Journal of Trauma & Orthopaedics – Vol 11 / Iss 2

OrthoFoam Knee Wedges

Nailing, nailed.

Simplify patient positioning for tibial or retrograde femoral nailing procedures with our range of trauma triangles. The knee remains in the correct position throughout the procedure with our durable foam providing the perfect balance of cushioning and stability.

Product Code:

OL.OF.KWS Ortholove Knee Wedge Small

OL.OF.KWM Ortholove Knee Wedge Medium

OL.OF.KWL Ortholove Knee Wedge Large

OrthoFoam Adult Ramp Elevator

Surgery, sorted.

Indicated for all surgical cases where elevation is necessary without offloading the heel. Frequently used in trauma cases to enable easy x-ray control. The ergonomic design, with slight concavity, ensures stable support of the limb without too much pressure on the calf.

Product Code: OL.OF.ARE

OrthoFoam SRE

Swelling no more.

Indicated following foot and ankle surgical cases for application in theatre or recovery or even preoperatively for trauma cases to ensure reduction of swelling. The ergonomic design ensures patient comfort, with stable elevation at heart level and without strain on the knee or hip. A home use version of the SRE allows patients’ seamless recovery after leaving hospital to the comfort of their home.

Product Code: OL.OF.SRE

Other shapes and sizes available. Call or email for more info

In this issue...

26 Features:

Alterations in commissioning and construction of British Orthopaedic Association Standards Fergal Monsell, Alex Trompter and Nick Aresti

6-7 BOA Latest News

14 Features: War and accidents – a driver for the NHS and the BOA Gary Robjent

16 Features:

20 Years of the National Joint Registry: who benefits? Part one: patients and hospitals

Elaine Young, Gillian Coward, Robin Brittain and Timothy Wilton

20 Features: Setting Up Revision Hip Networks: The British Hip Society Approach Andrew Hamer, Tim Board, Richard Holleyman and Vikas Khanduja

24 Features: The BOA and the independent sector (private practice): ensuring best care, identifying concerns and representing our members

Andrew Manktelow and Mark Bowditch

30 Features:

Improving breast radiation protection for female orthopaedic surgeons

Hannah Sevenoaks, Isobel Pilkington, Lynn Hutchings and Charlotte Lewis

32 Features: Building a culture of safety and health at work

Hiro Tanaka

36 Trainee: Non-selective state schools engagement programme: The British Hip Society Experience Marieta Franklin, Joanna Maggs and Vikas Khanduja

40 Medico-legal: Clinical guidelines and the standard of care: Part 1 Simon Britten

43 Subspecialty: Paediatric orthopaedics update: what’s new with the ‘Big Three’? Anna Clarke

Download the App

44 Subspecialty:

Evolution and current management of the paediatric supracondylar fracture James Hunter and Anna Clarke

48 Subspecialty:

Open tibial fractures in children: are they really just little adults? Jonny Jeffery, Thomas Wright, Anna Clarke and Umraz Khan

52 Subspecialty:

Paediatric Infection Update – Sticks and stones may break my bones, but infection makes me sicker Katie Hughes, Emily Baird and Anna Clarke

55 In Memoriam: Timothy Rowland Morley

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

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

JTO Editorial Team

l Simon Hodkinson (Executive Editor)

l Hiro Tanaka (Editor)

l Simon Britten (Medico-legal Editor)

l Abhinav Singh (Trainee Editor)

l Anna Clarke (Guest Editor)

BOA Executive

l Deborah Eastwood (President)

l John Skinner

(Immediate Past President)

l Simon Hodkinson (Vice President)

l Mark Bowditch (Vice President Elect)

l Fergal Monsell (Honorary Secretary)

l Ian McNab (Honorary Treasurer)

l Bob Handley (Appointed Trustee)

BOA Elected Trustees

l Deborah Eastwood (President)

l John Skinner (Immediate Past President)

l Simon Hodkinson (Vice President)

l Mark Bowditch (Vice President Elect)

l Fergal Monsell (Honorary Secretary)

l Ian McNab (Honorary Treasurer)

l Fares Haddad

l Amar Rangan

l Sarah Stapley

l Hiro Tanaka

l Cheryl Baldwick

l Deepa Bose

l Caroline Hing

l Andrew Price

l Andrew Manktelow

l Andrea Sott

l Paul Banaszkiewicz

l Stephen Eastaugh-Waring

Copyright

BOA Staff

Executive Office

Chief Operating Officer - Justine Clarke

Personal Assistant to the Executive - Celia Jones

Education Advisor - Lisa Hadfield-Law

Policy and Programmes

Head of Policy and Public Affairs - Gary Robjent

Head of Education and Programmes

- Alice Coburn

Programme and Committees Officer

- Eliza Heng

Educational Programmes Assistants

- Lina Mirghani & Mia Gordon

Communications and Operations

Director of Communications and Operations

- Annette Heninger

Marketing and Communications Officer

- Pujarini Nadaf

Membership and Governance Officer

- Natasha Wainwright

Interim Membership and Governance Officer

- Vicky McGuinness

Publications and Web Officer - Nick Dunwell

Interim Publications and Web Officer

- Michael Davis

Finance

Director of Finance - Liz Fry

Finance Assistant - Hayley Ly

Events and Specialist Societies

Head of Events - Charlie Silva

Events Coordinator - Venease Morgan

Exhibition and Events Coordinator - Anna Prunty

UKSSB Executive Assistant - Henry Dodds

Credits

From the Executive Editor

Simon Hodkinson

Awarm welcome to the June edition of the JTO. A year ago, when I welcomed you to the June edition of 2022 in the pouring rain on the south coast, I contemplated the possibility of flaming June arriving. It did indeed arrive and continued unabated into July and August.

Sadly, many of last year’s issues remain, and we now have our nursing and junior doctor colleagues involved in a series of strikes, the like of which we have never seen before. However, we soldier on and in this edition, we start with congratulations to all our runners, cyclists, and last but by no means least, our home-grown Tough Mudder team, raising money for Joint Action. Many congratulations and thanks to all who took part. Judging by the photographs, I’m glad the BOA is not responsible for their laundry bill!

We move on to a reflective piece on the origins of the NHS by our own Head of Policy and Public Affairs, Gary Robjent, as we celebrate its 75th anniversary. As he mentions, so much of what we have today has its origins in the two worlds wars and their aftermath, and to the traumatic fallout of the industrialisation of the UK.

The first of a series of articles from the NJR, as it celebrates its 20th anniversary, reflects on the positive changes in the outcomes from joint replacement, noting the continuing fall in the mortality of the operation, to the fact that 90% of hip and knee replacements now last more than 15 years.

Following on the theme of joint replacement, Andrew Hamer et al records the development and roll out of the revision hip networks. I am sure that this will not be the last national networks we see develop in our speciality, all to the benefit of our patients.

Andrew Manktelow has produced a timely article on the activities in the independent sector, and raises the potential disconnect between practitioners in the independent sector and the BOA. As an addendum to this article, I would invite anybody who wishes to engage with the BOA on this or any other issue that needs our attention to use the JTO e-mail address (jto@boa.ac.uk).

Fergal Monsell discusses the evolution of the BOAST guidelines, highlighting that in the future BOAST guidelines will continue, but on subjects of a generic interest to all orthopaedic surgeons and these will now be supplemented by SpecS documents focusing on specific issues related to specialties.

Copyright© 2023 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information:

Wendy Parker - Media Manager

Email: Wendy@ob-mc.co.uk | Telephone: +44 (0)121 200 7820

Open Box M&C, Premier House, 13 St Paul’s Square, Birmingham B3 1RB

Disclaimer

The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication.

