Journal of Trauma & Orthopaedics - Vol 9 / Iss 3

Journal of Trauma and Orthopaedics Volume 09 | Issue 03 | September 2021 | The Journal of the British Orthopaedic Association | boa.ac.uk

t a F F2 A in O B e th rdeen Abe

Science may never come up with a better communication system than the coffee break Waiting for the knife – orthopaedic surgery in the time of COVID-19 p32

Future Leaders Programme – Why leadership matters p40

Top 10 tips to avoid periprosthetic joint infection p60

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3

From the Executive Editor

5

From the President

Deborah Eastwood Bob Handley

6-9 BOA Latest News 10 News: 2020 Honorary Fellowships

and Presidential Merit Award

12 News: BOA Annual Congress 2021 20 News: Conference Listing 2021/22 22 Features:

The orthopaedic ostrich: surgeons’ responses to complications Deepa Bose

26 Features:

National Selection to T&O ST3 posts in England 2020 & 2021 Mark AA Crowther

28 Features:

Post-COVID-19 trauma care: The end of the new patient trauma clinic?

Ian Crowther, Nick Kalson and Simon Chambers

32 Features:

Waiting for the knife – orthopaedic surgery in the time of COVID-19 Bibhas Roy and James Wilson

36 Education:

BOFAS ‘Lectures of Distinction’: Experience and lessons learned from the launch of a National Virtual Educational Programme in foot and ankle surgery Yaser Ghani, Tim Williams, Robert Clayton and Rick Brown

54

40 Education:

Future Leaders Programme – Why leadership matters Hiro Tanaka and Lisa Hadfield-Law

44 Features:

Reflections of an octogenarian skeletal trauma surgeon Christopher Colton

48 Trainee:

Tourniquet safety – case report and national survey: Tourniquets in Orthopaedic Practice Study (TOPS) Caesar Wek, Alice Wales, Jonathan C Compson and Ines LH Reichert

54 Medico-legal:

Drilling down into orthopaedic claims Gemma Taylor and Andy Norman

56 International:

Education and training in orthopaedic oncology in Ethiopia; CURE & Black Lion COSECSA course Max Gibbons

60 Subspecialty:

Top 10 tips to avoid periprosthetic joint infection Graham S Goh and Javad Parvizi

62 Subspecialty:

Investigation of Prosthetic Joint Infection of the Knee – The Exeter approach to this challenging condition Jonathan Phillips, Ben Waterson, Andrew Toms and Keith Eyres

66 Subspecialty:

The Bone and Joint Infection Registry (BAJIR) and its role in supporting the Bone and Joint Infection MDT in our institution Michael Petrie and Pedro Foguet

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.

Open Box Media & Communications are proud to be corporate sponsors of Heart Research UK (Midlands)

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

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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) Rhidian Morgan-Jones (Guest Editor)

BOA Executive l Bob Handley (President) l Don McBride

(Immediate Past President) l John Skinner

(Vice President) l Deborah Eastwood (Vice President Elect)

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Programmes and Committees Officer

- Harriet Wollaston

l Mark Bowditch (Honorary Treasurer)

Educational Programmes Assistant

l Simon Hodkinson (Honorary Secretary)

Education and Careers Manager

l Phil Turner

BOA Elected Trustees l Bob Handley (President)

- Eliza Khalid

- Alice Coburn

Communications and Operations Director of Communications and Operations

- Annette Heninger

l Don McBride

(Immediate Past President)

Marketing and Communications Officer

l John Skinner

(Vice President)

Membership and Governance Officer

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

- Sabrina Nicholson

- 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 Events Coordinator - Anna Prunty 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, 38-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507

From the Executive Editor Deborah Eastwood

T

o quote the first two lines of a song from my youth “I’m so excited, I just can’t hide it” – international travel, F2F science and gossip, coffee and perhaps some other beverages all coming soon for a North London Orthopod. But... after the 18 months we have just had, even I will admit to being a bit apprehensive at this next step towards my old normality.

Much of this edition of the JTO relates to a new normality and the end of old familiar concepts – the trauma clinic perhaps (page 28), revamping how we look at our waiting lists (page 32) and how we select (page 26) and educate (page 36) our trainees and ourselves. All these articles involve leadership and Hiro and Lisa discuss the FLP and why leadership matters to all of us (page 40).

Like all our patients, we want and need to avoid complications at all costs. The medico-legal article (page 54) reminds us that 50% of claims relate to post-operative problems and if problems do occur, Deepa Bose’s Robert Jones prize winning essay advises us not to behave like an ostrich in either burying our head in the sand or running away fast! With this in mind, it was sobering to realise that when asked about tourniquet use and safety – a survey said that only 10% of respondents felt they had been trained in their use whilst 37% had observed a complication (page 48). The BOAST on ‘The Safe Use of Intraoperative Tourniquets’ is published this month.

The subspecialty articles on periprosthetic infection, (page 60 onwards) give us some ‘top tips’ on avoiding complications and demonstrate that if you can’t avoid them you can deal with them – by being expert at what you do!

Two articles gave me personal pleasure: many years ago, after my first registrar presentation at a BOA meeting, Chris Colton made a particular point of coming to find me to congratulate me – perhaps simply a minor detour on his way to coffee in his mind – but to me, a major event and one that I have tried to pass onwards to the next generation of trainees. Reading his reflections on life and trauma surgery was fun!

Secondly, the award of the Presidential Medal to Julia Trusler – a real star of the BOA ‘show’ and one who has made all our lives easier – a richly deserved honour and I look forward to celebrating her success with her and the team in our new offices very soon.

With the start of the new school year imminent, it is perhaps a time to look forward too – so this edition contains an article from Bob – his last as President, and from John, as incoming President. To quote another song – the “times they are a-changin”!

I hope to see many of you in Aberdeen for the BOA meeting and if you would like to help us with the work we do, why not get involved (page 8) and apply for one of the positions up for election? n

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 03

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From the President

To rally or to be rallied Bob Handley

Back to normal? I don’t think so. Congress will as usual be an opportunity to update knowledge and meet friends and this year has what is now the added novelty of speaking without having to remember to unmute. However, this year there is also the burden of events. The pandemic has exposed the strengths and frailties of our health service. In T&O we have to continue to tackle our acute work whilst retaking the lost ground of the elective front. This is no small task and requires leadership, is it for us to do the rallying or do we wait to be rallied?

“C

aring for patients, supporting surgeons” is never a bad foundation when considering how to approach a T&O problem from a BOA perspective, and I believe it is now more pertinent than ever. To care for patients we surgeons do need support. In his article Chris Colton describes T&O as “scientific art”, others label it a “craft specialty”, whatever the terminology it is a fact that for patients to benefit from modern T&O surgery we need sufficient trained hands to be available as well as sufficient facilities, allied professionals and time. The necessary support and the time will largely be dictated by others, it is the availability of surgical workforce which is our direct concern. Efficiency and innovation will gain us some ground but it is fanciful to believe stemming the rising tide of the waiting lists can be achieved without a sustained increase in hard work. So just who will do all this work? It takes little imagination to see that there is the potential for problems at each stage of the Consultant career pathway. Will those of us in the current surgical workforce be prepared to put in more hours, or will pension uncertainty and work/life balance pressures discourage us? Will there be a welcome increase in the size of our workforce from an enthusiastic cohort of newly CCT’d trainees, or will the decrease in logbook cases delay the completion of their training? Will the pandemic lead the more senior among us to delay or accelerate our retirement plans? In an attempt to better understand each of these and what impending storm may await us, we have recently surveyed BOA members.

So to rally or to be rallied? I think both are needed. I shall aim to stand behind the podium at Congress intending to display all the gravitas of Ian McKellen rousing Middle Earth, and we all need to be positive with our own teams.

However, our Politicians, National NHS leaders and our Trusts need to be aware that they not only need to provide material sustenance for the health system but also rally the ‘Hearts and Minds’ of their workforce of which we with our ‘craft speciality’ hands are a vital component. The results of the BOA members survey will be presented at Congress. These results will inform both us and others to aid in plotting a course out of the backlog which hangs over us.

Whoever is rallying, communication and openness are necessary to make us all feel involved and empowered. How to best maintain good communication is a challenge, but a glance around any theatre coffee room leads me to believe that the best route to anyone’s mind is through their phone; it seems more likely a message will be received if it arrives electronically rather than by actually speaking. Enter the new BOA App; which is now no longer confined to the Congress week alone but an ever present portal to updates, the website and more. Install it on your front page.

It has been an unusual year to be BOA President, but a rewarding one.

The desire of colleagues in the workplace and the committee zooms to do their best for patients is undimmed. To deliver on this we need not just material things, but also to nurture group morale and have our group morale nurtured. On reading the contents of this edition of JTO it is quite apparent that we are an exemplary group of which to be member. If only in the last year I had ever met anyone to receive the BOA Presidential medal of office I would have worn it with great pride. Thank you. n JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 05

Latest News

Incoming President – John Skinner It really is the greatest privilege to be elected President of the British Orthopaedic Association and this is clearly a year where Trauma and Orthopaedic surgery matters more than ever. The world remains unsettled as we traverse from the COVID-19 pandemic to it becoming endemic and we all learn to live with the SARS-CoV-2 virus. COVID has affected every one of us in different ways and we now need to restore our surgical services to the level that our patients deserve and so clearly need.

It is our patients who have suffered most. At a time when healthcare resources were diverted to treating this new and relentless disease, elective surgery was curtailed and waiting lists increased. With surgical and specifically orthopaedic surgery waiting lists at unprecedented levels, we now need to work together to solve one of the greatest challenges that the NHS has ever faced. Elective surgery is not optional, and these patients really need their operations. Orthopaedic surgeons are highly skilled, hardworking and resourceful and I know that between us we will find a way to prevail for the good of our patients.

It is important that we leave the profession in safe hands and ideally in a better place better than we found it. Our trainees have had an extremely difficult time during the pandemic and feel frustrated that they have not gained the surgical experience that they need.

So much surgery was cancelled in the last 18 months. They have responded admirably in the crisis showing themselves to be resilient, flexible, team workers who are willing and able to respond to the greatest clinical need. Orthopaedic surgery still attracts the brightest and best trainees, and we now need to look after them more than ever, teach and guide them and get them operating again to enable them to hone their surgical skills and reach their potential. We need well trained, dynamic young Consultant colleagues now, more than ever before.

At a time when our patients really need us, this is a time when the NHS is listening. The BOA Leadership team will do everything in our power to influence those charged with NHS institutional and systems leadership, to provide the most effective and efficient environment in which we can deliver our extensive responsibility for our patients. Most of us overestimate what we can achieve in a day while underestimating what we can achieve in a year. I am very much looking forward to meeting up with as many members and Fellows as possible at this year’s Congress in Aberdeen. I am always happy to hear directly from Fellows if I can be of any help. Despite the inevitable challenges ahead, the leadership of your Association will do all that we can in order to continue “Supporting surgeons Caring for patients.” n

Download the new year-round BOA App! Keep up to date with all things BOA straight from your mobile, including: ·Latest News ·BOASTs ·Standards and Guidance ·BOA Annual Congress ·and much more!

Find out more at www.boa.ac.uk/boa-app Search for ‘British Orthopaedic Association’ on the Apple App Store or Google Play 06 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

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Get involved at the BOA! The BOA is now holding its latest round of recruitment for a variety of different committee roles. This is your chance to use your skills and expertise to influence and input into the work of the BOA. If you have an interest in trauma and orthopaedics that you would like to pursue further as part of your national specialty body, the BOA needs you! We have exciting opportunities for BOA members who are Home Fellows or SAS surgeons to represent, lead and effect change across the trauma and orthopaedic profession.

Surveys on workforce, career intentions and waiting lists In July we ran two important surveys of the BOA membership and wider networks - one survey was of trainees and Post-CCT grades, and one for consultants and SAS surgeons, and both aimed to gain an insight into what the workforce looks like both now and for the future, particularly in the context of significant waiting lists. We have had an excellent response to these surveys, so a huge thank you to everyone who participated.

At the time of this JTO going to press, the analysis is still underway, but do watch out for updates from us on this, which should be ready in time for the BOA Congress.

The BOA is committed to equality of access to a T&O career and to the services of the Association as per our Diversity Strategy we would particularly invite applications from underrepresented groups within the BOA. • Committees Would you like to be involved in the BOA with writing new BOAST guidance? Or help to review how our Research funding is used? We are recruiting for posts in the following four committees: Trauma, Orthopaedic, Research and Medico-legal.

• UKITE Editorial Roles We have vacancies for UKITE Editors across all subspecialty areas. Editors play a key role in the continued success of UKITE by contributing and reviewing questions for the examination. You will gain experience in question authoring, editing and validation processes. Onboarding, support and best-practice guidance are provided throughout.

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

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

I really enjoy being part of the BOA Research Committee. It is a great opportunity to share ideas and learn from some of the most experienced orthopaedic researchers in the UK. Never has it been more important to our patients for us to advance the quantity and adoption of high quality orthopaedic evidence in the UK and to inspire the next generation of orthopaedic researchers. It is an honour to be part of the strategic planning to help facilitate this.

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COVID-19, waiting lists and elective recovery At the time of writing, the UK nations are at varying stages in making final steps to release their respective lockdown rules. Case numbers of COVID are climbing, with hospitalisations also increasing after a slight lag time. The potential impact on elective surgery is as yet unknown; we are aware of certain areas where operating has been scaled back but we are aware of others that are less affected and are pulling out all the stops to keep going to tackle the backlog. All this is in the context of the longest waiting lists that have been seen this century and the urgent need to tackle these in order to deliver much-needed surgery to patients. The BOA is monitoring developments closely and will report further at Congress and on our website on these issues.

08 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

Dame Clare Marx Dame Clare Marx has announced she is stepping down as Chair of the General Medical Council for health reasons. Clare was President of the BOA (2008/2009), and was awarded an Honorary Fellowship of the BOA in 2017. As a well-known member of the T&O community, we know many members will join us in sending very best wishes to her at this time.

New BOASTs published The BOA Trauma Committee has recently published two new BOASTs. • ‘Cervical Spine Clearance in the Trauma Patient’ - has been co-badged by BASS and the BSSR, and defines an early clinical and radiological pathway for patients with suspected cervical spine injury.

• ‘Early Management of the Paediatric Forearm Fracture’ has been co-badged by BSCOS, OTS and the RCEM. This gives guidelines for early closed reduction by manipulation for forearm fractures, to avoid the need for admission and general anaesthesia.

The BOA Orthopaedic Committee is also making final preparations on a new BOAST ‘The Safe Use of Intraoperative Tourniquets’, which will be launched soon.

All BOASTs can be viewed at www.boa.ac.uk/BOASTs.

Latest News

BOA holds ‘Law for orthopaedic surgeons’ course

BOA Virtual Courses The BOA Training Orthopaedic Trainers (TOTs) course and the Training Orthopaedic Educational Trainers course are now running entirely online. Both courses are facilitated by the BOA Educational Advisor Lisa Hadfield-Law. • Training Orthopaedic Trainers (TOTs) Much of the work for TOTs 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) This nine-hour TOES programme is designed to help Educational Supervisors make the necessary changes so that the new T&O curriculum works for them and their trainees. Again it is taught through a mixture of live online sessions as well as personal learning outside of fixed times.

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

In June we ran our first ever course to provide broad coverage of the interface between law and the practice of orthopaedic surgery. It was specifically designed to highlight potential pitfalls in practice from the medico-legal perspective and to help steer surgeons away from potential jeopardy.

Prior to the course day, video lectures on topics such as consent, gross negligence manslaughter and safe social media use were available for six weeks. Then a one-day virtual course day followed, when each faculty member explored their topic with delegates through case discussion and Q&A. This initiative was coordinated by the BOA’s Medico-legal Committee, and has been a great success, with excellent feedback from delegates (100% would recommend to a colleague).

“As a new consultant the course made me feel better prepared for everyday decisions.”

Due to the popularity of this course, we intend to run this again in 2022.

If you are interested, please keep an eye on our emails and courses webpage (www.boa.ac.uk/learning-and-events.html) for confirmed dates, and, in the words of an attendee: “DO IT! You won’t regret it.”

2022 BOA Future Leaders Programme Applications for the next round of the popular Future Leaders Programme are now open and will close at 23:59pm 6th September.

To be eligible to take part in the programme, when the programme begins, you must be either: • A senior trainee (ST8 or above) • A newly appointed consultant (less than 3 years) • An SAS Surgeon (FRCS Tr & Orth) • A post-CCT Surgeon More information on the FLP, the different application routes and how to apply can be found at: www.boa.ac.uk/flp.

UK and Ireland In-Training Examination (UKITE) UKITE 2021 will run from 10th – 17th December 2021. Registrations will open later in the year and all participants should register by 30th November 2021 to access the exam.

BOA trainee members must ensure that their membership subscriptions are up to date to enable them to register for UKITE free of charge. Subscription payments must made no later than 31st October 2021.

Non-BOA members can register for UKITE for a fee of £150. Non-members wishing to join the BOA must apply for membership by the 30th September 2021 to be eligible for free UKITE registration in 2021.

Any participant wishing to register for UKITE 2021 after the registration deadline will attract an additional fee of £50.

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

BOA Travelling Fellowships Applications for the 2021 BOA Travelling Fellowships will launch on 6th September and close 23:59pm 25th October 2021.

Every year, the BOA offers a number of Travelling Fellowships to its members. These fellowships offer a unique opportunity to visit centres of excellence to gain knowledge and experience. Historically we required these fellowships to be undertaken abroad, but we now are also welcoming applications from individuals wishing to visit one or more centres in the UK to give a broader range of options.

More information on the 2021 BOA Travelling Fellowships, including funding, how to apply, and instructions and advice, is on the BOA website at: www.boa.ac.uk/travelling-fellowships.

Queen’s Birthday Honours The BOA would like to congratulate Professor Sir Keith Willett who was knighted in the 2021 Birthday Honours for services to the NHS. Sir Keith has been a transformative clinical leader; as a Consultant trauma surgeon in Oxford, the first National Clinical Director for Trauma for England and latterly a series of high-profile roles at NHS England. For the T&O patients he was a prime mover in the advancement of care of the injured frail and the development of Major Trauma Centres. More generally as Medical Director for Acute Care & Emergency Preparedness with significant responsibilities during the COVID-19 pandemic. Congratulations Sir Keith!

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 09

News

Honorary Fellowships

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

David Beard Having originally qualified as a physiotherapist David Beard returned from an overseas posting in Canada to complete higher degrees at Kings College London (MSc – Biomedical Science) and Oxford University (DPhil – Medicine). After a Senior Lecturer period at the University of Sydney, Australia, he has been Professor of Musculoskeletal and Surgical Science at the University of Oxford (Kellogg College) since 2011.

He has been at the forefront of surgical evaluation, particularly in orthopaedics, for several years and is currently the Rosetrees RCSEng Director of the Surgery and Interventional Trials Unit [SITU NDORMS]. He also maintains a small NHS clinical role for Swansea Bay UHB.

Having first published research on anterior cruciate ligament deficiency in 1991 he has now logged over 300 published articles, several of which are high level practice changing clinical trials in surgery, orthopaedics, and rehabilitation. He has also supervised over 30 higher degrees. With his special interest in the knee (clinical and research), David is a longstanding member and supporter of BASK (research committee).

He is Chief Investigator/Co-app in several ongoing and planned trials with contributions to methodology, placebo control designs (CSAW), outcome measurement, and most recently innovation/robotic surgery. He sits on many committees and is a core member of the RCSEng Working Group on Robotic Surgery (RADAR), the BOA linked MSK RAS working group, RCS Digital Device Science Group and TSC Chair of many NIHR HTA trials. Any spare time is devoted to volunteer Search and Rescue activities with the National Coastguard (and a little 5-aside football!). n

Colin Howie Colin graduated from Edinburgh in 1977 completing a post fellowship in orthopaedics in Edinburgh with John Chalmers. He became senior registrar on the Exeter/Truro rotation in 1986 working with Robin Ling.

