either general or regional anaesthesia in

combination with local infiltration anaesthesia (LIA). The evidence supported a multimodal anaesthetic approach and LIA or nerve blocks were found to be equally effective when combined with a general or regional anaesthetic. Using the two together produced no additional benefit and the committee therefore recommended LIA in preference to nerve block given the reduced time and cost associated with this procedure. Surgical approaches for hip replacement: There was a lack of high-quality evidence supporting one approach over another and the recommendation therefore supported the use of three established hip approaches (posterior, anterolateral and anterior). Due to the lack of evidence, newer approaches such as the direct superior and SuperPATH could not be recommended and were instead included in a research recommendation. For knee surgeons and hospital trusts providing knee replacements Pre-operative rehabilitation: For knee replacement as with hip replacement, there was good data on multi-modal pre-operative rehabilitation. Anaesthesia: Regional or general anaesthetics were both considered acceptable and should be used with local anaesthetic infiltration for all cases. A nerve block could be used in combination with this if it takes up a relatively short period of theatre time (no more than 10 minutes) but the evidence was not conclusive on this. Tranexamic acid: There was good data on the use of combined systemic and topical tranexamic acid during knee replacement. Partial or total knee replacement: For people with isolated medial compartment osteoarthritis, the evidence demonstrated benefits for partial knee replacement in some outcomes, such as early pain, satisfaction, and rates of VTE, but also benefits for total knee replacement for other outcomes, such as need for revision. The non-surgical committee members (especially patients) had strong views that patients differ in their priorities and values, that they rank different outcomes differently, and should be allowed to make the decision themselves. They concluded that people should be presented with a fair and balanced summary of all the differences between the two procedures, and both services should be available to them. It was recognised that this may require service reconfiguration in some regions and changes to referral pathways, but this was trumped by ensuring patients had access to both treatments and were able to make a judgement themselves. >>

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Tranexamic acid: Economic modelling was carried out for the use of tranexamic acid (TXA) to prevent blood loss and reduce transfusion events. This costeffective intervention should be administered intravenously at induction of anaesthesia. Surgeons should also consider intra-articular or topical administration of TXA prior to wound closure. This mode of delivery was extrapolated from the hip and knee evidence but the committee agreed it should also apply to shoulder replacements as a safe and inexpensive intervention. Shoulder replacement for osteoarthritis (OA): NICE recommends a conventional total shoulder replacement (TSR) for patients with an intact rotator cuff and adequate glenoid bone stock. It is important to highlight there is a lack of evidence in patients under the age of 60, and for the use of a reverse TSR to treat this condition. As such, two research recommendations were made to compare conventional TSR to reverse TSR; and to compare conventional TSR to humeral hemiarthroplasty in patients under the age of 60. Patella resurfacing during total knee replacement: The committee considered three possibilities: No resurfacing; selective resurfacing; and routine resurfacing. There was extensive evidence comparing no resurfacing to routine resurfacing, demonstrating no difference in patientreported outcomes, but a higher rates of secondary patellar resurfacing in the non-resurfacing group. Patellar fracture was rare in the evidence reviewed. Although the economics favoured resurfacing, with a large potential saving across the NHS, the primary reason for the decision to offer patella resurfacing was that patients were clear that a secondary resurfacing was not an inconvenience but a major event associated with pain and risk. Patients preferred resurfacing at the time of TKR to prevent this risk. There was insufficient data on selective resurfacing and a research recommendation was made on this.

For shoulder surgeons and trusts providing shoulder replacements Pre-operative rehabilitation: The value of pre-operative rehabilitation for hips and knees was not replicated in the shoulder evidence review. A research recommendation was made to determine if preoperative rehabilitation would be beneficial.

â&#x20AC;&#x153;Published guidelines are supported and endorsed by NHS England and have a greater impact than guidelines from specialist societies. For this reason, when a new orthopaedic NICE guideline is proposed, it is critical we engage to ensure there is orthopaedic expertise on the guideline committee.â&#x20AC;?

Anaesthesia: Prior to surgery, options for anaesthesia (general and regional) and analgesia (local infiltration and nerve blocks) should be discussed with patients. General or regional anaesthesia combined with local infiltration demonstrated some benefit to patients. However, with continued advancements in day case shoulder replacements, the optimal combination of anaesthesia and analgesia to enhance the recovery pathway remains unclear.

Shoulder replacement after previous proximal humeral fracture: With no high- quality evidence available, a research recommendation was made to look at the long-term outcomes for shoulder replacements after previous proximal humeral fracture (not acute trauma).

Research recommendations NICE guidelines take considerable resources to produce. Despite the sheer prevalence of joint replacement surgery and the acknowledgement from patients of its life changing impact, the multiple systematic reviews in this guideline indicate an ongoing lack of high-quality evidence around a number of topics. As such the committee needed to make many research recommendations to produce evidence in these areas of uncertainty.

Conclusion This article is aimed at providing you with a summary of the process and content of the new NICE guidelines on hip, knee and shoulder replacement, and how they might impact your surgical practice. The full guideline can be accessed at: www.nice.org.uk/guidance/ng157 and we would encourage surgeons conducting these procedures to read these carefully. Finally based on our experiences we would encourage BOA members to put themselves forward for future NICE guideline committees. n

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The MSK training pathway to First Contact Practitioner and Advanced Practitioner in primary care Amanda Hensman-Crook

For the first time, primary care has a standard of practice for MSK for diagnostic clinicians. The development of a career pathway using an educational training roadmap to work in Primary care at Master’s degree level, (supported by specific supervision) is now in place to ensure the quality of care from the start of the patients’ journey with MSK conditions. Amanda Hensman-Crook is an AHP National Clinical Fellow, Consultant MSK Physiotherapist and Fellow of the Chartered Society of Physiotherapy, specialising in MSK for 26 years, 14 years of which in orthopaedics and outpatients before moving into primary care. Amanda is currently working for HEE to develop the primary care workforce focusing on training, supervision and governance to create a sustainable standard of practice for new roles in primary care.

The NHS Health Education England resource ‘First Contact Practitioners and Advanced Practitioners in Primary Care: (Musculoskeletal) A Roadmap to Practice’ can be found at: www.hee.nhs.uk/sites/default/files/documents/A%20Roadmap%20to%20Practice.pdf.

What is First Contact Practitioner (FCP)?

A First Contact Practitioner is a diagnostic clinician working in Primary Care at the top of their clinical scope of practice at Agenda for Change Band 7 or equivalent and above. This allows the FCP to be able to assess and manage undifferentiated and undiagnosed MSK presentations. It is the minimum threshold for working as a first point of contact with undifferentiated undiagnosed conditions in Primary Care. With additional training, FCPs can build towards advanced practice. To become an FCP, recognition is required through Health Education England, whereby a clinician must have completed a taught or portfolio route.

FCPs work at master’s level (QAA level 7) in their clinical pillar of practice but have not yet reached an advanced level in all four pillars of practice to be verified at AP level across all four pillars.

The clinician must have a minimum of three years of postgraduate experience in their professional specialty area of practice before starting Primary Care training to become an FCP.

FCPs refer patients to GPS for the medical management of a patient’s condition with non MSK presentations and pharmacology outside their agreed scope of practice.

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How does the model work? the ability to rule out red flags and visceral masqueraders, and detect early serious pathology at the first point of contact. They must also have a good understanding of local care pathways including two week waits. The aditional primary care training typically includes radiography, MSK bloods, injection therapy and prescribing as well as developing the ability to work with complexity and medical uncertainty. FCPs have the same access as GPs to diagnostic services and onward referral into secondary care, so it is important that these capabilities are assesed and verified to the right level of practice.

Figure 1: High Impact Investigations First Contact Practitioner for MSK Interventions 2019 NHSE and NHSE/I

What is the educational training pathway?

It is also important to note that although MSK First contact practitioners have a focus on rehabilitation providing exercises and advice for MSK conditions pre and/or post operatively, they do not â&#x20AC;&#x2DC;treatâ&#x20AC;&#x2122; patients. This service is provided with an onward referal into core physiotherapy or other rehabilitation services as required.

How does FCP impact on orthopaedics? National evaluation has shown that the referal to orthopaedics from FCPs is low (average of 2.9% of MSK caseload) with a high conversion rate to surgery. The Phase 2 national evaluation of First Contact Practitioners showed up to a 56% reduction regionally of referal to orthopaedics from primary care. Further information can be found at: http:// arma.uk.net/wp-content/uploads/2020/05/ FCP-MSK-review-with-authors_v3.pdf.

Figure 2: First Contact Practitioners and Advanced Practitioners in primary care (Musculoskeletal) HEE

Once clinicians have been registered post HEI training, as novice practitioners they are encouraged to work across all specialities (neurology, medicine, respiratory, paediatrics, orthopaedics, rhumatology etc) and across all healthcare settings for two years. This is to build a broad base of knowledge in practice within and outside MSK and to learn multi sytem care pathways across all settings. Following this, and now in MSK, they continue to develop across the MSK spectrum and move from a novice to experienced clinican over a

minimum of three years prior to commensing prmary care training. This time is spent widening their MSK learning across MSK specialitites, and consolidating understanding of how their wider knowledge of other conditions and pathologies can be drawn into one clinical consultation to effectively manage the presenting condition. It is essential for clinicians to have this firm foundation when working with undifferentiated and undiagosed conditions in primary care. All clinicians need to have

FCPs prepare patients with an explanation of the pros and cons of possible surgical interventions pre referral to orthopaedics, and review post-surgery to ensure that rehabilitation is maximised and to identify any early complications should they arise post-operatively.

Conclusion By setting a standard of practice for MSK in primary care, it guarantees capability and expertise at the front of a patient care pathway which streamlines MSK patient care across the whole healthcare system providing a gold standard of care for this patient cohort. n

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ODEP and Beyond Compliance: Our response to Cumberlege, the MDR and the UKCA... making UK plc a good place for safe innovation of implants Keith Tucker and Peter Kay

After about nine month’s delay, Baroness Julia Cumberlege’s long awaited ‘Independent Medicines and Medical Devices Safety Review’, “First Do No Harm” was published on 4th July 2020.

Keith Tucker is the Chair of ODEP and the Beyond Compliance Advisory Group. He has also served on the NJR Steering committee, the MHRA metal on metal advisory group and the ISAR board. He continues to serve on the NJR Implant scrutiny committee, NORE and as a trustee for ORUK.

Peter Kay is a Consultant Orthopaedic Surgeon at Wrightington, Wigan and Leigh NHS Foundation Trust, honorary Clinical Professor of Orthopaedic Surgery at Manchester University and honorary Professor in Orthopaedics at University of Central Lancashire. Peter has been President of the British Orthopaedic Association (2011), British Hip Society (2008) and British Orthopaedics Trainees Association (1992). He is Chair of the Beyond Compliance Steering Committee.

It must be the view of the great majority of us that what she recommends makes perfect sense. As far as orthopaedics is concerned, it will impact on us (provided parliament adopt her recommendations) in several ways:

So where is ODEP and Beyond Compliance in this? Well, she mentioned the NJR as a beacon organisation that others should follow and I am sure we all agree it certainly is! We think it was unfortunate that ODEP and BC were not introduced to her but what we have been doing since 2002 for ODEP and 2012 for Beyond Compliance fits very closely with her recommendations.

