Journal of Trauma & Orthopaedics - Vol 10 / Iss 2 by British Orthopaedic Association

Journal of Trauma and Orthopaedics Volume 10 | Issue 02 | June 2022 | The Journal of the British Orthopaedic Association | boa.ac.uk

Black box thinking: changing the surgical mindset p20

How diverse and inclusive are the BOA membership? p32

The ability in disability p46

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Journal of Trauma and Orthopaedics

Contents

In this issue... 3

From the Executive Editor

From the President John Skinner

6-7 BOA Latest News 14 News: BOA Annual Congress 2022 16 News: Conference Listing 2022 20 Features: Black box thinking: changing the surgical mindset Alisdair Felstead

24 Features:

British Orthopaedic Directors Society (BODS) network: Reporting the state of the nation Mike Reed

28 Features:

Breaking down barriers to flexible training in trauma and orthopaedics Caroline HM Bagley, Rob Gregory and Paul Harwood on behalf of the SAC in T&O

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

32 Features:

Simon Hodkinson

How diverse and inclusive are the demographic, socio-economic and disability profiles of the British Orthopaedic Association membership in the United Kingdom? Neal Rupani, Caroline Hing, Deborah Eastwood, Justine Clarke, Rob Gregory and Salma Chaudhury

36 International:

Challenges of maintaining overseas orthopaedic partnerships during the pandemic Daniel Yeomans, James Berwin, Rosemary Wall (on behalf of the WOC-Guyana Orthopaedic Partnership) and Chris Lavy

40 Trainee:

Professionalism within trauma and orthopaedic surgery Lisa Kells, Marieta D Franklin and Cronan Kerin

42 Medico-legal:

Should Montgomery be altering the way we do things? – Part 1 Simon Gregg-Smith

46 Subspecialty: The ability in disability Deborah Eastwood

48 Subspecialty: Disability and ability in sport participation in children Virginie Pollet

52 Subspecialty:

Keeping up with the active amputee John McFall

56 Subspecialty: The use of orthoses to return young

patients to impact activities following complex foot and ankle injuries Louise McMenemy and Arul Ramasamy

60 In Memoriam:

Lori A Karol Obituary by Deborah Eastwood

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

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Credits JTO Editorial Team l l l l l

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

BOA Executive

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

John Skinner (President)

- Lisa Hadfield-Law

Bob Handley (Immediate Past President)

Policy and Programmes

Deborah Eastwood (Vice President)

- Eliza Khalid

Simon Hodkinson (Vice President Elect)

Fergal Monsell (Honorary Secretary)

Mark Bowditch (Honorary Treasurer)

BOA Elected Trustees l

John Skinner (President)

Bob Handley (Immediate Past President)

l Deborah Eastwood (Vice President)

Programmes and Committee Officer Education and Careers Manager

- Alice Coburn

Educational Programmes Assistant

- Kathryn Hawthorne

Communications and Operations Director of Communications and Operations

- Annette Heninger

Marketing and Communications Officer

- Pujarini Nadaf

Membership and Governance Officer

- Natasha Wainwright

Publications and Web Officer

Simon Hodkinson (Vice President Elect

Fergal Monsell (Honorary Secretary)

Finance

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

Director of Finance - Liz Fry

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

- Nick Dunwell

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

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 Simon Hodkinson

laming June has arrived, or hopefully it will have by the time you read this, although it’s currently pouring down on the south coast as I write this editorial. This is my first one having taken over from Deborah Eastwood and I hope I can do justice to her and all she has done during her time as Executive Editor. In her last editorial back in March, she reflected on the uncertainty of the world we found ourselves in but also the hope for a reduction in COVID numbers and the potential for a sort of normality in the months to come. Well, COVID is beginning to settle but that was not before Omicron reminded us how quickly things can change. As we look to recover from a pandemic what a World, we now live in. A war in Europe for the first time in nearly 80 years and inflation going through the roof on the home front. To cap it all, as COVID recedes, at least for the time being, we have a waiting list mountain to climb making Mike Reed’s article on BODS (page 24) all the more important in the current climate. However, there is much change for good in our profession although a long way to go. In this edition of the JTO we continue with the theme of Equality and Diversity with thought provoking articles on disability, socioeconomic profiles in the BOA (page 32) and the barriers to flexible training in the UK (page 28) which despite significant advances in recent years still exists and no doubt adversely affect some people’s decision to consider T&O as a realistic career option. Finally, the trainee article from BOTA considers ‘Professionalism in T&O’ (page 40). Alisdair Felstead considers the need for a change in surgical mindset in reviewing Matthew Syed’s well known book ‘Black Box thinking’ (page 20). Ian Winson was calling for a ‘Just Culture’ many years ago but sadly we seem unable to move on from the blame game! Professor Eastwood makes a rapid return for a guest appearance as editor of our subspecialty section considering the ‘Ability in disability’ (page 46) reflecting in part, on some astonishing achievements of those considered ‘disabled’. Virginie Pollet’s article (page 48) highlights why a disability is not a ‘non-ability’ and shouldn’t limit children with an impairment from participating in sport. John McFall (page 52) gives his own personal account as an amputee of the opportunities, both sporting and professional, he took up and Louise McMenemy’s article (page 56) highlights how advances in orthotic design are benefiting young patients returning to impact activities. Finally, our sister publication ‘The Transient Journal’ is undergoing a change. Introduced in the height of the pandemic by Bob Handley to facilitate rapid dissemination of information and best practice, it has been a huge success. However it must evolve and continue as the online arm of the BOA, and so under the editorship of Caroline Hing the Transient Journal is to become permanent and will be rebranded as ‘Orthopaedics Online’. I hope you will continue to support it. I do hope you will enjoy this edition of the JTO and hopefully we see some sunshine in the months to come. n

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From the President

Green shoots of elective recovery? John Skinner

As we approach the middle of 2022, we are starting to see some green shoots of elective recovery after the pandemic.

or the first time in two years, many Trusts are starting to see short runs of time where no new cases of COVID are reported in staff. For so long, recovery has been frustrated by the triad of sickness, leave and patient isolation requirements with an already depleted workforce. We know all too well that hospitals have got used to diverting beds, wards, anaesthetic teams and nurses away from treating elective orthopaedic patients and latterly from trauma services too. We must continue to make our patients’ voice and plight impossible to ignore and I will continue to highlight the inequity of this at the highest levels. In the last waiting list figures released on 12th May, we saw that the number of patients waiting more than 104 weeks had reduced by 26% after a focused national drive. It was also encouraging to see that the total number of admitted procedures in T&O was up by 14% on the last month. This is essential for our patients and we wait to see if it is sustained. I have travelled to Belfast with Tim Briggs, to meet with the Government, the Health Service leads and a really dynamic and frustrated group of surgical colleagues who are almost at a standstill for elective surgery. The reasons are complicated by political stasis but are a severe example of diverting the orthopaedic resource as above. It just shows what happens if we continue to de-prioritise elective surgery and surprising how quickly it reaches the end game. We have proposed some solutions and I really hope that for the benefit of patients and surgeons, they can be adopted quickly. I have also been in correspondence with the Welsh and Scottish Governments on exactly the same issues. I was interviewed on the BBC World at One programme to discuss Liam Gallagher’s widely reported claims in the Press that he would rather be in a wheelchair that have his ‘bashed up hips’ replaced. This gave an opportunity to highlight the misery of arthritis pain and the skills of surgeons to relieve it with effective surgery. The Sun reported his change of heart as Liam’s “UP FOR HIP OP” after he has played his sold out Knebworth concerts this summer. We also marked our concern with the Times and other papers for reporting “Stop taking pain killers for arthritis NHS patients told.” This may have validity in the early stages which is what NICE said but they did not consider waiting list patients. While waiting for surgery, these patients are in a lot of pain and painkillers remain an important part of making life bearable. As summer begins many colleagues will be planning holidays and I hope you all manage to get some well-earned rest and time together with family or friends. n

Latest News

BOA & BOTA Culture & Diversity Champions 2022 The new ‘Culture & Diversity (C&D) Champions’ are representatives of BOA and BOTA and will work together to encourage, inspire and stimulate positive change in work culture and to build a more diverse and inclusive environment for our specialty. The C&D Champions will be a point of contact for junior and senior T&O surgeons within their region promoting a more diverse and inclusive community within T&O that accurately reflects the population we care for. An election was held in February to elect representatives for each region and the BOA and BOTA are pleased to announce the winners. Congratulations to all our C&D Champions: East Midlands: Rosie Gnap & Sheikh Nomaan East of England: Rachel Clegg & Ghulam Abbas North East: Sarah Johnson-Lynn North West & Mersey: Kohila Vani Sigamoney, Tony Clayson, Hannah Sevenoaks & Theophilus Asumu Northern Ireland: Fazal Hassan & Ravikanth Pagoti Scotland: Jennifer Cherry & Thisara Chamupathie Weerasuriya South West (Peninsula): Kimberley Shuttlewood London: Kate Atkinson Kent, Surrey, Sussex: Zaid Ali & Ogho Obakponovwe Thames Valley: Asanka Wijendra & Salma Chaudhury Wales: Yusuf Mirza & Kodali Prasad Wessex: Saharish Saleem & Joanna Higgins West Midlands: Alastair Stephens & Kowshik Jain Yorkshire & Humber: Sohail Nisar & Elizabeth Moulder

Two new paediatric BOASTs published We are pleased to announce the addition of two new BOASTs (BOA Standards), each considering aspects of paediatric orthopaedic care.

The Management of Children with Acute Musculoskeletal Infection This BOAST was jointly developed by the BOA and the British Society for Children’s Orthopaedic Surgery (BSCOS) and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG). This document considers the initial diagnosis, special investigations, and surgical and non-surgical management of children with osteo-articular and soft tissue infection. This is an important consensus document that will reduce variance and encourage the multidisciplinary management of these patients.

The following roles are still vacant: North East – Junior; South West (Peninsula) – Senior; South West (Severn) – Junior and Senior; London – Senior. Details on how these roles will be filled will be available soon on the BOA website at www.boa.ac.uk/C&D-champions.

You can view the full document at www.boa.ac.uk/childrenMSK-infection.

The Management of Anterior Cruciate Ligament Injury in the Skeletally Immature Patient This BOAST was jointly developed by the BOA, the British Society for Children’s Orthopaedic Surgery (BSCOS), and the British Association for Surgery of the Knee (BASK). It suggests the skill set required to manage this patient group, in addition to providing advice on the diagnosis, special investigations and operative and non-operative management. It makes general recommendations about the operative detail and stresses the importance of surveillance until skeletal maturity. View the full document at www.boa.ac.uk/paediatric-ACL. All BOASTs – including Trauma, Elective and Speciality – can be found on the BOA website at www.boa.ac.uk/boasts.

SAS Professional Development Programme – new course dates New dates now available for the popular SAS Professional Development Programme! As an SAS T&O surgeon this is your chance to maximise your untapped potential and help you develop professionally and personally. • Session One – Polishing Your Portfolio – Wednesday 29th June 2022 • Session Two – Selecting and Engaging with Mentors, Supervisors and Sponsor – Tuesday 26th July 2022 • Session Three – Stepping up to the Training Plate – Tuesday 30th August 2022 Book now at www.boa.ac.uk/SAS2022.

Previous course feedback: “It was well organised to the needs of SAS doctors. Pre-course work and feedback was very valuable. It was interactive and relevant burning questions could be asked.” “This course has given me an insight to my own abilities and within a short period of time has generated an action plan for me to work on to achieve my goal.”

Save the date: Ortho Update – Saturday 7th January, 2023 Book now for the BOA Virtual Ortho Update Course to establish strong foundations for practice and assessment, and prepare for the FRCS exam. The course provides curriculum driven clinical updates and critical condition assessment opportunities aimed at T&O trainees and SAS surgeons. Further information can be found at www.boa.ac.uk/OrthoUpdate.

News

Zimmer Biomet Trauma Travelling Fellowship to Ludwigshafen Daniel Burchette

he Berufsgenossenschaftliche Unfallklinik (BG Klinik) Ludwigshafen is a dedicated trauma, orthopaedic and plastic surgery hospital and Level 1 trauma centre in the Rhineland-Palatine region of Germany. It forms part of the BGU group of trauma hospitals that are nationally renowned for their musculoskeletal trauma care. I was fortunate to spend a six-week BOA / Zimmer Biomet Travelling Trauma Fellowship with their acute traumatology team focussing on their extensive experience of intraoperative crosssectional imaging, which is a topic I have long been interested in, but not exposed to in my UK training. The majority of the six-week attachment was spent in the operating theatre suite with the acute traumatology team, observing and assisting in a wide range of acute trauma cases. During this time I observed and assisted in a broad range of extremity trauma operating, picking up ‘tips and tricks’ from their expert traumatology team and learning how they integrate 3D imaging into their routine theatre practice. Applied

to all periarticular fractures in this institution, the concept is simple: fix the fracture as per usual using fluoroscopy, before performing a scan to critically analyse the reduction, with a readiness and appetite to start again if required. Over the course of the fellowship the arguments were convincing; on a few occasions a seemingly good reduction on fluoroscopy was betrayed on scan, leading to intraoperative revisions of the fixation. I wish to thank the Head of the Acute Traumatology team, Dr Jochen Franke and his Oberarzt colleagues, Dr Benedict Swartman and Ann-Kathrin Blessing for their kind hospitality throughout my stay and taking the time to demonstrate and involve me in their work. Finally, I am supremely grateful to the British Orthopaedic Association and Zimmer Biomet for funding this opportunity. n

British Society for Children’s Orthopaedic Surgery (BSCOS) update Simon Barker and Dan Perry

onsensus is booming in children’s orthopaedic surgery! Consensus guidelines are now available on the BSCOS website for DDH, Clubfoot and MSK Infection. The success of the infection guideline has now resulted in the publication of a new BOAST. An adolescent ACL injury BOAST has also resulted from joint working with BASK. There is lots of consensus – and lots of ongoing friendly debate! As a group we now know where we agree (and where we don’t!) and have committed to try to overcome variation through consensus until high-quality evidence is available.

The generation of evidence continues to be a growing (and is now a massive) part of BSCOS. The BOSS study was published in the BJJ in April and involved almost every centre in Britain treating SCFE and Perthes’ disease children. BOSS formally demonstrated the variation that occurs and the potential for RCTs. This has now resulted in an NIHR RCT being funded for children with severe SCFE (called BigBOSS) and another (hopefully to be) funded amongst children with Perthes’ disease. Our ongoing portfolio of NIHR RCTs continues to grow with the first big NIHR trial (FORCE – torus

fractures) soon to publish. Others are recruiting well with the sunny playground weather! The others going - Medial Epicondyles (SCIENCE – 60% recruited), Distal Radius Fractures (CRAFFT – 52% recruited). The new studies to look out for include ODDsocks (SH2 fracture RCT) and PICBone (decision making in infection cohort). There are even more to come (though they remain top secret… be excited!). The consensus is that children’s orthopaedics will soon be an awesome evidence rich zone – and we all agree that recruitment to studies is our team game!