Originally intending to be a general orthopod, in 1990 he joined the team in Inverness doing almost everything including cervical spine fractures and arthroscopy tutor for the shoulder and elbow! In 1995 he was asked to move back to Edinburgh to join the arthritis surgery practice of Willie Souter and Peter Abernethy. His lists included shoulders, elbows, hands, hips, and knees developing a specialist interest in young complex hips following the paediatric hip service of George Mitchell and Malcolm Macnicol, and complex revision surgery.

Unusually his research output accelerated throughout his career with over 120 peer reviewed publications and many book chapters. He has contributed to NICE guidance on rheumatoid arthritis and heavily criticised (correctly!)

NICE guidance on DVT. He continues as a permanent vice chair on the NICE Interventional Procedures committee reflecting his belief in evidence rather than opinion-based medicine. He has been visiting Professor and eponymous guest lecturer around the world. He set up the Scottish Arthroplasty Project, the ‘Scottish NJR’, which continues to monitor arthroplasty real time. His ongoing research revolves around patient outcomes.

He was made an Honorary Professor at Edinburgh University in 2014. In the past he has been Chair of SCOT, Specialist advisor to the CMO, President of the Rheumatoid Arthritis and British Hip Societies and was BOA President in 2014. n

10 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

News

Kristy Weber Kristy Weber, MD is the Abramson Family Professor in Sarcoma Care Excellence in the Department of Orthopaedic Surgery at the University of Pennsylvania. She is from St. Louis, Missouri and attended medical school at Johns Hopkins. Kristy completed her orthopaedic residency training at the University of Iowa and completed a two-year research/clinical fellowship in orthopaedic oncology at the Mayo Clinic. She joined the faculty at University of Texas M.D. Anderson Cancer Center in 1998 and was later recruited to Johns Hopkins in 2003 as chief of the Division of Orthopaedic Oncology and Director of the Sarcoma Program. She received the Kappa Delta national orthopaedic research award in 2006 and was promoted to Professor in 2009.

Kristy has served on the Boards of Directors of many national orthopaedic and cancer organisations including the American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Association (AOA), Orthopaedic Research Society (ORS), and the Connective Tissue Oncology Society. As Chair of the AAOS Council on Research and Quality, she oversaw initiatives related to clinical practice guidelines, evidence-based medicine, appropriate use criteria, patient safety, biomedical engineering, biological implants and the development of orthopaedic clinician-scientists.

She has been President of the Musculoskeletal Tumor Society and the Ruth Jackson Orthopaedic Society (RJOS), Secretary of the Orthopaedic Research Society and Critical Issues Chair on the AOA Executive Committee.

Kristy recently served as the first woman president of the AAOS (2019) and currently serves as President of the International Orthopaedic Diversity Alliance (IODA). n

Presidential Merit Award

The BOA is pleased to announce the recipient of the 2020 Presidential Merit Award, which will be presented at BOA 2021 Congress.

Julia Trusler Julia Trusler has been awarded the Presidential Merit Award this year for outstanding contribution and service to the BOA and Trauma and Orthopaedics as a whole, particularly in recognition of her work over the past year. During the pandemic, she has worked diligently to support the BOA Executive in providing advice and guidance to members; often at short notice and applying excellent analytical and drafting skills to condense significant and complex material into easy to digest messages.

Julia has worked at the British Orthopaedic Association for the past nine years, and been involved in a wide range of policy issues and activities across the orthopaedic landscape. Through the COVID-19 pandemic she has represented the BOA at meetings of NHSEngland, ARMA (the Arthritis and Musculoskeletal Alliance) and with other relevant stakeholder bodies, and overseen the production of a wide variety of resources and guidance documents by the BOA for the membership as well as the public and patients. She has a degree in Biomedical Sciences from the University of Cambridge as well as a Masters in Medical Ethics and Law, and has spent her career in the health/biosciences non-profit sector. n

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News

BOA Annual Congress 2021 21st – 24th September, P&J Live, The Event Complex Aberdeen (TECA) www.boa.ac.uk/Congress #BOAAC21 The Naughton Dunn Lecture from our very own Honorary Secretary Simon Hodkinson.

New for 2021, delegates will need to register separately for all Friday sessions of the BOA Annual Congress. Educational sessions, include: Good Clinical Practice Training, Clinical Examination Course, TOES, NonTechnical Skills Training & Medical Students Session, as well as a virtual Webinar co-hosted

by International Orthopaedic Diversity Alliance (IODA) & Women in Orthopaedics Worldwide (WOW), focussing on ‘Career Breaks & How to Bounce Back’. The programme is available at www.boa.ac.uk/ programme. Don’t forget to visit the BOA stand while walking around the venue to meet the BOA team!

Flagship event Following a successful application for gateway status, this year’s Congress has been designated a Flagship event by the Scottish Government, which means it will be going ahead as a face-toface event. Further information can be found on the events sector guidance page on the Scottish Government website: www.gov.scot/ publications/coronavirus-covid-19-stadia-andlive-events-advice-for-event-organisers.

Registration Full registration will close on Sunday 5th September and late registration will open online on Monday 6th September until 14th September. Due to COVID-19 restrictions, there will be no on-site registration this year, so please book your place before 14th September if you wish to attend in Aberdeen. Please find the registration rates on the Congress website at www.boa.ac.uk/registration.

COVID-19 guidance The BOA would like to confirm that plans are in place to deliver Congress taking government restrictions into consideration that will still be in place in Scotland in September.

Please read through our stay safe guidelines www.boa.ac.uk/covid-guidance.

Programme update The theme of the Annual Congress 2021 is ‘Tackling Infection’ and we look forward

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to presenting to you a mix of educational and scientific sessions with a number of high calibre speakers for our plenary and revalidation sessions.

This year’s presidential Guest Lecturer is Professor Stephen Powis, looking at COVID 19, Lessons and Challenges. Stephen is the National Medical Director of NHS England and NHS Improvement and Professor of Renal Medicine at University College London.

The Howard Steel Lecture will be delivered

by Oliver Budd, Chartered Civil Engineer who works for COWI. He has given papers at international conferences and has interests including better design, high strength materials, and minimising embodied carbon in bridges.

The Robert Jones Lecture from Sarah Muirhead-Allwood entitled ‘Joint Ventures’ focusses on the value and importance of orthopaedic surgeons collaborating with engineers and other scientific disciplines to further improve orthopaedics. Sarah is a highly regarded British orthopaedic surgeon, operating exclusively on hips.

Other sessions from the BOA Include BOA Ortho Committee’s ‘Elective Care Restart and Recovery: Where are we now and what have we learnt?’, BOA Research Committee’s ‘Research for Optimising Orthopaedics’ and Medico-Legal Committee’s ‘Guilty or Not Guilty; Cases of Potential Medical Negligence’ & ‘Medicolegal Reporting – Why, How and When’.

Download the new BOA App to access Congress content Make sure to download the new BOA app to access everything you need for Congress this year. Just search for ‘British Orthopaedic Association’ in the Apple App Store or Google Play. Plan ahead and bookmark your sessions in advance, create your own itinerary, view podium and poster presentations and connect with other delegates. The BOA App will ensure that you have all the information you need at your fingertips for an enjoyable Congress! There is no printed Programme Book this year so make sure to download the BOA App to ensure you can make the most of your Congress experience, before, during and after the event. Find out more at www.boa.ac.uk/boa-app.

Accommodation & travel Make sure to book your accommodation now so you don’t miss out! More information on hotels near to the Congress venue is on the BOA website at www.boa.ac.uk/accommodation which includes a helpful distance map.

Exhibition & Sponsorship We are delighted to welcome over 70 exhibitors including, DePuy Synthes, Medacta, Circle Health, Heraeus, Link Orthopaedics, ConvaTec, Smith and Nephew, Corin Group, Stryker, Zimmer Biomet and many more! For further details please visit www.boa.ac.uk/annual-congress/exhibitorsand-sponsors.html. n

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News

British Indian Orthopaedic Society (BIOS) update Bijayendra Singh, Amit Tolat and Sunil Garg

T

he British Indian Orthopaedic Society (BIOS) recently held its 22nd Annual Conference in Cardiff.

It was an online meeting with the Council and the local organisers getting together at Mercure North Cardiff. The meeting was well attended with over 800 registrants and 500 delegates watching it live throughout the day. This was streamed live via Ortho TV and there were over 3,500 viewers of the live telecast. The Presidential Lecture was delivered by Dr Nishith Shah from Ahmedabad on Knee Ligament Injuries in the paediatric age group whilst the Organisers Lecture was delivered by Dr Ashish Babhulkar from Pune on Fractures of the Proximal Humerus. The current BOA President, Mr Bob Handley and IOA President Dr B Shivashankar also presented at the meeting.

Sessions on Pain Management, Specialist Rehabilitation, Trauma and

Arthroplasty was delivered by local and international faculty. The meeting received RCS accreditation with 11 CPD points. Trainees had an opportunity to present podium papers and poster abstracts which will be published in the BJJ. The industry support was well appreciated.

BIOS will be presenting two revalidation sessions at the 2021 BOA Annual Congress titled ‘My joint is still painful after surgery’.

These will be delivered by infection and pain specialists as well as orthopaedic Consultants.

COVID-19 continued to impact our educational activities with cancellation of the 2020 conference as well as all the fellowships planned for 2020 and 2021.

We replaced the lack of face-to-face

interaction with Webinars for Core Trainees on the Common Orthopaedic Problems that shadowed the curriculum and these have been received very well. We delivered lectures for medical students which were very well attended. All the videos are available on the BIOS YouTube channel – www.youtube.com/ channel/UCTL3HEGRr6E3Wllz5NLUqMQ.

At present the BIOS membership stands at approximately 530 life members and plans on expanding the society’s educational goals in 2022 – it stands shoulder to shoulder with the BOA in helping to educate the current and future generation of orthopaedic surgeons. n

The British Orthopaedic Oncology Society (BOOS) update Robert Ashford and Tom Cosker

M

etastatic disease presenting to orthopaedic surgeons is on the rise and it is crucial that all orthopaedic surgeons have a sound understanding of the principles of treatment, which can be very different from standard orthopaedic trauma surgery.

The British Orthopaedic Oncology Society is focusing this year on providing a greater understanding of those with metastatic disease and ensuring that all surgeons, no matter which area of practice they subspecialise in, have a sound treatment algorithm for this important patient group. Increased life expectancy (largely due to a reduction

Radiograph showing ‘vanishing bone’ seen in a mid-shaft metastatic humerus

Radiograph showing intercalary prosthesis preserving function of the shoulder above and elbow below

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in mortality from common conditions such as myocardial infarction, stroke and infection) mean that patients are presenting with increased frequency from metastatic disease. We are also seeing more primary malignant bone tumours in conjunction with this increased life expectancy. Combined with this is the fact that treatment for common cancers has become exponentially more effective meaning that the survival from previously fatal cancers (particularly renal, thyroid and breast) is now much longer and often in excess of 10 years.

Surgeons must avoid the common pitfalls of misdiagnosing such lesions, failing to investigate fully, not organising sufficient investigations, over-estimating the efficacy of adjuvant therapy, under-estimating survival and failing to communicate with Oncology colleagues. BOOS has worked hard to develop new guidelines for the management of metastatic disease and will be disseminating this information at Regional Specialist Study Days, the BOA Annual Congress in Aberdeen, and at Society Specific Meetings such as recent presentations by Tom Cosker at the London Shoulder Meeting and a BOOS session at the British Hip Society. All units are encouraged to ensure they have a dedicated metastatic lead in post who is supported by a regional network and a designated specialist tumour unit (in England, one of the five specialist bone tumour services).

Communication is the key and all surgeons are encouraged to fully discuss, investigate and communicate such cases with colleagues so that these, traditionally under-served patients, are given the treatment that they deserve. n

BASS 2022 S The BAS xecutive nt E e e in Tra e prese tee will b Congress Commit A O B coming hoping to re at the up a e W . n e e rd s spinal e in Ab d discus n a t of e e ,m with all network gression re ro a p u d o n y a If training eagues. ll o c is d th n s a res our peers the BOA cong S at the BAS in jo present to ke il li a ld -m u e o w se year and eting days, plea r o k .u e c m .a eons trainee spinesurg via trainee@ vely contact us ti a e rn in e p alt @BASSs Twitter -

www.spinesurgeons.ac.uk

Conference and Exhibition of the British Association of Spine Surgeons

SAVE THE DATE 23-25 March 2022 ICC Belfast, NI

@BASSspine

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News

British Elbow & Shoulder Society (BESS) update Amar Rangan

B

ESS 2021 returned to our virtual conference environment once again. This year we have included three great events in one: Annual Scientific Meeting; Instructional Course; and Elbow Update Symposium.

We were excited to host USA as our guest nation with ASES and ASSET contributing. It was a great opportunity to forge closer links with our international colleagues. For our Annual Scientific Meeting, our live launch day took place on 30th June hosted by our local organising committee alongside President (Amar Rangan) and Honorary Secretary (Steve Drew). Guest lectures were given by Dr Mark Frankle and Dr Margie Olds and we

ended the day with Mark and Margie joining us for a live Q&A session.

All the usual elements were catered for in the meeting including Hot Topics, Masterclasses, and Research and AHP Symposiums. For a different perspective Steve Drew redesigned the format of the meeting to include a Getting It Right FirstTime section in each of our themes which has proved very popular.

Shantanu Shahane and his committee led the way on our instructional course programme which has now gone full cycle and starts again on course 1. Shantanu

approached the course content differently focusing on case studies developed specifically for online learning.

And finally, our Elbow Update Symposium, which launches on 9th September, has been organised by Joideep Phadnis, Adam Watts and Val Jones. It features a staggering 30 international speakers supported by UK faculty with pre-course and post-course webinars.

Our meeting has been awarded 32 CPD points and all the content is available on demand until 31st October 2021 and you can still register at www.bess.ac.uk.

BESS would like to thank to our Northeast team for hosting this most enjoyable and successful conference. We now look forward to a face-to-face meeting BESS 2022, hosted by our Liverpool team. n

Combined Services Orthopaedic Society (CSOS) update Liam Kilbane, Tom Wood and Ian Winson

T

his year’s CSOS meeting was held at the D-Day Museum and Southsea Castle in Southsea, Portsmouth on 22nd July. The meeting was a significant challenge for the organising committee who postponed the meeting once and needed to keep a close eye on the Government’s lockdown easing rules. Despite this, they managed to pull off a very successful and unusually exclusive face-to-face event, there was certainly a palpable sense of excitement to be at a meeting which wasn’t hosted online!

The main meeting was preceded by a trainees’ Instructional course with teaching on Damage Control Orthopaedics and a hands-on saw bone session on lower limb external fixation.

There was a high standard of presentations given with the prize winners below: Best Overall Presentation – Surg Lt Cdr Louise McMenemy for the summary of her recent PhD work in predicting outcomes with the Bespoke Offloading Brace (BOB) in foot and ankle injuries.

Best of the Best – Maj Charles Handford for his presentation on cost utility analysis in bilateral femoral osseointegration in trans-femoral amputation following blast injury. This found a decreasing QALY cost approaching the NICE criteria for cost effectiveness in the patients at the 5 – 6 year point post-procedure.

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Best Trainee Paper – Maj Abigail Johnson for her collaborative work in establishing a new tourniquet pressure safety margin. Aiming to create a formulaic approach in setting a minimal safe tourniquet pressure, her work with Professor David Warwick may lead to new national guidelines.

Special guests at the meeting included Mr Don McBride, immediate past president of the BOA and the Surgeon General, Major General Timothy Hodgetts. The Society heard a ‘state of the nation’ address by our chair, Colonel Alistair Mountain, and the meeting concluded with a strategic overview from the Surgeon General.

The meeting crescendo was a very memorable Mess Dinner held on board HMS Victory. This special occasion honoured several military surgeons who have recently retired from military service including Surg Capt Sarah Stapley who received standing applause despite the rather restricted headroom. We also said farewell to Mr Ian Winson who concluded his term in office as our President, and handed the Presidency to Mr Simon Hodkinson. A beating the retreat and music during the dinner was provided by members of the Royal Marine band. Changing tempo slightly we all joined in with a local sea shanty group to finish the evening on a high!

We look forward our next meeting which will be held in Exeter in May 2022. n

Power to protect surgical incisions.

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Reduction in reoperations (p=0.017)1‡

Learn more and request a product demo at www.3M.co.uk/Prevena 1 Newman JM, Siqueira MBP, Klika AK, Molloy RM, Barsoum WK, Higuera CA. Use of Closed Incisional Negative Pressure Wound Therapy After Revision Total Hip and Knee Arthroplasty in Patients at High Risk for Infection: A Prospective, Randomized Clinical Trial. J Arthroplasty. 2019 Mar;34(3):554–559. † 10.7% for Prevena Therapy (8/79) vs. 23.8% for silver impregnated dressing (10/80) : 23.8% -10.7% / 23.8% = 57% ‡ 2.5% for Prevena Therapy (2/79) vs. 12.5% for silver impregnated dressing (10/80) : 12.5% -2.5% / 12.5% = 80% Note: Specific indications, contraindications, warnings, precautions and safety information exist for these products and therapies.

Please consult a clinician and product instructions for use prior to application. This material is intended for healthcare professionals. © 2021 3M. All rights reserved. 3M and the other marks shown are marks and/or registered marks. Unauthorised use prohibited. PRA-PM-EU-00481 (03/21). OMG168046.

News

World Orthopaedic Concern (WOC) UK update Deepa Bose

T

he global pandemic has been tough for all of us, regardless of where we live or what language we speak. If we in the UK (a developed nation) find it hard, it is not too difficult to imagine how much more challenging and devastating it is for those without access to adequate healthcare even in the best of times. The lack of ability to socially distance, and lack of access to hygienic facilities and vaccines affect a significant percentage of the world’s population.

The pandemic has seen considerable changes to the way WOC operates, in common with many other charity organisations working in low and middle income countries (LMICs). The curtailment of international travel has meant that those of us who have ongoing projects overseas have not been able to visit in person since the start of 2020. As with most clouds, there has been a silver lining, which has seen the growth and development of virtual platforms for distance learning, as well as for clinical case discussions. These have allowed us to keep in touch with the medical staff on the ground, continuing our educational and clinical input.

WOC held its first virtual conference on 5th June 2021, hosted

by Orthohub. This has allowed us to reach a wider audience than usual, for which we are very grateful. It was especially heartening to see the interest it generated in trainees, and we are delighted that our trainee

subcommittee is going from strength to strength. Several of them have initiated collaboratives with trainees in LMIC countries, which are mutually beneficial. The conference recording can be accessed via the Orthohub website at: https://orthohub.xyz/course/world-orthopaedicconcern-conference-2021 or via YouTube: www.youtube.com/ watch?v=qb7gXrPxcPE. n

You’ve saved your patient’s life.

What’s next for them?

We're on the ward with practical and emotional support so people can make their best possible recovery.

Find out how we can work with you.

www.dayonetrauma.org Stand 58 at BOA Congress.

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News

Joint Action update

Appeal to Members Public donations and legacies form a core part of our research income but contributions from BOA members also have a significant impact on the funds available to support our work. Resetting donation preferences following GDPR has significantly reduced our regular member donations and we would be delighted if members would commit to renewing their contribution to this vital fund.

T

he BOA aims to promote and help sustain high quality research in Trauma and Orthopaedics. Our work to support and grow the T&O research infrastructure and develop future researchers is only possible through the generosity of the public and BOA members. We are truly grateful to all those who have fundraised for and donated to Joint Action.

Donating to Joint Action actively supports: • The newly expanded programme of infrastructure funding for Clinical Trials Units, with two new centres in the University of Exeter and University of Nottingham.

• Three Surgical Speciality Leads (SSLs) who play a key role in advancing the agenda for T&O clinical trials.

• James Lind Alliance Priority Setting Partnerships (PSP), a key collaboration area with our Specialist Societies.

We are pleased to report that trainee engagement with research has never been higher, with several trainee delivered research projects being completed in 2020. T&O trainees are also very well represented in the new National Institute for Health Research Associate Principal Investigator scheme.

