Journal of Trauma & Orthopaedics - Vol 9 / Iss 1

Journal of Trauma and Orthopaedics Volume 09 | Issue 01 | March 2021 | The Journal of the British Orthopaedic Association | boa.ac.uk

Great opportunities to help others seldom come, but small ones surround us every day – Sally Koch

The posterior malleolar fracture p28

Reflections on eight Arthroscopic meniscectomy years in Malawi p36 for isolated meniscal tears p46

Because the best surgical brains protect their own minds Protecting your mental health is vital to being a great surgeon.

Members of the College have access to a 24/7 helpline with trained counsellors.

Call 020 7869 6221 or visit rcseng.ac.uk/csas for confidential support now.

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3

From the Executive Editor

5

From the President

6

Deborah Eastwood Bob Handley

News:

Incoming BOTA President Ran Wei

8 BOA Latest News 10 News: Conference listing 2021 11 News: BOA Annual Congress 2021 12 News: Specialist Society Updates 18 Features: Treasures of the BOA Archive Collection – Foundation Dinner 28th November 1917 Ian Stephen

20 Features:

Ronnie Furlong, the man, his hip, his philosophy, the manufacturing breakthrough…

Alister Hart

24 Features:

Reflections of an orthopaedic surgeon as Medical Director for planned care Andrea H Sott

28 Features:

The posterior malleolar fracture – is the rule of a third or use of percentages an orthopaedic myth?

Lyndon Mason, Andrew Molloy and Gavin Heyes

32 Research:

The anatomy of an awesome randomised trial Ben A Marson and Daniel C Perry

36 International:

Standing on the shoulders of giants Reflections on eight years in Malawi John Cashman

46

40 Medico-legal:

50 Subspecialty:

42 Trainee:

54 Subspecialty:

46 Subspecialty:

56 In Memoriam:

Surgical rationing in times of COVID-19 pandemic – how does it affect the Montgomery ruling andGMC guidance on consent?

Shyam Kumar and David Warwick

Training in the independent sector Ran Wei, Rob Gregory, George Holland and Josh Burke Arthroscopic meniscectomy for isolated meniscal tears – changing practice Andrew Price

Management of the first-time lateral patellar dislocation: Improving care across the UK David Sands Johnson and Andrew John Metcalfe Is ACL repair possible?

Stephen McDonnell and Senthooran Kanthasamy John Ireland

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

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

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

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 01

AO UK & Ireland 2021 Courses & Seminars AO Trauma Courses

ckley n i H o t d e g n a Feb 25 - 2 Location Ch Principles of Fracture Management, for - 28 CJaann26celled ORP, Dublin, Ireland th

Basic Principles of Fracture Management for Surgeons, Dublin, Ireland

nd

th

th

- 11 CFaebn10 celled th

th

Mar Ca nchc7elled th

Managing Paediatric Musculoskeletal Injuries, Leeds, UK Introductory Course for Undergraduates, Edinburgh, UK Basic Principles of Fracture Management for Surgeons, Edinburgh, UK *NEW BLENDED*

March 8th - 11th

March 23 - 24 Foot & Ankle Reconstruction, London, UK Cancelled rd

th

April Cancelled 28thrd-

30thth

th rd

th

Current Concepts Cadaveric update for Trauma, Coventry, UK

Introductory Course for Undergraduates, Cancelled June 20 Leeds, UK

Basic Principles of Fracture Management June 21 - 22 Cancelled ORP, Leeds, UK st rd

nd th

Basic Principles of Fracture Management June 21 - 24 Cancelled for Surgeons, Leeds, UK st rd

th th

i Advanced Principles of Fracture June 23 - 25to Change Subject Management for Surgeons, Leeds, UK rd

th

June 22 - 25 Cancelled ndrd

th th

Advanced Principles of Fracture Management ORP, Leeds, UK

Sept 6th - 8th

Pelvic & Acetabular with anatomical specimens, Bristol, UK

Sept 27th - 29th

Management of Fractures of the Hand, Leeds, UK

Sept 30th - 1st

Management of Fractures of the Wrist, Leeds, UK

Nov 7th

Introductory Course for Undergraduates, Hertfordshire, UK

Nov 8th - 11th

Basic Principles of Fracture Management for Surgeons, Hertfordshire, UK

AO CMF Courses Postponed to September

CMF Undergraduate Course

Postponed to September

Management of Facial Trauma, Leeds, UK

Postponed to September

Principles in Craniomaxillofacial Management for ORP, Leeds, UK

AO Spine Courses July 15th - 16th Sept 24th - 25th

Spine Principles Course – Degeneration, Liverpool, UK

Spine Principles Level Specimen course, Spinal Tumors Coventry, UK

AO Recon Courses July 8th - 9th

Principles of Total Hip & Knee Arthroplasty, Birmingham, UK

AO VET Courses June 13th - 15th June 13th - 15th

Principles in Small Animal Fracture Management, Oxford, UK

Advanced Techniques in Small Animal Fracture Management, Oxford, UK

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

Credits JTO Editorial Team l l l l l

Deborah Eastwood (Executive Editor) Hiro Tanaka (Editor) David Warwick (Medico-Legal Editor) Ran Wei (Trainee Editor) Andrew Price (Guest Editor)

BOA Executive l Bob Handley (President)

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

l Don McBride (Immediate Past President)

Policy and Programmes

l John Skinner (Vice President)

Director of Policy and Programmes

l Deborah Eastwood (Vice President Elect)

Programmes and Committees Officer

l Mark Bowditch (Honorary Treasurer)

Educational Programmes Assistant

l Simon Hodkinson (Honorary Secretary) l Phil Turner

BOA Elected Trustees l Bob Handley (President) l Don McBride (Immediate Past President) l John Skinner (Vice President) l Deborah Eastwood (Vice President Elect) l Mark Bowditch (Honorary Treasurer) l Simon Hodkinson (Honorary Secretary) l l l l l l l l l l l l l

Phil Turner Colin Esler Grey Giddins Robert Gregory Fares Haddad Anthony Hui Andrew Manktelow Ian McNab Fergal Monsell Amar Rangan Sarah Stapley Arthur Stephen Hiro Tanaka

- Julia Trusler

- Harriet Wollaston - Eliza Khalid

Communications and Operations Director of Communications and Operations

- 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 Interim Finance Assistant - Chuks Nwandei

Events and Specialist Societies Head of Events - Charlie Silva Events Administrator - Venease Morgan Interim Events Coordinator - Amy Robinson Exhibitions and Sponsorship Coordinator

- Emily Farman

UKSSB Executive Assistant - Henry Dodds

Copyright

Copyright© 2021 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C, Premier House, 13 St Paul’s Square, Birmingham B3 1RB 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

S

o the New Year certainly started with a bang... not due to the fireworks that had all been cancelled but courtesy of the ‘New Variant’ of an ‘Old Foe’. We were straight back into the thick of things and recovery is only just starting but there are some green shoots of spring appearing and reasons to be cheerful.

And what do you do when the nights are still long and work is not quite what you would like it to be… perhaps relax, put your feet up, curl up on the sofa and peruse a magazine or indeed the JTO? Well, I think you should... this edition is a pot pourri of interesting bits and pieces for you to dip in and out of. Like any good magazine, this edition of the JTO has a travel section where we will take you abroad (something we are all sadly missing) to Malawi, and a reflection by John Cashman on what has been achieved there during his tenure and beyond (page 36). Reflecting is a little bit of a theme this issue with Andrea Sott writing about her experiences not only, of rising to the challenges of a Medical Director post but in COVID-19 times too and the knock on effects of the ‘casual comment’ both good and bad (page 24). However, if its reflection you are after, look no further than the excellent article by Alister Hart looking at Ronnie Furlong the man and his hip (page 20) and going even further back, Ian Stephen our BOA Archivist, reflects on the origins or our Association (page 18). Looking at that menu and the signatures on it, always gives me a slight shiver down my spine.

We can’t spend all our time in the past though so the challenges of being a trainee and where you are going to be trained is a constant concern at present – but hopefully the words by Ran Wei and Rob Gregory will be reassuring. I will take this opportunity to remind you that the new curriculum starts in six months time and trainers as well as trainees must be ready – this will involve you learning new things!

I know orthopods and there is only so much relaxing we can take so, of course, this JTO covers research and academia too – particularly clinically relevant research via our research champions and Hunterian Professors.

Andrew Price and colleagues would like us to remember ‘it’s all about the knee’ – the soft tissues anyway, if not the joint! I think it’s all about the kids – but perhaps that will be for a future edition!

2020-21 has seen us embrace ‘alternative’ media, so if reading the JTO cover to cover is more than your attention span can cope with, I suggest you have a look at the Transient Journal webpages (www.boa.ac.uk/T-JTO) where you will find podcasts on knitting and pieces on constructing dinosaurs; perhaps they are vying for inclusion in the indicative procedures section of our new curriculum? Or maybe not… maybe it’s just for fun and happiness and we are all in favour of that at the moment.

As we head into Spring, and the future looks brighter please remember – “Great opportunities to help others seldom come, but small ones surround us every day.”– Sally Koch I hope you enjoy this JTO and if you have any ideas for future articles, please let me know. n

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 03

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From the President

Déjà vu Bob Handley

“I refer you to my statement of December 2020”, is the type of phrase you associate with the beginning of a political speech in Parliament. However, when it came to writing this ‘From the President’ I began with enthusiasm and then became concerned with what seemed to be some rather familiar phrases.

I

looked back to the December 2020 JTO and saw that indeed little had changed.

With an optimistic slant I could suggest that the first article was ahead of its time, however, it is more realistic to accept that the year-end surge in COVID-19 had put a brake on many of the issues discussed. We were again forced into a period of damage control. At the time of writing this, we seem to be over the peak of the surge and at the BOA are again pursuing the issues such as appropriate prioritisation of patients, provision of adequate resource, protection of training and career progression. Hopefully the next time I write for JTO it will not be titled ‘Déjà vu, again’.

During the period of crisis, many members have supported the general effort to combat the coronavirus by working outside of their normal areas. The adrenaline rush and urgency of the crisis will subside and we will be left with the customary long term problems (made worse by the pandemic) but without the euphoria of NHS clapping and the backslapping the goes with a sound team effort. We need to be motivated, energetic and up for the task. We therefore await with interest the results of the recently completed well-being survey of members, which will give some insight into how well prepared we really are for this period of our practice.

Continuing the spirit of optimism, we can look forward to the 2021 BOA Congress which has as its theme, infection. Short case presentations often have a happy ending or occasionally a quick sad one, but whenever there is a long presentation, no matter what the initial subspecialty, there is a good chance infection is involved. As an unwanted common pathway of all of our areas of practice, it is something that we can genuinely share, particularly if we do not remain socially distanced.

The conference centre in Aberdeen is huge and we are preparing for all eventualities for Congress, but my earnest hope is that it will be the opportunity to renew old acquaintances and make new ones face-to-face.

The new Trustees; Sarah Stapley, Hiro Tanaka, Amar Rangan and Fares Haddad have yet to join Council; taking their seats next month. It is therefore surprising that it is already approaching the time to consider whether you will stand at the next election. By way of encouragement I can report that this year we have started to conduct entrance and exit interviews for Trustees. I have now spoken with most and can report that overall there was a pleasing enthusiasm for the role expressed in conversations laced with many constructive suggestions. It countered the pessimism of Groucho Marx’s quote, “I refuse to join any club that would have me as a member”. Not everyone wants to be a representative, but everyone should be represented.

It is your choice who you vote for, but remember, don’t restrict who you can vote for by forgetting that it is also your choice who is nominated. n

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 05

News

Incoming BOTA President – Ran Wei Trainees and trainers across the UK have endured extraordinary challenges over the last year and it is difficult to remember a time when our thoughts and conversations were free of COVID-19. The impact of the pandemic on every aspect of our daily lives is unprecedented. There has never been a more turbulent time for T&O training nor has there been a more arduous time to be a T&O trainee.

BOTA remains committed to delivering pivotal work in all facets of surgical training. I am honoured to be afforded the opportunity to lead BOTA at this crucial time and I will endeavour to ensure that the interests of trainees during, and in the wake of, the COVID-19 pandemic are fully represented.

The time that I have spent representing T&O trainees on the SAC and the JCST has taught me that excellence in training and in patient care must remain at the heart of everything we do. The fallout from COVID-19 threatens these fundamental tenets of our profession. It is therefore more important than ever that BOTA helps to formulate innovative and robust ideas that optimise T&O training whilst ensuring the highest quality of care for our patients.

To achieve our aim, we will require collaboration and focus. T&O trainees and trainers have demonstrated their ability to collaborate across professions, specialties and grades throughout this pandemic. We now need to focus our efforts on addressing the deficit in T&O training caused by COVID-19. n

“ I am honoured to be afforded the opportunity to lead BOTA at this crucial time and I will endeavour to ensure that the interests of trainees during, and in the wake of, the COVID-19 pandemic are fully represented.”

Ortho Update 2021 Maryam Ahmed

M

ost face-to-face courses have been cancelled, but the BOA adapted quickly to the restrictions and for the first time since 1972, the BOA Ortho Update Course, formerly the BOA Instructional Course, took place on a virtual platform in January. With the aim of establishing strong foundations for the FRCS(Orth) exam and future practice, this course has been a valuable learning opportunity for T&O trainees across all grades.

This year, 100 delegates along with a faculty of expert educators in a range of specialist areas met together from the comfort of their own homes.

The programme covered key evidence-based topics, including Spines, Paediatrics, Shoulder and Elbow, Hand and Wrist, Hip, Knee and Foot and Ankle, all pertinent to the T&O curriculum. All presentations were detailed, extremely engaging, relevant to current practice and exam preparation and were each followed by a Q&A session. The key concepts of Paediatrics covered the most common dilemmas faced by every T&O trainee during an on-call; the Hip Update and the Knee Headlines Updates focused on examination and operative techniques.

06 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

The programme concluded with an important discussion around how to navigate through exams and how to apply exam techniques with current COVID-19 rules.

In these challenging times, the hard work and dedication of the faculty to education of the next generation of T&O surgeons have truly made this course a success. n

News

69%

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

69

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

www.heraeus-medical.com

Latest News

BOA Virtual Courses With the current cancellation of face-to-face educational courses, the BOA have developed Virtual Training courses facilitated by the BOA Educational Advisor Lisa Hadfield-Law.

Committee appointments Following a successful round of applications, the BOA would like to congratulate all those who have been appointed onto the BOA Committees: Orthopaedic Committee Lucky Jeyaseelan, Mukesh Hemmady, Siva Prasad Research Committee Hamish Simpson (Chair), Chloe Scott, Hemant Sharma, Yuri Kulikov Education and Careers Committee Niall Eames (Vice-chair), Usman Ahmed

New Year’s Honours

• Training Orthopaedic Trainers (V-TOTs) The BOA has run V-TOTs programmes since March 2020. Much of the work can be done at a time, place and pace convenient to participants, with attendance at live virtual meetings to supplement personal learning. Learning is monitored through learning logs with written feedback from expert faculty. The V-TOTs course will last for approximately six weeks.

• BOA Virtual Training Orthopaedic Education Supervisors (V-TOES) V-TOES will be offered through two routes, and either 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).

If you are interested in either course, find out more at www.boa.ac.uk/v-toes or www.boa.ac.uk/v-tots.

2021 Medical Student Essay Prize Applications for the 2021 Medical Student Essay Prize will open on 1st April and close on 30th April. Medical students from the UK and Republic of Ireland are invited to submit an essay of no longer than 1,000 words on the question: ‘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?’

Further information on the 2021 Medical Student Essay Prize can be found at www.boa.ac.uk/medical-student-essay.

08 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

The BOA would like to congratulate Professor Chris Moran who was awarded an OBE in the New Year’s Honours, for services to trauma surgery.

Arterial BOAST update The BOA Trauma Committee has recently updated the BOAST ‘Diagnosis & Management of Arterial Injuries Associated With Extremity Fractures and Dislocations’. This BOAST will be the next to be published in Injury.

As this issue goes to print two new BOASTs ‘Cervical spine clearance in the trauma patient’ and ‘Providing a Continuous Safe Elective Orthopaedic Environment’ – are nearly ready for publication, so keep an eye out for these!

All BOASTs – including Trauma, Elective and Specialty - can be found on the BOA website at: www.boa.ac.uk/boasts.

