Journal of Trauma & Orthopaedics - Vol 9 / Iss 4

Journal of Trauma and Orthopaedics Volume 09 | Issue 04 | December 2021 | The Journal of the British Orthopaedic Association | boa.ac.uk

Every piece matters

Why should we care about human factors in surgery? p38

Gender balance in medico-legal reporting p46

The history of conservative management of acute Achilles tendon ruptures p57

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3

From the Executive Editor

5

From the President

Deborah Eastwood John Skinner

6-7 BOA Latest News 12 News: BOA Annual Congress 2021 -

Congress review

14 News: New BOA Trustees (2022–2024) 17 News: Conference Listing 2022 20 Features:

Core curriculum topics in orthopaedics – a BIOS initiative Maneesh Bhatia and Bijayendra Singh

22 Features:

It’s all in the state of mind: A reflection of my orthopaedic journey Bart Day

26 Features:

British Orthopaedic Foot and Ankle Registry – Where are we now, and where are we going?

Lyndon Mason, Edward Wood and Paul Halliwell

30 Features:

Anthropology of the human foot – the past, present and future Kartik Hariharan

Journal of Trauma and Orthopaedics

Volume 08 Issue 04

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

Journal of the British Orthopaedic Association The Journal of Trauma and Orthopaedics (JTO) has a dedicated news section, a features section containing interesting articles on various themes, a subspeciality section and a medico-legal section.

2020 NICE Guidelines: Virtual Learning – key recommendations p22 Moving Forward p38

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

Amputation in the context of tumour or infection p57

Journal of Trauma and Orthopaedics Volume 08 | Issue 02 | June 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

Journal of Trauma and Orthopaedics Volume 08 | Issue 01 | March 2020 | The Journal of the British Orthopaedic Association | boa.ac.uk

A Surgical Day Begins*

Don’t let a fracture obscure the bigger picture Reflections of a Training Programme Director p28

FFN UK Orthogeriatric medicine p52

Rib fracture management in the older adult p54

Volume 08 Issue 03

Training in orthopaedics: Non-accidental injury in COVID-19: My experience The show must go on p12 children during COVID-19 p14 of testing positive p16

Volume 08 Issue 02

*From the editor p03

NOA – Improving quality in orthopaedic care p29

34 Features:

Advances in digital orthopaedic education: Techniques to enhance learning and avert a generational crisis in orthopaedic training Andrew J Hall, Rosemary J Hackney, Gavin SC Brown and Emily J Baird

38

38 Education:

Why should we care about human factors in surgery?

Chris Lewis, James Tomlinson and Hiro Tanaka

42 Trainee:

Workforce culture and diversity: Our questions answered at BOTA Congress Oliver Adebayo, Thomas Key, Kathryn Dayananda and Ran Wei

46 Medico-legal:

Gender balance in medico-legal reporting

Jo Round, Sarah Johnson-Lynn,

Charlotte Lewis, Jacquelyn McMillan,

Jan McCall, David Warwick,

Deborah Eastwood and Simon Britten

50 Subspecialty:

Reflections from the Oxfordshire Multi-disciplinary Diabetic Foot Care Service Jodie Buckingham, Lucinda Barrett, Dominic Howard, Garry D Tan and Constantinos Loizou

54 Subspecialty:

Collaborative Ankle Arthritis Networks Jim Carmichael and Martin Raglan

57 Subspecialty:

The history of conservative management of acute Achilles tendon ruptures – “the other Northern Irish protocol” Matthew Lynch-Wong and Andrew Adair

Peter James Witherow

60 In Memoriam:

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.

Improving the undergraduate T&O experience p32

Volume 08 Issue 01

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.

Did you know that as well as advertising in our Journal publication, we can offer footer banner advertising on the JTO App! For more information please contact Wendy Parker. Email: Wendy@ob-mc.co.uk | Telephone: +44 (0)121 200 7820

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

JTO | Volume 09 | Issue 04 | December 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) Oliver Adebayo (Trainee Editor) Rick Brown (Guest Editor)

BOA Executive l John Skinner (President) l Bob Handley

(Immediate Past President) l Deborah Eastwood

(Vice President) l Simon Hodkinson (Vice President Elect &

Honorary Secretary) l Mark Bowditch (Honorary Treasurer)

BOA Elected Trustees l John Skinner (President) l Bob Handley

(Immediate Past President)

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 Committee Officer

- Eliza Khalid

Education and Careers Manager

- Alice Coburn

Communications and Operations Director of Communications and Operations

- Annette Heninger

Marketing and Communications Officer

- Sabrina Nicholson

l Deborah Eastwood

(Vice President)

Membership and Governance Officer

l Simon Hodkinson (Vice President Elect &

Honorary Secretary)

Publications and Web Officer

l Mark Bowditch (Honorary Treasurer) l Colin Esler l Grey Giddins l Robert Gregory l Fares Haddad l Anthony Hui l Andrew Manktelow l Ian McNab l Fergal Monsell l Amar Rangan l Sarah Stapley l Arthur Stephen l Hiro Tanaka

- Natasha Wainwright - 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 Coordinator - Venease Morgan Interim 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: Wendy Parker - Media Manager Email: Wendy@ob-mc.co.uk | Telephone: +44 (0)121 200 7820 Open Box M&C, Premier House, 13 St Paul’s Square, Birmingham B3 1RB

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

S

o… where has this year gone? It seems, to me at least, to have flown by. We thought that 2020 was a year like no other but 2021 seems to have been similar but different. There has been much sadness and loss, including one of my mentors (page 62) but now also happier times with parties, weddings, theatre trips and sporting events (and yes I did attend my first ever premier league game!) and simple nights in or out with friends and family.

At work, we continue to tackle a seemingly insuperable mountain of cases that require our skills and care. As we heard presented at the BOA Congress, the stark reality is that with a 5% increase in workload nationally, it would still take us nearly 9-10 years to recover the deficit without counting the potential second wave of lost and late referrals. The pandemic taught us to work differently and showed us that change can be achieved quickly when needs must – well needs must now and as our President says, we must work well with our colleagues, for example at #BestMSK Health, to be innovative and resourceful. At all times we must respect and care for our patients and our trainees – both their viewpoints, one individually (page 22) and one collectively (page 42) have an important place in this edition. In this changing world, the way we deliver education at all levels has undergone a seismic change ( pages 20, 34 & 38) – we may all be ‘webinar-ed’ out but out of this change, good things have happened and they may simply need tweaking as we swing back towards the ‘good old times’. However as 2022 approaches, we must not let ourselves get caught in this wish to ‘go back to how it was’ – the future is bright, the future is different and the future is ours.

It is still attracting the brightest and the best trainees and students (page 8).

Along with all this looking forward, there is always scope to be fascinated by our past and if you want to know if you look like Lucy, you should read Kartik Hariharan’s article on the anthropology of the human foot (page 30), and the subspecialty section on the foot and ankle makes interesting reading too.

The new year will bring new members to council with a wide expertise to help us in our work, and by the time you read this, we will have a new Honorary Secretary too! Diversity, equality and inclusivity remain high on our agenda and we are delighted to see this reflected in our Council, Committees and membership. There is still work to be done in terms of gender diversity in the medico-legal world it seems (page 46), and my personal pledge for 2022 is that we will concentrate on the wider issues of diversity and of engagement.

As with last year, the front cover echoes our sentiments for this year ‘every piece matters’ and on behalf of the BOA and the JTO, I would like to thank all our members from Trainees to AHPs, from students to our SAS and Consultant colleagues for contributing to the bigger picture and making it complete.

We wish you all a relaxing festive season. n

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 03

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From the President

Another year over but the challenge goes on John Skinner

As we enter December, we hope to get some peace, rest and recharge time with family and friends over the holiday period. It has been another tough year for the orthopaedic community and for our patients. I would like to start by thanking everyone involved in delivering orthopaedic and trauma care, and who have supported the NHS and patients in so many ways during the pandemic.

O

ur consultants, SAS colleagues, trainees, therapists, nurses and practitioners of all aspects of musculoskeletal care are coming to the end of a uniquely difficult two-year period.

And I fear that we are not out of the woods yet.

The orthopaedic community has continued to provide a quality service through the heights of the pandemic and some trying conditions. There are many examples of new ways of working and innovation that have been developed by surgeons and surgical teams, to improve efficiency, effectiveness and provide better patient care. It is highly likely that many of these could be shared and adopted more widely. As orthopaedic surgeons we are nothing, if not practical, resourceful, forward thinking and good at solving problems. I would love the BOA to be a focal point to gather these ideas and then between us, find the best way to refine and disseminate them.

If you have an idea that you would like to discuss and develop further, then please let us know.

We are fully aware of the difficulties being faced by colleagues with delivering both elective and trauma care at the current time. The health system is running hot and the demand for our services, seemingly limitless. We preside over the longest waiting lists that are not of our making and in so many parts of the country we cannot get access to the resource needed to reduce them. I can assure you that I and the BOA Executive, Council and Committees remain focused on these issues. I continue to meet with the four National Clinical Directors involved in the elective recovery and MSK delivery programmes. I have met with the NHS England Medical Director and meet regularly with the President of the Royal College of Surgeons of England.

My message always focuses on the issues of: sites, staff and strategy. On sites, we must protect and prioritise elective care recovery and this starts with preventing the orthopaedic care pathway from being used as a reservoir of beds, wards, nurses, theatre lists, theatre teams and anaesthetists to be deployed elsewhere at the drop of a hat. For this to happen there must be enough surge capacity elsewhere in the system to handle peaks in demand, as has now been provided for ITU care. We need Green Hub sites across the country where we can separate elective from emergency care to allow year-round elective operating.

Our patients need and deserve this.

On staff, our survey results highlighted some important issues (discussed in more detail on our website at www.boa.ac.uk/wellbeing-survey. I am particularly concerned about the pension taper Tax and Lifetime earnings Laws and feel this must change to allow surgeons and anaesthetists to deliver the extra work that the NHS so urgently needs.

On strategy, we need to have ways to ensure that surgery can be delivered efficiently, year-round. We need to foster strong local leadership and support for the whole workforce involved in MSK care.

The NHS clearly needs more front-line staff in nursing and theatre roles and these staff must be supported in order to maintain morale across the workforce.

Elective surgery is not optional and trauma care is urgent.

Our patients really need their operations. I and the BOA Team will continue to lobby on all of these issues, on your behalf. I know it is frustrating and we will continue to do all we can to improve the landscape for our members and our patients.

On behalf of all at the BOA may I wish you a merry Christmas, a happy new year and a peaceful and restful time over the holidays. n

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 05

Latest News

SAS surgeons: At the Heart of the BOA The BOA ‘SAS Career Development Position Statement’ was launched at Congress (see www.boa.ac.uk/sas for the document and more). It highlights the vital role that SAS surgeons play in T&O teams and our commitment to supporting their development through every stage of their careers. We recognise Specialty & Associate Specialist (SAS) surgeons or Locally-Employed Doctors (LEDs) will have distinct needs for career and educational support specific to their situation. We are building resources to assist with SAS career development, and if there are resources that you would find helpful in developing your career we would love to hear from you at info@boa.ac.uk.

Medical students getting involved in the BOA and getting together as BOMSA! We were proud to host the launch of BOMSA, the newly founded British Orthopaedic Medical Students Association, at our Medical Student Day at Congress.

BOMSA will encourage collaboration between medical school societies to enhance early positive exposure of orthopaedics to medical students on a national scale and has already had buy in from over 70% of UK medical schools. We look forward to working closely with BOMSA in the future.

BOA discussions on practicing in the Independent Sector We recently published an update on the work that the BOA does in engaging with private practice issues. BOA Council member Andrew Manktelow is our representative on the Council of the Federation of Independent Practitioner Organisations (FIPO) and the BOA lead for the Private Healthcare Information Network (PHIN), both of which have significant relevance for any members who have a private practice. You can read the article on our website at: www.boa.ac.uk/private-practice-update.

Lots of interest in new BOA roles!

We have recently been recruiting new members for BOA committee roles and have had a great response. The current selection process is ongoing but we will publicise the successful applicants in the next JTO. It’s great to have this level of interest in BOA roles and thanks to everyone who has put themselves forward. If you’re looking for a way to get more involved, we are looking for UKITE Editors and have other opportunities available at www.boa.ac.uk/getinvolved.

06 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

Other highlights of the day were the practical sessions, with locking screws into apples and getting hands-on with cement (kindly donated by Heraeus). The quality of abstracts was outstanding, and congratulations to Catherine James, who took first place with her Crash Course in Orthopaedics webinar series.

Congratulations also to Sulaiman Uppal, winner of the 2021 Medical Student essay prize (see page 8).

The title for 2022 will be “How can we make Trauma & Orthopaedics in the UK more eco-friendly?” and entries will be open 1st – 28th February 2022.

Hundreds taking BOA’s UKITE Exam More than 800 trainees from across the UK and Ireland are expected to take the UKITE Exam online between 10th – 17th December. Since its inception in 2007, UKITE has helped trainees prepare for section 1 of the FRCS Tr and Orth with questions covering the full spectrum of sub-specialties, contributed by our volunteers. We would like to thank our team of over 30 editors and subspecialty leads, and Ajay Malviya our clinical lead, for their tireless work. For any queries, or to get involved for 2022, please contact ukite@boa.ac.uk.

Latest News

Two new BOASTs published Announcing New Research Fellowship funding – Joint BOA/ORUK fellowships The inaugural BOA & Orthopaedic Research UK (ORUK) joint research fellowship will be fully launched soon – watch the BOA website and emails for more details. This pilot scheme will award two fellowships of up to £65k for a project in any area of orthopaedics.

Funding will be available for salary (maximum £60k) or as a stipend at UKRI levels. BOA Members at any trainee grade and SAS surgeons are invited to apply. To support diversity and inclusion within trauma and orthopaedics, we encourage applications from individuals who wish to undertake their research flexibly or less than full-time.

For more information: www.boa.ac.uk/researchfellowships.

The BOA has produced the following new BOASTs, which are available on our website at www.boa.ac.uk/boasts.

• ‘The Safe Use of Intraoperative Tourniquets’ BOAST has been published in collaboration with BSSH and BSCOS. Local tissue damage is a significant potential consequence of tourniquet use, particularly in vulnerable patients. This BOAST provides strategies for the prevention, diagnosis and management of tourniquet related injuries.

• The ‘Peripheral Nerve Injuries’ BOAST has been published in collaboration with BAPRAS, BSSH and OTS. All clinicians undertaking musculoskeletal care may be involved in the management of peripheral nerve injury, either as a complication of surgery or as the result of primary trauma. The consequences of a missed peripheral nerve injury have considerable impact on the patient. This BOAST discusses the early identification and timely management of injured nerves.

End of an era for the Clinical Examination Course, but a bright future ahead Where we started – the original faculty

How we’ve grown – 2021 faculty

After 11 fantastic years running the Clinical Examination course at Congress, Fazal Ali has retired from his post as Course Lead. Fazal designed the original course and has grown it from the faculty of eight, managing with the most basic equipment, to over 25 members delivering high quality education and hands-on practice for perfecting techniques. Also retiring from the course faculty this year are Shantanu Shahane, Joe Garcia, Amjid Ali, James Fernandes, Paul Haslam, Paul Banaszkiewicz, Irwin Lasrado and Kevin Wembridge. The faculty have made the course the success it is today and we pass on our appreciation for their hard work and years of commitment.

We are delighted that Fazal is handing over the baton to Karen Robinson from 2022 and we are sure it will continue to grow and develop under her leadership and guidance.

BOA Virtual Ortho Update 2022 The BOA Ortho Update 2022 will be taking place virtually on Saturday 8th January 2022 from 9am to 4.30pm. Places are extremely limited so register early to guarantee your place.

The one-day programme provides curriculum driven clinical updates and critical condition assessment opportunities aimed at T&O trainees and SAS surgeons. The course will include plenary update lectures delivered by expert clinicians and Case Based Discussions (CBDs) across a range of critical condition topics, including compartment syndrome, neurovascular injuries, painful spine in the child and spine trauma.

For the final programme and further information, including how to register, please visit the BOA website at www.boa.ac.uk/orthoupdate.

SAC Committee Vacancies The Specialist Advisory Committee for T&O has seven imminent vacancies and is currently advertising with a closing date of 12th December 2021.

The SAC is the influential body that advises JCST regarding all issues relating to training and its members share a desire to raise training standards and to provide support for trainees and trainers across all areas. If you are interested, please visit www.jcst.org/committees/ sac-membership-vacancies for more details, or contact Rob Gregory, (DM Twitter @ rjhgregory) Chair of the Committee.

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 07

News

2021 BOA Medical Student Essay Prize Winner

S

ully Uppal is the winner of the 2021 BOA Medical Student Essay Prize and a fifth year medical student at the University of Oxford. His interest in T&O began after his visits to A&E following rugby matches in school and was solidified by his placements on the other side of the stretcher.

Sully sits as the Medical Student Representative on the BOA Education and Careers Committee as well as the BOA Representative on the executive committee of the newly formed British Orthopaedic Medical Students Association.