• All implants used on patients will have to Where are we all with the new MDR? go into a registry and ‘Scan for Safety’ is highlighted and plans are already afoot for its Oliver Bisazza from MedTech Europe has development. summarised the introduction of the new MDR • The monitoring of new devices should not be very well in Figure 1. left to the PI (Principal Investigator), their team and the manufacturer. An independent However, earlier this year, because of COVID-19, body should be involved which is, of course, the next time point in the implementation stage what the Beyond Compliance advisory group was put back until May 2021. The important have been doing for some years now. points to realise are: • Anyone involved in the introduction of new devices should increase their emphasis on PROMS and PREMS. • We all need to increase our engagement with patients and the lay public when dealing with implants. • She emphasised the importance of anyone externally monitoring implants should be completely independent and without a conflict of interest (COI). That’s pretty easy for ODEP and Beyond Compliance as none Figure 1: Introduction to MDR – Courtesy of Oliver Bisazza (MedTech Europe). of us are paid!

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• Manufacturers will not be able to introduce a novel device without a pre-clinical investigation. • We expect only a few devices will get a CE mark on the basis of ‘equivalence’ (look-a -like). • There will be a ‘panel’ set up in Brussels to oversee the assessments made by the NBs (Notified Bodies such as BSI, British Standards Institute). • Manufacturers of legacy devices (yes, even the Exeter V40 stem) will have to undertake ‘clinical investigations’ around their products, on a regular basis, to keep their CE mark. • Manufacturers of some ‘Boutique’ implants, such as those primarily designed for DDH cases, might well withdraw them from the market on account of the expense involved. This won’t please some surgeons. Clinical investigations and going through a CE assessment is expensive.

Where will ODEP and BC fit with the MDR? Well we think, with everyone’s co-operation, we can do a good job for patients and manufacturers alike. ODEP With the new MDR clinical data that will be needed by manufacturers to maintain their CE marks, we hope that the clinical data they submit to ODEP ‘will be a copy and paste job’. Our European credentials increased about four years ago when hip, knee and shoulder surgeons joined ODEP from the Netherlands. The EPRD (German Registry) would also like to start sending delegates. For the past 2-3 years EFORT have been discussing introducing ODEP across Europe. Per Kjaersgaard-Andersen, recently president of EFORT, has been very keen to do this with Rob Nelissen, the chair of NORE (Network of Registries of Europe). In fact ODEP is already a global brand, (Figure 2).

Figure 2: ODEP a global brand: Geographic distribution of users.

Beyond Compliance Beyond Compliance appears to fit with the aims of the new MDR. At present BC assesses implants as to their novelty and risk, besides monitoring them very carefully through NJR data, review meetings and our user group meetings. One consequence to the new MDR is that the ‘preclinical investigation stage’ is devoid of monitoring except by the manufacturer and the PI (Principal Investigator). Although manufacturers say that clinical trials are much stricter than they were in ‘metal on metal days’ there is still a strong feeling in many peoples’ minds that external validation is essential. This is massively supported by Cumberlege and we would concur. BC wishes to be available to manufacturers to oversee the pre-CE space if invited. BSI and TUV SUD, the two largest Notified Bodies in Europe support this initiative.

Figure 3a: Current Beyond Compliance Service – Courtesy of Patrick Palmer (Northgate PS).

Figure 3b: Beyond Compliance Service Post MDR – Courtesy of Patrick Palmer (Northgate PS).

Figure 3a and 3b shows where BC fits at present. With the new MDR, Figure 3b shows the period when there will not be external monitoring / validation. It is marked ‘Patients with a novel device’. What we think we should now be offering is shown in Figure 3c and at present we are in a pilot stage.

Figure 3c: Proposed New Beyond Compliance Service Pre-CE – Courtesy of Patrick Palmer (Northgate PS).

“For the past 2-3 years EFORT have been discussing introducing ODEP across Europe. Per Kjaersgaard-Andersen, recently president of EFORT, has been very keen to do this with Rob Nelissen, the chair of NORE (Network of Registries of Europe). In fact ODEP is already a global brand.”

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UK plc So do we want to make the UK a good place for the innovation and safe introduction of new implants? Back in 2011, Jeremy Hunt, the then secretary of state, made it clear that we must protect patients from disasters like Metal on Metal but ‘British Innovation’ must not go under. It seems to us in ODEP and BC that we can help. The vast majority of joint replacements on the market work well. In BC we have discouraged some manufacturers from bringing some new implants, which we thought poor, to this country. We have initiated steps to improve the design or the use of others and some instruments have been improved following suggestions by surgeons at our user group meetings. However, by the fact we have reported mainly excellent results many implants are being taken up by surgeons and prospering. ODEP does make it difficult for implants with poor results continuing in the market but promotes implants that do well.

UKCA - United Kingdom Conformity Assessed

What will all this mean for manufacturers, ODEP and BC?

You are probably all aware that with BREXIT approaching HMG has decided that they will develop GB’s own version of the CE mark. It is the UKCA which is presently being developed by MHRA. The timetable is below:

It must be the wish of manufacturers, that market both in the UK and EU, that a lot of the data the MDR will need, will be the same as that for the UKCA and we hope it will essentially be the same data required for ODEP and where appropriate, for BC.

• The UKCA will be used for certain goods, including medical devices, being placed on the GB market after the transition period. • From 1st July 2023, to place a device on the GB market, the UKCA mark will be required. • Manufacturers of Class I medical devices and general IVDs will be able to self-declare their conformity for the UKCA mark from 1st January 2021. The CE mark will remain acceptable in the UK until 1st July 2023. Further advice is regularly updated at: www.gov.uk/guidance/regulatingmedical-devices-from-1-january-2021.

Figure 4: From 1st July 2023, medical devices will require the UKCA mark.

If the UK is a difficult place to introduce new implants, there will be no encouragement for the joint replacement industry in this country and the multinationals will be reluctant to bring new devices to the UK. The USA will become the favourite place to launch new products

“The UKCA will be used for certain goods, including medical devices, being placed on the GB market after the transition period.”

Last January, ODEP and BC held a meeting in the MedTech Europe facility in Brussels which was attended by members of the Commission, notified bodies and the organisations representing manufacturers. The main purpose of the meeting was to flesh out the MDR in terms of the clinical investigations and monitoring of patients. At the end of the meeting we were asked to write up our recommendations for the new MDR. This opus has been accomplished and we do hope that it is going to be of value to the designers of the UKCA. Very shortly it will be on the ODEP and BC websites. The demands of the MDR are very much in line with Cumberlege and one imagines Cumberlege will be mirrored in the UKCA.

So, what might all this mean for UK orthopaedic surgeons?

• For your favourite implants, outcome data and PROMS will be even more important. • Therefore, making sure all implant data is uploaded into the NJR is even more critical and making sure that PROMS data is captured in clinics and that patients are encouraged to complete follow-up PROMS questionnaires is equally critical. • We must also ensure that we all listen to our patients and report their concerns appropriately. n

Resources www.beyondcompliance.org.uk. www.odep.org.uk.

Features

Double pandemic, Dr Forte and the fork in our road Ben Caesar

There are currently not one but two pandemics affecting healthcare workers. COVID-19 was preceded by the pandemic of burnout amongst doctors, nurses and allied health professionals. The coalescence of these two pandemics are compounding the risks to the wellbeing of all healthcare workers, particularly those on the frontline. However, it is possible that these two pandemics occurring simultaneously may offer us an opportunity to create a new working environment as we search for different ways to deliver medical care. Double pandemic

Ben Caesar is a Consultant T&O Surgeon based in Brighton with an interest in major trauma and sports injuries, who joined the Army at the age of 39 as a reservist just as he became a consultant; he changed to a regular commission three years later. Over the past nine years, he has deployed on three operational tours and is currently posted to 16 Medical Regiment in Colchester. He has set up and leads a clinic for Service Personnel and Veterans (the Chavasse Clinic) and has an interest in burnout and wellbeing in healthcare.

Healthcare workers were already teetering on the brink of the burnout Abyss, but nevertheless, everyone rallied to the calls of their governments to help manage this unprecedented crisis. The physical, psychological and emotional strains have been recognised, and emergency measures have been put in place. These, however, have been haphazard and piecemeal crisis management. Any attempts to address the underlying causes of burnout have been relegated to the backburner. The short-term resilience of all members of staff has been exceptional but running on those high levels of adrenaline for many months at a time is unsustainable and takes an additional toll.

In the UK, the public’s initial overwhelming support, often compared to the ‘Blitz spirit’ of the 1940s, is slowly waning as the pandemic becomes part of normal day to day life. The easing of restrictions and the return to a semblance of normality is giving the patients the impression that normal service is resuming within the NHS. This couldn’t be further from the truth. Within orthopaedics, whilst trauma services continue, but in a less efficient manner due to the restrictions required as a result of the COVID-19 virus, elective operating is at a fraction of its previous levels. The public are increasingly frustrated that their planned surgeries are still not happening and may not happen for many months to come. This is adding to the stresses on the clinicians who feel a sense of moral injury that they cannot provide the levels of service expected of them. Originally a military term, moral injury can be defined as the psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code. In the COVID-19 pandemic, many of us are having to live with uncomfortable decisions about the allocation of limited resources. >>

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Greenberg’s article in the BMJ earlier this year highlights the risk of moral injury and burnout on frontline staff who have to struggle with the adversity of the current pandemic1.

Dr Forte My unexpected journey into the world of physician burnout started on 25th June 2016, Armed Forces Day. I met a veteran in a wheelchair who was the secretary for my grandfather’s old regimental association. We got chatting and I asked him if his wheelchair use was as a result of an injury he’d sustained whilst in the Army. His reply was not unlike many soldiers, sailors and airmen that I would subsequently meet. He could remember an incident when the trouble started, jumping from the back of a 10-ton truck, but, as is the way with service personnel in general, he just put the pain

in his back out of his mind and carried on. Progressively his back pain worsened, and now retired and living off his pension, his back pain was so severe that he couldn’t walk and was forced to resort to a wheelchair to get around. Having taken the gentleman’s details, I spent the following Monday calling around various contacts and investigating the Armed Forces Covenant. By close of play, I had organised a pain clinic appointment for him within four weeks and had started along the road to setting up the Chavasse clinic, a service I now run in Brighton for the MSK care of Service Personnel and Veterans. The clinic is unique in that I work in close partnership with a mental health specialist nurse from The Veterans’ Mental Health Transition, Intervention and Liaison (TIL) Service (formerly known as London Veterans’ Service (LVS)).