Recent publications relevant to BOA members: • The second wave of NHS-England-backed programme ‘Evidence Based Interventions (EBI)’ has been published and can be found on the AoMRC website. This wave contains guidance on 31 interventions, including ten relevant to a range of orthopaedic and/or surgical issues, and we encourage members to review the guidance relevant to their area of practice. The BOA would like to thank all involved in the EBI process last year.

• The latest NHFD (National Hip Fracture Database) report was published in January and is available on the NHFD website: www.nhfd.co.uk/20/hipfractureR.nsf/ docs/2020Report.

Latest News

UKITE 2020 All programmes across UK and Ireland sat UKITE between 4th – 11th December 2020, as well as trainees from across South Africa on 11th – 12th December 2020. We are pleased to announce that in total 922 Trainees and SAS surgeons from the UK and Ireland sat the exam and 187 Trainees from South Africa. The training programme that achieved the highest mean score was North West (Mersey) with 67%.

The average score across all participants was 54%.

We would like to thank all those involved in the production and delivery of UKITE. For more information on sitting the exam in 2021 or getting involved in the UKITE editorial process, visit www.boa.ac.uk/UKITE or email ukite@boa.ac.uk.

2021 Council and Presidential nominations

New BOA resource: COVID-19 and fracture service patient leaflets and videos The BOA Trauma Committee has collated a number of patient information leaflets and videos from those trusts with established trauma triage services to help colleagues involved in redesign of their own services. The BOA website has a new webpage at www.boa.ac.uk/fracture-rehab with links to the information leaflets and videos used by other trusts to support fracture clinic staff. These resources can be used as templates and adapted for local use. We are also keen to expand this resource and if you have high quality patient documents/videos for injuries not covered here please contact policy@boa.ac.uk.

Attention Home Fellows - Council Trustee and Presidential nominations open on 15th March!

The BOA believes that Trauma and Orthopaedics should be an inclusive surgical profession that inspires, attracts and retains the best talent from a wide variety of backgrounds. One of the ways we believe we can best make that a reality is by ensuring we elect a Council that fully represents all our members and better reflects the broad and diverse population we serve.

You have the opportunity to bring your skills and expertise to help us grow and develop the BOA and Trauma and Orthopaedics as a whole.

A more diverse BOA, and a broader range of voices, better serves our patients and best supports our colleagues and we welcome applications from across our membership.

For further information about Council, the trustee roles and reflections of previous Council members please see the December JTO. Please be sure to submit your nominations for Council before the deadline of 15th April and for BOA President by 1st June. More information and how to apply is available on the BOA nominations website at https://www.mi-nomination.com/BOA.

COVID-19 resources for members Since the beginning of the pandemic, we have provided regular email updates for our members on the latest guidance and other important developments in caring for their patients during this time and other support for surgeons and trainees. We continue to update our website with the latest information for both members and patients, and you can find all resources at www.boa.ac.uk/COVID-19.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 09

Latest News

Coping with COVID webinar series

Wellbeing and support Wellbeing of our members and wider colleagues is an important issue for the BOA at this difficult time. In December we held a webinar, ‘Supporting surgeons through the challenges of the COVID era’. The participants in the webinar have kindly provided either a short slideset or write-up, to provide some useful nuggets of ideas for others to use.

These are all available on the Transient Journal at www.boa.ac.uk/T-JTO.

The BOA has created a new series of webinars on ‘Coping with COVID’, which focus on issues affecting trauma and orthopaedic surgeons and patients as we go through the ‘second wave’ of COVID-19. The following are the first three webinars in the series and members can view the recordings at www.boa.ac.uk/ copingwithCOVID. • Elective operating and the second wave of COVID-19 • Supporting surgeons through the challenges of the COVID era • Medico-legal aspects of T&O care in the COVID era

Conference listing 2021: BRITSPINE

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

BOFAS (British Orthopaedic Foot and Ankle Society) www.bofas.org.uk 11 March 2021, Virtual

BSSH (British Society for Surgery of the Hand)

www.bssh.ac.uk 14-15 April 2021, Virtual

BLRS (British Limb Reconstruction Society) www.blrs.org.uk

OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 10-11 June 2021, Virtual

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

BIOS (British Indian Orthopaedic Society)

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

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

15 April - 18 June 2021, Virtual

BORS (British Orthopaedic Research Society)

BASK (British Association for Surgery of the Knee) www.baskonline.com

BOA (British Orthopaedic Association)

www.borsc.org.uk 13-14 September 2021, Virtual

18-19 May 2021, Virtual

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

WOC (World Orthopaedic Concern) www.wocuk.org

BTS (British Trauma Society)

5 June 2021, Chester

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

BHS (British Hip Society)

BSS (British Scoliosis Society)

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

10 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

www.britscoliosissoc.org.uk November 2021, Edinburgh

News

BOA Annual Congress 2021 21st -– 24th September, P&J Live, The Event Complex Aberdeen (TECA) www.boa.ac.uk/congress

U

nder the theme of ‘Tackling Infection’ the 2021 Congress will take place 21st – 24th September at P&J Live, The Event Complex Aberdeen (TECA). The programme will include the BOA keynote lectures, plenary speakers and an update from the BOA President, Bob Handley, on his Presidential year. We are working closely once again with the specialist societies to deliver revalidation and hot topic sessions. The programme will also include Hunterian Professorship Lectures from both 2020 and 2021 with topics covering ankle, hip, infection and knee.

BOA Abstract Submissions

BOA abstract submissions including Medical Students are now open and will close at 23:59 on Friday 7th May 2021. Categories include ATOCP/Physiotherapy, Basic Science, COVID-19, Developing World Orthopaedics, Education, Foot and Ankle, General Orthopaedics, Hands, Hip, Infection, Knee, Limb Reconstruction, Medical Students, Paediatrics, Quality Improvement, Simulation, Shoulder and Elbow, Spines, Sports Trauma, Trauma and Tumours.

Registration Early bird registration exclusively for BOA members, will open on Monday 12th April and close at 23:59 on Sunday 23rd May. General Congress registration will open at 00:00 on Monday 24th May and close at 23:59 on Sunday 5th September. Late registration will open at 00:00 on Monday 6th September until the close of Congress.

Currently during this COVID-19 pandemic, 2021 is still looking a bit unsettled. With this in mind, the BOA would like to confirm that plans are being developed to deliver Congress taking government restrictions into consideration that may still be in place in the UK in September. Keep an eye on the BOA website for further updates.

Over the upcoming months please check the website for updates on abstract submissions, programme, speakers, sponsors, accommodation and more, www.boa.ac.uk/congress.

Exhibition and Sponsorship Opportunities www.boa.ac.uk/exhibition-sponsorship The BOA Annual Congress puts you in a room with over 2,200 healthcare professionals. Join us to build a quality database, increase your sales, meet competitors and keep up to date with the needs of your customers.

With over 80 exhibitors every year this is a must attend event that provides you with the platform to sell your business products/services to prospective clients. Maximise your exposure at the Annual Congress by taking advantage of our Programme, Digital Advertising and Sponsorship opportunities.

Please contact us to discuss other ideas you may have for sponsorship opportunities or how we can best support your organisation. Our exhibition packages are designed to be comprehensive and competitive, but above all we aim to be flexible. If you are interested in any of the opportunities at Congress please contact the Events and Fundraising Coordinator, Emily Farman at e.farman@boa.ac.uk or 020 7406 1754.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 11

News

British Trauma Society (BTS) update H urry get your diaries out and make a note: our annual scientific meeting is planned for Oxford, 24th – 25th November 2021.

There will shortly be a call for abstracts – please see our website www.bts-org.co.uk and follow us on twitter @britishtrauma for more information.

We have an exciting provisional programme that will appeal. We aim to make it an unforgettable event so please come and join us and together we will put behind our difficult year.

We are a multi-disciplinary society, involving all those in the care of the injured patient. We aim to create standards for certain categories of polytrauma patients in collaboration with other specialties, ranging from obstetrics to ophthalmology, culminating in ‘go to’ documents.

Inspired by Dr Chris Turner’s insightful keynote speech at our 2019 conference on how ‘civility saves lives’ we have been thinking more about how behaviour can affect outcomes in trauma and how we can reduce the risk of medical error (especially during the current climate). We hope to run our Human Factors Conference at the Queen Elizabeth Hospital, Birmingham, at a safer time – provisionally planned for 21st June, 2021.

Several regional external fixator courses are being planned throughout the year aiming to cover principles of external fixation and their application in long bone and pelvic injuries. These courses are aimed

at all grades of surgeons with particular emphasis on ‘hands on’ practicals. Previous courses have been well received by attendees and are ideal for revalidation in trauma.

We strive to be adaptable in order to deliver the best learning opportunities possible during the COVID-19 pandemic. Let us hope that we can meet, greet, socialise, and exchange ideas at our events in 2021! n

British Orthopaedic Foot and Ankle Society (BOFAS) update James Davis

“Our weekly ‘lectures of distinction’ designed for trainees and the general orthopaedic surgeon has received excellent feedback and we aim to continue these through 2021.”

12 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

T

he British Orthopaedic Foot and Ankle Society (BOFAS) has, much like most other societies, been unable to hold its normal annual conference. We have been innovative and cogent of the virtual conference weariness experienced by the majority of the medical profession by holding short punchy webinars throughout the year. These have been designed to deliver small, focussed aliquots of education to both our consultant members and general orthopaedic surgeons. Our weekly ‘lectures of distinction’ designed for trainees and the general orthopaedic surgeon has received excellent feedback and we aim to continue these through 2021. We are about to start a virtual journal club with authors presenting their published articles and being available for questions.

Our Scientific Committee held a virtual conference encompassing the experience of foot and ankle practice worldwide during the COVID-19 pandemic.

This unsurprisingly mirrored the UK‘s experience with significant interruption to normal elective activities.

Our annual conference has been condensed to an afternoon on 11th March where we have organised a short scientific programme with paper presentations and two short lectures followed by an educational section discussing differing opinions in the management of three controversial topics. All virtual activities are well signposted on the BOFAS website (www.bofas.org.uk).

We have made progress with our GIRFT agenda and the development of virtual horizontal networks for supported decision making for joint replacements along with discussions with ‘Beyond Compliance’ and ODEP for implant rating.

Our BOFAS registry is becoming more active and as a society we are excited to see the development of registries in clinical practice particularly in light of the Cumberledge report and the requirement for implant companies need for follow-up data.

The times may be unsettling but we in the BOFAS community stay positive and strive to improve the treatment of our national foot and ankle patients. n

News

British Orthopaedic Sports Trauma & Arthroscopy Association (BOSTAA) update Adit Prinja, Neil Jain and Fares Haddad

B

OSTAA has had a very busy 2020 in spite of the impact of the COVID-19 pandemic. We have taken this opportunity to expand the Executive, partly in an effort to engage more junior members and allied health professionals, and partly to support our diversity drive. We were pleased to add two members at large, Mr Guido Geutjens and Ms Jo Banks, to the Executive as well as a Trainee Committee led by Adit Prinja comprising Matthew Hampton, Christina Kontoghiorghe, Eshelle Hara and Lisi Hu. This has helped us to improve the reach of BOSTAA which will also have a new website in 2021 as well as a revamped annual meeting. We will also imminently finalise a strategy document that the Executive Committee has been working on throughout 2020.

We are also very pleased to have finalised and published the Best Practice for Management of ACL Injuries Document with a one page elective care standard which have taken several years to compile and has been completed with the careful stewardship of Sanjeev Anand and in collaboration with BASK.

Our relationship with other societies continues to strengthen.

We are hosting a joint instructional with BSCOS in 2021, and we

are now working with members of BASK and other interested parties on ACL injury prevention working group. We continue to foster links with international sports and arthroscopy societies.

Following a successful trip to Egypt in February 2020 for the EGAA meeting, we will have a presence at the virtual ESSKA meeting in 2021.

The BOSTAA Executive and members are hopeful that a faceto-face annual meeting will take place on 14th July 2021 in Westminster with the new BOSTAA FRCS (Orth) instructional course on sports related topics running at the Institute of Sport, Exercise & Health in London on 13th July 2021.

Whilst the COVID-19 pandemic has taken up a lot of our time and prevented us from meeting formally face-to-face, it has afforded us an opportunity to develop BOSTAA, engage the next generation and set a template for the progress of the society over the next few years. n

Society for Back Pain Research (SBPR) update

O

ur society missed the opportunity in 2020 to share the output of our members which covers the breadth from bench to bedside. We’d like to highlight some of the studies that we have been involved with.

At a cellular level and the studies by Rustenburg et al.1 and Binch et al.2 looked at mimicking the degenerate disc environment and characterising it. Deane et al.3 examined whether spine shape was a factor for degeneration. The impact specifically in our older population was examined by Williamson et al.4. Roberts et al.5 considered ways to improve and communication in remote consultations. Despite pathways for sciatica, Ryan et al.6 showed how they do not work for all and Shaheed et al.7 called for the appraisal of our use of analgesics.

Hallegraeff at al.8 and Mannion et al.9

14 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

reminded us of the importance of psychosocial factors. Geraghty et al.10 looked to trial a cost effective way to manage back pain in primary care.

Clinical collaborators are sought for three projects: • Spinal kinematics in disc degeneration and back pain to get you or your patients involved with fluoroscopy and computer modelling. Having mapped the kinematics in asymptomatic people, studies are moving towards symptomatic and post intervention patients. We are looking to see how these groups differ and the impact of our interventions. For further information please e-mail: AlexBreen@aecc.ac.uk.

• NIHR funded study investigating prognostic indicators for injected steroid (POISE).

If you think you know what patient factors predict outcomes, we would like to hear from you. We will then be looking to see if this does through a multicentre clinical trial.

To be involved in deciding the factors and the trial please e-mail: s.stynes@keele.ac.uk.

• DELPHI study into treatment algorithm for lumbar spinal stenosis. To be involved in gaining consensus for the best way to manage patients with this condition please register your interest via e-mail: c.comer@leeds.ac.uk. n References References can be found online at: www.boa.ac.uk/publications/JTO.

News

British Orthopaedic Trainees’ Association (BOTA) update

Ran Wei

Disruption to regional/national teaching events

T

he COVID-19 pandemic has undoubtedly posed the biggest challenge to surgical training within our lifetime. Redeployment, cessation of elective operating, cancellation of exams, postponement of professional courses, and disruption to regional/national teaching events are but a few of the issues that have plighted trainees of all grades and specialties. Over the last year, the BOTA Committee has worked hard with the relevant bodies to ensure that the inevitable disruptions to surgical training were minimised as much as possible.

We are under no illusion that our work is nearing completion or that our efforts are enough to satisfy the needs of our members.

Redeployment During the first wave of the COVID-19 pandemic, T&O trainees across the country were redeployed to aid with the national response. The GMC found that 70% of doctors in training were either redeployed within or outside their specialty1.

Subsequent waves of the pandemic have resulted in yet more redeployment and lost training opportunities. The resolve demonstrated by T&O trainees throughout this pandemic has been a true testament to the character and integrity of our community. BOTA will continue to work hard with the relevant educational bodies to ensure that guidance principles2 set out by the GMC and the four statutory educational bodies are adhered to.

Operative training Training in craft specialties, such as T&O surgery, has encountered the most disruption throughout the COVID-19 pandemic.

Cessation of elective operating across the NHS posed, and continues to pose, a considerable issue for trainees nearing their CCT. The high volume of elective procedures performed within our specialty has led to T&O trainees suffering the largest reduction in surgical logbook numbers when compared to other surgical specialties. Relocation of elective operating to ‘Green Sites’ that are often, but not exclusively, based in the independent sector (i.e. private sector) have resulted in significant regional variance in experiential attainment.

In effect, T&O training over the last year has become a postcode lottery. Areas where NHS and hospitable IS Green Sites were able to expeditiously re-establish elective activity in the wake of the first national lockdown afforded their trainees an opportunity to recoup some desperately needed operative training. In regions where re-establishment of elective activity at NHS sites has not been possible and where IS sites have not been hospitable, trainees have reported losing almost 12 months of elective surgical training. Addressing the barriers encountered by trainees when attempting to train in the IS will help tackle one facet of our current predicament. It is by no means the panacea. BOTA are therefore working closely with BOA, T&O SAC, BASK and BHS to produce guidance on various aspects of training to ensure that every training opportunity is utilised.