Essay Summary Picking a specialty to pursue is a decision that most medical students spend years mulling over. With such a wide array of differing specialties, each with their unique

pros and cons, the dynamics of this decision are incredibly multifaceted. So why do people choose Trauma and Orthopaedics?

As we often hear in the world of medicine and surgery, a systematic approach is useful when dealing with complex questions. To that end, I used the COM-B framework, an approach taken from behavioural science, to categorise the different factors that influence a potential T&O applicant.

The COM-B framework is based on the interplay of three key components: capability, opportunity and motivation. Within these categories, influential factors can either drive interest, or act as barriers that impede it. Within the bracket of ‘capability’, the literature suggests that perceptions of manual dexterity drive interest, whereas the ability to manage the physical and psychological demands of the career pose

­

08 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

a barriers. Factors more external to the potential applicant are encapsulated within ‘opportunity’. This category contains some of the largest drivers of interest, including positive role models and participatory surgical experiences. However, there are also large barriers such as the stereotypical perceptions of a ‘boy’s club’ environment within the field. Both of these categories coalesce in ‘motivation’, which energises and directs action towards the pursuit of a career in T&O. Here, the evidence points toward plans for the future as well as other lifestyle factors having the largest impact.

The mixture of drivers and barriers faced by medical students is often unique to their personal circumstances, but exploring them systematically allows us to better understand why people may choose this path. The framework uncovered that surgeons in the field can have a significant influence upon this decision by providing positive learning experiences and inspiring the next generation of T&O surgeons. n You can read Sully’s winning essay on the Transient Journal at www.boa.ac.uk/T-JTO where we will be featuring the highest ranked essays throughout December.

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News

British Orthopaedic Research Society (BORS) update Wasim Khan, BORS Honorary Secretary

T

he British Orthopaedic Research Society (BORS) is a multidisciplinary association founded over 50 years ago, in 1961, and devoted to pursuing research relevant to orthopaedic and musculoskeletal surgery. Unlike most of the 22 BOA affiliated Specialist Societies, it benefits from a more diverse membership including surgeons, scientists, engineers and vets as well as allied health care professionals. The research interests of its membership are varied and include: Biological Science, Biomechanics, Osteo-articular Pathology, Biotribology, Molecular Biology, Bioengineering, Medical Imaging, and Patient Management. After a successful virtual meeting last year, the 2021 Annual Meeting was also held virtually on 13th – 14th September with over 100 attendees.

The Presidential Lecture was delivered by Professor Brigitte Scammell (Nottingham). An OATech session saw Professor Tom Andriacchi (Stanford) talk on ‘Bridging disciplines as a pathway to finding new solutions for osteoarthritis’. A session on One Health Initiative was moderated by Professor Debbie Mason (Cardiff) and Professor Chris Little (Sydney). Another session of the meeting focused on in-silico and invitro models and modelling. There were also free paper sessions on biomechanics and biology. The programme has become more clinically orientated in the last few years, reflected by an increasing number of surgeons attending. This year saw a joint session with the British Hip Society (BHS) as well as free paper sessions on the Hip and a keynote lecture by Professor

Vikas Khanduja (Cambridge) entitled ‘Navigating the Cam: Collaboration is the Key’. The poster session themes included implants and arthroplasty, trauma and soft tissue injuries, perioperative analgesia, and optimising surgical practice and surgical guidelines.

The next International Combined Orthopaedic Research Societies (ICORS) Meeting is being held in Edinburgh from 7th – 10th September 2022, and we look forward to hopefully meeting more of you face-to-face then. n

British Limb Reconstruction Society (BLRS) update Om Lahoti, BLRS President, on behalf of the Executive Committee

B

LRS conducted its annual scientific meeting BLRS 2021 as a virtual event, due to COVID-19 restrictions. We launched the event on 15th April 2021 and the content was accessible to the registered members until 6th July 2021. Virtual format allowed us to reach out to the orthopaedic limb reconstruction community all over the world and we received a brilliant response. We have put together an excellent programme including Major Incidents Masterclass, Topics in Focus included 3D printing, Knee and Foot and Ankle Deformities. The Keynote Lecture was on basic science of fracture healing. The Nurses and Allied Health Professionals section focussed on pre-operative preparation, care during COVID-19 and patients’ experience of treatment using a frame. Free paper sessions included a very popular ‘Best of the Best’ free paper webinar.

Industry also supported the event by hosting webinars, and we appreciate it.

10 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

At the BOA Annual Congress 2021, BLRS hosted two sessions.

Our first session was on Osteomyelitis, in keeping with this year’s theme of ‘Tackling Infection’. The second session included a round-up of Recent Advances in Limb Reconstruction, and free paper presentations. Our Secretary, Simon Britten, presented planning and delivering BLRS’ diversity and inclusion survey in the education section of the BOA programme.

This year BLRS has started a Modified Delphi process - BLRSRPS – British Limb Reconstruction Society Research Priorities Study - to achieve consensus on research priorities amongst limb reconstruction surgeons and health care practitioners.

Response is encouraging and I urge those who haven’t contributed to respond to the email from the society or directly at http://bit.ly/blrsdelphistudy.

BLRS continues to support educational activities. We have started awarding financial support to the courses that meet certain criteria, details of which are available on our website (https://blrs.org.uk).

Courses receiving support will display our logo on their flyer.

We encourage course organisers to apply. BLRS has been sponsoring one candidate for the Future Leaders Programme for several years and this year we have increased it to two and hope to continue. I am pleased to announce that the BLRS 2022 Annual Meeting will be in Brighton from 24th – 25th March 2022. n

News

British Association for Surgery of the Knee (BASK) update Alexander Dodds, BASK Honorary Secretary

T

he BASK Spring Congress was held as a hybrid event from Ashton Gate, Bristol in May. BASK members were able to join virtually over two days with live faculty including international faculty from the US and Canada. The meeting was interactive allowing for questions to be put directly to the faculty.

BASK also organised three revalidation sessions at the BOA Congress in Aberdeen. An excellent Adrian Henry lecture was delivered by Daniël Saris of the Mayo Clinic on the management of osteochondral lesions. Revalidation sessions on fragility fractures of the knee, unicompartmental knee replacement and management of the young arthritic knee were delivered. Earlier in the year a successful registrars teaching day had also been organised by BASK.

There has also been a strong focus over the last year on developing research strategy for the organisation. This has involved the input of the membership via a survey to guide further areas of research. The BASK research fellow program continues to be successful. A number of working groups are also at present developing best practice guidance following the success of the revision knee working group in publishing

guidance including BOASTs. The ACL injury prevention group and the Primary Knee Arthroplasty working group are active at present.

BASK is committed to incorporating equality within its core objectives and developing good working relationships to eliminate discrimination within our organisation. An equality and strategy framework has been developed, and a diversity questionnaire will be circulated to members by the end of the year.

The BASK Spring Congress is being planned for May 2022 in the ICC Wales – further details to be released soon.

Applications for the exec posts of Honorary Secretary, Education Lead and Early Years will be advertised by the end of the year. n

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 11

News

2021 BOA Congress Review Simon Hodkinson

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ell, we made it. The first major face-to-face conference since the pandemic started and we would like to thank all the delegates and exhibitors for their efforts in helping keep it COVID-19 safe.

We had spent the year worrying whether we could and would be allowed to hold it and safety of delegates was always paramount against the desire to meet up once again.

The venue was in many ways perfect for such a situation being close to the airport and outside of the city. It was virtually brand new, and its size and facilities were ideal given the circumstances.

Thanks has to go to the Scottish Government in supporting Congress and awarding us ‘Gateway status’. Thanks are

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also due to the venue itself but primarily to Charlie Silva, BOA Head of Events.

With three months to go, due to various staff changes, Charlie was The Events Team.

Without her and the hastily resurrected team, Congress would not have happened.

Overall, we had just under 2,000 attendees across the three days. The Congress was packed with excellent plenary lectures and lively discussions in many of the sessions. It was very busy as there were two years’ worth of material to get through and catch up on, but hopefully those who attended managed to get to what they wanted. We were also delighted with attendance and engagement with trade the exhibition as our industry partners are a key element for the success of the event.

The theme for this year was Tackling Infection which was expertly reflected across the sessions and exhibition, alongside posters demonstrating a fascinating new genre in the art world, ‘Bug Art’.

Building on 2019 we increased the material on the web site with content going up 24 hours post session. As a delegate you have exclusive access to this material for three months post congress event before it is made more widely available.

Finally, a new addition to the Congress format was the bridge building competition.

A serious team working exercise culminating in a tense final assessment of the loadbearing capacity of the bridges. The question remains who was most stressed, the teams or the venue staff seeing the volume of water used over their expensive clockwork under the stage.

By popular demand it will return for 2022 and planning for Congress 2022 in Birmingham ICC is well underway.

I hope those who attended enjoyed themselves and those who log on to access the material on the website find it worthwhile.

I look forward to seeing you all in Birmingham. n

News

Bridge Building at the BOA Caroline Bagley, Adeline Clement, Joanna Maggs and Lawrence Moulton

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t 7.30am on Wednesday at the 2021 BOA Congress, whilst other Orthopods were enjoying a welldeserved lie-in or leisurely breakfast, teams from the Future Leaders Programme (FLP), BOTA, BHS and OTS arrived at the Aberdeen TECA to be briefed for the ‘Bob Handley Bridge Building’ challenge.

The rules were simple – build a bridge that would be tested to destruction using only a pack of A4 printer paper, two rolls of Sellotape and a customised BOA metal plate with attached hook. The bridge needed to span a gap of 80cm between two tables with a bucket hung from the hook and filled with increasing amounts of water; failure was defined as the point the plate fell beneath the level of the table surface. The prize was ultimate glory.

We had until the following day to create our structure which would be tested in the main auditorium. In the spirit of healthy and (mostly) friendly competition, each team went off to plan and build! What followed was hours of fun, teamwork and collaboration using our basic science knowledge and applying biomechanical and engineering principles to design and create the strongest possible bridge.

Thursday’s public testing was the cumulation of an enjoyable competition that tested the four teams who participated. All teams created stunning bridges. The FLP were thrilled to be victorious, winning chocolate orthopaedic tools and yellow hard hats which were worn with pride! n

2021 Awards and Medals

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ongratulations to our Congress prize winners! It was fantastic to be able to celebrate the brilliant achievements of our members with our Awards and Medals show case at Congress in Aberdeen.

The Best of the Best Certificate went to Fatima Rashid representing the Mersey region – for her talk on “Coronavirus infection in Hip Fractures (CHIP) Study: A case matched multi-centre study of 1,633 hip fracture patients.”

The Medical Student Podium Prize winner was Catherine James for her “Crash Course in Orthopaedics: Lessons form a 12-week Webinar Series for Medical Students”.

The quality of the medical student abstract presentations was extremely impressive this year. In addition to the winner, the panel highly commended Benjamin Rouse for “The Incidence of Major Complications following Per-Acetabular Osteotomy (PAO)”, Ciaran O’Hanlon for “Outcome comparison of Superior Capsule Reconstruction and Subacromial Balloon Spacers for the treatment of massive rotator cuff tears: A systematic review”, and Rory Teed for “Epidemiology and long-term outcomes of lateral end clavicle fractures in an adolescent population”.

Jacob Feathers was the winner of the Best Poster Prize with “Uncemented Total Hip Arthroplasty can be used safely in the elderly population”.

Thank you to all our exhibitors who supported us to help make Congress happen. The winner of the Exhibitors Cup for Best Large Stand was Stryker UK and the Exhibitors Plaque for Best Compact Stand went to Healthcare Business Solutions UK Ltd (HBSUK). n

Fatima Rashid

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 13

News

New BOA Trustees (2022–2024) Cheryl Baldwick I have been a consultant in North Devon for 13 years and have a full clinical practice in general trauma and my subspecialist interest of shoulder and elbow surgery. I have been involved in medical education, spending several years as our Foundation Training Programme Director and developing new Specialty Registrar posts in T&O at my Trust. I have also had a number of medical leadership positions and have just been appointed to a Deputy Medical Director role.

Since 2014, I have been a member of the BOA Trauma Committee, contributing to the development of BOASTs and chairing a number of multi-disciplinary hip fracture reviews around the UK. The next few years pose immense challenges for us as orthopaedic surgeons as we try to recover elective services after the pandemic while continuing to provide excellent trauma services across the country.

The BOA has an integral role to play in this process and it is important to me that Council represents surgeons from a wide variety of units around the country, including strong trauma representation. I work in a small rural Trauma Unit and, while involved in the BOA, I have always highlighted issues relating to smaller units and promoted generalisability in the guidance the Trauma Committee has released. n

Deepa Bose Ms Deepa Bose is a consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham. Her practice is exclusively in adults, and includes general trauma, major trauma and post-traumatic limb reconstruction: osteomyelitis, malunion, non-union, limb lengthening and deformity correction.

Deepa is currently Vice Chair of the Specialist Advisory Committee for Trauma and Orthopaedics, and the lead for CESR approval process. She has also contributed to the revision of the curriculum.

She holds an MSc in Medical Education and has been admitted to the Faculty of Surgical Trainers of RCS Edinburgh, as well as being a member of the Academy of Medical Educators. She is involved in national selections for core and orthopaedic surgery, and sits on ARCP panels for both. She was regional training programme director for core surgery in West Midlands from 2015 – 2019.

Deepa is the Chairman of World Orthopaedic Concern UK, a specialist society of the British Orthopaedic Association, and a charity which focuses on teaching orthopaedics in low resource countries. She is co-director of the postgraduate orthopaedic training programme in Guyana. Deepa also visits Gaza as part of the UK limb reconstruction team of the charity Medical Aid for Palestinians.

She has been on the Emergency Response Team of UK Med, a first response team for international disaster relief, since 2012.

Deepa decided to run for the BOA Council because she is passionate about safeguarding the future generation of orthopaedic surgeons. She hopes to achieve this by promoting the highest standard of education and training, both in the UK and in low and middle income countries. n

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News

Caroline Hing Caroline is a professor of orthopaedics at St George’s Hospital in London. She trained on the Percival Pott rotation before fellowships in trauma and knee surgery in Australia. She has an academic interest in knee surgery and trauma, having completed a BSc, MSc and MD. She currently leads research in her department and has built up participation in trauma trials within the department. She has committee positions with the NIHR, Orthopaedic Trauma Association, British Orthopaedic Association and the British Association of Surgery of the Knee. She is a founding member of the International Orthopaedic Diversity Alliance and has hosted webinars on diversity to increase support for change.

Caroline has previously helped to develop the BOA’s diversity strategy and ran for council hoping to continue to support the BOA in diversity initiatives, education and research. She is keen to support encouraging medical students to consider a career in trauma and orthopaedics by highlighting the varied career trajectories that are possible and the contribution that SAS doctors, AHPs and surgeons all make to patient care.

In her free time she likes to stay active by rock climbing, swimming, cycling, skiing, freediving and travelling. She is happiest outside in the sea or amongst the mountains, ideally somewhere hot and sunny. n

Andrew Price Andrew studied medicine at the University of Cambridge before completing his clinical studies at St. Thomas’ Hospital in London.

For his orthopaedic training he joined the Oxford training programme and joined the Nuffield Department Orthopaedics Rheumatology and Musculoskeletal Science (NDORMS) as a Clinical Lecturer in 2001.

He was awarded a DPhil in 2003 through the University of Oxford (Worcester College) and then completed a year of specialist Knee Fellowship training in Melbourne, returning to Oxford in 2004, where he was appointed Reader and Honorary Consultant in Knee Surgery. In 2011, through the University of Oxford Recognition of Distinction exercise, he was made a Professor of Orthopaedic Surgery. He is a Fellow of Worcester College in Oxford.

His clinical work as a Consultant Knee Surgeon is based at the Nuffield Orthopaedic Centre, where he has recently been appointed Clinical Director T&O. His research is based in NDORMS, where he leads the Knee Research Group, with research focused on using mixed methodologies to improve clinical pathways in orthopaedics.

He is the immediate Past President of the British Association for Surgery of the Knee (BASK) and is actively involved in the UK National Joint Registry.

He was delighted to be elected to join the British Orthopaedic Association team. Andrew applied so he could have an active role in the development of orthopaedics within the UK, using the experience he has gained through working on the BASK executive. n

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News

New Lay Trustee (2022–2024) Paul Buckley Paul Buckley retired from the General Medical Council at the end of 2020 after almost 25 years with the organisation, 16 years of which he was a Director and member of the Senior Management Team. In his most recent role he was responsible for the development of the GMC’s corporate strategy and overseeing its policy work including a major regulatory reform programme, and leading other key functions including Equality, Diversity and Inclusion, business planning, research and data. He was also a Director and Managing Director of GMC Services International Ltd, a consulting subsidiary.

Paul is now building a non-executive portfolio in healthcare, and in addition to his role with the BOA he is a member of the Healthcare Safety Investigation Branch Citizen’s Partnership and is the independent chair of the Scope of Practice and Education Committee which is reviewing standards across six organisations for counselling and psychotherapy with adults. n

AGM update

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e were delighted to see so many of you attend the AGM in Aberdeen, the room was packed with members to hear updates on the BOA financial performance and activities, and for voting on some important changes to the Articles and Rules of the Association. The BOA is in sound financial state and all proposed resolutions were passed and we will now be implementing the changes to enhance the governance of the Association.