BOA contact details

The British Orthopaedic Association, 38-43 Lincoln’s Inn Fields, London WC2A 3PE

Telephone: 020 7405 6507

How to contact JTO

Email: jto@boa.ac.uk

The next two articles focus on health and safety at work. The article by Hannah Sevenoaks and her colleagues discusses the issue of improving the protection of the breast in female orthopaedic surgeons, raising issues of potentially inadequate protection from the conventional tabard-type lead gowns. The next article by Hiro Tanaka –the first in a series of health and safety articles to be produced – discusses in more detail the generic issues of radiation and how we should pay attention to protecting ourselves. Something that I suspect we have all at some stage in our careers ignored.

This month’s trainee section looks at the British Hip Society’s programme that they ran during their annual meeting, engaging non-selective state schools with the idea of a career in medicine, and subsequently trauma and orthopaedic surgery. We are indebted to Marietta Franklin and her colleagues in the British Hip Society for producing not only the article, but for creating the project as an example of engaging our profession with a wider audience.

Simon Britten, as chair of the medical legal committee at the BOA, has produced an interesting article on the issue of clinical guidelines and standards of care, and delves into their place in ours and our legal colleague’s practice.

Finally, but by no means least, we come on to our specialty features for the June edition, edited by Anna Clarke. As she says in her introduction to the three articles, they cover the big three paediatric problems that historically have caused a degree of stress to the coronary arteries in the general orthopaedic surgeon when on call. These three articles cover supracondylar fractures, infection in the paediatric patient and open tibial fractures. They’re excellent articles for both general and specialist orthopaedic surgeons alike and hopefully there’s something for everyone in the articles.

I do hope you enjoy the June edition of the JTO and let us hope for a quieter more peaceful summer. n

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You reap what you sow…

Deborah Eastwood

Now there is a phrase straight from my childhood days and what is more, I can still hear my mother’s voice reciting it and visualise my eyeballs rolling in response. While I am no gardener, I gather there are two basic ways of going about the task: either you simply sow the seeds in a random fashion and hope some take root and grow, or you spend happy hours within the protected environment of a greenhouse, planting individual seeds and nurturing them with food and water, plus a sprinkling of love. Either method, it seems to me, can work and work well.

All this year, I have been asking you to sow the seeds of the change you want to see. At the Royal National Orthopaedic Hospital, we have been reviewing the instruments on our trays with a significant reduction in the number of sets used per case. We have been recycling much more of the equipment we loan to patients and challenging the need for endless drapes for minor cases.

Next month, with Malue, the BOA will be launching a SOS (Sustainable Orthopaedic Systems) questionnaire to ask you more specifically about what you think should change. So, get your thinking caps on... we are looking for ideas!

Last month, I hosted the Council Dinner at the recently revamped Royal College of Surgeons of England. It was a fun night and a great opportunity to thank our past presidents, council members and training programme directors, for all that they do to support our colleagues and our profession.

On behalf of the BOA, I continue to make the most of the opportunities that come my way and recently I visited both Bangor and Stockport – the latter included a trip to Stockport County Football Club (I was a fan for a brief while, many moons ago) for Phil Turner’s retirement party. The room was full, the dance floor busy and many ‘do you remember’ anecdotes were told!

The BOA continues to promote our equaIity, diversity and inclusion agenda and several pieces of work are coming to fruition. We now know, thanks to the GOAST study, that female trainees operate on less cases and with less autonomy than their male counterparts, although we have yet to clarify what this difference means. Work on the differential attainment agenda is also making progress and we hope to have valuable information on those who are LOST from surgical training to present at Congress.

We are also working hard to broaden our base of engagement with you, our members. Ideas on widening the eligibility criteria for Trustee positions will be presented to you at the AGM in Liverpool. We have also updated the job descriptions for the Executive roles and will be suggesting changes to the voting regulations too.

Trauma and Orthopaedics continues to own a large chunk of the NHS waiting list. We remain saddened by the perception that most patients with orthopaedic problems can be managed in the community without the input of surgeons – the reality is that the surgeon is a valuable member of the team, whether or not the intervention delivered is a surgical procedure or explanation and reassurance. The ORTHOPOD data confirmed significant variation in trauma workloads from one trust to the next and such variation in practice will need to be challenged.

We are beginning to make our mark on the political scene, and hope that our ideas will be listened to and will take root. Perhaps one day soon we will be able to reap the harvest of the seeds planted now (with apologies to RL Stevenson for the misquote!). n

GIRFT pathway to help increase paediatric forearm fracture manipulation in the ED

A pathway supporting clinicians with paediatric forearm fracture manipulation in the ED is on offer from the Getting It Right First Time (GIRFT) programme. The pathway has been developed with clinical stakeholders from across orthopaedics, paediatric trauma and orthopaedics, emergency medicine, paediatric emergency medicine, and trauma and outlines best practice at all stages of the patient pathway, from triage and assessment through to discharge and follow-up. It has been co-badged by the British Orthopaedic Association.

Read the full news article at https://gettingitrightfirsttime.co.uk/pathway-tohelp-increase-paediatric-forearm-fracture-manipulation-in-the-ed/.

Resources to support parenthood in orthopaedics

UK and Ireland In-Training Examination (UKITE)

The dates for this year’s UKITE are 9th to 16th December 2023. The UKITE is an online annual assessment that allows trainees of all grades to practice for Part 1 of the FRCS (Tr and Orth) examination, with similar formatted questions based on the UK and Ireland T&O Curriculum. Information on UKITE is available on the BOA website www.boa.ac.uk/ukite

ORTHOPOD study

ORTHOPOD is a multi-centre collaborative study investigating real-time performance of trauma services, including characteristics and distribution of injuries across the United Kingdom. It emerged out of growing concerns among members within the trauma community that injuries with recommended time-to-surgery windows were being missed and the delivery of trauma care within a nationalised health service was suboptimal.

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

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

Running for 10 consecutive weeks, across 90 hospitals, data were gathered from 23,138 trauma cases and 709 weeks’ worth of theatre capacity. From this, two key works were produced.

The first publication defined current UK trauma performance in its generality, highlighting significant variation in delivery of trauma services (operative demand and capacity). The second publication described day-case trauma services or lack thereof. You can read more about the study on the BOA website at www.boa.ac.uk/ORTHOPOD

Save the Date – Ortho Update 2024 – 6th January 2024

Save the date 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

A blueprint for T&O mentorship

The Birmingham Orthopaedic Training Programme within Health Education England, West Midlands have set up a successful mentorship scheme for ST3-ST8 trainees, which is being piloted in other areas.

They have presented their approach in how to set up a mentorship scheme for T&O trainees via a screencast, using a 10-point plan. The aim is to provide a framework with useful links and documents to assist others keen to set up such a scheme. You can view them on the BOA website at www.boa.ac.uk/mentorship

UCLH PRESENTS Preparation for FRCS (Tr&Orth) Course

Wednesday 13th September 2023

UCLH Education Centre, Euston London

Course Convenor:

Mr Alistair Hunter

The emphasis of this national course is on technique and aims to provide a framework early in a trainee’s preparation for understanding the nature of the FRCS (Tr&Orth) exam, develop strategies for optimising revision and for maximising scoring in the Viva and Clinical Examinations.

Accredited by:

BOA Educational Courses

The BOA runs a wide range of courses under the Education Committee. These courses cater to the educational needs of a wide range of members (and non-members in some cases) at all stages of their careers.

Training Orthopaedic Education Supervisors (TOES)

This course is designed to help members prepare for the new curriculum and learn how to supervise trainees to be the very best they can be. We have one remaining date for the small-group virtual TOES courses in 2023. For more information or to book, please visit www.boa.ac.uk/toes

Training Orthopaedic Trainers (TOTs)

The underlying premise of TOTs is that if T&O trainers understand how people learn and how the T&O curriculum works, by translating that understanding into action, they should be able to improve their teaching. Further information or to book is available at www.boa.ac.uk/tots.