We are proactively looking at our portfolio of research work to ensure that it remains current and relevant and supports our members to drive innovation.

Donating to Joint Action is easily done either as part of your membership renewal or through our website at www. boa.ac.uk/donate. Or visit us at the BOA stand at Congress.

We would be delighted to see you after all this time!

London Marathon The Virgin Money London Marathon will be held on 03 October 2021. We’d like to wish the best of luck to our runners: Imran Ahmed, Zaid Ali, Tim Davies, Robert Jordan, Lee Longstaff and Richard Secular who are all raising funds for Joint Action.

You can support our runners by donating to Joint Action at www.virginmoneygiving.com/fund/JAlondonmarathon. n

Conference listing 2021/22: BSSH (British Society for Surgery of the Hand)

BOFAS (British Orthopaedic Foot & Ankle Society)

BORS (British Orthopaedic Research Society)

BSCOS (British Society for Children’s Orthopaedic Surgery)

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

www.bscos.org.uk 10-11 March 2022, Maidstone

BOA (British Orthopaedic Association)

BASS (British Association of Spine Surgeons)

www.bssh.ac.uk 8-10 September 2021, Oxford

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

BOOS (British Orthopaedic Oncology Society) www.boos.org.uk 8 October 2021, Bristol

BTS (British Trauma Society)

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

BSS (British Scoliosis Society)

www.britscoliosissoc.org.uk November 2021, Edinburgh

20 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

www.bofas.org.uk 9-11 March 2022, Bournemouth

www.spinesurgeons.ac.uk 23-25 March 2022, Belfast

SBPR (Society for Back Pain Research) www.sbpr.info 12-13 May 2022, Warwick

CAOS (The International Society for Computer Assisted Orthopaedic Surgery) www.caos-international.org 8-11 June 2022, Brest

OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 16-17 June 2022

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Contact a Bioventus representative by phone at 0800 05 16 384 (UK) or 00800 02 04 06 08 (IR) Summary of Indications for Use: Europe: DUROLANE (3 mL): Symptomatic treatment of mild to moderate knee or hip osteoarthritis. In addition, DUROLANE has been approved in the EU for the symptomatic treatment associated with mild to moderate osteoarthritis pain in the ankle, shoulder, elbow, wrist, fingers, and toes.

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References: 1. Bioventus LLC. Supporting quantity of global patients treated with a single DUROLANE injection. Data on file, RPT-001056 4 2. Q-Med Scandinavia, Inc. DUROLANE approved in Europe for the treatment of osteoarthritis of the hip joint. Posted March 9, 2004. https://mb.cision.com/wpyfs/00/00/00/00/00/04/2D/C9/wkr0006.pdf 3. Lindqvist U, Tolmachev V, Kairemo K, Aström G, Jonsson E, Lundqvist H. Elimination of stabilised hyaluronan from the knee joint in healthy men. Clin Pharmacokinet. 2002;41(8):603-13. doi: 10.2165/00003088-200241080-00004 4. Krocker D, Matziolis G, Tuischer J, et al. Reduction of arthrosis associated knee pain through a single intra-articular injection of synthetic hyaluronic acid. Z Rheumatol. 2006;65(4):327-31. doi: 10.1007/s00393-006-0063-2 5. McGrath AF, McGrath AM, Jessop ZM, et al. A comparison of intra-articular hyaluronic acid competitors in the treatment of mild to moderate knee osteoarthritis. J Arthritis. 2013; 2(1):108. doi: 10.4172/2167-7921.1000108. 6. Leighton R, Åkermark C, Therrien R, et al. NASHA hyaluronic acid vs methylprednisolone for knee osteoarthritis: a prospective, multi-centre, randomized, non-inferiority trial. Osteoarthritis Cartilage. 2014; 22: 17-25. 7. Ågerup B, Berg P, Åkermark C. Non-animal stabilized hyaluronic acid: a new formulation for the treatment of osteoarthritis. BioDrugs. 2005;19(1):23-30 doi: 10.2165/00063030-200519010-00003.

Bioventus, the Bioventus logo and DUROLANE are registered trademarks of Bioventus LLC. ©2020 Bioventus LLC SMK-003033

07/20

Features

The orthopaedic ostrich: surgeons’ responses to complications Deepa Bose

This article is an abridged version of the winning entry for the 2021 Robert Jones essay competition.

“Science does not, ostrich-like, bury its head amidst perils and difficulties. It tries to see everything exactly as everything is.”

– Garrett P. Serviss

Deepa Bose is a Consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham.

She is Vice Chair of the Specialist Advisory Committee for Trauma & Orthopaedics, and the lead for CESR application reviews.

She has also contributed to the revision of the curriculum.

She holds an MSc in Medical Education and is a member of the Academy of Medical Educators.

Complications are an inevitable part of surgery. It is said that if a surgeon has no complications he or she is either lying or not operating.

S

urgeons respond in different ways to post-operative complications; denial, anger, despair and acceptance. These are perfectly understandable if one considers the surgeon as a craftsman.

Any craftsman is wont to take criticism of his or her creation personally. It is this perceived apportion of blame which can result in surgeons “burying their head in the sand”, as ostriches are said to do, when complications occur.

What is a surgical complication?

“History as well as life itself is complicated - neither life nor history is an enterprise for those who seek simplicity and consistency.”

– Jared Diamond (Collapse: How Societies Choose to Fail or Succeed) What constitutes a surgical complication?

Whilst there is a broad understanding that it refers to an adverse event, there is no consensus, although many attempts have been made at a definition. Dindo and Clavien1 propose the definition “any deviation from the ideal post-operative course that is not inherent in the procedure and does not comprise a failure to cure.” They divide negative outcomes after surgery into 1) Sequelae (a natural result of surgery, for example a scar); 2) Failure to cure (the purpose of the surgical intervention was not achieved) and 3) True complications. Other authors have adapted this to different surgical specialties, including orthopaedics2.

Visser et al.3 highlight the wide variation in and subjective nature of what surgeons report as complications. Interestingly, Woodfield

22 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

et al.4 found that when patients reported complications themselves, there was a rate of over 40%, and that many of these, although clearly of significance to the patient, would not have otherwise been identified.

The notion of a surgical complication is closely linked to medical negligence in the minds of the general public and medical practitioners alike. Negligence, however, has a very specific definition whereby a duty of care must have been owed and the breach of which resulted in harm to the patient. This association in the minds of patients and surgeons is difficult to escape, and goes some way to understanding the reticence in acknowledging a complication.

Surgeons’ responses to complications “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.”

– René Leriche There are numerous documented accounts of the negative impact complications have on surgeons’ wellbeing, and therefore on patient care5,6. These authors found that emotional reactions range from anger and guilt to performance anxiety and fears about one’s surgical career. Furthermore, although the intensity of such feelings dims with time, there are a few cases that haunt surgeons for many years; this is the basis of the quote above by French surgeon René Leriche, a popular one amongst surgeons. Wu7 has coined the term “the second victim” for the physician affected by an adverse event, although some

Features

think this is insensitive to patients. It is important to recognise that all responses described above are natural – there are no right or wrong emotions.

Surgeons are traditionally regarded as possessing a certain personality; emotionally tough, confident, high achievers. One may be forgiven for thinking, therefore, that surgeons should be well equipped to deal with setbacks.

Nothing could be further from the truth. The ‘flip side’ of the so-called ‘surgical personality’, if this can be said to exist, consists of some very negative characteristics; perfectionism, workaholic, poor delegators and poorly able to prioritise tasks. These can lead to an unhealthy response when things do not go according to plan. Surgeons are taught and encouraged to take responsibility for their patients.

Consultants ‘carry the can’, ‘the buck stops’ with them; all these are viewed as necessary qualities, but they merely add to emotional stress when

“Surgeons are traditionally regarded as possessing a certain personality; emotionally tough, confident, high achievers.

One may be forgiven for thinking, therefore, that surgeons should be well equipped to deal with setbacks. Nothing could be further from the truth.”

Although adverse events are visited upon all medical specialties indiscriminately, there is something very personal to the surgeon when it comes to a post-operative complication. Surgery is often referred to as a ‘craft’ speciality; this conveys the concept that surgery requires more than just sound scientific principles, and that the ‘expertise’ so avidly sought and so dearly won by trainees is to be found at the sweet intersection of manual dexterity, anatomical knowledge, delicate handiwork and creativity.

When a post-operative complication occurs, there is a sense that one has caused the event “by one’s own hands”. These feelings of failure, guilt and frustration are the seeds of our emotional reactions to adverse surgical events.

things go wrong. It is well known that medical practitioners in general are prone to burnout and mental health problems. The rate of burnout is especially high amongst surgeons, and Money8 emphasises the contributory role of high stakes human outcomes in this.

Turning the tide; healthy responses to complications “You people with hearts, have something to guide you, and need never do wrong; but I have no heart, and so I must be very careful.”

– Tin Man (The Wizard of Oz) Several years ago I attended an event organised by the excellent Surgery and Emotion project, run under the auspices of the Royal College of Surgeons of England. It was enlightening and fun. I found the members of the public to be highly insightful. Twice I was asked what support there was for surgeons when things go wrong. Having been in this unenviable position myself, I responded “Not very much, actually.”

They were both taken aback; they had naturally assumed that such an important service would be readily available to us.

So how do we cope with complications? Head down to the local for a pint with a friend? >>

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 23

Features

Speak to a mentor? Analyse endlessly? Adopt risk-averse behaviour? Accept disproportionate blame or shrug off any responsibility?

There are as many coping mechanisms as there are surgeons. Pinto et al.6 report that discussion, deconstruction and rationalisation (putting things into perspective) were the most common responses. These are very positive measures, and result in the emotional and professional growth of the surgeon.

Unsurprisingly, there are also negative coping mechanisms such as alcohol and substance abuse. These can heighten feelings of depression, guilt and shame, and ultimately result in predictable problems on a professional and personal level.

have all been mentioned as vital in helping surgeons to deal with their emotions after an adverse event. Making this a normal part of practice represents an acknowledgement that complications are not unusual, are emotionally challenging for the best surgeon, and that seeking support is not a sign of weakness.

“Peer support, mentorship and a team structure which encourages open and frank discussions have all been mentioned as vital in helping surgeons to deal with their emotions after an adverse event.”

The question we must now ask ourselves is how to manage the aftermath of surgical complications in a way which is both supportive and conducive to growth. It is noteworthy that this very important aspect of surgery is not usually addressed in surgical curricula. We, like our friend the ostrich, tend to bury our heads in the hope that the emotions will eventually pass, but this is a most unhealthy strategy.

Peer support, mentorship and a team structure which encourages open and frank discussions

24 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

Dorsey and Ritzer9 have coined a marvellous phrase called “the McDonaldization of medicine” for the application of corporate values such as efficiency, calculability, predictability and control to the practice of medicine. These institutional values often result in a ‘blame’ culture when things go wrong. Several authors point out that lip service is paid to a supportive environment, but the reality is that surgeons are often made to feel that they are solely responsible for adverse events.

A non-adversarial governance culture is essential in allowing surgeons and patients to benefit from the valuable lessons to be learnt from unintended outcomes.

Fear of litigation and malpractice is known to be a factor in the negative impact on surgeons after a post-operative complication. A no-fault compensation

system for surgical complications would foster a blame-free environment, and a better surgeon-patient relationship.

What lies ahead?

“There is no separation of mind and emotions; emotions, thinking, and learning are all linked.”

– Eric Jensen Recently we are seeing the emergence of not just an awareness of the negative impact of complications on surgeons, but the necessary tools to combat this. The Royal College of Surgeons of England have released ‘Supporting Surgeons after Adverse Events’10. In this they stress the role of a ‘first responder’ whose primary role is to focus on the surgeon’s wellbeing.

It is also vital to consider how we prepare our trainees to deal with surgical complications, and with the emotional fallout of these.

Finally it seems, we are lifting our heads from the sand.

Disclaimer The author is aware that ostriches do not actually bury their heads in the sand! n

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

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Features

National Selection to T&O ST3 posts in England 2020 & 2021 Mark AA Crowther

Mark Crowther is a Consultant T&O Surgeon for North Bristol NHS. Since 2015 he has been a member of and now chairs the National Selection Design Group for recruitment of orthopaedic registrar surgeons. In 2017 he was appointed to the Specialty Advisory Committee and is National Selection Lead for Trauma & Orthopaedic Surgery.

As National Selection Lead on the T&O Specialty Advisory Committee (SAC), I chair the Selection Design Group (SDG) made up of consultants, Training Programme Directors, SAC members and representatives of the British Orthopaedic Trainees Association (BOTA) all experienced in many aspects of training and education with a collective desire to ensure the best potential registrars are chosen for higher surgical training.

W

e convene several times a year to scrutinise the most recent process using data released by Medical and Dental Recruitment and Selection (MDRS), a body responsible to the Statutory Education Bodies (SEBs), and to improve the following year’s process. We then implement delivery of the process used to select T&O ST3s done on a national basis since 2013. During this time, we have introduced a number of changes and improvements to the interview process undertaken with between 300 and 500 applicants over several days at Elland Road football stadium in Leeds. We have removed the infamous ‘killer’ station, developed the role of simulation with actors and successfully implemented the use of iPads to allow real time scoring which has facilitated early recognition of scoring errors. I took over as Chairman at the end of the 2019 process knowing we had a fair and robust process in which trainees, programme directors and trainers had confidence, in no small part because of the hard work of my predecessors David Large and James Hunter.

When the COVID-19 pandemic struck the MDRS acted swiftly in declaring that there would be no face-to-face interviews for any medical specialty in 2020. We found ourselves

26 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

in a strong position compared to other specialties given our historical process; our self-assessment form was well established and we knew it correlated well with the overall final score. We made a strong case for the use of the self-assessment score further validated with portfolio review, as a sole selection tool, and also for the appointment to LAT posts given the extraordinary circumstances surrounding the 2020 process. Neither proposal was adopted however due to the desire for uniformity across all medical specialties and the uncertainty of the rapidly changing global pandemic.

The decision of MDRS was to appoint to substantive training posts using unvalidated self-assessment scores.

We looked closely at our previous year’s data to carefully decide the ‘appointability’ score, the maximum possible being 32. The decision was a score of 21 which carried a reassuringly low risk of appointing an ‘unappointable’ applicant. With a threshold score of 20, the risk would have increased and at 19 that risk would have increased considerably. We predicted we would have 105 appointable applicants. The 12 questions contained within the selfassessment form were also ranked to be used in a tie-break situation prioritising clinical over academic achievement.

Features

After long-listing there were 444 applications in 2020 and these were ranked according to their unvalidated self-assessment score. After the tie-breakers were applied, adjudication was only required on a single pair of tied applications. On offers-day there was an unintended HEE administrative data processing error leading to a smaller than expected number of offers, but this was recognised quickly, and rectified resulting in 107 offers being made. The Training Programme Directors (TPDs) were rightly conservative in their declaration of ST3 vacancies knowing they may have ST8s whose post-CCT fellowship plans could be disrupted resulting in late requests for training extensions as ‘periods of grace’. Ultimately 96 offers of ST3 posts were accepted.

In autumn 2020 the SDG agreed what should be submitted to MDRS as Plans A & B (ideal and fall-back scenarios) given the decision there would be no in person interviews for 2021. The self-assessment form was adjusted adding 12 months to the banding for maximum scores in question 1 (total time since foundation programme or equivalent) and question 2 (time spent in T&O posts) to ensure no applicant was disadvantaged by the events of the pandemic. We were relieved that our Plan A, validated self-assessment and a 30-minute video interview, was agreed. Having written questions that could be delivered without repetition over five days, and confident we would have assessor panels over such a period using three question per interview station, we wrote to the HEE Selection Lead expressing our desire to interview all applicants in accordance with the normal process in Leeds. For logistical reasons HEE were only able to support 90 interviews over four days hence the maximum of 360 interviews. Following several years of declining numbers, 604 applications were submitted in 2021, the most since the advent of National Selection. After a small number of withdrawals and some long-listing rejections, we had 571 applications.

In February 2021 the SDG met remotely over two days to validate the evidence uploaded by each applicant relating to the 12 questions of the self-assessment form. For quality assurance the first session of the process was performed in pairs before breaking out individually. There was real-time discussion of queries, seeking clarity on inconsistencies and consensus decisions made over the course of the meeting.

Evidence relating to 6,852 questions was validated with some scores adjusted up or down and justification notes recorded. An impressive undertaking by dedicated T&O surgeons in their own time. Ten days later, a smaller group reassembled remotely for another day to address the 430 appealed questions, 54% being deemed unsuccessful. This resulted in the final ranked order of the 571 eligible applicants, of which the top 360 were offered video interviews. These were to comprise three tenminute stations akin to three of the five stations

traditionally used in Leeds. The ‘Technical Skills’ and ‘Communication’ (with Actors) stations were felt impractical to deliver virtually and aspects of the latter would naturally be assessed in the remaining ‘Portfolio’, ‘Clinical’ and ‘Prioritisation’ stations.

The constrains of COVID-19 meant this year each applicant could only be seen by three interviewers in the half hour interview with each one asking one question which was independently scored by their two colleagues from their own home or office. We ensured the process was as fair as possible with Quality Assurance involving lay reps and SDG members as ’flies on the virtual wall’ to confirm the delivery of a consistent process.

For each of the four days of interviews we ran ten panels, each with three interviewers, each overseen by an HEE administrative staff member and each having intermittent QA presence, with each panel undertaking nine interviews per day. The administrative staff and QA members provided me and other senior SDG members with feedback and we were able to see the scores being submitted in real time. This allowed us to address issues with the interviewers immediately by relaying messages to them via the administrative staff.

For example, relating to technical errors in submitting scores or to challenge significant discrepancies in marking when identified.

There was never any intention to persuade the assessors to change their scores, merely to ensure that they could justify their scores and that this was recorded accurately. Our interview panels comprised experienced assessors well versed in the selection process and extensively trained, for example relating to equality and diversity, so discrepancies were rare, but occasionally scores were modified in accordance with the marking descriptors.

Over four days we delivered successful remote interviews for 360 applicants and of those only 20 failed to reach the appointability threshold. This is not a concept peculiar to T&O. HEE require every medical specialty to draw a line somewhere and ours is an average score of 3.25 out of 5 for each question plus an average selfassessment score. This left us with 340 appointable applicants to fill 177 posts – a roughly 50% chance of success if interviewed – but successful applicants must rank regions and those with specific geographical preferences may still be disappointed.

Regarding geographic preferences, we have made it very clear this year that barring unexpected and compelling reasons, we expect all trainees to receive their training in their accepted Programme.

The SDG is acutely aware of the potential for unconscious bias to influence the outcome of the selection process. Under normal circumstances an applicant can emerge from a station in which they have underperformed, compose themselves and start afresh in the next station with a new pair of interviewers. An applicant could see at least ten assessors in the process and we feel this is preferable to this year’s compromise. In addition, as a craft specialty the public and future employers understandably assume that some assessment of technical skills is undertaken when selecting consultant surgeons of the future and whilst core training does involve such assessment, we strongly believe in the face-toface validity of a technical skills assessment as part of our ST3 interview process. For these reasons we have appealed to HEE that we should return to face-to-face interviews, assuming government rules allow. n

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 27

Features

Ian Crowther is a ST5 Orthopaedic trainee in the Northern Deanery.

He completed his undergraduate studies at Newcastle University and has completed both his foundation and early surgical years in the North East of England.

Nick Kalson is an NIHR Clinical Lecturer in Orthopaedics and ST7 trainee, Newcastle.

Simon Chambers is a Consultant Orthopaedic surgeon and is the Clinical Lead for Trauma at the Newcastle MTC. His subspecialty interests are in limb reconstruction and foot and ankle.

Post-COVID-19 trauma care: The end of the new patient trauma clinic?

Ian Crowther, Nick Kalson and Simon Chambers

(On behalf of the Orthopaedic and Emergency Departments, Great North Trauma Centre, Royal Victoria Infirmary, Newcastle upon Tyne)

The COVID-19 pandemic that struck in March 2020 has forced hospitals to adopt new ways of working. To protect the public and reduce pressure on a stretched workforce systems were implemented to reduce hospital attendance.

