Journal of Trauma & Orthopaedics - Vol 10 / Iss 1

Journal of Trauma and Orthopaedics Volume 10 | Issue 01 | March 2022 | The Journal of the British Orthopaedic Association | boa.ac.uk

Orthobiologics for Ms X? Yes No Don’t know Diversity in Trauma and Orthopaedics p26

My experience of tragedy, Orthobiologic injectables; disasters and war p38 Yes-No-Don’t know p46

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3

From the Executive Editor

5

From the President

34 Features:

Deborah Eastwood John Skinner

8-9 BOA Latest News 16 News: BOA Annual Congress 2022 17 News: An interview with Bob Handley 18 News: Conference Listing 2022 20 Features: Reflections on leadership Philip Turner

22 Features:

My patient has a pacemaker and needs an MRI scan - a review of the guidance and regional survey of referring orthopaedic surgeons James Dundas, Andrew Brown, Iain Matthews, Thomas Green, Craig Runnett, David P Ripley and Honey Thomas

26 Features:

Diversity in trauma and orthopaedics: Rationale for an inclusive culture Simon Fleming, Jennifer Green, Laurie Hiemstra, Samantha Tross and Kristy Weber on behalf of International Orthopaedic Diversity Alliance (IODA)

30 Features:

Knife before wife, or so they say James Berwin

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

James Lind Alliance Priority Setting Partnership - ‘Top 10’ research priorities in foot and ankle surgery Jitendra Mangwani on behalf of the Foot and Ankle JLA PSP Steering Group

58

38 International: My experience of tragedy,

disasters and war Amer Shoaib

42 Trainee:

Demonstrating commitment to specialty for the Core Surgical Training self-assessment portfolio for under £20 Sarah Choi, Daphne Chia and Ignatius Liew

45 Medico-legal:

BOA medico-legal roundup Simon Britten, Chair of the BOA Medico-legal Committee

56 Subspecialty: Orthobiologics: Tendinopathy

Iain R Murray, Andrew W McCaskie and Neal L Millar

46 Subspecialty: Orthobiologic injectables; Yes-No-

58 Subspecialty: The decision to add PRP to my

48 Subspecialty: Orthobiologics: Scientific background

62 Subspecialty:

52 Subspecialty:

64 In Memoriam:

Don’t know Mark Bowditch

Iain R Murray, Martyn Snow, Cosimo De Bari and Andrew W McCaskie Orthobiologics: Osteoarthritis Iain R Murray, Martyn Snow, Cosimo De Bari and Andrew W McCaskie

practice – a personal perspective Ansar Mahmood PRP – a personal view Philip Turner Clive Lee

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 10 | Issue 01 | March 2022 | boa.ac.uk | 01

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Credits JTO Editorial Team l l l l l

Deborah Eastwood (Executive Editor) Hiro Tanaka (Editor) Simon Britten (Medico-legal Editor) Oliver Adebayo (Trainee Editor) Mark Bowditch (Guest Editor)

BOA Executive

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

l

John Skinner (President)

l

Bob Handley (Immediate Past President)

Policy and Programmes

l

Deborah Eastwood (Vice President)

Director of Policy and Programmes

l

Simon Hodkinson (Vice President Elect)

Programmes and Committee Officer

l

Fergal Monsell (Honorary Secretary)

Education and Careers Manager

Mark Bowditch (Honorary Treasurer)

Educational Programmes Assistant

l

BOA Elected Trustees l

John Skinner (President)

l

Bob Handley (Immediate Past President)

l Deborah Eastwood (Vice President) l

Simon Hodkinson (Vice President Elect

l

Fergal Monsell (Honorary Secretary)

l

Mark Bowditch (Honorary Treasurer) Colin Esler Anthony Hui Andrew Manktelow Ian McNab Fares Haddad Amar Rangan Sarah Stapley Hiro Tanaka Cheryl Baldwick Deepa Bose Caroline Hing Andrew Price

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

- Lisa Hadfield-Law

- Julia Trusler - Eliza Khalid

- Alice Coburn

- Kathryn Hawthorne

Communications and Operations Director of Communications and Operations

- Annette Heninger

Membership and Governance Officer

- Natasha Wainwright

Publications and Web Officer

- Nick Dunwell

Finance Director of Finance - Liz Fry Deputy Finance Manager - Megan Gray Finance Assistant - Hayley Ly Interim Finance Assistant - Chuks Nwandei

Events and Specialist Societies Head of Events - Charlie Silva Events Coordinator - Venease Morgan Exhibition and Events Coordinator

- Anna Prunty

UKSSB Executive Assistant - Henry Dodds

Copyright

Copyright© 2022 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

M

arch winds and April showers... but in February? Perhaps just another example of the somewhat topsy-turvy world we find ourselves in at the moment? Although we are told, ‘restrictions’ are ending and ‘things’ are returning to normal, from a T&O point of view, we may still beg to differ. However, as an endlessly naïve optimist, I do believe that the winds of change are passing through our specialty and now is a great opportunity for innovative thinking and sustainable solutions. We certainly need to think differently when you realise the scale of the problem as outlined in John’s ‘From the President’ article (page 5). #SolvingTogether (https://solvingtogether.crowdicity.com) challenges you to submit your ideas that you think will make a difference for our patients – it gives you the opportunity to look at the ideas of others too and to vote for those you think will truly make a difference. So please just go ‘do it’ and put your idea forward.

Both our subspecialty section, (from page 46), and our recent online document www.boa.ac.uk/orthobiologics look at orthobiologic treatments critiquing the rationale and the evidence for their use in different situations and asking the question posed on our front cover: are they the right treatment for Ms X? This review of the evidence is balanced by two interesting and personal perspectives from a surgeon (page 58) and a patient (page 62).

My pledge to you for 2022 was to concentrate on the wider issues of diversity and engagement and as we approach #International Women’s Day it is pleasing to see how far IODA has come in the last two years (page 26). The BOA guidance on parental leave (www.boa.ac.uk/parenthood) is supported by James’s article (page 30) where he asks you to consider being the person you cannot see and supporting them when you do see them. Another group of trainees (page 42) show that you can demonstrate commitment to your profession whilst gaining experience and having fun all without spending a fortune.

There is perhaps no greater change that a person can make than exchanging their UK day job for a role providing humanitarian support to those in dire need in crisis areas (page 38) and encouraging us to recycle to boot! As I begin to introduce you to my presidential theme of sustainable systems, we all need to find ways in which we can contribute little and often.

I always like to learn so was delighted to read the article on implantable devices and MRI (page 22) – some common sense information that we can all put to use for patient benefit.

This issue of the JTO welcomes Fergal Monsell as Honorary Secretary and Simon Britten as Medico-legal Chair – both excellent additions to the BOA team. If you would like to join the team we will be looking for nominations for Trustee positions soon (page 9) – we need yet more diversity: northerners would be very welcome!

Unbelievably (to me!) this is my last editorial and as I hand over the JTO reins to the capable pair of hands that belong to Simon Hodkinson, your new Executive Editor, I would like to thank Nicholas Dunwell and Annette Heninger for guiding my editorial hands over the last 18 months and Hiro Tanaka and Fergal Monsell for helping to commission the content for JTO. Your help has been much appreciated. I will take a short breather before returning – albeit on a different page of the JTO! n

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 03

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From the President

Elective recovery of care John Skinner

I hope that we are now through the worst of the storm season and along with Dudley and Eunice arriving, February saw the publication of the much-awaited NHS Elective Recovery Plan (ERP). It was delayed by the Omicron wave of COVID-19, and real uncertainty regarding what will happen to the 10 million missing patient referrals that didn’t happen during the pandemic. Some of the best brains and modelling systems have been deployed to try and predict what will now happen to these patients.

M

any of these patients will have musculoskeletal conditions and we know that the NJR is already short of 200,000 joint replacement operations that would normally have been performed by now. There are 6.1 million patients on all waiting lists and if just over half of those 10 million patients were to come forward, the waiting list could double.

We won’t know for sure until early next year. We are aware of the particularly difficult situations that affect colleagues and patients in Wales, Scotland and Northern Ireland and continue to work with them to influence change throughout the United Kingdom.

The NHS had already committed to increase elective care delivery by 30% compared to pre-pandemic activity in the 2021 government spending review and this is now timetabled to happen by March 2024. March 2024 is also the date by which the Recovery Plan mandates that waiting lists will start to reduce. It is acknowledged that waiting list numbers will rise before they fall, and we know that many of our patients are waiting too long already. The plan stipulates that no patients will wait beyond 104 weeks by July this year. Currently that represents 4,400 T&O patients who must be treated by July, but this number rose by 12% in the last month. The other headline target is that no-one will wait more than 52 weeks by March 2025. At present there are 60,000 T&O patients in this category.

Increased investment in the NHS is welcome but comes at a time when the cost of living, fuel prices and individual tax burdens are rising. This will mean increased scrutiny and rising expectations for healthcare, as suggested when the Daily Mail reported the launch of the Elective Recovery Plan with “Is that all we get for £12 billion?”

Investment to increase elective orthopaedic capacity nationwide is essential. Developing hub sites and theatre provision in all regions is welcome as it appears to be the only way that we can guarantee high quality elective surgical provision year-round. The term ‘winter pressures’ justified suspending surgery for patients with end stage arthritis for several months, each year. This is not acceptable, and these patients need and deserve timely surgery. Joint replacement and many other orthopaedic operations transform lives and represent some of the best value healthcare interventions in all surgery. We know that many non-cancer diagnoses are in no way benign conditions for patients. We deliver important and effective healthcare.

As we traverse the new health landscape of ICS working, surgical hubs, elective care prioritised and the massive backlog, orthopaedic surgeons must be empowered to deliver for our patients. We must take this opportunity to influence and improve our working day, to lead efficient theatre teams that maximise surgical throughput and minimise delays in the working day.

We’ve addressed long waiting lists before and I know that we will do it again. I hope that this time it comes with NHS investment and leaves a legacy to future proof the system.

This will improve job satisfaction for the whole team, and we must grab all opportunities to train the next generation of surgeons as we help them to catch up the lost theatre cases that came with COVID. Our patients need their operations and I hope that this represents an opportunity for us to do what we enjoy doing best. Rest assured that the BOA will continue to represent you as we go forwards addressing these challenges in the recovery of timely elective orthopaedic surgery. n

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 05

News

2021-2022 BOTA President – Oliver Adebayo

F

ollowing our hugely successful first ever virtual BOTA Congress last year, held six months later than planned due to the COVID-19 pandemic, it was an honour to be voted in as the new BOTA President.

Records were broken, with the highest attendance recorded for our Congress, and BOTA’s highest voting turnout in the AGM via our transparent online polling system.

The pandemic has had a profound effect on all our lives, particularly with how we interact as a profession online. As BOTA webmaster last year, I felt at the centre of an orthopaedic digital revolution with an explosion of content, discussion and opportunity for our specialty to be at the forefront of digital health. I delivered on creating and launching our new interactive website to allow it to become a hub for all orthopaedic junior doctors for key information, courses, and some of the amazing content created by orthopods around the world.

I am currently an ST6 trainee in London on the Stanmore rotation, with an MSc in Surgical Innovation. I firmly believe that BOTA, representing the future of our specialty, needs to engage and lead on innovation and sustainability within orthopaedics.

Furthermore with the challenges within surgery with regards to culture and diversity, I hope that we can continue the good work started by last year’s committee. As such we have established working groups within our committee to tackle these key areas.

Finally in the wake of a faltering elective restart program post COVID-19, I am committed to ensuring every trainee has the opportunities they need to gain confidence in elective operating and will be working closely with RCSEngland to do so. However we can’t do it alone. We look to the whole orthopaedic community to help in pushing through an agenda of change in all areas for a better future.

“I firmly believe that BOTA, representing the future of our specialty, needs to engage and lead on innovation and sustainability within orthopaedics.”

Ortho Update 2022 Vishal Kumar

T

he BOA Orthopaedic Update held on the 8th of January 2022 was a virtual course that has contributed an immense amount of knowledge and understanding for me. I am an ST6 trainee in the East of England Deanery and due to approach my exams next year. This course has not only consolidated my knowledge but also has given me practice and taught me a method of how to approach vivas.

The course included pre-course learning material in the form of short lectures distributed to candidates.

These lectures were delivered by experienced faculty members who had intricate knowledge in their areas of subspeciality. They delivered lectures expanding on avenues of how to assess conditions and how to manage conditions with good references from evidence-based practice.

On the day of the course we were allocated to groups over zoom. These groups were rotated around the faculty for viva style learning. Cases were presented as they would be in the exam setting and each case lead to questioning about various fields of expertise in orthopaedics. The organising team were excellent in the smooth allocation of rooms and dividing groups of candidates at a similar level. In my personal experience as my level of training had changed since the course application, the organisers were very considerate

06 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

and allocated me to another group. The interaction with the faculty was amazing. The interaction started as a case-based discussion which lead to a viva style questioning and discussion.

I felt very supported and the questions that I did not know the answers to were very well explained. I did not feel under pressure to know all the answers to the given questions but felt supported to be pushed to attempt answering the questions using my own knowledge and experience.

I would highly recommend this course to my colleagues at all levels. This course is well organised and very educative in day-to-day practice and exam preparation. n

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Latest News

BOA Educational Courses

National Hip Fracture Database (NHFD) Report The latest NHFD annual report was published in October 2021 and is available on the NHFD website: www.nhfd.co.uk/20/hipfractureR.nsf/docs/reports2021.

Committee Appointments Following a successful round of applications, the BOA would like to congratulate all those who have been appointed onto the BOA Committees:

Orthopaedic Committee Nick Aresti (Vice Chair)

Research Committee Training Orthopaedic Education Supervisors (TOES) Thanks to Lisa Hadfield-Law for an enormously successful succession of regional TOES courses to support the launch of the new curriculum in 2021. Over 400 of you took advantage of the opportunity to brush up on your skills, which was wonderful to see. We have four dates for the small-group virtual TOES courses in 2022. For more information or to book, please visit www.boa.ac.uk/toes.

Training Orthopaedic Trainers (TOTs) The underlying premise of TOTs is, if T&O trainers understand how people learn and how the T&O curriculum works, by translating that understanding into action, they can improve their teaching. It is taught through a mixture of live online sessions as well as personal learning outside of fixed times.

Further information or to book is available at www.boa.ac.uk/tots.

SAS Professional Development Programme The third session of our new SAS professional development programme, ‘Stepping up to the Training Plate’, is scheduled to take place on 15th March.

This follows on from ‘Polishing your Portfolio’ and ‘Selecting and Engaging with Mentors, Supervisors and Sponsors’ to round off an insightful series led by Grey Giddins and Lisa Hadfield-Law. We will be using the feedback we get from you to develop and improve the SAS professional development programme, so do please get in touch with any comments to policy@boa.ac.uk.

Arul Ramasamy (SAC Research Lead)

Medico-legal Committee Simon Britten (Chair) Stephen Hepple Sameer Singh

Trauma Committee Will Eardley (Vice Chair) Iain McFadyen Bilal Jamal

RSPA Regional Vacancies As part of the BOA Get Involved Initiative, the BOA and RCS England are seeking Regional Speciality Professional Advisors (RSPAs) to improve local standards and share service delivery in the UK. Current vacancies and how to apply can be found at: www.boa.ac.uk/rspa.

Law for Orthopaedic Surgeons This year will also see the return of the very popular 'Law for Orthopaedic Surgeons – Avoiding Jeopardy' course after a sell-out debut in 2021.

Highlights of last year included Safe Social Media, Dos and Don’ts in court and the mock Coroner’s inquest. To see the 2022 programme, please visit www.boa.ac.uk/law-for-orthopaedic-surgeons.

Peripheral Nerve Injury BOAST The BOA have recently published a new Trauma BOAST (BOA Standard) on Peripheral Nerve Injury. The Peripheral Nerve Injury BOAST was jointly developed by the BOA, the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), the British Society for Surgery of the Hand (BSSH), and the Orthopaedic Trauma Society (OTS). You can read the full document here at www.boa.ac.uk/peripheral-nerve-injury. All BOASTs – including Trauma, Elective and Speciality – can be found on the BOA website at www.boa.ac.uk/boasts.

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BOA Wellbeing Resources The BOA has a number of resources to help ensure we also look after ourselves as well as caring for our patients. Recent times have been especially challenging and we should all occasionally take time to check how we are feeling and to ensure we are ‘ok’. View personal wellbeing stories and access other resources available on the BOA website at www.boa.ac.uk/wellbeing.

Latest News

UKITE 2021 BOA/ORUK Research Fellowships We are very excited that the inaugural BOA & Orthopaedic Research UK (ORUK) joint research fellowship scheme is open for applications until 24th March. This new 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 that wish to undertake their research flexibly or less than full-time (minimum 0.5 FTE). More information at: www.boa.ac.uk/researchfellowships.

We had an excellent turn out of over 800 trainees from across the UK and Ireland for UKITE in December 2021. They were joined by 184 candidates from Malta and South Africa, a record number of international delegates. Congratulations to Wales, who were the highest scoring training programme this year with an average score of 60% for the 34 trainees who took part.

We couldn’t put UKITE together without our excellent team of editors and subspecialty leads who write and select the questions.

Thank you all for your contributions. If you’re interested in getting involved for this year, you can find out more information www.boa.ac.uk/ukite or email ukite@boa.ac.uk.

Incoming Honorary Secretary – Fergal Monsell I was born in Dublin and emigrated to England shortly before the World Cup last came home.

I graduated without distinction from the Welsh National School of Medicine, completing higher surgical training in Manchester and fellowship training in Sydney. I was appointed to the Consultant staff at the Bristol Royal Hospital for Children in 2005 and I am involved in the management of paediatric patients with a special interest in limb deformity and trauma.

I am visiting Professor at Cardiff University, King James IV Professor in 2018 and have a longstanding interest in education. I have made a slightly greater than average contribution to the canon of lower-level evidence as a hobby researcher.

I have been a BOA member since 1990, an ABC travelling fellow in 2000 and was an elected BOA Trustee 2018-2021. My tenure on Council was defined by the COVID-19 pandemic and I had the opportunity to contribute to the Trauma and Elective committees, diversity agenda and production of all BOASTs published during this period. I was elected Honorary Secretary in 2021 and hope that this will enable me to continue to give something back to the Association and its members.

2022 Council and Presidential Nominations Attention Home Fellows – Council Trustee and Presidential nominations open on 15th March!

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

You have the opportunity to bring your skills and expertise to help us grow and develop the BOA and Trauma and Orthopaedics as a whole. A more diverse BOA, and a broader range of voices, better serves our patients and best supports our colleagues and we welcome applications from across our membership.

Please be sure to submit your nominations for Council before the deadline of 15th April and for BOA President by 1st June.

More information and how to apply is available on the BOA nominations website at www.mi-nomination.com/BOA.