Inbuilt motorised drive offers effortless movement combined with ultimate control.

Available with our QA3 Patient & Emergency Stretchers.

For more information and to book http://training.ucheducationcentre.org/home/viewcourse/688/

BOA Travelling Fellowship Report – Limb Reconstruction Service

NSW, Sydney, Australia

Iundertook a six-month fellowship under the supervision of Dr Tim O’Carrigan at the Limb Reconstruction Service NSW, based at Macquarie University Hospital. After completing training, I was keen to undertake a fellowship where I would be exposed to a breadth of techniques in foot and ankle surgery, as well as complex deformity correction.

My specific aims were to develop experience in the areas of minimally invasive foot and ankle surgery, ankle arthroplasty and lower limb deformity correction. The fellowship provides extensive exposure to minimally invasive procedures, including bunion correction (eg, MICA), lesser toe deformity correction, distal metatarsal minimally invasive osteotomy (DMMO), calcaneal osteotomy as part of flatfoot or cavovarus corrections, as well as applications in diabetic foot

to offload bony prominences. In addition to learning the techniques, it was particularly interesting to see the benefits of a minimally invasive approach when patients return to clinic with less pain and swelling than I have observed with some of the traditional open procedures.

There was an emphasis on ankle arthroplasty using computed tomography (CT)-based planning, and 3D-printed patient specific jigs to narrow the error margins when judging implant position and alignment. In complex cases, a weight bearing CT was used to assess and plan correction of intra/extra-articular deformities, which was carried out either at the time of the ankle arthroplasty or as a staged procedure in more severe cases.

There is a fortnightly combined complex clinic where patients with severe deformities attend for assessment and a consensus opinion on management. CT imaging is linked with modelling software to understand the deformity and to plan the correction in detail. This formed the basis for manufacturing 3D-printed patient specific jigs to maximise the accuracy and effectiveness of the deformity correction. It was particularly interesting to understand the process using the modelling software, which is led by Dr Mustafa Alttahir, and to see how this translated into very accurate and easy-to-use jigs in the operating theatre. This clinic was a great learning experience, seeing a high volume of cases in patients with deformities associated with, for example, trauma, congenital abnormalities and polio. n

British Limb Reconstruction Society (BLRS) update

Simon Britten, President Elect of the British Limb Reconstruction Society

The BLRS educational committee are busy working on the content of the subspecialty slot at the BOA Congress in September. This follows hard on the heels of a really excellent BLRS Annual Conference held in March this year, hosted by our friends and colleagues Niall Breen and Luke Ogonda in Belfast. There were several outstanding international guest speakers, including Vaida Glatt from San Antonio, Texas (the biomimetic haematoma as a scaffold), Leo Donnan from Melbourne (complex foot deformity), Mauritz Laubscher from Cape Town (titanium cages for segmental bone defects) and Michael Wagels from Brisbane (3D-printed bioresorbable regenerative implants). The programme was also admirably supported by other notable experts in their field from the UK and Ireland. Gone are the days when we all just sat around and talked about frames! Congratulations to Niall, Luke and colleagues for such an excellent educational experience. The social highlights were the Titanic Museum and the appearance of the DeLorean DMC-12 sports car/time travel machine from the Back to the Future film franchise. We were also delighted that Deborah Eastwood was able to attend as an invited guest and speaker in her role as BOA President.

At the AGM, the membership supported the proposal to reduce the Presidential term from two years to one year, in line with other subspecialty societies and the BOA, with the aim of improving throughput on the committee and encouraging diversity in its widest sense, maximising the number of colleagues who participate in the development of the BLRS as an organisation and as a charity.

Again, on the educational side, we are hoping to improve collaboration with BOTA and develop a series of sessions on limb reconstruction for the FRCS(Orth) examination. The BLRS continues to support two slots on the BOA Future Leaders programme, and travel bursaries for our consultants, trainees and nursing/ AHP members. We are continuing to sponsor and badge courses in limb reconstruction nationally. In addition, we are looking to fund travelling fellows to the UK from other countries on an annual basis and we are also developing research grants – details of these to follow on the BLRS website https://blrs.org.uk/. We are completing a Delphi study to determine research priorities in limb reconstruction, led by Simon Graham, with results to follow.

The BLRS welcomes applications for membership in the following categories – consultants, trainees, nursing/AHP, and overseas. n

Miguel Fernandez

Mr Royston and BLRS President Professor Sharma

British Hip Society: A Year In Review

Vikas Khanduja MA (Cantab), MSc, FRCS (Orth), PhD.

BHS President 2022-23

The Annual Scientific Meeting in Edinburgh was a huge success being the largest ever BHS meeting, with 614 delegates faceto-face and 84 online. The programme was reimagined to encompass equity, the new additions including: programme for local school children, BOMSA day, plenary hour, JAM sessions, session on unconscious bias, inaugural BHS Awards and Charnley Legacy Lecture. A big thanks to Simon Buckley and Jai Mistry, and the whole Exec among others for making this meeting a truly memorable and inspiring event.

We have a strong membership of over 700 now, with a comprehensive and easy to access website (www.britishhipsociety.com) with excellent educational content on offer. This includes all the episodes of the midweek special webinars, surgical legacy podcasts, plus content from the annual meetings and the instructional courses. I would also encourage all the members of BOA involved in hip surgery to consider joining the BHS.

As I reflect on my term as the President, a role that has become so much more than just work for me, I can only hope that I have contributed in some part to the vision of ‘Evolving the Society and making it more accessible’, and thereby helping to uphold its position as an example of a world-class society known for delivering quality care, supporting innovation, and propagating science.

So yes, the BHS is evolving. We are becoming more integrated and diverse in our membership, and more inclusive in subject matter, be it hip preservation, primary hip arthroplasty, revision hip arthroplasty, trauma or innovation. And perhaps this is how it should continue, as the needs of our members and society at large evolve; we can’t stand still and plan for a suitable workforce for the future and equity in healthcare!

Finally, it’s time to bid farewell and welcome our new President, Professor Dominic Meek, under whose leadership BHS will only further flourish and thrive. It’s been an absolute honour, privilege, and pleasure to serve as the President of this esteemed society. Once again, many thanks to the Executive Board, Past Presidents, the BOA leadership and the membership for all your support! n

Save the Date: BSSH Autumn Scientific meeting

Lilongwe Hand Unit

For five years, the BSSH and the British Association of Hand Therapists (BAHT) will assist the Lilongwe Institute for Orthopaedics and Neurosurgery (LION) in the delivery of treatment for elective and traumatic conditions of the hand in Malawi.

BSSH and BAHT volunteers will work in the LION Hand Unit throughout this period, collaborating with local staff in the running of specialist hand clinics and regular hand trauma and elective lists, while promoting sustainability through education and training.

LION aspires to become selfsufficient in the provision of specialist hand services by the end of the project.

Please scan the QR code to find out more about the project or to donate.

Student and Trainee Association for Surgery of the Hand (STASH)

Membership of STASH provides students and junior trainees with an interest in hand surgery with the opportunity to connect, share experiences and become part of the

largest professional body of Hand Surgeons in the UK. The annual subscription is £25, which includes online access to the Journal of Hand Surgery (European volume), as well as discounted rates to attend BSSH meetings and courses.

British Society for Children’s Orthopaedic Surgery (BSCOS) update

Adelle Fishlock, Consultant in Leeds and Early Years member of the BSCOS board

What a time to work in paediatric orthopaedics! Funding for multimillion pound worldwide RCTs, multiple evidence-based BOAST guidelines published, plus amazing new observership/fellowship opportunities!