News

The British Society for Surgery of the Hand (BSSH) update IFSSH 2022 The triannual Congress of the International Federation of Societies for Surgery of the Hand, hosted by the BSSH, takes place at the ExCel in London, 6th – 10th June, with over 3,000 delegates. In advance, 33 International Fellows are participating in Travelling Fellowships, showcasing hand surgery in the UK. STASH The BSSH has established a Student and Trainee Association for Surgery of the Hand (STASH), introducing new membership categories for student and foundation/core trainees. The launch takes place on 10th June at the ExCel. Book your place on the BSSH website www.bssh.ac.uk.

focussing on the complex and extraordinary hand trauma colleagues in Ukraine are facing. The first webinar attracted 300 attendees, with 104 from Ukraine. BSSH Mentoring Our fledgling mentoring programme is running successfully with 14 paired mentors and mentees. Mentees are BSSH members between CCT and the end their fifth year of consultant practice. Early feedback is very positive.

Lilongwe Hand Unit The BSSH has committed £100,000 to launch a hand unit within the Lilongwe Institute of Orthopaedic and Neurosurgery in Malawi. The project plans to provide the continuous presence of a volunteer Hand Surgeon, Hand Therapist and Hand Trainee in Lilongwe for five years. Those involved will work with and train local surgeons, aspiring to a staged withdrawal of support after five years leaving a self-sufficient hand unit. Raising Hand Surgery Standards Best practice pathways for Carpal Tunnel Syndrome and Traumatic Amputations of the Digits, Hand and Wrist have been developed by BSSH and published on the GIRFT website. Further pathways will be released in 2022, including Dupuytren’s contracture, hand lacerations, trigger digits, ganglia and bites.

‘Hand in Hand with Ukraine’ Webinars Together with the Federation of European Societies for Surgery of the Hand, BSSH has created a series of weekly webinars

British Hip Society (BHS) update BHS Annual Meeting Bournemouth After a hiatus of two years, we hosted a faceto-face meeting and had a record attendance of over 550 delegates in Bournemouth. The theme for the instructional course was the ‘Young Adult Hip’ which had excellent Faculty from the UK and abroad. The Charnley Lecture was given by Thorsten Gehrke from the Endo Klinik in Hamburg on their outstanding work with single stage revision for infection and the Presidential guest lecturer was Robert Townsend, a microbiologist from Sheffield. We had an amazing range of ‘Topic in Focus’ presentations on dual mobility bearings, training, digital pathways and the Non Arthroplasty Hip Registry. After the excellent introduction of the Culture and Diversity Committee (C&D) last year, we 10 | JTO | Volume 10 | Issue 02 | June 2022 | boa.ac.uk

Vikas Khanduja, BHS President

had an inspirational and challenging session on C&D including a talk from Amy Grove about the issue of unconscious bias. Thank you to all those who attended and we look forward to seeing you in Edinburgh next year. For those who were not able to attend, the content is available via our on demand access at www. britishhipsociety. com/annualmeeting-2022. The future of the society The portfolio of the society has expanded significantly as has the membership and we continue evolving to be a diverse, inclusive, and stronger society. The mantra for this year is to maintain and strengthen all the activities on our portfolio with continued responsible fiscal management. We wish to

focus on curating and storing our rich history, harnessing the power of technology to support our trainees via virtual and augmented reality training, support our patients on the waiting list through scientifically robust prioritisation and help the BOA and RCS in their strategy for addressing the ever-growing waiting lists. We endeavour to broaden our membership, further develop our international reputation and collaborate with other hip societies globally. I would like to congratulate the following who were elected to the Executive Committee: Satish Kutty, Education Committee Chair; Joanna Maggs, Culture and Diversity Committee Chair; Matt Wilson, Honorary Treasurer; Kate Gill, Honorary Secretary and Anil Gambhir, Vice President. Finally, a note of appreciation and thanks to my predecessors Andy Hamer, Jonathan Howell and Steve Jones who have been inspirational leaders and whose tireless energy and vision have seen the society blossom. It is certainly an honour, pleasure, and a privilege to be serving as President of the BHS in such an exciting phase.

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News

British Limb Reconstruction Society (BLRS) update

n 24th and 25th March 2022 we held our annual conference in Brighton and tickets sold out within a few weeks. The theme of the meeting was limb reconstruction in a major trauma centre and started with a fascinating paediatric session looking at using modern 3D planning software to correct upper limb post traumatic deformities and novel implants to correct rotational deformities with guided growth. The talks are available to view on demand if you would like to see the thoughtprovoking discussions regarding the management of open pilon fractures. The keynote presentations discussed modern trauma solutions and insights into limb reconstruction. Leaders from BLRS, BOA, BAPRAS, BOFAS, BGS and OTS discussed the management of open elderly ankle fractures as well as funding problems facing MTCs as complex cases become regionalised. The hugely entertaining and interactive session on managing open fractures with bone loss involved delegates planning and describing their management.

The ability of MTCs to manage these complex injuries with plastic surgeons formed the discussion of their soft tissues management, timing of surgery and how to manage the first stage of open fractures. Our allied professionals enjoyed sessions on trauma psychology, nutrition, wound healing, pain control, rehabilitation together with managing flaps and amputation. The registrars also had a separate educational session with industry together with over 50 free paper presentations. The principles of limb reconstruction haven’t changed but the collaboration with plastic surgeons and the regionalisation of complex trauma evoked the theme of this meeting and provided an alternative insight into limb reconstruction. BLRS, which was founded in 1997, is a diverse organisation with wide representation incorporating allied health professionals (AHP) as full members. BLRS provides travel bursaries to Consultants, Trainees and AHP’s. Please join us in Belfast March 23rd-24th March 2023 for our next annual meeting. n

British Scoliosis Society (BSS) update

he British Scoliosis Society, founded in 1976, represents surgeons, healthcare workers and researchers to ensure the highest possible standards of management for individuals with spinal deformities; patient and professional education; and research into the origin, natural history and management of spinal deformities. In June this year, the BSS is supporting the Zorab Symposium in London which is very much a research orientated spinal deformity meeting attracting an international audience. The last face-to-face BSS meeting was in Cardiff in November 2019 and we are looking forward to meeting up again in Edinburgh in November this

year. In 2015, we realised that whilst all the surgeons are away at an annual BSS meeting, other members of the team have less clinical work to do with no clinics or theatres running. So in addition to the educational day for the trainees, we started meetings for our AHPs, those doing spinal cord monitoring (Neuromonitoring UK), the paediatric spinal anaesthetists (National Paediatric Spinal Anaesthetists Network) and this year, a meeting for Spinal Orthotists (a new addition). They each hold their own separate meetings in the same venue as the main BSS event and joint sessions relevant to the different groups are planned. This has created a more diverse and inclusive

“The BSS has committed to support a candidate for the BOA Future Leaders Programme this year and will soon be advertising for a new Research Fellowship combined with ORUK and BASS.”

Enis Guryel and Hemant Sharma

Ashley Cole, BSS President

Society and the exchange of ideas must enhance patient care. As is the case for several Societies, we are currently changing the structure of the BSS to a Charitable Incorporated Organisation which will allow us to continue our objectives. We are producing a few ‘Standards of Care’ documents to ensure that patients with spinal deformity get the same high-quality care across the UK. The BSS has committed to support a candidate for the BOA Future Leaders Programme this year and will soon be advertising for a new Research Fellowship combined with ORUK and BASS. There seems to be a new enthusiasm for research in the BSS and the Research Committee led by Professor Adrian Gardner will take advantage of this and advance the UK input into spinal deformity research. n

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News

BOA Annual Congress 2022 20th – 23rd September, ICC Birmingham www.boa.ac.uk/Congress #BOAAC22

Join us at the BOA Annual Congress 2022! Under the theme of ‘Technology, Data and Recovery’ the 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. This is your chance to get all the CPD points you’ll need in one place. The programme will include King James IV Professorship Lectures, the Howard Steel lecture, a Presidential Guest Lecturer, Revalidations, and hot-topic sessions by specialist societies. Full details of the provisional programme is available at www.boa.ac.uk/programme.

BOA Abstract Submissions The BOA Abstract submission for Congress 2022 is Now Closed! Abstract authors will receive notification regarding their submission by the end of July. View full details on the abstracts process at www.boa.ac.uk/abstracts.

Skills Training & Medical Students Session. Full registration details can be found at www.boa.ac.uk/registration.

Get the BOA App to plan your Congress experience If you’ve not already done so, make sure to download the BOA app to access everything you need for Congress this year. Just search for ‘British Orthopaedic Association’ in the Apple App Store or Google Play. Plan ahead and bookmark your sessions in advance, create your own itinerary, view podium and poster presentations and connect with other delegates. There is no printed Programme Book so make sure to download the BOA App to ensure you can make the most of your Congress experience, before, during and after the event. Find out more at www.boa.ac.uk/boa-app, or scan this QR code.

Registration General registration is now open and will close on Friday 4th September 2022. We have made a change to the booking procedures, so make sure to register separately for all Friday sessions when booking. Educational sessions, includes, Good Clinical Practice Training, Clinical Examination Course, TOES, Non-Technical

Accommodation & Travel Make sure to book your accommodation now so you don’t miss out! More information on hotels near the Congress venue can be found on the BOA website at www.boa.ac.uk/ accommodation.

Exhibition & Sponsorship We are delighted to announce our platinum exhibitors for this year’s event, including: Circle Health Group, DePuy Synthes, Link Orthopaedics, Smith & Nephew, Stryker and Zimmer Biomet. Please visit our website over the next few weeks to find further details about our exhibitors this year. Stand spaces are still available, for further information on our sponsorship and exhibition opportunities please contact our exhibitions team, exhibitions@boa.ac.uk 020 7406 1754 or take a look at our stand options and brochure www.boa.ac.uk/ sponsorship-brochure.

NEW - Technology & Innovation Zone This year, we are pleased to announce our NEW Technology Zone for this year’s exhibition. Explore the innovations revolutionising the orthopaedic industry all in one place, and experience the latest development in technologies for orthopaedic surgeons and patients with emerging solutions, products and services. Including AI, computer-assisted surgical technology, cloud-based software, surgical robotics, 3D imaging scanners, real intelligence, digital platforms, Apps and more. Visit our website for more details and to see who is exhibiting www.boa.ac.uk/exhibition-sponsorship.

S AV E T H E D AT E

COMBINED BRISTOL AND OXFORD

Unicompartmental Knee Arthritis Symposium 1st November 2022 Jurys Inn, Oxford

CPD points applied for

Challenging the success and outcome of UKR

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News

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

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

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

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org 22-24 June 2022, Lisbon

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

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

BIOS (British Indian Orthopaedic Association) www.britishindianorthopaedicsociety.org.uk 08-09 July 2022, Mansfield

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 12-14 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 2022, Liverpool

BTS (British Trauma Society) www.britishtrauma.com 22-24 November 2022, Oxford

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10th & 11th November 2022 Ascot Conference Centre

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Additive manufacturing offers medical professionals’ freedom of design, adaptability, personalisation and is changing the lives of so many people on a daily basis with disabilities and in sports performance. 3D Printing is being used to create medical tools, equipment to custom made prosthetics and even bio printing using plastic, resin, or metal 3D printing. Additive Manufacturing enables the creation of objects and solutions that are easy to use and adapted to personalised needs, making it easier, faster and cheaper. Ultimaker Dr. Boyd Goldie, an orthopaedic surgeon in London, wanted to make surgical procedures more efficient and improve communication between the patient and doctor. In order to achieve this, 3D printing makes invaluable visualisation aids for surgeries, saving time and money in the process. The technology offers numerous benefits, including better surgical preparation, significant reduction of surgical costs and more opportunities for better patient education. 3D printing is commonly used in complex surgery, but most surgeons order externally-made 3D prints. Dr. Goldie wasn’t content with this arrangement. It was very expensive (hundreds of pounds per print) and took weeks for the 3D prints to be delivered. Dr. Goldie purchased an Ultimaker 2+ 3D printer. When used in combination with open-source software, Ultimaker Cura, he can 3D print accurate fracture replicas in a matter of hours; depending on the size of the area. Dr. Goldie explains “Ultimaker 3D printers are designed and built for Fused Filament Fabrication with Ultimaker engineering thermoplastics within a commercial/business environment. The mixture of precision and speed makes the Ultimaker 3D printers the perfect machine for concept models, functional prototypes and the production of small series” Request a consultation with one of our experts to learn how you can adopt additive manufacturing into your business: https://3dgbire.com/pages/ book-your-free-consultation. Read the full case study here: https://bit.ly/3kUcoSf Website: www.3dgbire.com

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News

Joint Action update

n 2nd October 2022, nine amazing runners will be taking part in the TCS London Marathon to raise money for Joint Action, the research appeal of the British Orthopaedic Association. They are aiming to raise over £13,000 to support vital research into Trauma and Orthopaedics, transforming lives and giving people back their freedom and independence. Two of our amazing runners tell us why they are running for Joint Action below. Please support all our runners and help raise vital funds for Joint Action through our Just Giving link www.justgiving. com/campaign/JAlondonmarathon2022, or scan this QR code.

Alex Chipperfield I am an orthopaedic surgeon specialising in hip and knee replacements. I see the life changing effects of joint disease every day in my patients. Although I like to think that I can improve their quality of life with joint replacement surgery, I would love to see a world where people never reach a stage where this is required. Running in support of Joint Action will help us all reach that goal. Running is not something that comes naturally to me, so having a target to train for and a cause that’s close to my heart to support helps massively with my motivation. It’s easier to get out of bed early for a run, or tie on the trainers after a long day at work if you feel that a worthy cause will benefit from it.

A common misconception is that running is bad for your joints and can bring on arthritis. The opposite is true, running can be hugely beneficial for people who have wear and tear arthritis, strengthening muscles and supporting structures around failing joints, helping with weight loss and general cardiovascular fitness. This is advice that I often give to patients so it’s about time I applied it to myself! Running can be quite a solitary pursuit, and although occasionally that can be helpful in itself (sometimes even meditative) I find that including my wife, children and Roxy my Goldendoodle on my runs can keep me going and give me a lift on slower days. Please donate and help support Joint Action, and feel free to follow me on Strava to see my progress in the months ahead.

Amol Tambe I am acutely aware of the significant impact of musculoskeletal disease and disability on all aspects of life. After all life is motion; motion is life! As an orthopaedic surgeon, I strive to improve this very aspect of people’s lives. However, much more can be done and I am lucky to be able to challenge myself at the TCS London Marathon 2022 and at the same time raise money for the BOA Joint Action Research appeal. As someone who loves the outdoors and is always up for an adventure or physical fitness challenge, it is immensely important for me to help a cause that promotes advances in the understanding and treatment of bone and joint disease. I am grateful to the BOA for providing me this opportunity. I am sure the BOA members will be generous in supporting the BOA London marathon runners in their mission to raise money for the Joint Action Orthopaedic Research Appeal. n

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Features

Black box thinking: changing the surgical mindset Alisdair Felstead

The concept of learning from one’s mistakes is not a new one. Many of us will be familiar with the now ubiquitous comparison of the approach to safety by airlines with that of healthcare organisations. The mandated ‘cockpit silence’ for the WHO checklist shows how far we have come in healthcare regarding reducing medical errors by instituting protocols. Alisdair Felstead is currently a Senior Trauma Fellow at The Royal Sussex County Hospital in Brighton, having completed a Foot and Ankle Fellowship at Queen Alexandra Hospital Portsmouth. He completed his specialist training in the KSS region, and will soon be taking up a consultant position in Foot and Ankle Surgery.

atthew Syed expands upon this idea and introduces the theory of ‘Black Box Thinking’ in his excellent book1. The premise is that each of us can employ a metaphorical ‘black box’, which can be opened after an error and used to influence future practice. The key to opening the box is by supressing some of the natural human traits such as confirmation bias and cognitive dissonance, and by eradicating the blame culture that so pervades the modern-day NHS. The book begins with the account of the death of Elaine Bromiley during a routine sinus operation. This young mother was a low-risk elective patient who suffered hypoxia under general anaesthetic despite the intervention of several senior anaesthetists. The futility of the interventions, and the lack of perspective which prevented the initiation of a surgical airway, provide the opportunity for significant learning. The fact that her widower is an airline pilot has further amplified the ability of her story to change the way individuals work in healthcare. Syed argues that a ‘no blame’ culture is essential to benefit from the learning that these incidents provide. This is not to say that negligence should be ignored, more that professionals acting in good faith and under pressure should be supported to engage with the learning process, and not castigated or ostracised. Unfortunately, Syed argues, we have a long way to go in modern healthcare to achieve the safety profile of the airline industry.