Elective Care Recovery Plan In February the Government published its plan for recovery of elective surgery for NHS England which is available to view on the NHS England website. You can read the BOA’s response on our website at www.boa.ac.uk/elective-recovery-plan.

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News

BOA Launches Resources to Support Parenthood in Orthopaedics

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e are delighted to say that, just before Christmas, we published a range of resources to support parenthood in T&O. The two documents – a Statement of Expectations on Pregnancy and Parental Leave in T&O, and a guide to support educational supervisors and trainers – together with wider information and support for expectant surgeons and parents are available on the BOA website at: www.boa.ac.uk/parenthood.

Please make sure to let colleagues know that this information is available.

The BOA believes that T&O should be an inclusive surgical profession that inspires, attracts and retains the best talent. Time out for parents raising a family should not be seen as a barrier to progression for surgeons and we hope these resources will support all those looking to combine family life and orthopaedics.

James Berwin, an orthopaedic trainee, has written an article – Knife before wife, or so they say, on page 30 – which describes his, and his wife’s (who is also a surgical trainee) early steps in parenthood, and particularly their considerations and choices regarding shared parental leave. n

#SolvingTogether T Challenge

he BOA is really pleased to have participated in the #SolvingTogether challenge, a new initiative created to capture, assess, test and share ideas that can support elective recovery. It was started by Tim Ferris, Director of Transformation for NHS England and Improvement, and takes the form of a crowdsourcing platform where people post ideas.

The first challenge launched in mid-January and focussed on supporting people waiting for hip and knee replacement operations. In addition to the BOA, this challenge was led by the Arthritis and Musculoskeletal Alliance, Versus Arthritis, Arthritis Action and the Chartered Society of Physiotherapy.

We are looking forward to seeing the results which we hope will feed in to a set of high value changes that can be spread across the country and that link with and amplify other local, regional and nationwide initiatives supporting people waiting for hip and knee replacement surgery in this difficult time.

The initial hip and knee challenge was open for approximately four weeks and received number of responses from people working at the point of care, service users and families, clinical and managerial leaders, and partners in other sectors. The major phase of #SolvingTogether started in midFebruary 2022 and consists of five more challenges. You can find out more at https://solvingtogether.crowdicity.com.

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News

Heraeus-sponsored Andrew Sprowson Management of Infection fellowship Moez Zeiton

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his three week fellowship was completed at the renowned Endo Klinik in Hamburg, Germany who are international leaders in the management of prosthetic joint infections (PJIs).

I aimed to gain experience of PJI management in a high-volume centre, understand the diagnostic protocols, decision making process and revision techniques to ultimately benefit patients in my own practice in the UK. The set-up for arthroplasty surgery at Endo Klinik is slick, refined and ultra-efficient allowing for maximum theatre utility using predefined protocols and procedures for the management of primary and revision (septic and aseptic) procedures. In particular, aggressive management of prosthetic joint infections results Evening outside Helios in very high success Endo Klinik in the Altona rates in this complex neighbourhood of Hamburg group of patients.

I was able to scrub in and assist on approximately 32 primary and revision arthroplasty procedures.

Surgeons were very accommodating and explained their techniques, strategies and decision-making algorithms. It was particularly fascinating to see the aggressive approach towards 4 x Pod theatres preparing and soft tissue and bone setting up at 07:30am for primary and aseptic revision cases debridement in PJI revision procedures.

I had the opportunity to gain exposure to some of the research projects taking place at Endo Klinik and contribute to several ongoing projects as well as help to plan future international collaborative projects which I am hopeful will come to fruition.

The educational experience of this fellowship was excellent, and I would like to thank Dr Mustafa Citak and Professor Thorsten Gehrke for their help with facilitating this fellowship. I would also like to thank the BOA and their sponsors for their generous support and funding to allow me to pursue this opportunity. n

British Orthopaedic Foot and Ankle Society (BOFAS) update Heath Taylor, BOFAS President

T

he British Orthopaedic Foot and Ankle Society (BOFAS) has, much like all other societies, had our usual activities restricted by COVID. We have, however, begun to run face-to-face meetings and coordinated two sessions at the BOA meeting in Aberdeen, including a lively debate on complex ankle fractures and a session on Rheumatoid foot surgery.

The Education Committee has maintained an excellent online educational

12 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

commitment, including the Master Techniques Webinars, a collaboration with AOFAS. They have also restarted face-toface educational meetings, including the Advanced Fellows Forum and the Principles and New Consultant Courses.

The Scientific Committee has also been busy. The James Lind Alliance PSP project and the UK-FalCoN Project have completed. We are working towards a national research network for Foot and Ankle fellows and hope to restart the review and funding for BOFAS grant applications soon.

The Outcome Committee has continued to encourage the use of the BOFAS registry and a number of new pathways are now live. They have also contributed to an excellent paper on ankle arthritis

networks, a project that ensures that we keep to the GIRFT principles.

As part of the NHS COVID recovery plan, I met with BOA, NHS England and the College of Podiatry, to work together in dealing with the problems of waiting lists for Foot and Ankle surgery. We continue to ensure the highest standards of care are offered to our patients, including equivalence in standards of training and governance, for clinicians treating patients with Foot and Ankle conditions.

Finally, plans are being finalised for a good old fashioned face-to-face annual meeting in Bournemouth, in March 2022.

We have an excellent academic programme planned, with the aim to have the usual mixture of instructional sessions, keynote speakers and workshops.

Keep well, and I look forward to seeing as many of you as possible in Bournemouth. n

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News

50 + years of the L Society for Back Pain Research (SBPR)

ast year was the 50th anniversary of the Society for Back Pain Research.

Unfortunately, due to the pandemic we were unable to hold a meeting and celebrate our 50th year, so this year’s meeting is going to be special in many ways.

The title for our meeting is ‘Panning for Gold’ and we have some fantastic speakers including Professor Manuela Ferreira from the University of Sydney, Professor Annina Schmid from the University of Oxford and Professor Frances Williams from Kings College London.

Friday afternoon sessions at our meetings always involve a lively debate and we expect this year to be no different. The title for the debate is ‘50 years of Back Pain Research. Has SBPR made a difference?’

Motion for: “This house believes that the Society for Back Pain Research is a valuable forum because it has had a positive influence on back pain outcomes for most people over the last 50 years.”

Motion against: “This house believes that the Society for Back Pain Research is redundant as back pain research has not improved back pain outcomes for most sufferers in the last 50 years.”

The meeting will be held on Thursday 30th June and Friday 1st July 2022 at the Warwick Conference Centre, Coventry, UK. Abstract submission is now open, please visit our website to download instructions and to submit your abstract www.sbpr.info/ meetings. The deadline for submission is 6th March 2022.

We welcome members and non-members and encourage new members. If you would be interested in becoming a member of our society, please visit www.sbpr.info/about-us where you can download the membership application form. n

British Orthopaedic Sports Trauma & Arthroscopy Association (BOSTAA) update Nick Nicolaou and Fazal Ali THE VETERAN ATHLETE – ‘MASTERS’ OF THEIR SPORT? Annual Conference 7th July 2022, Westminster Hall, London

A

quick look around the theatre changing room highlights the change in levels of physical activity that has occurred recently. The abundance of damp lycra draped over lockers suggests a large number of colleagues cycling or running to work, and this is just commuting. Not all of this can be attributed to the absence of acute site parking spaces. The involvement of all in physical activity at an older age is being seen widely across the nation.

Without doubt, sport and exercise is good for us. But what constitutes an ‘older’ athlete? If elite sport is a guide, then ‘Masters athletics’ would suggest this is someone 35 years and above. Also, does being active for longer lead to problems for the treating Orthopaedic Surgeon and should age be a guide to treatment?

The current European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) guidance on meniscal tears suggests that if over 35 years of age, a one month history of knee pain without a locked knee should be managed non-operatively for three months before MRI imaging and if a meniscal lesion is then identified, a partial meniscectomy should be performed. On the other hand, evidence suggests a 50-year-old with an ACL rupture will do as well with surgery as a younger patient1. It also seems that femoroacetabular impingement (FAI) in 40-60 year olds with mild arthritis is not considered a contraindication to hip arthroscopy by many hip arthroscopists2. What about the role of arthroplasty? Andy Murray, the most successful British tennis player turns 35 this year, although his hip resurfacing is considerably younger.

Other controversies exist in management of pathology in other subspecialty areas in the older athlete and BOSTAA is pleased to invite you to our annual meeting where we look forward to debating these topics. n

BOSTAA President Deiary Kader, like many ‘veteran’ orthopaedic surgeons, getting involved in sport

14 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

References 1. Dahm DL, Wulf CA, Dajani KA, et al. Reconstruction of the anterior cruciate ligament in patients over 50 years. J Bone Joint Surg Br. 2008;90(11):1446-50.

2. Toobaie A, Ayeni OR, Degen RM. Mild to moderate osteoarthritis is not considered a contraindication to arthroscopic treatment of symptomatic femoroacetabular impingement: results of an international survey. Knee Surg Sports Traumatol Arthrosc. 2021;29(12):4082-90.

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News

British Trauma Society (BTS) update Ansar Mahmood

T

he British Trauma Society annual scientific meeting went ahead last November as a virtual meeting due to the uncertainty regarding COVID-19 at the beginning of 2021. It is the first time in our history we have had to do this and I am very proud to say it received excellent feedback. Industry support was strong and very welcome given this novel format.

Not faced by geographical constraints we took advantage by inviting keynote speakers from around the globe to fit with the theme of Global Trauma Challenges.

The evening keynote speaker sessions were well attended with well over 100 listeners at each session even though online access to recordings of the talks would be available to all registrants for six months.

Professor Fiona Lecky and Dr Carl Marinowitz discussed the effect of COVID on trauma based on data from TARN. Dr Jan Jansen, a trauma surgeon from Birmingham, USA, spoke about contemporary techniques of haemorrhage control and innovation in this area. Sarah Tucker, a consultant plastic

BOA Annual Congress 2022

surgeon from Oxford, spoke of her experiences in trauma care overseas and in Oxford with an aptly titled talk ‘Orthoplastics care across continents’.

Dr Jamie Colman, a leading trauma surgeon from Denver, gave us an eye opening talk on wellness and sleep deprivation for surgeons and how it impacts on our work and lives. Mr Bob Handley, BOA immediate past President, tackled Getting It Right First Time (GIRFT) in trauma. Mr Alberto Gregori, an orthopaedic surgeon and chair of World Orthopaedic Concern joined from Africa to give his experiences of delivering care in low and middle income environments.

Professor Hans-Christoph Pape from Zurich, well known internationally for his research work on DCO concepts, presented an update on damage control orthopaedic concepts and safe definitive surgery.

We had our AGM and selected some fantastic new committee members.

It is our vision to realise the true value of a truly multidisciplinary society and push ahead with publication cross specialty

20th – 23rd September, ICC Birmingham Under the theme of ‘Technology, Data and Recovery’ the 2022 Congress will be taking place from 20th – 23rd September, at the ICC in Birmingham, with four days of lectures, debates and discussions including three days of exhibition. The programme will include the Howard Steel Lecture, the Robert Jones Lecture, Revalidations, BOA Ortho Committee, hot topic sessions by specialist societies and an update from the BOA President, John Skinner, on his presidential year.

The provisional programme is available at www.boa.ac.uk/programme.

16 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

recommendations and guidelines for polytrauma patients as well as improve our educational offering. Professor Ian Pallister was appointed as our new Director of Education to drive this agenda forward. A new members area is being created on our new website which will have educational content, videos and talks available.

BTS were proud to have hosted the inaugural Human Factors in Trauma conference in Birmingham as a hybrid event in September 2021. This was very well received and we hope to make this an ongoing event, perhaps biennially.

I would encourage non-members to join NOW! - as this year there is a one-off offer of only £20 for annual membership via the website www.britishtrauma.com. n

www.boa.ac.uk/Congress

#BOAAC22

BOA Abstract Submissions

Registration

The BOA abstracts this year are sponsored by Heraeus Medical.

General submissions are now open and will close on Friday 6th May 2022.

We have 22 different categories including Technology, Data & Recovery (new for 2022), Trauma, Medical Students, Quality Improvement, Spines, Trauma and more. Further details about abstracts and our categories for 2022 can be viewed at www.boa.ac.uk/abstracts.

BOA members can register at a discount of 100% for a limited time only during the Early Bird Registration period. Early Bird registration will open on Monday 11th April and close at 23.59 on Sunday 22nd May. General registration will open on Monday 23rd May and close on Friday 4th September 2022. Late registration will close on Tuesday 13th September.

Please keep an eye on the BOA website over the upcoming months for updates on abstract submissions, programme, speakers, sponsors, accommodation and more at www.boa.ac.uk/congress. n

News

An interview with Bob Handley

By Charlotte Lewis, President of OTS I had the privilege of chatting to Bob Handley and interview him for this article. He has been a Consultant at the John Radcliffe Hospital in Oxford since 1994. He is the Immediate past President of the BOA, Past President of the OTS and AOUK, has chaired two NICE fracture related groups and is the current National Clinical Lead for GIRFT Orthopaedic Trauma. In his ‘spare’ time Bob enjoys spending time with his family, walking his dog, cycling and cricket.

I remember hearing Harold Ellis respond to the question, “If you could change one thing about the NHS what would you change?” His response was bring back the firm structure. What would yours be?

Similar but it’s not just the firm structure that is important. The patient needs to be the centre of the team not the speciality. Juniors are then able to access support easily from all involved in the patients care.

What have you learnt from your GIRFT visits that you were both expecting and not expecting?

I was expecting to find a huge variation between the amount of collaboration involved in looking after a single patient. However, when there is collaboration, an environment is created that allows an almost effortless continuous natural improvement. I was not expecting how under supported many of our ward juniors feel.

Orthowomen_uk once asked me for my words of wisdom for an Instagram post.

What would yours be?

Two phrases spring to mind... “Training is for today, teaching is for tomorrow.”

– Training allows the trainee to complete a task and do the job. Teaching is instructing the mind to complete their whole career in an intelligent way.

“No success without succession” – Realising there is a baton and remembering to pass it on.

Where do you find the time to be a trauma surgeon, take on all the roles listed above and manage a healthy work-life balance?

I started as a consultant trauma surgeon working a sustainable work pattern that has always timetabled time away from work after working on call. That time is protected by trusting colleagues to allow me to shut off clinically.

Probably more important is a family and a natural ability to nap at will!

What have been the highlights of your career?

A single 12 hour day springs to mind. I operated on two individuals with ages 105 years apart; an elderly femur fracture followed by cutting the umbilical cord of my own child.

Working at the John Radcliffe for 28 years has been a sustained highlight as it has given me stability at work and is a place where I work with so many people that I respect and like.

What have been the low points of your career?

The frustration of people not taking professional responsibility. Specialities retreat into silos and the shutters go up.

Desert Island Discs style question! What surgical instrument would you take, what book and what luxury?

A hammer, Three Men in a Boat and a hammock. n

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 17

News

Conference Listing 2022: BOFAS (British Orthopaedic Foot and Ankle Society)

BESS (British Elbow and Shoulder Society)

BSCOS (British Society for Children’s Orthopaedic Surgery)

EFORT (European Federation of National Associations of Orthopaedics and Traumatology)

www.bofas.org.uk 09-11 March 2022, Bournemouth 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

BASK (British Association for Surgery of the Knee) www.baskonline.com 18-19 May 2022, Bristol

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

www.bess.ac.uk 21-24 June 2022, Liverpool

www.efort.org 22-24 June 2022, Lisbon

BOSTAA (British Orthopaedic Sports Trauma & Arthroscopy Association) www.bostaa.ac.uk 07 July 2022, Westminster

ICORS (International Combined Orthopaedic Research Societies) www.borsoc.org.uk 07-09 September 2022, Edinburgh

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

BOTA (British Orthopaedic Trainees Association) www.bota.org.uk 21-25 November, Liverpool

Exhibition and Sponsorship Opportunities

The BOA Annual Congress is the UK's largest orthopaedic conference with over 2,400 healthcare professionals.

Take a look at the opportunities available in our exhibition and sponsorship brochure at

www.boa.ac.uk/sponsorship-brochure For more information contact our exhibition team: exhibitions@boa.ac.uk 020 7406 1754 18 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

News

Joint Action update

W

e would like to thank every single person that donated to the Joint Action Christmas appeal. With your help we raised over £8,000 for Joint Action, the Orthopaedic Research Appeal of the BOA. We understand it is a difficult time for fundraising and that everyone has pressures on resources but we are delighted that as we emerge from the pandemic, we can push forward with our fundraising activities with two great events for 2022. The funds will continue to support our vital work supporting CTU’s but will also fund our exciting new fellowships in conjunction with ORUK. These offer fantastic research opportunities for trainees, Post CCT and SAS surgeons.

After a break Ride London is back! We have three amazing riders taking part in the ride which heads out in Essex before a fantastic finish at Tower Bridge on 29th May. Please support our riders: www.justgiving.com/ campaign/JARideLondon2022.

Robert Jordan and Imran Ahmed

Later in the year, on 2nd October, we will have a strong team of runners taking on the challenge of the London Marathon and you can support them here: www.justgiving.com/campaign/JAlondonmarathon2022.

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 19

Features

Reflections on leadership Philip Turner

Philip Turner is a Consultant at Stepping Hill Hospital, Stockport. He was BOA President from 2018 to 2019 and was elected to Council of the Royal College of Surgeons of Edinburgh in 2019. He was the founding Chair of the Greater Manchester Orthopaedic Alliance (GMOA) and is co-Chair of the Greater Manchester recovery CRG.

Signing a Memorandum of Understanding with the Chinese Orthopaedic Association in Xiamen 2019.

“Leadership, like swimming, cannot be learned by reading about it” – Henry Mitzberg

I

am desperately trying to avoid the word ‘journey’, but there is no getting away from the concept of moving forward through leadership roles. I certainly never set out to be a leader – I just wanted to be a good surgeon. However, it was very clear from early on that good leadership made a huge positive difference to patient care and that poor leadership was incredibly destructive. At that stage I didn’t have the vocabulary to describe what I observed but I knew what worked and what didn’t.

My passion has always been medical education, so I progressed through organising regional teaching, meetings and courses, post-graduate degrees and ATLS and AO courses in the UK and overseas. I joined the training committee, became TPD and Head of School, Chair of the Confederation of Post-Graduate Schools of Surgery and IQA Chair for JCIE. Away from education, I have been Clinical Director, Chair of the Greater Manchester Orthopaedic Alliance, and Improving Surgical Care committees as well as roles with GIRFT.

20 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

Before setting out my thoughts on leadership, particularly relating to my time as BOA President, it may help to set out the pathway to achieving the highest office in the organisation.

The first step is to become an elected Trustee selected by the entire membership. This requires a profile that members recognise and a wellcrafted statement that shows you have delivered previously and clearly demonstrates what you will bring to the organisation. Election to the Presidential line is by a ballot of the Trustees so once again you must have proven you will be both safe and effective as well as having a vision of where the Association should be heading. You will be committing to at least four years on the Executive as Vice-President elect, Vice-President, President, and Immediate Past President.