Restrictions on group gatherings has resulted in major disruptions to regional teaching, professional courses (mandatory and aspirational) as well as conferences/ meetings. Most have now been adapted to utilise digital platforms (e.g. Zoom, GoToWebinar, etc.) for its delivery but courses involving desk-based simulation (i.e. ATLS, BSS, etc.) have not. BOTA will continue to work hard to ensure that trainees approaching their critical progression points are prioritised for mandatory courses. In 2020, the Wrightington Upper Limb Unit established the Sunday Supper webinar series alongside BOTA. These one hour FRCS focused teaching sessions received excellent feedback from trainees across the UK. In 2021, BOTA have re-launched the Sunday Supper webinars with our own educational programme. BOTA Sunday Supper will feature guest speakers from across the UK and will be delivered monthly in tandem with BOTA Bare Bones webinars, which aims to cover core T&O topics for pre-registrar trainees and medical students. We would like to offer our gratitude to Mike Hayton and Matthew Ricks for their hard work and dedication in cementing the foundations upon which BOTA aim to build our national teaching programme.

2020 has been a testing year for BOTA and our members. Trainees and trainers across the UK have been plagued with adversity and uncertainty. As we emerge from a year of disruption to surgical training, we must concert our efforts to ensure that we maximise the training opportunities available in order to minimise the damage caused by the COVID-19 pandemic. n

References 1. IFF Research (2020) The State of Medical Education and Practice (SoMEP) Barometer survey 2020. Available at: www.gmc-uk.org/-/media/documents/ somep-barometer-2020-report_pdf84743621.pdf.

2. General Medical Council (2020).

Supporting the COVID-19 response: Guidance regarding medical education and training. Available at: https://www. gmc-uk.org/news/news-archive/guidanceregarding-medical-education-and-trainingsupporting-the-covid-19-response.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 15

News

Joint Action update

W

e would like to thank every single person that donated to the Joint Action Christmas Appeal which closed on Sunday 31st January, with your help we raised over £13,000 for Joint Action, the Orthopaedic Research Appeal of the BOA.

It’s been a year like no other, and while much of the world’s attention has been focused on COVID-19, the needs of people with musculoskeletal disease have not gone away and sadly in many cases the need has grown.

We know that thousands of people across the UK have experienced long waits for surgery and cancellations of other medical appointments. The BOA has continued to focus on the needs of these patients, and Joint Action, its research appeal, is forging ahead with ambitious plans for 2021.

You can read more about the ways we are contributing to trauma and orthopaedic research on the BOA website at www.boa.ac.uk/research.

Taking place Sunday 3rd October 2021, support our Virgin Money London Marathon runners by donating to Joint Action online, www.virginmoneygiving.com/fund/JAlondonmarathon.

16 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

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Features

Treasures of the BOA Archive Collection – Foundation Dinner 28th November 1917 Ian Stephen On 28th November 1917 a pivotal event in the history of the BOA occurred when fifteen surgeons met to dine at the Café Royal in London, and we hold in the archive several important related artefacts.

T

hey were invited in a letter signed by E Muirhead Little, who became the first BOA President, T H Openshaw and Sir Robert Jones (Figure 1). The stated aim was the formation of a British Orthopaedic Association, although the moving spirit behind the proposal was in fact an American from Boston, Robert Osgood.

All those invited were men, as was the way in those days. Although this was the fourth year of war, the menu shows that they dined well. It was signed by all those present (Figure 2). We hold several original versions, including one in a frame that came from the Family of Robert Osgood, inscribed in his handwriting (Figure 3).

The event was recorded by Harry Platt (Figure 4) who, as Temporary Honorary Secretary issued invitations on 14th January 1918 to become Original Members of the Association (Figure 5).

Figure 1: Invitation to dine November 1917.

The first meeting was held on 2nd February 1918 at Queen Mary’s Convalescent Auxiliary Hospital at the Roehampton Limbless Hospital in London, where Muirhead Little was on the staff. Thirteen surgeons attended and appear on the photograph taken at the time (Figure 6).

They are identified on the accompanying key (Figure 7).

These artefacts form an important part of the history of our Association and show why it is important to maintain a functioning archive so that there is a corporate memory of events that might otherwise be forgotten. n

Ian Stephen is a Consultant Orthopaedic Surgeon in East Kent since 1983, eventually specialising in Foot and Ankle Surgery, and retired from practice in 2007. Past President of the British Orthopaedic Foot and Ankle Society, and of the Orthopaedic Section of the Royal Society of Medicine.

Presently Honorary Treasurer of both the History of Medicine Society and the Retired Fellows Society at the Royal Society of Medicine, and Honorary Archivist for the British Orthopaedic Association.

18 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

Figure 2: Signed Café Royal menu 28 November 1917.

Features

Figure 5: Invitation to become Original Member 14 January 1918.

Figure 3: Signed menu from the Osgood Family.

Figure 6: Photograph of First Meeting 2 February 1918.

Figure 4: Record of Founding Dinner.

Figure 7: Key to photograph 2 February 1918.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 19

Features

Ronnie Furlong, the man, his hip, his philosophy, the manufacturing breakthrough…

Alister Hart It is 50 years since the founding of the UK hip implant manufacturer, JRI Ltd, by Ronnie Furlong. Actually it is now 51 years, because this anniversary was overlooked in 2020 because of COVID-19. I met him, and his wife Eileen, whilst working on the surgical training rotation at St Thomas’ Hospital in 1998. He was an inquisitive doer, entrepreneur, and leader who was at the epicentre of British orthopaedics at a crucial time.

1970 is arguably the key year for hip implant innovation in the UK: the year the Exeter stem was invented; the year that Bill Harris started the renowned Harvard hip course to disseminate the use of the Charnley hip replacement throughout the USA; and the year that Ronnie Furlong set up JRI Ltd to import the Muller ‘Banana’ hip from Germany to the UK.

Alister Hart is a hip surgeon at the Royal National Orthopaedic Hospital NHS Trust and the UCL chair of orthopaedics. The BBC nicknamed him the ‘Hospital Hip Detective’ for his clinical and research work on hip implants which has led to changes to international health policy and regulation.

He has pioneered the use of 3D printing for primary and revision hip surgery.

Key dates in Ronnie Furlong’s life (1909 – 2002) • 1969 – Director of the Orthopaedic Department at St Thomas’ Hospital.

• 1970 – Established JRI Ltd to enable import of the Muller stem from Germany.

• 1976 – JRI manufacturing plant in Sheffield.

• 1979 – Clinical use of new cemented Furlong straight stem: based on the conical stopper of a wine decanter.

• 1985 – The first hydroxyapatite ceramic coated (HAC) prosthesis, the cementless Furlong straight stem, was implanted by Ronnie Furlong.

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Ronnie Furlong.

Features

The war Ronnie Furlong joined the army during the war and in his five years of service he commanded orthopaedic units in North Africa, Egypt and Italy. This active war experience was invaluable to his orthopaedic career. In Caserta, Italy, he plated and documented 200 fractured femora and then in Germany he observed Kuntschner himself using his nail.

St Thomas’ Hospital In 1969 he became Director of the Orthopaedic Department at St Thomas’ Hospital, where one of his responsibilities was the teaching of hip replacement surgery. He was neither keen on Charnley’s small 22.25mm head and the surgical technique of removal and rewiring of the greater trochanter, nor on Mckee’s hip. He met Professor Maurice Muller of Switzerland, and learnt his operative technique of the Muller curved stem with a 32mm diameter head, which he named the Muller ‘banana’.

Plain radiograph of a Furlong HAC stem with CSF cup.

Joint Replacement Instrumentation (JRI) Ltd He was so impressed with Muller’s Banana hip that in 1970, in order to obtain an import licence for the Muller hip, he established Joint Replacement Instrumentation (JRI) Ltd. In 1976, in order to encompass his growing interest in the design and manufacture of prostheses and instrumentation, he expanded the Company by setting up its own manufacturing plant in Sheffield. The company has grown on the clinical success of its hip implants and continues today.

Scientific collaborators: Professors Pauwels and Osborn He had two key scientific collaborations that helped him design hip implants that lasted decades. First, Ronnie Furlong sought out the World’s most notable expert in biomechanics, Professor Friedrich Pauwels of Aachen in Germany. This led him to design the Straight stem in 1979, one of the first straight stem prostheses for use with cement.

Legend has it that Furlong’s concept of a straight stem was inspired by studying the effectiveness of a conical glass stopper in a wine decanter.

Secondly, he collaborated with Professor Osborn, Facio-Maxillary Surgeon in the University Hospital of Bonn. Professor Osborn heard of the failures of hip replacements due to loosening from his orthopaedic colleagues and he began to question whether hydroxyapatite could be used as an alternative fixation. On 23rd May 1985 Mr Furlong, whilst travelling to Switzerland, decided to deviate to Stuttgart in order to visit the factory of Feldmuhle AG, to see the production of the ceramic ball heads.

He was met by Dr Dore who was interested in the prosthesis on to which Mr Furlong wanted to use the ceramic head.

He needed to see the design of the taper. Quite uncharacteristically it so happened that Mr Furlong had his newly designed coned prosthesis in his pocket. On the large boardroom table at Dr Dore’s request, the prosthesis was displayed. There was no doubt as to the sudden excitement of Dr Dore. Mr

Furlong was bemused. Dr Dore took the prosthesis and disappeared through the big double doors. After 15 minutes Mr Furlong was getting anxious as he remained awaiting his host’s return, accompanied by the entire R&D team of Feldmuhle. The ceramic ball head had been forgotten which seemed amusing to Mr Furlong since that was the object of the visit. Mr Furlong was then besieged with questions because it was realised that surely this was the prosthetic stem which would be appropriate for their newly developed ceramic coating. The very English name of Osborn was constantly referred to in the electric atmosphere which prevailed, and Mr Furlong became intrigued with this excitable confusion.

A prosthetic box was brought to him containing a test coated stem to show the latest development of a bioactive ceramic coating. In fact, the stem was coated with hydroxyapatite ceramic (HAC). >>

“In 1969 he became Director of the Orthopaedic Department at St Thomas’ Hospital, where one of his responsibilities was the teaching of hip replacement surgery.”

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 21

Features

Implant loosening, osteolysis and ‘cement disease’ The success of his HAC straight stem was partly due to a misinterpretation of the cause of loosening of cemented stems. In the 1980s, prosthetic loosening became the dominant factor leading to increasing revision surgery and cement fragmentation was considered largely responsible for this problem. 40,000 hip replacements were performed in Great Britain each year, of which 10% were revisions. As a result, cementless prostheses had begun to emerge, but the results were indifferent and disappointing and they too began to add to the revision surgeries.

However, Ronnie Furlong had appreciated that polyethylene debris, and not cement fragmentation, was the cause of the loosening and stated with conviction that the cause of loosening “to be cementless by itself was not enough”. The recognition that a similar pattern of bone osteolysis and loosening occurred in both cemented and cementless implants led to the understanding that polyethylene debris was the culprit.

Retrieval analysis: conclusive proof that HAC works

The latest Furlong hip can now be planned in three dimensions prior to surgery to ensure the optimum size and position so that the patient’s hip biomechanics are ideal for function and longevity.

This stem had been rejected

by Professor Osborn due to inappropriate design. The excitement from the ecstatic group transferred to Mr Furlong himself. There was the coating.

There was the wrong shaped stem lying in the box and there was the correct stem, his stem, on the table uncoated. For one moment it was all unreal. He thought an English source had eluded him as continuously the name of Osborn was referred to by the group and as the innovator behind the technology.

In November 1995, the histological findings of a nine-year explant, a patient of Mr Furlong’s, were presented by him at a symposium held at the Royal College of Surgeons of England and attended by 600 delegates worldwide. This explant was an HAC coated prosthesis of the longest duration that had been retrieved in the world. The hydroxyapatite ceramic (HAC) had remained at full thickness in all stress areas and proved conclusively that the coating worked.

Millions of implants have now been produced by many manufacturers using an HAC coating.

“Ronnie Furlong sought out the World’s most notable expert in biomechanics, Professor Friedrich Pauwels of Aachen in Germany. This led him to design the Straight stem in 1979, one of the first straight stem prostheses for use with cement.

Legend has it that Furlong’s concept of a straight stem was inspired by studying the effectiveness of a conical glass stopper in a wine decanter.”

Mr Furlong was ready to return to England and find Osborn but, no, Professor Osborn was in Bonn and to Bonn he travelled the next day together with Dr Dore. There, the historic meeting of scientist and surgeon so

22 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

long searching for each other became reality as Osborn and Furlong met. There was an immediate affinity which was momentous and held within itself a future revolution in orthopaedic history.

Throughout Mr Furlong’s long working life, he was supported by his wife, Eileen, and their achievements continued as the Furlong Charitable Research Foundation which became Orthopaedic Research UK, ORUK. n

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Features

Reflections of an orthopaedic surgeon as Medical Director for planned care Andrea H Sott

A Andrea H Sott is a Consultant Foot & Ankle Orthopaedic Surgeon and Divisional Medical Director for Planned Care at Epsom & St Helier NHS Trust/ London. After graduating from medical school in Germany, she completed 10 years of basic and Higher Surgical Orthopaedic Training on the SW Thames Training Programme, London.

She entered the GMC Specialist Register as a fully specialty qualified Orthopaedic and Trauma Surgeon in 2004, when she joined Epsom & St Helier University Hospitals. She is a Senior Examiner for JCIE and previously Surgical Tutor for the Royal College of Surgeons of England, sits on Consultant Appointment Committees as Royal College Rep and attends standard setting meetings for the JCIE, Edinburgh.

few years ago, when I was a recently appointed Clinical Director for Trauma & Orthopaedics, I was facing our executive panel across the board room table during my first high level performance meeting. With a welcoming smile our paediatrician Medical Director greeted me and exclaimed her delight and surprise to see an ‘orthopod’ at a very senior leadership meeting with the words: “We usually don’t expect orthopaedic surgeons here – aren’t you guys always busy down at the private hospital?” In that moment, reflecting on the implication of her remarks I promised myself and our executive team that things were going to change...and for the better! High time to demonstrate our skills, dedication, passion and determination as Orthopaedic Surgeons to step up to the top table and have our valuable clinical voice heard.

How I got here I joined the NHS 28 years ago as a Senior House Officer in A&E working day and night to earn a living, give my best as a doctor and learn the language to pass the FRCS and gain a training number in T&O in the South West Thames rotation.

Now a Consultant Surgeon with a subspecialty interest in foot and ankle surgery and trauma at Epsom & St Helier since 2004, the ethos of hard work and absolute focus never left me and permeates my clinical and managerial work at all levels.

In my early years, I mainly focused on building our Foot and Ankle Unit where there was none before as well as helping to establish one of the best performing Hip Fracture Units according to the NHFD. We now run a well-recognised foot and ankle service with three Consultants, a BOA fellow, two SpRs and a surgical scrub practitioner who manages our PROMS Amplitude database as well.

Tao Te Ching: • A leader is best when people barely know she exists • Not so good when people obey her • Worse when they despise her • Fail to honour people they fail to honour you • But of a good leader who talks little • When her work is done...aims fulfilled • They will say: “We did it ourselves!”

24 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

I remember my SpR interview in 1997 only too well. My first child was still recovering in neonatal ICU after an eight week premature delivery. This was then followed by 6.5 years of full-time training as a single parent without any immediate family in this country.

Hail to my au-pairs and friends who were the backbone at home and allowed my career to take off including passing the FRCS Orth and a trauma fellowship at Hannover Trauma Unit.

Fast forward to 2015 when my CEO rang me during a summer holiday run at Saunton Sands beach to see how I would enjoy interviewing for the new role of T&O CD? By then happily settled in life with my lovely supportive firefighter husband and two more children, I embraced the challenge which over time led to the role of Divisional Medical Director in planned care – one of five divisions at our Trust.

Features

DMD role - What’s in a day?

As Medical Director for planned care I am now part of a TRI structure leadership team (Director of Operations, Director of Nursing and Medical Director) responsible for the day to day running of our large division which includes all surgical specialties, A&E, anaesthetics, theatres and critical care as well as endoscopy and outpatient services overseeing over 110 consultants, several hundred junior doctors and even more nursing staff. Little did I know back in 2019 when I accepted the job how this role would magnify a thousand times during the pandemic.

I manage daily operational processes of patient care, chair clinical governance meetings, undertake disciplinary procedures, oversee job planning, AAC work and represent our division at Trust executive committees and regional meetings. I am responsible for managing a £60 million budget and I lead a large team with purpose, compassion, clinical insight and accountability. My management days (five per annum) are filled with a variety of leadership demands and requires decisions to be made in a continually changing playing field.