These changes were: • Extending the voting rights to include members in the SAS 11 years+ category.

• Appointment of Lay Trustees to the Council. This is an important development to support the ongoing enhancement of the BOA’s governance processes by filling identifiable skills gaps and to bring relevant, non-clinical experience onto Council. We are delighted that Bertie Leigh moves from Lay Member to Lay Trustee and that Paul Buckley, formerly General Medical Council, joins us as a new Lay Trustee.

• Changes to Council Members terms of office. This facilitates continuity within Council and removes the need to be retired from Council for a period of time before seeking re-election. Trustees wishing to continue for a second term will have to stand for election in the same way as all other candidates.

Trustees have the choice not to stand for concurrent terms of office and if necessary stand for a further period of three years at a later date, but the overall term of office will still be limited to six years. This does not preclude anyone from standing for a position as an Officer at a later date.

We really appreciate members taking their time to attend the AGM and helping ensure that we achieved the required quorum for making important governance changes. We are looking at ways of developing the AGM to allow more time for discussion with the BOA leadership, details to follow. If there is anything you would like to see included please contact us at info@boa.ac.uk. n

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News

Conference Listing 2022: BHS (British Hip Society)

www.britishhipsociety.com 02-04 March 2022, Bournemouth

BOFAS (British Orthopaedic Foot and Ankle Society) www.bofas.org.uk 09-11 March 2022, Bournemouth

BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk 10-11 March 2022, Maidstone

BASS (British Association of Spine Surgeons) www.spinesurgeons.ac.uk 23-25 March 2022, Belfast

BLRS (British Limb Reconstruction Society) www.blrs.org.uk 24-25 March 2022, Brighton

SBPR (Society for Back Pain Research) www.sbpr.info 30 June-01 July 2022, Warwick

CAOS (The International Society for Computer Assisted Orthopaedic Surgery) www.caos-international.org 08-11 June 2022, Brest

OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk 16-17 June 2022, Southampton

BESS (British Elbow and Shoulder Society) www.bess.ac.uk 21-24 June 2022, Liverpool

BOA (British Orthopaedic Association) www.boa.ac.uk 20-23 September 2022, Birmingham

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk 12 October 2022, Winchester

BSS (British Scoliosis Society)

www.britscoliosis.org.uk 02-04 November 2022, Edinburgh

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 17

News

Virgin Money London Marathon 2021

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ongratulations and thank you to Imran Ahmed, Robert Jordan, Lee Longstaff, Zaid Ali and Philippa Turner for running the London Marathon on Sunday 3rd October.

Their amazing efforts have raised over £10,000 to support vital research in orthopaedics. If you would like to show your support for these fantastic runners please donate at www.justgiving.com/boa.

Imran, Robert and Lee have shared their experiences which we hope will inspire you to get involved. If you are interested in running the London Marathon to help raise funds for Joint Action, please contact us at jointaction@boa.ac.uk.

Imran Ahmed: “Running my first marathon was a great experience and I am extremely grateful to the BOA for providing me with the opportunity to fulfil this ambition. It was also rewarding to help raise money for a worthwhile cause. This experience has allowed me to develop my interest in distance running which is something I am looking forward to for the foreseeable future. It was also really fun being able to run with Robert Jordan for the majority of the race. I’d like to once again thank the team at BOA for all the support to make our experience a smooth one. I look forward to the opportunity to do this again!”

Robert Jordan and Imran Ahmed

Lee Longstaff

Imran Ahmed

Robert Jordan: “Thank you to Joint Action for the opportunity to take on the London Marathon again. After all the cancelled events over the last 18 months, it was great to be running the iconic London Marathon, making all those early morning training runs worthwhile! The crowds were fantastic and it was especially rewarding to complete it with my friend, Imran Ahmed, both of us fundraising for Joint Action. I am sure the money we raised will be put to good use.”

Lee Longstaff: “Thank you BOA for giving me the opportunity to run the London Marathon and raise funds for joint action in 2021!

It was an absolutely fantastic day. Beautiful weather, cheering and supportive crowds and the camaraderie of the runners around me. It was a great first marathon even after hitting ‘the wall’ at about mile 22. The knowledge that so many sponsors were behind me and the positive impact that the funds would have spurred me on to the finish. This will not be my last!”

Make a difference in 2022

Zaid Ali

Caring for patients, supporting surgeons. We prevent and relieve pain to keep people moving. We transform the quality of life for millions of people who have debilitating musculoskeletal conditions or are recovering from life-changing trauma or illness. We give them back their freedom and independence.

RideLondon Returns

In 2022 we will be raising vital funds for Orthopaedic Research through two world class sporting events.

The world’s greatest festival of cycling returns on Sunday 29 May 2022, with a new format and an exciting new route!

We ask all riders to aim for a fundraising target of £500 to help fund vital T&O research.

At time of going to print we still have space available in Ride London. If you would like to be part please contact us at jointaction@boa.ac.uk.

London Marathon 2022 Places for the 2022 London Marathon are currently full but please keep an eye out for notification of the 2023 event as this returns to its usual April slot.

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News

Joint Action Christmas Appeal 2021

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aring for patients, supporting surgeons. We prevent and relieve pain to keep people moving. We transform the quality of life for millions of people who have debilitating musculoskeletal conditions or are recovering from life-changing trauma or illness. We give them back their freedom and independence.

With over 20 million people in the UK living with a musculoskeletal condition there has never been a more important time to invest in pioneering research in trauma and orthopaedic surgery. Joint Action raises and distributes funds for research across the range of musculoskeletal conditions.

Following the success of the British Orthopaedic research Centre in York, this year the BOA has awarded grants to two new Clinical Trials Units. They will identify and develop new and existing T&O researchers to continue the growth of high-quality T&O research in the UK and develop new and innovative trials that deliver answers to complex clinical questions. They will also be supporting new researchers by offering opportunities to discuss new ideas with clinical trials researchers.

New for 2022: Next year we will be launching an exciting new surgical fellowship scheme in partnership with Orthopaedic Research UK. This will support two fellows at any trainee or SAS grade to undertake research projects in any aspect of the field of orthopaedic surgery or surgical care including basic science, diagnosis, treatment, surgical technology, logistics or audit.

Please help us continue to transform the quality of life for thousands of people this Christmas: www.justgiving.com/ campaign/JAChristmasappeal2021. n

Help transform the quality of life for thousands of people this Christmas

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 JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 19

Features

Core curriculum topics in orthopaedics – a BIOS initiative Maneesh Bhatia and Bijayendra Singh The British Indian Orthopaedic Society (BIOS) is a specialist society affiliated to the British Orthopaedic Association (BOA).

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IOS caters to the broad specialty of trauma and orthopaedics and its main role is to provide educational support to orthopaedic surgeons of Indian origin. Whilst BIOS celebrates its Indian connection, it is also equally proud to be a body of British surgeons who happen to be of Indian origin.

BIOS organises various meetings (including its annual meeting in July), courses and social events besides acting as a forum for informal discussion among its members on issues of mutual interest. BIOS also plays a key role in liaising between the Indian Orthopaedic Association and the British Orthopaedic Association. BIOS organises an Indian Summer scientific session at BOA’s annual congress in collaboration with the Indian Orthopaedic Association, besides its own specialty session which is usually well attended and has always received excellent feedback.

BIOS also organises a range of travelling fellowships to support professional development of surgeons. It has a wellestablished senior and junior travelling fellowship programme, where surgeons from India visit the UK on short term fellowships and gain experience from interacting with their UK counterparts. BIOS also facilitates a reciprocal travelling fellowship programme where British surgeons are sponsored for their visit to India. This gives an opportunity for UK surgeons to experience a large volume of diverse pathologies seen in India.

The COVID-19 lockdown necessitated a new approach to deliver BIOS’s aim of

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Professor Amit Tolat Current BIOS President

Professor Bijayendra Singh Immediate Past BIOS President

Sanjeev Anand Current BIOS Education Secretary

Maneesh Bhatia Immediate Past Education Secretary

providing educational support to aspiring and established orthopaedic surgeons.

For medical students, a range of webinars covering basic orthopaedics topics were run over a period of three months. These very well attended sessions are now available on BIOS’s YouTube channel archives.

opportunity for listeners to interact with and discuss their queries with the expert panel.

These sessions are then available on the BIOS YouTube channel for subsequent viewing.

Our postgraduate training programme was severely affected during COVID-19. In order to continue providing educational support to our trainees, BIOS launched a webinar series on ‘Core Curriculum Topics in Orthopaedics’ in 2020. This webinar series covers each subspecialty of orthopaedics, with the intention of covering the full curriculum over a threeyear period. Sessions are presented live on the second Sunday of each month at 11am with each session covering three topics of a sub-specialty. There is an

These sessions have been very popular and have received excellent feedback.

The second series of these lectures has started this year. Based on the feedback received last year the time for discussion has now been increased giving the trainees plenty of opportunity to interact with the trainers.

This educational content is available at: www.youtube.com/c/BritishIndianOrthopaedic SocietyBIOS/videos or using the QR code. n

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Features

It’s all in the state of mind: A reflection of my orthopaedic journey Bart Day

Figure 1: In hospital after my accident.

Life can change in an instant

J Bart Day is a marketing professional and father of two, living in South-East Wales.

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ust before my 25th birthday I had a climbing accident (Figure 1). It left me with a leg that was an inch and a half shorter than the other and a rebuilt foot with limited movement and sensation. On the other side, an ankle that was basically bone on bone (Figure 2 & 3). By the time I was in my mid- thirties, I was married with two children and a career.

I was walking with a stick, on ever increasing doses of pain killers and in severe discomfort that was getting more and more debilitating.

I only realised the profound impact these injuries would have on my life when the initial surgery had ceased and I had to come to terms with the fact that this was the new me. I had been extremely active, I ran, swam, climbed and snowboarded.

I was a cocky, invincible twenty-something year old. After the accident, my life had changed.

I married soon after I was able to walk down the aisle unaided, had a family and got on with life the best I could. As my children got older, and my condition deteriorated, the impact of my injuries became apparent. My children, like most children, were active.

They played football, rugby and hockey.

They ran, swam, cycled, climbed, and did gymnastics and trampolining, everything that I’d dreamed of being able to do with them. I now found myself on the side-line.

I could swim and cycle, but I couldn’t kick a ball or run. Physically and mentally, I felt as though I were far older than my years, and it got me down. Looking back now, I realise that I wasn’t being the dad or husband I had wanted to be when I was growing up, and my children were having to make excuses for me to their friends at a time when they just wanted to fit in.

Features

Figure 2: Severe arthritis of my ankle with nerve injury.

A fork in the road After a change of jobs took us to another part of the country, I was taken on by a new consultant.

He and I spoke at length about what I had wanted to achieve, and the options available to me. We discussed three main avenues: 1) Alternative pain management 2) Reconstruction 3) Amputation I had never really liked the thought of taking tablets long term and having been on a wide selection of drugs over the previous ten

Figure 3: Deformed right ankle and arthritis of my left ankle.

years, this wasn’t a route that appealed to me. The reconstruction option felt like a lot of disruption to try something which was, at that time, not entirely reliable, so an amputation was something that I had to seriously consider. I went home to talk it through with my friends and family.

As expected, there were differing opinions of what an amputation would mean to me, and to us as a family, and in hindsight, these fit pretty closely to the usual outlook of those who offered them. Everything from “this is terrible, your life will be over” through to “it’s great, you’ll never get a cold foot again” and a lot of abstainers.

My wife and I had a second conversation with my consultant and one of his colleagues, and both assured me that if they were in my situation, at my age with my level of health, this would be their choice.

I’d be up and walking within a few months and wondering why I’d not had this done years ago. They booked me an appointment with the consultant at the artificial limb centre to talk about rehab.

Figure 4: My leg before amputation surgery.

Of all the moments in my life relating to this accident, I don’t think anything has traumatised me as quite as much as that appointment.

I guess, his job was to make sure I was absolutely serious about the amputation and I was going in to it with my eyes well-and-truly open.

I came out of his office with a portents of doom ringing in my ears. I would be confined to a wheelchair for the rest of my life, I

would never be able to wear a limb, I would have sores, and blisters and infections, and I would possibly even shorten my lifespan!

I’m pleased to be able to report that I never actually saw that consultant ever again, and the nurses, physios and prosthetists were far more akin to my consultant and his ‘this is the best decision, and together we will make it work’ attitude. We chose to go ahead with the amputation.

The road less travelled The surgery was relatively straightforward.

I was admitted to hospital one morning, my consultant came with a black marker pen and drew an arrow on the correct leg (Figure 4).

I went down to surgery and then woke up with everything done. He came to see me over the next couple of days and then I was discharged.

That night, as I bum-shuffled along the upstairs landing to kiss my children good night I realised that, I actually felt far less disabled with half a leg missing than I had with the mangled one. It was then I knew that this had been the right decision.

At this point, I will say that I had arranged for a car with hand controls through the Motability scheme, so I wasn’t reliant on others for mobility. I was also, by now, a football coach for my son’s U9’s team and playing in a local band. I was more than just my injuries. They were part of me, but they didn’t define me.

Six days after my amputation I was bowling with the family. Six weeks after the amputation, I was back at work. Ten weeks after the amputation I was walking.

Rehabilitation was challenging, but the team supporting my consultant and the team at the Artificial Limb centre were completely aligned with what was best for me and how I was going to get there. The prosthetists >>

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Features

In the past, to other healthcare providers, I’ve been a patient, or I’ve been a case or I’ve been an NHS number. With my current team I am Bart Day. I have a family. I have a life outside of the sterile walls of whichever medical facility I might be in. Being recognised as me, and being treated as me, I knew that I was still me, and that, I think, was pretty fundamental in the successful outcome of my journey (Figure 7).

“As I bum-shuffled along the upstairs landing to kiss my children good night I realised that, I actually felt far less disabled with half a leg missing than I had with the mangled one. It was then I knew that this had been the right decision.”

Five things to share and reflect upon having been through trauma and an amputation are:

Figure 5: My new leg.

took plaster casts, had fittings and gave me a leg (Figure 5). The physios taught me how to walk and deal with my new limb.

My consultant and his team made sure the stump healed and was ready to carry me. I can honestly say that ever since my amputation, even on the rare occasions when I have been unable to wear my leg due to sores or blisters, not once have I doubted that it was the right decision.

It’s now 12 years later. Since my amputation, I’ve also had my left ankle replaced and once again, everyone involved in my care before, during and afterwards, knew who I was, what my ambitions were and how they were going to make sure I achieved them (Figure 6).

Figure 6: Achieving my ambitions.

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1. Try to keep your life as normal as possible. I know, that sounds silly.

But although it’ll feel as if everything is different, try to keep your life as normal as possible. Cook meals, spend time reading to the kids, help them with homework, do some housework. Just because you’re in a wheelchair, it doesn’t mean that you’ve lost the use of your other limbs. If it’s your turn to cook supper, then cook supper. It gives you something to think about other than the injury and surgeries.

2. Keep busy for a reason. If you sit and wallow in self-pity, it’ll be a long, hard road to recovery. You have to have a ‘thing’ that needs to be done every day, and make sure the ‘thing’ you do has a purpose. How about these as ideas? a. Take up a hobby. b. Learn a language. c. Sort out Lego.

Figure 7: Back to doing what I love.

3. Document things.

Even if it’s only a few lines a day in an old notebook, write things down. When did you stop taking pain killers? When did you take your first steps? When did you feel unable to even get out of bed? I did this quite a lot, and ten years later, it’s really empowering to look back and see what I went through and how strong I really was even though at the time I probably didn’t think I was. Also, if you can face it, take photos of your progress. I’ve got so few photos after my initial accident because I refused to let them be taken.

Now, I wish my family had ignored my wishes.

4. Don’t take your frustration out on those who care about you.

Remember, the vast majority of people you know won’t ever have been through what you’re going through, but that doesn’t mean they don’t care. There will be many times when you just want everyone to leave you alone, but they are probably feeling as scared as you are. Most people are nice and want to help. So if you see them as interfering busybodies, then that probably says more about you than them.

5. If you want it to, it will get better.

This point initially didn’t have the first five words, but I totally believe that I am the person I am today, as active as I am today and doing what I do today because I really wanted it to happen. I know amputees who have never walked on their legs because it’s been too tough, and I don’t doubt that I think I’ve had it easy, but in the words of Walter D Wintle, “If you think you’re beaten, you are… it’s all in the state of mind.” n

Features

British Orthopaedic Foot and Ankle Registry – Where are we now, and where are we going?

Lyndon Mason, Edward Wood and Paul Halliwell

O

Where we are in 2021

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

He is the Chairperson for the Outcomes Committee in the British Orthopaedic Foot and Ankle Society.

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n the 21st of February 2018, the then Secretary of State for Health and Social Care in the UK, Jeremy Hunt, issued a statement in the House of Commons in response to the reports about harmful side effects from medicines and medical devices.

A review was commissioned to consider how to strengthen the patient voice in order to help build a ‘system that listens, hears and acts – with speed, compassion and proportionality’1.