PTSD

Physician Burnout

Re-experiencing:

Physical signs and symptoms:

• Flashbacks • Nightmares • Repetitive & distressing images or sensations • Physical sensations (pain, sweating, feeling sick, trembling)

• • • • • •

Avoidance and emotional numbing:

Emotional signs and symptoms:

• • • •

• • • • • • •

Avoidance of people or places Distracting with work or hobbies Emotional numbing Isolation, withdrawn, giving up activities they used to enjoy

Feeling tired and drained most of the time Tiredness that does not respond to adequate rest Lowered immunity, feeling sick often Frequent headaches, back pain, muscle aches Change in appetite or sleep habits Drop in libido or impotence

Sense of failure and self-doubt Feeling helpless, trapped, and defeated Detachment, feeling alone in the world Loss of motivation Increasingly cynical and negative outlook Decrease satisfaction and sense of accomplishment Activities you used to enjoy are no fun anymore

Hyperarousal:

Behavioural signs and symptoms:

• Irritability • Angry outbursts • Sleeping problems (insomnia) • Difficulty concentrating

• • • • • • • • •

Other problems: • Mental health (depression, anxiety, phobias) • Self-harming or destructive behaviour (drug or alcohol misuse) • Other physical symptoms (headaches, dizziness, chest pains, stomach aches) Table 1.

Withdrawing from responsibilities Isolating yourself from others Procrastinating, taking longer to get things done Using food, drugs or alcohol to cope Cynicism or a negative attitude towards your patients or co-workers Taking out your frustrations on others Driving aggressively, road rage Snapping at your spouse, children, staff or coworkers inappropriately Skipping work or coming in late and leaving early

It was because of the significant number of veterans that I was seeing with PTSD and other mental health issues in conjunction with their MSK issues, that I needed to become more informed about the signs and symptoms of these disorders.

Post-traumatic stress disorder and burnout As I began to learn more about PTSD, I wondered whether this was something surgeons might suffer from too. In fact, I discovered there were similarities between the signs and symptoms of PTSD and physician burnout but also significant differences, as shown in Table 1. We conducted a study investigating levels of burnout in acute specialties in Brighton’s major trauma centre2. The results of our study using the Copenhagen Burnout Inventory demonstrated that 36.7% of physicians surveyed showed high levels of burnout. This was consistent with Shanafelt’s work with US surgeons using the Maslach Burnout Inventory which showed 40% of respondents had either a high emotional exhaustion score and/or a high depersonalisation score, and were considered burned out3. What was also apparent was that there were a significant number of physicians on the precipice of burnout, with a further 56.3% showing moderate levels of burnout and only 7% showing low levels of burnout. This gave a combined figure of 93% of respondents demonstrating either moderate or high levels of burnout. This study was different in its response rate of over 75%, compared to Shanafelt’s paper where the response rate was 32%. Prior to its publication, this work was presented in 2019 in several meetings and had varied responses. For example, at CSOS, there were numerous questions from the senior members of the audience including the Surgeon General who asked if, as the senior member of the chain of command, whether he was putting his military personnel in harm’s way by sending them to work in the NHS. By contrast, at the BOA, I was not asked a single question by the audience about my presentation. Afterwards, when I spoke to a friend who had also done significant work in this field and told him that no one had raised any questions about the paper or its implications, his response was, “As orthopaedic surgeons, we simply do not have the vocabulary to discuss this yet.” This wasn’t the first time I’d heard this.

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our second pandemic. COVID-19 arrived and changed our world completely.

The cost of burnout • A majority of doctors (80%) in a 2019 BMA survey were at high/very high risk of burnout with junior doctors most at risk. Burnout was driven mostly by exhaustion rather than disengagement from one’s role as a doctor. • Burnout, fatigue and work unit safety grade were independently associated with major medical errors4. • In this paper, 54% reported symptoms of burnout, 32% reported excessive fatigue, and 6.5% reported recent suicidal ideation. 3.9% reporting a poor or failing patient safety grade in their primary work area and 10.5% reporting a major medical error in the prior three months.

and the Abyss’. Through a dreamscape fantasy journey, we invited the orthopaedic community to engage with the all too often taboo subject of burnout. Following the BOA congress in 2019, I was overwhelmed by the response I received from members of the audience, as clearly, I had touched on something. I’ve never before received fan mail via social media. The BOA was also incredibly supportive, and, after discussion with the President and the Secretary, we had planned to send out a questionnaire to the membership to assess the levels of burnout amongst orthopaedic surgeons in the UK. The questions were submitted for council approval just prior to my deployment overseas in January, and then, whilst I was away, we were struck by

There is room for optimism. If the organisational structure of healthcare delivery in the UK is reimagined for a post-COVID environment, and takes into account the need to optimise the healthcare workers’ physical, psychological and emotional health so that they may provide their very best for their patients, then we have an opportunity for post-traumatic growth as we enter the new normal. Sadly, if this opportunity is missed and there is a return to trying to squeeze more out of us in these difficult times, the burnout pandemic will escalate further with detrimental effects for patients, healthcare workers and the NHS. We are at that fork in the road and the route we choose to follow will have profound effects for years, maybe decades to come. Currently, Prof Mansoor Khan and I are working on a further paper looking at what the military have learned about managing their service personnel’s psychological and emotional wellbeing in times of high stress and crisis, and how these tools can translate to the NHS environment. We hope that this may offer some guidance to those looking to manage the burnout pandemic where they work, and to help build a supportive working environment in their own departments for the benefit of their patients, colleagues and supporting staff. n

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

• The suicide rates among doctors were higher than those in the general population and among other academic occupational groups. The rate has been variably estimated at between two and five times the rate of the general population5-8. • The relative suicide risk is higher amongst female doctors compared to men although the crude mortality rate is the same8. • An estimated 4.6 billion USD were lost per annum as a result of burnout in the US9. • NHS sickness rate hit record high during COVID-19 peak with more than 1 in 20 NHS staff days lost10.

The fork in our road With the help of two amazingly creative people, the writer, Regina Tingle, and the artist, Robin Smith, known for his work on Judge Dredd, we produced a comic strip to illustrate the dilemma of burnout in physicians – ’Dr Forte

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Major Alexander William Lipmann-Kessel MBE MC: Surgeon, paratrooper, prisoner of war, and orthopaedic innovator Simon Hurst, Dylan Griffiths and Roger Emery

Origins and training

Simon Hurst is a Trauma & Orthopaedic surgeon and reservist serving with 144 Parachute Medical Squadron, 16 Medical Regiment. He is currently pursuing fellowship training at Hôpitaux de Paris, Hôpital Avicenne, France, and Shock Trauma, University of Maryland, USA. His doctoral thesis at Imperial College examined the digitalisation of PROMS. He has post-doctoral research interests both at Imperial College, and Université Sorbonne Paris Nord, France. These are in the fields of surgical robotics, and the use of augmented reality headsets to enhance surgeon capability. Simon’s subspecialty interests are in upper limb surgery, and the battlefield forward surgical care of major trauma patients.

Alexander William Lipmann-Kessel was of diverse heritage being born in Pretoria, South Africa in 1914 to a German mother, and a Lithuanian father. ‘Lippy,’ as he was better known was of Jewish heritage, and a practising Jew throughout his life. In early adulthood he moved to London to study medicine at St Mary’s Hospital, Paddington. The LipmannKessel prize day remains an important part of the academic calendar for orthopaedic trainees on the London North West Thames rotation1-4.

The Parachute Surgical Team Lipmann-Kessel volunteered for the Airborne Forces shortly after finishing medical school, and passed selection at No 1 Parachute Training School, Ringway, Manchester, (Figure 1).

His first operational activity was as part of 16 Parachute Field Hospital, (16 PFA), (Figure 2) during Operation Fustian, an ultimately successful bid to capture the strategically important Primosole Bridge in Sicily. Fustian saw the first successful deployment of ‘The Parachute Surgical Team (PST)’, (Figure 3). Lipmann-Kessel was a principle pioneer of this concept. Airborne operations allowed for rapid insertion behind enemy lines but, placed troops outside of the normal chain of medical care. The PST included a surgeon, an anaesthetist, and four other para trained members from other ranks with focus on nursing, and other medical training. 80% of cases were operated on within five hours of injury. Musculoskeletal injuries including seven open long bone fractures comprised the majority of cases5.

Operation Market Garden 1944

Figure 1: No 1 Parachute Training School, Ringway, Manchester – provided training to all 60,000 allied paratroopers in Europe between 1940 and 1946. (Image courtesy of Imperial War Museum, London, UK).

The PST has evolved into the modern ‘forward surgical team,’ and continues to be an important capability on contemporary military operations.

On the afternoon of the 17th September 1944, Lipmann-Kessel and the rest of 16 PFA landed on drop zone (DZ) X en-route to a Dutch hospital in western Arnhem – St Elisabeth’s. Here they treated early casualties from the 10,000 strong Allied airborne forces whose aim was to circumvent German lines through the capture of key bridges (Operation Market) and then hold them until reinforcements

Features

Dylan Griffiths has been a Consultant Orthopaedic Surgeon at Imperial College Healthcare NHS Trust for seven years. His subspecialty interest is in Shoulder and Elbow surgery and he is the clinical lead for Shoulder and Elbow trauma. Dylan has also spent 23 years as part of the British Military, with service in the Parachute regiment and operational tours of Afghanistan, Iraq and Bosnia.

Roger Emery is Professor of Orthopaedic Surgery at Imperial College, London. He graduated in 1979 from St. Thomas’s Hospital Medical School, University of London, and undertook his orthopaedic training in London, Cambridge and Hong Kong. Awarded a Wellcome Surgical Fellowship at the Kennedy Institute of Rheumatology, and the Zimmer Travelling Fellowship by the British Orthopaedic Association in 1989, including later the first SECEC/ ASES Travelling Fellowship by the European Society for Surgery of the Shoulder and Elbow in 1993. He served as President of the British Elbow and Shoulder Society (2003-2005),  and ex-officio Member the International Board of Shoulder and Elbow Surgery (2011). He was President of SECEC (2016-2018), International Editor of the Journal of Shoulder and Elbow Surgery (2008-2009), and has been a trustee of the Journal of Shoulder and Elbow Surgery since 2014.

arrived (Operation Garden). By the end of the operation over 3,000 Allied forces personnel had died with none of the key objectives achieved. The outstanding human courage displayed in such a severely flawed operation remains an enduring legacy. Within 24 hours of landing at the DZ, the hospital was overrun by German forces, and most of his colleagues at 16 PFA were taken prisoner. However, Lipmann-Kessel and his respective surgical team were allowed to remain. His ability to influence their SS captors was all the more remarkable given his Jewish heritage, and even involved him attending an SS mess dinner on invitation. Practical provisions for surgery were often makeshift and included using a Jeep piston tyre pump as a suction device.

Figure 2: Lipmann-Kessel’s British army parachute wings and RAMC cap badge in the Airborne Museum Hartenstein, Oosterbeek, Netherlands. (Image courtesy of Simon Hurst, London, UK).

Men considered suitably recovered by the SS were most often taken to prison camps. However, under Lipmann-Kessel’s direction many patients escaped to the Dutch resistance.