The year as President The two years run-in to President really is necessary. The organisation is complicated and the issues wide-ranging. It would be impossible for the President to simply hand over their portfolio.

Features

The year itself is incredibly busy so the time as Vice President is when you should set out the practicalities of what you want or need to achieve. I was so lucky to be the last pre-pandemic President who had the opportunity to represent our profession across the world in person.

International guests and speakers attended Congress, networks and long-standing friendships established and we could promote the best of UK orthopaedics across the globe. We were the guest nation in Germany and China along with the established ‘Carousel’ engagements with all the English-speaking Associations. BOA Council and committees had to be organised, attended, or chaired, Meeting of all the International Presidents at the American Academy of Orthopaedic Surgery in Las Vegas. invitations to national and international events dealt with and meetings with NHS and education bodies arranged, often and should never be used to list problems crisis but I have seen some bad decisions made at short notice. All this along with the day to or grievances without also having a list of when whole committees have been pushed day running of the BOA and keeping a clinical potential solutions. They must be carefully to adopt them against their better judgement. service going back at base. organised ensuring all participants are briefed.

Additionally, leadership for self-promotion will They should not be used for disseminating always be seen through!

Now my reflections on leadership. These are information alone but for developing plans and just a few of the lessons I have learned from making decisions after full and open discussion.

You need support experience and observation.

Chairing a meeting is always a balance of maintaining focus yet allowing or encouraging Taking on the Presidency or any other key people to speak. Ensure that an action list with leadership role would be impossible without Learning to be a leader responsibilities is completed as the meeting the support of your colleagues, managers and Trainees, new consultants and indeed all staff concludes. This avoids the meeting after the especially your partner and family. Plan ahead should have leadership embedded in their meeting when some regard the real decisions and be honest about what you will need of development plans. Those choosing to take it are made. Never ‘throw your toys out of the them and how you will repay them in terms of further have access to the BOA Future Leaders pram’ as it makes you look foolish and wrecks giving them time and returning the support they Programme or NHS leadership fellowships. My the whole event. gave you so willingly. initial inspiration came from reading Stephen Covey’s book ‘The Seven Habits of Highly Play to your strengths Letting go Effective People’ and then pushing myself to take on roles that stretched my knowledge and skills.

You must be honest with yourself. You need After an extra year added on to my time to help You must be willing to accept and learn from to know what you are both good at and enjoy the Association through COVID-19, I finally failure. A successful surgeon will influence the doing as well as where your weaknesses lie. I left the executive at the BOA Congress in lives of a few thousand patients, a trainer will was fortunate to be in the Executive at a time Aberdeen. Five years of being totally immersed affect tens of thousands and perhaps dozens when we had the opportunity to completely in the politics of our profession at a national of trainees, but a leader can have a positive renew the structure, processes, and governance and international level ended abruptly. My direct or indirect impact on at least hundreds of of the BOA with the appointment of a new Chief details were removed from e-mail chains and thousands of patients.

Operating Officer which was an ideal project WhatsApp groups, the messages and calls for me. A similar skill set was needed to guide stopped, and my in-box was much closer to the organisation and our professional response controllable. All my experience and knowledge Structure your committees through the early months of COVID-19. suddenly didn’t seem to matter and to be Committees are a necessary component of any Support is always available from others – be it honest I felt bereft! These emotions were short sizeable organisation, but they should never from the staff and officers, the sub-committees, lived as I realised that you must move on both develop organically. They can expand when specialist societies and particularly (for me), the for yourself and for the outstanding team that out of control, appointing people who have Treasurer and Finance Director. are now running the BOA. the same safe opinions. The members should be selected through a transparent process that I had a wonderful time at the helm, and I Leadership styles ensures diversity of experience, age, knowledge, will treasure all the memories both good and and skills to ensure all points of view are Much is written about leadership styles and challenging. I am now an elected Council represented, there are no blind spots and much how to adapt them for the task in hand. member of RCSEd and chair the Professional richer discussions are encouraged.

Ultimately, you are who you are and if you Standards Committee. I have found my usual have the attributes of integrity, credibility, niche in the quality assurance and provision accountability, drive, and discipline then you of examinations for the College. I intend to Run effective meetings will be able to cope. The one style I do struggle remain in surgical practice for as long as I am Ineffective meetings are a drain on time and with is charismatic. The ability to persuade safe and enjoy the job - and to maintain that all effort. Every meeting must have a purpose by force of personality can be very useful in a important credibility. n

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 21

Features

James Dundas is a final year Cardiology registrar, training in the North East and subspecialising in advanced cardiac imaging.

He is Level 3 accredited in Cardiac MRI by the European Association of Cardiovascular Imaging, and in Transthoracic Echo by the British Society of Echocardiography.

My patient has a pacemaker and needs an MRI scan - a review of the guidance and regional survey of referring orthopaedic surgeons James Dundas, Andrew Brown, Iain Matthews, Thomas Green, Craig Runnett, David P Ripley and Honey Thomas Background

Andrew Brown is an Internal Medicine Trainee, Northumbria Healthcare NHS Foundation Trust.

Iain Matthews is a Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust.

Thomas Green is a Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust.

Craig Runnett is a Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust.

22 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

The prevalence of patients with cardiac implantable electronic devices (CIEDs) continues to increase, with approximately 57,0001 implanted in 2018/2019 in the United Kingdom. These devices include permanent pacemakers (PPM) for the treatment of bradycardia; implantable cardioverter-defibrillators (ICD) for the treatment of life-threatening ventricular arrhythmia; cardiac resynchronisation therapy (CRT) pacemakers for certain patients with severe heart failure; and lastly implantable loop recorders (ILR) used for diagnosis of intermittent arrhythmia. Some devices can perform multiple functions (e.g.

CRT-defibrillators).

Historically, the presence of a CIED was considered an absolute contra-indication to MRI examination due to perceived risk of device malfunction, inappropriate device therapy (including inhibition of required pacing, inappropriate pacing and inappropriate ICD shocks), and direct tissue effects such as heating. This has resulted in patients having to undergo alternative imaging modalities, which can be inferior to MRI, particularly where definition of soft tissues is required for diagnosis.

More recently, the majority of CIEDs implanted are designated as MRI conditional – meaning that they have been

demonstrated to pose no known hazards, in a specified MRI environment under certain conditions (for example, magnetic field strength and the scan protocol chosen).

All of the major device manufacturers market MRI conditional CIEDs, and MRI scanning for patients with these devices is robustly supported by UK and international guidelines2,3. Many centres have developed straightforward standard operating procedures (SOP) whereby the devices are reprogrammed by cardiac physiologists to MRI-safe modes before the study, and then otherwise scanned in the usual fashion.

Loop recorders (ILR) and non-electronic cardiac implants (e.g. coronary stents, prosthetic heart valves) do not pose a safety risk to the patient, although it may be prudent to arrange for ILRs to be interrogated prior to scanning to acquire any useful ECG data stored. Most guidelines2,3 consider scanning redundant pacing leads (i.e. leads, or parts thereof, left behind after device upgrade or extraction) to be contraindicated, along with scanning within the first six weeks after device implant.

However, experienced centres report undertaking scans in both situations 4,5.

The only absolute contraindication to scanning is a ventricular assist device (VAD). Figure 1 illustrates which devices can usually be safely scanned.

Features

David P Ripley is a Consultant Cardiologist, Northumbria Healthcare NHS Foundation Trust.

Figure 1: Which CIEDs are safe to scan?

Honey Thomas is a Consultant Cardiologist and has worked for 11 years within the Northumbria Healthcare NHS Foundation Trust. She has a subspecialty interest in heart failure and advanced rhythm management/complex device implantation. Honey introduced and jointly lead the service within her Trust for implantation and follow-up of complex cardiac devices and lead the local multidisciplinary heart failure service. She is lead author for the national guidance for management of cardiac devices around the time of surgery.

Image quality is generally only modestly affected

by CIEDs, with magnetic susceptibility artefacts commonly seen around the generator device (usually implanted in the left prepectoral position), and to a lesser extent the pacing leads (Figure 2).

Even where the device overlaps with the region of interest (e.g. in cardiac MRI examinations) the images are usually of diagnostic quality. Where the region of interest is distant to the device, (e.g. spinal, limb, or joint MRI away from the left pectoral

region) then image quality is usually unaffected.

MRI sequences can be specifically chosen and optimised to ameliorate susceptibility artefact.

MRI conditional CIEDs come at an increased cost, but most cardiologists implant them, recognising the potential future benefit if the patient requires MRI. Nevertheless, choosing to implant an MRI-conditional CIED is of no benefit to a patient, if healthcare professionals in different specialties remain unaware that they can request an MRI for them. We sought to gauge the awareness of this issue amongst orthopaedic colleagues. A nine-question survey (Appendix 1) was sent to orthopaedic surgeons both within our trust, and across the regional orthopaedic network.

Results A total of 53 orthopaedic surgeons responded to the survey, of which 16 (30%) were Consultants, 34 (64%) specialty trainees, and 3 (6%) SAS grades. Six NHS trusts across the North East of England were represented, with 46 respondents (87%) working in four district general hospitals and 7 (13%) between the two regional tertiary referral centres. Regionally, one DGH trust and both tertiary centres have well-established programs for scanning CIEDs, but many of the other hospitals do not.

Figure 2: Cardiac MRI images demonstrating magnetic susceptibility artefact around a pacemaker generator (bold arrow) on localisers (Image A), and the associated pacing leads in the right atrium and right ventricle (dashed arrows) on balanced steady state free precession cine imaging (Image B). The images remain of diagnostic quality.

No surgeon thought it was ‘Always’ possible to undertake MRI in a patient with a pacemaker, whilst 41 (81%) thought it was ‘Sometimes’ possible and 10 (19%) wrongly thought it was ‘Never’ possible. >>

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 23

Features

considered no hazard at all to the patient) were wrongly thought to be a barrier to MRI. Over half the surgeons were unaware of whom to contact to arrange a scan, implying that better knowledge amongst referrers could lead to wider access to scanning for CIED patients.

The problem may not only be confined to referring clinicians. Half of surgeons reported having appropriately requested an MRI for a device patient but not having it completed, with our assumption being that these scans were declined by the radiology department.

In 2017, half of UK MRI departments reported being unable to scan CIED patients, with the reasons frequently cited including lack of training, concerns regarding safety, Figure 3: A ‘one-stop’ service model for MRI-conditional CIED imaging – kindly adapted from lack of support from Bhuva et al. BMJ Quality & Safety 2019;28:853-8. cardiology, and logistical difficulties6. Even within When the same question was applied to ICDs, departments who undertake scans in patients again no surgeons thought it was always with CIED, the referral process can often be possible, and the percentage who incorrectly cumbersome and scans may be inappropriately thought it was never possible increased to 27 declined or delayed.

(51%). For patients with an ILR, the results were 2 (4%) for always, 35 (66%) sometimes, Nationally, there remains a ten-fold under and 15 (28%) never. provision of MRI for patients with CIEDs, despite improvement over the previous four Only 4 (7.5%) surgeons reported having years7. Where individual trusts do not offer requested an MRI for a patient with a CIED and a service to carry out MRI scans in CIED having the examination carried out. 26 (49%) patients, clinicians and radiology departments had tried but the scan was not performed, may initially seek to refer to other centres with and 21 (40%) had never attempted to request experience in this area. However, given the a scan for a CIED patient. Greater than half increasing prevalence of device patients, this (57%) of surgeons felt that they would not is not a sustainable solution and setting up a know whom to contact to arrange a scan for service requires optimal collaboration between these patients. Lastly, almost all surgeons, radiologists, cardiologists, MR radiographers, (50/53, 94%) felt that clinical outcomes might and cardiac device physiologists. Figure 3 is an be improved if patients with CIED could be example of a one-stop MRI service for CIED offered MRI scanning. patients, developed by colleagues at Bart’s Heart Centre (London, UK)8. Scanning CIED patients requires multidisciplinary engagement Discussion and adequate staffing, and this can limit the Misunderstanding regarding the suitability for capacity for these scans. However, there is a CIED patients to undergo MRI scans was common strong argument that encouraging referrals may among our regional cohort of orthopaedic help drive investment and service development. surgeons. A majority were aware that it could be possible, at least for simple PPMs, but this There is also growing recognition that, proportion fell when more advanced devices were where the clinical indication is strong and considered. Interestingly even ILRs (which are appropriate precautions are taken, even

24 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

non-MR conditional devices can often be scanned with a very low incidence of adverse events9,10. Patients should however be counselled regarding the risks and benefits as this lies outside the manufacturers’ recommendations. This discussion should be individualised to a patient’s circumstances – for example, a patient who is pacingdependent (without underlying intrinsic cardiac rhythm), would be at much higher risk of death from asystole (in the unlikely event of pacing being inhibited during the scan), when compared with a patient with good underlying rhythm and only intermittent bradycardia.

Studies in these patients therefore require a robust clinical indication from the referrer, identification of the device by a physiologist, a suitability and risk assessment by a cardiologist prior to scheduling, and usually medically-led supervision of the scan. In our institution this is undertaken by a cardiologist specialising in cardiac MRI, but in other centres this role is carried out by cardiologists specialising in CIEDs and/or electrophysiology.

It is our suggestion that centres considering starting to scan CIED patients, initially restrict this to patients with confirmed MRI-conditional devices. This pathway is more straightforward, requiring less additional consultant time, and once it is established can be led by device physiologists and MRI radiographers. With increasing experience consideration can be given to supporting the more complex requirements for scanning patients with non-MRI conditional CIEDs. Information for patients and referring clinicians, as well as international guidelines and device MRI SOPs from established centres, can be found at www.mrimypacemaker.com.

Conclusion There was an overwhelming consensus from orthopaedic specialists that their patients with CIEDs could benefit from MRI scanning, so there is a clear impetus to improve practice in this area. It is important that all MRI scanning sites develop this capability to avoid device patients continuing to be disadvantaged for no valid clinical reason. Education and information provision to relevant medical specialties is also crucial. It is the authors’ view that change in behaviour amongst referrers, to actively refer CIED patients for MRI, is required to stimulate service development and appropriately expand CIED MRI services that already exist. We would encourage orthopaedic colleagues to request MRI scans for their patients with CIEDs, whenever they believe that such imaging will benefit them by altering clinical management. n

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

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Features

Simon Fleming is a Londonbased T&O registrar. He is a founding member and the trainee representative for the International Orthopaedic Diversity Alliance (IODA), on the Executive board for the NIHR Clinical Education Incubator and Associate Editor for Medical Education and The Clinical Teacher.

He was previously Vice Chair of the Academy of Medical Royal Colleges Trainee Doctors’ Group (ATDG) and President of the British Orthopaedic Trainees’ Association (BOTA).

Diversity in trauma and orthopaedics: Rationale for an inclusive culture Simon Fleming, Jennifer Green, Laurie Hiemstra, Samantha Tross and Kristy Weber on behalf of International Orthopaedic Diversity Alliance (IODA)

The International Orthopaedic Diversity Alliance (IODA) is an orthopaedic surgeon-led, not-for-profit collaboration with a vision to unite leaders and industry to promote equity, diversity, and inclusion (EDI) in orthopaedic surgery around the globe.

Jennifer Green is an Orthopaedic Hand & Wrist Surgeon. She is a Founding Member of IODA and a member of the Australian Orthopaedic Association (AOA) Champions of Change. She is a Past Chair of AOA Orthopaedic Women’s Link (OWL) and assisted in establishing the AOA Cultural Inclusion Working Group. Jennifer is an active member of the Australian Hand Surgery Society (AHSS) and the Asia Pacific Orthopaedic Association (APOA) Hand & Upper Limb Section. She is also the Australian Representative on the Asia Pacific Federation of Hand Surgery Societies (APFSSH).

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I

ODA is supported by more than 30 past, present and future national orthopaedic association presidents. IODA members are actively driving discussions around EDI by organising symposia, creating educational webinars, collecting data and collaboratively publishing in the orthopaedic literature. IODA is focused on diversity in orthopaedics writ large, not just gender, envisioning a global culture of inclusivity, where everyone can thrive.

Orthopaedic surgery is one of the least gender and ethnically diverse medical specialties1,2.

This lack of diversity has been recognised as a ‘critical issue’ by many national and international orthopaedic associations. Multifocused diversity strategies are being or have been established by International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS), the New Zealand, American, Australian, New Zealand, British, Canadian Orthopaedic Associations, and the American Academy of Orthopaedic Surgeons (AAOS). Women in orthopaedics initiatives have been established in the Societe Internationale de Chirurgie Orthopedique et de

Traumatologie (SICOT), European Federation of National Associations of Orthopaedics and Traumatology (EFORT), European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), and the Asia Pacific Orthopaedic Association (APOA). These, along with over 40 national ‘Women in Orthopaedics’ societies and those focussing on underrepresented groups, working to address implicit biases, lack of mentorship3, to act as role models and drive change at the leadership level4.

Despite women representing close to 50% of medical graduates globally and an increasing percentage of practicing doctors in many nations, less than 5% of orthopaedic surgeons are female in most nations1,2,5. Gender bias and gender-based stereotypes in orthopaedics are pervasive, affecting women throughout their careers, from residency, to research and clinical work, to career advancement and compensation. Recruitment of qualified women into orthopaedics remains an issue, perpetuated by the negative perceptions of orthopaedic surgery as a career that have been disclosed by female medical students6-9. A perceived lack of

Features

Laurie Hiemstra is an Orthopaedic Surgeon working in Banff, Canada and a clinical Associate Professor at the University of Calgary. Laurie is on the Board of Directors of the Patellofemoral Foundation, Banff Sport Medicine Foundation, Canadian Orthopaedic Association (COA) and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). She is the Chair of the Gender Diversity and Inclusion Task Force for both the COA and for ISAKOS. She is a founding member of IODA and Women in Orthopaedics Worldwide (WOW). Laurie is the President Elect for the COA and will be the first female president of that organisation.

mentorship remains a barrier10. Leadership and career advancement opportunities are less available to women with the numbers decreasing significantly as rank increases. This leads to burnout that can be more prevalent in women, especially senior women physicians11,12. These barriers also translate into a pay gap with female orthopaedic surgeons making less money than male surgeons for the same work13.

Flexibility has been recognised as a necessary factor in promoting the inclusion of women in orthopaedics, many of whom train and work through their childbearing years. This includes flexibility for pregnancy and childbearing considerations, parental leave, lactation facilities, and recognition of family responsibilities.

Flexibility is not a gender-specific policy. It offers significant benefits to all orthopaedic surgeons, whether its purpose be academic advancement, pursuit of a skill unrelated to orthopaedics, recovery from personal illness, or care of an unwell or elderly family member.