Patient groups had campaigned for years, if not decades, to achieve this acknowledgement. An independent safety review was commissioned for medicines and medical devices led by Baroness Cumberlege, with specific investigation of two medicines and one medical device.

reported outcomes measures (PROMS)”. This recommendation is important due to its need for centralised data collection on all patients with implantable devices and the prospective collection of PROMS data on all patients.

In July 2021, the government published their response to the Cumberlege report (Figure 1)3. In chapter 8, the government accepted the aforementioned recommendation number seven, legislating through the Medicines and Medical Devices Act 2021, to give power to the secretary of state to regulate for the establishment of a UK-wide Medical Device Information System (MDIS). Central to the development of the MDIS is PROMS. Patientcentred registries have been high on the agenda at BOFAS for some time, and we have been working closely with the BOA as part of the Trauma and Orthopaedic Registries Unified Structure (TORUS) project for several years, which includes the majority of the musculoskeletal registries outside the National

On 8th July 2020, the First Do No Harm Report (otherwise known as the Cumberlege Report) was published (Figure 1)2. The review found that the system in which patients concerns could be raised regarding medicines and medical devices was “disjointed, siloed, unresponsive and defensive”. A total of nine recommendations were made. Recommendation number seven was of particular importance to orthopaedic registries.

It stated that “A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation.

This can then be linked to specifically created registers to research and audit the outcomes in terms of both Figure 1: The Cumberlege report and governments response. the device safety and patient

Features

Edward Wood is a Trauma and Orthopaedic Consultant in the Countess of Chester Hospital NHS Foundation Trust.

He is Co-opted Chairperson for the Outcomes Committee in the British Orthopaedic Foot and Ankle Society.

Figure 2: The number of BOFAS pathways created by year and pathway type.

Joint Registry. Both the BOA and BOFAS have welcomed the opportunity of the Cumberlege Report to promote the importance of robust prospective collection of validated, patientcentred clinical outcome measures.

Lessons from the BOFAS Registry

Paul Halliwell is a Trauma and Orthopaedic Consultant in the Royal Surrey County NHS Trust.

He is Previous Chairperson British Orthopaedic Foot and Ankle Society Outcomes Committee and President-Elect of the British Orthopaedic Foot and Ankle Society.

The BOFAS registry is neither the oldest nor the largest patient outcome registry in musculoskeletal disease in the UK. However, it is one of the few registries which is both funded and managed solely by its specialty society and its members. Collection of PROMS is central to the BOFAS registry. It was initially formed as a national audit tool to allow foot and ankle surgeons to know their own results, with patients filling in their own scores prospectively using an electronic portal. As the data collection has increased and matured, we have been able to produce an Annual Report for each of the last three years.

Despite the Registry’s major growth, this has been due primarily to input of enthusiasts working without support. Only 80 of BOFAS’ membership of 465 (17.20%) are registered, active contributors despite the Registry being available to all and funded by members’ subscriptions. Its use is entirely voluntary.

The number of patient pathways created on the registry has increased almost exponentially in the last three years but still captures only a small percentage of the BOFAS members’ activity. (Figure 2)4.

Although the sheer difficulty in absorbing further tasks into already-busy clinical lives undoubtedly plays a significant part in this low engagement, there are two practical issues which continue to impede colleagues:

1. Permission from Trust Information Governance Officers (IGO) is required to permit consenting patients to be contacted for collection of PROMS. There is enormous variability in the extent and type of documentation demanded of potential users.

The registries would welcome standardisation on this front.

2. Busy surgeons cannot afford to spend time inputting data and contacting patients for their responses without reducing their clinical activity. Some Trusts appreciate the importance of data collection so employ dedicated staff, but this is far from ubiquitous.

Even with these difficulties, the basis for a mandated registry is in place, with most barriers being the lack of support and centralisation.

Accuracy and quality of data Analysis of the BOFAS registry data was performed in 2020 by Birmingham University. Across the three pathways analysed (ankle arthrodesis, 1st metatarsophalangeal joint arthrodesis and general foot and ankle) the rate of PROM completion significantly reduced over time: PROMS collection at 1 year dropped below 20%. The registry primarily uses email addresses to contact patients to collect PROMS. Approximately 25% of patients do not possess or use an email address which partly explains the above.

In those with email addresses they may end up in junk mail, old email addresses or simply be ignored. The registry moved to use additional text message data collection this year in the hope of increasing the yearly data collection of PROMS. >>

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become more established, and Responsible Officers awareness of them increases, we anticipate appraisers asking for specific evidence of such activity. The BOFAS Registry incorporates a downloadable Revalidation Report for this reason. As a requirement of every medical and surgical practitioner, more facilities should be put in place in every hospital to allow registry use and completion of data.

Conclusion The landscape in the NHS regarding registries is changing very quickly. The political developments, due to the Cumberlege report and the government’s response this year, appear to be in favour of the creation of an all-specialty PROMS registry for all surgical interventions. The BOFAS registry is well placed to share experience in the development of a MDIS, especially the pitfalls in data capture in real-life clinical environments.

The BOFAS Registry can be accessed via the BOFAS website: www.bofas.org.uk/clinician/ bofas-registry/registry-login. n

References Figure 3: The compliance data on outstanding task completion on the registry by month.

The current compliance on completion of tasks in the registry is approximately 60% over the last two years (Figure 3). It is likely however that funding for staff to directly collect this data, either face to face or by phone, is likely to achieve the most success. The general data has supported the success of the procedures in all PROMS, even with very variable nature the procedures had been performed.

Unlike arthroplasty surgery, where techniques can be relatively standardised, foot and ankle surgery encompass many diverse procedures, and standardisation would be difficult to achieve. Therefore, picking apart implant level data with such variability requires massive and complete data sets. For an all-encompassing MDIS to be successful, data entry would need to be mandated and staff allocated to the collection of data.

General Data Protection Regulation (GDPR) The Data Protection Act 2018 is the UK’s implementation of the GDPR, which all TORUS registries undertook measures to comply with. Registry data is currently regarded as supplemental to a patient’s normal clinical records. Therefore, the legal basis for collection and processing is the patient’s consent in common with other registries such as the NJR. In time, the data might be regarded as sufficiently in the patient’s best interests that consent is not required.

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Information governance across the UK is dependent on the information governance officer of the trust. Navigating past the Information Governance Officer (IGO) of each trust remains one of the greatest challenges of a surgeon wanting to collect PROMS on their patients. Current advice from the Information Commissioner is that potential registry users must be granted permission to consent their patients to submit data by their Trust’s Medical Director (MD). MDs do so on the recommendation of their IGO. IGOs vary enormously in the compliance requirements and documentation imposed on applicants. In many cases the process is impenetrably onerous and deters surgeons from participating. This remains one of the greatest challenges for a surgeon wanting to collect PROMS on their patients.

Appraisal requirements Participation in available national audits is a General Medical Council (GMC) requirement under Good Medical Practice5. Reflection on the outcomes of these audits is expected to form part of the supporting information to demonstrate quality improvement activity at appraisal. The BOFAS Registry is a national audit and is available to all foot and ankle surgeons who are members of the society. Surgical disciplines lend themselves to evidence capture, and a registry is an ideal method of demonstrating the nature and success of one’s practice. As registries

1. House of Commons (2018). Medicines and Medical Devices Safety Review.

Volume 636: debated on Wednesday 21 February 2018. Available from https://hansard.parliament.uk/ commons/2018-02-21/debates/7DA2E2F3E1E6-40CB-8061-680E0399CA97/ MedicinesAndMedicalDevicesSafetyReview.

2. Cumberlege J (2020). First Do No Harm.

The report of the Independent Medicines and Medical Devices Safety Review Open Government Licence. Available from www.immdsreview.org.uk/downloads/ IMMDSReview_Web.pdf.

3. Department of Health and Social Care (2021). Government response to the Report of the Independent Medicines and Medical Devices Safety Review. Available from https://www.webarchive.org.uk/wayback/ archive/20200805110914/https://www. immdsreview.org.uk/Report.html.

4. BOFAS (2021). BOFAS Registry Annual Report. Available from www.bofas.org. uk/Portals/0/Registry%20Documents/ Annual%20Reports/BOFAS%20 Registry%20Report%202021.pdf?ver=_ z7ZdvZ9llHjbITDLuZCGg%3d%3d.

5. General Medical Council (2020). Guidance on supporting information for appraisal and revalidation. Available at: www. gmc-uk.org/registration-and-licensing/ managing-your-registration/revalidation/ guidance-on-supporting-information-forappraisal-and-revalidation.

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Features

Anthropology of the human foot – the past, present and future Kartik Hariharan

From single cell amoeba to the human species

L Kartik Hariharan is a Consultant Foot and Ankle surgeon at Aneurin Bevan University Health Board.

He is Past President of BOFAS and delivered the Naughton Dunn lecture in 2015 on which this article is based.

ocomotion more than any other single factor is, in my eyes, the most important attribute for the successful survival of a species. Locomotion allows the species to find sources of nutrition when one area is depleted, allows rapid movement from one area to another in times of adversity, allows for successful reproduction and the propagation of species DNA in areas of plenty.

Perhaps most important of all, it allows preferential mutations to accumulate by the cross transfer of genetic material thereby avoiding inbreeding and its attendant genetic degradation. From a single celled amoeba to a vast collective tribe of wildebeest, every species has to move to survive and flourish.

Figure 1: Primitive tetrapod limb showing three tarsal rows.

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This incredible attribute was not bestowed upon us nor was it a single event or sequence of events. It is one that went through many millions of years of subtle, sudden, random but serendipitous changes, often going down dead ends and failed transformations and eventually to where we are today.

We are not the only species to have this attribute, but perhaps, are one of the few species to exploit it, to dramatically alter the functions of other aspects of our body: the ability to use our hands, transform our brains to think and to transform the very environment, which in itself is the most potent driver of evolution.

Therefore in essence this article is a bird’s eye view of human bipedalism: a process that took several million years of change and refinement to reach the stage we are in today.

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Evolution at work Initially vertebrate land animals were waddling tetrapods like our modern crocodilian species. Therapsids perished because like our modern alligator they couldn’t breathe when they walked or ran due to compression of the respiratory system.

If we were to look at the skeletal anatomy of a primitive tetrapod limb, we would see three tarsal rows (Figure 1). This was however a simplistic arrangement that lacked sophisticated concepts such as a subtalar joint, so this foot was rudimentary but adequate in function for its day.

A very important evolutionary event that took place to change a Therapsid limb to a mammalian foot was the introduction of a construct where a talocalcaneal articulation capable of independent movement developed.

Let us take a marsupial foot for example.

The foot of a bush tailed possum is clearly a prehensile one, used for clutching climbing grooming and mating. What is impressive is that the fibula is as much a weight bearing bone as the tibia with wide articulations with the talus and the Os Calcis. Closer inspection of their ankle joint reveals a fascinating structure; a meniscus that separates the articular surfaces of the tibia and fibula whilst also contouring the articular surface into a trochlear shape somewhat replicating a human talus.

As we follow the evolution from ancient marsupial to modern man, one can clearly see the decrease in the articulating area of the fibula and the compaction of the talus into a trochlear structure within a mortise between the tibia and fibula. What also happened is that there is now clear separation into ankle, subtalar, and talonavicular joints by synovial septae.

Now why did these early marsupials need such unstable and unrestrained ankles?

The reason probably was climbing; scaling vertical tree trunks with the plantar surface of the foot opposed against them. This required significant rotary motion of the tibia relative to the fibula somewhat analogous to the pronation and supination seen in the upper limb between the radius and ulna.

Development of bipedalism There are many types of bipedalism.

Facultative bipedalism is often seen in the primate population sometimes assisted by knuckle walking. This form of locomotion only manifests in about 2 to 6% of all mileage covered by most apes including the bonobos and the orangutans our closest relatives.

As the name suggests habitual bipedalism is the main mode of locomotion in many species including the Australian marsupials and of course all birds which are obligatory bipeds with forelimbs transformed into wings.

The ungulates are a group of herbivores including horses, sheep, rhino hippo and pigs. Also curiously they include whales and porpoises who have lost terrestrial locomotion.

They are characterised by walking on one toe: in the horse this is the middle toe which is remarkably adapted for speed and agility.

They can use these adaptations to generate remarkable speeds! Not unsurprisingly sesamoiditis is not uncommon in horses and arthroscopy of the MTP joint is not an uncommon veterinary procedure.

As we move on to the Avian group, birds morphed their forelimbs into wings which still bear the skeletal pattern of any other forefoot or hand.

Although birds walk bipedally, the avian foot’s main function is grasping either prey or branches of trees where they land and roost. We now enter the realm of the tree climbing primates.

Many lower primates have horizontal bodies during climbing which require Figure 2: Cast of Lucy. the use of all four limbs and their tail such as in golden tamarins. The orangutans and the bonobos exhibit a much Lucy did walk upright but her hallux was more sophisticated type of climbing with an divergent, her upper limbs were long and orthograde body and effective utilisation of gangly, her phalanges were curved and all four limbs. Their feet are very prehensile her knees were not straight; all of these with an abducted opposable hallux and long were attributes of climbing creatures but phalanges which are curved to help with her pelvis was orientated like that of homo grasping and climbing functions. sapiens as was her femur skull and spine and ankles. Was she a hominid a creature that walked upright? Did she or could she Finding Lucy still climb trees? Were her feet prehensile?

About 3 - 4 million years ago there appears These are questions that still wait to be to be a breakthrough in evolutionary terms. answered by anthropologists worldwide.

Nature seems to have stumbled upon a winning formula to start the trend of modern obligatory In 1978 the celebrated anthropologist bipedal walking.

Mary Leakey and her associates discovered footprints in solidified volcanic ash in On a hot and sweltering mid-day in Hadar, Laetoli Tanzania which were thought to Ethiopia on the 24th November 1972, Donald be made by two individuals possibly a Johansson and his colleague Tom Gray male and female of the Australopithecus were returning from a fossil hunt when they Afarensis species (Figure 3). Since then, chanced upon a fossilised ulna. Further several footprints of varying species have digging revealed an almost complete skeleton. been discovered including that of homo She was named Lucy during a post expedition erectus, Cro Magnon and neanderthal man. party when ‘Lucy in the Sky with Diamonds’ What these footprints showed us was that was playing repeatedly. She was 3.2 million significant changes in the morphology of the years old and was the oldest hominid or erect foot were occurring as bipedalism continued walking ancestor found to that date (Figure 2). to be reformatted and refined. >>

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as the Triceps Surae and the tibialis anterior contracting eccentrically to reduce the shock of ground reaction force: not to forget a torque converter that is the subtalar joint with its pitched calcaneus and complex midfoot articulations. The ability to use our hands and our brains to make tools, plan hunting and resource management strategy, carrying food and flint for fire, carrying offspring etc is now much easier because of the luxury of our modern feet and lower limbs.

The price of evolution

Figure 3: Ancient hominid footprints in Tanzania.

Sapiens Possibly as far back as 40,000 years ago, the features we associate with modern homosapiens started to appear. By now hominin had been endowed with remarkable feet, which took on the quintessential functions of propulsive ambulation and shock absorption by several mechanisms.

There has been a price to pay for these remarkable changes though. Two feet can’t cope with the shock absorbing functions of four, so we traded speed for efficiency and economy of energy. As we have retained the double curve of our spines, we suffer backache and other musculoskeletal problems. We are cursed with enthesopathy, stress fractures and the fragile soles of our feet that can’t stand the damage of rough or sharp objects. As we lost speed and were better able to absorb shock, we lost bone mass. We have the thinnest lower limb bones amongst all modern apes.

Indeed, Osteopenia is a finding almost only in humans amongst all primates.

Several anatomical changes took place: verticalisation of the pelvic skeleton, walking with an extended knee to create our stiff kneed gait, altered biometrics of the foot, longer legs, longer metatarsals, unopposable hallux, straighter and shorter phalanges, stable mortised ankle joints, rigid mid-feet, and a complex subtalar joint. Remarkable changes, each of which were naturally selected to promote efficient bipedalism.

So we now have this biomechanical marvel of locomotion technology; a walking organ with an array of shock absorption mechanisms from the plantar fat pad of the heel, a longitudinal arch with a sophisticated windlass mechanism which also conserves and stores energy, proprioceptors and motion sensors, proximal muscles such

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Figure 4: Future human evolution?

Technology can overcome almost any deficiency. Our walking needs are decreasing with rapid transit systems cars with endless solar and renewable power taking over. But where are we heading in the future? With climate change almost certainly accelerating and the surety of massive increases in sea levels, are we heading for a watery world where the need for swimming and webbed feet starts to ascend? Or are we going to inhabit worlds with lesser gravity so the need for shock absorption becomes less important? Or is the function of the subtalar joint going to become redundant with shoes, orthoses, and ultra-predictable walking surfaces? The consequences of unpredictable and random evolution with natural selection are something that we are now familiar with and can understand; but our terrifying ability to manoeuvre and engineer this remarkable phenomenon is in my opinion, leading us to unchartered territory (Figure 4).

The best part of the story of the human foot is that it is never ending.