Life with the Dutch resistance Lipmann-Kessel’s partnership with the Figure 3: Modern day military parachutists supported by 144 Parachute Medical Squadron, 16 Medical Dutch resistance began Regiment (16 PFA’s modern equivalent) - training for airborne operations as part of exercise Falcon’s Leap whilst he was still at St in Ermelo, Gelderland, Netherlands. (Image courtesy of Simon Hurst, London, UK). Elisabeth’s under SS control. This included organising a mock funeral in order to bury in the ground under barns, and other farm small arms, and ammunition for them. buildings. He usually had less than an hour All aspects involved considerable risk to in the fresh air each day. himself. Notably he refused safe passage back to Allied lines provisionally organised Lipmann-Kessel eventually made it back by a senior SS officer. behind Allied lines in February 1945 after utilising a canoe to make his way through His own escape saw months under the the canals and waterways of the Biesbosch protection of the Dutch resistance where in freezing conditions. He had failed only life was extremely tough. Often he lived 24 hours previously due a serious leak in the in what amounted to no more than a hole canoe he was using. >>

Features

Innovation and inspiration

Legacy

He is probably best remembered by the prothesis which bears his name - ‘the Kessel total shoulder replacement’6. The name is misleading as the implant was in fact an early example of what is now commonly termed a reverse shoulder replacement, (Figure 4). 46 replacements of this type are reported in the literature6,7. Prior to the Kessel prothesis poor results had been achieved with constrained implants using a traditional ball and socket orientation in rheumatoid arthritis. Concerns about the use of cement within the scapula were also starting to emerge. LipmannKessel aimed to address these by reversing the ball and socket position and by having an uncemented glenoid component. Results were mixed with early failure in some patients due to instability, and implant failure. This ultimately limited the implant’s use with none implanted after 1985. However, long term follow-up of these patients has suggested a survivorship similar to conventional anatomic prostheses of the time7.

Every three years since 1980 shoulder surgeons, and other specialists in the field, meet from across the globe at The International Congress of Shoulder and Elbow Surgery (ICSES). This truly global society was conceived by LipmannKessel and has met on most of the world’s continents.

Other innovations included a new technique for accessing the shoulder for repair of massive rotator cuff tears – an acromial osteotomy in the coronal plane, with the advantage of avoiding compromise of the deltoid musculature8. Another used a carbon fibre, and free graft of the long head of biceps tendon to close cuff defects. Extensive contributions are also captured in the many books he authored6, 9-12. It is likely that he had several influences but perhaps the greatest was Valentine Ellis at St Mary’s Hospital, Paddington, London who is attributed to providing the earliest spark towards Lipmann-Kessel’s life-long interest in the shoulder6.

The famous Arnhem film ‘Theirs is The Glory’ ends with the words, “if ever you meet a man from Arnhem, raise your glass to drink with him”13. On seeing this Lipmann-Kessel is reported to have remarked; “...exciting and wonderous enterprise is more profitably to be found in peaceful construction than in war. Let us not be deluded by the glory and excitement of War – it is a beastly business unbecoming to civilised man.”

Figure 5: Lipmann-Kessel’s final resting place in Municipal Cemetery North and South Oosterbeek (Airborne Cemetery), Netherlands. (Image courtesy of Simon Hurst, London, UK).

Lipmann-Kessel was a surgeon, first and foremost. He was dedicated to alleviation of human suffering through all means, no matter how austere or dangerous the environment in which he found himself. He was beautifully human, and this quality was made greater by the hardships and challenges he faced. Many professional legacies will continue to endure, but perhaps the greatest is the example that he set (Figure 5). WE DO NOT FORGET PROFESSOR OF ORTHOPAEDICS SURGEON TEACHER HUMANIST FIGHTER FOR FREEDOM LIPPY: REMEMBERED FOREVER BY ALL WHO LOVED YOU AND THOSE YOU SERVED n

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

Figure 4: The Kessel Shoulder Replacement. (Image courtesy of Lipmann-Kessel’s widow, and Professor Emery, London, UK).

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Features

Virtual learning – moving forward Usman Ahmed

COVID-19 has brought about carnage that has tested our profession, our patients and our communities to limits we never knew we had. As the first wave reared its head, we didn’t just witness the acute and profound impact on healthcare of COVID-19 but also the fallout and consequences on all other aspects of the NHS and society. Usman Ahmed is a Consultant Orthopaedic Surgeon with a special interest in Lower Limb Revision Arthroplasty at the Princess Royal Hospital, Telford. He is Head of Virtual Learning for Health Education West Midlands.

s clinicians up and down the nation mobilised to serve the NHS, one area that was severely hit was training. Yet as we know, necessity is the mother of all inventions, and with that the pre-COVID dabbling in virtual learning suddenly became a collective commitment to put together something, anything, to allow ongoing teaching. Surgical training in particular was hit by COVID-19 with more cautious consultant led emergency surgery and a complete halt to elective work, which in orthopaedics is often more significant than other specialties.

Virtual learning is not new. Globally universities, schools, public organisations and private companies have developed or acquired platforms to facilitate online learning. The odds are that you’ve probably participated in it without even knowing as many mandatory training modules are on such platforms. But this pandemic is probably the first time that the spotlight has been shone brightly on the role of virtual learning in postgraduate medical education, and a plethora of new terminology is being thrown around with more gusto than ever before.

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Where to begin? There are a variety of platforms available that can be utilised for education. Multiple specialty websites exist such as Orthobullets© and Radiopedia© which are phenomenal collaborative resources. The quality of the freely available information is such that it is a wonder that anyone ever needs to buy any books! But these can lose their sheen as the ability to engage users with the information beyond reading it and doing quizzes can be limited. Twitter® (a microblogging site) has been growing in popularity with clinicians and there are small pockets of clinicians having positive and educational discourse online. But there is no formal quality assurance and like all social media should be acknowledged to be a completely public platform, and not always for the purpose of education1. The same applies to YouTube®, however it does provide the opportunity for educators to easily and economically upload high quality content for dissemination. Then there is the role of video conferencing and webinars. With some companies offering free or heavily discounted subscriptions, Orthohub2 is one example of an educational programme that has risen up from a local audience to an internationally recognised platform providing high-quality webinars from recognised specialists. The engaging nature of the webinars, which are also available for review on the website, is one aspect of many that is fuelling the new culture of flexible online learning. However, watching a video after the live event often lacks the real-time charm which is more engaging. Teaching and training comes with administrative needs. Educators in formal roles have to assess how to not only deliver the content but also optimise it and appropriately administer it. And this is where we can learn from schools and universities who utilise Learning Management Systems (LMS) such as Moodle™ and Canvas. The LMS platforms offer the ability to deliver content in many different and flexible ways whilst providing data on user activity and engagement tracking. The ability to build an entire school online, develop areas for specific specialties, collate and curate resources, record attendance and feedback, and exploit built in web-conferencing platforms means that the possibilities are endless. This then allows more focus on the human element of virtual learning. Acknowledging the heterogeneity of every group of trainers and teachers is complicated by technological capabilities and facilities. Therefore, there is a tremendous emphasis in engaging all groups to not just participate but to change well-established habits of teaching/learning to adapt to the new normal. Culture change can be incredibly slow and requires patience and persistence.

The Postgraduate Virtual Learning Environment (PGVLE) Recognising that regular structured teaching programmes needs to have administrative back-up led to the development of a Moodle/ BigBlueButton based platform which has now expanded beyond orthopaedic borders. The HEEWM supported PGVLE3 initially starting as an online school for surgical training but organic growth has led to it now facilitating medical and psychiatric programmes in the region. Programmes traditionally reliant on regular face to face teaching days now have access to an entire virtual environment that is akin to moving into a partly furnished flat but with a concierge service and a relaxed landlord. The ambition of having a flexible environment that allows not only for the transfer of existing face to face programmes to the Internet, but also enough capability to allow for creativity and refinement of these programmes is being realised. In its current format the PGVLE has become the hub for teaching programmes, out of hours trainee sessions, regional meetings, administrative meetings and standalone courses.

The rise of the Digital Teaching Fellow One strategy to drive ventures such as the PGVLE forward is to engage stakeholders by giving them ownership of the educational processes. Alongside the PGVLE we created the Digital Teaching Fellow (DTF) post where each specialty in the region has a trainee coordinating, organising and building the desired teaching environment. The DTF role works in close collaboration with training programme directors to integrate and customise the online platform in order to comfortably transition into the virtual environment without it being too disruptive to the normal teaching programme.

The fact that the training programmes have the opportunity to build their programme online within a comfortable framework has led to creativity on the part of the DTFs and the expansion of shared ideas. The result of this empowerment has been an organic trainee driven growth of the platform which has expanded beyond just surgical training and into other clinical schools.

Evolution Almost every initiative that started with the lockdown in March 2020 has evolved, with many of them finessing their main events with both a warm-up (reading, case, resources) and a warm-down (quizzes, podcasts, consolidation sessions). This has been shaped by the participants providing honest feedback and teachers being open and receptive to it. There is no doubt that with current variability in guidance on physical interaction that virtual learning is here to stay, and training programmes must have the capability to go either completely virtual or at least hybridise teaching easily. However, this can only happen if there is due thought and consideration given to the culture and governance of education in the real world and not just the virtual mechanism of delivery. n

References 1. Sahu MA, Goolam-Mahomed Z, Fleming S, Ahmed U. #OrthoTwitter: social media as an educational tool. BMJ Simulation and Technology Enhanced Learning. September 2020 [Epub ahead of print]. 2. OrthoHub. Available at: www.orthohub.xyz. 3. Postgraduate Virtual Learning Environment (PGVLE). Available at: https://pgvle.co.uk.

PGVLE screenshot.

Features

Zambia, FlySpec & the Rotary Doctor Bank Rhidian Morgan-Jones Much as I had always been interested in working abroad in different healthcare systems, I had never considered Zambia as a destination. Out of the blue however I had a message from the Rotary Doctors Bank asking if Iâ&#x20AC;&#x2122;d be interested in a working visit to Mongu, Zambia. Why had they asked me? Circuitously a visiting Priest from Mongu, was staying in South Wales and happened to ask his hosts if they knew of a surgeon with experience in bone infection, they passed the request onto a friend in Rotary, who knew the retired Dean of the Medical school who knew me! Rotary Doctors Bank Rotary Doctors Bank is a charity that helps initial funding and matching doctors and overseas medical need in developing countries. After an initial meeting, we quickly arranged a date for a hospital visit to assess the need and potential for me to help.

The Republic of Zambia Rhidian Morgan-Jones is a Fellowship trained Knee Surgeon working at the University Hospital Llandough, Cardiff. Having trained in the UK, South Africa and Australia he now provides a tertiary referral service for complex and infected Revision Knee Replacements and Chronic Ostemyelitis. He has lectured nationally and internationally and is widely published. Rhidian is currently an elected BOA Trustee.

Zambia is a landlocked country in southcentral Africa (Figure 1). On 24th October 1964, Zambia became independent of the United Kingdom and Prime Minister

Figure 1: Zambia.

Kenneth Kaunda became the inaugural President. The capital city is Lusaka, located in the south-central part of Zambia. The population of over 17 million is concentrated mainly around Lusaka and the Copperbelt Province to the northwest, the core economic hubs of the country. When I first visited, I believe there were only 12 qualified orthopaedic surgeons working in Zambia.