G

overnment and BOA guidance recommended1,2 that patients with traumatic injuries receive consultant delivered care with an emphasis on providing a definitive management plan at first presentation to the emergency department minor injury unit (ED-MIU). In our unit, a major trauma centre in England, we removed the new patient trauma clinic and instead provided the ED-MIU with 12-hour consultant cover. This successfully reduced the patient re-attendance rate by over 50%. One year later and with a successful vaccination programme, decreasing COVID-19 incidence and a return to more familiar working patterns, rather than return to the tried and tested pre-COVID system we have developed a sustainable model to deliver definitive management on day of presentation without the need for a next-day newpatient trauma clinic.

Traditional nextday trauma clinic pathway The pre-COVID-19 trauma pathway at our unit was similar to many other hospitals nationwide. A normal

28 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

day would see 120-150 patients attend the ED-MIU; of these a significant proportion would have a musculoskeletal problem. Initial consultation was by the ED doctors/MIU nurse practitioners, who either discharged the patient or referred to the orthopaedic team. Typically, this would be via a next-day face-to-face acute trauma clinic. On average our consultant led clinic was seeing ~20 new patients per day (~7,000 appointments annually).

“With a successful vaccination programme, decreasing COVID-19 incidence and a return to more familiar working patterns, rather than return to the tried and tested pre-COVID system we have developed a sustainable model to deliver definitive management on day of presentation without the need for a next-day newpatient trauma clinic.”

COVID-19 pathway During the early stages of the pandemic ED-MIU attendance dropped ~50% to an average of 64 presentations per day. A move to a virtual fracture clinic was considered but not implemented in particular because of the potential need for reattendance, which would fail to reduce hospital visits. To optimise patient flow and minimise further attendance our unit redeployed a consultant to the ED-MIU from 08:00 to 20:00. This resulted in patients receiving specialist review at first presentation, often without the need for re-attendance.

An emphasis on definitive care and the increased use of removable casts,

Features

12:00. This is the period that the consultant was previously in the trauma clinic pre-COVID-19 and therefore did not require additional manpower.

From 12:00 to 20:00 the consultant is available for advice or face-to-face review as required.

From 20:00 to 08:00 the on-call StR performs face-to-face reviews in ED-MIU, implementing provisional plans with telephone support from a consultant. These plans are then either confirmed or altered in the morning trauma meeting. A letter to the patient and their GP is dictated by the consultant as it would have been had they been seen in clinic.

Figure 1: Pre-COVID-19 trauma pathway

What does the new system achieve?

Immediate same-day review of walking wounded presenting to our ED-MIU saves >4,000 acute trauma clinic appointments per year whilst maintaining a consultant led service.

Providing a definitive management plan on day of presentation has reduced the follow-up clinic appointment burden by >75%. There are several reasons for this: • Same day specialist review • Consultant led plan for all patients • Streamlining of patients requiring follow-up into subspecialty clinics • Increased use of removable casts, splints and boots • Provision of injury specific patient information leaflets >>

Figure 2: Current pathway

splints and boots resulted in a >50% reduction in follow-up appointments generated. This reduction rendered the traditional nextday trauma clinic unnecessary and it was suspended. If patients did require subsequent review, they were streamlined into an existing clinic for follow-up. No new slots were required because these were patients who would have been reviewed again routinely. Outside these hours the on-call StR provided the same service, with plans marked as provisional prior to consultant discussion at the following day’s trauma meeting.

Orthopaedic same day review pathway After the initial wave of COVID-19, presentations to ED-MIU increased, and

by September 2020 were at >80% of pre-

pandemic levels. With the increased trauma workload and the resumption of elective work it was no longer feasible to provide ED-MIU with 12-hour consultant attendance. To continue to sustainably deliver this care model we reduced consultant presence to 09:00 to

Next-day Trauma Clinic Pathway

COVID-19 Pathway

Orthopaedic Same Day Review Pathway

Daily ED-MIU presentations

136

64

112

Daily referrals to orthopaedics

20

29

41

Daily acute trauma clinic appointments generated

19

5

8

Daily fracture review clinic appointments generated

41

6

9

Table 1: Comparison of the three pathways.

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 29

Features

The current system is more efficient and has released resources and personnel which is important as we tackle the postCOVID-19 backlog. There are also financial considerations; our department is saving an estimated £150,0003 on acute trauma clinics alone, this figure rising to over £500,000 if the savings on review clinics are included.

Whenever practice changes there will be challenges. There is increased workload for the on-call team, with over twice as many referrals. Additional time is required in the trauma meeting to finalise management plans from the previous day. As a department we feel this is an acceptable trade off.

From a patient’s perspective there were teething problems.

Initially we found that >50% of the patients discharged at first presentation would have preferred followup, with over one third of them re-presenting to ED-MIU or their GP

with queries or concerns. In an attempt to address this, we developed injury specific patient information leaflets for common injuries with a focus on rehabilitation and recovery. These have reduced the re-attendance to under 7% and improved satisfaction.

Acknowledgements

The effects of COVID-19 will long be felt throughout the healthcare service. As focus shifts from urgent and emergency care to re-establishing elective services it is vital to improve efficiency. Significant changes have been rapidly implemented; it is important to identify those that should be maintained.

In our unit COVID-19 stimulated the development of a system that allowed us to remove the fracture clinic and definitively manage walking wounded on day of presentation. This has widespread benefits for patients and is proving to be safe and sustainable and should encourage other units to consider definitive management on day of presentation for common orthopaedic injuries as part of their post-COVID recovery plan.

References

“The effects of COVID-19 will long be felt throughout the healthcare service. As focus shifts from urgent and emergency care to re-establishing elective services it is vital to improve efficiency.”

30 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

Liam Alcock and Chris Thornhill, orthopaedic trainees, contributed to data presented and helped write this report. The support of Peter Worlock, Helen Whittaker (Orthopaedics) and Matt Cadamy (ED) was vital to this project’s success. n

1. NHS England and NHS Improvement [2020]. Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic. Available from: https://sogacot.org/wp-content/ uploads/2020/03/specialty-guideorthopaedic-trauma-and-coronavirus-v1-16march-2020.pdf. Accessed 28th August 2020.

2. British Orthopaedic Association [2020].

Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available from: www.boa.ac.uk/uploads/assets/ee39d8a89457-4533-9774e973c835246d/4e3170c2d85f-4162-a32500f54b1e3b1f/COVID-19BOASTs-Combined-FINAL.pdf. Accessed 28th August 2020.

3. Andersen GH, Jenkins PJ, McDonald DA, et al. Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital. BMJ Open.

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Features

Waiting for the knife – orthopaedic surgery in the time of COVID-19 Bibhas Roy and James Wilson

H

ealthcare has long recognised that rules are necessary to distribute medical resources equitably in situations of scarcity1. Various models are described, all require ‘triage’ in some way. This inevitably creates ethical questions and requires specific policies.

Bibhas Roy is a Consultant Orthopaedic Surgeon, Manchester University Foundation Trust.

James Wilson is an Upper Limb Consultant Surgeon from Bolton.

32 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

Waiting for care is a characteristic of many health systems; more so in publicly funded ones2. It is also clear that waiting times statistics exist mainly in countries with tax-financed health systems, rather than countries with health systems funded through contributions3.

The COVID-19 pandemic has affected and sometimes overwhelmed healthcare infrastructure and resources4 requiring concepts of ‘triage’ to be introduced.

Originating from the French verb ‘trier’ meaning ‘to sort’, triage has been used in healthcare primarily in ‘mass casualty’ incidents. Although used extensively in the military5, the concepts are also used in emergency departments6.

Effective triage is a specific skill, and authors have noted that ‘most who write scholarly articles on the subject have never practiced triage, or even witnessed it!’5.

It is also important to recognise that demands can create the need to ration medical equipment and interventions7, making concepts of resource allocation necessary for a complete solution.

The three components of triage are sorting, prioritising and allocating resources.8 Sorting requires assigning a ranked value or priority to what is being sorted, which inevitably creates a prioritisation hierarchy.

Resource allocation becomes necessary as the magnitude of the problem increases to an ‘overwhelming’ level, highlighting the concept of ‘the greatest good for the greatest number’ and implying a shift in decision making from a focus on individual patient outcomes to population-level outcomes.

These concepts are not new, with theories of utility described first in the 1700s, along with other philosophical principles such as the difference principles of justice, principle of equal chance etc9.

In addition, triage does not necessarily conform to modern ‘values’ of medicine such as autonomy – the right of the patient to choose treatment via informed consent and fidelity – the clinician is not always able to act on the best interest of individual patients, etc. A system that allocates the benefits of healthcare as well as the burden of limited or deferred care within the population is created.

“Waiting for care is a characteristic of many health systems; more so in publicly funded ones. It is also clear that waiting times statistics exist mainly in countries with tax-financed health systems, rather than countries with health systems funded through contributions.”

Elective orthopaedic surgery Systems to prioritise elective surgical patients10 and their validation have been discussed for many years11. These have addressed the entire patient pathway including the referral, the clinical symptom load, and the management of waiting lists2,10,12. In the setting of COVID-19, elective orthopaedic surgery has suffered particularly as the problem is perceived to be less important than other clinical scenarios such as cancer care13.

Features

Waiting is a key characteristic of the NHS and in the UK over 100,000 patients are waiting for joint replacement surgeries13. Unlike many aspects of the quality of care, waiting is relatively easy to measure and hence has received much attention14. Complex waiting list clinical prioritisation models in the NHS have not been adopted, and the simplistic first in first out (FIFO) model is used widely.

While FIFO is simple to use and can be a good tool to model healthcare demand, it uses arbitrary thresholds (i.e. 18 weeks) to prioritise lists. Combining waiting times with clinical variables to create better queuing systems have also been explored.

COVID-19 response At all institutional/governmental levels the COVID-19 pandemic response has considered systems adhering to the above principles.

Systems were optimised to care for COVID-19 patients with cancellation rates between 71.2– 87.4% for elective non-cancer surgery during the initial 12-week period following March 202015. Worldwide, possibly over 115 million operations have been cancelled16. Elective surgery has now restarted in most areas, and policies are in operation to process the procedures safely. There are examples where active surveillance of resource availability and case urgency have been taken into account to develop comprehensive policies17.

NHS surgical priority groups The Federation of Surgical Specialty Associations (FSSA) Guide was first produced at the request of NHS England at the start of the pandemic. The Guide states that “it is a short-term expedient to the pandemic and not for long term use” and it follows the prioritisation systems (P1-4) used in emergency departments5. Evaluating the potential benefit of a treatment to a patient, involves determining the incremental benefit of that treatment compared with receiving a less resource-intensive or delayed treatment, but rarely does this mean no treatment.

It is now recognised that the FSSA prioritisation system, especially the P3/P4 categories, is not valid for T&O but it does map to more familiar clinical systems (Table 1).

Category

P1 A P1 B P2 P3 P4

Urgency

Urgent Soon Routine

Timescale

<24 hrs <72 hours <1 month <3 Months >3 Months

Table 1: FSSA prioritisation mapped to more traditional prioritisation systems.

We acknowledge that waiting time is an important metric, RTT is measured routinely in the NHS, and should not be abandoned.

Without RTT management, it is possible that a patient will never reach the front of the queue.

If the FSSA categories are ‘abandoned’ a more discrete five-stage process could be developed. Appendix 1 illustrates a suggested process of managing an orthopaedic waiting list incorporating the FSSA P1-4, P5 and P6 categories into ones that are more familiar and have been used historically, so the ‘routine’ patients are managed more effectively.

However, we believe a composite system that considers both waiting time as well as clinical prioritisation elements is a better system to deliver elective services that are effective and equitable. We propose a modified RTT system, which takes into account, variables such as, demographics, clinical state (PROMs), state of deprivation etc. The modifiers added according to local agreements with weighting of these variables yet to be determined.

Examples are provided in Appendix 2.

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

Appendix 1 - SOP waiting list management Step one: Clinical prioritisation at the time of listing for surgery.

Step two: A technical validation of the waiting List data for current accuracy/completeness.

Step three: Contacting the patient to explain what is happening. They should receive indication of the likely waiting time,

how the categorisation works and which category they are in. They should be given contact details for questions or if their symptoms change. (Template letters are available from NHS England. See link below.) Patients may express the wish to be taken off the waiting List (TOWL), to postpone their surgery due to COVID-19 concerns (P5) or non-COVID-19 concerns (P6). They may also request a consultation to discuss things further.

Step four: Remote or face-to-face consultation with appropriate up-to-date imaging conducted in a COVID-secure manner. The patient/clinician explore the implications of proceeding with surgery versus delaying or pursuing alternative treatments. The discussion should follow the principles of shared decision making.

Again the outcomes are, remaining on the waiting list, P5, P6 or TOWL, which should be confirmed in writing to the patient and their GP. The patient remains free to change their mind but after 28 days, a GP re-referral would be required for a TOWL outcome.

Step Five: Planned review of patients waiting a long time for surgery including P5/ P6 cases. The review should consider whether the treatment type or complexity has changed. Discussion should include the impact of COVID-19 and the delay in treatment in terms of patient de-conditioning and options to mitigate this. It should also examine whether there is a need to alter the priority level. We recommend this is performed at least every six months3.

The BOA recommends that these consultations are scheduled and resourced with allocated appointments. The time taken to perform and document these reviews should be included in job planning. >>

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 33

Features

• NHS England template letters for patient communication www.england.nhs.uk/ coronavirus/publication/validatingwaiting-lists-framework/?preview=true.

• BOA and Specialist Society Position paper on caring for patients awaiting surgery www.boa.ac.uk/uploads/assets/cbe0c0ed40c3-405f-a5daffe7f8c2f350/BOAspecsoc-prioritisation-patient-reviewsFINAL-v11.pdf.

• Scottish Government - Coronavirus (COVID-19): supporting elective care clinical prioritisation framework www.gov. scot/publications/supporting-electivecare-clinical-prioritisation-framework/ pages/principles.

Appendix 2 - Modified RTT modelling modifiers to enhance RTT usability The Referral to Treatment Time (RTT) measure is well established as a means of monitoring and incentivising trusts to manage their waiting lists. Additional information can be combined with this one metric to improve this basic queuing model for a Modified RTT (MRTT).

This assessment of priority could continue to be measured in terms of weeks. Keeping the same units that we already use to retain a degree of realism and ease of interpretation.

Age modifier for RTT To illustrate this concept, we have fabricated a section of a waiting list and look at age as an additional factor in prioritisation. In general, older patients would have fewer years left to gain benefit from an intervention. Therefore trying to reduce the number of months or years on a waiting list with diminishing health is a reasonable justification to prioritise these cases.

Patient E, is an 82-year-old man awaiting TKR. He may have an RTT of 55 weeks, high by the standards of recent years (prior to the COVID-19 pandemic). Unfortunately this would not, by itself, increase his priority as many other individuals have waited longer for the same operation. However, if increased age were used to modify the RTT, his prioritisation may alter.

34 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

One way to effect this modification would be to calculate the number of years over 70 the patient is and increase the RTT by this.

As Patient E is 82 (12+70) he would get his RTT increased by 12%. Other models i.e., choosing a different age to start modifying the RTT or greater weightings, or a non-linear adjustment could all be considered to alter exactly how an age-modifier might perform.

The OKS is useful to help assess patients awaiting primary TKR and could be used for other knee pathologies although comparing across different conditions might require a generic quality of life PROM such as the EQ5D. Other patient demographics such as living alone, may also justify increasing their prioritisation such as living alone. A blanket modifier could be applied for this category e.g. RTT + 10%.

PROM modifier for RTT

As with any data manipulation exercise assumptions are made which are open to criticism. The chronological age of an individual does not necessarily govern their frailty or life expectancy, using specific PROMs for a group of patients with the same diagnosis may be useful but where a waiting list includes a diverse set of diagnoses then this would not be appropriate.

Using the generic health status score assumes that the reduced EQ5D is due to the problem they are listed for and that all orthopaedic problems have similar reductions in EQ5D for their severity.

Validated and standardised tools such as patient reported outcome measures (PROMs) are routinely collected pre- and post-operatively, for the NJR. They are designed to summarise and quantify symptom burden and impact on a patients’ life. The average pre-op OKS for patients awaiting primary knee replacement surgery is from 17-19 in large UK datasets18. Using this data, one could choose a value to allocate an additional priority weighting.

For example, if the OKS were below 17 then the RTT could be increased by an extra 2% per point. Again, other thresholds, weightings or non-linear adjustments could be used.

The intention would not be to produce an algorithm to replace clinical decision or assessment but to provide some relevant data in a structured fashion to help support the process of managing our swollen waiting lists. n

Name

Operation

RTT (Weeks)

Age

Age Modified (70) MRTT (Weeks)

Patient A

Right TKR

61

70

61+0

61

Patient B

Left TKR

59

61

59+0

59

Patient C

Left TKR

57

75

57+2.85

60

Patient D

Right TKR

56

86

56+8.9

65

Patient E

Right TKR

55

82

55+6.6

62

Name

Operation

RTT (Weeks)

OKS

PROM Modified (70) MRTT (Weeks)

Patient A

Right TKR

61

21

61+0

61

Patient B

Left TKR

59

18

59+0

59

Patient C

Left TKR

57

13

57+4.56

62

Patient D

Right TKR

56

31

56+0

56

Patient E

Right TKR

55

10

55+8.8

64

Age modifier for RTT.

PROM modifier for RTT.

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Visit us at the BOA – Stand 32 for further information JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 35

Education

BOFAS ‘Lectures of Distinction’: Experience and lessons learned from the launch of a National Virtual Educational Programme in foot and ankle surgery Yaser Ghani, Tim Williams, Robert Clayton and Rick Brown

T

Yaser Ghani is currently a Foot and Ankle Fellow at Imperial having completed his training on the Stanmore Rotation. His interest in medical education and surgical training led him to instigate the ‘Lectures of Distinction’ webinar series with BOFAS and he is now a member of the BOFAS Education Committee.

he global pandemic of Coronavirus disease 2019 (COVID-19) significantly affected the working patterns of UK Higher Surgical Trainees with many reassigned to ‘COVID-19 rotas’. Face-to-face post-graduate surgical teaching was cancelled in line with the UK National Social Distancing policies. A survey of the UK orthopaedic trainees during the COVID-19 pandemic demonstrated that the majority of trainees felt that the most significant areas affected were the reduction in the operative experience and of post-graduate teaching.

In response to this, the British Orthopaedic Foot and Ankle Society (BOFAS) Education Committee recognised the need to supplement the education of trainees and promptly designed a solution using online educational methods to develop a series of webinars covering the foot and ankle (F&A) topics of the FRCS Trauma and Orthopaedics (T&O) syllabus. These interactive weekly ‘BOFAS Lectures of Distinction’ (LoD) webinars are being delivered by leading F&A surgeons from the UK.

webinars was free of charge. It was presented as a video conference using ZoomTM for a maximum of 60 minutes in duration and included a didactic lecture lasting around 30 minutes, followed by an interactive session.

The interactive component allowed the attendees to post questions, participate in live polls, case-based discussions (CBDs), or mock viva practice. The webinar series was advertised via Training Programme Directors (TPDs), BOFAS members, trainee network groups and social media. After each live attendance a link was emailed to collect both quantitative and qualitative feedback. The final feedback summary was emailed to the lecturer for quality control and annual appraisal.

The webinar series was launched at the end of the first UK lockdown on the 6th July 2020 and continued until February 2021.

The webinar was recorded and this was subsequently made available for free access on both the BOFAS website (www.bofas.org.uk/ clinician/webinars/lectures-of-distinction) and the BOFAS Education YouTube channel.

Our response the Lectures of Distinction

Tim Williams is a Consultant Orthopaedic Surgeon at East Suffolk & North Essex Foundation Trust with a specialist interest in the Foot and Ankle. He is current secretary of the BOFAS Education Committee and moderator for the BOFAS ‘Lectures of Distinction’.