Conclusion Spontaneous and random mutations will continue to shape the features and functions of the human foot for as long as humanity exists and endless forays into selection of favourable attributes will continue to occur through our time on this earth and shape its destiny. I hope I have, in some small way, kindled your interest in the anthropology of the human foot and its connotations and echoes in the modern world.

There is so much to learn and understand, for I do believe that very many abnormalities and dysfunctions of the foot have their origins in human pedal evolution. I do hope you will look at the foot in your clinics somewhat differently and perhaps treat its disorders with an evolutionary ear to the ground. n

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Features

Andrew Hall is a T&O SpR (SE Scotland) and PhD Research Fellow at the Scottish Hip Fracture Audit & Golden Jubilee National Hospital. His principal interest is in Sports Orthopaedics, working in professional sports as a Team Doctor for Heart of Midlothian FC and the Scottish Rugby Union.

Advances in digital orthopaedic education: Techniques to enhance learning and avert a generational crisis in orthopaedic training Andrew J Hall, Rosemary J Hackney, Gavin SC Brown and Emily J Baird

Rosie Hackney is in her third year of run-through orthopaedic training. Her main interests include medical education and training, and global surgery.

Gavin Brown is an Honorary Consultant Orthopaedic Surgeon at Edinburgh Orthopaedics, and Senior Clinical Lecturer in Orthopaedics and Digital Education at the University of Edinburgh. His principle academic interest is the development of digital techniques in undergraduate education and surgical training.

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Opportunity in adversity rthopaedics faces a monumental challenge to overcome a doubleedged educational emergency: postgraduate trainees are receiving a lower standard of surgical training as a result of reduced clinical volume, and undergraduate trainees are being discouraged from pursuing careers in surgery1.

Many of the problems facing our clinical and educational services were brought about by the COVID-19 pandemic, however this has proved to be a catalyst for innovation. Orthopaedic training in South East Scotland has experienced growth through the adoption of digital solutions in postgraduate and undergraduate settings.

Protecting the education of trainees now is key to ensuring an effective surgical workforce for the future. This article considers how advances in educational techniques might solve an impending generational crisis in orthopaedic training.

Postgraduate training Bridging the training gap with simulated surgery In August 2020 a focus group of trainees identified a training gap in arthroplasty procedures resulting from a nationwide decrease in elective surgical

volume as a result of the COVID-19 pandemic2.

Junior trainees felt that their position in the latent phase of the learning curve meant that they were affected disproportionately, and that the necessary prioritisation of available cases for senior trainees prevented the development of a sound foundation upon which to build their own competence.

A Total Knee Arthroplasty (TKA) Bootcamp was created for junior trainees that employed a multi-modality set of activities. This included short tutorials introducing fundamental knowledge such as indications, anatomy, and basic principles of TKA, followed by an afternoon of higher order activities including interactive workshops on patient selection and clinical discussion, technical tasks using saw-bones (Figure 1) and a VR-mediated TKA simulation (ATTUNE® Knee System VR Module, DePuy Synthes) that has been shown to be effective in arthroplasty training (Figure 2)3,4.

A ‘working lunch’ encouraged discussion between trainees and the experienced faculty, and the flattened hierarchy and convivial environment facilitated curiosity-based learning that was more reflective of a clinical setting, rather than a classroom. Trainees that were not accustomed to working with industry representatives found their input especially valuable, and expressed a greater appreciation for the surgeon-rep partnership.

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improve trainees’ ability to understand the process of procedures. Given the reduced volume of surgical activity, this form of simulation may add value to each learning opportunity in theatre.

Virtual Orthopaedic Trainee Education A reduction in training opportunities and physical distancing precautions halted our region-wide postgraduate orthopaedic education programme. The Virtual Orthopaedic Trainee Education (VOTE) Programme was established in March 2020, within a week of national social distancing policies being introduced, and aimed to: 1) provide continued FRCS-specific teaching for all trainees; 2) facilitate workplacebased assessments in lieu of clinical activities; 3) maintain morale and social contact, and 4) provide opportunities for trainees to develop medical education skills through near-peer teaching and support.

Emily Baird is a Consultant T&O Surgeon in Edinburgh Orthopaedics at NHS Lothian Trust and Head of Education for the South East Scotland T&O Rotation, UK.

Acknowledgements: The authors would like to thank the following for their input: Joseph N Brennan Joe DT Esland Louise Chabrut (Johnson & Johnson) Scott R Morrison Jamie A Nicholson A Hamish RW Simpson Phil J Walmsley Neil RL Wickramasinghe

Figure 1: Saw-bone component of the Total Knee Arthroplasty Bootcamp.

In the context of severely reduced clinical exposure, trainees and faculty found that the programme provided a useful reflection of an ‘ideal’ training process that mirrored the patient journey from clinical consultation, through surgical planning and management, to the consideration of complexity, complications, and continued care.

Feedback was very positive, with trainees being especially appreciative of: 1) the safety to practice power tools and arthroplasty kits without the pressures of time and sterility; 2) the chance to consider the process of TKA in detail, with expertise on hand to explain intraoperative decision-making, and 3) stimulating group discussions regarding selection, complex cases, and managing complications that replaced lost training opportunities in outpatient clinics.

Figure 2: A trainee conducting a simulated total knee arthroplasty using the virtual reality module (DePuy Synthes, Johnson & Johnson).

There are limitations to VR simulation: unrealistic soft tissue replication; absence of faithful haptic feedback, and fixed procedural workflows.

Nonetheless the VR session was extremely popular amongst the trainees and faculty. VR is not a panacea – rather a training adjunct with enormous potential to aid comprehension of surgical concepts and

There were nine live online VOTE sessions per week (reflecting the extraordinary working pattern at the time) each lasting one hour. The sessions were chaired by a consultant surgeon of the appropriate sub-specialty, and trainees were rostered to deliver a short multimedia précis of their chosen topic, with the programme aligned to the FRCS (Tr & Orth) curriculum.

All sessions were recorded, generating an educational repository of over 90 hours of material for South East Scotland trainees.

Almost all trainees found the live sessions useful and the majority revisit the content online on an on-demand basis. The multimedia modality added value to the existing in-person clinical sessions, and the near-peer model strengthened buy-in from trainees. On the downside, opportunities to practice clinical examination were necessarily reduced, but this was tempered by the production of reference clinical examination videos by trainees, and group discussion was hindered by the virtual delivery method.

We commend this model to other regions.

Undergraduate training A digital orthopaedic curriculum for undergraduates Undergraduate T&O education in South East Scotland faced a challenge ahead of the 2020-21 academic year when the University of Edinburgh curriculum was overhauled. Rotations through clinical placements were replaced with an allonline delivery of specialty-specific teaching and a greater focus on ‘generic skills’ on ward and primary care placements5. This approach was catalysed by the COVID-19 pandemic but will endure beyond any necessary >>

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Further, it is of great concern that students reported online-only exposure to be inadequate to inform future career choices. In addition to a potential reduction in undergraduate interest in orthopaedic careers, a side-effect of an all-online teaching model may be a reduction in the accessibility of clinical orthopaedics.

Perceptions of the specialty improve following exposure to the clinical environment, and the visibility of clinicians from minority groups helps to increase diversity in recruitment8,9.

There is a drive to recruit more generalists from medical schools, but clinical workforces should reflect the population they serve and by reducing accessibility and visibility we risk undoing efforts to increase equity, diversity, and inclusivity.

Figure 3: Extract from the Virtual Orthopaedic Shift component of the undergraduate online module.

reduction in contact time, with the stated aim of this deviation from the time-served model of undergraduate education being a desire for the curriculum to facilitate the skills required by a doctor on the two-year UK Foundation Programme. This follows a nationwide trend towards reducing specialty exposure at university, preparing undergraduates primarily for ward-based roles in the early years of training, and encouraging students into generalist careers1.

Against this difficult backdrop, the undergraduate T&O module was redesigned in order to replicate the varied clinical orthopaedic experience by creating a highly-interactive and engaging curriculum in a virtual orthopaedic learning environment.

Following the principles of Miller’s pyramid (in which learning is achieved progressively through demonstrating knowledge, competence, performance, and action) a cache of short, carefully-composed, narrated Core Lectures were made available for students to access on an on-demand basis.6 These were supplemented resources such as BOAST and NICE Guidelines and optional sub-specialty educational materials, and a series of short, easy-toconsume Orthopaedic Quick Breaks webinars (created by SM, Acknowledgements) provided bitesize overviews of key topics.

A series of six Core Tutorials, delivered online by orthopaedic faculty, developed the fundamentals introduced in the Core Lectures, emphasised key concepts, and helped students apply new knowledge and skills to clinical contexts. Integrated online quiz functions allowed students to test their knowledge (relevant to upcoming exams), consider simulated clinical scenarios (replacing lost ‘realworld’ opportunities), and afforded real-time feedback on their learning. The module reached a climax with a highly-interactive Virtual Orthopaedic Shift – a live online activity that

36 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

assimilated the themes of the course through a series of clinical cases that simulated a day as an on-call orthopaedic trainee (Figure 3).

A particularly successful introduction to the module was the inclusion of small group T&O Clinical Breakout Sessions, facilitated by T&O trainees and Foundation Programme doctors, that aimed to: replace the lost community of learning in the clinical environment, afford junior doctors opportunities to develop teaching skills, and protect access to near-peer clinicians for support, tutelage, and mentorship. Sessionspecific workbooks developed by a senior medical student (JB, Acknowledgements) reduced the burden on tutors to increase junior doctor engagement, and served as useful ‘take home’ study tools for students.

Virtual Trauma Meeting The Virtual Trauma Meeting (@EdinburghVTM) is a venture introduced to provide supplementary clinical orthopaedic exposure to undergraduates and junior doctors. Established by a senior medical student (JB, Acknowledgements), the monthly live online sessions provide a multimedia introduction to the orthopaedic subspecialties. Supervised by consultant specialists, T&O registrars present bespoke clinical cases for teaching and interactive discussion in a format that simulates a real clinical meeting. The series is extremely popular and continues to draw participants from across the UK.

All-online education: a future workforce problem?

Despite high levels of satisfaction with the online T&O module activities, there is evidence to suggest that students feel less prepared for clinical practice with an online teaching approach7, which was mirrored by our own findings of an overwhelming majority of students expressing a desire to gain access to real-world T&O settings.

Alarmingly, a significant proportion of students we surveyed reported a lack of confidence in their ability to conduct MSK clinical examinations to a level appropriate for basic clinical practice, as well as a perceived a deficit in informative exposure to MSK pathology.

Opportunities to gain experience were severely restricted by the removal of the T&O clinical placement, and the widely-reported reluctance of non-orthopaedic clinicians to teach or observe MSK clinical examination skills compounded the neglect of this body system which accounts for one-third of all primary care visits. A recent UK-based study found that a significant proportion of undergraduates do not experience an orthopaedic clinical placement at medical school, and the duration of attachments that still exist is decreasing10. If we are to train more generalist clinicians then a greater emphasis on MSK health is required if they are to be competent in managing the needs of the population.

Discussion The extraordinary events of 2020 and 2021 have revealed a deficiency in orthopaedic education that may develop into a major workforce challenge. As we strive to increase accessibility and inclusivity in our teams, and the specialty grows to meet the changing needs of the population, concerted efforts must be made to address: 1) the reduction in postgraduate surgical training opportunities, and 2) the trend towards steering pluripotent undergraduates away from surgical specialties.

These challenges must be met by us all – the Royal Colleges, specialty associations, training deaneries and programmes, academic and clinical departments, and individual clinicians.

This article offers an example of some of the solutions to difficulties we’ve encountered, and describes how digital advances in medical education might support training for undergraduates and postgraduates. It’s the start of a conversation. n

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

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Education

Why should we care about human factors in surgery?

Chris Lewis, James Tomlinson and Hiro Tanaka “Too err is to be human” – Alexander Pope Why human factors is important

M Chris Lewis is an ST7 on the North Yorkshire Rotation. He is the current BOTA secretary and is a member of the Faculty of Surgical Trainers, RCSEd. He is the previous BOTA education rep and has undertaken a Clinical Leadership Fellowship focusing on teaching leadership skills, non-technical skills and human factors to higher surgical trainees..

ost of us take it for granted that flying is one of the safest forms of transport, in fact we are more likely to die from the car journey to the airport than in a plane crash. During the 1970s, the media were quick to blame pilots for aviation accidents. After several high profile events, aviation woke up to the importance of understanding, recognising and managing human factors involved in error. Healthcare has one of the most highly trained, motivated and well selected workforce of any industry and yet 1 in 20 hospital admissions in the UK has some form of error. A recent meta-analysis of 70 studies involving 330,000 patients found that when there was an error, this can be severe or lead to death in 12% of cases1.

Some of the most important human factors issues affecting surgeons and the surgical team include tiredness, emotional state, communication, interpersonal behaviour, being able to challenge authority and situational awareness.

It is well known that humans make errors.

Surgeons are not exempt. In a complex system such as healthcare it is essential that we design systems to account of errors and train our trainees to recognise why, how and when errors occur.

James Tomlinson is a Consultant Spinal Surgeon at Sheffield Teaching Hospitals. He has an interest in surgical education and training, and is the Academic TPD for HEE Yorkshire and Humber, and Deputy Director of the Faculty of Surgical Trainers, RCSEd. He is a member of the NOTSS faculty has taught nationally and internationally on surgical nontechnical skills and human factors.

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The benefits of bootcamp in early years training Transition points in training can be stressful, with trainees often feeling underprepared for their new role2. Reduced clinical working hours and an increased focus on patient safety have increased pressure on trainees. Bootcamps are one strategy to mitigate these challenges and are normally short, intense educational events designed to help trainees transition to a new phase of training3.

Bootcamps have traditionally focused on acquisition of technical skills training with mixed success. Such a model is potentially flawed. Motor learning theory has demonstrated that distributed practice is more effective than massed practice in learning new motor skills4. It is thus foolish to think we can materially change the operative learning curve over six years of training with a two or three-day technical intervention. Bootcamps with a primary focus on technical skills training are highly resource and cost intensive.

Non-technical skills and human factors training have been shown to correlate with favourable patient outcomes5. Surgical trainees have identified a lack of exposure to these skills early in their training despite an appetite for such6. Trainees in other surgical specialties report their nontechnical and inter-professional skills are not sufficiently developed for consultant practice at completion of training. The new curriculum and introduction of Generic Professional Capabilities and Capabilities in Practice means a welcome increasing focus on the development and assessment of nontechnical skills.

Ethnographical work on the Scottish Core Surgical Bootcamp has identified a clear role bootcamp can play in establishing behavioural norms and expectations, whilst also allowing relationships to develop with key members of the training team.

Yorkshire and Humber Bootcamp The Yorkshire and Humber region developed and piloted a novel ST3 bootcamp with primary focus on human factors, nontechnical skills and professionalism.

Sessions were led and delivered by trainees wherever possible to reduce the perceived

Education

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 JTO. He led the development of the BOA Bootcamp Programme as Chair of Education Committee.

authority gradient between faculty and learners, encouraging those attending to speak up and voice any concerns. A further objective was to allow trainees to develop their professional identity through discussion with senior peers, and role modelling by senior trainees. The bootcamp ran over two days with a mix of sessions on human factors and non-technical skills giving a brief overview of these topics. A virtual fracture clinic and ex-fix workshop were also included.

All of those attending the bootcamp reported the non-technical skills and human factors sessions were relevant to their registrar role, and all felt more aware of the impact of their own behaviour on others, more able to challenge inappropriate behaviour and had an increased recognition of the importance of non-technical skills in delivering high quality patient care.

Several of those attending had not received any postgraduate training in human factors or nontechnical skills. Trainees were unsure about the inclusion of human factors in a bootcamp prior

to the intervention, but all subsequently felt it had been useful, and relevant.

Introducing these concepts at the start of higher training is not without potential flaws.

Motor learning theory identifies the three stages - cognitive, associative and autonomous.

Trainees are likely to be at the early stages of this process, and the additional focus on nontechnical skills could potentially overwhelm them. This concern was not born out in discussion with trainees, with many of them already using these new skills to complement their operative practice. Several trainees were already reflecting on their own behaviour in theatre and the impact they were having on the surgical team around them, using this to help shape their early professional identity.

The role of non-technical skills in improving patient outcomes is well established, and previous reports have highlighted complex issues with surgeon behaviour significantly impacting patient care7. >>

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 39

Education

ST3 bootcamp offers an ideal opportunity to introduce trainees to these concepts at an early stage, highlighting their importance and embedding the right behaviours. Delivering this training regionally also allows an ideal platform for trainees to develop relationships with their peers and training team.

The BOA Bootcamp The BOA ran a fully funded national pilot between 2018 and 2020 to demonstrate the benefits of a combined non-technical and technical skills programme in a bootcamp course for ST3 trainees. A delegate’s review was reported in the September 2018 JTO. The purpose of the pilot was two-fold: firstly, to determine the value gained from cadaveric technical training which in most cases would not be affordable for deaneries to run locally and secondly, to structure a template for human factors training which was reflective of the changes in the curriculum and which resonated with the day to day practice of trainees. It was the latter aspect of the programme which was innovative and it was developed with input from experts in the fields of psychology, education and military training.