This problem is not restricted to the NHS, indeed up to 400,000 deaths per year in the USA are attributed to preventable harm. The issue is the divergent approach to failure when comparing the two sectors. After an air accident, the black box will be obtained, and searched for clues as to the causative factors. Key players will be interviewed without prejudice. Sometimes simulations will be run to look at the effect of modifying individual factors. Only once the learning has been put into place will flying resume. Unfortunately, in health care we are crippled by a fear of litigation from the patient, and shame in front of our peers. Despite official protestations, the impression is given that there must always be somebody ‘at fault’, a scapegoat if you like. It has always struck me as odd and disturbing that some staff in the NHS see the obligatory Datix form as an instrument of blame. This completely misses the point of the exercise and obliterates the opportunity for learning. Syed illustrates this concept neatly referencing a Harvard study comparing two hospitals, one where a ‘blame culture’ was endemic and staff lived in fear of reprisal, and one where the environment was open and honest. The reported incidence of mistakes in the former was lower, but the actual measured level of patient harm was higher. The same effect was seen in the ‘Baby P’ case in Haringey, where castigation of the social workers led to resignations, staff shortages and the rate of child homicide increased by 25%. The message is that paradoxically, an open and honest ‘no blame culture’ leads to a safer environment for patients. >>

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Features

As well as the culture of the organisation, Syed explores human traits which tend to lead to ‘closed-loop thinking’. I found his observations enlightening, and easy to extrapolate the theories to one’s own professional and personal life. He spends time discussing cognitive dissonance, which in simple terms means the discord created when the values of the subject clash with the reality of the situation. The human trait is to try and explain away factual data that seem to not to fit with their own beliefs. The example used in the book is one of the Iraq war, and the presence or otherwise of weapons of mass destruction. He is at pains to point out that he is not expressing political opinion, simply stating the facts as they were presented. Tony Blair’s justification for the invasion of Iraq hinged upon there being weapons present, hence the risk to his legacy and by implication, moral standing, if this theory was disproved. Syed states that it is natural that we try and protect the narrative at all costs, often subconsciously, as not to do so incurs significant risk. I believe that we see this within orthopaedic surgery. A poor surgical decision will be defended, because the risk to the surgeon’s moral, professional pride and self-belief is too great to allow it to be proven wrong. How many times have we blamed the patient, colleagues or standard of kit for a less than satisfactory result? Looking inward, reflecting, learning and changing practice is a much healthier way to proceed. Unfortunately, practicing defensively is further

entrenched by the way we operate. Too many ‘metalwork meetings’ end up with aggressive personal criticism rather than critical analysis. We are judged on our X-rays, with no thought as to the integrity of the soft tissues or other crucial variables. I once heard it said that the most useful journal that will never be published is ‘The Journal of Failure’. Unfortunately, we are often reduced to reading single surgeon, single centre data regarding a small number of patients who all did very well from a particular procedure. The learning from this is minimal. This notion of cognitive dissonance is referenced in the excellent article by Deepa Bose in the September 2021 issue of the JTO2. She states that the natural reaction to mistakes is to ‘bury one’s head in the sand’, but the healthier way to proceed involves discussion, deconstruction and rationalisation. This process should be automatic after any adverse result in surgery, acknowledging that complications do occur, and crucially learning from them. The book briefly touches on confirmation bias, as this is inextricably linked to our approach to failure. Syed states that it is a human trait to want to confirm what we believe to be true, but a much more effective tactic is to examine the alternative truth or null hypothesis. In orthopaedics we are often tempted by the potential of success, so much so we design studies specifically to look for it, we selectively analyse our outcomes, often explaining away

outliers. Unfortunately, this blunts our ability to pick up when things are going wrong, potentially delaying the modification of practice and harming patients. There is no doubt that the increasing use of PROMS data, level 1 research and joint working help moderate the effect of confirmation bias, yet in orthopaedics we are still hamstrung by surgical dogma. Why analyse unfixed / poorly fixed trimalleolar ankle fractures that did badly, when we can quote the ones that had an ‘acceptable result’? One of the key themes is the ‘paradox of success’. The application of the feedback loop is something that we can use to drive improvement in our practice. The most effective learning occurs when the feedback is instant, and the learning can be applied in real time. Syed uses the example of learning to steer a car versus steering a ship. If we introduce delay or worse still, break the loop so that we don’t gain feedback, then improvement and refinement cannot happen. Numerous examples are quoted from both industry (the Unilever nozzle designed by biologists) and sport (David Beckham taking a free kick). This contrasts markedly with the approach often taken in medicine, which does not utilise evolution, but employs a linear model of research: theory – design – application. Black box thinking is peppered with examples of individuals who are motivated and inspired by ‘failure’. Trevor Bayliss was driven by the lack of batteries in Africa to design his wind-up radio, and James Dyson by the loss of suction of traditional vacuum cleaners. I believe that we can use this to drive improvement in surgical practice. If the theatre list starts late, then there may be small incremental improvements (marginal gains if you like) that we can implement to change the status quo. Sometimes I think we are guilty of trying to redesign services from the ground up, rather than utilising an evolutionary approach. On a personal level, we should all be malleable, constantly refining and improving our practice rather than chopping and changing from one implant or technique to another. A supervisor of mine once told me that the most interesting thing is not what a surgeon does, but why he does it, as this reveals an open and intelligent surgical mindset, rather than one driven by surgical dogma. In the words of George Bernard Shaw: “A life spent in making mistakes is not only more honourable but more useful than a life spent doing nothing.” n

References 1. Syed M. (2015). Black box thinking: The surprising truth about success (and why some people never learn from their mistakes). John Murray. 2. Bose D. The orthopaedic ostrich: surgeons’ responses to complications. Journal of Trauma & Orthopaedics 2021;9(3):22-24.

EFAS CONGRESS 2022 SAVE THE DATE

European Foot & Ankle Society

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EDINBURGH / UK 27-28-29 OCTOBER

Features

British Orthopaedic Directors Society (BODS) network: Reporting the state of the nation Mike Reed

What is the function of BODS?

Mike Reed is a Consultant Orthopaedic Surgeon for Northumbria Healthcare NHS Trust He is President of the British Orthopaedic Directors and sits on Council of the British Orthopaedic Association.

In 2004 the original constitution named the group British Association of Clinical Directors and Lead Clinicians in Trauma and Orthopaedics. This was then shortened to the British Orthopaedic Directors Society or BODS. The initial objective of the Association was to provide a forum for discussion of the issues facing Clinical Directors and Lead Clinicians in Trauma and Orthopaedics across the United Kingdom. The society was seeking to support the BOA in influencing government health policy in a process of dialogue and engagement. Over the years, key topics have been discussed and debated via e-mail and in face-to-face meetings. The current medium is WhatsApp and Zoom – in an ‘open mike’ format rather than a webinar. All are encouraged to join in.

Who is able to join and how can they join? Clinical Directors or Lead Clinicians may join. There are some exceptions, for instance the BOA Executive are keen to hear what’s happening on the ground. Julian Owens was president of BODS as COVID hit and he led at a vital time as Clinical Directors grappled for information on how to reconfigure. It was a crucial lifeline with live discussions every day on WhatsApp and regular briefings from senior NHS leaders, with mutual feedback to them about what it was like on the ground. Clinical Directors or Lead Clinicians can join by e-mailing mike.reed@nhs.net, or ask another Clinical Director to propose them.

What is the BODS network meeting and what are the current issues being discussed? Posts on WhatsApp are wide and varied. There is normally someone in the UK having a problem and usually someone within the network to propose a solution or at least offer a show of support. Examples in recent months have been job plans, medical teams moving into our beds, the Emergency Department, pension tax, COVID rules and science, virtual fracture clinics, trauma waits, NHS payment structures for Trusts and Health Boards, leave rules. The list goes on...

Are there challenges in trauma delivery? The pandemic appears to have hit trauma hard although it is less well publicised. Theatres are less efficient and have been undermined by COVID rules and inefficiencies. Staff have been absent and have been moved to support other teams in the hospital. According to the National Hip Fracture Database, prompt surgery rates (within 36 hours) are the lowest they have been in the last 10 years. Teams have reported long waits for ‘cold’ trauma that is waiting at home.

What are the reported challenges from your members regarding elective restart? There is a mountain to climb. Orthopaedic patients in England have fared badly from the pandemic, and the devolved nations have arguably fared even worse. As clinical leaders of their respective departments the members are well placed to plan and deliver the elective recovery plans from the various governments that oversee the NHS in the UK. At the

Features

moment, most units are struggling to deliver their pre-pandemic levels of clinics and surgery. Some are running slightly more operating sessions but universally we have become less efficient. The NHS recovery plan has us delivering 30% more elective activity by 2024/25 than before the pandemic – and this seems difficult to achieve. Some Trusts are better placed with staff and investment. Returning to a version of ‘payment by results’ funding in England, and payments for Trust activity rather than whole System activity (i.e. the surrounding group of trusts as a whole) should help planning and investment. Specific challenges are a lack of nurses and other staff, although in some areas we are short of theatre and ward estate. The latter is being addressed by a huge investment in new and refurbished estate. The former is harder to solve and it is hard to see clearly if this being addressed.

We work in teams with huge skill sets and training requirements – and they are years in the making.

“The pandemic appears to have hit trauma hard although it is less well publicised. Theatres are less efficient and have been undermined by COVID rules and inefficiencies.”

Are there any examples of innovative solutions from units to address these challenges? Many units are getting ahead and are willing to share information such as protocols and contracts. BODs have led specific sessions on Limited Liability Partnerships formation as a way of delivering the large volume of NHS work required over the next few years.

What is the leadership structure of BODS?

There is a management committee elected from the members. This group designs the Zoom meetings, run any surveys of what’s happening on the ground, and invites the speakers and runs a session at congress.

The members decide the discussion topics every day. The President and Vice President are elected by the management committee. The President is in post for two years and is followed by the vice president. The president sits on BOA Council and the past president on the Orthopaedic Committee. BODS has no accounts and no employees which keeps it simple.

What are the plans for BODS in the future? This depends very much upon the members and we are keen to have volunteers to join the management committee. We aim to remain agile and able to respond quickly to demand. The group is bigger and more active than ever in discussions, although there is little need for national Zoom calls in this period of relative stability.

Current Management Committee • • • • • •

Mike Reed – President Julian Owen – Past President Alan Middleton – Vice President Bibhas Roy Ajit Shetty Vinay Takwale n

Features

Caroline Bagley is an ST8 Orthopaedic Trainee on the NE London UCLH Rotation. She has a specialist interest in Foot and Ankle Surgery. Having successfully worked LTFT for much of her specialist training she has mentored many other trainees considering flexible training.

Breaking down barriers to flexible training in trauma and orthopaedics Caroline HM Bagley, Rob Gregory and Paul Harwood on behalf of the SAC in T&O

Rob Gregory is a Consultant T&O surgeon who works in Durham. He has a longstanding interest in surgical training, is currently Chair of the SAC for T&O and is a recent Trustee of the BOA.

raining in trauma and orthopaedics must evolve to attract the best trainees from across the diversity spectrum. The traditional route of fulltime training progressing to consultant practice does not suit everyone. As Neil Mortensen said, “We have to have a profession where it’s acceptable to work part time, flexibly. It must be acceptable to have some time in and out of the profession as your personal circumstances require. It’s a matter of self-preservation.”1

Paul Harwood is a Consultant Orthopaedic Surgeon specialising in trauma and limb reconstruction at the Major Trauma Centre in Leeds. He has a particular interest in medical education and is the Deputy Training Program Director and the Joint Head of Year 3 MB ChB undergraduate program at Leeds University Medical School. He is a member of the Trauma and Orthopaedic SAC, including a responsibility for LTFT trainees.

The option to work less than full time (LTFT) opens the door to a more diverse workforce. A doctor who trains LTFT works reduced hours, calculated as a percentage of full-time training, with resultant pro-rata extension of their total training time to meet CCT requirements. It has been reported that LTFT foundation trainees are less likely to be appointed to Core Surgical Training (CST), that female CSTs are more likely to have adverse outcomes at ARCP, especially if LTFT and LTFT CSTs are more likely to fail the MRCS. At present only 4% of orthopaedic trainees work LTFT but demand is increasing. Since 2021, the JCST made LTFT training available to all trainees for Figure 1: Reasons trainees have not gone on to LTFT training. personal choice.

Our survey examines attitudes and potential barriers to flexible orthopaedic training.

A survey of UK trainees A voluntary, confidential, online survey was distributed to all orthopaedic trainees in the UK via BOTA and the TPD’s forum. The survey was designed to understand the experiences of trainees who had or were presently working LTFT, the attitudes towards LTFT training and its impact on others, and any perceived barriers to LTFT training. >>

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References: 1. Dasa V, et al. Percutaneous freezing of sensory nerves prior to total knee arthroplasty. Knee. 2016;23(3):523-528. 2. Radnovich R, et al. Cryoneurolysis to treat the pain and symptoms of knee osteoarthritis: a multicenter, randomized, double-blind, sham-controlled trial. Osteoarthritis Cartilage. 2017;25(8):1247-1256.

B I O S C I E N C E S

PP-IO-GB-0001 2021/07

Features

with a sample of the direct quotes from which the themes and subthemes were derived, are found in Appendix 1.

Discussion The results of this survey provide insights into LTFT higher surgical training in trauma and orthopaedics. The opinions expressed here are important, however we must be mindful that only 160 responses were received. This represents less than 20% of potential respondents and may be subject to selection bias. These views may therefore not be generalisable to the whole group.

Thematic Analysis

Less than full time surgical trainees have traditionally been perceived as less-thanfully-committed to their career, driving a fear of discrimination2. Unfortunately, this belief persists, with 53% of respondents to our study stating that anxiety around potential negative effects on their career put them off applying to work LTFT. This finding is supported in a recent survey of female surgeons, where a third of participants felt flexible pathways were looked down on3. Adverse perception of LTFT from TPDs and trainers was identified by a majority of all trainees in our study when asked about barriers to requesting LTFT training (65% and 33%). Conversely, most who had worked LTFT felt the attitude of their TPDs (74%) and trainers (78%) was positive, indicating that some anxieties about stigma may be outdated. More worrying was that only 59% of those who had worked LTFT felt supported by their peers. This perhaps relates to the fact that 47% of the entire group reported that they had covered additional clinical duties for LTFT colleagues at the expense of training activities. A principal challenge to normalising LTFT training is covering the deficit in service created. It is unfair to expect full-time colleagues to increase their workloads and creates understandable resentment amongst both groups. Extra support for departments is required to help design work programmes that accommodate the needs of all concerned.