As the first ‘Early Years Representative’ on the BSCOS board, I have been working collaboratively with our subcommittees to enhance opportunity and training for all our early years members. For medical students and junior trainees, we have produced a list of centres and link consultants throughout the UK to facilitate an observership programme. This is an excellent opportunity to create new collaborative bonds and enable individuals to broaden their experience in paediatric orthopaedics.

BritSpine 2023 – Glasgow

The long-awaited postCOVID-19 biennial meeting of UK Spine Societies – the BritSpine conference and exhibition – was held at the SEC Centre in Glasgow, 18-20 April 2023, with pre-meeting masterclasses and the hosting of the National Spine Network annual meeting the day before.

The conference was attended by 40+ exhibitors and 600+ delegates from a large range of professions who work within the sphere of spinal care and research.

The highlights of the conference were the multiple keynote sessions from Dr Frank Kleinstück on adult deformity, Dr Brian Kwon on novel approaches to cervical spinal cord injury, Dr Mark Kotter on degenerative myelopathy and Professor Alf Collins on personalised spinal care, with a further 35+ plenaries, debates and paper sessions over the three days in sunny Glasgow.

Plus the BSCOS board are extremely excited to announce the ‘Gwyn Evan Early Year BSCOS Travelling Fellowship’. These fellowships will enable two BSCOS members to create an individualised UK travelling fellowship to optimise experience and exposure. We hope these will enhance orthopaedic training, allowing for continuous medical education and knowledge transfer. This is an excellent opportunity for any early years consultant.

BSCOS research continues to be AWESOME… we’ve now randomised nearly 300 medial epicondyle fractures (40 to go!), 550 displaced distal radius (200 to go) and have studies in infection (PICBONE), SCFE (BigBOSS), CP (Spell & Robust) and distal tibial fractures (ODD SOCKS) starting in the next few months. BE PART OF IT!

Please see the BSCOS website for further details on both of these exciting new opportunities! n

In addition to the educational sessions, the event also had a large exhibition featuring the latest spinal care products and services from a variety of companies and charities, along with plenty of networking and scientific posters. The conference dinner was held at the Glasgow Science Centre, where we were treated to fantastic food and entertainment with Ceilidh dancing! Fundraising for our nominated charity, Myelopathy.org raised over £4,000 for on the night via a raffle too.

The UK Spine Societies Board (UKSSB) would like to thank the City of Glasgow and the SEC Centre for being such wonderful hosts, as well as Mosaic Events for their hard work and dedication. Visit us on Twitter at @BritSpine and @UKspineSB for photos and videos from this fantastic event.

We are currently searching for a venue for the next BritSpine planned for spring 2025, so follow us on Twitter and bookmark www.BritSpine.com and www.UKSSB.com for further news and updates! n

“This is an excellent opportunity to create new collaborative bonds and enable individuals to broaden their experience in paediatric orthopaedics.”

Sashin Ahuja, UKSSB Chairperson

Mark Thomas, UKSSB Treasurer

Mike Grevitt, UKSSB Secretary

Henry Dodds, UKSSB Executive Assistant

Conference Listing 2023:

BOOS (British Orthopaedic Oncology Society)

www.boos.org.uk

09 June 2023, Burton-on-Trent

UKPJI (UK Prosthetic Joint Infection) www.ukpji.com

15-16 June 2023, Exeter

BESS (British Elbow and Shoulder Society) www.bess.ac.uk

27-30 June 2023, Newport

BIOS (British Indian Orthopaedic Society) www.britishindianorthopaedicsociety.org.uk

07-08 July 2023, Windsor

BOA (British Orthopaedic Association) www.boa.ac.uk

19-22 September 2023, Liverpool

BORS (British Orthopaedic Research Society) www.borsoc.org.uk

25-26 September 2023, Cambridge

BOSTAA (British Orthopaedic Sports Trauma and Arthroscopy Association)

www.bostaa.ac.uk

09 November 2023, London

BSS (British Scoliosis Society) www.spinesurgeons.ac.uk/event-5235572

09-10 November, Liverpool

BTS (British Trauma Society)

www.britishtrauma.com

22-24 November 2023, Oxford

BSSH (The British Society for Surgery of the Hand)

www.bssh.ac.uk

22-24 November 2023, Glasgow

BASS (British Association of Spine Surgeons)

www.spinesurgeons.ac.uk

20-22 February 2024, Bournemouth

BOFAS (The British Orthopaedic Foot and Ankle Society) www.bofas.org.uk

06-08 March 2024, Belfast

BOA Annual Congress 2023

19th - 22nd September, ICC Liverpool

www.boa.ac.uk/Congress #BOAAC23

Programme update

Under the theme of ‘Sustainable Systems’, the 2023 Annual Congress will take place 19th - 22nd September at ACC, Liverpool. We are working closely once again with the specialist societies to deliver revalidation and hot topic sessions. The programme will include keynote lectures, including the BOA’s Presidential Guest Lecture from Dr Kristy Webber and the Robert Jones Lecture being delivered by Professor Andy Carr. The BOA President, Professor Deborah Eastwood will also give an update on her presidential year.

Guest lecturers

Professor Andrew Carr, Orthopaedic Surgeon, University of Oxford

Andrew Carr is the Nuffield Professor of Orthopaedic Surgery at the University of Oxford and trained at Bristol, Sheffield, Oxford, Seattle and Melbourne. He established the shoulder surgery service in Oxford and is past President of the British Shoulder and Elbow Surgery Society (BESS).

Kristy Weber, MD, Abramson Family Professor in Sarcoma Care Excellence, Department of Orthopaedic Surgery, University of Pennsylvania Hospital

Kirsty Weber is a recognised national and international leader who has served on Boards of Directors of orthopaedic and cancer organisations, including the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association and the Orthopaedic Research Society.

Registration

General Congress registration is now open. Early Bird registration runs until Sunday 23rd July and General registration from Monday 24th July to 23:59 on Sunday 3rd September. Late registration will open at 00:00 on Monday 4th September until the close of Congress. Register for the BOA Annual Congress today through the BOA website www.boa.ac.uk/registration.

Accommodation

Book your exclusive accommodation rates online, through BCD M&E with HotelMap, the BOA Annual Congress 2023’s official hotel booking partners. Find out more online at www.boa.ac.uk/ accommodation

BOA App

Make the most of your Congress experience by downloading the the BOA App! Available to download onto your smartphones and tablets through the Apple App Store and GooglePlay.

Please keep an eye on the BOA website over the upcoming months for updates on the programme, speakers, sponsors, travel, accommodation and more, www.boa.ac.uk/Congress. If you have any questions regarding this event, please contact the BOA Events Team, events@boa.ac.uk.

Exhibition and Sponsorship Opportunities

Thank you to all our Industry Sponsors at this year’s exhibition. We are delighted to welcome over 80+ exhibitors, including our Diamond and Platinum sponsors – Biocomposite, Circle Health Group, DePuy Synthes, Let’s Talk Dr, Link Orthopaedics, Orthofix, Smith & Nephew, Stryker, and Zimmer Biomet. Please visit our website to view the full floor plan and find out further details about all our exhibitors at www.boa.ac.uk/exhibitors

Exhibition stand spaces are still available, but are selling fast! For further information about our sponsorship and exhibition opportunities, please contact our exhibition team, exhibitions@boa.ac.uk – 020 7406 1754.