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28 core topics of Foot and Ankle surgery were selected from the ISCP syllabus and the standard of lecture was set at the FRCS T&O level. The BOFAS Webinar Team invited leading F&A surgeons from around the UK and Ireland. One Royal College of Surgeons of England (RCSEng) Continued Professional Development (CPD) point was accredited to each webinar.

Registration for the

Figure 1: Average feedback scores with 95% confidence intervals of the 28 lectures in each feedback domain.

Education

Feedback and reflection

Robert Clayton has been a Consultant Orthopaedic Surgeon in NHS Fife since 2010. He has an interest in elective and trauma surgery in all conditions of the Foot and Ankle, and is also interested in postgraduate specialist surgical training. He has served as Director of Media and Communications for BOFAS since 2017.

Rick Brown is a Consultant Orthopaedic Foot and Ankle Surgeon at The Nuffield Orthopaedic Centre, Oxford.

He is the Chairman of the BOFAS Education Committee.

He has been Course Director of many face-to-face courses and enjoyed the challenge of using technology in education and initiating several new online teaching courses.

A total of 2,709 attendances were recorded for all sessions, with a mean number of live attendees per webinar of 97 (range 39 - 259). The level of the participants ranged from UK Specialist Orthopaedic Registrars, Core trainees, Consultants, Podiatrists and Physiotherapists, as well as international Orthopaedic Trainees. A steady state of attendance was established from October with a monthly mean of 69 attendees per lecture.

Viewing on the BOFAS Education YouTube channel was more popular than we expected with 750 views within the first week of its launch, with 1,875 views in the first month and has reached over 13,000 views since the end of the first season.

Quantitative and qualitative data have been collected from 69.4% of attendees on the first season of 28 webinars. The five domains of the feedback are shown in Figure 1.

The illustrative quotes from the qualitative responses, shown in Table 1, suggested that the 30 minutes webinar format with CBDs and Q&A sessions was appropriate for their learning. Feedback also suggested that the topics were not only relevant for FRCS T&O preparation but also for the earlier years of higher surgical training. Some Consultant attendees also found it useful for their on-going CPD.

webinars were effective at fulfilling this need.

They can either be viewed live or later at a convenient time, or included as an adjunct to the restarted post-graduate teaching. A recent survey of the Scottish orthopaedic trainees demonstrated that there has been a high satisfaction rate with virtual teaching amongst these trainees since the pandemic.

Furthermore the majority of these trainees would like the e-learning format to become part of the formal teaching programme1.

There are a number of likely reasons for the success of the BOFAS LoD webinar series.

The quality of the teaching was due to careful selection of speakers, standard setting by a national surgical specialist society with clear standardised instructions to lecturers, incorporation of the views of experienced FRCS T&O examiners and responding to the high levels of feedback. Within the positive feedback, we found attendees wanted large topics to be split up and more FRCS T&O type ‘hot seat’ vivas and CBDs. These were incorporated to later lectures of distinction.

The award of CPD points from RCSEng further validated the high standard.

The recorded webinar technology allows interactivity, geographical flexibility without venue requirements, travel time or cost to either the trainer or trainee. A recent metaanalysis of 12 randomised controlled trials demonstrated that webinars were more effective than faceto-face classroom instructions and showed an increase in the knowledge and skill of the participants2. A recent four nations survey of over 100 orthopaedic trainees showed that 90% of participants were of the view that webinars should continue following the COVID-19 pandemic3.

One drawback is that it requires a robust infrastructure and set up to ensure Table 1: Examples of feedback comments received for the lectures. smooth running of the programme. In our series, the running costs and IT support Future use of webinars within were provided by our surgical specialist society, integrated surgical training BOFAS, and thus content was provided free of The BOFAS Lectures of Distinction (LoD) cost to the learner. In addition to the time of the webinar series was designed to address a lecturer, members from the BOFAS Education sudden pressing need for maintaining quality and the IT committee freely contributed their education and training when face-to-face time for planning and running the sessions. post-graduate training was greatly reduced A pre-lecture meeting was organised between around the UK. Our attendance figures the lecturer, technical support team, and feedback suggest these post-graduate moderator and any volunteer registrars. >>

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 37

Education

lectures may reduce the need to gather trainees in a single location. The gathering of health care workers for surgical education will continue to be scrutinised for cost effectiveness, time efficiency, environmental impact and personal safety.

Pre-learning with the LoDs will allow more time at the face-to-face courses to be spent in discussions with higher order thinking.

Conclusion The exceptional circumstances surrounding the COVID-19 pandemic prompted the introduction of remote webinar teaching of Foot and Ankle Surgery.

Our experience has shown that high quality, validated, structured learning opportunities can be provided using webinar technology that is easy to access either live or later at a more convenient time with no cost to trainees.

This study has shown the phenomenon of ‘webinar fatigue’. The mean attendance for the first two months was 155. However, there was then a significant drop off to a steady state of 65 for the following three months. This coincided with the return to normal working patterns including the on call trauma duties.

Several months after LoD first launched, there has also been a surge in non-validated orthopaedic webinars hosted by commercial organisations causing ‘webinar clash’.

For other societies and educationalists that wish to set up a similar programme, some of our key learning points, which we feel have contributed to success, are summarised in Table 2.

The BOFAS LoD webinar series could be the start of a potential wave of long-term change that we will see in education of Medicine and Surgery. These highly co-ordinated, validated, up-to-date, easily accessibility

This effective national post-graduate orthopaedic training can be delivered effectively and can be an augment to a regional teaching programme.

Acknowledgements The authors would like to show their gratitude to all the lecturers, Jo Millard, the BOFAS Administrator, Karan Malhotra, Shelain Patel, Matthew Welck, and the BOFAS IT Committee for continued support and help with the BOFAS LoD webinar series. n

References 1. MacDonald DRW, Neilly DW, McMillan TE, Stevenson IM and SCORE Collaborators On behalf of the SCottish Orthopaedic Research collaborativE (SCORE). Virtual orthopaedic teaching during COVID-19: Zooming around Scotland. Bulletin of The Royal College of Surgeons of England. 2021;103(1):44-9.

2. Gegenfurtner A, Ebner C. Webinars in higher education and professional training: a meta-analysis and systematic review of randomized controlled trials. Educ Res Rev. 2019;28:100293.

Table 2: Learning points, which have contributed to the success of this webinar series.

38 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

3. Gonzi G, Gwyn R, Rooney K, et al. The role of orthopaedic trainees during the COVID-19 pandemic and impact on post-graduate orthopaedic education: a four-nation survey of over 100 orthopaedic trainees. Bone Jt Open. 2020;1(11):676-82.

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Education

Future Leaders Programme – Why leadership matters Hiro Tanaka and Lisa Hadfield-Law “Before you are a leader, success is all about growing yourself.

When you become a leader, success is all about growing others.”

– Jack Welch

Why leadership matters

Hiro Tanaka is a Consultant Foot and Ankle Surgeon at Aneurin Bevan University Health Board.

He is a council member of the BOA and Editor for the JTO. He led the development of the Future Leaders Programme as Chair of the BOA Education Committee and currently runs the programme in partnership with Lisa Hadfield-Law.

Lisa Hadfield-Law has spent 20 years in clinical practice and surgical education. She has managed an orthopaedic/trauma service of a teaching hospital and has insight into the circumstances and challenges facing surgical teams. She is Education Advisor to the British Orthopaedic Association & AOUKI, and contributes to the T&O SAC, FST Advisory Board and ISCP Management group.

40 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

Over the last decade, the role of clinicians in the NHS as leaders of healthcare has been viewed as critically important in the delivery of patient safety and improving outcomes.

The shift away from increasing managerialism to engaging clinicians was encapsulated in a wave of policies published by the Department of Health in 2009: High Quality Care for All. Lord Ara Darzi had been appointed as health minister in 2007 and his vision was to put quality at the heart of the NHS. The need for clinicians as leaders has become even more pressing in the face of a global economic downturn and pandemic crisis because improving care within an environment of shrinking resources becomes a major challenge.

The transition from an individual clinician to a healthcare leader is a significant step, one which requires a change in selfimage, values, behaviours, knowledge and skills.

People understand the term leadership in different ways. Perhaps the most stereotypical view is that of the individual, powerful, charismatic leader who authoritatively manages a team or organisation.

Whilst many surgeons are appointed to management positions, this view of clinical leadership is somewhat

outdated, and the modern conceptualisation puts more emphasis on the process of leadership as opposed to the individual.

In a complex system such as healthcare, leadership is distributed and the responsibility of the clinician is to contribute to this process by nurturing and empowering the leadership capacity of others. This principle lies at the heart of the BOA Future Leaders Programme (FLP) and this article sets out its key learning outcomes. These outcomes are reflected in the 2021 T&O curriculum and the Medical Leadership Competency Framework [Figure 1) from the Academy of Medical Royal Colleges. >>

Figure 1 – Medical Leadership Competency Framework.

Education

The Action Learning Sets meet between sessions to share, reflect and challenge each other to improve their leadership skills.

3. Application to practice The fellows apply their knowledge and skills to their Ambition in Practice (AiP) which is the framework for a Quality Improvement Project (QIP). There is no expectation of the fellow to complete the project within the 12-month programme and it is important that their learning is focussed upon why and how to design an effective QIP. Afterall, QIPs which make the greatest and sustained changes to patient care often take years to come to fruition.

Where are we now?

FLP is a natural evolution of the BOA Clinical Leaders Programme which ran successfully for five years. The change in learning outcomes to the skills required to excel as an orthopaedic surgeon and to deliver quality improvement was necessary to reflect their needs in the early years of independent practice.

The third cohort of fellows will be starting the programme in 2021 which comprises four two-day modules over 12 months.

Each module is designed to be delivered in a face-to-face format although it has been adapted to a virtual format when necessary.

The selection of fellows has become increasingly competitive with demand for places exceeding capacity this year.

Fellows are awarded places either through trust funded positions or through specialist societies (BOFAS, BOA, BLRS, BASS, BHS, BOOS, BOTA/Postgraduate Orthopaedics, BSS, BSSH, WOC and Orthohub).

Individual applications are welcome from senior trainees, fellows, SAS doctors and newly appointed consultants.

Diversity is a core value of FLP and of the 31 fellows on the 2021 programme 30% are female. One third of fellows was in consultant posts at the start of the programme.

What are the key principles?

1. Each fellow has a unique journey FLP is best viewed as a learning journey where the programme facilitates the development of the fellow into the role of a clinical leader through reflection and experimentation. The concept that emerging leaders can be identified by their personality traits and that leadership can be taught in the traditional sense have not been realised despite vast amounts of literature. It is essential that fellows have the freedom to develop their own vision for their role as leaders in T&O regardless of whether they take on academic, educational, clinical, managerial or national roles.

“The need for clinicians as leaders has become even more pressing in the face of a global economic downturn and pandemic crisis because improving care within an environment of shrinking resources becomes a major challenge.”

42 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

2. Action learning Action learning therefore forms an integral part of the programme with fellows allocated to networking groups.

4. Reference to theory The curriculum of the programme is grounded in established leadership theory and as students of leadership, fellows are encouraged to use the lexicon, continue selfdirected learning of Quality Improvement methodology and to use the skills in everyday practice.

5. Alumni of BOA Future Leaders As the fellow completes the programme, they join a family of like-minded colleagues and can draw on the support and experience of a network of leaders.

With every annual cohort, the cadre of FLP fellows becomes larger and there is a celebration and networking event at each BOA Annual Congress.

What is the programme framework?

The four-stage format of the programme is designed to start with the individual fellow so that they develop an awareness of their own values, beliefs and behaviours. Once the foundation of leadership has been established, only then will they be able to effectively apply the technical and relational elements of leadership. The final session explores the context in which they lead whether it be at a local or national level.

This model is reproducible at deanery level and with the introduction of the new curriculum, trainees can be trained in these areas to meet the requirements of Generic Professional Capabilities.

Education

Aims and learning outcomes of the programme Session 3 - Relational leadership.

Session 1 – Personal leadership.

Leadership theory

• Define the evolution of theories of leadership (Great Man, Trait, Servant) • Development of emotional intelligence (Goleman) • Critically analyse what type of leadership is required within the NHS

Personality in leadership

• Analyse aspects of personality which will help or hinder their role as a leader • Consider the impact of Kahlers Drivers and their personality traits on their leadership role

Leadership style theory

• Define leadership styles (Goleman) • Plan how to use styles flexibly in practice • Identify options for practice in their workplace

Resilient leadership

• Explain the impact upon stress on behaviour and consequence upon others • Use tools for becoming a more resilient leader (Duckworth, Peters, Seligman)

Conflict

• Differentiate between conflict resolution styles (Robin) • Assess their own conflict resolution style • Apply strategies for maximising benefits and minimising damage resulting from conflict

Feedback, coaching and reflection

• Define the role of reflection, feedback and coaching for leaders • Explain the: o Advocacy enquiry model for debriefing o GROW model for coaching • Adapt to different contexts

Session 2 - Technical leadership.

What is quality?

Quality Improvement science

Experienced based codesign & qualitative data

Stakeholder mapping

• Establish a foundation of the principles of quality within healthcare • Explain what improving quality means • Describe how QI has evolved, relating to future strategy setting • Run Chart • Statistical Control Chart • Lean • Process Mapping • Flow/Lean Six Sigma • Model for Improvement (Deming PDSA) • Root Cause Analysis • Care Bundles/Checklists • Define the role of data • Critique faculty experience of: o Shadowing o Integrating experience into process mapping o Qualitative data analysis o Schwartz rounds • Identify key stakeholders with whom they need to engage on their project • Explain why and how they might do this • Identify how they link with each other • Integrate their knowledge of individual personalities and drivers

Social awareness

• Relate principles of transactional analysis to improve communication and recognise dysfunctional relationships (Berne) • Articulate their values, beliefs and identity using the principles of Life Scripts and Drivers • Manage cognitive bias and apply Unconditional Positive Regard (Kahneman, Rogers) • Use and read body language and micro-expressions to improve communication

High impact presentation

• Apply Monroe’s Motivated Sequence • Use appropriate body language and eye contact • Handle questions • Manage nerves

Reframing conflict

• Select the most useful framework for reflection for them • Review their own conflict scenarios with feedback from others • Identify potential spark points in their QI plans

Social management

• Apply principles of negotiation to achieve win/win scenarios • Communicate with assertiveness • Communicate with positivity and be aware of the culture of critique • Develop skills to manage difficult people • Demonstrate influence in leadership style

Session 4 - Contextual leadership.

Organisational culture

• Apply principles of organisational culture to read their immediate context (Schein) • Use appreciative inquiry to lead change in culture • Adapt leadership style with respect to authority position

Effective chairing

• Preparation to be able to facilitate the most productive meetings • Utilise social awareness and management skills to maximise engagement and inclusivity • Ensure that innovation turns into action

Power and networking

• Apply power effectively in leading change • Establish networks to enhance leadership at a wider level

Scaling up a QIP

• Technical and experiential tips from guest speakers

Shifting culture Leading at a national level

Conclusion There can be no doubt that recent events will result in a fundamental shift in the way in which the NHS delivers services. The impact upon the day-to-day functions of a T&O consultant, the expectations of their performance and the long-term effects upon their career must not be underestimated. As a professional body (BOA), we should do whatever we can to ensure that high quality patient care is protected and future colleagues are trained to flourish in an ever changing environment. Our future leaders will need a constant reminder of the words of Reinhold Niebuhr: “Grant me the serenity to accept the things I cannot change, the courage to change the things that I can and the wisdom to know the difference.” n

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 43

Features

Reflections of an octogenarian skeletal trauma surgeon Christopher Colton

Last year, I was invited to write a letter to myself as a final year medical student exhorting me to consider a career in Trauma and Orthopaedics.

I wrote: “Dear Chris,

Chris Colton is Professor Emeritus in Orthopaedic and Accident Surgery at the University of Nottingham and was a Consultant Orthopaedic, Trauma and Paediatric Orthopaedic Surgeon at Nottingham University Hospital for more than 20 years. He was an ABC Travelling fellow, BOA President, Founding Trustee and Lifetime Honorary Member of the Board of Trustees of the AO Foundation.

You are nearing the end of your time as a medical student, and I know that you will do well. Remember that it does not mean that you know everything, you simply knew enough!

I warn you that this is not the top of the ladder, just a chance to stand on the bottom of the next one. There will always be another ladder, but that is the essence of medicine – a lifetime of learning and challenge.

Never forget that you have a bounden duty of care to your patients, your colleagues, your profession, and to yourself.

Your journey ahead can take many pathways and only you can choose which. My instinct is that you are more a surgeon than a physician; should you select a surgical route, remember that you are first and foremost a doctor… one who also operates. Surgery is fun, but the hallmark of a good surgeon is to know when not to operate.

Permit me to dangle before you an enticing prospect. The specialty of Trauma and Orthopaedics is initially seductive by virtue of the drama, dare I say glamour, and immediacy of managing the injured. But, T&O is more than that and, whereas the trauma element is the portal of entry for

44 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk

many a young surgeon, there is much to elective orthopaedics.

In the past, orthopaedic surgeons were thought of as front-row forwards with a hammer in hand, but T&O has changed beyond all recognition in the last few decades.

You would enjoy a firm scientific basis for musculoskeletal surgery, a massive expansion in our biomechanical understanding, an explosion of investigative techniques and there is now available a huge inventory of relevant instrumentation.

Fifty years ago, an orthopaedic surgeon was expected to cover the whole field. With all the developments mentioned here, there has arisen an imperative to focus down to subspecialties.

This academic diversification includes posttrauma reconstruction, hand and upper limb surgery, pelvic and acetabular surgery, foot and ankle, shoulder, spinal surgery, bone tumours – and who knows what in the future, in any of these areas?

There are great opportunities for teaching and research.

Chris, whatever you decide, always remember that surgery is not a science, it is a scientific art: the art is two-fold. The first is the art of handling tissues with biological finesse and delicacy; the second is the art of handling your patients and their near ones with respect, humanity and humility.”

Features

I recall my first biology lesson, during which I was fascinated to see, for the first time, a human skeleton – not a plastic model such as would be used today – and was mesmerised by the thought that it once supported a human being. I went home and told my parents that I wanted to work with human bones. My father suggested osteopathy. Thereafter I was set on osteopathy, until one Christmas at a hotel, in Herne Bay, I got into conversation with a mature gentleman as he sipped his pink gin, and told him that I wanted to be an osteopath.

He almost choked on his Gordon’s and told me to become an orthopaedic surgeon, like him. Who he was, I have no idea, but thereafter orthopaedics was my goal.

I have no major regrets and can reflect on a satisfying journey. Trauma always exerted great traction on my interests and after five years as a general T&O consultant, the opportunity presented itself to ditch adult elective work, and I grabbed the chance to focus on trauma and paediatric orthopaedics.

The rest of my professional trajectory was set.

Although I had no medico-political aspirations, I got drawn into being active in the BOA and also in the AO Foundation. To my astonishment, I ended up as president of each.

Such honours are heady stuff and I confess that I revelled in the limelight and the travelling in style, notching up air miles by the bucketful.

These subsidised my passion of warm-water SCUBA diving that I took up in my sixties; I finally became a Master Diver, notching up over 600 dives before having to stop at 80 years of age because of respiratory disease.

With AO, I lived through an exciting period of development of fracture surgery and its scientific basis. I now feel that the future focus in trauma care should not be the invention of ever-sophisticated and increasingly expensive implants and instruments, but to focus on bringing modern osteosynthesis to that 75% of the world who are priced out of the market.

Let us bring low-cost fracture-care techniques to the LMICs. As a founder member of the AO Alliance Foundation (https://ao-alliance. org/), I champion its raison d’être.

I developed an interest in clinical research and thoroughly enjoyed contributing to many publications. This inevitably led to teaching activities and a number of Visiting Professorships. The greatest honour, however, was a Special Professorship awarded to me by Nottingham University for contributions to research and education.

This was my proudest achievement.