Thematic analysis of open questions was undertaken, including responses from all trainees regardless of previous experience of LTFT. This approach identifies common patterns in the responses in a systematic manner and groups these into themes so they are easier to understand. The results are summarised in Figure 6. More detail of this analysis, along

Concerns regarding quality of training whilst working LTFT were also highlighted. Whilst 74% of LTFT trainees felt their training needs had been met, more than 67% reported having to work outside of their designated hours to achieve their training requirements. Furthermore, 57% stated that they were given reduced pro-rata non-clinical sessions (for example, research and administration time) compared to their full-time peers. Despite a commitment by the JCST in 2017 to improve LTFT training4, it appears that many orthopaedic departments still struggle to accommodate LTFT trainees and create pro-rata training opportunities. 26% of respondents had negative experiences with hospital management and only 22% felt management understood how LTFT training

Figure 2: Responses to question posed to all respondents on their attitudes to LTFT.

What the trainees said One hundred and sixty responses were received from 1,196 training posts (13%). 56% of respondents were male and 42% female (3% preferring not to say). 68% were Caucasian, 14% Asian, 5% of multiple ethnicity, 6% from other ethnic backgrounds, with the remainder preferring not to say. 44% had dependent children and 13% dependents other than children. Responses were received from trainees at all stages of higher surgical training. Four respondents (2.7%) had worked LTFT prior to higher surgical training (HST), 86 (57%) had considered working LTFT at some point in HST. Of these, only 27 (31%) had gone on to work less than full time. Figure 1 summarises reasons the respondents gave that they had not undertaken LTFT training. Of 118 trainees who have not worked LTFT, 72 (61%) said they might consider doing so in the future.

Attitudes of all trainees to LTFT A series of questions explored all respondents’ attitudes to LTFT, responses are summarised in Figure 2. Experiences of trainees who have worked LTFT Further questions explored the experiences of those who have worked LTFT. Of the 27 respondents, 5 were previous and 22 current LTFT trainees. Responses to these questions are summarised in Figures 3-5. Overall, 48% felt LTFT working had a positive impact on their training with 30% feeling negative and 22% feeling it made no difference. 41% felt LTFT training had a negative effect on their future career prospects, 37% felt it made no difference whilst 22% felt it had a positive impact.

Figure 3: Responses to questions posed to LTFT respondents on their experience of the organisation of their LTFT training.

Features

worked and were supportive. This further supports the view that departmental management teams need to be educated and supported to provide good training experiences whilst covering clinical commitments. Access to LTFT pathways may also be an issue, 19% or respondents were put off applying because the process was too complex whilst only 33% felt they had been given sufficient support planning LTFT training. This exposes a need to clarify the application process.

Figure 4: Responses to questions posed to LTFT respondents on their experience of the supervision of their LTFT training.

Figure 5: Responses to questions posed to LTFT respondents on their experience of the working with hospital management.

The BOA is committed to improving diversity. Whilst numbers are growing, orthopaedics still struggles to attract female applicants5. 64% of medical school applicants are female dropping to 20% of Orthopaedic SpRs, and 7% of Orthopaedic Consultants6. Improved flexible training attracts more female applicants as training coincides with the natural time for having young children. Demand for more flexible training options is not just coming from women7. Applications for LTFT training are increasing across all specialities from both genders – 96% of applicants were female in 2008 and 80% in 20148. Retaining the best trainees is as important as recruiting them. Trauma and orthopaedics reported the highest trainee drop-out rate of all surgical specialties9,10. Losing a trainee late in their carer pathway comes with significant cost. Structured LTFT programmes could help prevent trainees from leaving. This is supported by the results of our study, where the 61% of respondents said they would potentially consider LTFT working in the future, a significant proportion of these being male. The respondents in this study were at varying levels of training and from a wide range of training programmes. The over representation of female and LTFT trainees compared to the whole training population does suggest responder bias. Nevertheless, results are concordant with previous studies. Many of the issues identified were also highlighted in the 2017 JCST LTFT Policy Statement11. Where our survey differed was that, for those trainees who trained LTFT, their experiences were mostly positive. 78% disagreed when asked if they had experienced bullying because of their LTFT status. This shows a significant improvement from the 2015 study by Harries et al., though our survey is smaller and looks only at orthopaedic trainees8. 48% felt that overall LTFT training had been a positive experience whilst 22% felt that it had made no difference to their training.

Conclusion Trauma and orthopaedics is committed to recruiting the best possible trainees. Access to quality flexible training is one way of improving inclusivity. This widens the pool of potential applicants and helps with trainee retention. It is wrong however to make assumptions about which groups of people might wish to pursue LTFT training. This option should be open to all in order to support a modern workforce and increase trainee wellbeing. A cultural change whereby LTFT training is accessible and accepted will help normalise it. Educating and supporting trusts to provide for LTFT trainees will not only improve LTFT training, but also make trauma and orthopaedics a more enticing training programme that attracts ‘the best’, creating a more diverse and stronger workforce. n

References and Appendix Figure 6: Results of inductive thematic analysis (Braun and Clarke) of open questions posed to trainees on experience of working as and / or alongside LTFT trainees.

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

Features

Neal Rupani is a Specialist Registrar in Trauma and Orthopaedics in the Health Education Thames Valley region. He has a special interest in Shoulder and Elbow surgery and Medical Education.

Caroline Hing is a Professor of Orthopaedics at St George’s University London with research interests in patellofemoral instability and trauma. She is a Clinical Director for corporate outpatients and she leads for research in orthopaedics in the Trust. She is co-Editor in Chief of The Knee Journal. She supports equality and diversity within the Executive Committee of the BOA.

Deborah Eastwood is a Consultant Paediatric Orthopaedic Surgeon in London and Vice President of the BOA. She believes that accepting diversity is the key to success.

orkforce diversity and inclusion are recognised as drivers of innovation, productivity, outcomes and better decision making in industry by the McKinsey report, which in medicine ultimately benefits patients1. Diversity attracts and retains better talent and improves job satisfaction. The critical mass for effective diversity is reportedly 30%2. Traditionally, diversity was defined by obvious categorisation into gender, ethnicity, culture disability and sexual orientation. However, this definition is evolving to encompass different perspectives, roles and experiences3. Despite the known benefits of diversity and inclusion, female and ethnic representation in Trauma and Orthopaedics (T&O) is the lowest within all specialties 4,5, despite being the largest surgical sub-speciality. Female T&O consultants and trainees in the UK formed 9% and 22% respectively between 2010 and 20216,7. Despite recent improvements the rate of change has neither kept pace with the demographic changes seen at medical school (55% female) nor the improvements in gender

parity seen in other specialities8. The UK was 15th out of 31 countries in recently published gender diversity status9 and alarmingly, in the USA, it is felt that it could take up to 200 years to achieve gender parity10 at current rates. This inequality is also reflected in the British Orthopaedic Association (BOA) female membership, who account for 12% of its consultant members and 19% of current Council Trustees11. Ethnic disparity is less well-documented in the UK. The proportion of ethnic minorities suffer from a funnelling effect, progressively dropping from medical school to consultant posts. Asians (Indian subcontinent) account for 25% of consultants, 28% of specialist trainees and 35% of core trainees. Almost half the medical student population are from the BAME group, but only 10% are Black/ Afro-Caribbean. The proportion of black doctors and medical students does not reflect the general population. Accessing accurate data sources makes it difficult to draw conclusions regarding representation of other demographic groups relating to sexual orientation, socio-economic background, disability and education.

Features

B Figure 1: Gender identity. Bar chart demonstrating the proportion (%) of males and females based upon level of experience. * This figure relates to data from survey respondents. BOA membership information shows that the number of females as 7% of consultants, 6% locum consultant, 20% Post CCT, 24% of trainees and 28% of Foundation years. Currently only data on gender is collected at time of application.

A diverse workforce should help address health inequalities in minority ethnic groups, which are likely compounded by clinical and social confounders. Studies have shown a reduced uptake of total knee and shoulder replacement in Hispanic and older black patients, despite equivalent arthritis rates, worse outcomes following hip and knee surgery in terms of PROMs, mortality surgical delays, re-operations, re-admission rates and longer waits for analgesia following trauma12-20. There is a paucity of high level evidence for health inequality in T&O, with only 6 out of 482 randomised controlled trials evaluating outcomes based on ethnicity21. Without detailed knowledge of the demographic make-up of our specialty it is difficult to formulate an action plan, and more importantly, it is difficult to assess the effectiveness of any initiatives. This study aims to determine the demographic, socio-economic and disability profiles of the orthopaedic community affiliated with the BOA.

National survey A national survey was undertaken of all BOA UK members to collect their demographic data. The survey aims were determined by the BOA Executive Committee, who designed the survey modifying previously published and validated surveys to optimise construct validity. The survey was emailed to all BOA members. Two separate email reminders were sent on 5th and 27th October 2020. Data was collected in accordance with Information Commissioners Office guidance and results are published anonymously. The eight survey questions had a minimum number of available response options, including the opportunity to select a ‘prefer not to disclose’ option, to minimise completion fatigue. Respondents could identify themselves as one of 16 pre-determined ethnicity sub-groups, identified by the Office of National Statistics22, 23.

Results 1,407 BOA members responded, representing 30% of 4,684 members surveyed. Consultants were the most represented of all groups, with responses from 35%. The most junior doctor training grade of foundation doctors were least represented, with a return rate of only 14%.

Gender 9.5% of consultant responders were female*, with greater female representation at more junior grades (Figure 1). Females represented 12% of locum consultants, 21% of post-CCT fellows, 35% of trainees and 46% of foundation year doctors. Ethnicity and national identity BOA orthopaedic consultants predominantly identified as white, which accounted for two thirds (66.8%) of the consultant cohort (Figure 2A). This proportion reduced for every more junior training grades, representing 56% for trainees, 54% for foundation trainees and 30% of medical students (Figure 2B). The second largest ethnic group amongst trainees were those who identified as Asian (Indian sub-continent), at 15%, and amongst foundation trainees was Chinese at 17% (Figure 2C). Only 1% of consultants were represented by black doctors, which rose to 4% for all training grades and 7% of medical students (Figure 2D). Half the associate specialist identified as Asian (Indian sub-continent), 24% as ‘other’ while only 4% were white.

Secondary education Approximately equal proportions of consultants, foundation doctors and medical students had either an independent or state school education (Figure 3). >>

Figure 2A-E: Ethnic identity. Pie charts demonstrating the ethnic distribution stratified according to different career grades.

Features

Justine Clarke is Chief Operating Officer for the BOA.

Figure 3: Type of secondary education. Horizontal bar charts demonstrating variation secondary school education type according to career level, with stratification of bursary requirement and selection within state schools.

Rob Gregory is a Consultant T&O surgeon who works in Durham. He has a longstanding interest in surgical training, is currently Chair of the SAC for T&O and is a recent Trustee of the BOA.

Salma Chaudhury is Salma Chaudhury is a Clinical Lecturer in Trauma & Orthopaedics in Oxford, with an interest in shoulder and elbow surgery. Salma sits on the BOA diversity and inclusion committee and is a senior BOA diversity and culture ambassador. She is the Orthopaedic Lead for undergraduate medical students at the University of Oxford.

Trainees had the highest proportion of state education, at 53% compared to 34% educated in the independent sector. 65% of staff grades were educated outside the UK. Most independently educated respondents did so without bursaries. 45% of those who received a state education, attended a selective school. Socio-economic background Approximately three-quarters of all orthopaedic grades are from a middle socioeconomic background (Figure 4). International members were most likely from a higher socio-economic background, accounting for 28%, followed by consultants and foundation year trainees at 18%. Medical students most commonly identified from a lower socio-economic background at 22%. 95% of all grades identified as heterosexual or straight, apart from medical students where 11% identified as bisexual (Figure 5). 1-3% of trainees identified as gay and lesbian. Disabilities Whilst very few consultants reported a disability, 15% of medical students identified a disability, with mental health related issues affecting 11.2% (Figure 6). Learning/ concentration issues were relatively prevalent, affecting 10.6% of post CCT trainees, and 3.7% of all trainees and medical students.

Discussion We present the first comprehensive national survey to-date describing the UK orthopaedic surgical community. A clear demographic shift is seen from medical student to consultants. Most consultants identified as white, heterosexual males from a medium socio-economic class. Junior training grades have a greater proportion of females and ethnic variation. Equal proportions of respondents had state and private education, although a significant proportion attended selective state schools or received a bursary to attend private schools. This survey also highlights demographic differences for our staff grade community.

“These results are important in understanding the make-up of our current workforce, identifying disparities and assessing whether initiatives to increase diversity and inclusion have been successful. Many factors are thought to drive the trends seen, including lifestyle concerns, unconscious bias, lack of exposure and mentorship.”

Unsurprisingly, 9.5% of consultants were females, however the proportion of female consultants appointed within the past five years has increased. The proportion of white respondents decreased from approximately twothirds of consultants, half of all trainees and one-third of medical students. A small but significant proportion of the non-consultant workforce have disabilities, particularly relating to learning and concentration (potential neurocognitive diversity), highlighting the need to destigmatise and support all disabilities. Only early years respondents identified as having mental health issues.

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Low reported consultant disabilities may reflect admission inhibitions. These results are important in understanding the make-up of our current workforce, identifying disparities and assessing whether initiatives to increase diversity and inclusion have been successful. Many factors are thought to drive the trends seen, including lifestyle concerns, unconscious bias, lack of exposure and mentorship24. A common perception is that T&O is a ‘boys club’ that predominantly consists of white, privately educated, wealthy, alpha males which potentially deters applicants. These results may help dispel some of these myths by identifying changing demographics. A multifaceted approach is required to improve diversity and attract T&O trainees, including supporting parents, recognising T&O can be fun and fulfilling, and earlier exposure and greater visibility of positive role models particularly in leadership positions25.

Figure 4: Socio-economic background. Horizontal bar chart demonstrating the self-reported socio-economic backgrounds according to level of experience.

This study has limitations. There may be selection bias as only 30% of the BOA membership responded to the survey. Respondents may not have been completely honest due to the personal nature of some questions and not all questions were completed by all respondents.

Future initiatives The BOA recognises that patient care will be improved by recruiting and developing the best workforce, irrespective of background, which requires effort and a mindset change. The BOA acknowledges its leadership fails to fully reflect its membership, and that its membership does not reflect medical student demographics. It has made efforts to understand the under-representation of gender, racial minorities, disability, and sexual orientation and in 2020 published its Diversity and Inclusion Action Plan, aiming to target five key related priorities over three years11. Numerous initiatives have been pursued, such as greater female representation on Council, presenters at the Annual Congress, through social media platforms and T&O Pride month.

Figure 5: Sexual orientation. Bar chart displaying self-reported sexual orientation according to level of experience.