These changes and challenges have been hugely amplified by the pandemic. We transformed our elective centre into a large critical care unit with a few days’ notice. Just when elective processes had restarted in June 2020 with completely new networks emerging. We had to respond to the directive to supercharge planned care processes NOW to manage thousands of long waiting patients, alongside tasks involving surgical redeployment, shielding staff and providing proning teams.

During my clinical sessions (six per annum) I completely enjoy surgical work including a 1:12 on call and undertaking regular trauma, elective clinics and operating lists which preserves my clinical credibility and sanity.

Leadership programme In 2018, I completed a six month senior clinical leadership programme (SCL) at the Kings Fund London which I would recommend highly.

I cannot emphasise enough how much this has shaped and helped me in overcoming the daily challenges of my role. Concepts such as instilling passion and leading your team with purpose, embracing a culture of kindness, holding difficult conversations amongst the frequent daily chaos of limited resources, fast paced imposed changes, managing deadlines and too many meetings. Our facilitators Matthew and Belinda frequently reminded us that leadership is indeed a contact sport!

Undoubtedly, the best and most powerful conversations are often those which happen by chance in the corridor, carpark or lunch queue. Your conversations and your learnt skill to LISTEN WITH FASCINATION will help you get on with people and have them stand by your side as their leader.

My natural curiosity (some might simply call it being ‘nosy’), the ability to chat and relate to just about everyone in the organisation and beyond helps me to develop great working relationships conducive to kind and understanding leadership.

To uphold quality and standards of care whilst remaining authentic as a clinician (as opposed to authoritarian) and most importantly, to develop personal resilience are amongst the pearls of wisdom forever in the back of my mind.

My Trust was extremely generous to offer funding for this programme as well as participation in a national QSIR (Quality and Service improvement course) and two personal coaching programmes. Currently, as a TRI, we are benefitting from a targeted SCL coaching programme giving me space to reflect, take stock and develop my skills as a leader.

Believe me, no one is born a leader. It is largely a learned skill and where some people truly excel, I just keep ploughing away… grateful for the mentorship and opportunity to be mindful amidst the current unprecedented crisis of society and the NHS.

Challenges as a Medical Director It goes without saying that leading a large division has its challenges. Difficult conversations occasionally need to be held, struggles around job planning principles resolved and being the arbitrator between feuding colleagues which is often a result of clinically stressful situations can be hard.

These, on occasion, continue to play in my mind. I tend to discuss this with my triumvirate and will not hesitate to lean on experienced senior leaders from other divisions as a sounding board to help me.

Having worked for many years as a surgeon alongside my wider team including surgeons, anaesthetists, nurses and managers definitely helps calm the waves and bring it all back to why we are here in the first place: to provide the best care we can for our patients despite often very difficult circumstances.

Continuous email streams (I get copied into just about everything at the Trust) and a permanent phone presence juggling several WhatsApp groups of general surgery, urology, head neck, critical care plus TRI can be wearing and requires discipline to switch off at times to recharge my batteries when off duty.

The female perspective - Girls most definitely can!

It is impossible to write this piece as a female surgeon without reflecting on my special position as a role model for women in surgery. >>

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Features

the River Thames after three years of project management (me after hours) and hard work (my husband and various contractors).

I am extremely grateful for an oasis of calm and refuge. Running, fitness and boating alongside family and friends are my remedies to restore strength and staying power when it gets tough.

Rewards As a senior clinical leader, I feel extremely privileged in my role. I feel I can add true value to senior decision making in our organisation. Just this year our Trust has been granted permission to plan a new major acute hospital to translocate our somewhat fragmented emergency services into one modern contemporary and wellplanned facility. From a planned care perspective, over many hours of analysing, planning and teamwork, my vision and clinical view have shaped this new facility and I felt very valued throughout this process.

For some reason, during medical school in Germany and throughout my UK training I have never really encountered boundaries because of my gender. The glass ceiling was not truly visible to me, rather a strong belief in my knowledge, skills and ability as well as absolute dedication to be a good surgeon dominated my outlook. I fully believe in meritocracy independent of gender.

However, we need to acknowledge the fact that currently 6% of UK Orthopaedic Consultants* are female and there remains a lack of female representation in subspecialist societies and councils. This clearly needs addressing and changing.

As mother of three (the youngest seven years of age) and a full-time working surgeon, I have complete empathy with female trainees and mothers who might feel the choice of being a senior leader and having a family might appear daunting. In my opinion, the UK has one of the best health care systems to allow female doctors to flourish: reasonable working hours, flexible working options, provision of childcare at the workplace and a salary to allow for at home childcare really makes a difference.

By comparison in Germany, the ‘Nanny’ is a virtually unknown concept and combined with surgical starting times of 7am or earlier this is a significant barrier to many female surgeons.

My salary and my working pattern plus a supportive husband allows me to flourish in

my career and I am endlessly grateful for it.

Less than full time training (LTFT) can be good choice for others and I would always support this. We currently have two LTFT trainees who are a real asset to the team as they have organised themselves in an effective way.

The fact that my oldest has chosen a career in medicine seems to reinforce my strong belief that girls need good role models. I believe the sky is their limit should they wish to take on a career in surgery as well as professional senior leadership roles.

All of this does not hide the fact that amongst 42 orthopaedic surgeons at our renowned Elective Orthopaedic Centre, mine remains the only female face on that large wall of impressive photographs in the entrance hall... time for change!

Show casing our newly developed T&O, urology and ophthalmology hub all developed at pace in the summer of 2020 to NHS London and GIRFT leaders, I felt so proud of what our Planned Care Division have achieved under the most challenging of circumstances.

It was a perfect opportunity to demonstrate effective senior clinical leadership and great patient care during elective recovery after COVID-19. I believe that my work as Divisional Medical Director has definitively added value to these achievements and pulled our large team together in the midst of a healthcare crisis.

“We need to acknowledge the fact that currently 6% of UK Orthopaedic Consultants are female and there remains a lack of female representation in subspecialist societies and councils.

This clearly needs addressing and changing.”

Work life balance matters. A lot. My husband and I had the unique opportunity to build a (German) eco house directly by

* Editor’s note: 30% of female consultants are ‘early years’ consultants within 5yrs of CCT (the other 70% qualified 5-30 years ago).

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As orthopaedic surgeons, we are very accomplished and skilled to fix what is broken.

Our unique knowledge and skillset, our resilience and calm in the operating theatre and our ability to restore are invaluable to senior leadership. Add to that passion, communication and listening skills and good time management and you have the perfect scaffold to develop into an effective and valued senior clinical leader. n

Features

Lyndon Mason is a Consultant Trauma and Orthopaedic Surgeon in the Liverpool University Hospitals Foundation Trust. Lyndon is the foot and ankle trauma lead in the Liverpool Orthopaedic Trauma Service and has published widely on foot and ankle trauma management.

He is the chairperson elect this year for the outcomes committee in the British Orthopaedic Foot and Ankle Society.

The posterior malleolar fracture – is the rule of a third or use of percentages an orthopaedic myth?

Lyndon Mason, Andrew Molloy and Gavin Heyes

Andrew Molloy is a Foot and Ankle Consultant in Liverpool University Hospital NHS Foundation Trust.

His work has been highly regarded internationally. He was one of the founding outcome committee members in the British Orthopaedic Foot and Ankle Society.

Gavin Heyes is a Consultant Trauma and Orthopaedic Surgeon in the Liverpool University Hospitals Foundation Trust. Gavin specialises in trauma and foot and ankle surgery including the management of diabetic foot disease. His research interests include trauma and foot and ankle surgery.

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The Hunterian Professorship is one of the proudest traditional honours of the Royal College of Surgeons of England and is bestowed to surgeons of eminence who have richly contributed to the field of surgery by original research or innovation. It is named after the pioneering surgeon, John Hunter, and has been awarded annually by the college since 1810. Professor Lyndon Mason delivered his Hunterian Lecture on his ground-breaking work on ankles fractures at the BOA Virtual Congress in 2020.

T

he posterior malleolar fracture of the ankle has come under major scrutiny over recent years with a marked increase in the published literature on the subject. Significant variations in morphology have been described which reflect differing mechanisms of injury1,2. Despite this there are still some that consider fracture fragment size in their decision making3,4.

The purpose of this paper is to outline the evidence that formed the basis for the traditional mantra that, “minimal posterior malleolar fractures involve less than one-third of the articular surface” or as some authors quote 25%5. Is there any clinical or

biomechanical evidence to substantiate this claim? Can size of posterior malleolus fracture be accurately assessed by radiograph? What evidence is there to support the link with size of posterior malleolus fracture and method of management of the fracture.

“The rule of a third or percentage is an approximation of the distal tibial articular surface involved in a posterior malleolar fracture, as gauged from a lateral radiograph. Nevertheless, as early as 1971, Mandell observed that superimposition between tibia and fibula could mask posterior malleolar fractures.”

The rule of a third

The rule of a third (or 25% by some authors) was first described in the historic paper

by Nelson and Jenson in 19405.

They described involvement of at least a third of the posterior tibial articular surface as a, “classical trimalleolar fracture” requiring early open reduction. They reported lesser involvement

Features

of the posterior articular surface as “minimal trimalleolar fractures” that could be managed by closed reduction and casting and reported good results even in the presence of residual posterior fracture fragment displacement.

However, due to its historic nature, the paper would not hold up to today’s level of scrutiny and does not use methods of treatment that would be recognised as standard in modern times. Regardless, the rule of a third became orthopaedic dogma.

Measuring fracture fragment size on a radiograph The rule of a third or percentage is an approximation of the distal tibial articular surface involved in a posterior malleolar fracture, as gauged from a lateral radiograph.

Nevertheless, as early as 1971, Mandell observed that superimposition between tibia and fibula could mask posterior malleolar fractures6. Since the increase in use of CT, the accuracy of the lateral radiograph in determining the degree of articular involvement of the posterior malleolar fracture has truly been called into question. There have been eight publications showing the estimation of posterior malleolar fracture size to be very poor on a lateral radiograph7-14.

As illustrated in figure 1, the position of the X-ray source and its orientation to the sagittal fracture line determines the percentage you can measure. In addition, any posteromedial involvement has a high chance of not being

seen as the fracture line is not orientated correctly. Meijer et al. (2015) found that the accuracy of measurement of posterior malleolar fracture size on lateral radiograph was only 22%12. Considering the current literature, basing the treatment of a posterior malleolar fracture on its size on the lateral radiograph is not logical and could be argued, below standard.

Classification The PMF has long been known to be heterogenous, however percentage articular surface is still discussed as the defining factor. The original classification Figure 2: Mason and Molloy classification using CT axial and sagittal slices1. of the PMF was by Drawing illustrates the differing mechanism for each PM type.

15 Haraguchi et al. , but this has since been superseded by classifications by Bartonicek Our work on the pathoanatomy of the et al. and by ourselves2,16. Our fracture posterior malleolar fractures identified that classification had value in its knowledge of the the smaller fractures were the consequence injury mechanism of rotation and thus the less than 25-33% and its associated fractures were simply not tested1. The injury patterns assertions made that over a third of articular providing guidance surface was required to give instability, is for treatment. The really akin to a posterolateral corner injury classification can of the knee being determined as stable by be seen in figure 2. only being tested using a Lachman’s test.

None of the recent More work is needed on the rotation Pilon classification systems fracture variant as the paper by Haraguchi use percentage as and Armiger only tested in pronation with their defining factor. the ankle in dorsiflexion which showed avulsion type injuries18.

Biomechanics

Figure 1: Examples of different type of posterior malleolar fractures, with similar lateral radiograph appearance but with very different articular involvement. The blue X and dotted line indicate the X-ray source for the lateral radiograph to show its relation to the fracture line.

The posterior malleolus has two main functions in the stability of the ankle; preventing sagittal plane translation and horizontal plane rotation (figure 3)17. Unfortunately, apart from the study by Haraguchi and Armiger, all the biomechanical studies in the literature only tested the posterior malleolar fracture in sagittal plane translation18.

Syndesmosis There are both clinical and anatomical studies looking at the PMF and syndesmosis.

Gardner et al.19 found that fixation of the PMF rather than using a syndesmotic screw provided better rotational stability. Whilst they also saw that the rate of stiffness post operatively was higher in those with syndesmotic screw fixation (70% of intact stiffness restored vs 40%). Baumbach et al.20 used three different methods in order to assess syndesmotic activity: no fixation (48.3%), ORIF (33.1%) or CRIF (18.6%). They found that the size of the fragment had no bearing on the rate of syndesmosis injury. They found that ORIF significantly reduced the frequency of trans-syndesmotic fixation compared to the other two groups. >>

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Features

Figure 3: Illustration of the different movements the posterior malleolus is involved in regarding stability.

In addition they found that the quality of fixation was also better in ORIF compared to the other two groups and concluded that all PMF irrespective of size should be treated via ORIF. Miller et al.21 looked at syndesmotic stability when patients are lied supine vs prone. They saw that positioning a patient prone to undertake ORIF of the PMF restored 97.9% of patient’s syndesmotic stability. In comparison 48.3% of patients treated in the supine positioning required some form of additional syndesmotic stabilisation. They also found that a further 29.1% required PMF stabilisation for posterior instability. Fitzpatrick et al.22 even found that the smaller fracture fragments had a greater determination on syndesmotic position than the larger fragments.

Therefore, the PMF is clearly pivotal to the posterior syndesmosis. However, not all PMF have injured syndesmoses. The injury of the syndesmosis is dependent on the mechanism of injury. Although we found that 100% of avulsion type injuries had a syndesmosis injury on testing, only 49% of rotational Pilon’s and 20% of axially loaded Pilon’s had syndesmosis instability1. Further anatomical work by our group concluded this was due to the extensive expansion across the posterior tibia of the superficial component of the posterior inferior tibiofibular ligament23. We also found that the more extensive the bone injury, the lower the risk of syndesmosis injury.

Thus, if the syndesmosis is injured PMF fixation will improve its stability, however in the rotational and axially loaded Pilon it is not always injured. Percentage joint involvement has no relevance to the PMF and syndesmosis injury.

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Outcomes In 2016 and 2018, two systematic reviews were undertaken looking at the outcomes of posterior malleolar fractures treated by traditional means (fixation only occurred if greater than a third of the articular surface)3,24.

Both concluded that there was generally poor functional outcomes throughout the studies reviewed and that articular step-off was the major significant factor in the outcome.

They also noted that articular percentage involved had no relevance to outcome.

Since 2018, there has been a vogue in fixation of the PMF. Although there has been no level 1 study directly comparing the old dogma and the new vogue, there has been many publications over the last few years showing a marked improvement in outcomes. Blom et al’s25 prospective study showed on multi-regression analysis that in rotational Pilon’s and axial Pilon’s articular step off was key and in avulsion type PMF syndesmotic reduction was key.

fracture types. Our aims were similar to Blom et al., with avulsion type fractures undergoing syndesmotic fixation and Pilon fractures (rotational and axial loaded) undergoing ORIF1,26. The recent paper from the Royal London hospital showed very similar results to ours, using the same treatment theories as ours27. Many other papers over the last two years have also shown very good functional results using similar methods. There has been a big shift away from the rule of third, with apparent improvement in results.

“Our own work using a treatment algorithm based on the pathomechanic classification was published in 2017, and resulted in a significant improvement in functional outcomes of all fracture types.”

Our own work using a treatment algorithm based on the pathomechanic classification was published in 2017, and resulted in a significant improvement in functional outcomes of all

Conclusion

Although numerous historic studies have mentioned that posterior malleolar fractures only need fixing if it is greater than a third or 25%, there is increasing evidence both radiological, anatomical and clinical to show that the rule of third or any percentage should now be discarded and dismissed as orthopaedic dogmatic myth. It is essential that the morphology of the ankle fracture is witnessed as this is one of the only predictors of outcome and will guide treatment. There is general consensus towards the use of CT scanning in the pre-operative management to help determine fragment morphology. n

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

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Research

The anatomy of an awesome randomised trial Ben A Marson and Daniel C Perry

Ben Marson is an Orthopaedic Registrar from the East Midlands North rotation who is currently out of programme and studying for a PhD at the University of Nottingham. He has been awarded a NIHR Doctoral Fellowship to investigate outcomes following childhood fractures.