FlySpec (Flying Specialists) Flyspec is a unique flying medical charity in Zambia, a country roughly two-and-a-half times the size of the British Isles, where roads are poor, and travel is expensive. Operating principally by air, FlySpec is the only orthopaedic, plastic and reconstructive service, reaching patients in the most remote areas of Zambia. No charges are made for any treatment. The charity was originally founded, and funds raised, by Professor John Jellis, an English orthopaedic surgeon and pilot, who has worked for almost his entire professional life in Zambia. Prof. Jellis is a truly inspirational man and FlySpec is now a charity recognised and supported by World Orthopaedic Concern.

Features

They became friends and this one act of kindness saw many more people coming for help. Without trying, by the summer of 1949 his home of Le Court, in Hampshire, had 24 residents with complex needs, illnesses and impairments. As Le Court became established, people from different parts of the UK and then the world began to rally in response to local need for similar homes in their communities. By 1970 there were over 50 services in the UK, five in India and activities in 21 other countries around the world, including Mongu, Zambia. Children with disabilities, including palsies, limb deformities and amputations are often neglected due to the harsh economic and cultural environment of Zambia. The Cheshire Home and its dedicated staff is truly a refuge and home for these children in need. I had the pleasure of taking my two eldest children, Myfanwy and Ioan, on one visit. They spent a couple of days, playing with and teaching the local children whilst I worked.

Figure 2: Lewanika General Hospital.

Figure 3: Guillotine amputation following a snake bite.

Mongu is the capital of Western Province in Zambia and boarders Angola across the flood plains. Its population is approximately 180,000. It is a 10-hour drive, on variable roads, from Lusaka and has a single former colonial hospital, Lewanika (Figure 2). The hospital has a small number of employed doctors covering most specialities at a general level. It also trains nurses, midwives and healthcare assistants. During one of my visits, nursing students from Canada were at the hospital teaching local nursing students, something that has been ongoing for several years. The only orthopaedic input is supplied by surgeons form Lusaka, via FlySpec, who visit twice a year. Most of the work is trauma based - all managed conservatively, a steady stream of snake bites, untreated cerebral palsy and a lot of chronic osteomyelitis.

Knowing that a visiting surgeon has confirmed dates, a lot of work happens by the hospital manager to spread the word via health workers to outreach ‘clinics’. In the days before the visit patients travel to the hospital and wait to be seen. The visitations I’ve undertaken have been for two days work,

with days of travelling either side. Day 1 is Clinic; starting at 8am and finishing normally around 10pm. Clinic patients are a mix of previously managed cases and new presentations. X-rays are a limited resource and often brought with the patient when available. Clinical acumen always to the fore. Patients needing interventions are listed for the following day. Day 2 is Operating; starting around 8am and finishing when the work is done. The one break is the communal lunch hour and everyone brings food. My lack of eating prowess was a source of constant amusement! Operations included: Plastering ‘fresh’ fractures, osteotomy and plastering of deformities, and release of contractures. Chronic wound and stump management was also needed. Chronic osteomyelitis was interesting and challenging but decision making was often simple, remove the sequestrum, curette and wash with saline. Antibiotics were unavailable and didn’t seem to be detrimental in their absence. There was no post analgesia for adults. Children, thanks to the care of the Catholic Sisters/Nurses from the Cheshire Home, did a little better. They were offered a mattress for the night in a communal room and simple analgesics. No-one complained and the children cried very little.

Final thoughts It seems obvious to say that working in Zambia was humbling, but more than that it was enjoyable. Lewanika is a hospital in need of support but given that support the local doctors, nurses, and healthcare workers are highly competent, caring and motivated. For anyone thinking of visiting a similar hospital to work with the local teams, I guarantee two-way learning and admiration for what is achievable even in the most under resourced health systems. n

Cheshire Homes Founded in 1948 by former RAF pilot, Leonard Cheshire took a dying man, who had nowhere else to go, into his home. With no money, Leonard nursed the man himself.

Figure 4: Chronic Osteomyelitis before and after removal of sequestrum.

Medico-Legal

COVID-19: second round legal issues Henry F Charles

We are now into the second wave of COVID-19 and it may be timely to have a look at the legal principles that may come into play. This article looks at three discrete challenges: COVID-19 wards, non-COVID-19 medical practice and health and safety of those working within hospital settings. COVID-19 ward

Henry F Charles is a clinical negligence and personal injury barrister, called to the Bar in 1987. He acts for Claimants and Defendants typically in complex and high value claims.

Let’s start with a nightmare. Assume the case of a consultant orthopaedic surgeon in an NHS hospital who has to be deployed to a COVID-19 ward because otherwise there would be no medical cover; however, the orthopaedic surgeon has not worked in A&E or respiratory medicine for 30 years. A patient is treated in a manner that no responsible body of A&E/respiratory physician opinion would logically support (i.e. Bolam/Bolitho negligent) and suffers a worse outcome than s/ he would otherwise have done. Where does the orthopaedic surgeon (or rather NHSR, who will indemnify him) stand? The starting point is that any patient in a hospital is owed a duty of care. The issue is the standard of care required. The issue of the experience of the clinician in relation to the standard of care to be expected in his or her given role has occupied the Courts for many years. In Wilsher v Essex Health Authority [1987] Q.B. 730, it was held that the length of experience of the clinician was not relevant, and the duty of care related not to the individual but to the post they occupied. A houseman had failed to reach this standard by failing to notice a patient’s spitting and pooling of saliva, in simply accepting what the patient’s representative said and failing to obtain a proper case history, thereby failing to elicit details of a difficulty in swallowing which would reasonably have required him to detain the patient pending examination by an ENT specialist. It was probable that such further investigation would have revealed the condition and that treatment at that stage would have avoided brain damage.

In FB v Princess Alexandra Hospital NHS Trust [2017] EWCA Civ 334, the Court of Appeal overturned a decision that only a senior doctor would have had the expertise to apprehend the claimant’s developing problem. Jackson LJ noted: “59. In Wilsher v Essex AHA [1987] 1 QB 730 the Court of Appeal for the first time gave detailed consideration to the standard of care required of a junior doctor. (This issue did not arise in the subsequent appeal to the House of Lords). The majority of the court held that a hospital doctor should be judged by the standard of skill and care appropriate to the post which he or she was fulfilling, for example the post of junior houseman in a specialised unit. That involves leaving out of account the particular experience of the doctor or their length of service. This analysis works in the context of a hospital, where there is a clear hierarchy with consultants at the top, then registrars and below them various levels of junior doctors. Whether doctors are performing their normal role or ‘acting up’, they are judged by reference to the post which they are fulfilling at the material time. The health authority or health trust is liable if the doctor whom it puts into a particular position does not possess (and therefore does not exercise) the requisite degree of skill for the task in hand. 60. Thus in professional negligence, as in the general law of negligence, the standard of care which the law requires is an imperfect compromise. It achieves a balance between the interests of society and fairness to the individual practitioner.”

Medico-Legal

That view was reiterated in the context of the facts of the case: “The conduct of Dr R---- in the present case must be judged by the standard of a reasonably competent SHO in an accident and emergency department. The fact that Dr R---- was aged 25 and ‘relatively inexperienced’ (witness statement paragraph 5) does not diminish the required standard of skill and care. On the other hand, the fact that she had spent six months in a paediatric department does not elevate the required standard. Other SHOs in A&E departments will have different backgrounds and experience, but they are all judged by the same standard.” The law thus requires a standard no higher, and no lower, than a reasonably competent healthcare professional of the role which is being fulfilled.

individuals are working in an unprecedented emergency; its purpose being to prevent a fear of liability acting as brake on such activity. This is now in statutory form via the Social Action, Responsibility and Heroism Act 2015. Section 1 of the Act states that it applies “when a court, in considering a claim that a person was negligent or in breach of statutory duty, is determining the steps that the person was required to take to meet a standard of care”. Sections 2-4 detail matters which the court must have regard to, relating to the circumstances of the alleged breach of duty: whether it occurred when the person was acting for the benefit of society or any of its members, whether the person demonstrated a predominantly responsible approach towards protecting the safety or other interests of others, and whether that person was acting heroically by intervening in an emergency to assist an individual in danger. That might help our

“The law has a principle – the ‘rescuer principle’ which in essence allows for a relaxation of the standard of care where individuals are working in an unprecedented emergency; its purpose being to prevent a fear of liability acting as brake on such activity.”

So our orthopod is in trouble. Unless … The law has a principle – the ‘rescuer principle’ which in essence allows for a relaxation of the standard of care where

orthopaedic surgeon and his or her hospital avoid a finding of negligence. Assistance might also be drawn from Section 1 of the Compensation Act 2006, which provides that, when considering breach of duty, the court may have regard to whether the steps that should have been taken by the defendant to meet a standard of care might either prevent a desirable activity from being undertaken at all, to a particular extent or in a particular way, or discourage persons from undertaking functions in connection with a desirable activity. Whilst this does not strictly apply to our orthopaedic surgeon, in that healthcare professionals clearly do not fail to carry out desirable activities in respect of treating patients, it does give a clear indication that the standard of care has limits. It suggests that in certain cases, the rights of individuals to be compensated for their loss is trumped by the necessity of defendants not being deterred from carrying out important activities. So it may be a helping hand. This principle has also appeared in case law, for example in Marshall v Osmond [1982] Q.B. 857, which involved a police officer whose driving caused injury to a passenger of a vehicle he was pursuing. In the first instance decision in this case, it was held that the defendant’s ‘actions must not be judged by standards which would be applicable if the situation were such that the officer had time to consider all possible alternative >>

Medico-Legal

best to ensure that the problems are discussed carefully and recorded. I recollect doing some training for local government health and safety officers many years ago on then recent health and safety legislation which involved the need for risk assessments. At the end one of the delegates stood up and said: “This is all splendid stuff but me and my boss know what we’re doing: and if you don’t write it down they can’t get you!” Hopefully their insurers had deep pockets …

Safety for those working in the hospital The government watered down protections for workers when it introduced legislation in the form of the Enterprise and Regulatory Reform Act 2013 that removed any civil liability from a breach of the Health and Safety at Work Act/regulations made under it. So a claimant alleging, for example, defective or inadequate personal protective equipment now has to show negligence – it is not possible to rely on what sometimes amounted to strict liability, or where the employer had to effectively disprove negligence. In practice there has not been much difference: if relevant regulations have not been complied with the judiciary is very content to take that as evidence of negligence but the burden is full square on the claimant. courses of action that he could have taken to discharge his duty successfully’. The Court of Appeal ([1983] Q.B. 1034) upheld the first instance decision, finding that there had been an error of judgment, but considering that there was not negligence. Sir John Donaldson M.R. referred to the circumstances of the collision, including that the officer was working in stressful circumstances. So it may be the case that the error of our orthopod incorrectly triaging a patient, this is more likely to be seen as a mere error of judgment.

Non-COVID-19 practice

But there is a problem here. We now know about COVID-19. The second wave has been predicted. The Courts are going to expect hospital management to have some planning in place. The Courts would also be asking our orthopod what if any steps s/he took to ascertain that it was a case of treatment from the orthopod or nobody better qualified.

Next, consent. There may be a subliminal temptation to get up to speed with operations on patients who really don’t fit the criteria. The urge would be entirely natural. I wonder if particular care with the consent process may provide the natural corrective.