In conclusion, this is the most comprehensive and detailed snapshot of the demographic and disability profile of the UK orthopaedic community. This study highlights important demographic shifts from consultants to medical students and highlights underappreciated disabilities. With acceptance that a more diverse and inclusive specialty will enhance delivery of high-quality healthcare outcomes, the orthopaedic stereotype of the white, male, affluent consultant is likely to change. n

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

Figure 6: Disability prevalence and type. Horizontal bar chart examining the prevalence and type of disabilities affecting different grades of BOA members.

International

Challenges of maintaining overseas orthopaedic partnerships during the pandemic Daniel Yeomans, James Berwin, Rosemary Wall (on behalf of the WOC-Guyana Orthopaedic Partnership) and Chris Lavy

Daniel Yeomans is an ST4 trainee in the Severn Deanery. He has a keen interest in Global Health and is the current World Orthopaedic Concern (WOC-UK) representative on the BOTA committee.

s international travel came to a standstill in March 2020 overseas partnerships needed to find new ways in which to adapt and maintain relationships with colleagues in Low and Middle Income Countries (LMIC). COVID-19 brought the world online, and with it a unique opportunity to provide regular remote support to such projects. World Orthopaedic Concern UK (WOC-UK) was able to provide a platform for information sharing and resource pooling to support the continuing international education and training. Casting our mind to the June 2019 JTO issue featuring a WOC subspeciality on ‘How the global surgery agenda is changing’ – no one anticipated quite how much it would have to change over the following two years. The dedication

and enthusiasm of UK orthopaedic surgeons has enabled many partnerships to continue to thrive and provide excellent learning resources for overseas colleagues. In this article, we hear from three such examples. Two trainees, Rosemary Wall and James Berwin,

International

on their experiences of supporting orthopaedic departments in Guyana and Ethiopia. Thirdly from Professor Chris Lavy, whose plans to build a new paediatric hospital in Zimbabwe were in the final stages when the pandemic began.

Guyana-UK teaching partnership James Berwin is a Specialist Trainee (ST8) in Trauma and Orthopaedic Surgery in the Severn Deanery and co-founder of the Bahir Dar Orthopaedic Network and Exchange with Severn (BONES) Partnership.

Rosemary Wall is a Specialist Trainee (ST6) on the Warwickshire training programme.

Chris Lavy is a Consultant Orthopaedic and Spine Surgeon in Oxford and elected council member of the Royal College of Surgeons. His passion is improving surgical services and surgical training globally. He has built orthopaedic hospitals in Malawi, Zambia and Zimbabwe, and was a founder of COSECSA the regional surgical training college for East Central and Southern Africa.

The Guyanese Orthopaedic Residents Training Programme started in 2017. It encompasses a Master’s degree alongside achievement of clinical competencies. The Guyanese orthopaedic faculty is small, currently four consultants at Georgetown Public Hospital, the tertiary referral centre. This was the impetus behind the creation of the Guyana-World Orthopaedic ConcernUK teaching partnership. This encompasses West Midlands orthopaedic trainees, under the supervision of trauma consultant Deepa Bose, facilitating bi-monthly, consultant delivered Zoom teaching sessions to support the Guyanese residents’ curriculum. This has been running since July 2018. The primary impact of the COVID-19 pandemic on surgical teaching was to restrict face-to-face interactions. Our partnership was already based upon remote interaction so this did not directly impact our sessions. In fact, we found benefits from the new restrictions. One advantage of the enforced change in teaching practice was a widespread up-skilling of surgeons in the use of online learning platforms. Suddenly, we were forced to use Zoom or Teams daily, resulting in a cohort of experts with new confidence in presenting online. Our partnership grasped this opportunity. The newly screen-confident consultants were willingly recruited throughout the UK and remotely delivered teaching sessions to the Guyanese residents in their sub-specialty areas of expertise. The pandemic resulted in the team on both sides of the Atlantic enhancing their experience and knowledge of the logistics of online learning. We had a much better understanding of how to achieve a balance between switching personal cameras on for better interaction versus off to improve reception in areas with limited bandwidth, the importance of well-structured pre-reading and the use of breakout rooms to simulate small group discussions. The Guyana residents reported more confidence and ease interacting remotely from the safety and comfort of their own home. Of course, some topics are challenging to cover remotely and there is no substitute for hands on patient examination. However, thanks to Mr Faisal Ali, a Consultant Knee Surgeon based in Chesterfield and the master of orthopaedic clinical examination, the Guyana residents have enjoyed 12 months of FRCS-level clinical examination virtual teaching and have even sat a

virtual full-length mock clinical exam. Once again it is questionable whether we would have had the confidence to engage in this without the impact of the pandemic. Although initially designed to support local teaching, the increased confidence in remote interaction the partnership gained during the pandemic has led to us working together in new areas. We are developing a collaborative research project on open fractures and it is largely down to the strengthening of our relationship during the pandemic that this is progressing so well. In addition, the Birmingham Orthopaedic Network trainee collaborative has assigned a new board member this year to future proof and drive forward the Guyana-UK partnership. The easing of restrictions and the ability to travel will no doubt change our partnership once more. Areas of the curriculum will be developed locally with the long-term goal of self-sufficient local faculty to take over the running of the teaching programme. Nevertheless, as one resident put it, “even during the pandemic, when the world was brought to a standstill… our education was still going full speed ahead.”

The Bahir Dar Orthopaedic Network and Exchange with Severn (BONES) The BONES project was founded in 2019 and is a regional orthopaedic partnership between Bahir Dar, Northern Ethiopia, and Severn Deanery. The project focusses on reciprocal teaching and learning but is guided by the educational needs of the Bahir Dar trainees. Following start-up funding from the Tropical Health and Education Trust (THET) along with support from AO Alliance and WOC-UK, we were able to fund a series of trips to perform a capacity assessment, provide a Primary Trauma Care (PTC) course, paediatric orthopaedic and trauma teaching. With support from BOTA, we hosted two trainees from Bahir Dar who visited a series of hospitals in Severn Deanery, were able to attend an AO basics course and were guest speakers at the WOC-UK trainee session at the BOTA Annual Congress. >>

International

Whilst a global pandemic and civil war in neighbouring Tigray prevented travel to our friends in Bahir Dar, innovation was born out of a necessity to keep the partnership going. Trainees from Bahir Dar were invited to join online regional registrar teaching and were also given access to the Bristol Orthopaedic Registrar’s Group (BORG) app – a compendium of recorded regional teaching lectures, FRCS revision notes, operative techniques and more. We utilised virtual reality training by collaborating with Virti, an interactive VR healthcare platform. We are also incredibly grateful to Dan Perry and the Bone and Joint Journal (BJJ) Research Committee for granting full remote access to their online research methodologies course. Dr Biniyam Biresaw is a consultant trauma and orthopaedic surgeon in Bahir Dar, and he was a trainee when we first met in 2019. This is what he has to say about the BONES partnership, “I am a surgeon working in a limited resource setting and I have had the chance to collaborate with partners from across the globe. The partnership we have with Severn has been a game changer. They have provided us with hands on as well as remote teaching, academic support and inventory… they give us the opportunity to tell them what we need and they will do everything they can to provide it. For us, they are more like family.” A huge thank you to everyone involved for their ongoing support. We are hopeful that BONES will continue to grow from strength to strength. We are tentatively planning in-person visits towards the end of this year or beginning of next year.

New orthopaedic hospital for Zimbabwe Orthopaedic Surgeons Collen Msasanure and Chris Lavy, from Bulawayo and Oxford have been friends for many years through COSECSA the College of Surgeons of East, Central and Southern Africa. They both had a dream of setting up a hospital in Zimbabwe where children could be a priority and where high-quality orthopaedic plastic and reconstructive surgery could be offered. Back in 2013 they teamed up with UK businessmen Neil Brown and Richard Little. The first step in this project was to contact all the orthopaedic surgeons in Zimbabwe to discuss the vision. This happened in Harare and was hosted by joint replacement surgeon and jazz pianist Alban Bowers at his colourful Jazz club. The next step was to form a local NGO, Zimbabwe Orthopaedic Trust (ZOT). ZOT worked with the Ministry of Health (MOH) to find a suitable site and an old isolation hospital in Bulawayo was chosen. The buildings had sadly been destroyed by fire but with the help of local architect Bruno and local builder Leo they were beautifully renovated, and a surgeon designed, operating block with three large theatres was built from scratch. The MOH and the management of the United Bulawayo Hospitals team worked with ZOT to set up an innovative public private partnership to manage the hospital, where the MOH retained overall ownership of the land and ZOT undertook to run the site and provide the services.

The conditions that disabled children in sub– Saharan Africa are sadly often linked to poverty and malnutrition and the hospital was therefore providing services for one of the lowest economic groups in society. The initial aim was to fund paediatric surgery by also having a private ward where market prices would be charged to adults for joint replacement and semi elective trauma surgery. Chris Lavy had experience of this model having used it in hospitals he had previously set up in Malawi and Zambia. It is a good model in terms of sustainability for a LMIC, but like any business requires careful management to avoid the risk of becoming just another private hospital and serving the affluent. We were very fortunate at the finishing stages of the hospital for ZOT to team up with Cure International, a US based Christian children’s surgical mission who offered their expert and experienced services to help fund and run the hospital. Cure Zimbabwe Children’s hospital was opened in the middle of COVID lockdown in May 2021 by the president of Zimbabwe Edson Mnangagwa and took prime spot on Zimbabwean TV that evening. The key surgeons are Collen Msasanure and Tongai Chitsatamunga, who having completed his training in Zimbabwe, spent two years in UK under the RCSEngland sponsored fellowship scheme in Oxford and Derby. They are joined by WOC-UK member Rick Gardner from Bristol who already has seven years consultant and teaching experience in the Cure Hospital in Ethiopia. Collen, Tongai and Rick have already started a local training scheme for fellows from Harare and Bulawayo and hope to become a regional centre for children’s orthopaedics.

Where next? I have no doubt there are many other overseas partnerships in the UK which have adapted to new challenges just as the examples in this article. As demonstrated, the involvement of trainees in overseas partnerships is invaluable and engagement can develop many additional skills. This year has seen the first set of WOCUK/BOTA bursaries awarded to trainees of all levels to help with the travel costs of overseas visits (or ongoing costs of virtual projects). We hope this will continue to be awarded annually to support trainees with a passion for such work. I would be delighted to hear from anyone who is interested in this kind of work or would like more information on the work of WOC-UK and can be contacted at: danyeomans@gmail.com. n

EDINBURGH INTERNATIONAL TRAUMA SYMPOSIUM 17-19th AUGUST 2022 AND

TRAUMA INSTRUCTIONAL COURSE 16th-19th AUGUST 2022

Professor Gardner

Professor Gjertsen

Dr Schepers

Professor Vallier

For more information on booking and our world-renowned faculty visit www.trauma.co.uk or email symposium@trauma.co.uk

Trainee

Lisa Kells is an FY2 doctor at the University Hospital Aintree having graduated with her MBChB from the University of Liverpool. She is due to commence her core surgical training in August 2022 at the Royal Stoke Hospital.

Professionalism within trauma and orthopaedic surgery Lisa Kells, Marieta D Franklin and Cronan Kerin

I Marieta Franklin is an ST7 registrar in Mersey where she is newly on the Surgery Training Committee. She is on the BOTA committee as the Women in Surgery Representative and forms part of their Culture & Diversity subgroup. She is also a member of the British Hip Society’s Culture & Diversity Committee and sits on the Royal College of Surgeons of England Women in Surgery Forum.

Cronan Kerin is a Consultant T&O Surgeon for Liverpool University Hospitals. He has a MA in Medical Education and is a Fellow of the Academy of Medical Educators. Since 2019 he has been the TPD in Mersey. He is also an examiner and a member of the Specialist Advisory Committee for Trauma & Orthopaedics.

n recent decades there has been an exponential growth in clinical knowledge and technological development in trauma and orthopaedic surgery. Over the same time period there have been significant changes in work-place culture. Trainees spend approximately ten years between core and speciality training, more if they take time out of programme for family, research or, as is increasingly popular if they choose to go less than full time.

guidance to help doctors in the development of their professionalism1,2. However, unlike operative numbers, professionalism is harder to quantify. Dictionary definitions exist, but how professionalism applies to doctor-patient and doctor-doctor interactions on a practical level is blurred by the lens through which the observer perceives the interaction. Generational theory goes some way to explaining the sometimes differing viewpoints of trainers and trainees on what constitutes professionalism.

Therefore, a greater gulf than ever exists between the speciality’s consultant body and their junior training colleagues. This issue is not exclusive to orthopaedic surgery and is increasingly reported, often in the context of professional behaviour. Surgical teams work best when there is good integration. If trainers better understand their trainees, they can offer better guidance; spot and guard against burnout; and foster and develop a stronger working relationship. Similarly, if trainees better understand their trainers and mentors, they will be better placed to get the most out of their training. This is increasingly important given the current challenges within training brought about by the COVID-19 pandemic working practices. Optimising one’s training opportunities is key. To work well together for our patients, and for future generations of skilled surgeons to care for them, there is a need for mutual respect within the trainertrainee relationship and professional behaviour is required.

Generation theory postulates that cohorts born within common time periods, largely accepted as twenty-year intervals, share common core beliefs as shaped by the socio-economic events that occurred during their early and adolescent years3,4. There are six generational groups discussed in the literature:

Professionalism has, and continues to be, a well-discussed topic within medicine and beyond. It is a widely agreed core attribute for all doctors regardless of their level of career progression1,2. Both the Royal College of Surgeons of England and the Royal College of Physicians have released

1. ‘The Greatest Generation’ – Born before 1928 2. ‘Silent Generation’ – Born between 1928 and 1945 3. ‘Baby Boomers’ – Born between 1946 and 1964 4. ‘Generation X’ – Born between 1965 and 1981 5. ‘Generation Y’ / ‘Millennials’ – Born between 1982 and 2000 6. ‘Generation Z’ – Born after 2000 It is worth noting that there is some discrepancy in the literature regarding the upper year end limit for the generation Y group4,5. This discrepancy highlights that there will of course be overlap in generational beliefs at the extremes of the denoted time periods. Each of these generational cohorts will have experienced different socio-economic and global events compared to the other and this has led to trends in certain characteristics and character archetypes in these cohorts (Table 1).

Trainee

Generation

Birth years

Archetype

Basic values

Silent Generation

1928 - 1945

Artist

Conservatism, Duty before pleasure, Patriotism, respect for authority, silence.

Baby Boomer

1946 - 1964

Prophet

Achievement, Loyal to their children, optimism, workaholics, personal growth, anything is possible.

Generation X

1965 - 1981

Nomad

Adaptation, entrepreneurship, family focus, individualism, self-reliance, technology literacy.

Generation Y

1982 - 2000

Hero

Avid consumers, Ability to obey, diversity, tech savvy, highly tolerant, optimism, hotly competitive. Technology savvy.

Generation Z

After 2000

Artist

Ambition, pragmatism, technology reliance/savvy.

Adapted from Table 1 in Lepeyko TI, Blyznyuk TP. Generational Theory: Value-Oriented Approach. Business Inform, 2016.

Table 1: Characteristic trends of generational cohorts.