It is critical that the promotion committees in academic departments have ways to level the playing field for women who bear a greater share of childcare and family responsibilities. In the surgical theatre, options and improvements in the ergonomics of surgical tools have enabled women to be equally effective from a technical perspective. Appropriate protective equipment such as lead vests that protect female anatomy allow a safe and equitable environment in which to practice. The male culture that exists in orthopaedics creates an unwelcoming environment for women, laying the groundwork for discrimination, harassment and bullying14,15.

The international data availability for racial and ethnic diversity in orthopaedics is not robust but it is widely noted that the field is also

lacking in this area. It is imperative that this data is improved, be transparently available and measures put in place to counter it. In the United States and the UK, the lack of ethnic and cultural diversity in orthopaedics has been recognised16-18. In the United States, persons of colour (Black, LatinX, Asian) are underrepresented in surgical residency programs compared to medical school classes19.

For African Americans 4.1% vs 13.3% and Hispanic 4.5% vs 17.6%20. Of practicing surgeons, in the USA, persons of colour comprise 9.9% of the workforce21. Within the UK, figures are similar with black surgeons comprising 2% of the consultant surgical body versus 5.2% of the medical workforce. Asians, the largest underrepresented group (URG), comprise 27.8% of the practising consultant surgeons compared with 30.2% of the medical workforce22. Trainees from URGs are more likely to leave or be dismissed from training programmes (17.5% vs 6.9% of all orthopaedic residents)19. Apart from the turnover in the workforce which has financial implications for the institution as well as individual, repeated discrimination over time is linked to increased medical co-morbidities and a lower life expectancy in African Americans23. URGs are also more likely to face discrimination, marginalisation, bullying, reduced confidence and a lack of career progression19. >>

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Features

It is recognised that intersectionality (being a member of more than one group that is under-represented) in orthopaedic surgery compounds the barriers for entry and advancement. The specific barriers and challenges that exist for those of diverse gender identities, abilities, religion, and socio-economic status in orthopaedic surgery has yet to be fully understood.

Samantha Tross is a Consultant Hip and Knee Surgeon, the current Lead Surgeon at Ealing Hospital.

She is the first female of AfricanCaribbean origin to become a Consultant Orthopaedic Surgeon in the UK. She is an advocate for Diversity in Surgery and works with many charities and schools to improve this pipeline. She is a Trustee and founder member of the British Association of Black Surgeons and member of Cultural and Diversity Committee of the British Hip Society.

Kristy Weber is a Professor and Vice Chair of Faculty Affairs at the University of Pennsylvania (US) and Director of the Abramson Cancer Center Sarcoma Program. She has served as the president of the Musculoskeletal Tumor Society, the Ruth Jackson Orthopaedic Society and the American Academy of Orthopaedic Surgeons. She is a recognised champion of diversity and equity in the field.

28 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

The McKinsey group in their 2020 report based on the business sector demonstrates that organisations with greater than 30% diversity attract the top talent, are more innovative, make better decisions, and are more profitable20. For businesses, 36% higher returns were realised when there were high levels of ethnic diversity and 25% higher returns with increased gender diversity22. This highlights the financial benefits of IODA’s agenda and supports giving attention to all aspects of diversity.

For culture change to occur, there must be awareness of the disparities that exist for women, URGs and especially those for whom intersectionality is present18, and a desire to want change. Allies, mentors and sponsors are essential to help mitigate the barriers faced by women and URGs in orthopaedics19,23-26. Cultural change is advanced by increased visibility of URGs from a particular country or region on selection boards, training programs, examination boards, scientific meeting panels and with engagement with medical schools.

Those with privilege in any culture can use it to increase the visibility of those underrepresented. Elimination of discrimination, bullying, and harassment will provide a safe and equitable workplace for both women and other URG’s15,27,28. Intentional mentorship and pipeline programmes will increase recruitment and improve retention29,30. Recruitment committees for new orthopaedic trainees and orthopaedic surgeons should include a diverse group of members in order to identify diverse candidates and include regular bias training31. The process for selecting leaders for international and national orthopaedic organisations should be critically evaluated to be sure best practices are used to mitigate against bias against candidates that don’t fit the majority culture appearance. It is also important to challenge the current organisational governance that maintains the status quo. Finally, recognition that URGs should not be treated as a homogeneous whole is important30. By understanding and appreciating their differences, the appropriate measures and support can be offered, where not only is recruitment a problem but also retention19,30.

A critical factor in changing orthopaedic culture is for leaders in each country and region to model appropriate behaviour, be open to feedback, and hold others accountable for the change we need to see. It is valuable to slow down, listen, and do the work necessary to learn about the background and values of those who do not fit the historic orthopaedic surgeon stereotype.

The goal is a culture of mutual respect where everyone can thrive, and where barriers specific to gender and race don’t exist and a sense of belonging is created. We enable what we tolerate. It requires courage to push for change in a traditional culture, and it is necessary.

To realise the benefits of diversity, the diverse voices in an organisation must be valued and included. Diversity is often considered as being ‘invited to the party’, inclusion is being ‘asked to dance’ and belonging ‘dancing without inhibitions’. Even nations such as Estonia who have the world’s highest representation of female orthopaedic surgeons, the percentage still does not reach the 30% required to achieve culture change and realise the greatest benefits of diversity. Most underrepresented groups in orthopaedics continue to have representation well below 30%.

In conclusion, diversity enriches our orthopaedic organisations as more voices with differing views are heard. Greater diversity leads to increased innovation, attracts the top talent to trauma and orthopaedics, and drives better decisions in governance. Successful diversity strategies include increased visibility of women and underrepresented groups in organisations, mentorship and sponsorship, increased flexibility for the workforce and mitigating unconscious bias in selection and promotion. More importantly, greater representation of women and underrepresented groups in orthopaedics is critical if the field is to better mirror the societies in which surgeons practice.

IODA acknowledges the commitment of EFORT to diversity in trauma and orthopaedics through the opportunity to publish in EFORT Open Reviews. n

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

Please see WOW article and video on our Transient Journal celebrating and recognising pioneers in our field - the first women in orthopaedics in their country and the first women leaders of national organisations: www.boa.ac.uk/TJ-WOW.

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Features

Knife before wife, or so they say James Berwin

Knife before wife, or so they say. But what if you and your partner both have careers, and you want to start a family? In this modern day and age, is knife before life the only way?

A

head of the birth of our daughter, my wife and I considered the amount of time we would take off on parental leave. My wife is a plastic surgical trainee; I’m an orthopaedic trainee. We are at similar stages of training and are essentially on identical pay.

Given the equality in our professional lives, why then would it be fair to divvy up parental leave in anything other than equal measure?

James Berwin is a Specialist Trainee (ST8) in Trauma and Orthopaedic Surgery in the Severn Deanery.

Disclaimer: there are many ways to do parental leave. The choices you make are specific to your situation. This article is not designed to pass judgement on those choices, rather to explain what I did and why, in the hope that it may help others feel able to take the time they want on parental leave.

Why take shared parental leave?

The ‘Share the Joy’ campaign launched by the government to promote shared parental leave (SPL) states that less than 2% of eligible parents in the UK take up the opportunity1. The explanation for this low uptake is multi-factorial, and could include financial considerations, office culture and professional reasons. Whilst there are barriers to taking SPL, from my experience the balance is tipped firmly towards being overwhelmingly positive. Sadly, there are perceptions, firmly held by some, which may be the legacy of a generation for whom work-life balance was inconceivable.

Many of my senior colleagues have spoken of their regret in not spending more time at home watching their children grow up. “Cherish those early years, you don’t get them back”, they say. In their defence, they didn’t have a choice.

Shared parental leave was only made possible in April 2015. My hope for today’s generation of

30 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

young doctors is a positive culture change that is supportive of modern professionals trying to balance their careers with family life.

Burnout We are in the midst of a burnout pandemic.

The BOA tells us that current levels are at 58%, up from 40% in 20182. Burnout is characterised by feelings of being overextended and the depletion of one’s emotional and physical reserves. Poor work-life balance is a major contributor to burnout, which itself is an important contributor to attrition from surgical training programmes. This represents a loss of both financial investment and human capital and its prevention is therefore vital to protect our future workforce. Thankfully, I have not experienced burnout myself, but taking SPL during those early weeks and months of my child’s life may have helped prevent it.

Gender equality Female surgical attrition is a proportionately greater problem3, a fact illustrated by the decreasing numbers of women at increasing levels of the surgical hierarchy (women make up 55% of UK medical school graduates 4, 41% of core surgical trainees, 30% of surgical specialty trainees and 12% of surgical consultants)5. This is reflected in the corporate world with only 7% of UKs FTSE 100 companies being chaired by women6. One possible explanation for this phenomenon is that work and home life is not yet shared equally between partners on a societal level.

A conscious or subconscious bias appears to exist against colleagues who choose to take an extended period of parental leave or work

Features

“What much of society has failed to grasp is that the next step in improving gender equality is not just improving women’s ability to achieve at work – it’s improving men’s ability to achieve at home. Society is largely OK with women who have careers and want to start a family... far less common is the notion that men may also want to take an extended period of parental leave.” ability to achieve at work – it’s improving men’s ability to achieve at home. Society is largely OK with women who have careers and want to start a family. We understand that they will need to take time out of work to do this. Allowances are made. Far less common is the notion that men may also want to take an extended period of parental leave. That was a big part of what motivated me to do it. Why should my wife get the lion’s share of all that time spent with our baby? I wanted that too.

My wife, Susan, baby Annabel and me.

less than full time (LTFT)7. Women on the ‘mummy track’ perceive that they are taken less seriously at work or are viewed as less committed and are therefore given fewer opportunities. This may be a contributing factor towards the glass ceiling preventing women from reaching their professional potential. If it were normal for men and women to share parental leave equally, this bias would begin to dissipate. By achieving equality at home, you take a big step towards achieving equality at work.

Let’s address the perceived disadvantage of taking time out for parental leave. In the grand scheme of a 30+ year career: does anyone honestly believe that six months out will significantly impact one’s training and subsequent professional capability? Having been back at work for almost a year, I don’t

think it has. The positive impact that time out has had on my family, however, is huge. Taking SPL has reduced the impact of delayed career progression for my wife.

More importantly, by being around as a full-time Dad for those formative months of my daughter’s life, I feel as comfortable with ‘how my baby works’ as my wife does – her schedule, what she eats, how to comfort her, or where her swim nappies are! This means much of the mental load is shared equally between us and has proven to be an unexpected and valuable investment in my wife’s career and sanity going forward, extending far beyond the end of our parental leave.

What much of society has failed to grasp is that the next step in improving gender equality is not just improving women’s

I often wonder how many men would like to take SPL but feel they can’t for fear of judgement. Many guys I know talk about doing it, very few make the jump. The bottom line is that gender equality works both ways. To create a culture free from bias, more men need to take extended parental leave. Be part of that change.

What are you entitled to as a parent in your child’s first year of life?

In the first year after birth or adoption of your child, you are now entitled to 50 weeks of parental leave and 37 weeks of statutory pay to be shared between you and your partner. This is in addition to the two weeks of statutory maternity and paternity leave you each get. You can share those 50 weeks however you like and can choose to take it at the same time or separately. There are of course certain stipulations and rules. The BMA has a useful page on it8. >>

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 31

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Provided you have been with the NHS for 12 months or more, continuously, by the 11th week before the expected week of childbirth, parents are entitled to Occupational Maternity Pay (OMP). OMP is determined by the NHS and consists of eight weeks full pay, 18 weeks of half-pay, 13 weeks of Statutory Maternity Pay (SMP) and 13 weeks of unpaid leave. Your pay (or half-pay) is determined by your average salary over the eight weeks prior to the 15th week before the expected week of childbirth. SMP is £151.20 per week.

This is shared out between you if you overlap

your parental leave, so the total amount of leave and pay is the same regardless of how you split it up.

As of 1st April 2019, enhanced shared parental pay was made available to consultants, specialty doctors, associate specialists and junior doctors in Scotland. Full details can be found on the BMA website.

It’s important to remember that you can take Shared Parental Leave in Touch (SPLiT) days.

These enable you to go back to work for a day

or more at a time before your parental leave officially ends. They are designed to ease the transition back to work. A couple is entitled to 20 SPLiT days to be divided between you however you want. You are entitled to be paid at your basic daily rate minus any statutory or enhanced shared parental pay you are already receiving for that day. If a SPLiT day is worked in the full pay period of SPL (or during accrued annual leave, which is of course also paid at full pay), you are entitled a day-in-lieu following your return to work.

What did I do?

I took 22 weeks of SPL in addition to two weeks of statutory paternity leave and two weeks of accrued annual leave.

My wife and I decided to take our parental leave at the same time, and she went back to work eight months after our daughter was born. Many thought we were mad, pointing out that we’d have to fork out more on childcare and suggesting that my wife wouldn’t want to go back to work at eight months as it would be too soon. The best of the lot was one colleague who asked if we were just trying to have a jolly! (Those of you with small children will know that, whilst having a new baby is a wonderful time, it’s anything but a jolly!)

Like so many of the personal /professional lines that are crossed every day at work, the response to all those critics is “it is none of your damned business”. These are your rights as a new parent, end of story. It’s like those friends and family members who give unsolicited advice about how to care for your baby: thanks, but no thanks. Just like the technicalities of raising your child, how you choose to spend your time raising them is up to you. Carte blanche. Do it however you want. Subject to terms and conditions, of course.

What were the negatives?

The glamour of shared parental leave – taking out the nappy bin.

32 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

As I have alluded to, you will take a financial hit whilst on shared parental leave. Once you’re on statutory pay, you are facing a weekly combined budget of £151.20 per week. It did help that our parental leave coincided with the height of the COVID-19 pandemic and lockdown, so opportunities for spending money were thankfully limited, and I think it was worth it, not least because, in the grand scheme of the combined income my wife and I will make over the entirety of our careers, it’s peanuts.

Features

The other challenge was administrative.

Dealing with HR is difficult at the best of times, but as SPL isn’t common it was difficult to find someone who knew how it worked. I’ll be honest, it was a headache.

My advice would be to find out whether there is a member of HR who champions parental leave. Most trusts nationwide also have appointed consultant clinicians in a mentorship role to support trainees taking time out of training (SuppoRTT mentors).

They are generally easy to find and may be able to help with overcoming obstacles.

“It’s important to remember that you can take Shared Parental Leave in Touch (SPLiT) days. These enable you to go back to work for a day or more at a time before your parental leave officially ends.

They are designed to ease the transition back to work. A couple is entitled to 20 SPLiT days to be divided between you however you want.”

What were the positives?

I will cherish the six months I spent on shared parental leave for the rest of my life. My wife and I overlapped our leave.

We shared the good times and the difficult times. Whilst there were certain tasks only my wife could do, there was plenty I could do too. That felt good. There is no doubt that it has made life after parental leave easier too.

If I’m honest, I also experienced firsthand how boring (and at the same time exhausting!) looking after a newborn can be.

Those with recent experience of this will no doubt agree. But whilst it may not have been a jolly all the time, I imagine it was much more fun doing it together than doing it on your own.

Conclusion I recently heard the phrase, “you can’t be what you can’t see”. It refers to minority groups breaking into professional spheres or spaces that have historically lacked diversity.

Well, there you have it. A male orthopod who took some time out of training to look after his child. Not so exceptional when you say it like that. Especially when it’s what our female counterparts have been doing all along. n

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

Have you seen our parenthood guidance?

The BOA has compiled a comprehensive resource of guidance and information which can be viewed at www.boa.ac.uk/parenthood.

It wasn’t all sleepless nights and nappies. Annabel and I enjoying a mid-week bike ride.

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 33

Features

James Lind Alliance Priority Setting Partnership - ‘Top 10’ research priorities in foot and ankle surgery Foot and Ankle JLA PSP Steering Group

Jitendra Mangwani on behalf of the Foot and Ankle JLA PSP Steering Group

R

Jitendra Mangwani is a Consultant Orthopaedic Foot and Ankle Surgeon at University Hospitals of Leicester. He was appointed as Chair of the Scientific Committee of the British Orthopaedic Foot and Ankle Society in March 2021 and is an active member of the BOFAS council. He is currently leading British Orthopaedic Foot and Ankle Society-James Lind Alliance Priority Setting Partnership project.

JM thanks members of the steering group, survey and workshop participants.

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esearch prioritisation necessitates involving both patient and clinical stakeholders, as well as considering questions of feasibility. Traditionally, research on the effects of various treatments has overlooked the shared priorities of patients, carers and clinicians1. One approach successfully deployed in healthcare is that of the James Lind Alliance (JLA), a non-profit-making initiative partly funded by the National Institute for Health Research (NIHR). JLA Priority Setting Partnerships (PSPs) enable clinicians, patients and carers to work together to identify and prioritise the questions they would like to address through research2.

PSPs are typically supported by multiple stakeholders, often including funders, patient advocacy groups and research charities with an aim to address the mismatch between what researchers choose to research, and what patients, carers and healthcare professionals actually want to know. PSPs thus ensure that those most affected by a condition are involved in prioritising research3. There is evidence that PSPs can have a great benefit on patient care, clinical practice of clinicians and organisational culture2.

History The JLA is named after James Lind, the Scottish naval surgeon who discovered the cure for scurvy by employing early trial design theories. The James Lind Alliance (JLA) was established in 2004 by Sir Iain Chalmers (co-founder of the Cochrane Collaboration), Dr John Scadding (then Dean of the Royal Society of

Patient and carer representatives: Amanda Roberts, Steve Ingram Clinical representatives: Brigitte Scammell, Patricia Allen, Mark B Davies, Noelene Davey, Rebecca Kearney, Lyndon Mason, Stephen Lines, Nick Gallogly, Veena Patel Information specialist team: Melinda Hau, Lauren Thomson, Douglas Grindlay Project lead: Jitendra Mangwani James Lind Alliance Adviser: Katherine Cowan Project administrator: Jo Millard

Medicine) and Sir Nick Partridge (former Chair of INVOLVE). The original launch and aims of the PSPs were described in an article in The Lancet4. The JLA’s evolution during the years 2003-2013 (as part of the James Lind Initiative) is described in an article in the Journal of the Royal Society of Medicine.

The first PSP was conducted in Asthma in 20075 and since then the initiative has gone from strength to strength; with over 100 PSPs registered on the JLA website www.jla.nihr. ac.uk/priority-setting-partnerships.

Principles The JLA have a well-established process (www. jla.nihr.ac.uk/jla-guidebook) which is founded on uncertainties. “Patients and the public have a right to expect that research funders, researchers and health professionals will identify uncertainties about whether treatments or other interventions are doing more harm than good or whether one treatment is better than another, and should expect them to organise the research needed to reduce the most important of these uncertainties.” More details can be found in the

Features

JLA Handbook6. The JLA PSP process sets out to establish all relevant research questions in a disease area and narrows these down to a ‘Top 10 List’ used to prioritise research questions for future work/funding.