The human factors section of the course ran over a two day period. Similar to the Yorkshire Bootcamp experience, it is essential that delegates learn and share their experience in a safe and comfortable environment.

The majority of learning was gained from facilitated discussion by faculty using case based scenarios and real life experiences of the trainees. For example: “You are running a fracture clinic on your own because the consultant is away. It is an overbooked clinic and the nurse tells you that patients are complaining about the wait. You see a child with a forearm fracture which has been manipulated a week ago but the position has slipped badly. The mother is very unhappy with the result and is starting to get abusive. How will this situation affect your performance? What will you be thinking?

How will you behave?”

The course introduces the lexicon of human factors in six key domains and each scenario is referenced to the skills and tools to manage the situation safely.

• • • • • •

Situational awareness Decision making Communication Leadership Conflict management Resilience

The core skill which was reinforced during the course was selfawareness of emotions which will allow the trainee to manage their behaviour appropriately, communicate effectively and make safer decisions.

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An overly emotional response to a stressful environment has been shown to be a significant factor in compromising patient safety8.

The experience trainees gain from an understanding of human factors can be immeasurable but can be described.

Reflections from one of the first trainees to attend the course defines it as: “As much pressure as there is on surgeons to uphold the fantasy of always being perfect, it is much more healthy, insightful and humbling to know that we are in fact not perfect. We are human and have weaknesses.

It is only once we accept these weaknesses can we begin our journey to greatness.”

What lies ahead?

The benefits of human factors in surgical training are great and far-reaching. It can be provided at minimal cost as compared to technical cadaveric courses and if provided early in a trainee’s career, will not only improve their well-being but also their performance, safer patient care and contribute towards a healthier work environment. We would recommend all deaneries integrate this as part of their core programme. Advice as well as templates for a one or two day course are freely available from the BOA (policy@boa.ac.uk).

Leadership training at higher levels should include integration of human factors in Quality Improvement methodology to ensure that we design systems to account for human error so that ‘just culture’ becomes the norm. n

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

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Trainee

Workforce culture and diversity: Our questions answered at BOTA Congress Oliver Adebayo, Thomas Key, Kathryn Dayananda and Ran Wei The Royal College of Surgeons of England’s unveiled its landmark review into the diversity of leadership of the surgical profession and of the College in April 2021. The report outlined a vision for the College and in turn set the surgical world talking about diversity, inclusion and equity.

C

oncurrently, throughout the world, there were great societal shifts and a spotlight had been shone onto diversity and inclusion through the George Floyd episode leading to Black Lives Matter and the differential COVID-19 death rates seen in ethnic minority communities across the Western World.

Oliver Adebayo is a registrar on the Stanmore rotation in North East London and is the current President of the BOTA. As part of his mandate this year he is committed to supporting diversity, innovation, and sustainability amongst T&O trainees.

The Royal College – Our professional home: An independent review on diversity and inclusion In September 2020 the new President of the Royal College of Surgeons England, Professor Neil Mortensen, commissioned an independent review into the College’s professional leadership. Led by Baroness Helena Kennedy QC, an assessment of diversity, inclusion and the sense of belonging among RCS college members was made in order to identify the barriers to fair representation and leadership within the College and the wider profession. 12 panellists across all seniority levels and surgical sub-specialties talked to a range of witnesses and engaged in focus groups, interviews and statements to produce the report.

The survey findings are stark; the most frequent barrier in achieving a senior role within the College life was the notion of the ‘old boys’ network’. Of those who felt this way, 3 in 5 members stated that the college did not

42 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

represent people like themselves and 3 in 4 members believed the college did not do enough to foster an inclusive environment1.

The report goes on to highlight the perception of surgeons and a career in surgery. Emphasis is placed on the importance of visibility and the accessibility of surgical role models across all career stages, including secondary-school, medical school, foundation and core / higher training years.

The report concluded with a 16-step action plan for the College to ensure reform in its processes and to create a more diverse and inclusive organisation demonstrating equality within its leadership. These recommendations include; reforms to the elections process, a clear SAS strategy and better Council representation at all levels.

Keynote session at BOTA Virtual Congress In response to the Kennedy report and its implications for the future of surgical representation, the British Orthopaedic Trainees Association (BOTA) theme for this year’s congress was Workforce Culture, Diversity and Sustainability. BOTA invited Professor Neil Mortensen to give the key note speech at this year’s virtual BOTA Congress to discuss the findings of the report.

Trainee

Thomas Key is an ST7 trainee in the Welsh Deanery and was the Welsh BOTA representative for 20192021. He has specialist interests in shoulder surgery and medical education.

Kathryn Dayananda is a Specialty Trainee in Trauma and Orthopaedic Surgery in the Welsh Deanery. She is the outgoing BOTA Women in Surgery rep.

Professor Mortensen emphasised the purpose of the Kennedy report in his lecture. The College represents a surgical workforce of which 40% is from an ethnic minority background, yet this was not reflected in the proportion of surgical tutors and faculty. With regards to women, only 14% of surgical consultants are female with a third (35%) of surgical trainees being female1.

Comparatively, just over half of all speciality trainees are female (57%) with the proportion of female consultants at 37% in 2020. Some specialities have a higher proportion of female doctors in training, such as paediatric surgery (53%) and plastic surgery (39%), however T&O has the lowest with 18%.

Professor Mortensen highlighted that the lack of diversity within RCS England demonstrated the need for change at the very top and that the report is a step in the right direction to create a more inclusive, diverse and representative College.

Ran Wei is currently a post-CCT knee fellow at the North Sydney Orthopaedic and Sports Medicine Centre.

He is the immediate Past President of BOTA and led the Committee to deliver the virtual BOTA Congress 2021 and conception of the Culture and Diversity Rep role.

Following his talk, Professor Mortenson (NM) was joined by Professor Michael Griffin (MG), President of Royal College of Surgeons Edinburgh and Mr Bob Handley (BH), President of the British Orthopaedic Association for a panel discussion on Workforce Culture, Diversity and Sustainability in Surgery. Their enthusiasm to take part in the session highlights the desire at the very top of the profession for change. The guest speakers were invited to answer the following questions: Question: How do we make surgery, in particular T&O more attractive to a diverse cohort of applicants?

BH: Unfortunately, the stereotype of T&O surgeons still persists in medical school today with the presumption that you have to be a white rugby playing male to get in and progress.

This puts off a lot of applicants at the medical school level. We need to show that we are just normal people, trying to live our lives and have a good work life balance, not putting ourselves on a pedestal. There are now more role models within T&O and those people need to be in a position where they are seen by medical students and people at school.

MG: ‘People can’t be what they can’t see’ – it’s essential that roles models exist within the College and that we work with medical schools to widen participation. Over 50% of state schools have never even had a pupil apply to study medicine. We need to look at the barriers to surgery, which includes how professional development is delivered and the appalling level of bullying and undermining. Through the RCS Edinburgh ‘Lets Remove it Campaign’, T&O surgery was found to have a high incidence of bullying and undermining behaviour. It’s important for people to understand it should be an inclusive environment.

Question: How do you feel the College will address the issues of differential attainment?

NM: We have been looking at the data around differential attainment within our exam results and will be reporting that. The College will be formally studying this as part of Kennedy Report. We need to do much more to help people be more prepared.

MG: There was an issue with ethnic minorities and differential attainment in the exam. Within the examination process, the issue of differential attainment is not so much an ethnic one but it was an issue of those not in training compared to being in training. The issue was with those not in training who were more likely to be >>

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 43

Trainee

medical students and pre-medical students, saw a world where surgery was much more open and flexible it would be much more open and attractive.

MG: Working practices have changed and the extended surgical team are important. We are no longer a one man band. It is a different, better and safer way of working now.

50% of women go into surgical training and only 15-18% are coming out at the end. We are losing a lot of women within the course of their surgical training. We are starting to get better with less than full time training options, however some trusts are very good at administering that, others put obstacles in the way. This has to change.

Question: How the BOA will ensure individual surgeons wellbeing will be protected in the post COVID recovery?

BH: We had a number of discussions with the BOA. It is important that we all help to look each other. We need to look at our own colleagues and peers on a personal and professional level. This is difficult to influence centrally but we can treat each other with respect in order to be able to look out for ourselves.

BOTA Culture and Diversity agenda This year’s keynote session was the perfect springboard for BOTA to launch our Culture and Diversity agenda for the upcoming year.

A new Culture and Diversity representative was voted in at this year’s AGM during virtual Congress and a new Committee working group focused on culture and diversity has been formed.

from an ethnic background. There is actually improved attainment in Asian trainees compared to white British trainees.

JCIE has been aware of these issues and in the last few years, examiners have had training in unconscious bias to try to make sure the exam is a fair process. The Kennedy report has highlighted that differential attainment is not just about exams however that it is hard for ethnic minorities and women to progress at all stages of their career.

BH: With regards to T&O SpR recruitment – women are more likely to be selected and more likely to do well at the FRCS. However they don’t seem to do as well at ARCP – this is being investigated.

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When looking at ethnic minorities and how they perform in exams, there is a difference in attainment however the difference is the same in section one and two, indicating that the bias is not due to examiners. There is no doubt that UK graduates fair better, with the reasons not clear.

Question: What has been done to improve retention within T&O and within surgery particular for parents?

NM: Surgery is no longer something which you have to be in day in and day out there all the time to have continuity of care. I think we can work collaboratively in teams to make less than full time working happen to allow more flexibility within training and beyond. If our

In the upcoming year, together with the BOA, BOTA will be looking for passionate, driven individuals to become Culture and Diversity champions within T&O departments across the UK. We want to encourage people from all levels of the career ladder to apply for these regional roles and support initiatives in culture change and equal opportunities for all. T&O surgery has always been a trailblazing specialty and this is an opportunity for us all to change our narrative and lead on positive change. n

References 1. The Royal College of Surgeons of England (2021). An independent review on diversity and inclusion for the Royal College of Surgeons of England. Available at: www.rcseng.ac.uk/about-the-rcs/ about-our-mission/diversity-review-2021.

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Medico-legal

Jo Round is a newly appointed Consultant at University Hospital Southampton NHS Foundation Trust specialising in Trauma and Limb Reconstruction.

Gender balance in medico-legal reporting Jo Round, Sarah Johnson-Lynn, Charlotte Lewis, Jacquelyn McMillan, Jan McCall, David Warwick, Deborah Eastwood and Simon Britten

The British Orthopaedic Association is committed to promoting diversity and inclusivity throughout Orthopaedics.

Priority 1 of the 2020-2022 Diversity and Inclusion Action Plan1, is to understand and define groups that are currently under-represented across the BOA.

Sarah Johnson-Lynn is a Consultant Orthopaedic Foot and Ankle Surgeon at North Tees and Hartlepool NHS Trust.

Charlotte Lewis is a Consultant Orthopaedic Surgeon at Portsmouth University Hospital.

Charlotte is an experienced medical expert who has been doing medico-legal work since 2014 focussing mainly on personal injuries and a little negligence work.

46 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

A

s part of the Medico-Legal Committee’s commitment to this, we investigated gender balance amongst UK experts involved in medico-legal reporting in T&O. 8% of home members within the BOA are female, yet only 1% of medico-legal experts appearing on the current registers in T&O, are female (Table 1).

UK Register of Expert Witnesses

1%

1/81

Expert Witness Institute

4%

2/54

Academy of Experts

0%

0/4

Association of Personal Injury Lawyers

1%

1/112

Medical Expert Witness Alliance

0%

0/109

Table 1: The number of females registered with each society.

The aim was to investigate the apparent gender imbalance in medico-legal reporting and identify we could do to address it. We sent out a survey to all BOA members, asking them to complete it, whether or not they had any medico-legal experience.

The results 68 people responded to our survey; 49 were male and 18 female. One respondent preferred not to say their gender, unfortunately their responses could not be analysed due to sample size.

8% of our respondents who do medico-legal work are women (Figure 1), in keeping with the gender balance amongst the BOA’s home fellows. Although there were only three female respondents to this question. Nevertheless some interesting insights can be seen.

Time in post Guidelines from the Royal College of Surgeons state, “It is unlikely that anyone would be called as an expert witness within the first five years of practice”2. Therefore we looked at how long our respondents had been in post. 40% of women surveyed had been in post less than five years. This compares with 8% of men, (Figure 2).

Discussion with senior authors confirmed that while at least five years experience is probably necessary for negligence work, it is reasonable to be practising in Personal Injury reporting sooner than that.

This unfounded perception by younger Consultants may be the reason some have not entered medico-legal work.

Private practice Only 27% of the women surveyed, are doing private practice. This smaller number may again relate to their experience and represent a time lag. So it does not seem as if women are doing private practice instead of medico-legal work.

Medico-legal

Motivation for medico-legal work

Jacquelyn MacMillan is a Consultant Orthopaedic Surgeon. She has run a medico-legal practice for 12 years and undertakes personal injury work for both pursuer and defender.

Jan McCall is advocate, Compass Chambers.

She was called to the Scottish Bar in 1999 after having been a partner in a nationwide PI firm.

We asked people who did medico-legal work what motivated them to do it. We then ranked reasons for each gender, as shown in Table 2. There was a lot of commonality between the genders. The top ranked reason for both was the fact that much of it could be done from home.

Of equal ranking in both lists was the fact that they felt medico-legal work gave them insight into their own practice and makes them less likely to have a claim submitted against them. Intellectual stimulation also appeared on both lists. Although the extra income comes in useful for both genders it seems women prefer to pay the school fees and men prefer to buy luxuries. There were some differences noted, however.

Women liked the fact that there is never an emergency whereas men seemed more likely to have an interest in the interface between law and surgery.

Deterrents to medico-legal work There was more of a difference in the reasons why people do not go into medico-legal work, between the genders, as shown in Table 3. Both men and women ranked ‘not liking confrontation’ highly. It is unclear from our question if this was confrontation during the joint reporting stage with the other expert witnesses, as opposed to the actual court process and conflict with the barrister. Many cases are settled after the joint reporting stage and before going to court. In the medico-legal session at the 2021 BOA Congress entitled, “Medico-legal Reporting – Why, How and When”, many of the guest speakers commented that they had rarely, if ever, had to attend court. Potential medicolegal experts should however recognise that the role of the expert witness in court is to aid the Courts’ understanding of the complexities of the medical world and not to advocate for one side or the other. So confrontation should not really be an issue. >>

Figure 1: Numbers of respondents that do medico-legal work.

Figure 2: Number of years in post.

Female

Male

1. Can do much of it at home

1. Can do much of it at home

2. Helps pay the school fees

2. Intellectually stimulating

3. Less likely to be sued

3. Less likely to be sued

4. Never an emergency

4. Helps to purchase luxuries

5. Intellectually stimulating

5. Have an interest in the interface between law and surgery

Table 2: Motivation for carrying out medico-legal work. Ranked in order from most popular to least.

Female

Male

1. Do not like confrontation

1. Do not like confrontation

2. Never had a suitable mentor

2. Boring

3. Never exposed in training

3. Hassle getting paid

4. Avoid encouraging compensation culture

4. Do not like lawyer

5. Difficulty balancing work life balance

5. Avoid encouraging compensation culture

Table 3: Deterrents from carrying out medico-legal work. Ranked in order from most popular to least.

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 47

Medico-legal

Women ranked not having a suitable mentor and never being exposed in training within their top five answers. This lack of understanding of the medico-legal process should be addressed to encourage people into the speciality.

Women were more likely to note difficulties in balancing work life as a dissuading factor.

When coupled with previous responses, that the advantages of medico-legal work are that it can often be done from home and is seldom, if ever an emergency, this may imply that female surgeons have greater responsibility for managing the home.

Alternatively, the younger female surgeons may be more likely to have young family at home requiring more hands on care.

Why do people stop doing medico-legal work?

The majority of men who had stopped doing medico-legal work had retired. This makes sense with the older age of the men responding to this survey. The Royal College of Surgeons guidelines2 recommend that although continuing a medico-legal practice after retirement can be done, it should only be continued for a couple of years after, to avoid the risk of being out of date. We had only one female respondent who no longer did medicolegal work; her reason appeared to be related to difficulties within the speciality, citing demands on time and an adverse court judgement.

What conclusions can we draw from these results?

It is difficult to draw conclusions from the small numbers involved in this survey.

There are some interesting findings that can be explored. These results can be used to encourage all genders to work as a medico-legal expert. There is commonality between the genders in why people go into medico-legal work, yet the differences in why people do not, are more interesting.

Some of these appear to be related to misconceptions surrounding the work.

We know that the numbers of female consultants are increasing, from 2.9% in 2004 to 8% in 2020 according to the Department of Health and NHS Digital figures. The lag in the medico-legal profession may be exaggerated by the misconception that medico-legal work cannot be started within the first five years of practice. Although medical negligence work benefits from the extra experience, personal injury can be started at any stage.

Mentorship When someone decides they would like to pursue medico-legal work, it can be difficult to know where to start. There are plenty of commercially available courses, aimed at the medico-legal expert who has already started out. Having someone to guide and offer advice on simple things like how to bill for work and the best courses could have a great impact. Mentors can be in different regions at different stages of their careers, this reduces competition which may be one reason people do not offer to mentor others. Mentorship can continue through a medico-legal career not just at the start. There may be a role for the BOA to instigate a course such as, an introduction to medico-legal practice, which could point senior trainees and newly appointed consultants in the right direction. Several BOA Fellows have offered to act as mentors.