The bulk of the current UK NHS work force is comprised of the following generations: Baby Boomer, Generation X, Generation Y, and Generation Z. Recent research exists that has explored how generational theory can cause discrepancy in how these cohorts view each other’s actions in the workplace, including, but not limited to professionalism4,5. A study amongst occupational therapists noted: mentors reported that juniors were often seeking immediate feedback, focusing on the positives; they also felt that electronic (non-face-to-face) methods of delivering performance review feedback were most desired by the juniors. However, the juniors disagreed regarding the method of delivering performance review feedback and largely agreed that they would prefer faceto-face feedback4. Discrepancies were also highlighted regarding written correspondence, be it via a messaging app or email, where text abbreviation was used (example: BTW – by the way)4. Through this work, further supportive and practical guidance has been issued to help bridge the generation and working gap within the occupational therapy community5. No such work currently exists within trauma and orthopaedics. We believe that the generational diversity in trauma and orthopaedic surgery is a strength and that we all as colleagues, mentors, seniors, and trainees now more than ever need to breed a culture of better understanding through strong working relationships to create an efficient, sustainable, and pleasant work environment. The expectation should not be for one group to change their behaviours to revolve around the others, but rather for all generational groups to increase their awareness and appreciation of the generational diversity among us. The Kennedy report published 16

fundamental recommendations for the Royal College of Surgeons of England with a goal of achieving symbolic change, institutionalised good practice, and building on strength – chief to this is increasing and celebrating diversity6. Recently, great strides have been made to fight racism and sexism within surgery yet more work needs to be done. A culture change has been called for7 – we feel understanding the perceptions around what constitutes professional behaviour is key to achieving it. We want to explore the attitudes to professionalism that exist in trauma and orthopaedic surgery. This work will build on a regional pilot study we conducted in June 2021. Participants took part in a 10 minute anonymised online questionnaire that explored attitudes on good and bad professionalism, leadership, first impressions, clinicians as teachers and students, and advocating for others. 57% of respondents were core or ST38 specialist trainees. The other 43% of responses were medical students (4%), FY1s (21%) and consultants (18%) all working in the trauma and orthopaedic environment. Of the core and ST3-8 responders, twothirds defined professionalism as being ‘a set of behaviours and attitudes defined by societal or workplace etiquette’ rather than selecting dictionary definitions. Expectations around attitudes to leadership, learning and teaching changed as responders’ grade became more senior. Over 60% cited a fear of damaging relationships with colleagues as a deterrent against advocating for themselves, a patient or colleague. Core trainees and below were more likely to introduce themselves to a new supervisor by email or in person on the first day of a placement, whereas registrars and above were more likely to email an introduction with a CV or to telephone ahead.

It seems attitudes around professionalism in orthopaedics are dynamic though clear core themes transcend grades. Following our pilot survey, modifications have been made and we are now rolling it out nationally. You can join in with one easy click by following the QR code.

Key learning points: 1. Generational perspective/experiences can be mutually beneficial. 2. When not accounted for, differences in generational perspectives can weaken professional relationships. 3. A shared mental model of professionalism should be outlined between generational groups. 4. Open dialogue is encouraged between seniors and juniors to establish expectations surrounding feedback and communication methods. 5. Further national roll out of the survey will better inform further recommendations and drive change. n

References 1. Tweedie J, Hordern J, Dacre J. Advancing medical professionalism. London: Royal College of Physicians, 2018. 2. Royal College of Surgeons of England. Professional code of conduct. Available at: www.rcseng.ac.uk/standards-and-research/ standards-and-guidance/service-standards/ surgical-care-team-guidance/professionalcode-of-conduct. [Accessed March 2022]. 3. Lepeyko TI, Blyznyuk TP. Generational Theory: Value-Oriented Approach. Business Inform, 2016. Available at: www.businessinform.net/search/?qu=Generations+Theory %3A+Value-oriented+approach&x=0&y=0. 4. Whitney RE, Morris ML, Harney J. Perspectives on the Professional Communication and needs of emerging occupational therapists of the millennial generation: A comparison study. The Open Journal of Occupational Therapy. 2021;9(1):1-16. 5. Deluliis ED, Saylor E. Bridging the Gap: Three Strategies to Optimize Professional Relationships with Generation Y and Z. The Open Journal of Occupational Therapy. 2021;9(1):1-13. 6. The Royal College of Surgeons of England (2021). An independent review on diversity and inclusion for the Royal College of Surgeons of England. Available at: www. rcseng.ac.uk/about-the-rcs/about-ourmission/diversity-review-2021. 7. Hamilton LC, Haddad FS. Getting the Culture Right. Bone Joint J. 2022;104-B(4):413-5.

Medico-legal

Should Montgomery be altering the way we do things? – Part 1 Simon Gregg-Smith

One of the benefits of a medico-legal practice is that it provides some insight into how other surgeons approach the diagnosis and treatment of patients, and how they record their decision-making, operations and follow-up. Although the style of clinical letters has changed a lot over the years, the amount of detail and length of the letters has changed surprisingly little. Simon Gregg-Smith has been a Consultant in Bath for 25 years now specialising in shoulder problems. During the last 10 years, he has prepared an increasing number of clinical negligence reports. He has just finished a term on the BOA Medico-legal Committee.

hose senior consultants in established practice when I started, would often make rather pejorative judgments about patients’ attitudes and behaviours (often in a very amusing manner), whilst current letters (perhaps wisely) are rather more bland and factual. They are definitely less open to criticisms of being judgemental about patients, but do not necessarily contain more insights into patients’ backgrounds and motivations. In recent years I have noticed a dramatic rise in the number of medical negligence claims which consider the issue of informed consent, undoubtedly linked to the Supreme Court’s Montgomery judgment in 20151.

From Bolam to Montgomery – from ‘doctor knows best’ to patient autonomy The evolution of case law relevant to consent is fairly well known. The Bolam Test was laid down in 19572. It is the best known and most quoted test for the standard of reasonable care. It stated that “If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”. The case itself was quite bizarre, involving Mr Bolam’s ECT for depression leading to bilateral acetabular fractures. He sued on the basis that he had not been given muscle relaxants or restraints, and had not been warned of such risks. He lost his case as medical opinion at the time was that the risk of fractures was low and acceptable, and it was not then standard practice to warn of the risks.

The Bolam Test was slightly modified by the Bolitho Test in 1996 – expert evidence that a given course of action would be considered reasonable by a substantial body of doctors was insufficient on its own3. The course of action also had to stand up to logical scrutiny. In other words, just because quite a lot of doctors believe something to be reasonable, it does not mean that a judge has to agree with them. It was emphasised that this sort of legal interference in medical decisions would be an exceptional rather than common event. Sidaway in 1985 narrowly failed to become a watershed in the shift in balance between ‘doctor knows best’ and modern moves to recognise individual autonomy in medical decision making4. Mrs Sidaway had been rendered paraplegic as a complication of cervical cord compression, and had not been warned of this risk in her consent. By a narrow 3-2 majority verdict the Law Lords concluded that informed consent was a matter for the doctor not the patient. The doctor could exercise professional skill and judgement in what they felt was in the patient’s best interests. Disclosing substantial risks might deter the patient from undergoing treatment that the doctor felt was in their interest. Thus Sidaway perpetuated the paternalistic relationship between doctor and patient. >>

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Medico-legal

Montgomery in 2015 was the first opportunity that the Supreme Court had to revisit the issue of patient autonomy versus medical paternalism since Sidaway in 1985. The judgment made it clear that consent is primarily an issue of patients’ rights, including the autonomous right to choose, and not only is the doctor obliged to discuss risks and alternative treatments, but should also make every effort to understand the individual patient’s circumstances and particular concerns.

By 2004 the pendulum had started to swing away from the doctor and towards the patient. In Chester vs Afshar the House of Lords took the majority view that a one to two percent risk of cauda equina in lower back surgery was a risk about which the patient should have been informed5. The court found that surgery for a lumbar disc prolapse was not performed negligently, but Miss Chester had not been warned of the risk of paralysis – had she been so warned, she would have had the opportunity to consider matters further and seek a second opinion – her individual right of autonomy had been violated. While there was debate surrounding the fact that the claimant admitted that she would have had the surgery at some point in any event, the failure to warn her of the risk and its serious consequences led Lord Steyn to pronounce “… In modern law medical paternalism no longer rules and a patient has a prima facie right to be informed by a surgeon of a small, but well established, risk of serious injury as a result of surgery…”

the risk to her large unborn baby of shoulder dystocia and lack of discussion of alternative treatments, namely a Caesarean section1. The Supreme Court concluded that the fact that the doctor did not feel that this was a risk that she should need to disclose was insufficient reason to deny Mrs Montgomery the opportunity to make her own decision. The judgment stated, “The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of

It is worth noting that the judges and Courts are really only catching up with the views of the profession and the General Medical Council. In 2006 the GMC issued guidance on ‘Good Medical Practice’6. Although much of what was written in this document has not changed, the issue of this type of consent was covered in one short paragraph: “To communicate effectively you must share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties.” By 2008 the GMC guidance covering these concepts consisted of fifty pages7 and included the sentence “You should do your best to understand the patients’ views and preferences about any proposed investigation or treatment, and the adverse outcomes they are most concerned about. You must not make assumptions about a patient’s understanding of risk or the importance they attach to different outcomes. You should discuss these issues with your patient.” This sentence, which was disseminated to the entire medical profession in 2008, effectively encapsulates all the legal conclusions of the Montgomery case, and demonstrates that in 2015 the law was simply catching up with the medical profession’s own views on what we should be doing.

“To communicate effectively you must share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them, including associated risks and uncertainties.”

The tribulations of Mrs Montgomery are well documented in the Supreme Court judgment in 2015, with lack of discussion surrounding

any reasonable alternative or variant treatments.” It went on to say, “The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is, or should reasonably be aware, that the particular patient would be likely to attach significance to it.”

Medico-legal

Treatment options and risks – a well-worn path in orthopaedics None of this should really be too difficult in orthopaedic surgery. During my training I spent several years as a Lecturer in an academic department, and one of my principal jobs was running the teaching programme for the medical students. The view that most of them had of orthopaedic surgeons (which they had picked up from our colleagues in other specialties, and has probably not changed very much!) was that we were not very bright and were either hewers of flesh or, at the best, semi-skilled carpenters. I tried to convince them that we were actually one of the most holistic specialties within medicine. By and large, making a diagnosis for us was not very difficult as most of the time we could take an x-ray, or the patient or referring doctor would have already told us what was wrong with them. The difficult bit was the range of treatments that we could carry out. For arthritis of a joint this invariably included doing nothing, sending them to someone else such as a physiotherapist or orthotist, or one of the surgical options of debridement, osteotomy, fusion or joint replacement. Deciding which of these six simple choices was the right one

was very much based on the individual patient requirements, which could be determined with a simple clerking at medical student level, focussing on the patient’s age, occupation, social and sporting activities and their past medical history. The choice of treatment was therefore entirely based around the individual patients’ circumstances and desires. I am not convinced that I changed the perception of any of the students about orthopaedic surgeons, but I did learn that it is futile to expect to change anyone’s opinion with rational argument.

In relation to failure to obtain informed consent cases, the four prong tests are:-

Practical legal consideration of the standard of consent

3. Had the appropriate advice about risks and side effects been given, the patient would have elected not to undergo the procedure/ would have made a different decision. (This is a subjective test and depends on the particular circumstances of each patient – what would they have done bearing in mind their current symptoms, prognosis, their lifestyle/job etc. and the other options that were available to them).

Although I am in absolutely no doubt that most of us do think hard about the issues of risk and benefit, and take the individual patient’s situation into account, and although most of us have been doing this throughout our careers, there does seem to be a substantial rise in the number of negligence cases that I see where a failure to obtain informed consent forms part of the case. One of the solicitors with whom I deal sent me a very helpful summary of the approach used by her in assessing the chances of a case succeeding or failing on this basis:

1. Failure to give the relevant appropriate advice about risks, side effects, benefits etc, would be considered to be negligent by a responsible body of clinicians in that field (the usual Bolam test). 2. The advice in question was not given (this is an evidential matter and is largely dependent on what is recorded in the notes).

4. The risk that has materialised is the risk that the patient should have been warned about. In Part 2 (to be published in the September edition) I will be considering each of these points and thinking about how it might affect what we do. We should not forget that all of this becomes utterly irrelevant if we actually do something badly or do not do something we should do! Most negligence cases still hinge on this standard issue of the quality of our diagnoses, treatments, operations and follow-up, and are still assessed by the Bolam Test. n

References 1. Montgomery V Lanarkshire Health Board [2015] UKSC 11. 2. Bolam v Friern Hospital Management Committee [1957] 2 All ER 118. 3. Bolitho v City and Hackney Health Authority (1997) 4 All ER 771. 4. Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital [1984] 1 All ER 1018. 5. Chester v Afshar [2004] UKHL 41. 6. General Medical Council [2006]. Good Medical Practice. 7. General Medical Council [2008]. Consent: Patients and doctors making decisions together.

Subspecialty

The ability in disability

e are in this profession of ours to make a difference, to make people better, to allow the person to be comfortable, functional and able to participate fully in what life has to offer. Our ‘standard’ joint replacement procedures virtually guarantee an enhanced quality of life for our patients with severe osteoarthritis and a THR remains one of the most satisfying operations I have ever done.

Deborah Eastwood is a Consultant Paediatric Orthopaedic Surgeon in London and Vice President of the BOA. She believes that accepting diversity is the key to success.

Along the line, however, I chose paediatric orthopaedics (or rather it chose me) because of the never-ending amazing processes of growth and development which have taught me so much about how we see ability and how we define progress. For all children, physical activity as much as physiotherapy is often key to improving symptoms and function which then encourages kids to join in. The London 2012 Paralympics, in my opinion, provided a sea-change moment where it became ok to ask questions – when children were heard to say “why can’t I have a football with bells in it?” or “those clip on legs look cool” and “I

Deborah Eastwood

wish I could run as fast as she can”. The ‘Last Leg’ television programme also encouraged an acceptance of people with abilities that differed from ours. Two years later came the first Invictus games – another turning point – which highlighted the achievements of those who’s level of ability had changed, often overnight. The games recognised the length of the road to recovery and the difficulty in reaching a point of acceptance of the new version of yourself. These athletes with an ‘acute’ change in function provided a contrast to those who have grown up with a need to adapt to their differing ability and these two sides of the coin are highlighted in the articles by John and Virginie. Life is rarely simple and should not be lonely so the importance of a supportive team must never be underestimated be it family, therapists, friends, the medical team or the prosthetists. Many people with a physical disability can be helped with the nuanced use of orthotics be it an insole or a prosthetic limb and Louise’s article highlights where some of the advances in design are taking place. Six years ago, Matthew’s wheelchair provided a mobile walker for his brother Yoshi who was learning to walk – innovation and thinking laterally should be integral to how we deal with the difficulties our patients face but also we must continue to listen and learn from them – what works for one may not be right for the other. This year, Matthew is on the front cover of this edition of our journal but much more importantly, to him, he is on the elite track for the next Paralympics. Success, however, is not defined by the Paralympics, the Invictus games or the Olympics – it is defined by those we see and treat being able to take part – in a fun run, a walk on uneven ground, or having easy access to a pool and feeling included in life.

Matthew and Yoshi - Brothers in Arms.