In order to start a PSP, the JLA should be contacted centrally in the first instance at jla@southampton.ac.uk to complete a readiness questionnaire. Gathering the right team is one of the first tasks; a guide to the roles is shown in Table 1.

Role

Example Tasks

JLA Advisor

• Chair meetings.

• Provide ad hoc support in use of the Guidebook.

• Provide support for data management process and interim priority setting exercise.

• Chair final priority setting workshop, with at least 2 other JLA Advisers to facilitate small group work.

PSP Lead

• Champion the PSP. • Ensure it is successfully promoted, completed and disseminated to funders.

PSP Co-ordinator

• Write and follow-up on action notes.

• Manage communications with the Steering Group, stakeholders and the community.

• Prepare a website.

• Communicate via Twitter.

• Develop the questions/survey and post online.

• Organise the priority setting workshop.

Information Specialist

• Organise the raw data from the initial PSP survey.

• Examine each submitted ‘uncertainty’ and allocate into categories with guidance from Steering Group.

• Liaise with the PSP Steering Group on work to identify relevant systematic reviews and guidelines, and any other relevant sources of evidence.

• Check the in-scope formatted questions against the evidence base.

• Prepare a long list of verified uncertainties for interim prioritisation.

Methodology James Lind Alliance methodology is a welldefined process and usually follows a pathway which includes; establishing a steering group with face to face or online meetings; an online/paper survey to gather uncertainties; organisation of responses and checking against up to date published evidence; interim priority setting to shorten the list of questions; a final workshop with a mixture of small and whole group discussions where all participants are present in person or online. The workshop brings together representatives from both the professional and lay communities who jointly refine the final top ten priorities. The JLA PSP process is outlined in Figure 1.

A PSP usually takes between 12-18 months to complete; however abbreviated processes have been published in the literature to condense this time, whilst adhering to JLA principles7. In recent years, the face to face elements of the PSP have been adapted to allow for remote options; keeping participants safe during the pandemic7 and in those with high infection risk8.

Following on from the process in Figure 1, the key is to disseminate and publish results of the priority setting exercise. This increases exposure of the priorities to potential funders and research teams; as well as feeding back to patients, carers, charities and health care professionals.

Figure 1: JLA PSP process.

Table 1: Guide to JLA PSP roles.

JLA PSPs in Trauma and Orthopaedics

The scope of the BOFAS JLA PSP was defined as:

In trauma and orthopaedics, there have been 13 registered PSPs so far; documented in Table 2.

1. Surgical treatments and injections for the treatment of foot and ankle conditions and injuries in adults (over 18yrs).

British Orthopaedic Foot and Ankle Society (BOFAS) JLA PSP BOFAS JLA PSP was conducted as part of the British Orthopaedic Association (BOA) research committee initiative. Foot and ankle conditions pose a particular challenge to the patients and their treating professionals due to a wide variety of conditions and the lack of high quality published evidence. This, in turn, introduces variation in clinical practice and indeed patient outcomes.

The PSP was conducted in accordance with guidance issued by the JLA and overseen by an independent JLA adviser. BOFAS JLA started in September 2019.

The initial survey was launched at the BOFAS annual meeting in November 2019.

2. Post-surgical rehabilitation or injection aftercare. >>

Broken Bones in Older People Broken Bones of the Upper Limb in People over 50 Common Conditions Affecting the Hand and Wrist Complex Fractures Early Hip and Knee Osteoarthritis Elbow Conditions Foot and Ankle Surgery Hip & Knee Replacement for Osteoarthritis Surgery for Common Shoulder Problems Revision Hip Replacement Revision Knee Replacement Paediatric Lower Limb Surgery Juvenile Idiopathic Arthritis Table 2: Registered PSPs in Trauma and Orthopaedics.

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Features

Figure 2: JLA PSP process.

Figure 3: Breakdown of respondents.

The PSP was conducted in line with the well-established JLA process (Figure 2).

A total of 198 people responded with 472 questions. The breakdown of patients, carers and healthcare professionals is shown in Figure 3.

Out of scope questions were eliminated. The remaining questions (330) were categorised and summary questions were generated which were verified against the published evidence. The interim survey was launched.

There were 291 respondents to the Interim Survey. The final workshop was carried out online on 13th July 2021. At the final prioritisation workshop, patients, carers and clinicians, using an inclusive facilitated approach developed by the JLA, agreed the final order of the 16 presented research questions in a series of three rounds of discussion and decision-making. The final top ten research priorities for foot and ankle surgery PSP focus on important aspects of interventions and rehabilitation in foot and ankle surgery (Figure 4). There were some inadvertent delays and changes in the process due to the COVID-19 pandemic, in particular use of online technology for steering group meetings and final workshop. This process was validated by the JLA team.

Declaration We declare no competing interests. This project was supported and funded by BOFAS. Pump priming funding was received from the BOA. n

Acknowledgements Thanks to BOFAS, BOA, Matt Costa, Rebecca Kearney and Linzy Houchen-Wolloff for their help and support.

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

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Figure 4: BOFAS JLA infographic with ‘Top 10’ research priorities in foot and ankle surgery.

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International

My experience of tragedy, disasters and war Amer Shoaib

The view through the windscreen of my vehicle is quite alarming. There are six armed men in the back of a pick-up in front of me, all carrying AK47 automatic weapons.

Amer Shoaib is a Consultant Trauma and Orthopaedic Surgeon at Manchester Royal Infirmary and Trafford General Hospitals with expertise in conditions affecting the Foot and Ankle. He served with the Royal Army Medical Corps in Bosnia, as well as providing humanitarian support in Haiti after the earthquake and in Syria, treating civilians caught up in the civil war. Amer runs a charity called Orthocycle which runs courses in the UK to train doctors in foot and ankle surgery, and also recycles medical equipment for use in less developed countries.

F

ortunately, they are here to protect me.

I am returning after a week of operating in Yemen, which is currently enduring a long running civil war. The injuries that I have seen are all related to weapons of war such as bullet injuries and bomb blast injuries. From the moment that we arrived, we could see men and women in the streets with crutches, negotiating their way through an obstacle course that is their daily life on the dusty streets. We are able to offer services not

Rebuilding and saving limbs You may wonder how I got here. Actually, this is exactly what I wanted to do when I went to medical school. Although I wanted to be an orthopaedic surgeon, I also wanted to work in other countries especially in low and middle income countries, treating people who might not otherwise have access to healthcare. I am able to have this alternative life mainly because I am an orthopaedic surgeon, and also because I have been able to take opportunities to gain surgical and non-surgical skills which are necessary to live and work in an austere environment.

I specialise in orthopaedic limb reconstruction surgery and foot and ankle surgery. This surgical background equips me with the skills required to deal with the vast majority of limb trauma, and this is what I do in my day job as a Consultant at the Manchester Royal Infirmary.

Figure 1: Being escorted in the Middle East.

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locally available because we have brought a lot of surgical equipment with us, as well as some specialist experience in dealing with complex fractures, deformities and bone infection.

Limb reconstruction surgery often involves the use of external fixators rather like a scaffold around an injured limb and I use these on a daily basis in the UK. These are a versatile method for the treatment of trauma, the sequelae of trauma and also ideal for the treatment of acute and chronic war injuries.

International

At home and abroad

Figure 2: Casualty of war, we frequently used Ilizarov method.

The Ilizarov external fixator was developed after World War II in the then Soviet Union, in order to deal with large numbers of disabling war injuries, that had previously failed to improve with conventional treatments. This treatment came to European civilian practice in the 1980s and has come full circle to be used in the treatment of war injuries again.

My work in the UK is also quite satisfying, dealing with complex fractures, bone infection and deformities. It involves a wide spectrum of orthopaedic implants and techniques from internal fixation, external fixation, arthroscopy, osteotomies, joint replacement and soft tissue reconstruction. Most patients have had multiple previous operations, and need psychological and social aspects of their care managed as well as the obvious surgical problems. Working in a major trauma centre puts me at the heart of what I enjoy, dealing with intellectually stimulating tertiary referral elective problems and equally demanding traumatic injuries. I don’t have a dull day, as every day brings fresh trauma and new challenges.

In 2017, my colleagues and I had to deal with casualties from the Manchester Arena bombing. Those of us with humanitarian experience found ourselves operating on the same horrific injuries we have seen abroad in the UK. Most injuries were orthopaedic, this is often the case with war injuries. The injuries suffered by those injured took several weeks to manage initially, and we still see some of these patients over four years later, still suffering physically and psychologically. It was possible for us to manage the injuries because we had seen and treated a lot of similar injuries before in other countries. In fact, we learned some new surgical tactics from the Syrian civil war, which helped with the emergency management and which we have integrated into our clinical practice.

“I have found that orthopaedic surgeons in many less developed countries have been glad to have someone to work with, discuss cases with and become true friends. It is a privilege for me to meet those with real professional difficulties.

I know I will be going home whereas they are faced with an infinite amount of difficult clinical work with limited resources.”

As an orthopaedic specialist, I have been able to work in austere environments, several wars and also natural disasters such as the earthquake in Haiti. There is a real paucity of orthopaedic surgeons in many countries, for example, there are more in Manchester than in four countries in East Africa. I have found that orthopaedic surgeons in many less developed countries have been glad to have someone to work with, discuss cases with and become true friends. It is a privilege for me to meet those with real professional difficulties. I know I will be going home whereas they are faced with an infinite amount of difficult clinical work with limited resources.

However, there are other surgical and nonsurgical skills required to allow safe working in warzones and low/middle income countries. There is always a security risk to me, my patients and my team, whenever we work abroad, and there is a responsibility to mitigate security and health risks when deploying. It is necessary to have the correct training to allow us to be able to manage problems such as basic personal safety to health risks. The knowledge required may be how best to hide if you are in a vehicle that comes under fire, how to avoid being a target for robbery in any environment, and how to take relevant health precautions to avoid getting ill while deployed which would render you a burden rather than an asset. >>

Figure 3: Making friends in Tanzania.

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International

I help to run a charity called Orthocycle (www.orthocycle.org).

This charity collects the single use items that are usually consigned to landfill after one patient use.

This includes Aircast boots, knee braces, orthotics and some surgical equipment. These are not used again in the UK due to infection control risks, but in less privileged countries, the risks of infection control are dwarfed by the risks of not having an orthotic at all. These orthotic devices are often used repeatedly, until they fall apart, and so many patients benefit from their use.

Surgical equipment such as out of date implants, out of date sutures and gloves can be used quite safely. Often implants are not re-sterilised because in the UK it is not cost effective.

Donated surgical equipment allows us to work in partnership with other countries, to deliver surgical training to fellow surgeons abroad, who may not have had the opportunity to have worked with external fixation in the same way. We also offer training in the UK on external fixation techniques and cadaveric training in foot and ankle surgery. This raises funds for the charity and also delivers quality training to UK graduates – another of the charities objectives.

trained to form part of a coordinated response to an international disaster either natural or man-made. They offer training to certify competence to work in these types of situations. UK-Med are a Manchester based charity that work with other similar groups to provide the manpower and training for such UK EMT missions.

How to get involved I am sure that there are many others who harbour similar ambitions as I did as a medical student and junior Figure 4: Funding of charitable work through educational courses. doctor. I didn’t find it straightforward to gain the right experience. I believe that there are more opportunities now for The routes to open these opportunities junior doctors to develop relevant skills to involve attending courses, working with pursue this type of work. relevant organisations and applying for out of programme training opportunities.

“Donated surgical equipment allows us to work in partnership with other countries, to deliver surgical training to fellow surgeons abroad, who may not have had the opportunity to have worked with external fixation in the same way.”

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There are many courses available to gain the relevant knowledge, skills and attitudes to be able to work outside the UK. I have attended the Medical Care of Catastrophes course at the Society of Apothecaries in London, but there are also specific surgical skills courses like the David Nott Foundation Hostile Environment Surgical Training (HEST) course and the RCS Surgical Training for Austere Environments (STAE).

These courses emphasise safe treatment and also thinking outside the box.

Working with appropriate organisations can allow the development of skills that are required to work and lead in austere environments. In the UK, there is a government funded group, the UK Emergency Medical Team (UK EMT), that is

Working for Médecins Sans Frontières (MSF) or the International Committee of the Red Cross (ICRC) is another way to gain experience, but I found that during my training, it didn’t fit in with my life to work in a surgical capacity.

These organisations want fully qualified consultants rather than trainees. The training environment has changed in recent years, and out of training programme experience is fortunately much more valued now. There are opportunities to work in less developed countries, which tie into existing projects.

Another option is to join the reserve or regular forces. This allows the development of some of the skills required, and the opportunity to deploy in a relatively protected manner. There is also an emphasis on teamwork. However, this may not suit everyone’s personal lives, ethical stances or motivation.

Ethical dilemmas may exist, if there are future conflicts, perhaps involving deploying to countries like Afghanistan or Iraq.

Nothing can compare to the learning curve from deployment on a mission – there are always new challenges to learn to overcome.

I couldn’t see myself doing anything else apart from orthopaedic surgery. I have the privilege of witnessing improvements in the quality of life of my patients, both in the UK and abroad, something that I find is immensely satisfying. n

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Trainee

Demonstrating commitment to specialty for the Core Surgical Training self-assessment portfolio for under £20 Sarah Choi, Daphne Chia and Ignatius Liew

Clare is an enthusiastic, imaginary Foundation Year 2 doctor applying for Core Surgical Training (CST). As the CST application process is highly competitive, she knew she had to maximise her portfolio points to secure an interview. To her delight, she found that she scored full points on the courses and conferences section (7 out of 7 points), for under £20!

D Sarah Choi is a Core Surgical Trainee in South Wales and is a BOTA Junior Representative. She is also a trainee representative for the CST advisory committee (CSTAC).

uring medical school, Clare was inspired by her elective in orthopaedics and signed up for a British Orthopaedic Association (BOA) membership (£17/year).

This allowed her to join the British Orthopaedic Trainee Association (BOTA) for free. She attended the BOTA congress, BOA Annual Congress and the Royal College of Surgeons (RCS) Future Surgery Show all for free, achieving 3 out of 3 points for conferences. While attending the BOTA Congress, she also attended the Medical Student Course (free, £10 deposit refunded on attendance). In her foundation training, she attended three other courses for free: The National Catheter Course, RCS Systemic Training in Acute Illness Recognition Course (free with the RCS promotion as of January 2022) and the Rouleaux Club: So you want to be a vascular surgeon, maximising 4 out of 4 points for courses.

All Clare had paid for was her BOA membership as a medical student (£17)!

Surgery is a competitive field to enter, requiring a robust portfolio to be considered for a Core Surgical Training (CST) interview.

The candidate needs to show dedication and commitment to surgery in their portfolio to be shortlisted for interviews, and further showcase their dedication and competencies during the interview process. This requirement for dedicated, surgically driven candidates, is

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reflected in the new CST recruitment selfassessment guide. The 2022 portfolio criteria introduced changes in the distribution of points and weighting of sections, especially in the ‘commitment to speciality’ section. Up to 7 points are awarded for attending surgical courses and conferences; 4 for courses and 3 for surgical conferences. This might at first seem like an expensive way to show commitment, however we would like to stress that there are several surgical courses and conferences that can be attended for free or for under £100. We have gathered this information from first-hand experience and information shared by fellow junior doctors.

Courses and conferences Listed in Tables 1 and 2 are surgical courses and conferences for Medical Students and Foundation Doctors for under £150. There are various Royal College of Surgeons or CPD approved events run regionally, which are often free or a low cost to attend. The best time to start gathering evidence of commitment is whilst a medical student. This is when courses and conferences are the cheapest or even free. However, there are also many options available for Foundation Year Doctors. Courses or conferences need to be accredited with one of the Royal Colleges of Surgeons, an international or national surgical organisation or regional deanery. Alternatively, courses require accreditation with CPD points to be accepted. >>

Trainee

Daphne Chia is a Foundation Year 1 Doctor in the East of England with an interest in medical education. She is a member of the RCS Women in Surgery Forum.

Organiser

Course

Cost (Student)

Cost (FY)

ASiT

Foundational skills in surgery

FREE (members)* / £50 (non-members)

FREE (members)* / £50 (non-members)

ASiT

Preparing for a Career in Surgery (P4CS)

FREE (members only)*

FREE (members only)*

ASiT

Foundational skills in Mentoring

FREE (members only)*

FREE (members only)*

ASiT

Pre-conference courses (various specialties)

£90

£90

BOTA

Medical Student Course

£10 (refunded on attendance for BOTA/BOA member)*

-

National Catheter Education Programme

Online Course

FREE

FREE

RCSEng

Surgical Skills for Students and Health Professionals

£99

£99

RCSEng

Systematic Training in Acute Illness Recognition and Treatment (START)

£139.50

FREE / £139.50 (Limited FREE spaces for FY1s promoted by RCS occasionally)

Rouleaux Club

So you want to be a vascular surgeon

FREE

FREE

Table 1: Surgical courses available to Medical Students and Foundation Doctors.

Regional RCS affiliated courses e.g. Wales include: • RCSEd: South Wales ENT Emergency Skills Course £20 • RCSEd: South Wales Orthopaedic and Trauma Showcase £15 • RCSEng: Orthopaedic Evaluation of X-rays Course £40.

Ignatius Liew is a Specialist Registrar in East of England Deanery with an interest in lower limb trauma and knee reconstruction. He serves currently as Webmaster for the British Orthopaedic Trainee Association.

Organiser

Conference

Cost (Student)

Cost (FY)

ALSGBI

Annual Conference

FREE (members)*

FREE (members)*

ASIT

Annual Conference

£89

£129

BOTA

Annual Congress

FREE (members)*

FREE (members)*

BOA

Annual Congress

FREE (members)*

FREE (members)*

British Transplant Society

Annual Congress

£63.60

£99

Duke’s Club

Educational meeting

FREE

FREE

Herrick Society

Education Day

FREE

FREE

RCSEng / ASiT

Future Surgery Show

FREE

FREE

RCSEd

Student and Foundation Years Research Symposium

FREE

FREE

RCSEd

Annual Audit & QI Symposium

£35

£110

RSM

Future Orthopaedic Surgeons Conference

£18 (member) / £33 (non-member)

£34 (member) / £63 (non-member)

SFO (ENT)

Annual Conference

£35 (member)* / £55 (non-member)*

£35 (member)* / £55 (non-member)*

Table 2: Surgical conferences available to Medical Students and Foundation Doctors.

*Membership costs in January 2022: ASIT Medical Student £40, Foundation Doctor £60. ALSGBI Medical Student £33, Foundation Doctor £88. BOA/BOTA Medical Student £17, Foundation Doctor £30. RCSEd Affiliate Membership Medical Student £10, Foundation Doctor £15. SFO Medical Student £20, Foundation Doctor £20.