Now let’s notch down the example and assume that a respiratory physician decides not to treat a patient according to a particular protocol or with a particular drug. We are back with Bolam/Bolitho and judging clinicians by the standards of reasonably competent practitioners in the particular role acting logically. If the treatment ticks that box then there has not been a breach of duty: the law allows for different approaches to problems, different views.

There are three problems here. Firstly, the five P’s – Proper Preparation Prevents Poor Planning. The problem is receding but in respect of high end and indeed even some basic procedures there is a re-learning curve. Absent dire emergency the Courts are going to take a dim view if injury occurs because a consultant has missed something basic.

Then there is the issue of post-operative support. Is it going to be there for the patient? Is an isolating eighty year old patient going to be in a position to undertake postoperative physiotherapy themselves following basic instruction? Would Zoom instruction be adequate? Has the patient access to Zoom? Even taking all that into account might it be better to operate? Essentially we are back with the informed consent process. If difficult decisions are involved – possibly unusual decisions based on available treatment and follow-up modalities then

In terms of exposure to COVID-19 the greater problem may be that of causation. How does the infected clinician show that it was defective or inadequate or non-existent personal protective equipment that resulted in the clinician contracting COVID-19 and falling very ill? That will be a matter of evidence gathering: if it is a one-off occasion that may be harder than a systematic failure. Of course the same issues pertain if a patient has become infected at hospital and believes that a clinician was not using PPE, for example. Finally, fatigue. This is pernicious – deep tiredness most certainly plunders the ability to appreciate and deal with the tiredness by taking a break/time off. That may in any event be difficult with waiting lists, but in terms of personal health and the health of patients it is a pretty critical issue. Hospital planning may not always have been perfect. These may all be issues requiring action at consultant, clinical director and deanery level. For all of the above it is worth remembering that the Courts are largely and rightly sympathetic to clinicians, and pragmatic. Note: This article is for general information only and is not intended to be, and nor does it constitute, legal advice on any general or specific legal matter. No liability is accepted for any reliance upon this article. n

Trainee Section

Ran Wei is a ST8 in South West London with an interest in Knee Surgery. He is currently the President of BOTA and represents trainees on a number of issues, including diversity and inclusion in T&O surgery.

The future of orthopaedic training: diversity and education Ran Wei, Kathryn Dayananda and Oliver Adebayo

Kathryn Dayananda is a Specialty Trainee on the Welsh rotation currently working in Cardiff. She was elected this year as the Women in Surgery Representative for BOTA in 2019. Kathryn’s experiences working abroad and her ambition to be a representative voice for all has led to her involvement with the BOA D&I Strategy Group as well as with BHS Culture Working Group.

Oliver Adebayo is an ST5 trainee on the Royal National Orthopaedic Hospital rotation in North, East and Central London Deanery. He is currently the BOTA webmaster. He has a passion for global surgery and is a founding member and on the committee for the Global Anaesthesia, Surgical and Obstetric Collaboration, a trainee advocacy group for global surgery since 2015. He has a MSc from Imperial in Surgical Innovation and has a keen interest in quality improvement, education, digital transformation and clinical UX.

Over the last few years, BOTA have utilised our flagship session at the BOA Annual Congress to tackle issues such as bullying in surgical training, barriers to surgical training and the attributes of excellent surgical trainers. The success of our sessions has relied on engaging content as well as its interactive delivery. It was clear from our first BOTA Committee meeting in January 2020 that our main focus this year would be Culture and Diversity / Inclusion in T&O training.

e assumed that our biggest challenge would be to create engaging and thought-provoking content. What we had not anticipated was a global pandemic. Needless to say, the decision to deliver BOA’s Annual Congress over a virtual platform resulted in a few sleepless nights. This new mode of delivery made gauging audience engagement extremely difficult. In a bid to overcome this we employed the Q&A function of the GoToWebinar platform as well as social media channels. We titled the session ‘The Future of Orthopaedic Training: Diversity & Education’. The Committee unanimously agreed that both culture and diversity / inclusion as well as simulation in T&O education were important areas to explore, irrespective of, but especially in the wake of the current COVID-19 pandemic.

We aimed to cultivate discussions regarding these important issues both during and after our session. Our team utilised Twitter (#FutureOfOrthopaedics) to achieve this. A recording of the session has been made available by the BOA for viewing on their website at: https://www.boa.ac.uk/liverecordings. Please check it out if you were unable to attend the live session, using the QR code reader.

Trainee Section

Culture and diversity / inclusion in T&O surgery In the first half of the 90-minute session we explored issues surrounding Culture and Diversity / Inclusion within T&O surgery. Miss Kathryn Dayananda and Mr Jonathan Howell (President of the British Hip Society) delivered thought-provoking presentations that sparked ample debate on GoToWebinar and Twitter. Miss Dayananda presented data from the triennial BOTA census, undertaken in 2019. She also showcased BOTA’s Culture and Diversity / Inclusion promotion video1, which features recordings of the BOTA National Committee reading out a series of blinded comments collected from a small-scale survey from T&O trainees across the UK.

BOTA 2019 census data Culture 590 trainees completed the BOTA 2019 census. 42% stated that they suffered from stress and anxiety as a result of work. In 16% of cases, negative morale at work was caused by either colleagues (4.9%), other consultants in the department (4.8%), their consultant trainer (3.8%) or the TPD (2.5%). Despite the huge improvements seen following the ‘HammerItOut’ campaign, 16.3% of trainees continue to experience bullying behaviours within the workplace. The top three identified offenders amongst the respondents to this survey were T&O Consultants (38.3%), Hospital Managers (12.1%) and Nurses / Scrub nurses (8.7%). No one should be subjected to inappropriate behaviours within the workplace. It is vital that we understand that anyone can make another person’s life difficult or unpleasant with racist, homophobic, misogynistic, undermining or harassing behaviours. Anyone can fall foul of these behaviours. It is important that we bear this in mind the next time we engage in ‘banter’ at work.

This video highlights issues of sexuality, gender, ethnicity and overarching culture among the T&O community. Reactions to blinded comments helped provide a real time appreciation of the impact and responses triggered. These acted as a springboard for discussion. Mr Howell attempted to answer two fundamental questions in his presentation titled ‘Diversity and Inclusion – The Future of Orthopaedics?’. 1) Why do so few female medical students enter into surgical / orthopaedic careers? 2) Why do so few women complete their training in surgery / orthopaedics to become consultants? He focused primarily on gender but acknowledged that minority groups were likely to have experienced some form of discrimination as well. He expertly explored topics such as habitus, fitting in, why woman leave surgical training, assessment bias, price paid by woman and culture. Having impressed the audience with his progressive and feminist views, he concluded his presentation by advocating some ‘house rules’ at work – Be Polite, Be Kind, Treat People as People and Pull Together as a Team. It may sound simple but it is too often forgotten.

Inclusion Engaging with and inspiring future T&O surgeons is one of the most important responsibilities of a T&O surgeon. The BOTA 2019 census found that 51% of T&O trainees decided to pursue a career in T&O surgery either within medical school (39%) or before medical school (12%). Of the remainder, 30% decided during foundation years training, 15% during core surgical training and 4% during time out of training. It is worth bearing this in mind next time you have a medical student or foundation year doctor in your clinic or operating theatre. To become an inclusive specialty, we must understand and learn to accept that not all trainees will be able to work full time. Our census found that only 4% of trainees were Less Than Full Time (LTFT). The majority were either 60% LTFT (40.9%) or 80% LTFT (36.4%). 4% of full-time trainees stated that they would like to be LTFT. If we are to improve accessibility of T&O training, we must relinquish the false narratives surrounding LTFT trainees. A change in culture and attitudes within our specialty and across the wider NHS is the first step towards creating an inclusive and more diverse working environment. We must remember (against all odds) to be kind and thoughtful. We must acknowledge our weaknesses, utilise our strengths, and be accepting of our differences.

Diversity Gender imbalances persist amongst T&O trainees. More than 1,000 trainees (NTN and non NTN) were surveyed and of the 590 NTN holders who responded, 75% were male and 24% were female. The remaining 1% preferred not to disclose their gender. Ethnicity within the T&O trainee body largely reflects the UK ethnicity distribution documented by the UK Census in 20112. Comparisons made can be seen in Table 1. BOTA Census (2019)

UK Census (2011)

White

56%

86%

Asian

21%

7.5%

Black

3.3%

Mixed

2.6%

2.2%

Other

12%

Table 1.

Specialty training should aim to produce a workforce that reflects the population it serves. A more diverse workforce will help us better understand the needs of our patients. It is therefore an essential piece of the healthcare puzzle.

Simulation in T&O education The second half of the virtual session explored the utilisation of computer simulation in T&O education. Two of the most accomplished academics in computer simulation education in the UK T&O community, Professor Duncan Tennent and Mr Kapil Sugand, shared with us their thoughts on the subject. In his talk, titled ‘Simulation in Training – The BOA’, Professor Tennent briefed us on the current state of simulation provision in T&O training across the UK3. He explored the barriers to uptake of computer simulation training as well as a vision for the future of this adjunct to training. Mr Sugand explained the fundamental principles of surgical simulation and examined the evidence for the tools and methods currently being utilised and >>

Trainee Section

developed in simulation technology. He highlighted the need for simulation to recreate the clinical exercise in an immersive, realistic, interactive and controlled environment that enables learning, development and mastering of technical and non-technical skills without compromising patient safety. On reflection, both presentations highlighted two important themes - limitations of simulation and innovation in simulation. Limitations of simulation Loss of training opportunities as a result of disruptions caused by the current COVID-19 pandemic lends support to the mandate for increasing surgical simulation training. However, it is important to understand that simulation is limited by its ability to recreate a true surgical environment. This is known as validity. Validation is what every simulated exercise is measured against and is categorised into four distinct entities (Table 2). Concurrent validity of a simulation tool is the aim of every simulation developer.

Type of Validity

Description

Face

Does it look real?

Content

Are the operative steps realistic?

Construct

Can the exercise differentiate between levels of skill/training/ expertise (e.g. medical student vs. consultant)?

Concurrent

Can the skills learnt in simulation be transferred to the operating theatre?

Table 2.