BOA Congress and speciality meetings The 2021 BOA Congress’s medico-legal sessions this year were intended to encourage people into medicolegal reporting. The Congress is attended by medical students to Consultants. The sessions gave some insight into cross examination within a courtroom and guest speakers discussing how they set up their practice and their reasons for entering the profession.

More events like this are planned, including the OTS Conference in 2022.

“Medico-legal clients come with their own diversity.

Some clients may feel more comfortable with a medico-legal professional who can understand their perspective, while more diverse groups of experts will have a greater collective cognitive diversity and therefore may drive a wider understanding of long term problems facing medico-legal clients.”

Why is diversity important in medico-legal work?

Matthew Syed in his book Rebel Ideas3 talks about cognitive diversity, where people with different perceptions, experiences, insights and thinking styles can bring an uplift in ideas. Medico-legal clients come with their own diversity. Some clients may feel more comfortable with a medico-legal professional who can understand their perspective. A more diverse groups of experts will have a greater collective cognitive diversity and therefore may drive a wider understanding of long term problems facing medico-legal clients. Although the expert witness has a responsibility to the Court rather than the client, being able to understand the client’s cultural background may help with giving a more informed opinion.

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The proportion of female expert witnesses is unlikely to exceed the percentage of doctors qualifying five years previously, although there are actions that can be taken to maximise the take-up within the available pool of potential candidates.

How can we attract more women into medico-legal work?

Registrar exposure Trainees are generally not exposed to medico-legal practice. In some instances working for a Consultant who has a specific interest may give a brief glimpse into medico-legal work. However it is unlikely a full understanding of how the system works will be gained. Working with Deaneries and medico-legal professionals to provide teaching may improve understanding at the trainee level.

So by reducing some of the mystery surrounding medico-legal work and offering mentors we can increase the diversity of medico-legal expert witnesses. n

References 1. British Orthopaedic Association (2020).

British Orthopaedic Association Diversity and Inclusion Action Plan 2020-2022.

Available at: www.boa.ac.uk/about-us/ diversity-and-inclusion/diversity-andinclusion-strategy-and-action-plan.html.

2. The Royal College of Surgeons of England (2019). The Surgeon As An Expert Witness – A Guide To Good Practice. Available at: www.rcseng.ac.uk/standards-and-research/ standards-and-guidance/good-practiceguides/expert-witness.

3. Syed M, 2019. Rebel Ideas: The Power of Diverse Thinking. John Murray Press, London.

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Reflections from the Oxfordshire Multi-disciplinary Diabetic Foot Care Service Jodie Buckingham, Lucinda Barrett, Dominic Howard, Garry D Tan and Constantinos Loizou, on behalf of the OUH Diabetic Foot Team Diabetic foot complications often progress rapidly and require multifaceted intervention to prevent limb loss.

New integrated ways of working have been established.

This article explores the reflections from key team members on this re-configuration.

Jodie Buckingham is Lead Podiatrist at the Oxford Centre for Diabetes Endocrinology & Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford.

Lucinda Barrett is a Consultant in Infections Diseases at the Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford.

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The challenges ICE guidance NG19 (“Diabetic Foot Problems: Prevention and Management”, 2015) recommends that there should be a Multi-disciplinary Foot Care Service (MFCS) in place to care for people with a limb or life-threatening diabetic foot problem and for those with diabetic foot problems that cannot be managed by the foot protection service. Each acute NHS hospital is expected to have a referral pathway for those who present with acute diabetic foot problems.

Oxford University Hospitals (OUH) NHS Foundation Trust is a large teaching organisation made up of four hospitals.

Similar to many Trusts, split site working makes co-operation difficult, with orthopaedic surgery based at the Nuffield Orthopaedic Centre (NOC), vascular surgery at the John Radcliffe (JR), and diabetes/podiatry at the Churchill Hospital. Infectious diseases/microbiology, radiology and plastic surgery are generally available at all sites.

Figure 1: Clinical pathways of people with diabetic foot problems before introduction of a Multi-disciplinary Foot Care Service.

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Dominic Howard is a Consultant Vascular Surgeon, Department of Vascular Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford.

Figure 2: OUH MFCS Team.

Garry Tan is a Consultant Diabetologist at the Oxford Centre for Diabetes Endocrinology & Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford.

Prior to 2014 patients presented with acute diabetic foot problems to any of the different entry points. There was no formalised pathway and this fragmented care was further disrupted by the split site nature of the Trust (Figure 1).

To address this, an inpatient podiatry service was established to act as a triage point for all patients with an active diabetic foot problem admitted to OUH and to act as a gatekeeper and navigator of patients to the relevant specialities. This was partially successful but did not result in a true multidisciplinary approach.

The weekly MFCS clinic runs for two hours, 49 times per year, delivering about 700 outpatient contacts per year. In addition, clinicians of all specialities are available every day to review emergency or deteriorating inpatient cases, either face-to-face or virtually (Figure 3).

After the third year of the service, the successful financial (Table 1) and clinical (Figure 4) outcomes justified the provision of long-term funding. >>

The solution

Constantinos Loizou is a Consultant Orthopaedic Surgeon, Department of Orthopaedics, Oxford University Hospitals NHS Foundation Trust.

In 2017, NHS England called for bids for Diabetes Transformation Funding to improve access to multi-disciplinary foot care teams. We were granted two-year funding for a Multi-disciplinary Foot Care Service (MFCS) based around a weekly diabetic foot clinic in which patients would be seen by podiatry, diabetes, microbiology/ infectious diseases, interventional radiology, vascular and orthopaedic surgery (Figure 2).

Figure 3: Clinical pathways of people with diabetic foot problems after introduction of a Multi-disciplinary Foot Care Service.

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Reflections After nearly five years of the MFCS, representatives of some of the specialities have reflected upon what they have learnt from involvement in the service to date.

• Orthopaedic Surgeon Diabetic foot ulcer patients with underlying osteomyelitis are complex and hence their needs are complex too. Access to specialist opinion has been invaluable as well as the education that comes with it. Our close links with our plastic surgery colleagues has improved our understanding of angiosomes of the foot, where and how to make incisions and more importantly how to close those wounds avoiding excess bone resection that could be detrimental to function and future accommodation within shoes.

In addition, our links with our infectious disease colleagues has advanced our knowledge on the role of appropriate and careful biopsies, avoiding contamination and then prescribing guided antibiotic use (‘start smart and then focus’). Local antibiotic use has also been a recent addition to our armamentarium for our diabetic foot patients who may have issues with systemic delivery, absorption and compliance. This acquired knowledge from access to our wonderful colleagues has spilled over to our non-diabetic patients benefiting the wider patient cohort.

Figure 4: Impact of the introduction of a Multi-disciplinary Foot Care Service on major and minor lower limb amputation rates.

One thing we still need to improve and not solved yet is the management of the potentially acute Charcot foot. When a diabetic patient presents with a swollen, warm, erythematous and sometimes painful foot to community podiatry or hospital podiatry, these services are very good at referring to orthopaedics for assessment within 24 hours as the guidelines suggest.

Unfortunately, when these patients present to busy A&E departments, treatment centres or GP practices they are often treated as cellulitis or sprains. Hence the majority of Charcot feet only present for orthopaedic review when they are into the fragmentation phase with joint involvement and deformity. By this stage, the opportunity for early intervention has been missed. There is work to be done in raising awareness of this uncommon condition and educating these services.

The consequences of delayed management of Charcot arthropathy are profound with complications of deformity, subsequent ulceration, deep infection and amputation.

Our orthopaedic trainees attend the MFCS clinics and they go on to spread this knowledge by osmosis to our ward nursing staff and to GPs with more comprehensive clinic letters.

Technology has also helped our split site model tremendously when opinions from members of the MFCS cannot always be provided by bedside review.

The ability to access electronic patient records (EPR) with diagnostic imaging and especially photography of feet and wounds has made virtual reviews a success, which was especially valuable during the COVID pandemic.

No of patients admitted due to foot disease

Average length of stay (days)

Total bed days

Cost

July 2016 – June 2017

476

11.5

5457

£2,051,832

July 2018 – June 2019

194

6.4

1250

£470,000

Change

280 fewer admissions

5.1 days shorter stay

4207 fewer bed days

£1,581,832 saved

Table 1: Impact of introduction of a Multi-disciplinary Foot Care Service on hospital inpatient admissions.

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• Infectious Diseases The bed side teaching in MFCS clinic has led the whole team to learn the spectrum of activity of antibiotics, adverse reactions, allergy and monitoring, as well as to embrace the principles of the antibiotic management of diabetic foot infections.

They have been empowered to make sensible decisions in settings outside the clinic. This weekly collaboration has led to all members of the team readily and promptly seeking additional microbiological advice for more complex cases.

• Vascular Surgeon The MFCS provides a platform for managing emergency interventions and is equipped to perform urgent investigations, wound debridement, and initiate immediate antibiotic therapy. The rapid access to vascular, podiatric, and orthopaedic opinions streamlines the patient pathway and facilitates emergency admission under the correct specialist when required. We have found that this approach translates to improved resource usage, a reduction in overall amputation rates, particularly with regard to severity of amputation (Figure 4) and a positive impact on mortality and quality of life for patients with severe diabetic foot disease.

A core strength of this MDT approach has been shared knowledge and synchronised intervention. Tailoring vascular intervention to provide optimal perfusion for the foot and ankle reconstruction and timing the delivery of antimicrobial agents to target

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soft tissue and bone infection pre- and post- intervention are common logistical discussions in our clinic. This joined-up approach provides the best solution for these high-risk patients.

From a vascular point-of-view, we have many new effective intervention options for patients with ischaemia due to occluded distal vessels. Some of the technical advances that we regularly perform include transpedal retrograde angioplasty, arterial flossing with anterograde-retrograde intervention, drug-coated balloon and stenting, distal venous arterialisation, angiosome-directed revascularisation, and distal bypass surgery.

The next step in our service is to standardise the assessment of the severity of diabetic foot disease and degree of ischaemia across our network. This will incorporate the use of objective measures of distal malperfusion, such as toe pressure assessment, and the use of the Wifi (Wound, Ischaemia, foot infection) scoring and GLASS (Global Anatomic Grading System) to help guide intervention approach and prioritisation.

• Interventional Radiologist (IR)

allows for learning and clinical development to occur. It provides an opportunity for innovative discussions to happen, and most importantly, it has allowed sometimes challenging cross professional discussions to occur whilst focussing care on the patient.

It has also facilitated a more flexible clinical service. As trust has increased, it has allowed us to move away from a traditional model of follow-up and continuing care. We use the right people, with the right skills at the right time.

Finally, it has highlighted the strengths of what the podiatry profession can bring to the patient group and the wider team. As a small profession the scope of practice and skills of podiatrists is often not fully understood by other professions. In this clinic set-up, each clinician has developed a full appreciation of

improvement) of the service as well as its ongoing commissioning.

Opportunities favour the prepared: recognising an unmet clinical need, we had already built the outline of a business case with the commissioners for a MFCS even before the initial funding call. This allowed a prompt (and successful) funding application to the Diabetes Transformation Fund.

Focus on populations not just the individual: clinical governance of the clinical pathway, even for patients not presenting directly to the MFCS has been important to improve care, although this is still a work in progress.

Conclusions The establishment of a Multi-disciplinary Diabetic Foot Care Service (MFCS) in response to the NICE guidance has led to improvements in patient care, such as reduced amputation rates and shorter inpatient stays. Financial savings have demonstrated the sustainability of this model of care. More importantly, team working in this collaborative approach has led to education and empowerment which has seeped into other areas of the Foot and Ankle service.

“Diabetic foot ulcer patients with underlying osteomyelitis are complex and hence their needs are complex too. Access to specialist opinion has been invaluable as well as the education that comes with it. Our close links with our plastic surgery colleagues has improved our understanding of angiosomes of the foot, where and how to make incisions and more importantly how to close those wounds avoiding excess bone resection that could be detrimental to function and future accommodation within shoes.”

The MFCS has resulted in greater engagement from several professional groups and dramatically speeded up the response times in dealing with difficult and complex patients with varied needs. IR assesses the underlying anatomical problems such as blocked or narrowed arteries, and then undertakes endovascular interventions such as angioplasty, stenting and distal venous arterialisations. Having regular contact with the patient also gives the IR the ability to continually monitor how these interventions can improve the patient’s outcomes.

• Lead Podiatrist The MFCS gives a platform for learning and advancing clinical skills and knowledge in a natural and supportive environment.

Being able to take the first steps in advancing practice whilst your colleagues from other specialities are there for advice and support is immensely valuable to our team of Podiatrists. There is a shared responsibility across the professions. This collegiate approach has broken down traditional professional boundaries. It

their colleagues’ skill set. It has highlighted the continuity that podiatry can bring to the patient pathway. We will see them throughout their entire clinical journey, from presentation and assessment, throughout their inpatient stay and into long-term preventative care. This consistency allows us to be strong advocates for the patient group.

• Diabetologist The funding and development of a MFCS is challenging, particularly as the management of diabetic foot disease crosses multiple speciality boundaries. There were three key lessons: Data is king: the ongoing funding of the service was dependent on the provision of evidence of both financial and clinical benefit. The ability to collect, analyse and present data in a convincing manner supported the efficient performance (and

Declaration of Interest

GDT is supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Acknowledgements The contents of this article reflect the collective effort of a large group of individuals including, but not only: Rachael Porter (Ultrasonographer), Alex Ramsden (Consultant Plastic Surgeon), Regent Lee (Consultant Vascular Surgeon), Mark Rogers (Consultant Orthopaedic Surgeon), Tina Mackinnon (Consultant Radiologist), Raman Uberoi (Consultant Radiologist), Raf Patel (Consultant Radiologist), Angela Hillier (Podiatrist), Paul Swan (Commissioner), Amar Latif (GP and Commissioner), Emily Neville (Orthotist), Katie Hards (DSN) and our three plaster room technicians: Paula Burton, Hannah Gunn and Georgina Neville. n

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Collaborative ankle arthritis networks Jim Carmichael and Martin Raglan Why do we need a network?

Jim Carmichael is a Consultant Orthopaedic Foot and Ankle Surgeon at North West Anglia NHS Foundation Trust. He has a strong interest in the management of degenerative disorders of the foot and ankle and is a Fellowship and Course Director for the International Bone Research Association.

Martin Raglan is a Consultant Foot and Ankle Surgeon based at Nottingham University Hospital NHS Trust. He has a specialist interest in Ankle Arthroplasty, Revisions and Collaborative Networks.

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Patients with end stage ankle arthritis have physical and mental disabilities equivalent to end stage hip arthritis1.

However the surgical solutions are more varied because the ankle is not an isolated joint. One of the challenges in our specialty is that it is not always clear whether a Total Ankle Replacement (TAR) or an Ankle Fusion (AF) would better serve the patient, especially in the long-term.

T

his is reflected in the variation of AF and TAR’s offered in the UK. In 2018 the National Joint Registry (NJR) showed an eight fold variation in TAR activity per head of population by region2. Multiple NJR reviews have identified significant outcome variability in TAR survivorship between cases performed by a developer, an expert or an infrequent surgeon. It is also concerning that the majority of units performing TAR were low volume (<5 TARs per year) raising questions about patient outcomes and costs. Currently the lack of a national registry for AF makes it difficult to comment on longer-term outcomes between the two treatments.

In 2015, the Get it Right First Time (GIRFT) Programme was established to challenge variation in clinical practice, to improve outcomes and subsequently provide cost savings. GIRFT has already changed the orthopaedic landscape having been instrumental in the establishment of regional networks for hip and knee arthroplasty and supporting the reestablishment of hot and cold orthopaedic sites. GIRFT is now being rolled out across other surgical specialities. Early in this re-organisation Nottingham was established as the centre of the revision hip and knee

network in the East Midlands. It has demonstrated the benefits of GIRFT3. The principles developed by GIRFT are powerful and can be modified for the treatment of ankle arthritis.

It is difficult to ignore the increasing evidence confirming the importance of unit volume on outcome and survivorship in arthroplasty, especially in revision arthroplasty4-7. It follows that concentrating revision TARs into centres, working in collaboration with surrounding hospitals ensures that a high quality service is maintained.

BOFAS has proposed that an ankle arthritis network should be collaborative, so that it can both support local units who wish to offer and perform TAR in sufficient numbers and to allow centralisation of revision TARs8.

This would optimise the outcomes from revision TAR surgery, which involves a range of rapidly evolving techniques. The network would also connect centres that perform more complex ankle fusions requiring deformity correction. Collaborative networks aim to offer the patient the most appropriate treatment tailored to that patient’s specific needs and when possible, perform this close to the patient’s home and rehabilitation services.