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 43

Trainee

BOTA BOTA stands strong in promoting surgical training to all promising candidates irrespective of their background. The changes in the CST self-assessment should not be a barrier for potential candidates. Within the section of ‘Commitment to Speciality’, operative experience and surgical experience can be gained during medical school and foundation training without any cost. The MRCS Part A exam costs £550 and scores candidates four points for passing it. However, it is not a prerequisite for the CST applications and can be taken during CST. The authors believe that passing the MRCS Part A exam shows immense dedication to surgery and is a fantastic achievement that should be acknowledged.

This article hopes to reassure candidates and trainers that there are many courses and conferences available at a low cost or for free.

We hope this article provides suggestions as well as tips and tricks to boost surgical portfolios prior to the interview, all without breaking the bank!

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“Surgery is a competitive field to enter, requiring a robust portfolio to be considered for a Core Surgical Training (CST) interview. The candidate needs to show dedication and commitment to surgery in their portfolio to be shortlisted for interviews, and further showcase their dedication and competencies during the interview process.”

Disclaimers Please note that availability of courses and conferences may have changed since publication of the article. To the best of our knowledge, prices of courses and conferences are accurate as of time of publication. Attending the suggested courses will not guarantee a CST invitation to interview and/or position through the competitive process. There are no financial disclosures to declare. Miss Sarah Choi is a member of the CST advisory committee and was involved in creating the 2022 CST selfassessment guide for CST selection. n

Medico-legal

BOA medico-legal roundup Simon Britten, Chair of the BOA Medico-legal Committee

It has been a busy 12 months for the BOA Medico-legal Committee.

A welcome return to face-to-face conferencing saw two very well attended medico-legal sessions at the BOA Congress in Aberdeen.

G Simon Britten is a Consultant Trauma & Orthopaedic Surgeon in Leeds specialising in lower limb reconstruction and he is the current Secretary of the British Limb Reconstruction Society. He has been awarded the taught degree of Master of Laws with Distinction in Medical Law and Ethics by De Montfort University Leicester. He is Chair of the BOA Medico-legal Committee and faculty member of the BOA course ‘Law for Orthopaedic Surgeons’.

rey Giddins ran a great session on ‘Guilty or not guilty’ with cross examination of experts in clinical negligence scenarios by the not to be trifled with Bertie Leigh. The second session looked at some of the practicalities of engaging in medico-legal practice, with valuable talks from orthopaedic experts Charlotte Lewis, Jacqui McMillan, Deborah Eastwood and David Warwick, and from advocate Jan McCall. Jo Round presented on the topical issue of gender balance in medico-legal practice. 8% of BOA home members are women and this gender imbalance is amplified in medico-legal practice, where only 1% of orthopaedic experts listed in UK registers are female. Jo cited lack of exposure to medico-legal work during training, lack of a suitable mentor or role model, and perceived difficulties with work-life balance as dissuading factors for taking on such work.

qualified and experienced in medical law, and a senior advisor from one of the defence organisations. Topics covered include consent, gross negligence manslaughter, court etiquette, patients who refuse blood transfusion on religious grounds, coroner’s law and inquests, clinical negligence, and the pitfalls of social media for doctors.

Gender balance in medico-legal practice was published in the medico-legal section of JTO, along with other articles which considered the coming together of COVID-19, surgical rationing and consent post-Montgomery; an analysis by the MDU of causes of negligence claims, particularly delayed diagnosis, surgical complications and omissions in the consent process; and current medico-legal considerations in the orthopaedic management of Jehovah’s Witnesses. These articles are available on the Medico-legal section of the BOA website – www.boa.ac.uk/medico-legal-articles.

Going forward into 2022 we are preparing for the medico-legal sessions at Congress in Birmingham. We are hoping to cover discussion of the Medco system, set up to facilitate the sourcing of medical report providers for low value personal injury claims in road traffic collisions. We also hope to have an introduction to medico-legal reporting session, and exploration of two different tipping points – when can problematic surgery flip from a civil matter to a criminal matter?

And separately, the point at which crown indemnity may be withdrawn in NHS cases.

We are also working with the BOA Trauma Committee looking at developing a BOAST guideline on Consent in Trauma.

Shyam Kumar has worked hard to collate additional medico-legal resources for members on the BOA website, including useful advisory documents from NHS Resolution, the MDU, the Law Society, and the GMC, including their updated guidance on consent. They can be found alongside relevant articles from the JTO and GIRFT – www.boa.ac.uk/medico-legal-resources.

The new BOA educational course ‘Law for Orthopaedic Surgeons: Avoiding Jeopardy’ is now up and running. Faculty members for the one day course include barristers, coroners, surgeons

We aim to run the course every nine months, alternating between online and face-to-face.

It is anticipated that an extra topic will be added, covering the work of the regulator via the Medical Practitioners Tribunal Service and GMC. In addition to the course delivery day with case based discussion format, the course also gives access to faculty’s online recorded talks as pre-course educational materials. Further details about the course can be found at – www.boa.ac.uk/law-for-orthopaedic-surgeons.

On behalf of the BOA we would like to thank the outgoing Chair David Warwick, under whose organised and calm leadership the BOA’s medico-legal portfolio has flourished; and thanks are also due to Grey Giddins and Simon Gregg-Smith for their sterling contributions. Finally we welcome Caroline Hing, Sameer Singh and Steve Hepple to the Committee and we are very much looking forward to working with them. n

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Subspecialty

Orthobiologic injectables; Yes-No-Don’t know Mark Bowditch

Can a simple ‘jab’ be the answer for all evils? Well so it seems with COVID. Given this success, who would blame the public for looking for ‘magic injectable’ solutions in other areas of healthcare.

Mark Bowditch is a Consultant and Divisional Clinical Director for MSK & surgical specialties at the East Suffolk and North Essex NHS Foundation Trust.

Mark’s specialist interests are in surgery of the knee and all levels of surgical education and he is currently the Head of School of Surgery in the East of England.

Mark is BOA Honorary Treasurer, Research Committee Executive Vice Chair, Elective Care Review Lead and Executive Lead on the Orthobiologic Injectables SLWG.

C

OVID disruption has led to horrifyingly long orthopaedic waiting lists, particularly arthroplasty for end stage arthritis.

We all know that increased capacity and access is needed but this requires much more than a simple point-of-care ‘jab’.

Patients, patient groups and perhaps even BOA members rightly ask is there a quick alternative – such as a ‘magic jab’ that could reduce the symptoms whilst they wait or even reverse the condition and stave off invasive surgery. Whilst this might be an ask too far for end stage bone on bone arthritis, what about those much earlier in the disease process, the so called ‘treatment gap stage’ or with slow healing tendon problems.

Ever since medical school (light years ago…) the future was always said to be ‘an injection of stem cells’. Science, as we have seen with the COVID vaccine does find the answers and whilst stem cell treatments have advanced significantly in many areas, it is perhaps unclear to many of us in ‘routine clinical orthopaedic practice’, just how far they have come in MSK. The term ‘stem cell’ is banded around somewhat glibly for a number of, what we have termed, orthobiologic injectables, sometimes without a clear understanding of whether they include or have any relationship to true stem cells. It is a fast changing and advancing area.

Versus Arthritis and BOA

members have asked for help in clarifying where we are with respect to potential treatments so that we can advise knowledgeably and signpost appropriately when our patients ask questions.

It is important that we do so with as much evidence as possible and support those conducting high quality trials to give us those answers. Promoting such treatments without this scientific rigour leads potentially to stifling regulation and the ‘baby is thrown out with the bath water’. New regulation of such point-ofcare injectable treatments is on the horizon from the MHRA and these orthobiologics are definitely in scope.

The BOA held a well-attended session at Congress 2021 and we are grateful to Ansar Mahmood, Andrew McCaskie, Iain Murray and co-authors for sharing their extensive knowledge and experience in the following articles. Thanks too, to Phil Turner’s (BOA member and Past President) description of his very own personal treatment dilemma illustrating the ‘hope’ patients might have in choosing ‘an MSK jab’.

“Patients, patient groups and perhaps even BOA members rightly ask is there a quick alternative – such as a ‘magic jab’ that could reduce the symptoms whilst they wait or even reverse the condition and stave off invasive surgery.”

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Our duty as doctors is to help patients in shared decision making with guidance from high quality evidence however ‘magic’ a new treatment may sound. The BOA has produced an information document on Injectable Orthobiologic Treatments for Osteoarthritis which we hope will inform patients and clinicians, available at www. boa.ac.uk/orthobiologics. n

Subspecialty

Orthobiologics: Scientific background Iain R Murray, Martyn Snow, Cosimo De Bari and Andrew W McCaskie

T Iain Murray is a Consultant Orthopaedic Surgeon at Edinburgh Orthopaedics and Honorary Senior Lecturer at The University of Edinburgh. He is a member of the Orthopaedics and Musculoskeletal Therapies Committee for the International Society for Cell and Gene Therapy (ISCT) and the Biologics Association. He is an Associate Editor of the Bone and Joint Journal (BJJ).

issue engineering is a term popularised in the 1990s and familiar to orthopaedic surgeons, developed on a paradigm of interplay between cells, materials, and molecules. The paradigm is a useful way to consider regenerative medicine, as it is thought that many future therapeutics will be developed from combinations of the three areas e.g. a scaffold impregnated with specific molecules can be seeded with cells. The term orthobiologics can be considered in this context, with a definition based around ‘ortho’, meaning an application in musculoskeletal tissue, and ‘biologic’ which is typically used to mean a naturally occurring substance with the ability to heal.

However, the term should not be confused with a ‘biologic medicine’ or disease modification therapy.

Cells Embryonic and induced pluripotent stem cells In the natural world, the extraordinary capability of a stem cell to form nearly all cells in the developing human (pluripotency) coupled with the ability to self-renew is clear and can be illustrated with two examples: Embryonic Stem Cells (ESCs) and Induced Pluripotent Stem Cells (iPSCs). The former are found in the inner cell mass of the blastocyst and are key to development (Figure 1); the latter are somatic cells that in the laboratory have been reprogrammed back into a pluripotent state1,2.

The biological capability of stem cells has huge therapeutic and regenerative potential, but in relation to orthopaedics ESCs and IPSCs are currently not close to use in patients in the clinic.

Figure 1: Schematic showing embryonic stem cells with characteristics of self-renewal and pluripotency. Adapted from ‘Human Embryonic Stem Cell Differentiation’, by BioRender.com (2022). Retrieved from https://app.biorender.com/biorender-templates.

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Mesenchymal stem and stromal cells Early studies on cells isolated from bone marrow identified a population of cells with the ability to differentiate into multiple cell types relating to musculoskeletal tissues; hence, the terminology ‘mesenchymal stem cells’ or ‘MSCs’ was proposed3.

Following the identification of similar cell populations in other connective tissues e.g. fat, the International Society for Cellular Therapy (ISCT) proposed changing the name to ‘mesenchymal stromal cells’ (multipotent connective tissue

cells of any organ), while retaining the acronym MSC, recognising that these populations rarely met defining criteria of true ‘stem’ cells. Their proregenerative effects after administration in vivo likely arise through the release of mediators, for example immunomodulatory, rather than engraftment and differentiation (Figure 2). In the remainder of this article the abbreviation MSC refers to Mesenchymal Stromal Cell. The ISCT also introduced minimum defining criteria that related to MSC characteristics; these criteria include cell adherence to plastic in culture, the presence or absence of certain cell surface markers, and the in vitro capacity to differentiate into osteoblasts, chondrocytes, and adipocytes4. More recently, the ISCT published a position statement on nomenclature5, which suggests the tissue of origin should also be provided e.g. bone marrow, adipose, synovium or umbilical cord, and that “Unless there is rigorous functional evidence in vitro and in vivo to demonstrate the self-renewal and differentiation properties, the term mesenchymal stem cells should not be used.”

Cell nomenclature and its importance Understanding the behaviour of a cell and then accurately describing the cell to reflect this behaviour is key to avoid confusion, and this also applies to stem cells. The self-renewal ability and pluri- or multi-potency of ESCs, iPSCs or some adult stem cell populations such as haematopoietic stem cells are not generally attributable to cultured mesenchymal stromal cell populations. Attention has been drawn to the potential for confusion over the term ‘stem cell therapy’ when applied to MSCs, and the term ‘stem cell’ in the setting of orthobiologics is now discouraged6, 7. Improved descriptions have now been proposed in relation to D—Donor, O—Origin tissue, S—Separation Method, E—Exhibited Characteristics (including potency), S—Site of Delivery, which can be abbreviated to DOSES8.

Cell therapy In addition to inconsistent nomenclature, heterogeneity in cell preparation (e.g. cell number, identity, purity) and manufacture (e.g. cultured or not) makes research evaluating the effectiveness of these products difficult, and the comparison across studies is at times impossible9. Systematic reviews have reported a high risk of bias within previous studies10.

Subspecialty

Martyn Snow is Professor of Regenerative Medicine at Keele University and Honorary Professor of Chemical engineering at the University of Birmingham. He is a Consultant Knee and Shoulder Surgeon at The Royal Orthopaedic Hospital in Birmingham and The Robert Jones and Agnus Hunt Hospital in Oswestry. His clinical and research interests include cartilage repair and joint preservation.

Cosimo De Bari holds a Clinical Chair in Experimental Medicine and Rheumatology at the University of Aberdeen. He is Director of the Aberdeen Centre for Arthritis and Musculoskeletal Health (a EULAR Centre of Excellence in Rheumatology) and Deputy Director of the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre.

Andrew McCaskie is Professor of Orthopaedic Surgery and Head of the Department of Surgery, University of Cambridge, with a clinical interest in lower limb. He is Director of the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre and an Editor of Bailey and Love’s Short Practice of Surgery.

MSCs can be broadly categorised on how they are extracted, processed, or manufactured. In general, we can consider two broad categories. In the first, autologous tissue is harvested, prepared, and delivered within the same visit (‘point of care’). Such preparations have generally undergone relatively limited processing (minimally manipulated) and include concentrate of bone marrow aspirate, commonly abbreviated to BMAC, stromal vascular fraction (SVF) and microfragmented adipose tissue (MFAT). The preparations are heterogenous, with MSCs making up only a small fraction of the total cell content. In addition, what is delivered to individual patients is rarely characterised.

This group of preparations are widely available as orthobiologic cell treatments in the UK, largely because of their relatively low cost and ease of delivery11.

Figure 2: Mesenchymal stromal cell characteristics including in vitro tri-lineage differentiation and immunomodulation. Created with BioRender.com.

The second broad category is culture expanded cells.

This features a period of manufacture in specialist GMP laboratories, where cells are cultured and expanded in number, which for autologous products, requires two patient interventions, the first for harvest and the second for delivery. Cells grown in a GMP facility can benefit from characterisation using markers on the cell surface and by assessment of their functional behaviour e.g., trilineage differentiation.

This information can then be used to precisely quantify what is delivered to the patient, ensuring quality and safety before release to the clinic.

Regenerative therapies and orthobiologics, represent an exciting field with many potential therapeutic options available to the surgeon. In common with other new treatments, it is important to consider not just the class of therapy but also how it works in relation to the target condition, who should receive the treatment, how it is manufactured and administered, and how effective and financially viable it is. Recent advances in science enhance our understanding of disease pathogenesis, mechanism of action of treatments, and patient stratification tools, which together with our ability to conduct clinical trials, will facilitate the acquisition of clinical evidence and subsequent impact. n

Autologous blood products

Acknowledgements

Products derived from autologous whole blood are attractive due to the presence of cells and factors with pro-regenerative activity, the ease of access, public acceptance, and the low morbidity of venepuncture. Products currently available include a spectrum of Platelet-Rich Plasma (PRP) and autologous anti-inflammatory preparations (AAIs).

CDB, AWM and MS acknowledge the financial support of Versus Arthritis through the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre (Grant 21156).

The term PRP refers to an autologous blood preparation with a platelet concentration that is higher than baseline and is achieved through differential centrifugation with collection of the PRP from above the white blood cell layer. Platelets are known to release growth factors and cytokines that are able to induce pro-regenerative attributes in laboratory studies, including promoting proliferation and recruitment of cells, modulation of inflammatory responses, and stimulation of new blood vessel formation12. PRP represents a broad spectrum of preparations containing platelets, leukocytes, red cells, and over 300 different growth factors and cytokines13.

Furthermore, the bioavailability of growth factors delivered depends on individual patient characteristics including comorbidities, platelet concentration, levels of leukocytes and red cells, and among other variables the method of activation14. PRP preparations are generally safe15. With increasing appreciation that many of the anti-inflammatory factors within blood arise from leukocytes rather than platelets, strategies focussing on concentrating leukocytes or the anti-inflammatory factors they release have been developed. These include autologous anti-inflammatory (AAI) preparations and platelet poor plasma (PPP).

Selected references l Takahashi K, Yamanaka S. Induction of pluripotent

l

l

l

l

stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell.

2006;126(4):663-76.

Viswanathan S, Shi Y, Galipeau J, et al.

Mesenchymal stem versus stromal cells: International Society for Cell & Gene Therapy (ISCT®) Mesenchymal Stromal Cell committee position statement on nomenclature. Cytotherapy.

2019;21(10):1019-24.

Caplan AI. Mesenchymal Stem Cells: Time to Change the Name! Stem Cells Transl Med. 2017;6(6):1445-51.

Murray IR, Chahla J, Safran MR, et al.

International Expert Consensus on a Cell Therapy Communication Tool: DOSES. J Bone Joint Surg Am. 2019;101(10):904-11.

Mussano F, Genova T, Munaron L, et al. Cytokine, chemokine, and growth factor profile of plateletrich plasma. Platelets. 2016:27(5):467-71.

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

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2

YEARS

DUROLANE POWERFUL & LONG-LASTING PAIN RELIEF

Long-Term Outcome Measures of Repeated Non-Animal Stabilized Hyaluronic Acid (DUROLANE) Injections in Osteoarthritis: A 6-Year Cohort Study with 623 Consecutive Patients.

SUMMARY OF RESULTS

DUROLANE Durability • A single injection of DUROLANE was shown to last up to 6-18+ months.

• 4 repeat injections were equally durable up to 4.5 years.

DUROLANE Longevity • Pain relief from hyaluronic acid injections was sustained for an average 466.8 days.

DUROLANE’s Voice of the Patient* • 76.1% of the patient satisfaction survey participants indicated that their pain relief was sustained for between 6 to more than 18 months post-treatment.

• 65% of the patients would recommend DUROLANE for OA.

• 65% of patients after their first injection felt significant relief from their OA symptoms.

• 81% of patients after their second injection felt significant relief from their OA symptoms.

*Patient experience and satisfaction survey completed by 233 study participants.

To learn more about DUROLANE, please visit our website: DUROLANE.com or visit bioventusacademy.com to view our educational webinars.

You can also access the full study by scanning the QR code at right:

2

YEARS

DUROLANE POWERFUL & LONG-LASTING PAIN RELIEF

Long-Term Outcome Measures of Repeated Non-Animal Stabilized Hyaluronic Acid (DUROLANE) Injections in Osteoarthritis: A 6-Year Cohort Study with 623 Consecutive Patients.