Product Theatre

New for 2023, and in partnership with the ABHI (Association of British HealthTech), we are pleased to launch our first Product

Theatre at this year’s exhibition. Join us and discover the latest innovative products and solutions to the market. We have a great line up planned, with sessions from DePuy Synthes, Smith+Nephew and the ABHI, who will discuss how the HealthTech industry is contributing towards the net zero targets and protocols for trusts. Register and join us! Limited spaces available and seats are on a ‘first come first serve’ basis. Visit our website for the full programme of events and discover all the exhibitors featuring inside the theatre at www.boa.ac.uk/product-theatre

In Partnership with

Save the Date: BOA Virtual Ortho Update Course 2024 – Saturday 6th January

This one-day course will give delegates the opportunity to access new understanding and support preparation for the FRCS exam. We will provide the facility for delegates to participate in Case-Based Discussions (CBDs), Practical Simulation sessions and new 2024 Exams and Clinical Examination sessions across a range of critical condition topics, delivered by expert clinicians.

Registration for this course will open in June! Further information can be found on the BOA website, www.boa.ac.uk/OrthoUpdate

Joint Action Update

Abig thank you to all of our runners, riders and tough mudders that participated in challenge events and have helped raise money for Joint Action, the BOA research appeal, this year! An amazing effort all round!

The TCS London Marathon Sunday 23rd April 2023

North London Tough Mudder 15th April 2023

If you have an idea or would like to get involved with the fundraising events for Joint Action and the BOA research appeal, please do get in touch jointaction@boa.ac.uk

Matt Owen

Hasan Rahij

Dan Thurston

Amol Tambe

Alex Chipperfield

Team BOA Before (l) and After (r)

War and accidents – a driver for the NHS and the BOA

Gary Robjent

In preparation for war – and in particular the anticipated and realised Blitz –the Chamberlain Government drew up the Emergency Hospital System (EHS). This followed surveys during 1937-38 that revealed that the 1,334 voluntary hospitals and 1,771 municipal hospitals were organisationally and financially disparate and failing. Twothirds of the hospitals had originally been erected before 1891, one-fifth before 1861. They were in poor physical state and lacked diagnostic facilities, pathology and radiology, and operating theatres. In addition to the voluntary and municipal hospitals were the cottage hospitals; often established and run by GPs, who carried out the majority of surgery.

The prestigious voluntary hospitals included the teaching hospitals (12 in London, such as Guy’s Hospital, and 10 in the provinces), which had been founded in association with a civic university. Some of the voluntary hospitals had existed for hundreds of years –St Bartholomew’s for over five hundred, but many, smaller had been established following the First World War.

Many of the municipal hospitals had grown out of the infirmary wards of the Poor Law workhouses. By the 1920s, particularly in the big cities, the infirmary sections were larger than the rest of the institution, with resident medical staff and some facilities for laboratory tests, X-rays and surgery. In 1929, when local authorities assumed responsibility for any municipal hospitals still under the control of ‘boards of guardians’, they provided three times the number of beds of the voluntary hospitals. However, most remained largely a ‘dumping ground’ for the elderly and chronic sick – many of whom had previously been under the care of the voluntary hospitals – and would remain there until death. By 1938, councils in England and Wales provided 75,000 general beds (excluding mental health and ‘fever’ beds for which they were also responsible).

In 1935, British Medical Association’s Committee on Fractures and a subsequent cross government study (1939) highlighted the poor outcomes for people injured (mostly in road traffic accidents despite a reduction following the introduction of the Highway Code in 1931). Pre-Second World War, only a few of the larger hospitals had separate orthopaedic wards. However, by 1939, the new specialties such as orthopaedics, were developing in general hospitals; anaesthetics was not yet a fully distinct specialty and a basic knowledge of its techniques was a useful skill for any doctor.

In addition to the prospect of the Blitz, there were other unforeseen consequences of war that prompted the development of trauma care. Industrial accidents in Birmingham had risen by 40% as inexperienced workers entered wartime factories. Widely regarded at the time as a radical plan to treat injured patients in a specialised setting, the Birmingham Accident Hospital was established in 1941 and staffed by specially trained trauma staff – concentrating not just on immediate care, but also on the rehabilitation of these patients. The Birmingham Accident Hospital and Rehabilitation Centre was the last voluntary hospital in the country, and its specified objectives included prevention of industrial accidents. Similarly, following a review of the attendance at the ‘casualty’ department of the Radcliffe

Infirmary, Oxford, the Oxford Accident Service was established in 1941 to provide a unified service for treatment of fractures and all other injuries. Planned in 1940, the aim was to ensure direction and supervision for the ‘casualty department’, to ensure a uniformly high standard of treatment with all injuries admitted to the Accident Service and treatment provided by the specialist departments of the hospital. The majority of the injuries were known to be fractures and soft-tissue injuries; burns and hand infections were also included as ‘accidents’, and managed in collaboration with the department of plastic surgery.

Orthopaedics and trauma care, and the NHS, were inspired and necessitated by the physical and social consequences of two world wars, and the social conscience that arose in response to the impact of the Industrial Revolution.

Unsurprisingly, these factors are also responsible for the creation of the British Orthopaedic Association. Robert Jones, one of the founders of the British Orthopaedic Association, was a surgeon to the Manchester Ship Canal. He witnessed a high accident rate to its 20,000 workers and so organised first-aid services, each backed up by a hospital, staffed with a resident doctor and nurses. Later, in 1916 he persuaded the War Office to reserve 400 military beds in Alder Hey Hospital. Subsequently, Hammersmith Infirmary became a military orthopaedic hospital and by 1918, the army orthopaedic service had 30,000 beds.

In 2023, the BOA continues to support the principles and ethos that underpin the NHS 75 years on. Sadly, it also finds it has a role in supporting colleagues working in conflict zones and disaster areas with its acclaimed battlefield trauma resources. n

Gary Robjent is Head of Policy and Public Affairs for the BOA.

Chen Diaphyseal Fracture Reduction Clamp

Designed to facilitate and maintain reduction of the internal fixation of diaphyseal and meta-diaphyseal fractures of long bones

PRODUCT NO: 1808

Coated Allis Bone Clamps

A traditional Allis Bone Clamp designed with a longer ratchet—for a wider opening to allow a bone and plate to be clamped and locked onto and coated end(s) to prevent from marring a component surface

Mantis Screwdriver Distractor

Designed to help facilitate reduction of a shortened fracture using two seated screwdrivers*, and allows for distraction of difficult-to-reduce fractures without the need to drill additional holes outside of the plate

The plate can be locked with a screw once length has been restored. Accommodates screwdrivers of varying sizes for use with both small and large fragment systems.

Large Bone Clamp with Plate Protection

Designed to help hold a bone/bone plate in position for reduction—the one-side coated jaw helps to protect from marring the bone plate

PRODUCT NO’S:

3659-L [Left] 3659-R [Right]

PRODUCT NO’S: 1381 [Single Coated End] 1382 [Double Coated Ends]

Argintar Claw Drill Guide Wire/Suture Passer

Designed by Evan Argintar MD

Expandable claw design allows for minimally invasive, reproducible one-step wire/ suture passage

PRODUCT NO:

8315 [Claw Unit]

1227 [3/32" Wire/Suture Pin]

Fracture Reduction Punch Clamp

Designed by Jong-Keon Oh, MD

Chen Low Profile Plate/Bone Clamp

Designed by Franklin Chen, MD

Designed for fracture reduction as well as plate to bone clamping in diaphyseal forearm and humerus fractures

Also useful for distal radius fractures, as well as a variety of lower extremity fractures.

PRODUCT NO: 1639

Designed for use in select cases when vertical (or sagittal) plane clamping is necessary during forearm reduction, humeral fracture reduction, or diaphyseal reduction of the tibial shaft

Stoll Bone Plate Clamp

Modification of design by Charles T. Resnick MD

20 Years of the National Joint Registry: who benefits? Part one: patients and hospitals

Elaine Young is the Director of Operations for the NJR, with responsibility for its overall management, as well as strategic direction and leadership of the NJR management team in supporting the work of the NJR and its committees.