We must continue to support and advocate for our patients thinking laterally whenever that is necessary. n

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Subspecialty

Disability and ability in sport participation in children Virginie Pollet

ports participation and physical activity (PA) in children are known not only to have a positive effect on general health and wellbeing but also to play an educational role in the development of psychosocial skills and self-esteem. Perhaps most importantly, sports participation creates a sense of belonging1-3.

Virginie Pollet is a Paediatric Orthopaedic Surgeon from Belgium working at the Royal Manchester Children’s Hospital and has a postgraduate degree in Sports Medicine. Her interests are hip dysplasia, knee & sport injuries and neuromuscular disease in children. She is currently studying Integrative Medicine.

The UN convention on the Rights of Persons with Disability, the legal binding international instrument addressing sports participation for persons with disability, asks us “To ensure that children with disabilities have equal access with other children to participation in play, recreation and leisure and sporting activities, including those activities in the school system.” (Article 30.5d). They also call upon governments to make sure “persons with disabilities have access to sport and recreational venues, both as spectators and as active participants.”4 In 2019, the UK Chief Medical Officers (CMO) published national guidelines on physical activity for the general population relative to age1. While most subgroups were addressed, physical activity levels for children with an impairment were not included. In February of this year, the UK CMO published, for the first time, guidelines on physical activity for disabled children and young people2. Evidence-based recommendations were created, and an infographic

communication was developed to highlight equality, inclusivity, and provide guidelines to facilitate the introduction of more activity into the child’s day. A minimum of 120-180 minutes of physical activity per week (e.g. 20 minutes of PA per day) are recommended, with strength and balance activities three times a week (Figure 1).

Figure 1: Infographic on guidelines for PA participation2.

Subspecialty

Figure 2: Oliver Miller, true ambassador for Cerebral Palsy Football.

These are all steps in the right direction but still leave many children without access to physical activity. Problems of acceptance, discrimination, access to sports facilities and a lack of clubs and coaches being inclusive for disabled children have all been factors leading to lower participation3. Also, parents, caregivers, health care providers, communities and schools are often unaware or do not know where to find access to all ability and inclusive sport activities and perhaps as healthcare professionals we fail to promote this as much as we should. In a hearing to the members of Commons Digital, Culture, Media and Sport Committee in December 2021, Lauren Rowles, double paralympic gold medallist in rowing and Ellie Robinson, paralympic gold medallist in swimming, provided evidence for National Lottery funding and the importance of grassroots level of participation5. Problems with access to facilities, equipment, and inclusivity for sport participation for people with disability, for all incomes, were raised. Moreover, they highlighted the importance of the continuation of the next generation of paralympic (elite) athletes to maintain funding. The London 2012 Paralympics, were a watershed moment with athletes competing in front of sell-out crowds and since then there has been more emphasis on sport participation for individuals with a

disability, but despite this access for children to grassroots and para-youth sport activities is limited. And nine years later, in 2021, as most of us watched the Tokyo Olympics Summer games, how many of us continued on watching the Paralympic games? I was fortunate enough to meet Oliver Miller, a 15-year-old GMFCS-level 1, Cerebral Palsy United football player, in my clinic recently (Figure 2). Ollie is an exemplar of successful grassroots sport participation. Both Ollie and his parents agreed to share his story to increase awareness (amongst health care providers) of the opportunities that exist. Ollie started playing football in primary school, as he enjoyed it and it kept him active. His physiotherapist pointed him towards the Bolton Wanderers Pan Disability Football Club and he joined the team. As it became clear Ollie had not just the love for the game but also the talent, his coach encouraged the family to contact Cerebral Palsy United and he was invited for a taster session. Ollie is now on the Football Association regional talent pathway, being awarded not only the Rising Star for Manchester FA but also the prestigious Bobby Moore award in 2020. He is also an ambassador for sport participation for children with a disability and helps others where he can. Kevin de Bruyne, Phil Foden, Jack Rutter - ex CP England and Paralympian, and

Matt Crossen, who is the current CP England captain, are his role models. He hopes to play for CP England one day. Oliver’s parents stated that the biggest obstacle was to find facilities for disability sport. Whilst his medical team has been supportive over the years, he was not really encouraged to participate in sport, but was referred to physiotherapy. This is where we can play a key role as (paediatric) orthopaedic surgeons, treating children like Oliver. Just as we encourage non-disabled children to participate in physical activities, why should this be any different for the child with an impairment? Focussing on the physical health and well-being is a good starting point in the non-disabled child but can hold back the child with disability (and the community) to develop and learn a sport-specific skill. Furthermore, the typical structure of a pyramid, with general health and well-being at the bottom, will make it difficult to reach top elite para-sport level6. By showing what is possible through individuals like Oliver, athletic successes can lead to further social changes and closing the gap between the non-disabled and the disabled youth athlete. With accessibility being the biggest hurdle, developing grassroot sports programmes >>

Subspecialty

are essential. This, however, requires a unique way of thinking and turning the pyramid into a wheel, circling around culture – the culture of the nation and the culture of disability (Figure 3). This was proposed by the international disability sport outreach program, led by Jean Driscoll, world-renowned wheelchair athlete and a global advocate for disabled individuals6. The success of a program is multivariable and requires a good project leader, policies for persons with disabilities, existing opportunities, an interest level of Paralympic sport and will depend on the nation’s demographics, healthcare, and education. By continuously identifying, assessing, and evaluating what is important on every level, the program can develop sustainably. We are fortunate to live in a developed country but regardless, there is still an important disproportion in funding, accessibility, and participation. Models like these can help improve awareness and social changes, the most important reason to promote sport participation for the child with disability, aiming at equality, integration, and inclusiveness in society, not only in sports, but also in work and in life. Just as the grassroots Paralympic sport development program is about changing the mindset through awareness, Disability Sport Wales (DSW) developed the Insport project, aiming at inclusivity of disabled people7. The program developed toolkits for clubs, national governing bodies and local authorities to widen and increase participation by awarding Insport incremental standards (Ribbon, Bronze, Silver, Gold) based on inclusive thinking, planning, and delivery, offering sport participation for all abilities. Furthermore, through their club finder tool, they made it accessible to find an Insport club in your local area. It would be great to see this project expanded across the country. If we can change our mindset and see the disability not as a disadvantage but as an advantage to make it into an ability, we have a lot to offer to our patients and their families. By encouraging children and young people into physical activity, we provide an integrated approach to our care, not just looking at the biomechanical problem, but stimulating general well-being, mental health, and social integration. The latter is known to be a struggle for many young people with an impairment. Oliver’s mindset is to ‘have a go’ at anything, he never blames his disability, is not afraid to take on the extra challenge. So why don’t

Figure 3: Grassroots Paralympic sport development model6.

we take a moment and identify our local track and field club, swimming club or football club offering programs for children with cerebral palsy, Down syndrome, spina bifida etc., being able to advise our patients on sport activities for all abilities and help to close that gap. With the origins of the Olympic Games dating back to ancient Greece, Olympia, and the Paralympics created in the 20th century, with ‘para’ meaning ‘side by side’, the question has been raised if both events should merge. With (world-wide) increased focus on inclusivity in present days, is the rise of a ‘Pan-Olympic Games’ – one I would enjoy watching – slowly becoming a reality? n

References 1) UK Chief Medical Officer’s physical activity guidelines. 2019. Available at: https://assets. publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/ file/832868/uk-chief-medical-officersphysical-activity-guidelines.pdf. 2) UK Chief Medical Officer’s physical activity guidelines for disabled children and young people. 2022. Available at: www.gov.uk/government/publications/ physical-activity-in-disabled-children-anddisabled-young-people-evidence-review/ physical-activity-for-general-healthbenefits-in-disabled-children-and-disabledyoung-people-rapid-evidence-review.

3) Spaaij R, Lusher D, Jeanes R, Farquharson K, Gorman S, Magee J. Participationperformance tension and gender affect recreational sports clubs’ engagement with children and young people with diverse backgrounds and abilities. PLos One. 2019;14(4):e0214537. 4) Convention on the Rights of Persons with Disability (CRDP), United Nations. Article 30: participation in culture, recreation, leisure and sport. 2006. Available at: www.un.org/ development/desa/disabilities/issues/ disability-and-sports.html. 5) Pring J. Paralympians tell MPs of concern access to grassroots facilities. Disability News Service. 2021. Available at: www. disabilitynewsservice.com/paralympianstell-mps-of-concerns-over-access-tograssroots-facilities. 6) Forber-Pratt A, Scott JA, Driscoll J. An emerging model for grassroots paralympic sport development: a comparative case study. International Journal of Sport & Society. 2013;3(1). 7) Insport project Disability Sport Wales. Available at: www.disabilitysportwales.com/ en-gb/programmes/insport.

ISHA 2022

More information:

Annual Scientific Meeting Glasgow, UK 13 - 15 October 2022

Registration Open Join us to learn about the latest and best science in hip preservation surgery and rehabilitation Basic Science Clinical Examination Post Operative Management & Rehabilitation Surgical Technique / Intervention Outcomes Focus on Technology

Special rates available for: ISHA Members

Mr Vikas Khanduja MA (Cantab), FRCS (Orth), PhD

Local Host Chair Mr Sanjeev Patil

Early Registration deadline: 31 July 2022

Programme Chair

MBBS, DNB (Tr & Orth), MS (Orth), FRCS, FRCS (Tr & Orth)

ISHA President 2021-22 Dr Allston J Stubbs MD

Residents/Fellows Physiotherapists/Allied Health Professionals Combined Registration & Membership Package

ishasoc.net

General registration is now open and will close on Sunday 4th September 2022 Register at www.boa.ac.uk/registration.

Subspecialty

Keeping up with the active amputee

I John McFall became an amputee following a motorcycle accident in 2000 and following that obtained a BSc and MSc in Sports and Exercise Science in South Wales, with a particular interest in biomechanics and gait analysis. John competed at the Paralympic Games in Beijing 2008 and then studied medicine, graduating from Cardiff University in 2014. He is currently a Trauma and Orthopaedic ST6 in the Wessex Deanery and lives with his wife and three children in the north east of Hampshire.

’m woken by the warmth of the infusion of contrast into my femoral vessels. Immediately I have flash backs to the accident. To the dust. The blood. The pain. To my helplessness. My elbow bloody hurts. I lift my head to see a spanning ex-fix on my right leg. The angiogram confirms an avascular limb, and the consequences of tissue ischaemia were starting to affect my physiology. I have an emotional conversation with my father who has flown urgently from the UK to meet me. In August 2000 at the age of 19, I crashed a motorcycle on Koh Samui, Thailand. I probably suffered an open knee dislocation or open tibial plateau fracture with vascular injury – but in truth, I can’t be sure. What was certain was that I returned to the UK with five fewer toes than I’d left with, and a piece of my right tibia and fibula in a jar of formalin. Quite the souvenir! In the months following my injury, I wrestled with coming to terms with my new identity. I

John McFall

shared more than one cathartic moment with my incredibly supportive family and close friends. I cursed and I cried. I recall lying in my hospital bed as an inpatient in Roehampton, back when the Douglas Bader ward still existed. It was about one o’clock in the morning and I couldn’t sleep for rumination. I found myself sobbing. Absolutely uncontrollably. I reached for a heavy book on my bedside table. It was a photo album that I had been filling with memories of my travels. I turned to the inside of the back cover and began scribbling some words. The gist of my ramblings brought into sharp focus the fact that I was alive and loved; and that behind the doors for which I was now reaching lay only opportunity. In 2001 I started a degree in Sports and Exercise Science at Swansea University. It was there that I taught myself to run again. It wasn’t pretty. Running on a prosthetic knee and foot designed primarily for walking requires you to go all in – you’ve really got to commit and put a lot of effort in to do anything that

Subspecialty

resembles sprinting. That also means when it goes wrong it can be quite spectacular! By far the most catastrophic was when the hydraulic cylinder would explode mid-sprint, spraying oil all over me and the track. I developed a very understanding relationship with Tom Wickerson, my Prosthetist at Roehampton. After the eighth or ninth hydraulic catastrophe, I contacted Tom to request a replacement cylinder. He, instead, suggested building a leg specifically for running as the amount of hardware being returned under warranty was starting to draw attention! In the spring of 2003 I took receipt of my first running leg. It comprised a small four bar link swing-phase only knee and the iconic carbon fibre blade. To our knowledge, at that time it was the first of its kind to be built on the NHS. I remember, so vividly, the first time I used my running leg. It was at the National Indoor Athletics Centre, Cardiff. I cried because this is what I remember what running felt like. I had underestimated how much impact physical activity, and the importance of having the right equipment, could have on my rehabilitation.

“The functionality of an advanced waterproof microprocessor knee has allowed me to live a ‘normal’ life. I can run for a Frisbee, go rock-pooling with my children, and help them learn to swim in the sea. I can walk up and down stairs foot over foot, and go about being a surgical trainee without people ever knowing I’m a through knee amputee.”

The Ninth International Games in Stoke Mandeville in 1960 is considered the first Paralympic Games. Publicity surrounding Paralympic sport was sparse. The tremendous media coverage by the Australians of the Paralympic Games in Sydney in 2000 was a huge step forward in terms of launching disabled sport onto the world stage. In 2005, it was announced that London was to host the Summer Olympic and Paralympic Games in 2012. In preparation, there was a huge amount of interest around disabled sport and national success at the 2008 Paralympic Games in Beijing boosted enthusiasm. When I competed in Beijing, I was humbled by the passion and admiration the Chinese people showed for the Paralympic movement. The 90,000 seater stadium was almost full during my 100m sprint final. Following my race, I could barely walk five yards from the stadium to the GB Team Headquarters without getting stopped by complete strangers wanting their photograph taken with me! It was in such stark contrast to the empty grandstands of Athens four years earlier. The Chinese really had embraced Paralympic sport and, most importantly, the world had noticed. Back at home, as a result of the war in Afghanistan there were increasing numbers of young, fit British soldiers feeding into the ever improving national Paralympic sporting infrastructure. In anticipation of a home Olympiad the Paralympic movement gained traction. The London 2012 Paralympic Games was an absolute triumph. It quenched the hearts and minds of a nation ready to see ability in disability. It was an event that moved us forward as a nation. I didn’t compete at the London 2012 Paralympic Games, choosing instead to go to medical school and get a proper job! I was, however, privileged enough to work there for several different organisations. In the lead up to London 2012 I was approached by a global healthcare company to give them some feedback on a running prosthesis they were planning on launching at The Games. One thing led to another and I ended up becoming the face of their global marketing campaigns for several prosthetic products. I’ve been using these world leading high end prosthetics for nearly 10 years, but as my contract with this company draws to close I worry that, as a civilian, I will no longer have access to these same components on the NHS. There has been significant progress in the provision of advanced prosthetics on the NHS in recent years, and, in 2016, the NHS clinical commissioning policy for microprocessor knees (MPKs) was published. >>

Subspecialty

However, there is still a marked discrepancy in prosthetic provision for the very active civilian compared to military personnel, with a K4 activity level (the highest) being a contra-indication for a microprocessor knee in the NHS patient. For the patient this leaves only an application to a specialist commissioning group where their individual case can be considered. It concerns me greatly to think that my future prosthetic provision could be determined by a body who may not appreciate my aspirations and ambitions, and whose judgement is likely to be constrained by the economics of a

As orthopaedic surgeons, what can we do to support our patients going through the trauma of amputations? Having a relationship with your local limb loss rehabilitation services and seeing what happens to these patients would help with future early signposting and management of patients’ expectations. What are the aspects of rehabilitation that are most important in maximising psychological and physical function? For me, physical activity was hugely important for my emotional recovery and I believe the two go hand in hand. For a prosthesis wearer having a good, healthy stump and being comfortable in a socket are fundamental to maximising physical function. It doesn’t matter what fancy componentry you put underneath a socket, if it’s uncomfortable the patient won’t wear it. Tell patients to fight for this. Not all amputees will end up using prostheses (usually complex high level amputations), but patients don’t have to wear a prosthesis to be active. Hand bikes and wheelchair sports are hugely popular and accessible. How can suitable and interested patients get involved in disability sport? Nowadays the vast majority of mainstream sports clubs welcome, and have provision for, people with disabilities. The website www.parasport.org.uk is supported by Paralympics GB and is probably the best

struggling public healthcare system. The functionality of an advanced waterproof microprocessor knee has allowed me to live a ‘normal’ life. I can run for a Frisbee, go rockpooling with my children, and help them learn to swim in the sea. I can walk up and down stairs foot over foot, and go about being a surgical trainee without people ever knowing I’m a through knee amputee. My own story is not important, because behind every person who has suffered life changing injuries is a story like mine. A story of loss, grief and metamorphosis. However, I believe the Paralympic movement has brought these individuals hope. The

place to start for grass roots opportunities in disability sport. What resources are available for patients and surgeons to help maximise quality of life, sports and recreation following traumatic amputation? There is a plethora of active amputee groups and forums that can be found online. For patients that have the means, there are a number of private prosthetic service providers, such as Dorset Orthopaedic, who have extensive experience making prosthetics from life like silicon finished arms to Paralympic running blades and cycling legs. For surgeons, NHS England and other Home Nations have published commissioning guidance for prosthetics. Patients are entitled to an ‘every day’ limb (which may include a MPK) and a recreational limb to meet their clinical needs and rehabilitation goals. Having an awareness of this will help manage patient expectation. What do patients need to be careful of when engaging with sports? The main thing to be aware of is meticulous stump care when doing sport using a prosthesis. Increased sweat, shear forces and fluctuations in stump volume can cause stump damage. Amputees should gradually increase activity levels and check their stump for damage regularly, especially denervated areas.