Georgia Carney Joint Health Institute – Melbourne, Australia Faculty of Medicine, Dentistry and Health Sciences – The University of Melbourne, Parkville, Victoria, Australia

Andrew Harrison Bioventus International – Netherlands

Jane Fitzpatrick Joint Health Institute – Melbourne, Australia Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne – Parkville, Australia Australasian College of Sport and Exercise Physicians – Melbourne, Victoria, Australia Carney G, Harrison A, Fitzpatrick J. Long-term outcome measures of repeated non-animal stabilized hyaluronic acid (Durolane) injections in osteoarthritis: a 6-year cohort study with 623 consecutive patients. Open Access Rheumatol.

2021;13:285-92. doi:10.2147/OARRR.S331562

STUDY PURPOSE To determine the duration of symptom relief following repeated administration of intra-articular hyaluronic acid (HA) injections for osteoarthritis (OA)

PRIMARY OUTCOME Length of symptom relief following repeated administration of DUROLANE HA injections for OA.

SECONDARY OUTCOME To determine patient satisfaction with the procedure.

REFERENCE: Carney G, Harrison A,** Fitzpatrick J.** Long-term outcome measures of repeated non-animal stabilized hyaluronic acid (Durolane) injections in osteoarthritis: a 6-year cohort study with 623 consecutive patients. Open Access Rheumatol.2021;13:285-92. doi:10.2147/OARRR.S331562 ** AH is an employee of Bioventus. JF reports grants from Joint Health Institute Ltd, during the conduct of the study; personal fees for consultancy from Bioventus Inc, grants, personal fees, non-financial support supporting clinical trial from Zimmer Biomet and Orthocell; consulting fees from Novartis, outside the submitted work. The authors report no other conflicts of interest in this work.

DUROLANE (3 mL): Argentina, Australia,* Brazil, Chile, Colombia, EU,* India, Jordan, New Zealand,* Russia, Switzerland,* Turkey,* United Arab Emirates: Symptomatic treatment of mild to moderate knee or hip osteoarthritis. In addition, DUROLANE has been approved in Australia, EU and New Zealand for the symptomatic treatment associated with mild to moderate osteoarthritis pain in the ankle, shoulder, elbow, wrist, fingers, and toes.

Mexico: Symptomatic treatment of mild to moderate knee osteoarthritis.

Taiwan: Treatment of pain in OA of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics, e.g., acetaminophen.

Canada*: Symptomatic treatment of mild to moderate knee or hip osteoarthritis. In addition, DUROLANE has been licenced for the symptomatic treatment associated with mild to moderate osteoarthritis pain in the ankle, fingers and toes. *DUROLANE is also indicated for pain following joint arthroscopy in the presence of osteoarthritis within 3 months of the procedure.

Bioventus, the Bioventus logo, and DUROLANE are registered trademarks of Bioventus LLC. ©2022 Bioventus LLC

SMK-004233

02/22

Subspecialty

Iain Murray is a Consultant Orthopaedic Surgeon at Edinburgh Orthopaedics and Honorary Senior Lecturer at The University of Edinburgh. He is a member of the Orthopaedics and Musculoskeletal Therapies Committee for the International Society for Cell and Gene Therapy (ISCT) and the Biologics Association. He is an Associate Editor of the Bone and Joint Journal (BJJ).

Martyn Snow is Professor of Regenerative Medicine at Keele University and Honorary Professor of Chemical engineering at the University of Birmingham. He is a Consultant Knee and Shoulder Surgeon at The Royal Orthopaedic Hospital in Birmingham and The Robert Jones and Agnus Hunt Hospital in Oswestry. His clinical and research interests include cartilage repair and joint preservation.

Cosimo De Bari holds a Clinical Chair in Experimental Medicine and Rheumatology at the University of Aberdeen. He is Director of the Aberdeen Centre for Arthritis and Musculoskeletal Health (a EULAR Centre of Excellence in Rheumatology) and Deputy Director of the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre.

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Orthobiologics: Osteoarthritis Iain R Murray, Martyn Snow, Cosimo De Bari and Andrew W McCaskie

Osteoarthritis (OA) affects around 8.5 million people in the UK alone1 and the success of treating end-stage disease with joint replacement is well known. The treatment of osteoarthritis at earlier stages is less clear and represents an important area of global unmet clinical need. Around half of the 8.5 million people with OA in the UK are between 45-65 years of age, in whom knee replacement is known to have a higher risk of failure, with around 33% of primaries performed between the ages of 50 and 55 requiring revision2.

T

he unmet need coupled with the limitations of conventional arthroplasty have led to great interest in the development of new treatments for early stage OA, in order to modify symptoms and/or modify the natural history, with the aim to delay replacement.

It is important to appreciate that OA at early stages is heterogenous, both in terms of disease progression and pathogenesis, with distinct clinical phenotypes3. Stratification of patients in early-stage OA therefore offers a ‘window of opportunity’ for intervention4 and this can increasingly be characterised by biomarkers and imaging e.g. MRI. We will review the therapies generally considered orthobiologics, which will exclude some types of regenerative therapies, for example those aimed at treating defined cartilage lesions before OA, such as autologous chondrocyte implantation, which has NICE approval5.

Orthobiologic therapies In recent years, novel intra-articular injectable therapies have gained increasing attention with both the biomedical community and the public6.

The most widely available Orthobiologic therapies are autologous blood products, and cell therapies prepared from bone marrow and adipose tissue. Autologous blood

products include platelet-rich plasma (PRP) preparations and autologous anti-inflammatory (AAI) preparations. Cell therapies can broadly be divided into those harvested and delivered at the point of care (including concentrate of bone marrow aspirate, commonly abbreviated to BMAC, stromal vascular fraction, (SVF) and microfragmented adipose tissue (MFAT)) and those requiring a degree of processing considered ‘more than minimal manipulation’ or a period of cell culture in a laboratory (Figure 1).

Autologous blood products Platelet-Rich Plasma (PRP): Growth factors contained in PRP act on pathways that can dampen the inflammatory response. In addition, growth factors present in PRP have been shown to stimulate collagen synthesis, extracellular matrix production, and promote cell proliferation in laboratory conditions7. The use of PRP in OA has been studied in more than 30 prospective RCTs, with most involving the knee. The data has been reported in multiple meta-analyses8-12 demonstrating improved symptom control, favoring PRP preparations over controls (including hyaluronic acid, saline and corticosteroid), when only prospective randomised studies were included8-12. There are no safety concerns but as yet there is no evidence demonstrating restoration or regeneration of articular cartilage8-16. Recent professional guidelines including the AAOS17,

Subspecialty

Figure 1: Cell therapies can broadly be divided into those harvested and delivered at the point of care, and those undergoing laboratory processing including cell culture and expansion.

(ATMP, Advanced Therapy Medicinal Product; GMP, Good Manufacturing Practice). Created with BioRender.com.

Andrew McCaskie is Professor of Orthopaedic Surgery and Head of the Department of Surgery, University of Cambridge, with a clinical interest in lower limb. He is Director of the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre and an Editor of Bailey and Love’s Short Practice of Surgery.

American College of Rheumatology (ACR)18, OA Research Society International (OARSI)19 and NICE20 have reported “inconsistent evidence” and limited reporting of variables critical to outcome e.g. the platelet count of PRP administered. As such, AAOS downgraded their support of PRP to ‘limited’ and NICE recommended the procedure only be used with special arrangements for clinical governance, consent and audit or research. ACR and OARSI “strongly recommend against” the use of PRP for OA18, 19.

Autologous anti-inflammatories (AAI): AAIs focus on concentrating white blood cells, or the anti-inflammatory factors they release, rather than on concentrating platelets. Autologous conditioned serum is a cell free serum collected from incubated WCCs with high concentrations of anti-inflammatory cytokines. Two RCTs have reported improvements in PROMs and pain scores in patients receiving autologous conditioned serum for knee osteoarthritis over placebo21,22. Autologous Protein Solution (APS) is generated from leukocyte rich PRP that is mixed with polyacrylamide beads and centrifuged to release inflammatory cytokine antagonists from WCCs. A recent RCT has reported improvements in functional and pain scores over placebo23. AAIs were not specifically evaluated in the most recent AAOS, ACR or OARSI guidelines.

Cell based therapies 1. Point of care cell-based therapies BMAC and bone marrow mononuclear cell (BM-MNC) preparations: BMAC contains bone marrow cells, small tissue fragments, and blood from venous sinuses24. The MSC concentration is low, comprising 0.001% -0.01% of all mononuclear cells25. Related preparations include BM-MNCs which are isolated and enriched from bone marrow aspirate by chemical density gradients26. The nucleated cells in BMAC may deliver cytokines and growth factors at the delivery site27. There is little support for restoration of degenerate cartilage and no reports of long-term survival or meaningful engraftment of delivered cells.

A small number of prospective randomised studies have evaluated the use of BMAC or BM-MNCs in the setting of OA, with conflicting results26,28-30.

Microfragmented adipose tissue (MFAT): Microfragmented fat products are prepared via non-enzymatic mechanical disruption of lipoaspirate into small particles partially releasing cells from the extracellular matrix.

The proposed mechanism relates to a role for cushioning and support, as well as the capacity for the cells present to release a range of immunomodulatory and trophic factors. >>

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Subspecialty

Patient stratification and the challenges of orthobiologics The heterogeneity in both patients with the early stages of OA (progression and pathogenesis) and in orthobiologic preparations makes the interpretation of findings from clinical studies challenging. Moving forward, sound clinical evidence will benefit from reduced heterogeneity in relation to manufacture, potency and delivery.

As always in medicine one solution does not fit all and the stratification of patients with OA will contribute to our ability to develop more targeted interventions (Figure 2). To achieve widespread adoption, in addition to effectiveness, cost-effectiveness is important, particularly in therapies looking to alter the natural history of OA, over and above symptom relief.

In conclusion, we are at the start of an era of unprecedented opportunity for orthopaedic and musculoskeletal therapy development, not least for patients suffering from OA. n

Figure 2: Schematic showing the heterogeneous nature of osteoarthritis and how stratification tools can help stratify patients to targeted treatments.

Created with BioRender.com.

There are a large number of non-randomised studies reporting promising results31-36, but no completed RCT of injection alone for large joint OA has been published.

Stromal vascular fraction (SVF): SVF is prepared from adipose tissue, typically by enzymatic digestion, and aims to harness the potential of the MSCs and other cell types. Two RCTs have reported improvements in PROMs with SVF over controls, with one study reporting improvement in MRI cartilage parameters37,38.

Point of care manufacture The Medicines and Healthcare products Regulatory Agency (MHRA) is currently considering a new framework to enable the safe development of point of care (POC) products. This will include the use of device

technologies for isolating tissues and cells or blood components, and may have a significant impact on their future use in the UK39.

“It is important to appreciate that OA at early stages is heterogenous, both in terms of disease progression and pathogenesis, with distinct clinical phenotypes.

Stratification of patients in earlystage OA therefore offers a ‘window of opportunity’ for intervention.”

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2. Cultured Cells Cultured ‘mesenchymal stromal cells’ (MSCs): In contrast to POC manufacture, laboratory culture allows for the administration of millions of MSCs. They are classified as an Advanced Therapy Medicinal Product (ATMP) and are highly regulated (MHRA) and generally more expensive to produce than POC products. Overall, published prospective RCTs evaluating culture expanded MSCs for knee osteoarthritis reported a positive effect on patients’ symptoms with some advanced imaging parameters indicating improvements in cartilage quality. The vast majority of studies only report outcomes to one year and larger and longer randomised controlled studies are required40-47.

Acknowledgements CDB, AWM and MS acknowledge the financial support of Versus Arthritis through the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre (Grant 21156).

Selected references l Mobasheri A, Saarakkala S, Finnilä M, et

l

l

l

l

al. Recent advances in understanding the phenotypes of osteoarthritis. F1000Res. 2019;8:F1000 Faculty Rev-2091.

Mahmoudian A, Lohmander LS, Mobasheri A, et al. Early-stage symptomatic osteoarthritis of the knee - time for action.

Nat Rev Rheumatol. 2021;17(10):621-32.

Tan J, Chen H, Zhao L, et al. Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Knee Osteoarthritis: A Metaanalysis of 26 Randomized Controlled Trials.

Arthroscopy. 2021;37(1):309-25.

American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Knee (NonArthroplasty) Evidence-Based Clinical Practice Guideline. 2021. www.aaos. org/oak3cpg. Accessed 29 Jan 2022.

Kolasinski SL, Neogi T, Hochberg MC, et al.

2019 American College of Rheumatology/ Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & Rheumatology.

2020;72(2):220-33.

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

Subspecialty

Iain Murray is a Consultant Orthopaedic Surgeon at Edinburgh Orthopaedics and Honorary Senior Lecturer at The University of Edinburgh. He is a member of the Orthopaedics and Musculoskeletal Therapies Committee for the International Society for Cell and Gene Therapy (ISCT) and the Biologics Association. He is an Associate Editor of the Bone and Joint Journal (BJJ).

Andrew McCaskie is Professor of Orthopaedic Surgery and Head of the Department of Surgery, University of Cambridge, with a clinical interest in lower limb. He is Director of the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre and an Editor of Bailey and Love’s Short Practice of Surgery.

Orthobiologics: Tendinopathy Iain R Murray, Andrew W McCaskie and Neal L Millar Introduction Tendinopathy refers to a complex pathology of the tendon, characterised by pain, functional impairment and reduced ability to exercise1.

Despite recent advances in our understanding of this condition, tendinopathy remains challenging to treat. While active rehabilitation through exercise remains the cornerstone of management there is increasing interest in new orthobiologic and regenerative therapies, some of which have shown promise in preclinical and clinical settings. These therapies will be particularly important for the 30–50% of patients who do not respond to targeted exercise programs2. At present orthobiologic therapies are frequently applied without explicit understanding of how these treatments may produce a therapeutic effect in a specific patient group. The development of new therapies for tendinopathy will be guided by increasing understanding of the underlying disease process.

Epidemiology

Neal L Millar is Professor of Orthopaedics at the University of Glasgow specialising in shoulder surgery. His laboratory’s research focuses on the immunopathogenesis and translational immunobiology of soft tissue musculoskeletal diseases including tendinopathy.

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insertional complex), knee (patellar tendon) and ankle (tibialis posterior tendon)3. The incidence of lower limb tendinopathy exceeds that of arthritis (10.5 vs 8.4 per 1,000 person-years)3, and tendinopathy accounts for ~30% of injuries in elite athletes4.

The pathophysiology of tendinopathy The pathogenesis of tendinopathy is multifaceted and complex, and scientific understanding is evolving. Repetitive tendon overload is thought to lead to injury of the microscopic collagen fibrils.

Under normal circumstances, early tendon matrix injury prompts an effective healing process. However, inadequate intrinsic healing capacity of the tendon, or insufficient time to recover, can lead to an accumulation of matrix damage1. These initial structural alterations can remain subclinical and patients may have no symptoms. However, as damage progresses, there is an accumulation of secreted cytokines and inflammatory mediators, and activation of nociceptors leading to the development of symptoms.

As repair mechanisms become overwhelmed and dysregulated, tendinopathy becomes established and chronic. Several factors that contribute to, or are associated with the development of tendinopathy have been identified. These include extracellular matrix dysregulation, interfascicular matrix changes, non-collagenous matrix alterations, oxidative injury, apoptotic pathways, molecular inflammation, microRNAs, resolution pathways and inflammatory cytokines5. Understanding these critical pathways offers the potential for developing targeted therapies (Figure 1).

“The prevalence of tendinopathy has increased worldwide over the last two decades, with a wide range of intrinsic and extrinsic risk factors identified including increasing age, female sex, metabolic disorders, medications and sporting and occupational factors.”

The prevalence of tendinopathy has increased worldwide over the last two decades, with a wide range of intrinsic and extrinsic risk factors identified including increasing age, female sex, metabolic disorders (diabetes, hyperlipidaemia, obesity), medications (fluoroquinolones, statins, hormone replacement therapy) and sporting and occupational factors.

The most common sites affected include the shoulder (supraspinatus), elbow (common flexors and extensors) heel (plantar fascia and Achilles tendon), greater trochanter (gluteal

Subspecialty

Management Individually tailored exercise programmes remain the most effective approach in the treatment of tendinopathy. While prolonged periods of exercise based treatment is frequently required to yield improvements, not all patients respond satisfactorily, and other treatment options are widely used as adjuncts or alternatives. Non-biologic Figure 1: Overview of the pathogenesis, clinical features and treatment options for tendinopathy. adjuncts to exercise Created with BioRender.com. include corticosteroid injections, glyceryl trinitrate, high volume saline injections, low reporting significant improvements in pain and energy laser and shockwave therapy. These function in the short and long term18,19. In strategies are generally applied with the aim general, PRP has not been demonstrated to of reducing the local molecular inflammatory be effective in systematic reviews evaluating response driving tendinopathy, with varying treatment for Achilles tendinopathy20,21.

5-8 levels of effectiveness . Surgery typically Mixed results following the use of PRP for involving excision of the degenerative tendon, treating rotator cuff tendinopathy have been debridement of adhesions and decompression reported22-24, with one study suggesting an of the tendon is considered a last resort9. More increased rate of apoptosis in cuff tendinopathy recently, there has been increasing interest in treated with PRP25. Despite more clinical orthobiologic therapies, some of which have evidence for LR-PRP formulations over shown promise in pre-clinical and clinical settings. leukocyte-poor preparations in a number of settings26,27, it can be associated with increased initial post-procedure discomfort over leukocyte Orthobiologic strategies poor-PRP28.

Two of the most widely studied orthobiologics Cellular therapies: There is increasing interest in the management of tendinopathy are platelet-rich plasma (PRP) and cell therapies. in the use of autologous cells (typically from bone marrow or fat) and autologous tenocytes PRP: Several factors present in PRP are to treat tendinopathy. Cells have been recognised to be involved in different phases evaluated in small clinical studies of Achilles of tendon healing (including TGFβ, PDGF, tendinopathy, lateral elbow tendinopathy, bFGF, VEGF, IGF1 and EGF) or to have patellar tendinopathy and rotator cuff immunomodulatory effects. As such, the tendinopathy29, although the majority have delivery of high concentrations of these factors been level III and IV studies. In an RCT could potentially support healing of tendon comparing the effect of intra-tendinous tissue, whilst tempering local inflammation10.

PRP with allogeneic-adipose derived cells The results of clinical studies to date have in patients with Achilles tendinopathy, both been varied11. A major challenge of research treatment groups showed reduced pain and in this area is the considerable heterogeneity improved physical function scores at six in patients, PRP preparations, techniques of months30. Several small case series and pilot administration and outcome measures. In studies have reported positive results with addition, the inadequate reporting of protocols, autologous tenocyte injections in the setting formulations and outcomes limits interpretation of rotator cuff, gluteal and, elbow tendinopathy of data, comparison between studies and the and higher order evidence is now required to ability to replicate experimental conditions12. evaluate effectiveness of these strategies30.