The National Joint Registry (NJR) was founded in 2002, and started collecting data to monitor the performance of hip and knee replacement surgery in England and Wales in 2003. Since then, we have expanded both our scope of joints and territories covered. In this three-part series, we describe the value of the NJR, its data resource and its outputs to our key stakeholders. In this first part, we focus on the benefits of the NJR to patients and hospitals; in part two, we outline the benefits to surgeons and implant suppliers; and in part three, we describe the benefits to service commissioners, regulators and policymakers, and the broader benefits to society (including research and innovation).

Benefits to patients

The primary stakeholder for the NJR is the patient. Joint replacement is routine surgery and patients rightly expect that their surgery will improve their quality of life. Evidence from NJR data collected over the last 20 years has demonstrated continuing improvements in core outcomes and generated a significant body of information for patients to use in the shared decision-making process.

Gillian Coward has been a patient member of the NJR Steering Committee for over six years and also volunteers with Versus Arthritis. Gillian has wide experience of joint replacement surgery due to living with rheumatoid arthritis for 40 years.

Core outcomes

Death following joint replacement surgery is a rare event. In the 20 years since the NJR’s inception and despite patients receiving joint replacement becoming higher risk over time, there has been a sustained reduction in the risk of mortality. Mortality rates 90-days following primary hip replacement reduced from 0.56% in 2003 to 0.29% in 20111. Mortality following knee replacement shows a similar reduction over time2. When the National Institute for Health and Care Excellence (NICE) first issued recommendations on hip replacement surgery, the suggested acceptable revision rate at 10 years was 10%. This has since reduced to 5%,

with the best-performing hip replacements in the NJR achieving revision rates that have halved since their peak from over 6% to around 2.5%, and for knees this has fallen from a peak of over 5% to less than 4%. Around 90% of hip and knee replacements now last more than 15 years, and 58% of hips and 82% of total knee replacements are expected to last 25 years3,4

Shared decision-making

Patient information and knowledge is vital to ensure understanding, confidence, managing expectations and contributing to shared decision-making. Information on the NJR’s work is shared publicly through its website. This includes our annual report (comprising analysis of surgical data translated into visual presentation formats), patient leaflets on the work of the NJR and guidance on surgery for different joints with what to expect. We publish surgeon hospital and implant-level information about patient outcomes following joint replacement surgery that enables patients to understand what to expect from their treatment, and to inform their decision about where to be treated and what implants are used. We produce guidance from NJR’s Annual Report to provide patients with digestible data on the type and quality of joint replacement surgery undertaken, to increase patient awareness and patient choice.

The NJR, through its publicly available information resource, makes data tangible and meaningful. This can assist patients and surgeons to explore the choices available regarding type of implant and surgery, and consider their options.

For example, the Patient Decision Support Tool (PDST) (https://jointcalc.shef.ac.uk/) is a freely available online tool that was developed using NJR data to help those considering joint replacement surgery, to better understand the risks and benefits5. The patient enters simple details, such as age, sex, height, weight, general

Elaine Young, Gillian Coward, Robin Brittain and Timothy Wilton

Robin Brittain is a patient representative for the NJR and has lived experience of musculoskeletal conditions, having been diagnosed in 1991 with ankylosing spondylitis and subsequently osteoarthritis and hip impingement to both hips. He volunteers for various organisations across a range of activities including patient support, advocacy and research.

health and how their joint disease affects them. The tool then uses data from similar patient experiences to calculate how much better they are likely to feel after surgery (Figure 1). The tool also calculates the likelihood of repeat surgery being needed and the risk of death after surgery.

Timothy Wilton is a Consultant Orthopaedic Surgeon at Department of Orthopaedics, Royal Derby Hospital, Derby, with specialist interests in knee and hip replacement surgery. He is Medical Director of the NJR.

The tool is an example of how the patient benefits from NJR-supported research, enabling both patients and surgeons to make informed decisions jointly as an important part of patient-centred medicine. The tool has now been accessed by many tens of thousands of patients across more than 110 countries, and some of the underlying methodology can be found at the following scientific reference6

Shared decision-making relies on NJR evidence, plus information and research outcomes being presented in a clear and understandable way through patient guidance, stories and interviews, quotes, infographics, and in easily accessible formats and locations. Patients with better understanding of their surgical procedure, their own risk level, and what will be happening to them are likely to be better prepared and to thereafter have better outcomes.

Recognising the importance of the patient perspective, a pre-op PROMs questionnaire is collected by the NJR for shoulder replacement and around a quarter of elective patients return these within the required timescale. Around a third of patients complete a further six-month PROMs, but engagement is poor beyond that. At six months following surgery, 5.3% of all patient responders reported a score worse than they did preoperatively. Patients with a high pre-op score – over 40 on the Oxford Shoulder Score – had an equal chance of being better or worse at six months. NJR-supported research has examined the use of these shoulder PROMs and a paper examining the Floor

and ceiling effects in the Oxford Shoulder Score found that the score does not exhibit a ceiling effect at six months, but does at three years and five years, which may influence the sampling and timing of NJR PROMs moving forward7

Benefits to hospitals

The NJR has invested in the development of a wide range of interactive reporting tools for both hospitals and surgeons over the years, most of which can now be accessed through the sophisticated new software platform: NJR Connect – Data Services (Figure 2).

Supporting best practice

We support local clinical governance through the provision of hospital and surgeon-level reports, providing an independent assessment of the safety and effectiveness of local practice compared to national benchmarks. We alert hospital medical directors of any adverse patterns in patient outcomes attributable to their hospital, and provide data and analysis to support local investigation of root causes for raised alerts. Recently, we also launched the NJR implant scanning app to support implant checking during the operation, to prevent the occurrence of ‘never events’ where incompatible implants are inadvertently used in patients. Twice a year a comprehensive analysis is undertaken of the performance of all surgical units undertaking joint replacement in the NJR’s operational areas. Each unit, regardless of their performance, receives a comprehensive in-depth analysis of their practice, including a list of all revisions and deaths, and this regular reporting mechanism enables units to reflect on best practice and address any issues relating to worse outcomes. >>

Figure 1: The NJR Patient Decision Support Tool helps patients better understand the risks and benefits of joint replacement surgery.

Annual Clinical Reports (hospital-level reports)

NJR Annual Clinical Reports are supplied to all hospitals submitting data to the registry, providing detailed analysis of activity and outcomes across joint replacement services. This also provides medical directors with a summary of the performance outcomes for each surgeon operating in their units. Outcomes data is supplemented by analyses that show the indications for revision across their unit so that trends can be identified, as well as a summary of how individual surgeons are contributing to a unit’s overall outcomes. This summary data is now supplemented by customisable reporting tools within our NJR Connect platform, as well as a detailed appendix of individual patient outcomes, which means that that data can be analysed locally.

• ‘Never events’ (a clinical incident eg, surgery performed on the wrong body part, or incorrect implant used). We can monitor and identify ‘never events’, and increasingly prevent them from happening with the scanning interface.

• Poorly performing units and surgeons are identified and supported to improve.

• Poorly performing implants are identified and this information is escalated to regulators

Price benchmarking

With a view to improving the costeffectiveness of joint replacement surgery, NJR’s implant pricebenchmarking service gives hospitals the information they need to benchmark the price they pay for hip, knee, ankle, elbow and shoulder implants against the ‘best’ national prices achieved across all hospital implant procurement services. Since 2017, the NJR’s enhanced implant price-benchmarking service EMBED (Figure 3) has been included

as part of the standard NJR subscription charge for all NHS trusts. This service enables the hospital to drill down into their pricing data, including the additional capability to give surgeons individual reports relating to their own implant use. EMBED provides the tools to enable hospitals to understand in greater detail their use of joint replacement implants in the context of cost, evidence and trends, in comparison to the national picture.