Daniel Perry is a Professor of Orthopaedic Surgery and Honorary Consultant Orthopaedic Surgeon at Alder Hey Children’s Hospital.

He is the chief investigator for several multicentre clinical trials of orthopaedic interventions including FORCE, SCIENCE and CRAFFT which have been funded by the NIHR. Dan is one of the three BOA Surgical Specialty Leads for Clinical Trials.

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In the past decade, orthopaedics has emerged as an academic speciality able to deliver high-quality randomised trials. We are experiencing an explosion of engagement in research trials from both within our speciality and from external sources including research funders. This has resulted in the publication of many trials, including many in the top medical journals1-7. However, there remain many uncertainties within our speciality that need proper investigation.

R

andomised trials are the gold standard to compare healthcare interventions. However, conducting randomised trials is expensive, with major trials typically costing in excess of £1million8. The cost of these is accrued through the rigour in design and conduct of these studies – to ensure that the trial is a definitive answer to a question, and ultimately to avoid the dreaded conclusion that “more evidence is required”.

As a community, we need to continue to ask clinical questions that can be answered through trials to continue to advance our understanding of the interventions we recommend. The purpose of this article is to unpick some of the features that convert these clinical questions into a trial that can be delivered for the benefit of our patients.

This process starts when the clinical question is translated into a research question that underpins the clinical trial.

Where to start: the clinical question There are several sources of questions abundant in orthopaedic clinical practice. There are so many questions and uncertainties that the issue is more where to start?

The panacea of a research question is to identify an issue with broad relevance. The question needs to be important to: 1) you, as you need to invest your own passion and energy into it; 2) your subspeciality colleagues, as you need their buy-in to deliver the study, and eventually to ensure your research findings have meaningful impact; 3) patients, who will be part of the study; 4) funding bodies to support the trial; 5) the public, who will ultimately benefit from the trial and 6) policy makers who use the research findings to shape commissioning decisions.

“The Gold Standard in research priority setting is the James Lind Alliance Priority Setting Partnership. This is based on a collaborative methodology to encourage meaningful engagement between researchers, clinicians and patients in setting research priorities.”

The need for research can be established through systematic reviews.

Cochrane reviews highlight needs for future research,

Research

which often clarifies uncertainties found following literature searching. The National Institute for Health and Clinical Excellence (NICE) prioritise a list of research questions with each of their guidelines which can form the basis of further study. For example, the FORCE distal radius study was inspired by the 2016 non-complex fractures guidelines requesting an evaluation of the effectiveness of interventions for torus fractures9.

Priority setting studies have also been completed by subspecialty groups including the AOUK10 and British Society of Childrens Orthopaedic Surgeons12. Several of these questions have already been addressed with multicentre trials and others are being developed to address these priority uncertainties. However, the use of these surgeon-focused lists potentially omits the important views of patients, the public and policy makers.

The Gold Standard in research priority setting is the James Lind Alliance Priority Setting Partnership. This is based on a collaborative methodology to encourage meaningful engagement between researchers, clinicians and patients in setting research priorities11.

This programme is part funded by the UK medical research funding body, the NIHR. Currently, eleven lists of priority questions have been published that are relevant to orthopaedics, with three further priority sets in development12-17 (Table 1).

Figure 1: The orthopaedic randomised controlled trial bridge with the keystone research question. Image supplied courtesy of the University of Nottingham ©

Crafting the keystone: the research question

2015

Where the clinical question identifies the problem to solve, the research question crystalises the problem into something that can be solved. If we imagine the trial as a bridge, safely transporting patients (with their surgeons) from illness or injury to recovery or rehabilitation, then the research question is the Priority Set keystone from which the structure of the bridge Scoliosis depends (Figure 1).

Spinal Cord Injury Crafted well and the trial will endure, crafted Hip and Knee Replacement for Osteoarthritis poorly then the trial may collapse.

Surgery for Common Shoulder Problems

2016

Early Hip and Knee Osteoarthritis

2017

Common Conditions Affecting the Hand and Wrist

2018

Broken Bones in Older people - Musculoskeletal Injury: fragility fracture of the lower limb and pelvis

2019

Broken Bones of the Upper Limb in People over 50 (Fractures of the Shoulder, Arm or Wrist)

2019

Paediatric Lower Limb Surgery (planned operations for children 0-16 years old with orthopaedic conditions affecting the lower limb from hips to toes)

2020

Revision Knee Replacement

2020

Degenerative Cervical Myelopathy

Date Published

2012 2014 2014

In Progress

OPEN 2019

Foot and Ankle Surgery

OPEN 2020

Complex Fractures

OPEN 2020

Elbow Conditions

Table 1: James Lind Alliance Priority Setting Partnerships relevant to orthopaedics.

A common language is used to structure a research question is the PICO format, initially attributed to Richardson et al. in 199518 and subsequently included in the 2008 Cochrane handbook19. The PICO format structures the question into the following four elements: Participants-(P): the population to be studied as defined through clear inclusion and exclusion criteria.

Intervention-(I): the intervention or interventions of interest that are being trialled.

Comparison-(C): the control intervention being used as a comparison. Historically, the ideal comparison has been with a placebo therapy. For surgery, this can be a sham procedure such as used to evaluate arthroscopic surgery20. However, for many orthopaedic trials this is less desirable, such as trauma surgery2, 21, 22. An alternative is to use the agreed current standards of care.

Outcomes-(O): the primary outcome and the timing of the primary outcome is the key to the trial. The study is usually designed to answer a single question related to the primary outcome at a single time point. Secondary outcomes are supplementary information to support the ‘story’ of the primary outcome.

How pragmatic should a trial be?

A trial can be designed as an efficacy or effectiveness trial. An efficacy trial is often a proof-of-concept study, conducted using strict criteria for participants, interventions, and comparisons. It asks, “Under perfect conditions, does an intervention work?”.

Carefully selected participants who meet trial inclusion criteria receive a standardised intervention that may be evaluated to ensure the intervention was completed as instructed.

These studies are often single centre to reduce operator variability and demonstrate the utility of an intervention in these controlled circumstances. This design has the advantage that effects are likely to be due to the intervention, but may overestimate the effect size in the wider population and is limited in generalisability to other settings23.

In contrast, an effectiveness trial tests the intervention in a ‘real-world’ setting, with broader inclusion criteria and more >>

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Research

relaxed definitions of the interventions and comparisons to reflect current clinical practice24. Effectiveness trials are termed as pragmatic to highlight the greater flexibility permitted in the definition of participants, interventions and comparisons.

The reality is that every trial sits somewhere on a continuum between these two designs.

For example, the UK FASHIoN trial of hip arthroscopy compared to physiotherapy led non-surgical management had many features of an effectiveness trial. The trial recruited patients from 23 different centres and included patients with cam or pincer anatomy in the absence of pre-existing hip pathology. Surgery was completed by 27 different surgeons. However, the selection of comparison was less pragmatic in the form of a physiotherapy package for which practitioners had to attend specific training to maintain the consistency of the therapy protocol provided by the 47 physiotherapists within the trial6. This was selected to provide a standardised comparison for arthroscopy but may not reflect the real-world care delivered in every hospital.

What and how to measure Each trial requires a primary outcome for which the sample size will be calculated.

Secondary outcomes will be selected

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to enhance our understanding of the interventions. The selection of outcomes will be driven by the clinical factors and should be informed by surgeons, patients, and other relevant stakeholders. Outcomes need to be relevant and are useful in helping surgeons and patients implement the trial findings.

So far, there are six core outcome sets in orthopaedics covering arthroplasty34, osteoarthritis35, hip fracture36, shoulder disorders37, Perthes disease38 and back pain39 with sets in development for disorders including childhood fractures40, childhood elbow fractures41, hip avascular necrosis42.

To develop trial findings into treatment guidelines and policy decisions, trials are aggregated through systematic review and metanalyses. By pooling results uncertainties in treatment effects are reduced. However, a common criticism of trials in these systematic reviews is a lack of consistency in the selection of outcomes limiting this pooling25-27. To address this, core outcomes sets have been developed in orthopaedics28.

Onto the trial

A core outcome set is a group of outcomes that have been agreed to be measured in all trials relating to a specific condition. A core set is not a comprehensive set as additional outcomes may be measured in addition to those identified in the core group29, 30. While the methodology varies between studies for the development of a core outcome set, the process typically focused on first agreeing the outcome domains that need to be measured in all trials. Once these broad outcomes are agreed, then candidate outcome measures (such as patient reported measures or other tools) can be evaluated for validity and reliability31-33.

With a keystone question sorted, the next step (ignoring the getting it funded) is to design and write a study protocol, with technical considerations such as randomisation schedules and plans for data monitoring, statistical analysis, and health economics etc. For all of this, help is at hand. In the UK we have support from the regional NIHR funded Research Design Service43, and the BOA funds access to experts in clinical trials units as part of the BOA Orthopaedic Surgery Research Centres44 and the BOA Surgical Specialty Leads for Clinical Trials (Dan Perry, Paul Baker and Xavier Griffin). These resources are available to support you in making the technical decisions, win funding and deliver a successful, awesome trial. n

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

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Standing on the shoulders of giants Reflections on eight years in Malawi John Cashman

“Are you serious? Have you really thought about this?

Is this fair on your family?”

John Cashman was an undergraduate at Southampton University Medical School and trained in Wessex deanery as a registrar. He worked as a Consultant in Bath Royal United Hospital and as a paediatric Orthopaedic Surgeon at Bristol Royal Hospital for Children prior to spending eight years in Malawi with CURE International.

John now works in Sheffield Children’s Hospital, is an Examiner for JCIE and Board member of BSCOS. 36 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

These were some of the encouraging comments shared with me by well-meaning friends when I first mooted the thought of leaving the UK to work as a paediatric orthopaedic surgeon with a charity in one of the poorest countries of the world.

I

was about to complete my first five years as a consultant in Bristol Children’s Hospital and everything was going well; a young family, excellent work colleagues whom I counted fortunate to also be my good friends, a job I enjoyed and even a fun cycle to work each day. Then an email arrived. A charitable children’s hospital in Malawi were looking for a fellowship trained children’s orthopaedic surgeon to help run the only hospital of its type in that region of Africa.

It was a difficult decision. I had visited Malawi as registrar mid-training when I had travelled to see Professor Chris Lavy, who was then one

of two orthopaedic surgeons in a country of 13 million people. I had arrived a young man who was struggling with the thought of a life spent doing adult arthroplasty in the UK. I left after nearly three months, having trod in the footsteps of David Livingstone with the naive enthusiasm modelled on Indiana Jones and impassioned with the thought of specialising in children’s orthopaedics. I then determined to become a consultant in the UK in paediatric orthopaedics, but to always be open to returning to a low income country if there was ever a specific need and I was invited.

Now, out the blue, these preconditions had been met in one short email.

International

My wife and I deliberated, I made a hasty visit and we thought and talked. We fought with the fears of bringing small children to a country with endemic malaria with a thin safety net regarding personal health, work acquired HIV and family security. We wondered if we could financially afford it.

The costs seemed high and the risks seemed considerable. But there was no peace in saying no. It seemed like an excellent fit and a once in a lifetime opportunity. It appeared the right thing to do. The UK would hardly miss my modest skills, but I reasoned I might really be able to make a helpful contribution in Malawi.

The team

I worked in the Beit Cure International Hospital in Malawi. This is a Children’s Orthopaedic Hospital built in 2002 with aid from The Beit Foundation and run

by CURE international – a Christian charity, originating in the US, but with a UK division. The hospital was the product of the vision and hard Many reading this will also have at some stage work of UK orthopaedic considered working or volunteering in a low surgeons Chris Lavy and income country and I suspect there are many Jim Harrison, both of common denominators in this interest. Many whom are now back in the will attest to a sense of stewardship. The BOA UK and will be known by rightly and frequently reveres the life of our many reading this. The famous surgical predecessors. Their sense of hospital provides free vocation and innovation continue to inspire care for children with and challenge us not only to safeguard the paediatric orthopaedic Geographical position of Malawi. baton they have handed us, but to hand it on problems in the country of in turn, not just to the next generation, but to Malawi and extending to other needful nations. Furthermore many will surrounding Mozambique recognise that at some level we are immensely and even Zimbabwe. It privileged educationally, financially and is set in a pivotal position professionally and wish to share this privilege between the medical school with those who materially have very little. Our and the main Government motivation was no different and as is so often teaching hospital called the way, as it turned out there was no sacrifice, the Queen Elizabeth only uncountable amazing experiences and Central Hospital. It has memories for which we will always be grateful. one large open paediatric ward which accommodates Leaving the UK was helped immeasurably by up to 52 beds. There is the kindness and support of my colleagues also a small private wing at work which paved the way to me being which offers adult private Burns contractures are common, often requiring release and simple local rotational flaps and skin drafting. granted a two year sabbatical by the NHS surgery including hip and Trust, with the proviso I would commit after knee arthroplasty. This one year to returning or to resign and stay helps raise a significant in Africa. I would commend this as a very proportion of the running costs of the hospital Training worthwhile strategy for anyone considering as well facilitating private practice for national similar ventures. surgeons, without which it would be practically The majority of trauma care in the 25 impossible to live and continue to work.

District General Hospitals and several We thus left the UK at the end of the summer smaller mission hospitals around the of 2007 and set up home again in Malawi.

We all know that a surgeon without a country is delivered by Clinical Officers.

The next eight years flew by. team is completely ineffectual. I was They are the equivalent of ANPs. Helping honoured to walk into support training of these clinical officers, a team of wonderful medical students, and orthopaedic anaesthetists, clinical registrars was a great privilege and good • One of the poorest 10 countries in the world, sits in the African Rift Valley. officers, nurses and fun. The real credit must go to the local • One of the lowest ratios to doctors to head of population in the world. physiotherapists, all Malawian surgeons, Professor Nyengo • Approximately 500 miles long and up to 100 miles wide. of whom had been Mkandawire who was then the orthopaedic • Almost quarter of the area is occupied by an inland freshwater sea with a assembled and trained lead and to Jes Bates who organised the unique ecosystem. by others and on whom registrar training programmes, to whom we • Currently all-time high of 13 orthopaedic surgeons working in the country I was completely simply lent support. (three in CURE) with six orthopaedic higher surgical trainees. reliant. There were • Extremely geographically varied and beautiful. Hot arid low lying river also fantastic colleagues We also hosted at least one UK trainee every valleys and high mountain extrusions. and friends in national year on our Fellowship programme. It was • Population of approx. 19 million with approximately 50% less than 16 surgeons from Kenya enormous fun to share the excitement of the years of age. and Uganda who helped work with a UK trainee and see in turn them • In 2010 60% of the population lived off less than $1.25 dollars per day. train me in a new way flourish from merely competent surgeons, • Average expenditure per annum per capita on healthcare $32. (UK £3,227). of working, as well as to confident surgeons with a rounded Jim Harrison to help experience and an often reignited passion Box 1: Facts about Malawi. orientate me. for orthopaedics. >>

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 37

International

The pivotal geographical location of the hospital meant it was easy to run training courses. Our proximity to the medical school cadaveric dissection room, to the adjacent Central Hospital and to our own lecture theatres and seminar rooms meant that we were able to run courses for orthopaedic trainees both nationally and internationally.

Instructional courses undertaken included those relating to paediatric orthopaedics, trauma management, limb reconstruction, knee surgery, foot and ankle surgery, plastic surgical reconstruction and Ponseti clubfoot treatment. These were often supported by visiting UK surgeons and charities and societies such as the Furlong Foundation, THET (Tropical Health and Education Trust) and BOFAS. The legacy of these still bear fruit today as I hear of past trainees around Africa still using and perfecting techniques first learnt at one of these events.

Ponseti programme CURE Clubfoot Worldwide (CCW) helped finance the formal establishment of a national clubfoot programme, following on from some foundational training by Chris Lavy and Steve Mannion some years earlier. With the help of a national programme coordinator, I was given the job of setting up 28 treatment centres in hospitals around the country and furthering the training of clinical officers and rehabilitation assistants (physiotherapy assistants) with regular training courses.

CCW financed the provision of foot abduction braces and we organised their local manufacture and distribution. The resultant drop-off in numbers of children needing major surgery was notable and gratifying: seeing just some of the thousands of kids successfully treated happily playing netball and football at a FIFA sponsored event at our five year anniversary was incredibly moving.

Smiling and happy patients at CURE.

The children Falling in love with the country was easy.