When I was younger, I enjoyed oil-painting (Figure 1), and this translated into a skill with computer graphics in the creation of visual aids for teaching. This became more of a hobby than an educational endeavour.

Figure 1: An early Provençal scene painted using a palette knife.

I was delighted to have been asked by the International Civil Aviation Authority’s cabin safety group to create the graphics of their recent report (Figure 2)

Similarly, the injury is not what you see on an X-ray, or scan – that’s just a broken bone – but, as Stanley Boyd said in 1895: ”The most important divisions of fractures – simple, compound and complicated – are based upon the condition of the soft parts; less important varieties rest upon the condition of the bone”3.

Who most inspired me along the way?

Figure 2: Graphic of escape from smoke-filled cabin.

The challenge of treating fractures comprises a sound knowledge of mechanics and of the biology of bone healing. It is this discipline of biomechanics that lies at the heart of being a fracture surgeon. In December, 1914, Dr Miller E. Preston of Denver addressed Medical Society of the City and County of Denver and stated: “The internal fixation of a fracture is decidedly an engineering problem, as well as a surgical procedure…”1.

Arguably, he was the father of fracture biomechanics.

The thrill of fracture care is that every fracture is different and every fracture patient is different, expressed by EA Nicoll as the “personality of the fracture”2. The individuality of the decisionmaking in every fracture problem, requires the surgeon to understand each patient, and to tailor his/her approach to the patient’s needs, fears and expectations, and with children to understand the family context.

When I was a registrar in Bristol, my wonderful mentor was Keith Lucas (Figure 3).

Without his support and encouragement, I would have given up.

I did cross swords with a certain consultant Figure 3: Keith Lucas. but it was the paternal encouragement of the beloved Keith Lucas, who had faith in me, that carried me through and led me to secure a registrar position at the RNOH in London.

There, I worked for two six-month periods with Lorden Trickey (Figure 4). I came to admire him unreservedly for his clinical acumen and, above all, for his immaculate surgical technique. It was a joy to see him operate and to learn from him. He never made one move Figure 4: Lorden Trickey. surgically that didn’t advance the procedure, and his reverence for the soft tissues was a true inspiration. >>

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 45

Features

I shall single out another – Nicholas Barton in Nottingham. He supported me hugely in my early consultant days as I fought for modern fracture care whilst facing a certain resistance from more conservative seniors. I believe that my philosophy and use of modern principles earned acceptance and respect.

Finally, I pay tribute to Maurice Müller of Bern, Switzerland. He was the intellectual powerhouse of AO. What inspired me about him? He was a brilliant technical surgeon – to watch him operate was magical: he was an accomplished conjuror and his brilliance at surgery evoked the same admiration as his baffling legerdemain. Additionally, he was the quintessential lateral-thinker and inventor: finally, he was friendly and approachable, with a wicked sense of humour. What a privilege to have spent many hours on many occasions and in many settings in his company. His life has been wonderfully encapsulated by Joseph Schatzker in “Maurice Edmond Müller – In His Own Words”4.

Figure 5: Doing what I loved best in retirement.

What would I (or should I) have done differently?

Not a lot. Each step that one takes along the professional path seems the best idea at the time and I seem to have been blessed with a certain intuitive capacity to do the right thing.

What was my best achievement?

This is a difficult question. My gut feeling is that my post-graduate teaching – clinical, didactic and as a mentor, is the vapour-trail that I am proud to have left behind. Bernard de Chartres said, in 1120: “We are as dwarves on the shoulders of giants, so that we can see more than them…”5, later plagiarised by Isaac Newton in 1676 in a letter to Robert Hooke.

I hope that I have been such a set of shoulders.

The establishment, by John Webb and myself, of the Nottingham Fracture Forum, which celebrates its 40th year in 2021, has moulded the attitudes of countless senior registrars to fracture surgery, and has become a template for similar initiatives abroad, notably the New England Fracture Forum.

I believe also that I have been a ‘good doctor’ in the holistic sense, connecting with the essence of my patients: a surgeon is a ‘doctor’ who happens also to operate.

“I would say to would-be T&O educators that you must know your stuff, don’t pretend that you know something that you don’t, and don’t be afraid, when questioned, to admit that you don’t know – “but I shall find out and tell you later.” The art of education requires knowledge, confidence and flair, as well as the ability to connect with your audience.”

I would say to wouldbe T&O educators that you must know your stuff, don’t pretend that you know something that you don’t, and don’t be afraid, when questioned, to admit that you don’t know – “but I shall find out and tell you later.” The art of education requires knowledge, confidence and flair, as well as the ability to connect with your audience.

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I have, in fact, treated a few high-profile patients, but that is not for what I should wish to be remembered.

They were no more important than all my other patients.

Just a bit more scary!

What of the future?

This is tricky as I have some health problems, and we currently endure the battle against COVID-19 pestilence.

I greatly miss diving (Figure 5). I look forwards to as many days as I have, in the company of my wife, enjoying reading, some editing, photography, walking

(on the flat and rather slowly). The light at the end of this tunnel would be an easing of restrictions and reconnecting with my wider family. After a very busy life, my aspirations for the future are modest and realistic.

In conclusion, I make no apology for leaving you with a reiteration of my advice to myself as a medical student: “Chris, whatever you decide, always remember that surgery is not a science, it is a scientific art: the art is two-fold. The first is the art of handling tissues with biological finesse and delicacy; the second is the art of handling your patients and their near ones with respect, humanity and humility.” n

References 1. Preston ME. Conservatism in the operative treatment of fractures. Colo Med 1916;13:83-8.

2. Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964;46:373-87.

3. Boyd, S. A System of Surgery by Frederick Treves, Cassell and Co., London, 1895.

Page 734 4. AO Foundation (2018). Maurice Edmond Müller—In His Own Words. Available at: https://aotrauma.aofoundation. org/-/media/project/aocmf/aotrauma/ documents/news/2018/aof_mem-in-hisown-words.pdf.

5. John of Salisbury 1159, Metalogicon.

Trainee

Tourniquet safety – case report and national survey: Tourniquets in Orthopaedic Practice Study (TOPS) Caesar Wek, Alice Wales, Jonathan C Compson and Ines LH Reichert

A

recent complication directly attributed to the use of a tourniquet at our institution has highlighted the significant level of harm that a chemical burn may cause to the patient. This incident prompted a review of tourniquet practice, in particular to aspects of safety and teaching.

Caesar Wek is an ST8 Orthopaedic Registrar in London, on the South East Thames Training Rotation.

Tourniquets are frequently used during extremity surgery in trauma and orthopaedic surgery to provide a bloodless field. However, tourniquet use is not without its risks and complications range from mild skin irritation to a slow-healing chemical burn as well as temporary paraesthesia to nerve damage and paralysis1,2.

The historical use of tourniquets dates back to the ancient Romans (199 BCE – 500CE) who used non-pneumatic bronze and leather devices to control bleeding when performing amputations on the battlefield3. The actual term ‘tourniquet’ was coined in the 1700s by Jean Louis Petit, a derivation of the French term tourner (‘to turn’)4. His simple device was a screw-like mechanism (see Figure 1) that was revolutionary in providing a constant pressure without the use of an assistant.

Alice Wales is the mother of the patient. She holds an MA (Nat Sci) from Cambridge University and is a Chartered UK and European Patent Attorney at Abel & Imray, specialising in life sciences and medical devices and methods.

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Following the advent of general anaesthesia, Joseph Lister performed the first non-amputation surgeries with a tourniquet in 1864, using this device to create a bloodless surgical field5.

Later, Friedrich von Esmarch created the flat rubber bandage that now bears his name and in the early 1900s, Harvey Cushing developed the pneumatic tourniquet, a variant of which is still used today3.

Figure 1: Petit tourniquet engraving from 1798.

This original design was further modified in the 1980s by James McEwen, who invented the modern microcomputer tourniquet. This top-of-the-range tourniquet device not only monitors tourniquet pressure but also leakage, inflation time, and various other parameters such as the Limb Occlusion Pressure (LOP)6.

The technique of tourniquet application varies amongst surgeons and at present there is a paucity of guidance for tourniquet use in the United Kingdom. Furthermore, the use of tourniquets may give rise to complications and preventable damage due to over-pressurisation, insufficient sealing, and prolonged application.

The aim of this study was to 1) establish current training and practice in the UK and 2) to estimate the incidence of post-tourniquet complications.

Our case report An eleven-year old girl required extensive release of her elbow joint including removal of heterotopic ossification and metal work a year following a complex elbow injury and fixation.

She was operated on in October 2019 as a joint procedure by two upper limb consultants. She was placed in a lateral position and a high upper arm paediatric-sized tourniquet was applied with standard wool padding and occlusive tape.

Standard surgical prep, alcoholic-based povidone iodine followed by alcoholic chlorhexidine was used and the upper arm was dried before surgical drapes were applied. The tourniquet time was recorded as 2 hours 6 minutes at a standard pressure setting for upper limb or slightly below, adjusted to blood pressure, but not clearly documented as such. No visible sign of injury was recorded in the notes immediately following removal of the tourniquet. The first sign of injury was noted on the following day when a painful purple area of inflammation was observed on the inside of her upper limb. This was initially considered to be pressure damage only, but developed rapidly over the following days into a sore approximately 7 x 6cm in size with superficial skin loss and de-roofed serous blisters. The paediatric tissue viability nurse was involved on one occasion and provided dressings but no ongoing treatment. After discharge from hospital, the wound deteriorated further

Trainee

to deep full thickness skin loss. Two courses of Flucloxacillin were prescribed for S.aureus infection of the wound. The soreness and pain of the wound complicated post-operative mobilisation significantly and the wound took in total around 6-8 months to heal. Treatment of a residual scar is ongoing.

Jonathan Compson is an Upper Limb Surgeon (elbow, wrist and hand) at Kings College Hospital, London. He has 25 years of tertiary referral practice and treating complex trauma. He is a previous council member of BSSH.

A questionnaire was constructed based on current practice and available standards from the Association of Surgical Technologists (AST, United States of America) for recommended practice of tourniquet application7. The survey was distributed primarily but not exclusively to orthopaedic trainees nationally with the support of the British Orthopaedic Trainees Association (BOTA). The key aspects that the survey aimed to assess amongst the survey respondents were: • Pre-operative tourniquet consent and WHO checklist • Tourniquet application and technique • Tourniquet type and padding • Tourniquet seal and skin prep solutions • Limb exsanguination and inflation pressure • Tourniquet complications • Tourniquet teaching and training

Figure 2a: Tourniquet related wound caused by a chemical burn at the inside of the upper arm in an 11-year-old girl, day 9.

The questionnaire was in the form of 26 shortanswer questions using the online platform Google forms (Google LLC, California, USA), see appendix.

Ines Reichert is a Consultant Trauma & Orthopaedic Surgeon at King’s College Hospital London with an interest in Trauma, Upper Limb (hand/ wrist) and Diabetic Foot. She has completed a PhD at Imperial College and has maintained an active involvement in research clinical and basic science. She serves presently as Treasurer on the Executive Board of the British Orthopaedic Research Society.

Learning points Examples of the wound at the inner aspect of the upper arm caused predominantly by the chemical burn related to the tourniquet are shown at four time points (Figure 2a – d). The incident highlighted a number of shortcomings:

Figure 2b: Tourniquet related wound day 23.

1. Requirement for consistent standard recording of tourniquet time and pressure.

2. Differentiated selection of tourniquet pressure taking site (upper / lower limb), blood pressure and age (adult / paediatric) into account.

3. Consider informed consent of a tourniquet complication.

4. Establish pathway for post-tourniquet identification of an adverse event, e.g. early recognition and documentation of any injury to skin, but also awareness of wool padding/ any sign of leakage of prep solution and establish pathways of treatment when a complication has been identified.

Figure 2c: Tourniquet related wound day 94.

5. Emphasis and inclusion of teaching on rationale / risks and benefits of tourniquet application to increase awareness of pre-, intra- and post-operative complications.

These shortcomings are both individual and institutional, and have been addressed in a national survey directed predominantly to trainees. >>

Figure 2d: Tourniquet related scar day 601.

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 49

Trainee

89.6% of those surveyed used alcoholic chlorhexidine for skin prep with 30.4% using aqueous chlorhexidine. 48.7% of respondents used alcoholic-based povidone iodine with 36.5% using aqueous povidone iodine.

Figure 3: Breakdown of respondents.

National survey A total of 118 completed questionnaires were collected for analysis. The respondents were comprised of 81.1% of ST3-ST8 Trainees, 10.3% Consultants, 2.6% Senior Clinical Fellows, and 6% Trust Specialist Registrars (see Figure 2). The majority of respondents were from England with 35.9% based in a District General Hospital (DGH) and 23.9% based at a Major Trauma Centre (MTC).

Pre-operative tourniquet consent and WHO checklist 82.9% of respondents reported that they did not include tourniquet use and/ or tourniquet-related complications in their consent for procedures. 17.8-22.2% of respondents indicated they believed a check of the tourniquet site was included at some stage in the WHO checklist but 48.7% of the respondents were clear that there was no inclusion in the WHO checklist.

Figure 4: Tourniquet-related complications.

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Tourniquet application and responsibility 83.8% of respondents indicated that the trainee predominantly applies the tourniquet cuff, with 88% of respondents stating that they understand the orthopaedic consultant has ultimate responsibility for final tourniquet position.

Tourniquet type and padding 48.7% of respondents reported that they used a sterile tourniquet for certain cases with arthroplasty being the most frequent, followed by sarcoma resection and combined orthoplastic cases. All respondents surveyed used padding with tourniquets, with wool padding used in 92.3% of cases and 24.8% used stockinette as an adjunct.

Tourniquet seal and skin prep solutions A U-drape was used as seal by 71.8% of respondents, with a plastic occlusive sleeve used by 38.5% and sleek tape used as by 22.2%.

60% of respondents used specialist tourniquets in high BMI individuals. In elective surgery,

Limb exsanguination and inflation pressure For upper limb surgery, 76.9% of individuals used elevation alone, with 43.6% using a crepe bandage as an adjunct and 31.6% using the Rhys-Davies exsanguinator.

In lower limb surgery, 76.1% of individuals used elevation alone, with 18.8% using a crepe bandage as an adjunct and 33.3% using the Rhys-Davies exsanguinator. Most respondents consider limb site (80.3%) and patient blood pressure (82.1%) when setting the tourniquet pressure. The respondents considered patient age in 30.8% of cases and limb size in 26.5% of cases. The Limb Occlusion Pressure (LOP) was considered a major factor by only 8.5% of respondents. The most commonly used inflation pressure in paediatric upper limb cases was 200 mmHg or less (32.5%), however 16.2% of respondents used pressures of 201-250 mmHg. In adult upper limb cases, the most used pressure was 201-250 mmHg (73.5%), with 15.4% of respondents using 250-300 mmHg. Tourniquet complications 37.1% of respondents reported observing a tourniquet-related complication (see Figure 4). The most common complications reported were: post-operative tourniquet pain (69.6%), contusion (43%), nerve-related injuries (24.1%), chemical burns (13.9%) and pressure sores (6.3%). >>

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For further information, please email JAS@mediuk.co.uk or call 01432 373500 JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 51

Trainee

Our results also indicated that tourniquet inflation pressures are often pre-selected using set pressures not necessarily individualised to limb size or systolic blood pressure.

In paediatric cases, it is recommended that tourniquet pressures are 50 mmHg above systolic9. In adults, a tourniquet pressure of systolic blood pressure plus 70-130 mmHg for the lower limb and 50-100 mmHg for the upper limb10.

Tourniquet training Of the 118 respondents, 105 (89.7%) reported having never received any formal training in tourniquet applications. 6% received training in tourniquet application and only 1.7% received training in tourniquet safety.

4.3% were unsure if this had been provided.

Recommendations The tourniquet is routinely used in operating theatres with various designs used in more than 15,000 procedures every day3.

When utilised correctly, the limb tourniquet is a safe and an invaluable tool for the surgeon and anaesthetist which helps improve patient outcome by reducing blood loss and operating time4. Most tourniquetrelated complications are preventable.

However, when these do occur they have a significant impact on patient outcomes and may have medicolegal implications8.

Furthermore, as seen in the case reported herein, a tourniquet complication may impair patient rehabilitation, cause significant distress and prolong recovery with longerterm and potentially permanent physical and psychological implications for the patient.

The results from our survey indicated that 89.7% of respondents received no formal training in tourniquet application and safety. A variety of methods were used to determine tourniquet application regarding padding, seal, and pressure. 82.9% of respondents did not routinely record tourniquet-related complications in the consent form.

48.7% of respondents reported that tourniquets were not included in the WHO checklist and there was little clarity as to who would be responsible for checking and documenting the tourniquet site post-surgery.

“Approximately 37.1% of respondents have experienced tourniquetrelated complications.

These varied from postoperative tourniquet pain and contusion to more serious chemical burns and nerve-related injuries.

These injuries may be preventable with careful tourniquet practice.”

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Approximately 37.1% of respondents have experienced tourniquet-related complications. These varied from post-operative tourniquet pain and contusion to more serious chemical burns and nerve-related injuries. These injuries may be preventable with careful tourniquet practice.

The number of individuals reporting tourniquet-related complications was higher than the 10% reported by Sadri et al. (2010)11. The survey is a voluntary snapshot across trainees and captured responses from about a third of trainees. There might have been reporting bias as trainees with first-hand experience of tourniquet problems might have been more inclined to take part in the survey.

Furthermore, the questions were frequently constructed to allow several answers, e.g. ‘all that apply’ and percentage numbers will need to be interpreted accordingly.

Importantly, it should be noted that only 1.6% of respondents reported receiving training in safe tourniquet practice. This is remarkable as tourniquet application is routine in orthopaedic and trauma surgery. The apprenticeship model of training has failed to include theoretical teaching on risks and safety of tourniquet application and use. We feel that in addition to the development of national guidelines for optimising tourniquet cuff pressure and technique, trainees should receive formal training in safe tourniquet practice and application and education as to the risks, identification and handling of tourniquet complications. n Editor Note: The BOA Orthopaedic Committee is also making final preparations on a new BOAST ‘The Safe Use of Intraoperative Tourniquets’, which will be published in September.

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

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Medico-legal

Drilling down into orthopaedic claims Gemma Taylor and Andy Norman The MDU recently analysed more than 400 claims notified to us in a recent five-year period by members working in independent orthopaedic practice and the issues that lie behind such claims.

Gemma Taylor was a GP partner before working for Bupa as a lead physician. She joined the MDU in 2017 and is now a high value medical claims handler, having gained qualifications in legal medicine and insurance.

W

e successfully defended 78% of the cases in this review, without paying compensation to the patient. However, a claim for clinical negligence can be brought many years after the incident occurred, often without warning. Our expert claims handlers and medico-legal advisers understand how stressful this can be and the importance of mounting a robust defence of your position.

Compensation is awarded with the aim of returning the patient to the position that they would have been in had the negligence not occurred.

If the injury suffered is such that the person can no longer work and requires a significant level of care, then considerable damages will be paid. The size of damages does not reflect the magnitude of the clinical error, but the injury to the patient.

Andy Norman has worked in personal injury litigation, before specialising in clinical negligence litigation initially with NHSR and at the MDU as a senior claims handler.

Reasons for claims The majority of claims files that the MDU received were due to one of four reasons: post-operative complications, delayed diagnosis, intra-operative complications and consent. Below we look at some of the most common allegations for each area.

Post-operative complications Post-operative complications featured in almost half of the claims examined.

Allegations included: • Long-term pain.

• Poor healing and wound infection.

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• Radial nerve damage and significant loss of function due to inadequate nerve protection during surgical fixation of the humerus.

• Femoral nerve damage following knee surgery leading to reduced mobility.

• Non-union of fractures due to poor surgical technique; for example, malpositioning.

• The use of wrong-sized implants and the failure of surgical components post-surgery.

• Inadequate post-operative wound management; for example, an above-knee amputation following total knee replacement.

• Post-operative wound infection. In some cases, this led to the failure of joint replacements leading to revision surgery.