It is vital to understand that every simulation tool is different and will therefore fulfil different roles within the education journey. Cognitive task simulations, popularised by the smart phone application ‘Touch Surgery’, allows users to rehearse steps of a procedure. This may help junior trainees learn the knowledge required for a particular procedure but does not improve their technical skills for that procedure. In order to improve their technical skills, augmented reality or desktop simulation (e.g. saw bones workshop) would be required. It goes without saying that there remain significant limitations to simulation technology and its implementation. The aim of simulation training is not to replace

real-life surgical training but to supplement it. Understanding a trainee’s need will ultimately allow trainers to employ the most appropriate simulation tool for the development of that trainee. The ultimate goal being a curriculum which fully utilises simulation to enhance surgical training. Innovation in simulation The BOA continues to advocate for the development of a surgical simulation curriculum. This will require close collaboration with a number of stakeholders (i.e. trainee organisations, subspecialty associations, governing bodies, etc.). The main challenges to successful implementation of simulation in surgical training are funding and willingness to embrace simulation culture. We are all exposed to simulation from as early as medical school. Desktop simulation such as saw bones workshops and cadaveric labs remain in the mainstream of post-graduate T&O training. We must now start to embrace alternative forms of simulation training. Various methods have been validated in the literature. These include Virtual Reality simulators, Augmented Reality simulators, Hologram images and Virtual worlds, and Distributed Interactive simulation. Distributed Interactive simulation is a type of desktop simulation that allows creation of a realistic bone and patient model to be used with real tools and instruments in a fully modelled environment (e.g. simulated operating theatre). The use of actors to simulate the multi-disciplinary team within this medium creates a fully immersive experience. As such, it is expensive but could well form the basis of evaluation and training in the future. Regardless of modality, in order to improve simulation, we must all engage with the resources currently available. The Virtual Reality and Simulation in Healthcare Summit is a fantastic opportunity for those interested in simulation to gain further insight. The BOA also offers opportunities for trainees to be recognised for their contribution to simulation. These include the education and simulation free papers at the BOA Annual Congress and the Innovation in Simulation Award. With ever increasing utilisation of technology in healthcare, not least due to restrictions imposed as a result of the COVID-19 pandemic, there has never been a better time to truly move into the future with simulation for T&O education in the UK.

Conclusion The current COVID-19 pandemic has presented the whole nation with significant challenges to overcome. BOTA is acutely aware of the additional stresses endured by trainees as a result of disruptions to training activities. It is now more important than ever that we look out for one and another. We must reflect on our behaviours within the workplace. We must aim for a diverse workforce that represents the patients we serve. We must strive to be inclusive in order to inspire the next generation. We must also look to the future and welcome new technologies that help enhance surgical education. Out of adversity comes opportunity. We must now seize this opportunity to better our profession and improve the training of future T&O consultants. n

References 1. BOTA’s Culture and Diversity / Inclusion promotion video. Available at: www. youtube.com/watch?v=3kCQBvaFJTU. 2. GOV.UK. Population of England and Wales. Available at: www.ethnicity-facts-figures. service.gov.uk/uk-population-by-ethnicity/ national-and-regional-populations/populationof-england-and-wales/latest#by-ethnicity. 3. James HK, Gregory RJH, Tennent D, Pattison GTR, Fisher JD, Griffin DR. Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey. Bone Joint J. 2020;1(5):103–114.

Note from the Editor: The BOA was delighted to hear and see how BOTA tackled the issues of diversity and inclusion at the Virtual BOA Congress which fitted in well with the launch of our Diversity and Inclusion Policy earlier this year. It was particularly pleasing to see that BOTA membership is 24% female while the 2019 NHSE statistics quote 18.9% women at registrar level and 29% at Core Training: BOTA is clearly managing to engage with female trainees. The BOA was also delighted to see that the NHSE 2019 ethnicity statistics for T&O show that core trainees identifying as English Asian were the largest ethnic group at this level accounting for 35% of trainees. At registrar level they represented 29% of trainees. Whilst it remains true that only 6.6% of consultant T&O surgeons are women, 30% of BOA female consultants are within 5yrs of CCT and hence Early Years Consultants. We do believe that the tide is turning and with the support of our members, consultant and trainees alike, we can continue to ensure that progress is made in all areas of our Diversity and Inclusion Policy.

Subspecialty Section

Pre-amputation: the first step in amputee rehabilitation Jennifer Fulton

Major limb amputation produces significant changes in the body structure and function in the immediate and long term. For the individual who will be living with limb loss the journey should begin with a pre-amputation consultation with a specialist rehabilitation team. The BRSM guidelines1 recommend that “a pre-amputation consultation with an appropriate member of the amputee rehabilitation team should be arranged where amputation is a treatment option”.

he purpose of the preamputation consultation is to provide the patient with relevant information related to the rehabilitation pathway, including challenges and benefits to allow them to make an informed decision about surgery and their future health and wellbeing.

Clinical assessment Jennifer Fulton is a clinical specialist Physiotherapist at the Royal National Orthopaedic Hospital. She is passionate about rehabilitation for patients with amputations and optimising functional outcomes with a particular interest in amputation due to sarcoma.

The clinical assessment (see Box 1) informs the discussion and education elements of the pre-amputation consultation. To be effective and informative these need to be personalised to the relevant needs and concerns for each patient and their unique situation.

A key aspect of a pre-amputation consultation is to establish an individuals’ expectations of amputation surgery and the functional goals they wish to achieve, management of these from an early stage is key to achieving a successful outcome. Figure 1 demonstrates the complex range of factors that contribute to achieving a successful outcome following amputation surgery and a few of the key areas are discussed further. Patient expectations The majority of patients having lower limb amputation expect to walk again and to use a prosthesis to return to function and quality of life.

Clinical Assessment during pre-amputation consultation: • Current health status including pre-existing medical conditions. • Social history and support network. • Neuromusculoskeletal assessment: o Peripheral nerves for any neuropathy or hypersensitivity. o Joints: range of motion and stability of joints proximal to proposed level of amputation. o Muscles: Length - key groups for flexion and abduction contractures at the hip and flexion contracture at the knee. Strength. o Circulation / skin. o Pain. • Level of fitness. • Current functional mobility and ability in relation to Personal and Domestic activities of daily living. Box 1.

Clinical discussion

Management of expectations can be done by focussing on the issues and challenges they can expect to meet at each stage of the rehabilitation pathway and highlighting the short-term goals or milestones that need to be achieved before moving to the next stage. It is important to introduce the idea that use of a prosthesis is not the only way to achieve goals or improve quality of life. Activities that rank high on quality of life measures

Subspecialty Section

it is a scarce resource in the NHS particularly on acute surgical wards in the post-operative phase. Reassurance can be given that nursing and allied health professionals have the ability to support in this early phase and can help with identifying strategies for adapting to change and ensuring social support on discharge. If there are particular concerns at the preamputation stage, it may be appropriate to refer to local mental health services via the GP for support closer to home.

Figure 1: Factors that contribute to achieving a successful outcome following amputation surgery.

relate more to living with less pain, being able to socialise, engage in meaningful pursuits and have a role within the family. Depending on individual circumstances a prosthesis may allow this and for others it may be achieved by using a wheelchair alone or a combination of both. Pain management Management of pain in the immediate postoperative phase is crucial for patient experience and to facilitate early mobilisation and engagement in rehabilitation. Many patients who are on high doses of opioids before surgery benefit from being referred to pain management services to work on medication reduction and to learn alternative strategies for pain management.

(PLP) and the range of sensations both noxious and otherwise they may experience. While patients are reassured that there are medication options to assist with management of PLP they also benefit from being informed about non-pharmacological treatment options such as acupuncture, TENS, relaxation and breathing and graded motor imagery, including mirror box therapy.

“A key aspect of a pre-amputation consultation is to establish an individuals’ expectations of amputation surgery and the functional goals they wish to achieve, management of these from an early stage is key to achieving a successful outcome.”

It is known that higher levels of pre-operative pain and particularly existing neuropathic pain symptoms predispose to greater experience of phantom limb pain in the first few months after amputation. Patient should be/are informed about phantom limb pain

Surgical consideration should also be given to management of peripheral nerves during the operation to manage neuroma formation, reduce PLP and maximise future corticoneural/ prosthetic interfaces. Emotional wellbeing and support

Many patients are concerned about how they will cope emotionally after amputation. There is often an expectation that if they are going through such a life changing event there will be psychological and counselling services to help them2. While many prosthetic rehabilitation centres do have counsellors or psychologists

Many prosthetic rehabilitation units have patient support groups with buddy systems. Patients can be signposted to these and some of the condition specific charities where they can benefit from peer support and lived experiences of others who have been through similar situations. There is much that still needs to be done in terms of patient support information in different formats to support the vast age range of patients who undergo amputation. It is important that someone considering amputation identify one or two key people who can support then through the process including attending appointments such as the pre-amputation consultation, when a lot of information will be provided. Home environment The majority of houses in the United Kingdom are not wheelchair accessible or friendly. This can result in many patients being discharged home to live in microenvironments while awaiting home modifications / adaptations or considering rehousing all of which can take many months. Involvement of an experience Occupational Therapist is key in the presurgery and acute post-operative stage to set these processes in motion, to manage expectations and to find workable/acceptable solutions for patients and families that maximise a patient’s independence and quality of life. Simple activities such as decluttering can improve circulation space, prepping and freezing meals before surgical admission, that can be reheated in a microwave to provide healthy nutritious food afterwards and provision of key pieces of basic equipment can often make a difference to someone being >>

Subspecialty Section

Pre-amputation

Surgery

Pre-prosthetic rehabilitation

Primary Assessment

Prostethetic Rehabilitation

Ongoing Management

arm strength and cardiovascular fitness. They can benefit from referral to dietician to optimise weight and nutritional intake, and smoking cessations services if appropriate.

• Inter-realtion ship between surgical and rehabilitation teams, patients and family • Information gathering, expectation management, informed decision making • Early referral to wheelchair services, social services, other professionals as required to optimise fitness for surgery

• • • •

Formation of optimal residual limb to faciliate rehabilitation Pain management, early mobilisation, wheelchair skills, stetching and exercises, wound and swelling management Preparation for safe discahrge home including falls management Depending on Length of stay start apects of pre-prosthetic management

• Ongoing physiotherapy: exercises, stretches, balance, reduction of swelling, residual limb desensitsation, pain management, use of early walking aids from day 5 onward, cardiovascular fitness • Psychological support as required • Goal setting: minimal flexion contracture, ability to stand for casting if required, ability to use early walking aid and progress gait pattern

• MDT assessment: Review of progress to date,if sufficient progress with goals and milestones, condition of wound, residual limb and pain management proceed to cast • Selection of prosthetic components based on goals and predicted ability • Time frame minimum 4-6 weeks

• • • • •

Provision of prosthesis: ecuation to don and doff and manage flucuating residual limb volume alongside initial gait training in therapy before progressing to community use Functional progress to include falls management, stairs, slopes, uneven ground Incorporation into activities of daily living, including return to work, school, hobbies Collection of outcome measures Timeframe 6-12 months

Use of a prosthesis will require lifelong access to limb fitting services, with a minimum of an annual check-up but frequently more regular attendance is needed for the refitting of sockets or changes to components such as when prosthetic feet and knee joints are trialled. While there are prosthetic rehabilitation units located throughout the country this still requires long journeys for many.

Conclusion • Regular prosthetic review to optimse aligment and socket fit and maintain components • Annual Consultant review for ongoing health needs and impact on safe prosthetic limb use • Lifelong

Figure 2: Rehabilitation pathway timeframes.

dependant on others or managing safely and independently. It is important that patients understand even with a prosthesis there will be times they may require a wheelchair and that this will become more frequent as they age. Timely referral to the local wheelchair service for provision of a suitable wheelchair is advisable for all patients proceeding to amputation. Access to rehabilitation services It is important for patients to understand the rehabilitation pathway and the stages and time frames involved in this (see Figure 2). Progression from each stage usually requires certain goals or milestones to be met.