Paralympic movement is not about elite sport. It is about challenging the perceived norms of physical disability, recognising the desires of individuals to push beyond the boundaries expected by the NHS clinical rehab office and, in my case, creating the conditions to meet the expectations of the highly active civilian amputee population. For hope to turn into reality it is imperative we provide a level of rehabilitation services that reflects our endorsement of the Paralympic movement. For the very active individual with an acquired amputation, we should never underestimate the role technology plays in the return journey to personal identity and sense of self. n

Anecdotally, because a below knee prosthesis is patella tendon weight bearing like a Sarmiento cast, I have seen several tibial plateau fractures in transtibial amputees (middle aged) secondary to disuse osteopenia. Insufficiency and fragility neck of femur fractures are also possible in trans-femoral amputees for the same reason. n

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Surg Lt Cdr Louise McMenemy graduated from Guy’s, King’s and St Thomas’ School of Medicine, in 2010. She passed out of BRNC in 2012 and has deployed extensively. She is a T&O trainee hosted in Wessex and gained a PhD from the Centre for Blast Injury Studies, Imperial College London, in 2021 entitled, ‘Optimising outcomes following complex foot and ankle trauma’.

The use of orthoses to return young patients to impact activities following complex foot and ankle injuries Louise McMenemy and Arul Ramasamy

T Lt Col Arul Ramasamy is a Consultant Trauma and Orthopaedic Surgeon at Milton Keynes University Hospital and Head of the Academic Department of Military Trauma and Orthopaedics.

he decision to salvage or amputate a mangled lower limb following trauma is not an easy one (Figure 1). In 1987 Hansen declared in his editorial, that Limb Salvage (LS) surgery following Gustilo and Anderson (GA) Type 3C tibial fractures leaves patients, ‘divorced, demoralised and destitute’1. Despite extensive research throughout the nineties, by the turn of the millennium, there was no consensus in the literature of the best treatment for the mangled lower extremity. Consequently, there was a need for an evidence base to elucidate which management option,

amputation or LS, would provide the best outcome for patients. The Lower Extremity Assessment Project (LEAP) was a North American based, multi-centre prospective longitudinal study, aiming to answer the question of whether amputees or LS patients had better outcomes following High Energy Lower Extremity Trauma (HELET)2. At 2- and 7-year follow-up, LEAP found no statistically significant difference in the Sickness Impact Profile (SIP), (the primary outcome measure), between the primary-, secondary-amputation, and LS groups, but all outcomes were worse than population norms3,4. >>

Figure 1: Radiograph following a deck-slap injury showing a mangled foot.

Subspecialty

Figure 2: Solid Ankle Foot Orthosis (AFO).

LEAP finished recruiting over 20 years ago and since then advances have been made in prosthetic design and rehabilitation pathways. Consequently, Patient Reported Outcome Measures (PROMs) and functional outcomes for some amputees, particularly young previously active individuals, are superior to LS patients5. It is, however, desirable to prevent amputation where possible due to the potential for long term health complications6. The observed technological advances in prosthetic design lend themselves to orthotic design to augment function following LS without the need for amputation. If orthotics can be improved to allow young active individuals to return to impact activities, PROMs for LS patients may be brought in line with amputees, or even potentially match population norms.

Pathology To understand which orthotic options are likely to improve outcomes for LS patients, it is important to understand the functional deficits these patients experience. Clearly, LS encompasses a wide variety of injuries, diagnoses, and therefore deficits. Deformity, weakness of plantar and/or dorsiflexors, and mechanical pain, as well as functional deficits consequent on arthrodesis and nerve injury, are present in LS patients following HELET. Functional outcomes are further reduced by resultant slower gait, asymmetry due to pain or functional deficit, and energy inefficiency.

Figure 3: Posterior Leaf Spring (PLS) orthosis.

Post LS surgery, despite efforts intraoperatively to minimise abnormalities, gait has been noted to change with the severity of the gait deviations predictive of a poorer outcome. Slower preferred walking speed, a lengthened stride time, a deterioration of balance control, and concomitant involvement of the knee joint are all associated with longer LS recovery times.

Orthotic use in those with a salvaged limb To allow individuals following LS to undertake activities, orthotic devices may be prescribed. Some patients may require several different orthoses to enable a spectrum of activities. Although there are a number of orthoses on the market they can be divided into broad categories. Ankle Foot Orthoses (AFO) are either passive or functional (using motors to enable movement). Passive AFOs fall into two further broad categories: static or dynamic. Static orthoses prevent any motion at the ankle joint and dynamic orthoses allow some motion in the sagittal plane. Solid AFOs (Figure 2) Are usually made from thermoplastics which are thin and light. They hold the ankle static throughout gait and are of use for patients with dorsiflexor weakness. This level of support however comes at the cost of compromise of the rockers of gait. An example is the Posterior Shell Orthosis. This type of orthosis may be of use during daily activities, but the material and restrictive design means it cannot be worn for impact activities.

An alternative is the patella tendon bearing AFO (PTB-AFO). The PTB-AFO is a static AFO that offloads the ankle joint by preferentially placing the forces through the patella tendon. This reduces axial loading of the distal limb and hence improves pain at the ankle joint. These orthoses can be very useful for patients with post-traumatic OA to reduce mechanical pain. Again, during daily activities this type of orthosis may be of use, however the lack of flexibility means it is not suitable for patients wishing to return to impact activities. Turning to dynamic AFOs, the Posterior Leaf Spring (PLS) (Figure 3) Is made of a flexible material to allow for some ankle motion. As the name suggests, a leaf spring action occurs when the AFO is deformed during stance. This energy is theoretically stored and returned at pre-swing. Although in theory this may help with forward propulsion, in practice this does not occur7. Although the PLS may be one of a spectrum of orthoses offered to patients, again it is not suitable for running or impact activities. To overcome deficiencies in the PLS, the Carbon Fibre Orthosis (CFO) was created to store energy and allow for impact activities. Unfortunately, although the lower and upper parts of the orthosis are made from carbon fibre, they are joined by a thermoplastic strut which breaks during impact activities. >>

Subspecialty

Phase of Gait

Name of phase

% of gait cycle

Action

Comment

Initial contact

0-2

The PDAFO positions the foot for heel/midfoot contact (depending on walking or running)

This is useful for patients with dorsiflexor weakness

Loading response

2-12

The PDAFO allows for the foot to be placed flat and there is a small amount of tibial advancement

This is useful for patients with dorsiflexor weakness

This aids with pain relief in the case of ankle arthritis

Mid-stance

12-31

The PDAFO acts as a ‘load sharing’ or ‘load redirecting’ device in a similar way to a patella tendon bearing device. This limits the load passing axially through the ankle joint and either shares or redistributes that load in an anterior direction

Terminal stance

31-50

The PDAFO acts as an energy storing orthosis (like the CFO) with the structs deforming to store energy

This aids patients with plantar flexor weakness or following fusion

Pre-swing

50-60

The PDAFO returns energy to augment function at toe off

This aids patients with plantar flexor weakness or following fusion

Swing phase

60-100

The PDAFO holds the foot in a dorsiflexed position to prevent the toe contacting the ground and ensures the foot is appropriately positioned for initial contact

This helps patients with dorsiflexor weakness

Table 1: Mechanism of action of the PDAFO.

The AFO most likely to return individuals to impact activities is a Passive Dynamic Ankle Foot Orthosis (PDAFO). A PDAFO combines the design features of the aforementioned orthoses, whilst being made entirely of carbon fibre. Two of the most prevalent PDAFOs are the Intrepid Dynamic Exoskeletal Orthosis (IDEO) used in the US and the Bespoke Offloading Brace (BOB) used in the UK. These orthoses were designed to improve patientperformance outcomes for young active patients following LS and attempt to prevent delayed/elective amputation.

note that the PDAFO works best when combined with a bespoke rehabilitation programme15. The PDAFO does not work for everyone, there is still a 20% amputation rate following use in patient populations previously considering elective amputation12,16,17. Despite this, the outcome for amputees following a trial of the PDAFO is not statistically different from those

Passive Dynamic Ankle Foot Orthosis (PDAFO) The PDAFO is a custom-made orthosis (Figure 4) and works in several different ways (Table 1). The PDAFO is of use in a heterogeneous population of patients including those with weakness in plantar and dorsiflexion, mechanical pain on loading of the hind and mid foot, nerve injury, and following ankle and/or subtalar fusion. Up to 80% of wearers have been able to return to running8,9. Statistically significant improvements have also been demonstrated in measures of agility, strength, and power bringing measures in line with population norms10-14. It is important to

who pursued amputation primarily15. Therefore, it is a good option to offer individuals prior to elective amputation.

The future Just as a non-disabled person may choose a pair of shoes for a particular activity, patients may require prescription of several orthoses designed for different purposes. The PDAFO is a good option to return previously active individuals to impact activities following complex foot and ankle injuries. Although it works for a heterogenous cohort of individuals, some will abandon it and others will pursue elective amputation, where again there are a range of prosthetic limbs to cover a variety of needs. Although the PDAFO is currently an expensive treatment option, it has the potential to return economically productive individuals to work and therefore should be considered as part of a rehabilitation package. Orthotic technology has progressed rapidly over the past twenty years, but research has not kept pace with that of prosthetic design and more can and should be done to augment function in limb salvage patients to prevent elective amputation. n

References Figure 4: PDAFO component parts.

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

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In Memoriam

Lori A Karol

7th November 1961 – 26th February 2022 Obituary by Deborah Eastwood At Scottish Rite, Lori started her career as a general paediatric orthopaedic surgeon and that is also how she finished. She became a consummate academic orthopaedic surgeon contributing to the literature with all the ‘go to’ papers covering Dr Lori A Karol visits with patient Adalynn of Waxahachie (Texas). Credit: Scottish Rite for Children. a wide range of topics from gait cannot remember my first meeting with and function following clubfeet treatment Lori but somehow I feeI I have known through pulmonary function in early her all my career – wherever I went in onset scoliosis and back to function and the world of paediatric orthopaedics, energy expenditure in children who have Lori was there too, to chat to about undergone amputations. She was also an life, kids, leadership and much else. exceptionally skilled clinician and a natural educator and ‘pearls of wisdom’ were the Lori was a native of Detroit, Michigan and hallmarks of all her teaching sessions, be began her medical studies at the University they in a hospital corridor or on the podium of Michigan which cemented her love of of an international meeting. medicine and her die-hard enthusiasm for the Michigan Maize and Blue! As a resident In addition to all that, she had a true gift her talents were clear to see as she won the in connecting with patients and their AOA-Zimmer Resident Research Award and families that was unparalleled and her when she moved to Dallas for her fellowship, clinical practice impacted thousands of it began a career long relationship with the children with both simple and challenging Texas Scottish Rite Hospital. Initially, she conditions: she guided the kids and their was recruited to the University of California, families through their treatment with the Davis, but she soon came back ‘home’. skill and humanity that too few can provide.

#Ilooklikeasurgeon – Lori on stage with Presidents of EPOS and POSNA in 2017.

We shared a ‘Tony’ mentor – mine is Tony Catterall and hers, Tony Herring. He called her “a trailblazer in the finest sense of the word. In her straightforward approach to every task, big or small, she did the work and always got the job done without fanfare or glory”. Leadership came naturally to Lori and I was privileged to be in the presidential line at EPOS whilst she was in the same line for POSNA. She was an unfailing advocate of diversity and provided the ultimate female role model. We shared a memorable #Ilooklikeasurgeon moment on stage at EPOSNA 2017 – with the organisers being surprised how long it took to get the ‘few’ women delegates on stage! She was headhunted on several occasions for a ‘Chief of Orthopaedics’ position and she finally left Dallas for Colorado Children’s Hospital in 2020 only to be diagnosed with her tumour too soon after her arrival. Lori managed to juggle work and play better than most. She cherished life, loved Jimmy Buffet (and Fleetwood Mac), read widely, was a fearless chef and a gardener, enjoyed yoga often followed (at least once to my personal knowledge!) by a glass of wine. She always took the time to get to know you and was a witty conversationalist and a truly great friend. Most importantly of all, she was devoted to the family of Bob and their three daughters, Abby, Leah and Molly. n

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Journal of Trauma & Orthopaedics - Vol 10 / Iss 2

Articles inside

How diverse and inclusive are the demographic, socio-economic and disability profiles of the BOA membership in the UK?

Joint Action Update

Specialty Society Updates

Zimmer Biomet Trauma Travelling Fellowship to Ludwigshafen

Latest News

Green shoots of elective recovery?

From the Executive Editor

In Memoriam - Lori A Karol

Keeping up with the active amputee

Disability and ability in sport participation in children

The use of orthoses to return young patients to impact activities following complex foot and ankle injuries

The ability in disability

Should Montgomery be altering the way we do things? – Part 1

Professionalism within trauma and orthopaedic surgery

Black box thinking: changing the surgical mindset

Breaking down barriers to flexible training in trauma and orthopaedics

News: BOA Annual Congress 2022

Challenges of maintaining overseas orthopaedic partnerships during the pandemic

British Orthopaedic Directors Society (BODS) network: Reporting the state of the nation