Delayed diagnosis Allegations of delayed diagnosis or referral featured in around 15% of cases. Diagnoses that were allegedly missed or delayed included: • • • • • • • •

Tendon ruptures Sarcoma Meningitis Vascular necrosis Ligament/cartilage tears Osteomyelitis Dislocations Nerve damage

Intra-operative issues Ten per cent of claims alleged poor operative technique, during the course of a procedure.

Such allegations included:

Medico-legal

• Equipment or other foreign body left in the patient after surgery.

• Chemical or diathermy burns, scarring or nerve damage.

• Incorrect equipment used or the lack of available equipment resulting in surgical procedures being abandoned, delayed treatment and additional procedures required.

• Severe bleeding due to perforation or puncture injury.

• Nerve damage due to poor operative technique; for example, damage to the sciatic nerve during a total hip replacement, resulting in foot drop.

• Intraoperative fractures, such as a femoral neck fracture during hip resurfacing surgery.

Consent Consent issues featured in many cases, but 10% of claims involved allegations centred on inadequate consent. The consent process is paramount in managing the patient’s realistic expectations.

Failure to either manage those expectations or adequately explain the risks and benefits of the procedure was a common theme across the cohort of claims.

In a number of cases, it was alleged the risk of a worse outcome or long-term damage, including nerve damage, wasn’t properly explained.

Consent cases are often difficult to defend and it is vital to be aware of the impact of recent judgments such as Montgomery v Lanarkshire Health Board (2015) and the GMC’s updated guidance on Decision Making and Consent.

Record-keeping is vital. Without a thorough contemporaneous record of the detailed discussion with the patient about potential risks and benefits, a surgeon can find it difficult to defend allegations of consent, even where their usual practice is to discuss such issues.

Managing risks Claims involving orthopaedic surgeons are made for a variety of reasons, but there are some common risk factors, which, if managed appropriately, can help to reduce risks.

These include: • Provide patients with detailed information on all treatment options verbally and in writing and ensure they have appropriate time to make a decision.

• Consider more conservative treatment options and whether all avenues have been exhausted before recommending invasive procedures to patients – particularly in spinal or joint replacement surgery.

• See the patient ‘as a whole’ not just the isolated issue at hand. This includes consideration of comorbidities and psychological factors.

• Give appropriate safety netting advice so the patient knows in what circumstances to return for further advice.

• Keep detailed records of your discussions with patients including any phone calls by you or your administrative team. Record discussions with other clinicians: GPs, outof-hours clinicians and other consultants involved in the care process. Many claims are brought a considerable time after events in question, so records can be vital.

• Make sure that the full range of equipment and necessary components are available when operating in the private setting.

Consider an urgent referral to an NHS hospital if necessary.

• Be aware of the increased difficulties when operating on morbidly obese patients.

Have a lower threshold for closer post-operative follow-up and early investigation of possible complications and consider whether it is more appropriate for these patients to be treated in an NHS setting with highdependency care available if needed.

• Ensure you have robust post-operative arrangements for patients in the private setting. Remember that you must be contactable or provide appropriate cover and must arrange for prompt assessment of the patient in the event of any issues.

• Consider your professional duty of candour. If something goes wrong, apologise and notify the patient and any necessary parties as soon as possible.

• While orthopaedic claim numbers have not increased in recent years, the cost of claims has spiralled. This is not due to clinical standards but to a deteriorating legal environment which the MDU is campaigning to reform.

See more at: www.themdu.com/faircomp. n This article was originally published in Independent Practitioner Today, April 2021.

JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk | 55

International

Education and training in orthopaedic oncology in Ethiopia; CURE & Black Lion COSECSA course Max Gibbons (Co Authors: Duncan Whitwell, David Wood, Flora Gibbons, Biruk Wamisho, Gelataw Tessema and Richard Gardner) The first Orthopaedic Oncology Course was in 2014 at the CURE Ethiopia Children’s Hospital and Tikur Anbessa Specialised Hospital in 2015 and the fourth review course planned for 2021.

I

n 2012 the College of Surgeons of East Central and Southern Africa (COSECSA) with Oxford University established the first Paediatric Trauma and Orthopaedic Surgery Course. The Programme was proposed to improve trauma management in sub-Saharan Africa through education, training and research.

Max Gibbons trained in Oxford and London and is a Consultant Orthopaedic Surgeon and Specialist in Orthopaedic Oncology and Hip and Knee Surgery at the Nuffield Orthopaedic Centre in Oxford.

He was awarded a Hunterian Professorship in 2016 by the Royal College of Surgeons of England for research on the surgical treatment of sarcoma.

He is involved in surgical training in Africa through the COSECSA Oxford Orthopaedic Link programme.

The link is supported by United Kingdom Department for International Development and is based on British Orthopaedic Association (BOA) and Royal College of Surgeons (FRCS) surgical training programmes. The success of the initial course was expanded to provide training courses in paediatric orthopaedics, deformity and in hip and knee arthroplasty with practical sessions.

Figure 1: Delegates Black Lion Hospital 2017.

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Orthopaedic surgical training in Ethiopia is developing to meet the increasing demand and surgical needs of young population of 100+m (19yr = median) in paediatric trauma, late bone infection, deformity as well as primary bone tumours.

However, with an oncology service now established in Addis Ababa, there is a desire to establish an integrated orthopaedic tumour service and a need to train the next generation of surgeons in treating bone tumours. The surgical management of malignant primary bone tumours in Ethiopia is primarily amputation due to advanced disease at initial presentation, as well as the need for specialist expertise and equipment needed for limb salvage.

International

In response to a request from local surgeons at Tikur Anbessa Specialised Hospital and CURE Ethiopia Children’s Hospital for a training course for resident surgeons in bone tumours, flaps and surgical techniques in limb sparing surgery, a practical course in orthopaedic oncology was proposed.

Faculty and delegates The Faculty at Addis Ababa University Hospital and CURE Ethiopia surgeons with visiting orthopaedic and plastic surgeons from the University of Oxford and Perth Australia.

Figure 5: Medial Gastrocnemius Flap.

approaches, joint replacement surgery, pelvis and amputation surgery. Common extensile and classic exposures are demonstrated and then hip knee and shoulder arthroplasty and anatomical dissections by trainees.

Delegates are limited to 35-40 final year residents in training and orthopaedic surgeons. All participants complete a pre and post-course MCQ comprising of 20 questions based on the course content and surgical anatomy.

The course is based on the FRCS Orthopaedic Examination Teaching Programme and is open to resident surgeons, recently appointed consultants and those with an interest in orthopaedic oncology and reconstructive surgery.

Programme All trainees sit a pre and post-course MCQ comprising 20 questions. Pre-course MCQ scores range between 30-75% and post scores range 65-95%. Certificates are awarded on successful completion of the module.

Lectures are undertaken in the morning sessions, followed by afternoon cadaver surgical anatomy; providing a comprehensive three-day overview in the diagnostic principles and management of bone and soft tissue tumours and the current surgical treatment of sarcoma and related conditions.

An example of one of the course days is shown in Figure 2.

Figure 3: Primary bone tumour case discussion.

The importance of the multidisciplinary team in the diagnosis, management and treatment of primary bone tumours is emphasised with illustrated lectures on the pathology, MSK imaging and surgical and medical treatment in orthopaedic oncology.

The interactive sessions include demonstrations of different surgical approaches and techniques, case reviews discussions (Figure 3), and the key concepts, tips and tricks in orthopaedic surgical oncology.

Delegates present FRCS examination cases, and host surgeons presented patients for discussion on local surgical management of these conditions in Ethiopia.

Cadaveric surgery

The final practical session is on raising common flaps, with all trainees expected to perform a clean medial Gastrocnemius Flap technique scored by the examiners (Figure 5). Feedback confirmed the value of the practical sessions where flap techniques were demonstrated.

These techniques were later successfully used by delegates to treat a patient with upper limb bone/soft tissue loss from a crocodile bite, as well as a patient needing a hindquarter amputation for pelvic osteosarcoma.

In addition, the cadaveric practical sessions allowed trainee and experienced surgeons to practice difficult amputations including forequarter, through hip and hind-quarter.

The current surgical management of malignant bone tumours in Africa, as it was historically in the UK, is primarily amputation with limited ability to offer limb sparing surgery and the use of endoprosthetic replacement for sarcoma.

These courses are aimed to highlight alternative biological and orthoplastic techniques, as well as developing the delegates ability to manage challenging cases. >>

The practical sessions are supervised and demonstrated by the faculty with dissection and surgical approaches undertaken by delegates on prepared cadavers in the Department of Anatomy at the Tikur Anbessa Specialised Hospital (Figure 4). This allows unique experience in surgical exposures and human anatomy in the Hunterian tradition.

Figure 2: Course Programme for day-two of the 2017 training course.

The afternoon sessions were divided over three days into upper limb and lower limb

Figure 4: Anatomy and approaches.

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International Developments The established course has by request of COSECSA, been expanded to other affiliated training centres and in 2019 at the Cancer Diseases Hospital Lusaka.

The sarcoma surgical experience in Ethiopia was presented by Dr Ermias, showing the application and development of new reconstructive techniques (Figure 6) in limb salvage and thus avoiding amputation and the extended use of flaps soft tissue reconstruction of soft tissue tumour, burns and trauma surgery (Figure 7).

Figure 7: Biological fibula graft used for shoulder reconstruction.

MDT and application of new techniques of biological reconstruction (fibula graft) and the use of PMMA in segmental defects and joint reconstruction.

Figure 6: A case from Tikur Anbessa Specialised Hospital: Sarcoma resection and reconstruction, avoiding amputation.

In addition to surgical approaches, regional anaesthesia techniques with practical cadaver demonstrations are performed by delegates and Faculty. The first endoprosthetic replacement in an 18-year-old male with an advanced giant cell tumour (Figures 9 & 10) affecting the distal femur was undertaken at CURE Ethiopia Children’s Hospital after cadaveric demonstration in the 2016 Course.

Delegate Feedback is key in improvement of course and content and also to address local surgical developments in managing bone tumours in Ethiopia (Figure 8).

This has led to a Global Surgery Initiative with Perth Australia, Oxford and Industry (Stanmore/Stryker and Signature Orthopaedics) to design and provide an affordable implant system available in Africa for bone tumour and arthroplasty surgery.

Updates and presentations on surgical pathology and medical oncology at Tikur Anbessa Specialised Hospital emphasised the development of integrated and dedicated

A RCS National Diploma in Orthopaedic Oncology was approved in June 2020 and will be available to surgeons in training through the COSECSA Oxford University Link.

Figure 8: Course feedback.

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Figure 9a: Giant cell tumour of bone and endoprosthetic replacement in an 18-year-old male.

Figure 9b: Giant cell tumour of bone and endoprosthetic replacement in an 18-year-old male.

Conclusion The collaboration of Oxford University, Tikur Anbessa Specialised Hospital and Cure International UK continues to bear fruit. We look forward to further developing this partnership in training and service provision in the management of sarcoma for years to come. n

Further reading and resources • WHO Classification of Tumours of Soft tissue and Bone 4th Edition 2013.

• Extensile Exposure AK Henry Churchill Livingstone 1957.

• Clinical Anatomy Harold Ellis Wiley Blackwell 1992.

• CURE Ethiopia Children’s Hospital: https://cure.org/hospitals/ethiopia.

• CURE International UK: https://uk.cure.org/.

• COSECSA Oxford Orthopaedic Link COOL: www.ndorms.ox.ac.uk/research/researchgroups/global-surgery/projects/cooltraining-in-trauma.

Figure 10: Endoprosthetic distal femoral replacement in an 18-year-old male with GCTB at CURE Ethiopia.

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◊Trademark of Smith+Nephew. All Trademarks acknowledged. ©May 2021 Smith+Nephew 30031-uki References 1. National Joint Registry for England, Wales and Northern Ireland: 17th Annual Report. Available at: http://www.njrcentre.org.uk/njrcentre Accessed 23 September 2020.2. Davis ET, Pagkalos J, Kopjar B. Bearing surface and survival of cementless and hybrid total hip arthroplasty in the National Joint Registry of England, Wales, Northern Ireland and the Isle of Man. JBJS OA. 2020;5:e0075. Available from: JBJS OA. 3. National Joint Registry for England, Wales and Northern Ireland: POLARSTEM cementless (Oxinium/XLPE/R3 cup) bespoke summary report. 14 August 2019. Available at: http://bit.ly/POLAR3_Aug2019 Orthopaedic Data Evaluation Panel (ODEP). Available at http://www.odep.org.uk Accessed 17/05/2021. **Compared to all other cementless stems in NJR, p<0.001 We thank the patients and staff of all the hospitals in England, Wales and Northern Ireland who have contributed data to the National Joint Registry. We are grateful to the Healthcare Quality Improvement Partnership (HQIP), the NJR Steering Committee and staff at the NJR Centre for facilitating this work. The views expressed represent those of the authors and do not necessarily reflect those of the National Joint Registry Steering Committee or the Health Quality Improvement Partnership (HQIP) who do not vouch for how the information is presented.

The data used for this analysis was obtained from the National Joint Registry (“NJR”). The Healthcare Quality Improvement Partnership (“HQIP”), the NJR and/or its contractor, Northgate Public Services (UK) Limited (“NPS”) take no responsibility for the accuracy, currency, reliability and correctness of any data used or referred to in this report, nor for the accuracy, currency, reliability and correctness of links or references to other information sources and disclaims all warranties in relation to such data, links and references to the maximum extent permitted by legislation.

Subspecialty

Top 10 tips to avoid periprosthetic joint infection Graham S Goh and Javad Parvizi

Total joint arthroplasty (TJA) is one of the most common elective surgical procedures across the globe. The annual volume in the United States is projected to exceed two million procedures over the next decade1. Periprosthetic Joint Infection (PJI) is a rare but devastating complication that has been suggested to be the main cause of failure in modern TJA2.

Graham Goh is a Research Fellow in adult reconstruction at the Rothman Orthopaedic Institute in Philadelphia, PA, USA. He received his medical degree from the National University of Singapore and is currently conducting research in periprosthetic joint infections, venous thromboembolism and glycaemic optimisation of arthroplasty patients under the mentorship of Dr Javad Parvizi.

R

ecently, several evidence-based guidelines were introduced to standardise the approach to a patient with a suspected PJI, including the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines on Diagnosis of Periprosthetic Joint Infection3 as well as the Proceedings of the 2018 International Consensus Meeting (ICM) on Periprosthetic Joint Infection4. While these comprehensive documents should be familiar to all orthopaedic surgeons, this article provides a brief overview on the top 10 ways to reduce the risk of PJI.

1. Pre-operative optimisation

Javad Parvizi is the James Edward Professor of Orthopaedic Surgery at Sidney Kimmel School of Medicine and the Rothman Orthopaedic Institute in Philadelphia, PA, USA. His area of interest in research includes the prevention and diagnosis of periprosthetic joint infections and venous thromboembolism following orthopaedic procedures. Dr Parvizi has published over 800 scientific articles and travels extensively across the world to give lectures related to his area of expertise.

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While it is well established that elective TJA should be contraindicated in any patient with an infectious lesion in their extremity until the infection is resolved, it is also important to search for other niduses of infection including the genitourinary tract, skin, nails or oral cavity5.

TJA should also be deferred in patients with uncontrolled medical conditions, such as uncontrolled diabetes, malnutrition, anaemia, and other immunocompromised states6. In particular, good glycaemic control remains an important modifiable factor in elective TJA, since a high proportion of patients undergoing TJA are diabetic (8–25%) and up to 50% of presumably non-diabetic patients have glucose levels in the diabetic or pre-diabetic range7,8.

Although glycated haemoglobin (HbA1c) is the gold standard test for monitoring glycaemic control, it remains unclear whether HbA1c is the most appropriate marker for glycaemic optimisation and perioperative risk stratification5,9. A recent multicentre study demonstrated that fructosamine, an intermediate-term glycaemic marker, was a better predictor of adverse events following TKA10 and THA11 compared to HbA1c.

2. Reducing bioburden This step involves pre-operative skin decontamination through the administration of pre-operative cleansing agents and removal of hair on the day of surgery. Pre-operative skin cleansing at home prior to the elective procedure has an important role in the reduction of surgical site infections (SSI) and PJI12. Specifically, chlorhexidine gluconate (CHG) has been shown to be an effective agent in previous randomised controlled trials13 and retrospective cohort studies14,15. The relatively high rate of hypersensitivity to CHG and bacterial resistance to CHG has made CHG based wipes and soaps lose popularity in recent

Subspecialty

years. One recent trial also suggested that iodine-based antiseptic solutions may be equally effective16. Overall, current Centers for Disease Control and Prevention (CDC) guidelines recommend showering or bathing with either soap or an antiseptic agent on the night before the operative day12.

3. Perioperative antimicrobial prophylaxis Perioperative antibiotic prophylaxis prior to TJA is considered the standard of care17, and has been shown to reduce the rates of SSI and PJI18. The American Academy of Orthopaedic Surgeons (AAOS) as well as other official guidelines recommend the use of first- or second-generation cephalosporin antibiotics as a means for prophylaxis prior to TJA due to their favourable side effect profiles and efficacy against the broad array of organisms19,20. This should be administered intravenously within 30 to 60 minutes before incision as a single and weightadjusted dose. Allergy labels have been shown to drive arthroplasty surgeons to use alternative antibiotics21, which have been associated with a higher rate of infection22-25. As majority of allergies to penicillin are minor and nonanaphylactic, and the fact that cross-reaction between cephalosporin and penicillin is rare, it is reasonable to administer test dose of cefazolin to patients with non-anaphylactic allergy to penicillin26. Some patients with anaphylactic reaction to penicillin may benefit from seeing an allergist22. Dual antibiotic prophylaxis using a cephalosporin in combination with vancomycin should be reserved for patients at a high-risk of infection, such as those undergoing revision surgery and those at a high-risk of MRSA infection (e.g. known MRSA carriers, healthcare workers, nursing home residents)19. This is recommended as the addition of vancomycin to the prophylactic antibiotic regimen has not been shown to decrease the rate of SSIs when compared with cefazolin alone, and could increase the risks of adverse events27.

Vancomycin should be started two-hours before incision due to the extended infusion time.

4. Respect for soft tissues This particular strategy and its importance in minimisation of SSI is often overlooked. It is important to respect the soft tissues during the surgical procedure by not being overly forceful, tearing the skin, or continuously touching the incision. Incision size should kept as small as possible, but large enough to allow adequate exposure and visualisation. The use of nonabsorbable sutures, foreign bodies and copious use of subcutaneous electrocautery have also been correlated with an increased risk of SSI28.

5. Expeditious surgery Prolonged operative time is another independent risk factor for SSI and PJI following TJA. It was

previously shown that a 20-minute increase in operative time was associated with approximately 25% increased risk of PJI29. The explanation for this association is likely multifactorial. A longer operative time would increase the risk of tissue desiccation as well as the duration of exposure to microorganisms within the operative environment, hence increasing the risk of wound contamination30,31.

Prolonged operative time may also be associated with a prolonged tourniquet time, which has been shown to induce wound hypoxia32. In addition, local tissue concentrations of systematic antibiotics could fall below therapeutic levels if not promptly re-dosed during longer surgical procedures33. Common factors known to influence the operative time include the surgical complexity of the case, experience and fatigue of the surgeon, experience of the surgical team, implant type, and use of cemented components34. Although these factors may not be modifiable, it is nonetheless important to ensure optimal pre-operative planning, procedural efficiency and surgeon education whenever possible35. Coordinated efforts to reduce the operative time without technically compromising the procedure may help to prevent infection.

6. Blood conservation There is wealth of evidence demonstrating that both pre-operative anaemia36 and the need for subsequent allogeneic blood transfusion37 are associated with an increased the risk of SSI or PJI6. As such, in addition to correcting pre-operative anaemia, strategies to minimise blood loss during surgery have been implemented to reduce the need for allogeneic blood transfusion. One such strategy has been the administration of tranexamic acid (TXA) during TJA, which has been proven to reduce blood loss and the need for allogeneic blood transfusion38. This likely accounts for its association with a reduced incidence of PJI after joint replacement39.