Malawi is beautiful and whilst its people are often grindingly poor, their friendly welcome and resilience are inspiring. I was rarely able to show visitors around without being rendered speechless by the sense of privilege of being part of such an amazing team offering world class surgery to the poorest and needy of children and their families. The pathology

Chronic Osteomyelitis is a very common and challenging condition treated.

38 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

presenting was exciting and challenging and included chronic osteomyelitis, severe burn contractures, sequelae of neglected trauma, angular limb deformities, neglected clubfoot and many rarer congenital limb deformities that would be plentiful as there was no other source of help nationally or even regionally in that part of Africa. Fortunately with a fine array of UK donated Ilizarov and TSF instrumentation, there was not much that our unit was unable to cope with. Being asked to preside over nine lists per week with only one outpatient clinic brimming with pathology, is perhaps a surgeons dream.

“Malawi is beautiful and whilst its people are often grindingly poor, their friendly welcome and resilience are inspiring. I was rarely able to show visitors around without being rendered speechless by the sense of privilege of being part of such an amazing team offering world class surgery to the poorest and needy of children and their families.”

International

“I was honoured to walk into a team of wonderful anaesthetists, clinical officers, nurses and physiotherapists, all of whom had been assembled and trained by others and on whom I was completely reliant.”

The lows There were few low moments and these were eclipsed by the many happy memories, but challenges included nearly losing our nine month old daughter to severe croup as there was no paediatric ventilator available in the entire country. There were also times that we lost friends to road traffic accidents and tropical illness which were also hard, but such problems are not exclusive to Malawi. Taking two different courses of antiretroviral therapy for needle stick injuries or eye splashes in HIV positive cases was also irritating, but the knowledge that seroconversion is almost unheard of was very reassuring.

Clubfoot football – a prerequisite to play was that you had to have been born with clubfeet and treated by the national Ponseti clubfoot programme.

Conclusion The only contributions I was able to make in my eight years in Malawi were entirely contingent on others, including the dedicated surgeons, both Malawian and from the UK that continue to live and work there and have invested their lives in training and improving the lot of their countrymen. We were also reliant on the committed hospital team that made the work possible and the financial support we had from CURE and from supporters in the UK. As Sir Isaac Newton now famously attested: “If I have seen further, it is by standing upon the shoulders of giants.” I cannot claim to have seen further, but can affirm that any contribution we made was built on the hard work of others.

I have listed one or two personal recommendations for those considering giving time to working in a low income country, (Box 2). I have never met anyone who regretted doing so. Personally it was most rewarding and is a continual reminder to me to be grateful for our NHS and all that we have professionally in the UK. But those considering similar would do well to ponder the words of Mark Twain: “Twenty years from now you will be more disappointed by the things you didn’t do than by the ones you did do.” There is rarely a convenient time to leave the securities of what is known as home and invest oneself elsewhere, but I am so thankful we were able to. n

Faculty and delegates from instructional course on knee surgery.

• Find a colleague or contact working in a country that you can support. Ask them what they need, not offer what you might have spare.

• Consider joining a teaching course (e.g. basic surgical skill / basic trauma course / other surgical instructional course) and visit the country. See if there are ways you can support existing surgeons or training schemes.

• Consider linking hospitals in UK with those overseas to promote and support education / research etc.

• Consider volunteering to provide skills as an external examiner or help running logistics of an exam or course.

• Consider taking a longer period of leave for 4-6 weeks to cover leave of a surgeon working in a hospital overseas.

• Consider taking a two year sabbatical / early retirement to support training overseas.

• Be humble and non-judgmental. You will invariably learn and gain more than you can give.

Box 2: Recommendations in supporting orthopaedics in Low Income Countries.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 39

Medico-legal

Surgical rationing in times of COVID-19 pandemic – how does it affect the Montgomery ruling and GMC guidance on consent?

Shyam Kumar and David Warwick

T Shyam Kumar is a Consultant Orthopaedic Surgeon based at the Royal Lancaster Infirmary. He has completed an LLM in Medical Law and Ethics with Merit. His other roles include; Member of the BOA Medico-legal Committee, Clinical Assessor-PPA (Formerly NCAS) and Member of Appointments Advisory Committee, Royal College of Surgeons of England. His name has been nominated recently to the Lord Chancellor to be a member on the Cumbria & Lancashire Magistrates’ Recruitment Advisory Committee.

David Warwick is Chair of the BOA Medico-legal Committee and a Consultant Hand Surgeon at University Hospital Southampton.

40 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

he Oxford dictionary defines a ration as “a fixed amount of a commodity officially allowed to each person during a time of shortage, as in wartime.”1 This allocation of scarce resources in healthcare inevitably leads to withholding of potentially beneficial treatment from some individuals or groups. Some commentators have accepted the fact that rationing care is a fact of life in the NHS2. Rationing happens on day-to-day basis as resources are always short in healthcare and this situation is not unique to the UK. On an administrative level, rationing happens in the macro-allocation of resources. Triaging at a scene of mass casualty (natural disasters, terrorist attacks etc.), deciding the appropriateness of a patient to be admitted to the intensive care unit (ICU) etc. are examples of frontline rationing which are typical and frequent.

With the advent of the COVID-19 pandemic, these issues are coming very close to us in Trauma & Orthopaedic also. In many hospitals, theatres are taken over by ICUs leading to loss of surgical output. This is compounded by the staff sickness absence3 and the increased anaesthetic time due the extra precautions that need to be taken4. As such, theatre time has become premium and the duration which patients spend on a surgical waiting list is increasing5. In order to cater to the neediest patients, at the request of NHS England, the Federation of Surgical Specialty Associations (FSSA) have come up with a new method to prioritise patients who are already on the waiting list for surgery6. This guidance, with which most surgeons would be familiar by now, grades patients according to clinical need from P1 to P4 based on the diagnosis and recommends the maximum waiting times for surgery. P1a comprises of procedure which must be done within 24 hours and P1b to be performed within 72 hours; P4 comprises procedures which can wait for more than three months.

From a medico-legal point of view these are not without implications. This approach would certainly have an impact on patients who have been waiting longer on the waiting list. Some conditions are likely to progress such that an inordinate wait can cause irreversible changes with poor outcomes (e.g.: progression of arthritis resulting in a straightforward joint replacement becoming a complex primary with added morbidity and mortality, or prolonged nerve compression causing irreversible limb function due to entrapment neuropathies).

The allocation of resources in rationing of care also means that “beneficial interventions are withheld from some individuals”.7 Withholding of any form of care as a result of rationing is likely to engage Article 2 and 3 of the Human Rights Act 19988.

Article 2 of the Human Rights Act deals with the right to life and Article 3 confers freedom from torture and inhuman or degrading treatment.

The NHS Constitution9 establishes the principles and values of the NHS in England. Principle 1 mentions that, “It (NHS) has a duty to each and every individual that it serves and must respect their human rights...”. Although rationing happens on the bedside for clinical reasons (e.g.: Intensive Care Units), the last decade has seen rationing for economic reasons driven by various state apparatus (NHS England, Clinical Commissioning Groups etc.). Concerns were expressed by the Royal College of Surgeons previously where the government decided to restrict elective operations10.

The above debates give an indication of the resource crunch the system was under even during normal times. COVID-19 has pulled the world into a war like situation and we are involved in day to day rationing while making treatment decisions. At the time of writing this article, the UK had reported more than 87,000 deaths while the vaccine is being rolled out. As this is unprecedented, rules

Medico-legal

which might have been deemed unacceptable may have to be introduced. This is recognised by all stakeholders. The BOA acknowledges through its BOAST guidelines that, “during the coronavirus pandemic, surgeons and patients will have difficult choices to make about management options for a wide variety of injuries and urgent conditions. They will need to balance optimum treatment of a patient’s injury or condition against clinical safety and resources.” The BOA recognises that non-operative management of many injuries and reduced face-to-face follow up will be increasingly the norm11.

The BOAST guidelines also recognises that changes to standard management plans may be required to minimise patient exposure to disease and overall impact on resources.

deviation from the generally accepted standard of care. It is reasonable to expect that claims are likely to be processed in the same manner in the future also. As advised by the BOA, it is important that documentation is clear about the decision making, and treatment which has occurred during the COVID-19 pandemic.

Although the above measures would make us feel comfortable, the effect of the Montgomery12 ruling and the GMC consent guidance cannot be ignored even in the current circumstances. By law, patients are entitled to make irrational choices. The judges observed that patients should be seen as individuals holding rights and not as “passive recipients of care”. Not surprisingly, the medical fraternity has suddenly woken up to the new reality and is calling for changes in the law13. In line with case law and the GMC guidance on consent, we are required to explain the options for treatment. There are a number of patients who would risk COVID-19 infection (with its associated mortality) to receive operative treatment for their fractures. This puts surgeons in a very difficult situation. As per the GMC’s new consent guidance, there is only one situation where the patient’s wishes can be refused: “If after discussion you still consider that the treatment or care would not serve the patient’s needs, then you should not provide it.”14

“COVID-19 has pulled the world into a war like situation and we are involved in day to day rationing while making treatment decisions.”

In this context, it is obvious that some patients undergoing elective surgery after a prolonged wait or those provided with non-operative treatment of some fractures are likely to end up with poor outcomes. Some of these cases might end with a legal challenges. From a practitioner’s perspective although there is communal support at present from professional bodies and NHS institutions for deviating from standard management plans, it is important that each surgeon takes the responsibility for their actions and document the reasons for any

In the current pandemic, the surgeon is not holding back operative treatment as “it would not serve the patient’s needs”. The choice of treatment is decided by a combination of factors including decreasing risk to the patient and others by minimising hospital contact and by preserving theatre resources.

Unfortunately, the GMC guidance does not cover this eventuality and surgeons may feel that their backs are uncovered in this unusual and unforeseen situation. It is the authors’ opinion that the GMC should update the guidance to include the current scenario which could repeat itself (where it is obvious that the patient is likely to get a better outcome with early operative treatment e.g. fractures), but it could cause potential harm to others directly or indirectly due to COVID-19 risk and consumption of theatre time from which more needy patients would have benefitted. The case law which is aligned with the GMC guidance15 mentions that confidentiality can be breached in exceptional circumstances where there is a danger to the individual or the public. Using the same principle, the surgeon should be enabled so that refusal of operative treatment requested by patient does not land the surgeon in deep waters and conflict with the current GMC guidance on consent. It is likely that there would be COVID-19 driven interpretations of Montgomery from the Courts to follow. n

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

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 41

Trainee

Ran Wei is an ST8 in South West London with an interest in Knee Surgery. He is the current President of BOTA, having previously served as Vice President and SAC Rep. He represents T&O trainees within a number of important forums including RCSEng Council, RCSEng L&A Committee, BOA Council, BOA EdCar Committee, IST Assurance Board, T&O SDG and ATDG.

Training in the independent sector Ran Wei, Rob Gregory, George Holland and Josh Burke

Events over the past twelve months have resulted in the greatest challenge to surgical training that we are likely to experience within our lifetime. Cessation of elective operating coupled with workforce redeployment has resulted in an effective pause in T&O training for most trainees across the UK.

I Rob Gregory is a Consultant and Lead Clinician in Trauma and Orthopaedics at County Durham and the Darlington NHS Trust. Robert has an interest in surgical education and is currently chair of the specialist training committee for T&O. He is quality management lead in the School of Surgery in the Northern Deanery, an examiner at MRCS level and also a Regional Specialty College Adviser in T&O.

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n the wake of the first national Survey data lockdown, concerns over the increased morbidity and mortality of patients In November 2020, BOTA began surveying who contract COVID-19 around the trainees across the country in an attempt time of surgery1 led to the guidance to understand and voice the issues provided by both the BOA2 and NICE3 to help encountered by trainees when trying to ensure a safe return to elective operating. The access training in the IS. The survey was requirement for the establishment of ‘Green’ conducted over a three-month period from sites, intended to minimise the risk of patients 16th November 2020. Through the Regional contracting COVID-19 during the perioperative Representative network, BOTA was able to period, meant that many NHS hospitals achieve 150 responses from trainees of all utilised independent sector (IS) hospitals for grades (Figure 1) in all 29 training regions their ever-growing elective workload. Initial across the UK (Figure 2). contracts between the NHS and the participating IS providers did not include any formal obligation to facilitate surgical training4.

This led to considerable regional variation in elective surgical training across the UK. Despite further contracts being negotiated between the NHS and the IS providers which included obligations relating to surgical training, and despite the subsequent release of position statements jointly agreed by IHPN, NHSEI and HEE5, and despite guidance set out

by HEE6, trainees continue to encounter problems when attempting to access Figure 1: Survey responses by grade. training in IS hospitals.

Trainee

George Holland is the current Vice President for the BOTA Committee, following on from the Secretary position in 201920 and Education rep in 2018-19.

He is an ST6 in the South East Scotland deanery, currently working in Edinburgh. As BOTA Vice President George attends meetings as the trainee rep on the JCST Quality assurance panel. He also sits on the BOA Trauma Committee and ICBSE Committee as a trainee rep.

Figure 2: Survey responses by training region.

The survey identified that 27.3% of respondents did not have access to any elective operative training at their NHS hospital(s).

56% of respondents worked in an NHS hospital that utilised IS hospitals for their patients. 26 of the 29 training regions surveyed utilised IS hospitals for NHS funded operating lists.

BOTA was concerned about the wide range and extent of the difficulties identified (Table 1).

Lists do not match Trainee’s timetable

BOTA’s national survey of training in the independent sector has revealed significant deficiencies relating to access to elective operative training within the UK associated with the COVID-19 pandemic. The survey suggests that 90% of training regions are currently utilising IS hospitals for NHS funded operating lists. BOTA understands that reliance on delivery of training within the IS setting is not a long-term solution to the deficit in training caused by COVID-19.

Initial efforts to minimise the Frequency (%) consequences of disruption to surgical training resulting from 42.4 COVID-19 are becoming largely 21.2 ineffective. It is therefore vital that every training opportunity 9 is utilised within the NHS and that further efforts are made to 6.1 engage the IS providers with 6.1 training of the next generation of T&O surgeons.

4.5

Administrative hurdles set by IS

3

Lack of support from NHS Trust

1.5

Lack of support from theatre staff

1.5

Restriction of trainee numbers (i.e. only allowed 1 per list)

1.5

Difficulty accessing information to plan for cases

1.5

Indemnity unclear

1.5

Discussion

Josh Burke is an ST3 in General Surgery based in Yorkshire and currently completing a RCSEng and Bowel Cancer UK PhD fellowship investigating gastrointestinal anastomotic leak at the University of Leeds.

He current President of The Association of Surgeons in Training (ASiT), postgraduate lead for the NIHR MedTech Foundation and Trainee Editor for the RCSEng Bulletin. Working closely with BOTA, he represents ASiT on the RCSEng Council, JCST, ATDG, BMA and the GMC.

training a daunting prospect. Failure of IS hospitals to comply with their contractual training obligations in addition to NHS hospitals failing to support their trainees further exacerbate the unrelenting disruption to surgical training caused by COVID-19.

Utilisation of IS hospitals for delivery of surgical training pre-dates the COVID-19 pandemic7. Trainees in regions where this care setting is not commonly used may find the emerging dependence on IS hospitals for Nature of Issue (66 responses)

Lists not regular Only allowed to assist Not given opportunity to attend Not been made aware of lists Lists under-utilised

Table 1

Whilst surgical trainees and trainers need to adapt to the ever-changing healthcare delivery landscape, additional support must be provided in order to minimise the inevitable reduction in the rate of trainees achieving CCT. After all, the next generation of surgeons will be providing care in both the NHS and the IS hospitals. >>

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 43

Trainee

Guidance: HEE guidance6: “The receipt of the most recent ARCP form as well as form R which can only be issued if the prerequisite employment and other checks have occurred.

This should negate the need for any other additional pre-employment checks although to fulfil requirements of the CQC Schedule 3 the independent healthcare provider will need to obtain this evidence from the NHS employer of the DiT with their consent to do so.

The DiT must give permission for release of the forms or provide the forms personally. If this is not possible then the DiT cannot work/train at the independent sector site.”

Suggestion for trainee: Inform your departmental service manager of your intentions to attend any IS lists so that the appropriate documents/forms are provided to the IS providers in good time.

Will I be Indemnified by my NHS employer when operating in the IS sector?

FAQs on Training in the independent sector Am I only allowed to assist in the independent sector?

Answer: No. Trainees and trainers need to be given the opportunity to utilise NHS patients relocated to IS hospitals for training.