Amputee rehabilitation is physically demanding. It requires the patient to commit to daily stretching, exercising, desensitisation work on the residual limb, managing pain, managing their thoughts and mood, practicing balance and walking with a prosthesis. It can take many months to achieve a basic level of walking with aids before progression to more advanced function and previous activities.

“Amputee rehabilitation is physically demanding. It requires the patient to commit to daily stretching, exercising, desensitisation work on the residual limb, managing pain, managing their thoughts and mood, practicing balance and walking with a prosthesis.”

Where appropriate patients can be referred to physiotherapy to start a targeted exercise programme before surgery to stretch tight muscles and joints, improve

The need for limb amputation is often seen as a failure by surgical teams. It is important to reframe this surgery as the key first step of an integrated pathway between surgical and rehabilitation teams. By referring patients for a pre-amputation consultation, it places the person the centre of care and allows informed decision making and optimal outcomes. n

References 1. British Society of Rehabilitation Medicine. Amputee and Prosthetic Rehabilitation – Standards and Guidelines, 3rd Edition; Report of the Working Party (Co-Chairs: Hanspal RS, Sedki I). British Society of Rehabilitation Medicine, London 2018. 2. Furtado S, Briggs T, Fulton J, Russell L, Grimer R, Wren V, Cool P, Grant K, Gerrand C. Patient experience after lower extremity amputation for sarcoma in England: a national survey. Disabil Rehabil. 2017;39(12):1171-90.

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Subspecialty Section

Amputation after trauma Jowan Penn-Barwell

Jowan Penn-Barwell is a Consultant Orthopaedic Trauma Surgeon in the Royal Navy and is the Clinical Lead of the Oxford Trauma Service. His research interests include ballistic trauma, outcomes after complex limb injuries and evaluating novel limb salvage techniques.

Surgical amputation following an injury is rare, and consequently few surgeons perform them frequently in this context. Overall, only around 5-15% of lower limb amputations are performed following injury, with the majority being due to vascular disease1,2. Reference texts and the literature mainly focus on dysvascular limb loss patients who are typically older, sicker and with less potential for rehabilitation than the trauma patient, which limits their utility to the trauma surgeon.

he aim of this article is to provide the reader with an overview of the difficult decisions that have to be made when contemplating and planning lower limb amputation after trauma, and place them in the context of current literature and understanding.

Initial surgical treatment of severe limb injury Severe limb injury frequently occurs in the context of polytrauma. In these instances, initial treatment should be focused on the techniques of damage control resuscitation and surgery: haemorrhage control, tailored resuscitation with blood products and skeletal stabilisation. Decision making around limb viability is extremely challenging in the context of surgery. Immediate completion of partial amputation is normally only necessary when the patient is in physiological extremis.

â&#x20AC;&#x153;Surgeons may be tempted to rely on scoring systems such as MESS to aid decision making; at least six systems have previously been proposed to quantify limb injury and identify those which are potentially viable and those in which salvage attempts would likely be futile.â&#x20AC;?

Surgeons may be tempted to rely on scoring systems such as MESS to aid decision making; at least six systems have previously been proposed to quantify limb injury and identify those which are potentially

viable and those in which salvage attempts would likely be futile3-8. The studies presenting these scoring systems share similarities: they are cohort studies of limb-threatening trauma, the presumptive treatment was salvage, and regression analysis was used to determine predictive factors that form the basis of the scoring systems they propose. These scoring systems have been shown to be poor predictors of limb viability in both the civilian9 and military context10, and do not adapt as techniques and therapies improve. In the absence of an algorithmic basis for decision making, surgeons must rely on a subjective process based on their experience and unit capabilities. If possible, severely traumatised limbs should be carefully examined pre-operatively by senior orthopaedic and plastic surgeons, photographed, and imaged using CT angiography in accordance with NICE11 and BOAST guidance12. Surgeons should postpone any absolute decisions about amputation until the limb has been fully assessed intra-operatively and crucially all non-viable or irredeemably contaminated tissue has been excised. This systematic excision or debridement may in fact involve a de-facto amputation.

Subspecialty Section

Severely injured but perfused limbs should be stabilised with an external fixator and the wound dressed with a Topical Negative Pressure dressing (e.g. Wound VAC®). This temporary stabilisation and wound management provides time for surgeons to have a fully informed discussion with the patient about whether a severely injured limb should be amputated or whether attempts should be made at limb reconstruction.

Amputation versus reconstruction; could versus should When deciding between amputation and reconstruction it is important to define what a successful outcome would look like. It is perhaps a natural tendency of the surgical character to push for reconstruction whenever possible. The surgeon’s perception of ‘success’ would be united fractures, healed wounds and an absence of infection. In this situation, the surgeon is assessing whether reconstruction could be possible. However, a patient is more likely to define success by function, the absence of pain, walking distance and the avoidance of prolonged treatment. Here, the surgeon should not assess whether they could reconstruct the limb, but whether they should. Would surgical reconstruction give the patient the outcome they desired?

Surprisingly military patients who ‘fail’ reconstruction attempts and go on to have a delayed amputation have been found to have superior outcomes to patients who have retained their limbs after open tibia fractures13 and severe hindfoot injuries14-16. It is important to note that this counter-intuitive finding might not extrapolate from a military cohort to a civilian one. This is also an extremely challenging area to quantify as superior outcomes following amputation may be limited to younger patients and a cross-over may occur when older patients with retained limbs eventually have superior function than similar, older amputees. Further confounders exist where the financial and social implications of limb loss versus retention typically favour the former, distorting quality of life metrics.

Amputation level

If the clinical situation permits, decisions about amputation or reconstruction should be discussed at length with the patient and their family. These should involve the Orthopaedic Trauma and Plastic & Reconstructive Surgeons, Prosthetist and members of the rehabilitation team. Realistic information should be given to the patient regarding the relative likelihood of them walking without a limp or pain and even running with the two treatment strategies. It is worth acknowledging that initial reconstruction does retain the option for later amputation.

Burgess’ description of a below knee amputation with a posterior flap17 has been adopted as the basis of trans-tibial amputation. He described a level 9-13cm below the joint. Given the huge functional advantage of retaining the knee joint, a trans-tibial level should be contemplated whenever the tibial tuberosity and extensor mechanism can be retained. There have been case reports of using distraction osteogenesis to lengthen short residual tibias that have been amputated just distal to the tibial tuberosity18,19. >>

Deciding the level at which an amputation should be performed presents its own challenges. The two broad treatment strategies are whether to perform the amputation proximal to the injury, or within the zone of injury. Terminalising a limb proximal to the zone of injury permits a robust stump to be formed in healthy tissue potentially requiring fewer surgical episodes. An amputation from within the zone of injury, often using plastic reconstructive surgery techniques to close or cover the stump, maximises residual limb length but often at the cost of a greater number of surgical procedures (serial excision and staged reconstruction) and a less robust stump.

Subspecialty Section

If it is not possible to perform a transtibial amputation, then the preferred level is a knee disarticulation. This is a controversial area; the LEAP team found that the very small number of knee disarticulation patients in their study reported poorer outcomes than trans-femoral amputees. However, a larger meta-analysis reported superior overall quality of life and greater walking distances in patients following knee-disarticulation compared to trans-femoral amputation20. While the transected end of a femur or tibia do not allow end weight bearing, in a knee disarticulation the distal femur does allow direct end-weight bearing. However, surgeons should be aware that prosthetists have few options with prosthetic knee joints designed specifically for knee disarticulations. Since these have to be as compact as possible to minimise joint level discrepancy they are typically less sophisticated and have a reduced maximum weight compared to joints designed for transfemoral amputees. The issue that normally dictates residual limb length is soft tissue coverage, not residual bone length. All bony prominences require coverage with muscle tissue to allow painless prosthesis use. Consideration should be given to using free-tissue transfer (flaps) for coverage, especially if this permits the retention of the knee joint. Gracilis and antero-lateral thigh flaps are associated with little functional deficit. Latissimus dorsi and rectus muscles have an important functional role after lower limb injury during the rehabilitation phase, and their use as donor tissue will incur a functional impairment.

Surgical principles The function of muscles should be balanced either by suturing to their antagonists (myoplasty) or to bone (myodesis). If the amputation is performed within the zone of injury then tight sutures should be avoided to prevent strangulation in the event of further swelling and to permit some drainage. However, if the soft tissue envelope is left mobile and bulbous, then socket fitting will be challenging and forces will not easily be transmitted through the socket-stump interface. In order to reduce potential contamination, the final bony resection should be performed at the time of final soft tissue coverage or closure. Amputations performed through the femur have the advantage of a thick, well perfused, soft tissue envelope. However, muscle balancing can be challenging; the adductors are de-functioned when the femur is transected proximal to the adductor tubercle. Unless myodesis of the adductors to the distal femur is performed then the hip abductors will be unopposed leading to a widened, difficult gait.

Summary Few Orthopaedic Trauma surgeons regularly perform amputations and much of the available literature on the subject is written from the perspective of vascular surgeons. The decision to reconstruct or amputate is challenging as surgeons must balance technical potential for limb reconstruction with likely functional recovery which, on occasion, will favour amputation.

2. Traumatic and Trauma-Related Amputations Part I: General Principles and Lower-Extremity Amputations. Tintle SM, Keeling JJ, Shawen SB, Forsberg JA, Potter BK. JBJS. 2010; 92(17): 2852-2868. 3. Traumatic and Trauma-Related Amputations Part II: Upper Extremity and Future Directions. Tintle SM, Baechler MF, Nanos GP, Forsberg JA, Potter BK. JBJS. 2010;92 (18) 2934-2945

When amputation is necessary this should be regarded as surgery to enable maximum rehabilitation and functional recovery. The knee joint should be preserved wherever possible, and when it is not, consideration should be given to a knee disarticulation. Muscle groups should be balanced and stump length maintained, especially above the knee. If these principles are followed, patients with severe limb injuries will have the best opportunity for maximal functional recovery.

These are two large and relatively modern articles in the JBJSâ&#x20AC;&#x2122; Current Concept Review series. They have useful clinical photographs and plenty of surgical technical detail. Although aimed for a general audience, these papers are written from the perspective of military surgeons dealing with combat injuries

Journal of Trauma & Orthopaedics - Vol 8 / Iss 4

Articles inside

Virtual learning – moving forward

Major Alexander William Lipmann-Kessel MBE MC: Surgeon, paratrooper, prisoner of war, and orthopaedic innovator

Subspecialty Section: Amputation after trauma

Subspecialty Section: Amputation in the context of tumour or infection

Subspecialty Section: Pre-amputation: the first step in amputee rehabilitation

Medico-Legal Section: COVID-19: second round legal issues

Trainee Section: The future of orthopaedic training: diversity and education

Double pandemic, Dr Forte and the fork in our road

ODEP and Beyond Compliance: Our response to Cumberlege, the MDR and the UKCA... making UK plc a good place for safe innovation of implants

The 2020 NICE guidelines for primary hip, knee and shoulder replacement: key recommendations and the ongoing need for better quality evidence in orthopaedics

BOA Council

The MSK training pathway to First Contact Practitioner and Advanced Practitioner in primary care

News: New BOA Trustees

From the Executive Editor

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From the President