The service provides clinicians, management, procurement and finance teams with an objective set of data and analysis to inform

their decision-making. This activity, with a focus on cost and value alongside procedure outcomes, underpins the Getting It Right First Time (GIRFT) and NHS England’s Model Hospital initiatives.

Summary

In this part one of our NJR benefits article, we hope we have given a flavour of some of the benefits the NJR delivers to patients and hospitals. A fuller picture of these benefits can be found in the relevant sections of the NJR website (www.njrcentre.org.uk). In the next part of this series, we will cover the benefits of the NJR to clinicians and implant suppliers. n

References

1. Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, et al 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013;382(9898):1097-104.

2. Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, et al. 45-day mortality after 467 779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet. 2014.

3. Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet. 2019;393(10172):647-54.

4. Evans JT, Walker RW, Evans JP, Blom AW, Sayers A, Whitehouse MR. How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019;393(10172):655-63.

5. Zotov E, Hills AF, de Mello FL, Aram P, Sayers A, Blom AW, et al. JointCalc: A webbased personalised patient decision support tool for joint replacement. Int J Med Inform 2020;142:104217.

6. de Mello FL, Wilkinson JM, Kadirkamanathan V. Metaparametric Neural Networks for Survival Analysis. IEEE Trans Neural Network Learn Systems. 2021;pp.

7. Singh HP, Haque A, Taub N, Modi A, Armstrong A, Rangan A, et al. Floor and ceiling effects in the Oxford Shoulder Score: an analysis from the National Joint Registry. Bone Joint J. 2021;103B(11):1717-24.

Figure 2: An extract from Management Feedback reporting in NJR Connect – Data Services.

Figure 3: An extract from EMBED, the NJR’s price benchmarking reporting service for hospitals.

Setting Up Revision Hip Networks: The British Hip Society Approach

Andrew Hamer, Tim Board, Richard Holleyman and Vikas Khanduja

Networks are not new in medicine. Networks for the early recognition and treatment of cancer have been in place for many years, and as orthopaedic surgeons we are well-aware of major trauma networks. A network can be defined as ’a group of people or organisations in different places who work together and share information’.

Andy Hamer was appointed Consultant to the Northern General Hospital in Sheffield in 1998 with a special interest in hip and knee arthroplasty and revision surgery. He was President of the British Hip Society 2021-2022, during which he led the BHS work concerning Hip Revision Networks.

There has been an increasing focus on quality of surgical care through the wide-ranging work of GIRFT (Getting It Right First Time), set up and led by Professor Tim Briggs. The programme has identified that in many units, small numbers of sometimes complex procedures are carried out (GIRFT report 2015)1. Such practices could lead to inferior outcomes and might also not be cost-effective, because loan equipment must be specially ordered in on an infrequent basis. On these grounds, it has been suggested that low volume high-complexity (LVHC) surgery such as knee and hip revision arthroplasty surgery can be improved by units working in networks.

GIRFT initially approached the British Association for Surgery of the Knee (BASK) to explore the feasibility of developing a network for revision knee surgery and the proposal was circulated to BOA members in 20192. There were two important proposals:

Professor Tim Board is a hip surgeon at Wrightington Hospital in Lancashire. He specialises in revision and complex primary and young adult hip problems. He is chair of the British Hip Society Research Committee.

• Consideration should be given to revision surgery being approached on a regional basis and delivered by networks of appropriately experienced surgeons at a smaller number of locations.

• Department of Health and NHS England should encourage behaviour change (for example, through tariff funding).

BASK were engaged to run the pilot project and as a culmination of this, many units performing large numbers of revision knee cases have been recognised as Major Revision Centres (MRC). These units have now received significant funding to help set up regional multidisciplinary teams (MDTs), fund appropriate support staff and audit outcome.

The British Hip Society (BHS) has observed this process closely with interest, but similar funding for the development of revision hip networks has not been made available thus far. Nevertheless, the BHS are committed to improving the care of all patients undergoing revision hip surgery and recognise the value of networks in the achievement of this aim. The BHS also recognises that there are significant variations in the way that surgical care is delivered to patients in different parts of England, Wales and Northern Ireland (Scotland is not part of the GIRFT process). As a result, the BHS decided early on to engage with its members with the following aims:

• To establish what existing arrangements were in place for the provision of revision hip surgery across England, Wales and Northern Ireland.

• To utilise a scientific approach to understand the relationship between unit/surgeon volume and surgical outcomes.

• To develop an easy-to-use comprehensive Revision Hip Complexity Classification (RHCC) so that all the cases can be classified appropriately and outcomes measured.

• To determine what guidance would help in the delivery of high-quality revision hip surgery.

Richard Holleyman is a ST7 in T&O based in the North East. He is currently undertaking a full-time PhD studying outcomes following hip surgery, co-funded by Orthopaedic Research UK and the British Hip Society.

• To support BHS members in developing improved provision of revision hip surgery – building, if possible, on existing well-performing networks.

• Providing a forum for discussion of network development.

What the BHS has done so far

The BHS Revision Hip Network Advisory Panel

This was formed in 2020 with members from across England, Wales and Northern Ireland who were all nominated by colleagues. The Advisory Panel eventually consisted of 60 representatives, both BHS members and non-members. Regular meetings have taken place to discuss and advise on what was required to support the development of local revision hip networks, and this led to the development of BHS guidance documents. These in turn became known as British Hip Society Surgical Standards (BHSSS) which are described

Vikas Khanduja is a Consultant

Trauma and Orthopaedic Surgeon in Addenbrooke’s - Cambridge University Hospital NHS Foundation Trust. He is the President of the British Hip Society and Trustee of NAHR. He has been involved in the initiation of the Revision Hip Networks and strongly believes in “data driven decisions” guiding the future development of this network.

below. The Advisory Panel continues to meet to discuss how revision networks have been developed already across England, Wales and Northern Ireland, and to share best practice.

Revision Hip Complexity Classification

This initiative was led by Professor Tim Board, with the intention of developing a simple, reproducible and useful classification of revision hip cases. Existing classifications were specific to certain diagnoses and it was felt that a comprehensive classification that could equally be applied to periprosthetic fractures, infection or aseptic loosening, for example, would be of value. Such a classification could be used to simplify the discussion of cases, for instance, at an MDT and for the recording of the level of case complexity that each unit was undertaking. The classification was developed using a modified Delphi process involving experienced hip surgeons and is summarised in Figure 1.

The classification has been termed the Revision Hip Complexity Classification (RHCC) and consists of three grades: H1, H2 and H3 with increasing levels of case complexity with the addition of a ‘*’ sub-categorisation for significant medical co-morbidity. The classification showed good intra- and inter-observer error in testing3. Further work is being undertaken to assess the utility of the RHCC in predicting outcomes and the BHS has also developed an app to further simplify adoption (Figure 2). It is hoped that the app will be launched this month and the RHCC classification will appear in the next version of the National Joint Registry MDS4

Joint funded BHS/ ORUK research fellowship

The BHS is committed to using data to drive and inform decisionmaking, and was delighted when ORUK (www.oruk.org) agreed to co-fund a research fellowship to support this activity for two years. >>

Figure 1: Revision Hip Complexity Classification (RHCC).

Richard Holleyman was appointed to this post and has so far completed a detailed analysis of NJR data, describing the volumes of revision hip arthroplasty currently performed by surgeons and hospitals, and examining in detail the variation in practice across the country. He has also outlined the rate of accrual of experience by early career arthroplasty consultants. The latter is a key consideration if any recommended or mandated volume thresholds are to be adopted, with implications for the adaptation of training pathways and consultant job planning, which is fundamental to delivering high-quality patient care. This study has been completed and is currently undergoing methodological review prior to journal submission. Further work is underway linking volumes to outcome data, including mortality, re-revision, re-operation, and serious medical complications.