There are formal training obligations detailed within the contracts agreed between NHSEI and IS providers.

Guidance: Joint position agreed by IHPN, NHSEI and HEE5 and HEE guidance6: “Trainees must be given the opportunity to gain a wide range of competencies. This will mean in specialties like surgery, taking part in theatre sessions.”

Suggestion for trainer: Support your trainee by identifying the training cases at the team brief prior to the start of the NHS funded IS list.

Suggestion for trainee: If you are only allowed to assist, then you should bring this to the attention of your Educational Supervisor who, through your TPD, will escalate the problem to the postgraduate dean.

Who should be making me aware of the NHS funded IS lists?

Answer: Your trainer(s) (i.e. Clinical Supervisor) should be making you aware of any NHS funded IS lists that are due to take place.

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Guidance: HEE guidance6: “Trainees should be included in the planning for the resumption of diagnostic and surgical services in order to ensure that training opportunities are identified and exploited wherever possible.”

Suggestion for trainer: Inform your trainee of any NHS funded IS lists as soon as they are confirmed.

Facilitate arrangements to temporarily alter preCOVID work timetables if required to allow trainees to attend these lists.

Answer: Yes, but only for NHS patients.

Indemnity for trainees treating NHS patients who have been relocated to the IS for treatment will be provided by the trainee’s NHS employer. However, HEE advises trainees to have additional indemnity in place. If additional indemnity is in place, then trainees should inform their indemnity provider of their work at the additional site(s).

Guidance: HEE guidance6: “NHS staff in the training grades who work in independent hospitals as part of their NHS training, are covered by NHS Indemnity (the Clinical Negligence Scheme for Trusts membership of the employing Trust), provided that such work is covered by an NHS contract of employment (as per Annex A of the NHS Indemnity Arrangements for Clinical Negligence Claims in the NHS) and the trainee is under the supervision of an NHS consultant.

“Trainees should be included in the planning for the resumption of diagnostic and surgical services in order to ensure that training opportunities are identified and exploited wherever possible.”

Suggestion for trainee: Engage with NHS service managers to ascertain updates about upcoming NHS funded IS lists. Utilise local trainee networks on secure social media platforms (e.g. WhatsApp) to inform other trainees if you identify an NHS funded IS list that you cannot attend.

What paperwork do I need to supply before attending IS operating lists?

Answer: Most recent ARCP form and Form R. Your NHS employer will be able to supply any additional documents/forms requested by the IS provider as part of their pre-employment checks, but you will have to give consent for this.

DiT are always strongly advised to have additional personal indemnity. If this is in place already, then the DiT should advise the indemnity provider of the additional site of working.”

Suggestion for trainee: If you have additional indemnity in place then you should inform your indemnity provider of your additional site of work. n

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

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Subspecialty

A significant proportion of knee surgery focuses on soft-tissue problems around the joint. In this specialist section we focus on three important clinical situations; arthroscopic meniscectomy, patello-femoral dislocation and anterior cruciate ligament repair. Each area provides challenges in; understanding the natural history of the pathology, interpretation of imaging, defining indications for surgery, improving the technical delivery of surgery and the measurement of outcome after treatment. The British Association for Surgery of the Knee (BASK), working with the British Orthopaedic Association, has recognised the importance of developing evidence-based care supported by clinical treatment guidelines. In the three articles that follow we can see the importance of evidence to guide the use of surgical treatments that are firmly established, have been more recently developed and are in development.

Professor Andrew Price Immediate Past-President of BASK

Arthroscopic meniscectomy for isolated meniscal tears – changing practice Andrew Price The use of arthroscopic meniscectomy continues to cause major debate. A number of recent publications have challenged its efficacy and called for an almost complete cessation to its use. Others have argued for a more targeted approach, as outlined in the Clinical Guidelines published by the British Association for Surgery of the Knee (BASK)1.

T

he development of these guidelines, whilst receiving criticism from some quarters, has been widely accepted in the UK as a step forward in delivering care for patients2. This article examines the issues that knee surgeons must consider before they recommend this treatment, summarising the present position and considers the way ahead.

Andrew Price is a Consultant Knee Surgeon based at the Nuffield Orthopaedic Centre and a Professor of Orthopaedic Surgery at the University of Oxford. His clinical work covers all aspects of knee surgery and his research is based in NDORMS at the Botnar Centre, where he Leads the Knee Research Group. He is a past President of the British Association for Surgery of the Knee.

46 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

The clinical reasoning for embarking on arthroscopic meniscectomy in centred on the premise that a meniscal tear is responsible for symptoms and that removal of the tissue will lead to a reduction of symptoms. When an individual has a bucket handle tear and a locked knee the situation is quite clear – either repair of the meniscus or resection will be beneficial and can be offered to patients.

However, in other situations the link between tears and symptoms is less clear.

The BASK Clinical Guideline provides a decision-making pathway for addressing this issue. In developing the guideline, the BASK Meniscal Working Group considered the following clinical considerations3. Meniscal tears are common, particularly in people over the age of 40 years. They occur as part of the aging process within the knee and are very often associated with other degenerative processes within the joint’s structure.

Articular cartilage changes are seen, along with changes to tendons and ligaments around the knee. In many cases meniscal tears are symptomless. At the same time the onset of knee pain in middle age is common.

In many cases it tends to be self-limiting and will settle with simple non-operative measures. During the management of knee pain, it is common practice to perform an MRI scan of the knee. This imaging modality has revolutionised our ability to identify structural change within the knee. >>

36th Edinburgh International Trauma Symposium and Instructional Trauma Course 16th to 30th August 2021

IN VIEW OF THE COVID PANDEMIC, THE PROGRAMME WILL ONCE AGAIN BE RUN ENTIRELY ON-LINE FOR 2021.

The Symposium will not be held as a physical meeting in Edinburgh in August this year. Instead, we intend to deliver the same high quality education via our website on a virtual platform as we did in August 2020.

As usual, there will be an Instructional Course aimed at trainees and those requiring an over-view and update in orthopaedic trauma, running in parallel with the Trauma Symposium, aimed at established surgeons interested in recent developments, debates, and controversies.

HIGHLIGHTS OF THESE COURSES INCLUDE:

• An experienced and enthusiastic faculty of national and international experts.

• Our programme of Instructional and Symposium talks, available to watch whenever convenient.

• Live, interactive, case-based discussion sessions run daily during the fortnight of 16th-30th August 2021.

• Additional material including cadaveric dissections of surgical approaches and techniques.

EARLY BIRD DISCOUNT AVAILABLE, BOOK BEFORE 31ST MAY 2021

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

SPONSORED BY

The Orthopaedic Trauma Society

www.trauma.co.uk symposium@trauma.co.uk.

Subspecialty

However, care is required in correlating the presence of a meniscal tear to the pain that patients endure. It seems in many cases the tear is part of a process within the knee commonly called ‘degeneration’ and the onset of pain is part of a wider clinical condition rather than specifically related to the meniscal tear. This explains why in the majority of cases symptoms settle without any surgical intervention. In some cases, symptoms persist for longer periods. It is important to exclude other less common diagnoses (e.g. patellar tendonitis, osteonecrosis, osteochondritis dissecans) and to assess if the patient has a more specific diagnosis of osteoarthritis. In these cases, focused treatment for the specific diagnosis is required and in established osteoarthritis there is good evidence that arthroscopic meniscectomy is of very limited benefit. This process of assessment identifies a subgroup of patients with residual symptoms who have a meniscal tear. Careful assessment of the pattern of meniscal tear is required at this stage to determine if there is unstable

meniscal tissue lying in an abnormal position within the knee4. The clearest example of this pattern of tear is a displaced fragment of meniscal tissue that has flipped under the medial collateral ligament, and often is very tender to palpate. It is in these cases there is evidence that targeted arthroscopic meniscectomy can be a useful intervention.

meniscectomy surgery offered to patients using a non-specific approach has been shown not to be beneficial5. In addition, arthroscopic surgery, including meniscectomy, in the presence of advanced osteoarthritis has also been shown to be ineffective. As an alternative treatment nonoperative method have been shown to be are effective in both these clinical situations6.

The emergence of clear evidence is already reducing the number of arthroscopic meniscectomy procedures performed in the UK, which is to be encouraged. However more recently some have argued that the current evidence available suggests that arthroscopic meniscectomy should have no real role in managing patients. Certainly, its use to treat all meniscal tears associated with knee pain cannot be supported. However, systematic review of the evidence suggests that in some groups the procedure can be beneficial, particularly in the case where symptoms persist and the MRI scan identifies a displaced meniscal tear that appears to correlates to clinical history and examination7. In these cases, at the point where non-operative treatment has failed to resolve symptoms, arthroscopic meniscectomy can be offered to patients as a potential alternative to further non-operative Recommendation care. This is the basis for the BASK Clinical Guideline. This approach Urgent Arthroscopic Meniscal Surgery to encourage the use of targeted meniscectomy has been supported by Consider Arthroscopic Meniscal Repair surgeons within and (if suitable candidate) outside the UK8.

“Historically arthroscopic meniscectomy was applied in a relatively non-specific manner to patients with knee pain and any form of meniscal tear. This approach was responsible for the dramatic increase in the number of patients receiving arthroscopic meniscectomy. There is now very compelling evidence to support a more cautious approach to offering meniscectomy to patients.”

Historically arthroscopic meniscectomy was applied in a relatively non-specific manner to patients with knee pain and any form of meniscal tear. This approach was responsible for the dramatic increase in the number of patients receiving arthroscopic meniscectomy.

There is now very compelling evidence to support a more cautious approach to offering meniscectomy to patients. Arthroscopic

BASK Meniscal Tear Management Guideline Common Clinical Presentations

1

Integrated Assessment

3

History

Symptoms, Duration

Examination Signs

Imaging

2

Meniscal Tear

(+/- osteoarthritis)

Per imaging protocol (overleaf): X-ray and/or MRI

Locked Knee Assessment: Arthroscopic meniscal surgery indicated Acute Injury with Meniscal Target (MRI) Assessment: Meniscal preservation may be appropriate Meniscal Target (MRI) & Corresponding Symptoms / Signs

Assessment: Arthroscopic meniscal surgery may be beneficial after a trial of non-surgical treatment

4

Possible Meniscal Target (MRI) & Corresponding Symptoms / Signs Assessment: Further non-surgical treatment is first line

Symptoms > 3 months

Symptoms < 3 months

Consider Non-Urgent Arthroscopic Partial Meniscectomy

Optimal Non-Operative Treatment & Re-Assess (e.g. provide information, physiotherapy, exercise, analgesia, steroid injection)

(Arthroscopic meniscal surgery may be indicated in selected cases if symptoms do not improve – to be decided on reassessment)

No Meniscal Tear

[Alternative Treatment Pathways]

5

Advanced Structural OA & Meniscal Tear (or Arthritic Symptoms / Signs only) Assessment: Arthroscopic meniscal surgery usually* not appropriate

(*except in uncommon special cases: a second opinion is advised)

No Arthroscopic Meniscal Surgery (Provide information and consider physiotherapy, exercise, analgesia, weight loss, steroid injection, arthroplasty, osteotomy)

NB. Patient treatment preferences must always be considered.

This guideline document should support, not substitute for, shared decision-making.

Figure 1: The British Association for Knee Surgery Meniscal Tear Management Guideline1.

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The targeted approach outlined by BASK guidelines is a real attempt to create a framework for treatment that protects patients from unnecessary surgery whilst allowing the subgroup of patients who may benefit continued access to care. The process should be supported by robust decision support so that patients can make an informed decision about surgical intervention as a treatment option for them. The Academy of Medical Royal Colleges, working in collaboration

Subspecialty

with NHS England and the National Institute for Heath and Care recently published Evidence Based Intervention clinal guidance for the use of arthroscopic menisectomy9. Their guidance supports the use of the BASK Clinical Guideline and the targeted approach captured within it. This approach should be adopted across the NHS by health care professionals involved in treating patients. In due course commissioning groups should insist that the guidance is adopted to drive change.

Despite the number of trials now performed there still remains uncertainty around the true efficacy of arthroscopic meniscectomy in

certain groups and there is further need for further research. More specifically a trial using contemporary indications as laid out in the BASK clinical guidelines is a critical next step. However, it must be remembered that the findings from trials cannot represent all patient specific clinical presentations and this must be reflected when developing guidelines for care. Most importantly the BASK clinical guidelines must be applied in the framework of shareddecision making, where interventions are offered to patients in a balanced way outlining the benefits and risks of all treatment options available.

Our increasing focus on evidence medicine will raise the standards of care that we offer our patients. Evidence based clinical guidelines have a critical role in changing established practice protecting patients from unnecessary surgery and allowing access to the option of surgical care where benefit exists. The changes occurring in the current practice of arthroscopic meniscectomy are a good example of this process. n

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

Take home messages •

The BASK Clinical Guidelines for meniscal surgery provide an evidence-based approach for managing patients.

•

These guidelines have been adopted by the Evidence Based Intervention program developed by The Academy of Medical Royal Colleges working with NHS England and the National Institute for Heath and Care.

•

Widespread adoption of these evidence-based guidelines will reduce unnecessary surgery through targeting arthroscopic meniscectomy as a treatment option for those patients who may benefit.

•

The guidelines should be used in the context of shared decision making, where patients are fully informed of their treatment options.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 49

Subspecialty

David Johnson is a Consultant orthopaedic surgeon at Stockport NHS Foundation Trust, and is an Honorary Professor at the University of Salford. His clinical practice is within knee surgery including soft tissue, arthroplasty, and patellofemoral joint problems.

His research focuses on the assessment of outcomes following knee surgery.

Management of the first-time lateral patellar dislocation: Improving care across the UK David Sands Johnson and Andrew John Metcalfe

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 including soft tissue, arthroplasty, and patellofemoral joint problems. His research focuses on the effectiveness of orthopaedic interventions and randomised trials.

Lateral patellar dislocation is a common condition that Trauma and Orthopaedic units manage on a regular basis. There is paucity of information in the literature about the best way to manage both first-time and recurrent dislocation, with increasing evidence showing a wide variation in management between treating clinicians and units. This issue was identified by the British Patellofemoral Society (BPFS) and the British Association for Surgery of the Knee (BASK) Patellofemoral working group, following a presentation at the BASK Annual Conference in 2018 which was subsequently published1.

F

ollowing discussion the BPFS and the BASK Patellofemoral working group created a project to assess the evidence, with a view to creating standards of care to be published within a British Orthopaedic Association for Standards in Trauma and Orthopaedics (BOAST) guideline. In addition, it was identified as a key area for future research to be prioritised and acted upon.

Current management and treatment Lateral patellar dislocation has a peak incidence in the second decade of up to 43 cases per 100,000. Recurrence is frequent and greatest

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in those who have anatomical abnormalities (especially patella alta or trochlear dysplasia) and/or joint hyperlaxity, although quoted rates vary from 10 – 50%. Up to 70% have some sort of ongoing symptoms such as subjective instability or pain. Those at risk of recurrence at first presentation include those younger than 18 years, females, those with a previous contralateral dislocation or family history of dislocation and those with associated developmental abnormalities. Operative intervention is recommended for some associated injuries, but there is much debate about whether primary stabilisation surgery should be undertaken or not. It is generally felt that although there is a high recurrence rate, as with ACL injuries,

Subspecialty

many patients do not require stabilisation, so surgical stabilisation should be reserved for recurrent instability. When undertaken it is important that the appropriate procedure be performed, following appropriate assessment. Guidance on the assessment and surgical management of recurrent patellar instability has already been published within two BOASTs produced in association with BASK and the BPFS2,3.

For conservative treatment of first-time dislocation, more is understood but variation in practice is wide with some therapies in use that may be outdated or even harmful.

Creating guidance for the future

care. The approach used to promote good practice is to develop a BOAST for first-time lateral patellar dislocation. The Society felt it important that the guidance be created by as inclusive a group as possible, covering a range of disciplines, rather than a small working group. As a result, following publication of a summary of the literature1, a series of ten questions were created to be asked of the membership of the BPFS. These were posed, in four break out groups, to the 102 delegates attending the First BPFS meeting in January 2020. The delegates included orthopaedic surgeons, physiotherapists and musculoskeletal radiologists. Aside from the clinical questions posed it became clear that there was a need to develop guidance that could be applied in any healthcare setting, providing a route to

“Lateral patellar dislocation has a peak incidence in the second decade of up to 43 cases per 100,000. Recurrence is frequent and greatest in those who have anatomical abnormalities (especially patella alta or trochlear dysplasia) and/or joint hyperlaxity, although quoted rates vary from 10 – 50%.”