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Our experience The establishment of multidisciplinary meetings (MDT) can be challenging because job plans and timetables rarely align. This form of collaborative working is novel and not all colleagues share the same interest in complex cases. These challenges are compounded when multiple units are involved. However, the experience we gained by the adoption of remote working during the pandemic has been invaluable and the IT infrastructure that was developed to maintain clinical services over the last two years has been instrumental in supporting the MDT.

meeting is arranged, to allow discussion of cases that might be suitable for referral between units and to give an update on the outcomes of previous procedures. The meeting is designed for the discussion of ankle arthritis cases but also allows for the discussion of challenging cases due to other conditions, such as those that might benefit from microbiology, vascular or plastic surgery services.

dial in with urgent cases for discussion as required. Cases are submitted in advance, to streamline the time for presentation and to allow more time for discussion.

In our experience, there are certain requirements which maximises and facilitates an effective MDT.

“The numbers of AF and TARs continue to increase each year in the UK and with an aging and yet active population, the rates are likely to rise. Both TAR and AF are effective methods of treating end stage ankle arthritis but each have complications, failures and long-term sequelae.”

The East Midlands Ankle Network covers a large geographical area, supporting a catchment of approximately 4.5 million people, including multiple large district general hospitals and several university teaching hospitals. Each hospital maintains its own MDT and complex case practices. Once a month, a centralised

The regional meeting is hosted in Nottingham University NHS Trust and MS Teams is used to link the peripheral sites. Regular attenders are the North West Anglia NHS Foundation Trust and Sherwood Forest Hospitals NHS Foundation Trust, the other regional hospitals

1. The IT and AV infrastructure needs to be robust. Although numerous solutions exist, we have found MS Teams to be the most widely available and easily utilised.

2. A dedicated meeting room with an adequate camera and microphone is also essential.

3. We found that lunchtime meetings were the easiest to coordinate and minimised disruption of clinical activity.

4. Organisational and administrative support is important to prevent ad hoc meetings which can easily become unreliable and untenable.

5. Documentation is essential and a record of the discussion is kept in the patient records. >>

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Not all cases of ankle arthritis require discussion. The principle reasons for discussion in our network are: 1. Patient or clinician request.

2. Evidence of degenerative disease in any adjacent joint that might compromise a proposed ankle fusion.

3. Revision cases: a) Painful ankle fusions. b) Failed primary TAR. c) Primary TAR with major bone loss.

Figure 1: Pre-op CT scan of painful Left TAR with bone loss.

4. Complex hindfoot deformity around an arthritic ankle.

Illustrative cases discussed in the Collaborative Arthritis Network Case 1: Failed ankle replacement Whether to revise to an ankle fusion or a revision ankle replacement?

Figure 2: After Revision to an Invision TAR.

A 71 year-old retired office worker, who had a left total ankle replacement five years ago and had ongoing pain and swelling. The patient also had rightsided end stage ankle arthritis and was awaiting surgery. Clinical examination of the left ankle revealed minimal deformity, CT revealed large cysts in the talus and tibia.

The following questions and options were discussed.

Figure 3: Left & Centre - Initial Radiographs; Right - MRI after Removal of Metalwork and Biopsy.

Figure 4: Radiographs, 3 months after Second Stage Open Ankle Fusion with bone graft.

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• Would a revision to a fusion or an ankle replacement be best for the patient?

• Should surgery be staged to exclude infection?

• What type of revision ankle replacement system?

• If revision to fusion was the best option, is a nail or a plate most appropriate?

• Should the ankle be shortened, or use a femoral head allograft or 3D printed custom cage to prevent shortening?

• What about the impact on the rightside which was equally painful?

• What are the realistic expectations to advise the patient?

A decision was made to proceed with revision to an Invision TAR with bone grafting. Six months after the patient’s surgery the outcome was reported to the network. The PROMS had shown significant improvement and the patient was walking independently with plans for a primary TAR on the right-side.

Case 2: Post-traumatic ankle arthritis What to do and where to do it?

A 60 year-old lady presented to the local hospital, two years following an open ankle fracture due to a road traffic accident which that had been treated with an initial ORIF at the regional MTC. There had been a rapid deterioration in the ankle joint with progressive avascular necrosis of the tibial plafond resulting in a failure of fixation.

Although this patient was never suitable for an ankle replacement, discussion in the MDT informed the initial treating institution of the complications following this complex case, and gave advice to the surgeons at the local hospital. She underwent removal of the metalwork with biopsy to exclude infection and then a secondary open ankle fusion with bone grafting. Receiving treatment closer to home had great benefits for the patient’s rehabilitation.

The future The numbers of AF and TARs continue to increase each year in the UK and with an aging and yet active population, the rates are likely to rise. Both TAR and AF are effective methods of treating end stage ankle arthritis but each have complications, failures and long-term sequelae.

Patients have an expectation that they will be given the best, most appropriate intervention. Low volume units are at risk of missing patients who might benefit from TAR and operating infrequently with inexperienced theatre teams, potentially leading to poor patient outcomes.

We believe that our patients, benefit from a collaborative network, because it allows for discussion of these complex cases. It drives forward best practice and allows us to audit our outcomes leading to improvements in patient care.

Within the foot and ankle speciality we need to avoid excessive variation and be able to justify our practice in line with the GIRFT quality improvement metrics. It is hoped that the benefits of this will provide safer care, improved patient access, better outcomes and rationalisation of costs across the UK3. n

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

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The history of conservative management of acute Achilles tendon ruptures – “the other Northern Irish protocol” Matthew Lynch-Wong and Andrew Adair

Matthew Lynch-Wong is a Specialty Trainee in Trauma & Orthopaedic Surgery in the Northern Ireland Deanery.

Andrew Adair is a Consultant Orthopaedic Surgeon specialising in foot and ankle surgery. He is an active member of the British and Irish Foot and Ankle societies. He is clinical lead for orthopaedics at The Ulster Hospital, Belfast.

Even as long ago as Achilles himself in the Trojan wars, ruptures of the Gastro-soleus tendon have been treated non-operatively. More recently after diagnosis of a ruptured Achilles tendon, the treatment pendulum has swung between conservative and operative management.

Historically, conservative management was advocated because it avoids the risk of wound healing problems and Sural nerve injury. For 25 years, the orthopaedic teams in Belfast have been running a service treating these common injuries conservatively and achieving good results1. This article reviews the modern evidence for the non-operative treatment of these injuries and gives guidance on how to do this well.

T

he evidence to support the conservative management for the majority of patients with acute tendo-achilles (TA) ruptures has been steadily accumulating.

Since 1996, all patients with a ruptured TA from across the province of Northern Ireland were referred into a specialist clinic.

Wallace et al1 published their large study demonstrating that conservatively managed ruptures had a low re-rupture rate of 2%, which was similar to surgical repair. The functional outcomes were excellent, with all 945 patients returned to work within three months of completing a functional rehabilitation protocol. All returned to preinjury sporting levels and 99.4% had good to excellent subjective assessment scores. This has been supported by subsequent studies.

The SMART (Swansea Morriston Achilles Rupture Treatment) Programme was

established in 2008 in which acute ruptures with a gap of 10mm or less were treated in an initial cast and then functional bracing.

Those with a wider gap underwent surgical repair. Hutchinson et al2 reported rerupture rates of 1.1% for conservatively treated patients and similar re-rupture rates and functional outcomes (ATRS) after nine months. Keating et al3 published their long-term results 15 years after nonoperative treatment of patients in a previous randomised trial, which showed no difference in outcome measures, satisfaction scores nor of re-rupture rates.

When is non-operative treatment appropriate?

Achilles tendon ruptures mostly occur in men in the 30 to 40-year-old range, affecting 11 to 37 per 100,000 population with an estimated 11,000 people each year in the UK. >>

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When is non-operative treatment not appropriate?

The consensus is that surgery is appropriate for the high-level athlete and for patients presenting after a delay of several weeks.

Athletes, such as jumpers, basketball players or sprinters require maximal push-off strength, which is achieved through correct tendon length and tension. Lantto et al6 showed that surgery led to faster and better recovery of isokinetic calf muscle strength.

It should be noted that for physically active non-elite athletes, conservative measures should still be considered. But when faced in clinic with an amateur athlete, there remains the unsolved question of what is a ‘high level’ athlete?

An open surgical technique is still the mainstay for most surgeons due to easy visualisation of Sural nerve as well as the apposition of the tendon itself, with ease of setting the correct tension, as well as the ability to perform adjunctive reconstruction procedures in cases of significant tendon retraction. Several meta-analyses have shown a lower risk of wound complications following minimally invasive surgery, such as using a specially designed device to aid insertion of the sutures (Achillon, PARS device). Percutaneous surgery is now less popular due to the reported higher risks from blind damage to the Sural nerve. Patients after operative fixation have also been shown to benefit from functional rehabilitation rather than cast immobilisation.

The number of ‘weekend warriors’ greatly outweighs the number of elite athletes. Nonoperative management is the commonest treatment for these patients with lower functional demands.

It is vital that the tendon ends are brought close together within a few days. Most evidence is based on the tendon ends being reduced within a maximum of two weeks and ideally within 48 hours. Ultrasound assessment has become more widely available across the UK and many acute hospitals have a protocol for rapid access to confirm the diagnosis and to assess the gap between the two tendon ends with the ankle in full plantarflexion. Checking the reduction of the tendon ends by ultrasound could be considered akin to checking bone ends by radiographs. The current question is, what gap is acceptable for conservative treatment?

In the long-term review, Lawrence et al4 showed that a gap in the Achilles tendon of more than 10mm led to an over-lengthened Achilles tendon and subsequent reduction

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in strength. Whilst a wider gap correlated with a sudden drop off in strength, this did not correlate with worse patient reported outcome measures. Furthermore, WEEK 0 work from Reading has shown that worse functional outcomes were achieved after non-operative WEEK 0 - 2 treatment in patients with a gap greater than 10mm5.

Today, there is no clear consensus on the size of gap to decide between operative and conservative treatment. During polling at the BOFAS Consensus Meeting in 2018, 42% of consultants routinely offered operative treatment for TA ruptures with a 10mm gap whilst 96% offered operative treatment when the gap measured 20mm.

Surgical repair needs to be considered when faced with a re-rupture, rupture at the insertion or a ruptured Achilles tendon after a delayed presentation, which is generally accepted as six to eight

Present to A&E 1. Equinus cast 2. VTE risk assessment Early Fracture/Orthopaedic clinic 1. Diagnosis confirmed with Simmonds triad +/- Ultrasound 2. Confirm suitability for conservative care 3. Complete two weeks in equinus cast 4. Non-weight-bearing

WEEK 2 - 8

Functional rehabilitation 1. Fixed angle boot + two heel wedges or variable angle boot 2. One heel wedge to be removed each week 3. Full weight-bearing 4. Boot removed for skin care and gentle ROM Exercises

WEEK 8 - 10

Wean from boot 1. Full weight-bearing 2. Active ROM & strengthening 3. Discharge to physiotherapy

Table 1: The Northern Irish Acute Achilles Tendon Rupture Protocol.

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weeks after the primary event.

However, even within these groups non-operative treatment may be preferred for those with severe medical co-morbidities or low functional demand. These situations will require referral to the local foot and ankle surgeon, who can employ specialist techniques involving tendon augmentation or fixation with biotenodesis screws. Arthroscopic transfer of the flexor hallucis longus tendon has been described to give push off power without wound complications for patients with very poor skin cover.

“Thanks to the early work of Wallace et al , the orthopaedic community in Northern Ireland have become accustomed and comfortable with the conservative management of acute TA ruptures and are satisfied with their good patient functional outcomes, which has subsequently been supported in the worldwide literature.”

What is the best way to manage Achilles ruptures conservatively?

Early detection and early placement of the injured ankle into an equinus position is important to give the orthopaedic surgeon the option to manage the rupture without surgery. Most acute hospitals will have a protocol in the Emergency Department and subsequent referral for assessment.

Table 1 shows an example of a typical protocol, which will need to be adapted to accommodate local practices, e.g. availability of ultrasound and availability of variable angle walker boots.

Historically an above knee cast was applied to control the whole gastrocnemius complex, but there is no requirement for this. Common practice became a below knee cast for eight weeks. This initially started in maximum equinus and would be repeatedly changed to bring the foot to plantigrade. Only then would full weight-bearing commence.

1

nine months or re-rupture rates. The mean total health and personal social care cost was £1,181 for the plaster cast group and £1,078 for the functional brace group.

Regardless of whether conservative or operative measures are chosen, venous thromboembolism (VTE) is a complication reported in around 7.5% of patients with TA ruptures. It is therefore an important issue to address. NICE recommend pharmacological VTE prophylaxis with low molecular weight heparin for people with lower limb immobilisation whose risk of VTE outweigh their risks from bleeding. Therefore, all patients should be risk assessed and if not otherwise contraindicated, thromboprophylaxis should be given as they have an extended period of significantly reduced mobility.

Conclusion

In summary, all patients should be assessed clinically for the Simmond’s triad.

Ultrasound is increasingly readily available to assess the reduction of the tendon gap.

But if not, clinical examination to palpate approximation of tendon ends is often sufficient.

Functional bracing with early weight-bearing is the first line treatment for almost all patients sustaining TA ruptures. All patients should be risk assessed for venous thromboembolism. Operative treatment should be reserved for patients who require maximal push-off strength, patients with a wide gap of probably over 10mm, a re-rupture or those who have presented late. Thanks to the early work of Wallace et al1, the orthopaedic community in Northern Ireland have become accustomed and comfortable with the conservative management of acute TA ruptures and are satisfied with their good patient functional outcomes, which has subsequently been supported in the worldwide literature. n

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

In most centres, serial casting has been superseded by functional rehabilitation in a removable boot.

Whilst functional rehabilitation protocols vary, the principles remain the same: early but limited range of movement in an orthotic device with early weightbearing as soon as practical. This loading encourages a biological response through an inflammatory process stimulating collagen fibre arrangement and vascularity of the tendon, all of which ultimately aids tendon healing. In 2020 the UKSTAR study reported their findings from a pragmatic multicentre trial involving 540 patients randomised between serial casting and functional rehabilitation7.

There was no difference in Achilles Tendon Rupture Score (ATRS) at

JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk | 59

In Memoriam

Peter James Witherow 10 March 1935 – 5 January 2020 Obituary by Martin Gargan and Helen Witherow

M

r Peter James Witherow was educated at Epsom College and studied medicine at Birmingham University where he became Chairman of the University Medical Students Society and was awarded University Colours for judo. He qualified in 1958.

After three junior hospital appointments he was called up to do National Service which he chose to do in the Colonial Service in Basutoland for three years. He returned to surgical training in Birmingham and Oswestry where he was seconded for six months to the Rheumatism Foundation Hospital in Heinola, Finland.

“Peter was a superb role model for any surgeon. He had a first class brain and was a well-prepared and informed clinician. He was a meticulous and gifted operative surgeon with the calmest of temperaments and thoroughly committed to training.”

60 | JTO | Volume 09 | Issue 04 | December 2021 | boa.ac.uk

He was appointed as successor to Arthur Eyre-Brooke in Bristol in 1973 and took over and developed an extensive single-handed paediatric and young adult orthopaedic and spinal deformity service. He was a firstclass surgical teacher, Head of the Bristol training programme and the Witherow post was always considered one of the ‘must do’ attachments for any trainee in the South-West.

He was forward thinking and with radiology colleagues established the first skeletal dysplasia clinic and database in the country, which still largely exists in its original format.

The most telling metric of his significant clinical workload is the fact that he has now been replaced by ten paediatric and five spinal deformity surgeons.

In addition to his extensive clinical workload, he was an international leader serving with distinction on the Executive of the European Paediatric Orthopaedic Society, the British Scoliosis Society, the Cerebral Palsy Surgical Society and was President of the British Society for Children’s Orthopaedic Surgery.

He had an extensive research interest and published widely, with a particular interest in cerebral palsy. His collaboration with Jane Pyman, MBE, was before its time and he would have been delighted to know that the long-term study of his initial cohort of multilevel surgery patients in cerebral palsy has been published since his death.

Peter was a superb role model for any surgeon. He had a first class brain and was a well-prepared and informed clinician. He was a meticulous and gifted operative surgeon with the calmest of temperaments and thoroughly committed to training. He was a kind and caring doctor who had a profound influence on several generations of children’s Orthopaedic Surgeons.

Outside work Peter had many interests. He became an expert in each and exhibited the same desire for perfection in his hobbies as he did in his work. He was well read and loved music and played the recorder to a very high standard. He loved working with his hands whether it was mending things or developing and printing his black and white photographs, making fibreglass kayaks or his beautiful cabinet making, lovingly crafting toys for his grandchildren. He was a member of the South Wales Potters and became an accomplished ceramicist with a Potter’s wheel and kiln in the garage. His ceramics were highly valued by others but not by himself. His own high standards often ended consigning the pots to the bin, only to be retrieved by his wife.

However, occasional pieces were felt to be of a sufficient standard to be exhibited in the South Wales Potters exhibitions.

He developed Parkinson’s disease in 2000 and died on the 5th January 2020 after a protracted illness. He was nursed at home

by Pat, his wife, whom he married in 1959.

He left two children, Helen, a Maxillofacial surgeon, Tim a classics scholar and four grandchildren who remember him not as an eminent Orthopaedic Surgeon but as the model aeroplane maker, the teacher of making pottery animals and for his kite flying prowess. n

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