Another strategy to manage perioperative blood loss pertains to post-operative venous thromboembolism (VTE) prophylaxis, since less aggressive agents such as aspirin have been shown to reduce the incidence of bleeding40,41 and infection42 after TJA.

7. Reduce operative room traffic The primary source of bacteria in the operating room (OR) is the OR personnel. Multiple studies have shown that unnecessary OR traffic increases the risk of surgical site infection (SSI)43,44. This has been attributed to the turbulence in airflow caused by the opening of doors, which may predisposed to increased wound contamination during the procedure45.

Since all individuals shed bacteria, an increased number of people in the OR would also lead to a higher bacterial count in the air and greater the likelihood for SSI.

8. Antiseptic irrigation solution The wound is a possible point of entry for bacteria residing on the skin or in the environment. Once the number of pathogens in the wound exceeds the host immune threshold, an infection can arise. Different ways to mitigate this risk during wound closure have been proposed46, one of which is wound irrigation with antiseptics. While a myriad of antiseptic solutions have been proposed, no consensus on the optimal irrigation fluid has been reached due to a lack of robust data47.

Dilute povidone-iodine is one option that has been endorsed by the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO)48,49.

9. Clean implants and instruments All instruments used during the procedure should be thoroughly sterilisation to prevent orthopaedic device-related infections. Bacterial adhesion to the implant occurs as a result of biofilm formation on the surface50.

Contamination of these implants during surgery can be avoided by minimising touching and preventing them from coming into contact with the skin during implantation.

10. Proper wound management It is vital to ensure that the wound is properly closed and appropriate occlusive dressing is applied. Wound closure with a running subcuticular suture and skin adhesive has garnered interest for its capacity to reduce superficial drainage and potentially deep infection. A running subcuticular suture may enable more robust wound perfusion compared to skin staples51. However, meta-analyses have reported mixed results with respect to SSI prevention52,53. The use of an occlusive silver-impregnated dressing rather than a simple gauze dressing has been proven effective in reducing infection rates in multiple studies on TJA54,55. As mentioned above, avoiding aggressive anticoagulation could also help to minimise wound drainage56.

Summary As new strategies for PJI prevention are developed, it is imperative that the orthopaedic community continues to test these strategies rigorously in a clinical setting in order to provide the best evidence for PJI prevention.

Notwithstanding, a multimodal approach and attention to detail remain paramount. This 10-step approach entails simple measures that should be considered by any surgeon performing total joint replacement. n

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

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Jonathan Phillips is a specialist knee arthroplasty, trauma and revision surgeon, appointed at the Royal Devon and Exeter Hospital in 2015.

He is a member of the ODEP and Beyond Compliance committees, as well as both the Primary and Revision BASK Knee Arthroplasty Working Groups.

Ben Waterson undertook his specialist training in orthopaedic surgery in Edinburgh and undertook the adult lower limb reconstruction fellowship in Vancouver. He was awarded a Medical Doctorate (MD) from Edinburgh University for his research in the field of knee surgery and the impact of alignment on total knee replacements. He has been working as a consultant in the Exeter Knee Reconstruction Unit since 2018 and is an Honorary Senior Lecturer at Exeter University.

Investigation of Prosthetic Joint Infection of the Knee – The Exeter approach to this challenging condition Jonathan Phillips, Ben Waterson, Andrew Toms and Keith Eyres

The Exeter Knee Infection MDT and collaborative working The investigation and management of prosthetic joint infection (PJI) is a clinical challenge that requires the application of surgical, medical and microbiological knowledge and experience.

Despite improvements in the understanding of PJI, clinical outcomes remain reasonably poor and the mortality rate is higher than in many common cancers. Patients present in a spectrum of ways; from the stable patient with the quiet sinus through to the patient in extremis requiring emergency management.

What has become abundantly clear is that a single person within a unit managing all of the infections or complex cases is no longer appropriate1. A team approach is preferred. PJI cases are complex, frequently requiring anaesthetic, ITU, pharmacological and rehabilitation team input as well as microbiological and surgical expertise.

“What has become abundantly clear is that a single person within a unit managing all of the infections or complex cases is no longer appropriate1.

A team approach is preferred. PJI cases are complex, frequently requiring anaesthetic, ITU, pharmacological and rehabilitation team input as well as microbiological and surgical expertise.”

A Multi-Disciplinary Team (MDT) approach is now accepted as the appropriate standard of care for patient with PJI1. The Exeter knee infection MDT was established in 2015 to discuss all cases of native or prosthetic joint

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infections around the knee2. Hip and knee teams in Exeter work independent of each other, so separate meetings were established. The precedence of cancer MDTs for decision making in complex clinical cases has made a robust argument for MDT working in cases of PJI3-5.

In our experience, establishing the MDT was one of the biggest challenges6. Negotiating and aligning the various invested parties job plans was difficult. An appropriate time of the week was identified (once every two weeks), with access to hospital MDT facilities (multi-screen functions with video sharing; Figure 1).

Appropriate personnel were assembled (orthopaedic revision knee, microbiology, pharmacy with plastic surgery available if required).

Colleagues at neighbouring units would dial-in or ask for advice, and on occasion local colleagues would ask for advice on shoulder or ankle PJI cases.

We published qualitative findings that demonstrated that team members thought MDT working was an improvement in patient care, and the MDT has continued in its current form to the present day6. Figure 2 is a Word Map illustrating the most commonly transcribed

Subspecialty

Andrew Toms is the Professor of Orthopaedics at the Princess Elizabeth Orthopaedic Centre, Exeter. He trained on the Stoke / Oswestry rotation and in Vancouver, Canada. He currently sits on the NJR Editorial Board, the Bone & Joint Infection Registry board, BASK Research Group and the RCS Robotic Advisory Group for Orthopaedics.

Figure 1: The Exeter Knee Infection MDT.

words associated with interviews about the MDT6. The benefits of a formalised MDT have meant improvement in documentation, communication and continuity of care. This is well supported by the published literature on MDT working improving the outcomes for complex conditions. Orthopaedic infection MDTs have now become well established throughout the UK1,7,8.

Keith Eyres is a Consultant Orthopaedic Surgeon practicing at the Nuffield Health Exeter Hospital and the Royal Devon and Exeter NHS Foundation Trust.

He specialises in hip and knee replacement, knee revision and rheumatoid surgery.

The establishment of our MDT has enabled protocolised care of PJI at our unit, which, in turn has led to research and educational opportunities. Exeter had representation at the ICM Philly Consensus meeting in 2018, which in turn led to the formation of the UK PJI group9. Our unit has collaborated with colleagues from Bristol and Oxford in establishing priority setting for revision knee surgery with the James Lind Alliance Priority Setting Partnerships10,11. As a direct result of this patient-clinician consultation, investigation and management of PJI has now been demonstrated as one of the key areas for research for knee surgery in the UK, enabling researchers the ability to access better levels of funding for research into PJI10.

We are collaborating with Exeter university and are leading an NIHR multicentre RCT on the treatment of PJI (MIKROBE study single vs two stage in the management of knee PJI)12. Our work on infection has also led to a number of publications on knee infection, its diagnosis and management over recent years6, 13-20 . Through this collaborative

work and future work planned we hope that this may lead to improvements in patient outcomes over time.

In 2018 the Revision Knee Working Group (RKWG), consisting of a group of high volume revision knee surgeons was established through BASK. This team, chaired by Exeter surgeon Professor Andrew Toms, has been responsible for the restructuring of revision knee surgery and infection treatment of knee PJI in the UK, and the development of a ‘Good Practice Guide’ to revision knee surgery.

One of the many outputs of the RKWG was a BOAST on ‘Investigation and Management of Prosthetic Join Infection in Knee Replacement’. This document presents appropriate diagnostic and management for PJI, as well as discussing the recommended organisational and administrative requirements to treat PJI.

Figure 2: Word Map: Fifty most mentioned words in the interviews about Exeter MDT.

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arthroscopically.

Samples should be processed urgently by the laboratory and broad-spectrum antibiotics should be started if not done already. These patients can then be passed onto the specialist team the following day to continue care.

Most patients do not present with systemic sepsis. For these, the investigation for PJI starts with a detailed history and examination.

Any previous perioperative problems or potential sources of infection should be reviewed. A medical and drug history is required to look for immunocompromise or impact on treatment options. Radiographs are required in all cases to ensure the implants are stable, and blood test inflammatory markers (CRP, full blood count and either ESR or plasma viscosity) should be performed. The routine use of more advanced imaging is not routinely recommended unless in specialist centres.

Investigation of knee prosthetic joint infection There are well-established criteria to define PJI (ICM 2013, 2018, EBJIS 2021). There are many similarities between these criteria, with subtle differences in the scoring and methods used to define PJI. All define a PJI with the major criteria as either two separately collected samples confirming the same organism, or the presence of a sinus.

The minor criteria and scoring systems differ between. The BOAST recommended use of the ICM 2013 criteria1.

The investigation and management alters, depending upon the type of presentation of the patient. Patients who present with evidence of systemic sepsis require urgent assessment and intervention13. It is appropriate to start antibiotics immediately, to contact the ITU team and to organise surgery to reduce the septic load, which in these cases is appropriate usually to perform

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Inflammatory blood marker results that are low (a threshold of ESR > 30 mm/hr and CRP > 10mg/L is recommended for chronic PJI), alongside a low clinical suspicion makes the diagnosis of PJI less likely.

Where the level of clinical suspicion is high, especially when inflammatory markers are raised, further investigation is recommended to define the presence of PJI and to importantly identify the infective organism(s). We believe that identification of the organism(s) is the key piece of the puzzle as it significantly impacts planning further treatment options and decision making. For surgeons unfamiliar with the diagnosis and treatment of PJI, we would recommend referral to a unit with an Infection MDT to further investigate these cases. The UK is now in the process of developing clearly defined clinical networks within each region to manage these cases17.

Prior to taking samples from the joint, all antibiotics should be stopped for a two-week

window to maximise the chance of identifying the organism. Aspiration of the joint should be performed aseptically in a clean environment such as a clean clinic room or operating theatre. A cell count should be performed on the fluid, alongside additional tests dependent on local policy in line with the ICM criteria.

It is our preference in Exeter to proceed with an arthroscopic biopsy (usually blind unless other diagnoses are considered) under anaesthetic, rather than an aspiration, to identify the organism. Currently unpublished data collected at our unit has demonstrated that multiple tissue samples provide more information than aspiration alone. Any biopsy procedure should collect five samples using different sampling sets for urgent evaluation. Histological examination with a quantitative assessment of neutrophil infiltrates is also recommended if the facilities are available.

For cases highly suspicious for infection where negative culture results are obtained, further discussion at the Infection MDT and investigation is recommended. A high index for suspicion is required for multiply-revised cases or cases previously treated for infection.

Consideration of additional fungal, mycobacterial and/or molecular testing may be performed alongside taking repeated samples.

It is then our aim to discuss all cases at both our Infection and Revision Knee MDT meetings prior to performing surgery. Cases are presented to colleagues and advice and guidance is often offered and gratefully received. This provides us the opportunity to plan the type of surgery (single vs two-stage), and the surgical equipment and implants. All patients are classified using the RKCC complexity classification system15.

Finally, all patients have a formal ‘Proforma’ completed ahead of surgery with the microbiologist. This details the organism, the resistance and sensitivity pattern, along with antibiotics that will be required on induction of the anaesthetic, to go into the cement and to be given post-operatively. Our orthopaedic pharmacist is then able to order the antibiotics ready for the date of surgery.

We believe that our method for investigating and managing infection through protocol and team working leads to a more streamlined and organised approach to managing PJI, offering the best chance of a good outcome for patients with this awful condition. n

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

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The Bone and Joint Infection Registry (BAJIR) and its role in supporting the Bone and Joint Infection MDT in our institution Michael Petrie and Pedro Foguet

Michael Petrie was the Senior Clinical Fellow at University Hospitals Coventry and Warwickshire and is currently the Cavendish Arthroplasty Fellow in Sheffield. He sits on the Executive Committee for BAJIR and is the Engagement Lead. His clinical focus is revision arthroplasty with a special interest in periprosthetic joint infection.

Pedro Foguet is a Consultant Orthopaedic Surgeon at University Hospitals Coventry and Warwickshire.

He is a lower limb reconstruction surgeon with a special interest in the management of periprosthetic joint infection. Fifteen years ago he was one of the founding members of the local MDT known as Bone Infection group Coventry & Warwickshire (BIGCOW).

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The UK Bone and Joint Infection Registry (BAJIR) is a national project established in 2018 with the aim of collecting information about demographics, co-morbidities, pathogens, treatment strategies and outcomes on all patients who are diagnosed with, and treated for, a bone or joint infection in the UK with the objective of providing an understanding of the burden of disease.

In time these data will be used to inform best practice, direct research and provide information for commissioners of healthcare1.

T

he registry is hosted by Northumbria Healthcare NHS foundation trust and overseen by a steering committee (Figure 1) of medical professionals consisting of orthopaedic surgeons and microbiology doctors who specialise in treating bone and joint infections. The registry is funded by contributions from industry partners2.

Bone and joint infections present a significant challenge to both patients and clinicians alike. Not only are they associated with significant morbidity and mortality but also they are the source of a considerable burden of cost to the health economy. Despite the continuous development of new diagnostic and therapeutic modalities, the progress in improving clinical outcomes had been hampered by the lack of standardised diagnostic criteria that made comparing differing treatment strategies between units difficult.

However, consensus agreement has been reached over the past few years on diagnostic criteria for a variety of bone and joint infections such as periprosthetic joint infection (PJI)3-6 and fracture-related infections (FRI)7.

Greater clarity on the diagnostic criteria for bone and joint infection has provided some standardisation between units and allowed for the establishment of BAJIR.

Figure 1: BAJIR Steering Committee.

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Since 2018 the number of sites that have been contributing to the BAJIR has been growing, with a corresponding increase in the number of patients being included in the registry. The registry is now beginning to achieve numbers of confirmed infections great enough to allow for data analysis, with early results being presented at the BOA Congress this year. To date, there are over 900 patients within the registry, including more than 360 confirmed bone and joint infections. BAJIR currently has 20 collaborating Trusts with a similar number of Trusts having engaged in the information governance process that will hopefully soon be able to go ‘live’. At this point in time, a registry such as BAJIR is unique in the world.

been re-designed to align with BAJIR and we have been submitting data to BAJIR for over two years.

Prior to our BIGCOW meeting, all patients to be discussed are entered onto BAJIR by the clinical fellow or specialist nurse and their patient record completed to include referral details, site and type of infection, chronicity, details of any surgery, microbiological sampling for diagnosis and antibiotic treatment; both local and systemic (Figure 3).

As is the case when managing patients with bone and joint infection, their clinical journey

evolves with time, for example narrowing the spectrum of parenteral antibiotics following microbiological culture results. A patients’ record often requires multiple visits to ensure it remains contemporaneous.

The diagnosis of infection must be confirmed according to the recognised diagnostic criteria appropriate to their infection. Currently, the criteria for PJI are MSIS 20133 and IDSA4; for fracturerelated infection and osteomyelitis we use the FRI Consensus 20187 and for native joint septic arthritis we follow the Modified Newman’s criteria.

The significant morbidity and mortality of PJI meant that a great deal of the initial work when setting up the registry was devoted to these patients and BAJIR engaged with the relevant specialist societies (BESS, BASK, BHS) in order to support them in their drive to develop regional networks centred around MDTs. Data submission to BAJIR is a recognised standard of the recently published Revision Knee BOASTs8-10 and the recently launched MDT module provides a record of the decision making and outcomes of the regional MDT meetings.

How BAJIR supports the management of bone and joint infection and our institution For well over a decade we have been running a MDT meeting on musculo-skeletal infections at University Hospitals Coventry and Warwickshire (UHCW). Our group is known as the Bone Infection Group Coventry & Warwickshire (BIGCOW).

Figure 2: Periprosthetic Joint Infection Dashboard for UHCW. BAJIR Dashboard presenting infographics on how our PJI patients compare to other confirmed PJI patients in the registry; providing data on microbiological isolates, reoperations and patient-reported outcome scores (PROMS).

Since its inception in 2015 our MDT has increased in size and scope of practice.

Currently, we manage both elective and trauma patients from the two hospitals within our Trust, one of the busiest Major Trauma Units in the UK, and from our neighbouring Trusts.

The meeting is run fortnightly and routinely includes revision arthroplasty surgeons, infectious disease and microbiology consultants, specialist trainees, specialist nurses and a specialist pharmacist. Increasingly, other subspecialty orthopaedic and plastic surgery colleagues can be in attendance.

When the possibility of engaging with BAJIR presented, it was an easy decision for us to go with it. As proud and comfortable as we felt about the BIGCOW meeting and its achievements, collaboration with other units from across the UK that specialise in the management of PJI and other bone and joint infections seemed the optimal path to further improve the quality of the care we offer to our patients. Our BIGCOW database has

Figure 3: Screenshot of a demo patient to highlight the clinical information included.

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Subspecialty

Figure 4: MDT Dashboard for UHCW.

Figure 5: MDT module.

It is the responsibility of the clinical team to obtain baseline PROMs (EQ5D-3L and EQ VAS)11 at the time of a patients’ infection diagnosis. Once confirmed as an infection, the BAJIR team contact the patients to obtain their consent and follow up PROMs at six months and then annually.

The BAJIR MDT module Recently BAJIR have launched their MDT module which we have used to support both our BIGCOW and Complex Hip and Knee Arthroplasty (CHAKA) MDT meetings.

The module is user-friendly and provides a comprehensive summary of the meeting which can then be inserted into the patients’ paper or electronic record. The MDT Dashboard provides an audit trail of the meeting to satisfy individual revalidation and the revision arthroplasty BOASTs (Figure 4).

Any patient uploaded to BAJIR from an individual Trust can be added to their MDT list for discussion. The software also allows for patients to be referred to the BAJIR MDT module of their Major Revision Unit to support the imminent hip and knee revision networks. However, for this to be possible all the units within a given network need to be registered with BAJIR. During MDT discussion the patient’s record can be accessed and updated accordingly, the discussion is summarised and a patient outcome confirmed (Figure 5). At the conclusion of the meeting the MDT is finalised and a summary document produced

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Figure 6: Individual patient MDT report.

for each patient (Figure 6). BAJIR provides an audit log of all MDT meetings, including all patients discussed, their outcomes and the clinicians present.

Challenges of BAJIR In spite of our unit’s enthusiastic support of BAJIR we have encountered a number of challenges with incorporating it into our practice and we have a number of concerns that will need addressing going forward.

In our unit, the administration of the registry is reliant upon the clinical fellow and specialist nursing team. An investment of clinical time is required that is currently approximated at three to four hours every fortnight. Although financial incentive has been promised to Major Revision Units through the Revision Knee Network this will only apply to a small number of Trusts in the country. Until adequate financial support for all units across the UK is agreed, BAJIR engagement will continue to rely upon enthusiasm and good will alone, which will impede its universal adoption.

Despite BAJIR being well-established within our unit, we do not have the buy-in from all of our subspecialty colleagues and we are working on increasing engagement to ensure we capture all bone and joint infection managed at our Trust.

Similarly, our sub-regional revision network involves units who are not yet registered with BAJIR. Currently, we are only contributing

those patients who are referred to our unit with PJI, rather than all bone and joint infection within the network.

Summary • The number of Trusts registered with BAJIR continues to grow but work is required to achieve the ultimate aim of adoption by all Trusts in the UK. • As the number of participating Trusts increases, so too will the number of submitted patients with a confirmed bone and joint infection.

• The evidence thus generated will be a powerful tool to inform best practice, direct research and provide information for commissioners of healthcare.

• Securing financial support to all units for the administrative provision of the registry should promote BAJIR engagement.

• At this point in time, there is no other registry comparable to BAJIR in the world.

Disclosures Mike Petrie sits on the BAJIR Executive Committee; Pedro Foguet sits on the BAJIR Steering Committee. n

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

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