Both the BFPS and BASK are keen that more uniform treatment is delivered for patients with a first-time patellar dislocation, so that they can achieve a good outcome without compromising future

delivery of best care. Also it was felt that the guidelines should be written in such a way that the standards could easily be audited, and results used to help clinicians change protocols / services to improve practice. Following this a draft BOAST was created with each and every item debated with the 17 attendees at the BPFS committee meeting held in November 2020. A revised document is currently being finalised for consultation with the 200+ members of the BPFS (although the consultation is open to non-members who wish to provide their input) prior to submission to the BOA for publication during 2021.

Proposed best practice Following the process above, the new BOAST will outline both how patients should be assessed and initially treated after a first-time patellar dislocation. The guidelines will set standards for service requirements to deliver these standards, but leaves the organisation of this to the implementing unit. This is on the understanding that the facilities available across the country vary widely depending on geography, funding and organisational history.

The guidelines also promote practice that will enable rapid diagnosis of associated injuries, along with guidance for their management.

It will be recommended that most patients >>

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 51

Subspecialty

will be treated conservatively, with proposals that move away from historical treatments, such as cast immobilisation, that are known to delay recovery. Surgical treatment will be recommended for a limited range of conditions, such as displaced osteochondral fractures. There will be emphasis on abandoning the use of an isolated lateral release which has no place in the management of this condition.

Future research In creating the guidance, the BPFS and the BASK Patellofemoral working group fully acknowledges that there are significant gaps in the literature. The BPFS plans to review where this knowledge is lacking and proposes to work collaboratively to set up studies, which will ultimately change practice to be reflected in future editions of the BOAST. As a result, the current BOAST proposed will be the first version of many to come.

Conclusion First-time patellar dislocation is a common condition that can present to any Trauma and Orthopaedic unit. Although treated well at most units, significant variation still exists

52 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

in management of this condition, especially with respect to non-operative interventions.

The BPFS is creating a BOAST to help guide clinicians as to best practice. The process used to develop the guidelines has been as inclusive as possible with multi-disciplinary involvement. The Society acknowledges the wide gaps in evidence for best practice and will promote research to answer questions that will ultimately be contained within future revisions of the BOAST. n

References 1. Johnson DS, Turner PG. Management of the first-time lateral patellar dislocation. Knee.

2019;26(6):1161-5.

2. British Orthopaedic Association (2020).

The Assessment of Patients with Recurrent Patellar Instability. Available from: www.boa.ac.uk/resources/ assessment-of-patients-with-recurrentpatellar-instability.html.

3. British Orthopaedic Association (2020).

The Surgical Management of Recurrent Patellar Instability. Available from: www. boa.ac.uk/resources/surgical-managementof-recurrent-patellar-instability.html.

Take home messages • Lateral patellar dislocation is a common presentation to T&O departments, but treatment is variable around the UK. • The BPFS and BASK are working together to create guidelines using the same evidence-based consensus approach that they used for the recurrent dislocation BOASTs. • Guidelines will have broad multidisciplinary involvement, with a national consultation period to review them before submission.

• Most people with first time patellar dislocations do not need surgery, and isolated lateral release is never indicated, but clinicians should be aware of the possibility of osteochondral fractures after dislocation.

Sodium Hyaluronate 0.5%

Don't Let Day-Case become “Stay-Case” VISCOSEAL®: Reduces Analgesic Requirement, Speeds Discharge Time and Improves Function Following Arthroscopic Surgery A randomised, prospective, controlled trial assessed the effect of Viscoseal on the short-term outcomes following shoulder arthroscopy.1 58 adult patients undergoing arthroscopic subacromial decompression were randomised into two groups. The first group received 10 mls of Viscoseal and 10 mls of 0.5% bupivacaine (local anaesthetic) injected into the subacromial bursa via the arthroscope at completion of the procedure (n=28). The control group received 20 mls of 0.5% bupivacaine only (n=30). 

The time to discharge from hospital for the Viscoseal group was 5.2 hours +/-13 +/- hours, and for the control group 9.6 +/- 5.3 hours. This was significantly earlier for the Viscoseal group (p = 0/0001).



The Viscoseal group experienced less severe pain 4 hours post-operatively than the control group, with 3.5% of the Viscoseal group experiencing severe pain compared with 23% of the control group. 29% of the patients in the Viscoseal group felt no pain at 4 hours post-operatively, while none of the patients in the control group were pain free at the same time point.

 The Viscoseal group also required less analgesia post-operatively than the control group. 25% of the Viscoseal required no analgesia, whilst all patients in the control group required analgesia. 33.3% of the control group required opiates compared with 10.7% in the Viscoseal group (Fig. 1).

In a single-center, prospective, randomized, controlled study2 aiming to evaluate the effect of a single immediate postoperative instillation of 10 mL of sodium hyaluronate (Viscoseal) into the knee following arthroscopy, 48 patients were randomized into two groups of 24. 

The study group received 10 mls of sodium hyaluronate intra-articularly, while the control group received an intra-articular instillation of 10 mL of Bupivacaine. Pre- and postoperative visual analogue scale scores for pain and WOMAC scores for knee function were obtained (Fig. 2).



Intra-articular infiltration of Viscoseal following arthroscopic knee surgery conferred significantly improved pain relief and function in the short term postoperative period (3 to 6 weeks) compared with Bupivacaine. compa



There was a statistically significant difference in pain scores favoring the study group compared with the control group at 3 and 6 weeks postoperatively (p < 0.05), and a statistically significant difference in WOMAC scores favoring the study group compared with the control group at 3 and 6 weeks postoperatively (p = 0.01).

1 Funk L, Wykes PR. Osteoarthritis Cartilage. 2004;12(Suppl B):S126 2 Anand S, et al. Effect of Sodium Hyaluronate on Recovery after Arthroscopic Knee Surgery; J Knee Surg 2016;29:502–509.

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Subspecialty

Is ACL repair possible?

Stephen McDonnell and Senthooran Kanthasamy

ACL repair is one of the surgical techniques that has reinvented itself on a generational basis. Its origins go back to MayoRobson in 1895 where he successfully treated a knee injury in a miner by stitching back the avulsed cruciate ligament with success and good functional outcome.

Stephen McDonnell is a University Lecturer and Honorary Consultant Knee and Hip Surgeon. His research interests are aimed at the identification and stratification of patients with early knee osteoarthritis, and defining their phenotypic features.

S

ince this time however, enthusiasm has come and gone with the acquired dogma that “the ACL cannot be repaired”. More recently, there has been a resurgence of interest again in some emerging literature that it ‘may’ be repairable in a small subgroup of patients. The discussion is therefore focused on who, when and how it may be possible to repair, whether it would have healed anyway, and if there is any evidence to support this procedure.

Why bother to look at the potential of ACL repair again?

Senthooran Kanthasamy is a Research Fellow and Honorary Specialist Registrar at The University of Cambridge. He is currently looking at both the acute biochemical changes to the knee and the differences in radiological imaging using standard 3T MRI and ultra-high field 7T MRI during acute ACL injuries.

54 | JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk

Not all knee injuries are the same, and therefore, individualised treatment strategies may offer the best outcome for patients. It is clear from the time of injury, clinical examination, degree of instability and damage to other structures, with concomitant ACL injuries that the tear type and tissue quality are important factors.

“Not all knee injuries are the same, and therefore, individualised treatment strategies may offer the best outcome for patients. It is clear from the time of injury, clinical examination, degree of instability and damage to other structures, with concomitant ACL injuries that the tear type and tissue quality are important factors.”

A lot has changed since John Feagin’s study in 1972 on the outcomes of ACL repair1. This includes the advent of MRI, allowing for stratification of patients by tear type. There are distinct patterns of tear (as classified

by Sherman et al.2) from proximal tears where the ACL is avulsed at its attachment to the medial wall of the lateral femoral condyle, to lower more disruptive mid substance tears (Figure 1).

Retrospective review of MRI scans suggested that 43% may be proximal enough to allow repair3.

Arthroscopic soft tissue techniques, visualisation, instruments, and fixation devices have also developed significantly after the last 40 years, thanks to the crossover of techniques used in arthroscopic shoulder surgery.

The degree of damage is an important factor in assessing the potential for repair of the ligament.

In some tears, there is minimal damage to the bundles of the ACL and preservation of the synovial sheath. This contrasts with others where there is significant disruption and loss of the inherent fibrillar and macroscopic structure of the ligament4. Time since injury has also been found to be an important factor, with the potential for successful repair decreasing as time from the injury increases. This goes against the current accepted practice of waiting until the knee has completely settled before embarking on surgical intervention.

ACL injuries are on the rise, particularly in young active teenagers and 20-year-olds.

These are potentially high-risk patients who have increased re-rupture rates which may potentially lead to symptomatic degenerative changes at a young age.

Subspecialty

with a specific extracellular matrix placed in the gap between the torn ends to facilitate ligament healing.

This research programme was undertaken

by Martha Murray in Boston. The results of this phase 3 study in which the BEAR procedure is compared against hamstring ACL reconstructions as part of the RTT is currently underway, and early results have been encouraging8, with the BEAR implant receiving recent FDA approval.

Figure 1: A: Acute femoral avulsion ACL injury. B: Healed ACL (not repaired) at arthroscopic assessment in the same patient - six months after injury.

Figure 2: Four examples of methods for repairing anterior cruciate ligament tears: A: Primary repair using internal brace (Arthrex®).

B: Primary repair using Brunel suture and anchors (Arthrex®).

C: Dynamic Internal Stabilisation system Ligamys™ (Mathys®).

D: BEAR Bridge-Enhanced ACL repair (MIACH Orthopaedics, Inc.®).

ACL reconstruction has become the gold standard with successful outcomes in the majority of patients. It is often the case that there is a significant amount of preserved ligament seen within the joint which could be utilised and is excised during the procedure. This contains blood and proprioceptive fibres which may aid a healing response and be potentially repairable in some cases whilst maintaining the proprioceptive mechanisms important for knee stability.

With a move towards more personalised surgery and individualisation of treatment pathways, ‘one size does not fit all’, and this may allow new or redefined techniques to find a place within the scope of practice of the soft tissue knee surgeon. This has been seen with ligament stump preservation and the lateral sided augmentation procedures, which had been lost for a generation, and has now gained traction, following a reappraisal of the anatomy and modification of surgical techniques with trial evidence supporting their use in subset of high-risk patients5.

Techniques being used for ACL repair Different techniques for repair have emerged over the last few years (Figure 2). Some use the principle of attaching the avulsed proximal ligament back to the lateral wall ‘primary repair’ with differing fixation techniques.

The re-attachment has been through the use of bone anchors and a Bunnell suture within the ligament (DiFelice et al.6) or a pull up stirrup/ cinch stitch tightened over a suspensory device on the lateral cortex (MacKay et al.7). Other devices allow micro-motion of the repair construct using a spring bolt mechanism (Ligamys™).

An alternative technique, which has been undertaken in a different subgroup of patients with all tear types included is the BEAR (Bridge-Enhanced ACL Repair). The BEAR procedure combines a suture repair of the ACL

Surgical techniques for ACL repair may have improved, but so has the threshold of evidence required to undertake new and adapted surgical techniques. In order for ACL repair to have a future, small cohorts of successful patients are not enough. The systematic reviews to date have led to the conclusion that there is a deficiency in the evidence. The technique needs to be assessed against the IDEAL framework (Idea, Development, Exploration, Assessment, Long-term Follow-up, Improving the Quality of Research in Surgery) of surgical interventions. Thorough assessment of the technique is required before adopting these into routine clinical practice, and this needs to include an economic assessment of costs and QALY benefit.

Early assessment and stratifications of patients with acute knee injuries has already started, with the advent of Acute Knee Clinics.

These specialist clinics, as recommended within the BOAST guidelines, will allow early triage, assessment, imaging, and stratification, which may produce a sub-group of patients who would benefit from early intervention and consideration of ACL repair.

Further work is hoped towards validating this technique and early stratified intervention in acute knee injuries, with an NIHR clinical trial. n

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

Take home messages • Anterior cruciate ligament rupture is commonly treated with ligament reconstruction, but repair may be possible is a small sub-group of patients.

• Repair involves preservation of ACL tissue with primary repair soon after injury may, avoiding reconstruction with graft tissue.

• Surgical techniques for ACL repair have been improved benefitting from new technology and advances in arthroscopic methods.

• New evidence is required to investigate the efficacy of modern repair and a UK based trial of ACL repair is eagerly awaited.

JTO | Volume 09 | Issue 01 | March 2021 | boa.ac.uk | 55

In Memoriam

On behalf of the BOA and the JTO, I apologise for the unpardonable error that occurred in the last edition of the JTO with respect to the obituary for John Ireland. The final two lines of the printed text referred to another BOA member and to his obituary, not to John Ireland. We are very sorry for the upset our error has caused the family and all who knew him and we appreciate that these words of apology will not heal, but we hope they may help.

Deborah Eastwood Editor, JTO

John Ireland

14 July 1942 – 16 May 2019 Obituary by David Ireland and Richard Parkinson

J

ohn Ireland was one of the leading knee surgeons of his era.

Among his surgical colleagues he was respected as a fine clinician and surgeon and the author of valuable and practical research on many aspects of knee surgery. His long-lasting care for his patients inspired affection and loyalty and a large number of amateur and professional sportsmen have been able to resume their sport at the highest level after his surgical interventions.

John Ireland was born in 1942, close to the RAF station where his father, an oral surgeon, was helping to treat the many pilots injured during the course of the war. After moving to East Grinstead, the family returned to its Suffolk roots at Ipswich where John was a fine middle distance and cross country runner. John trained in medicine at Westminster Hospital Medical School and from his early days he displayed an adventurous spirit and a desire to learn. His first House Job was on the orthopaedic firm, working for H. E. ‘Ding’ Harding, who became a mentor and friend. He did his student elective in France and returned to England with valuable surgical experience and with the ability to speak good French.

After qualification he sailed around the world as ship’s surgeon aboard the Ocean Liner Canberra before becoming a registrar at the Hillingdon Hospital in Middlesex, where he met his future wife Shahla, an SHO. He applied for, and was appointed to be a registrar on the orthopaedic training programme at the Royal National Orthopaedic Hospital, but had already arranged a post as the general surgeon to a hospital in Papua New Guinea, and was surprised and delighted that the RNOH agreed to delay his start there for six months. He worked on all the firms in the various sub-specialties, but it was working on the knee, especially for the late Lorden Trickey, that he found his particular interest.

His first consultant job was at the King George Hospital in Ilford where he increasingly specialised in surgery of the knee. He travelled extensively and pursued a relentless drive to achieve the highest possible standards in his surgical practice.

After thirteen years at King George’s when promised funding for a knee unit did not materialise, he left the NHS and worked solely in private practice, almost exclusively at the Holly House Hospital.

There he raised funds to employ a Knee Fellow, and for fourteen years there was an orthopaedic registrar rotation between Holly House and Newham, in the NHS, part-funded by Johnson and Johnson.

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Aside from work and family life, golf was his life’s passion.

He played whenever he could and set up the New Knee Golf Society, for players of golf of any standard who had undergone knee replacement surgery. Meetings were held at clubs from the West Country to the far north, with John organising tirelessly, setting up funding, and, attending meetings up and down the country to present prizes and encouraging new members to join.

This was a wonderful way to get post-operative patients back to normal life and fitness.

His love of chamber music was also a constant throughout his life. At every concert he attended he would be in the front row, pen poised, to write constructive notes and critiques of any performance. His characteristic handwriting reflected the man – bold and distinctive, yet at the same time, careful and precise.

The joy that he took in hand-written correspondence was the reason for his preference for the fax and letter over the meaningless impersonality of the email.

In 1978 John founded the Sesamoid Society, an orthopaedic travelling club, with a handful of orthopaedic registrars. The Society met every six months and recently held its seventy-ninth meeting. This was only the second meeting that John and Shahla failed to attend, due to John’s illness. John was also a founder member of the British Association for Surgery of the Knee.

Generous and tireless in helping others, John will be long remembered in the orthopaedic community for his surgical expertise, his distinctive style, his passion for golf, and his kindness. He bore his final illness with grace and courage.

He leaves his wife Shahla, two sons and a daughter. n

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