In the setting of lateral epicondylitis, several prospective randomised control trials have Future therapies reported leukocyte rich (LR-PRP) injections result in a significant improvement in pain over Integrating advances in basic science controls13,14. However, the value of PRP in this understanding and clinical research data to setting is not universally agreed with systematic provide a comprehensive picture of the disease reviews and meta-analyses drawing conflicting process involved in tendinopathy is likely to conclusions15-17. Similarly, systematic reviews accelerate the development of successful report contrasting results in comparative future treatments1. There are now a number investigations evaluating PRP and placebo of pharmacological treatment approaches in or other treatments for patella tendinopathy, early phase trials that seek to exploit recent although there are a large number of case series advances in understanding of pathogenesis

through cytokine manipulation, targeting of resolution and microRNA molecules, epigenetic modification and modulation of various signalling pathways (such as IL-17A, Wnt and NF-кB)1,5. Tissue engineering and gene delivery approaches, whereby exogenous genetic material is inserted into cells with the aim of inducing, silencing, upregulating or downregulating the expression profile and secretion of proteins show promise in pre-clinical studies31.

Conclusion Tendinopathy remains a significant cause of morbidity, with great heterogeneity in anatomical site, stage and phenotype. There is clear unmet need and a clear case for the development and evaluation of new therapies.

In addition to disease heterogeneity, the wide range of regenerative and orthobiologic approaches make the interpretation of clinical studies challenging, despite positive reported outcomes. Moving forward, the enthusiasm for new treatments from surgeons, patients, and researchers, together with the current opportunities in new therapeutics, will drive development. A greater stratification of patient and disease with improved targeting of therapy, together with appropriately designed and conducted clinical trials, will build up the clinical evidence for stratified and ultimately personalised interventions. n

Acknowledgements AWM acknowledges the financial support of Versus Arthritis through the Versus Arthritis Tissue Engineering & Regenerative Therapies Centre (Grant 21156).

Selected references l Millar NL, Silbernagel KG, Thorborg K, et al.

Tendinopathy. Nat Rev Dis Primers. 2021;7(1):1.

l Millar NL, Murrell GA, McInnes IB.

Inflammatory mechanisms in tendinopathy - towards translation. Nat Rev Rheumatol.

2017;13(2):110-122. l Shim JW, Lee JS, Park YB, et al. The effect of leucocyte concentration of plateletrich plasma on outcomes in patients with lateral epicondylitis: A systematic review and meta-analysis. J Shoulder Elbow Surg.

2022;31(3):634-645. l Karjalainen TV, Silagy M, O’Bryan E, et al.

Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain. Cochrane Database Syst Rev. 2021;9(9):CD010951. l Van den Boom NAC, Winters M, Haisma HJ, et al. Efficacy of Stem Cell Therapy for Tendon Disorders: A Systematic Review. Orthop J Sports Med. 2020;8(4):2325967120915857.

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

JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 57

Subspecialty

The decision to add PRP to my practice – a personal perspective Ansar Mahmood

Ansar Mahmood is a Consultant Orthopaedic Surgeon based in Birmingham with specialist interests including major orthopaedic trauma, sports and tendon injuries, post trauma reconstruction and regenerative medicine. He entered the field of regenerative medicine in 2010 while working with expert clinicians with an established background in the use of PRP in chronic tendon and inflammatory conditions. Ansar is the course director at the Academy of Regenerative Medicine, an instructor in Advanced Trauma Life Support (ATLS) and current President of the British Trauma Society (BTS).

58 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

I became interested in PRP about 14 years ago when faced with patients with recalcitrant pathology in the Achilles tendon or plantar fascia. With senior colleague support, I injected some with a ‘golden serum’. What piqued my interest was that the exact mechanism was unclear but related to growth factors and inflammation that the platelets were good at optimising. Follow-up several months down the line showed they clearly felt it had worked when all previous treatments had failed, including steroids, manipulation, needling etc.

I

became interested in PRP about 14 years ago when faced with patients with recalcitrant pathology in the Achilles tendon or plantar fascia. With senior colleague support, I injected some with a ‘golden serum’. What piqued my interest was that the exact mechanism was unclear but related to growth factors and inflammation that the platelets were good at optimising. Followup several months down the line showed they clearly felt it had worked when all previous treatments had failed, including steroids, manipulation, needling etc.

When I took up my consultant post, I had been studying PRP for several years and felt I understood the basic science and the potential pitfalls of the available commercial systems.

Due to UK restrictions and regulations, I had to make a decision to use something for research as well as for clinical application, so I set up a PRP lab at the Institute of Translational Medicine at the University of Birmingham and ran quantitative and qualitative analyses with Professor Harrison and Professor Grover.

Following this, I researched the literature on the different PRP types and systems and chose a system to evaluate further.

In my naivety as a fresh consultant, I had originally decided I would learn all there was to learn about PRP from my lab and the clinical research data before I used it on patients.

However, upon delivery of our first PhD student’s thesis after four years of work on burns and graft take, I realised that this was a decades long journey. For the multiple areas I was interested in from wound healing, bone healing, cartilage and tendon regeneration, it was likely I would have retired before I ever had the opportunity of using these autologous biological therapies. I attempted to speed up my journey by visiting the heads of R&D of various commercial providers which gave me invaluable insight into how the different systems evolved and the findings that led to so much variation in the substrate they produced. Regenerative medicine as it has been coined for more than a decade is evolving at a rapid rate and the indications, systems and patient/clinician interest are also growing quickly.

However, this treatment intervention was not new and had in fact been around for about 20 years already. So why had it not found mass market appeal and why were there conflicting reports around its efficacy? I was initially hesitant about >>

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Subspecialty

Almost all the metaanalyses and RCTs involving PRP and other Orthobiologics involve significant heterogeneity in both the disease and the substrate used. There is often poor protocol reporting and this is driven by a lack of standardisation in what is expected to be in a particular injection.

This has been well reported and addressed by Iain Murray et al2.

Once the different cellular profiles of the various PRP systems are understood, the literature starts to make more sense and the basic science can inform clinical practice. Some of the emerging evidence is helping us shed light on the factors that improve outcomes: using PRP therapy as I did not feel that the published evidence was sufficient to support its growing popularity. After conducting an extensive review of the evidence, attending conferences with the leading experts in regenerative medicine and understanding the basic science regarding PRP, it was clear to me that not all PRP was equal. There were big differences in the final delivered substrate and also variation in the pathology and patients receiving the treatment.

After almost a decade of interest, reading and study, I started treating patients initially with a ‘reliable’ PRP system and collected data on those patients in both the NHS and private sector. I have presented that data and continue to collect my and other clinician’s data in our unit. We have found that being open and transparent with patients on what we don’t know as well as what we do know about the treatments and explaining the reported outcomes, as well as our own data, has built trust and has helped the majority of our patients improve their pain and function. I am open with every patient and inform them that the area of ‘Orthobiologics’ is evolving quickly and that I would be surprised if I was delivering exactly the same treatments in a year’s time.

There is robust basic science in-vitro and a substantial amount of in-vivo work demonstrating the potential pathways and positive effects of PRP in different microenvironments. For orthopaedic clinical practice in joints and tendons, there are literally thousands of papers. There is no doubting the potential of these biological therapies but has this been translated into clinical practice? The answer to this is both yes and no. There are over 34 RCTs showing benefit and superiority

1. Recent advances in our scientific understanding confirm which components in whole blood augment PRP’s healing potential and which ones inhibit it. It is not all about platelets. The mononuclear cells and particularly monocytes appear to play an important role.

2. The components of an ideal PRP formulation for a target tissue are becoming better understood.

3. Reviewing the literature, experts can see why some studies showed that PRP was ineffective. The PRP used was far from an ideal system e.g. the recent JAMA publication of Kim L. Bennell et al3 looking at knee OA. They used a system that produces an average concentration of platelets of 1.2-1.3 fold versus the systems that experienced practitioners use for osteoarthritis which is usually a minimum of 4-5 fold above the patient’s baseline. The aim is to achieve a platelet dose of approximately 1x106 platelets/microlitre as there is growing evidence that this provides superior outcomes.4

“I was initially hesitant about using PRP therapy as I did not feel that the published evidence was sufficient to support its growing popularity. After conducting an extensive review of the evidence, attending conferences with the leading experts in regenerative medicine and understanding the basic science regarding PRP, it was clear to me that not all PRP was equal.”

60 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

of PRP to placebo, Hyaluronic Acid (HA) and steroid1. This is probably more evidence than is available for the majority of surgical procedures performed on our lists on a daily basis. However, there are also many trials showing no difference and occasionally inferior results of PRP. Understanding how this arises is fundamental.

Subspecialty

4. Because this optimal formulation has not been standardised to the pathology or to the individual patient, systematic reviews of the literature cannot exclude bias due to suboptimal formulations. Therefore, many reviews have inconclusive results.

Our understanding of how platelets function and how neighboring cells and plasma proteins influence their function has increased dramatically.

We now know that red blood cells and neutrophils have an inflammatory and catabolic (degrading) effect within the treatment area and inhibit the healing process. In contrast, monocytes and lymphocytes have an anabolic (regenerative) effect within the treatment area and are likely to enhance the platelets’ ability to heal5. This ‘catabolic to anabolic switch’ is likely to be different for each micro-environment we wish to influence and certainly requires more study and will be crucial in producing pathology customised regimes and protocols of PRP in the future.

The future of PRP may involve customised treatments such as: • A dose of platelets large enough to create a healing response in a given tissue.

• Minimising red blood cells for most applications.

• Minimising neutrophils or allowing selection in some tissues.

• Maximising monocytes in most tissues.

• Maximising lymphocytes in tendon but perhaps less so in cartilage.

Many PRP systems that produce poor quality injectate formulations are still on the market today. For example, there are over 40 PRP processing systems/protocols mentioned in the literature, but fewer than five can remove >99% RBCs from the PRP sample. Now that the understanding of the cellular content of PRP has improved, newer generation PRP systems (with more favorable formulations) are being developed. When these systems are used, outcomes are likely to be more favourable.

Standardisation and reporting into biologic registries and ‘big data’ collection will likely lead to a better understanding of what works best.

PRP Treatment Method in my hands in January 2022 Typical patient: Kellgren Lawrence Grade 1-3 knee OA still of working age with knee pain.

Previous knee arthroscopies in the past. No mechanical symptoms and BMI less than 30.

(Shorter term results in higher BMI although patients do usually respond).

All options discussed including: • Non-invasive: Exercise/physio, analgesia, bracing already undertaken.

• Minimally Invasive: Steroid, HA, PRP and potentially advanced biologics including plasma and progenitor cell products (this is an escalation therapy in our practice and not first line).

• Invasive: Surgery usually starting with joint preservation options if suitable.

If the patient elects for PRP, informed consent is started at consultation. A digital consent and PROMS form including VAS pain scale, OKS & WOMAC are sent electronically. The patient has an ultrasound guided injection for knee OA. I currently inject approximately 4-5 mls of injectate of a leucocyte poor high purity (0.1% RBC) made from 22 mls of whole blood with a yield efficiency of approximately 8590%. This is spun at 1,500 RCF (Relative Centrifugal Force) for 10 minutes and then concentrated to approximately 5x concentration of platelets. RBCs are almost completely eliminated, leucocytes are 95% eliminated but approximately 80% of the monocytes are retained.

I always use ultrasound guided injections for the best results as it has been shown that biological therapies must be delivered precisely to the appropriate anatomic site. There are quantitative and qualitative clinical studies showing superior outcomes in patients where ultrasound is used.

Patients are usually offered three injections as current evidence suggests that for results lasting 12 months and beyond this is the best protocol.

We are currently validating this. n

References 1. Filardo G, Previtali D, Napoli F, Candrian C, Zaffagnini S, Grassi A. PRP Injections for the Treatment of Knee Osteoarthritis: A Meta-Analysis of Randomized Controlled Trials.

Cartilage. 2021;13(1_ suppl):364S-375S.

2. Murray IR, Geeslin AG, Goudie EB, Petrigliano FA, LaPrade RF. Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO): Platelet-Rich Plasma and Mesenchymal Stem Cells. J Bone Joint Surg Am. 2017;99(10):809-19.

3. Bennell KL, Paterson KL, Metcalf BR, Duong V, Eyles J, Kasza J, et al. Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial. JAMA. 2021;326(20): 2021-30.

4. Bansal H, Leon J, Pont JL, Wilson DA, Bansal A, Agarwal D, Preoteasa I. Platelet-rich plasma (PRP) in osteoarthritis (OA) knee: Correct dose critical for long term clinical efficacy. Sci Rep. 2021;11(1):18612.

5. Lana JF, Huber SC, Purita J, Tambeli CH, Santos GS, Paulus C, Annichino-Bizzacchi JM. Leukocyte-rich PRP versus leukocyte-poor PRP - The role of monocyte/macrophage function in the healing cascade. J Clin Orthop Trauma.

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JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 61

Subspecialty

PRP – a personal view

Philip Turner

With age comes scepticism. I have seen so many ‘game changing’ theories and treatments that when subjected to science and experience just don’t stand up. This was the starting point in my experience of PRP.

Philip Turner is a Consultant at Stepping Hill Hospital, Stockport. He was BOA President from 2018 to 2019 and was elected to Council of the Royal College of Surgeons of Edinburgh in 2019. He was the founding Chair of the Greater Manchester Orthopaedic Alliance (GMOA) and is co-Chair of the Greater Manchester recovery CRG.

I

n November 2020 I was enjoying a much needed fitness programme until my personal trainer persuaded me to sprint as fast as I could up a steep hill whilst dragging a weight behind me. I felt a tearing sensation in both my Achilles tendons without much pain. The next morning I could hardly walk and getting down stairs was close to impossible. Self-examination suggested bilateral partial tears.

I started with the usual RICE and antiinflammatory gel, heel wedges and orthotics, stretching as per the best web-based evidence and then physiotherapy input. We agreed on

the diagnosis and a rehabilitation programme but after four months things were no better. The tendons were thick and tender. I couldn’t stand on tip-toe because of pain and the stretches seemed to make it worse. Comments on my gait varied from concern to hilarity and I could not keep up with my colleagues when walking down the corridor let alone return to my beloved High Peak hiking.

At this stage, MR scanning and ultra-sound confirmed multiple clefts in both tendons and thickened hyper-vascular paratenon. Having read around the options and discussed them with a sports physician, I almost reluctantly opted for PRP. The procedure was straightforward. Blood was obtained via a worryingly wide bore needle and spun down followed by separation of the platelet layer. Local anaesthetic and then the PRP was injected via multiple punctures under ultrasound control with minimal discomfort and total fascination as I watched the fluid spread into the tendon. The procedure was done on a Friday so I didn’t take any time off and I only required a couple of paracetamol tablets. Two weeks in a boot and four weeks of remobilisation was followed by the same process on the opposite side, when the scan showed clear evidence of obliteration of the clefts on the first side. Two more months of expert rehabilitation followed, supervised by someone more used to managing Olympic athletes.

Hiking with the family in the Dark Peak.

62 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

What is the outcome? I have now completely recovered. I can run 10K and walk in the hills with no problems and my VO2 max has gone back from a low of 32 to well into the 40s. Was it the PRP, the rest in a boot or the rehabilitation programme? Was it just the passage of time?

The objective evidence on the scan and the rapid improvement after intervention has persuaded me that at least for my tendon injury the PRP did have a significant impact. n

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JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk | 63

In Memoriam

Clive Lee

18 February 1939 – 2 November 2021 Obituary by John Timperley

Clive Lee standing next to a bust of Robin Ling at the entrance of the Princess Elizabeth Orthopaedic Centre in Exeter.

P

rofessor Clive Lee, who has died at the age of 82, was a talented engineer who worked in the department of Engineering at the University of Exeter. In collaboration with Professor Robin Ling, Clive Lee was co-designer of the Exeter Hip (née Ling-Lee Hip), a radically different design of hip prosthesis whose 50th anniversary after first implantation was celebrated last year.

Clive Lee, working as an engineer at the University of Exeter and Robin Ling, serving as a surgeon at the Princess Elizabeth Orthopaedic Hospital, collaborated in what proved to be a model relationship for how professionals should interact to design implants for the benefit of patients. They decided to restrict usage of the implant to Exeter for five years so that the fewest possible patients were exposed to any unforeseen risk. Although the practice would not be allowed today, Clive Lee would attend the operating room and assist

64 | JTO | Volume 10 | Issue 01 | March 2022 | boa.ac.uk

in surgery to gain better insight into the problems involved in surgery during this pioneering time.

Clive Lee’s hands-on training at Rolls-Royce was to define the way he approached his work; he described himself as a problem solver and practical person. As Robin Ling observed and reported how the Exeter Hip behaved in clinical practice, Clive Lee used his knowledge of materials and engineering to carry out laboratory experiments to explain how the Exeter Hip functions by a ‘taper-slip’ principle of fixation. His groundbreaking work on how the material used to fix the implant (polymethylmethacrylate), behaves in the body, now forms reference text in orthopaedic textbooks the world over. Between them, Ling and Lee built on the work of Sir John Charnley, the father of successful hip replacement, to explain how implants retain fixation to the skeleton in the long term and they developed instruments to further improve clinical results for patients.

Alan John Clive Lee was born in Kings Norton, Birmingham on 18th February 1939. He was awarded a direct grant scholarship to attend Solihull School, where he took his ‘A’ levels a year early.

He attended the University of Nottingham where he achieved a first-class honours degree in Mechanical Engineering. His five years at university included an apprenticeship at the Derby works of Rolls-Royce Limited, during which time he qualified as a Designer in August 1962.

He worked for 18 months in the drawing office at Rolls-Royce, working on jet engine design before returning to the Engineering Department in Nottingham to undertake a PhD which he submitted in December 1965. In August the following year, he was appointed as Assistant Lecturer at the Department of Engineering at University of Exeter where he maintained academic positions until his retirement. For a long time, he was Head of the School of Engineering. He was awarded an Honorary Doctorate at the University of Exeter, alongside his collaborator on the Exeter Hip, Robin Ling, in July 2009 and a Professorship at the same institution in 2020.

Clive Lee’s practical nature was reflected in his hobbies. He designed and made toys for his children and built models of several rigged ships, including one of the Royal Yacht of Charles II, the Royal Caroline, a name shared with his daughter. He painted in acrylic throughout his life and, whilst on sabbatical in New Jersey, even developed an interest in crewel art. His artistic creations adorn many walls in his home in Exeter.

Professor Lee will not only be remembered for his association with the Exeter Hip over a 50-year period but also for the excellence and clarity of his teaching, his scientific rigour, and his ability to work and inspire across teams. Clive is survived by his wife of 56 years, Pamela (née Hammond) and two children. His children, Philip, and Caroline both followed in the footsteps of their father to Nottingham University where they, too, graduated in an Engineering discipline.

He will be much missed by all. n

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