BHSSS (British Hip Society Surgical Standards) documents

The BHS Revision Hip Network Advisory Panel identified several clinical and organisational areas where it was thought that agreed guidance would be of benefit. The guidance documents

were all prepared by groups of experienced hip surgeons and then were reviewed by all members of the National Panel. The documents are now available on the BHS website5

• MDT working

• Organisation and processes

• IT support requirements

• Revision surgery for infection

• Revision surgery for periprosthetic fracture

• Revision surgery for aseptic loosening

• Revision for instability

• Perioperative care

• Dual consultant operating.

The future of Hip Revision Network Development

While the BHS Network Panel has done much to develop the tools necessary to help in the development of hip revision networks, the society has no mandate or power currently to effect change. The pilot project led by BASK for knee network development is observed closely by the BHS and clearly, if effective networks are developed for knee revision, it is likely that the same models will be used for hip revision. It should, however, be recognised that in many parts of the country, there are already well-developed hip revision networks which are tailored to the local circumstances in each area. Other areas of the country are in the earlier stages of hip network development, and the BHS would hope to support the units involved to set up a network appropriate to the local expertise and facilities.

One clear view expressed by the Revision Hip Network Panel is that the transfer of all patients requiring revision surgery to a central specialist ‘hub’ would be impossible and many cases will have to be dealt with in other hospitals in the network. This would apply to emergency cases such as patients with periprosthetic fractures or those with potential infection requiring debridement, antibiotics, and implant retention (DAIR). The panel view is that all cases requiring revision should be classified using the RHCC and then discussed at local MDTs, the case being escalated to regional MDTs if needed. Based on this discussion, the care of the patient may be transferred between units.

All parts of the case discussion should be recorded using the most appropriate IT system, to allow tracking of care and audit at every stage.

The revision knee network pilot project provides a fixed sum of money to help in the set-up of regional networks and their administration. The BHS is clear that similar funding will be necessary for hip network development.

Revision hip arthroplasty is costly. The current remuneration available to hospitals often falls short of the cost of each case and this inevitably makes such surgery unattractive to providers. At every stage of discussion of hip network development, the point is consistently made that appropriate funding should follow the patient, to ensure that hospitals do not lose money each time such a case is performed. Finally, while we await the mandate to develop these networks formally, we at the BHS shall continue to support existing networks and remain committed to using data to drive decision-making. n

References

1. Briggs T, Getting It Right First Time (GIRFT). A national review of adult elective orthopaedic services in England – Getting It Right First Time (date last accessed 18 July 2022).

2. British Orthopaedic Association. BOA/ BASK/BHS communication about changes to knee revision surgery in England. https://www.boa.ac.uk/ resources/policy-and-positionstatements/boa-bhs-bask-letter-reclinical-model-final-pdf.html (date last accessed 8 December 2022).

3. Leong JWY, Singhal R, Whitehouse MR, Howell JR, Hamer A, Khanduja V, et al. Development of the Revision Hip Complexity Classification using a modified Delphi technique. Bone & Joint Open. 2022;3(5):423–431.

4. National Joint Registry for England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Data collection forms – The National Joint Registry. https://www.njrcentre.org.uk/ healthcare-providers/njr-datacollection-forms-k1-k2-s1-s2-h1-h2e1-e2-a1-a2/ (date last accessed 5 December 2022).

5. The British Hip Society. Revision Hip Network Information. https:// britishhipsociety.com/revision-hipnetwork-information/ (date last accessed 5 December 2022).

EDINBURGH INTERNATIONAL TRAUMA SYMPOSIUM AND TRAUMA INSTRUCTIONAL COURSE 15th-18th AUGUST 2023

TRAUMA SYMPOSIUM 16th-18th AUGUST 2023

Three day meeting suitable for established orthopaedic surgeons

Renowned international faculty

Focused on revalidation and update through short interactive lectures and CBDs

Break out sessions include cadaveric surgery focusing on surgical approaches and fixation techniques

TRAUMA INSTRUCTIONAL COURSE 15th-18th AUGUST 2023

Four day orthopaedic trauma course suitable for established surgeons, trainees and AHP’s Comprehensive lectures and CBDs on the assessment and management of paediatric and adult fractures

Break out sessions including cadaveric anatomy teaching and FRCS viva practice

VENUE: SHERATON HOTEL AND EDINBURGH MEDICAL SCHOOL

For more information on booking visit: www.trauma.co.uk or email symposium@trauma.co.uk

The BOA and the independent sector (private practice): ensuring best care, identifying concerns and representing our members

Andrew Manktelow and Mark Bowditch

The relationship between the National Health Service and the independent sector (IS) has rarely been more complicated. Historically, there was a relatively clear delineation, as colleagues spent one part of their working time in the NHS and another ‘elsewhere’. Many were clear and definitive in separating these two clinical aspects of their practice. Many will have experiences and apocryphal stories of how boundaries were blurred.

Andrew Manktelow is a Consultant Orthopaedic Surgeon working within Nottingham University Hospitals NHS Trust, with a specialist interest in primary and revision hip surgery. A past President of the British Hip Society, Andrew has been on the BOA Council since 2019. Contributing to the Orthopaedic Committee, Andrew reports to BOA Council on matters relevant to the independent sector.

More recently, many aspects of care in the IS have changed. Traditionally, it was those who had insurance cover, individually or collectively through work, alongside those who could afford private care, who chose to utilise the ‘private’ independent sector. This ensured they were able to access a certain clinician, at a time they chose, to reduce delays and perhaps enhance the softer side of their experience. With longer waiting times, even pre-COVID-19, an increasing number of patients sought private care.

Subsequently, the NHS Choice framework has enabled provision of care by ‘any qualified provider’, leading to NHS patients accessing IS facilities for routine NHS treatment and procedures. With COVID-19 exacerbating pre-existing delays, there has been a significant increase in patients seeking treatment within the IS. Against that backdrop, it should be appreciated that many private providers acted in support of challenged NHS facilities, to deliver care as part of the response to COVID-19. Various models were utilised and in many areas, the provision of NHS cancer services during the COVID-19 pandemic were strongly supported

by the IS. During the same period, some elective orthopaedic surgery was carried out – within and outside existing job plans – in the IS to maintain clinical activity. With a significant part of the NHS COVID-19 backlog recovery plan involving the utilisation of IS capacity, this is likely to increase. The financial, governance and practical complexities of the relationship that exists between IS and NHS care will continue.

The requirement to comply with the Competitions and Markets Authority (CMA) Ruling of 2014 has been dealt with recently within this journal1. The effect of the ruling on how surgeons practise in the IS continues to develop, though it is perhaps important to recognise that much of the information clinicians are required to provide is reasonable. Many of us – wherever we were seeking care – would look to understand and be aware of the likely outcomes and clinical experience, when choosing one surgeon or facility over another. Similarly, few of us would feel comfortable accessing that service without a clear understanding of what the costs involved would be. Clinicians providing services within the IS should ensure that their practices, services and costs are presented accurately. Those responsible should ensure that data is presented accurately within their patient-facing facilities.

The Bishop of Norwich Report on the Paterson case has identified the important role of a multidisciplinary team (MDT) in the clinical decision-making process. It has been detailed that those who practise within

the IS are fully appraised and revalidated, and that their practice is reviewed fully, with any limitations in NHS activity highlighted. As part of that appraisal, an update on IS activity is required. As detailed previously1, the importance of surgeons validating their data will become increasingly important with a drive toward presumed publication. With improvements to the Private Healthcare Information Network (PHIN) patient-facing website and with additional Patient Reported Outcome Measures (PROMS) data available, patients will increasingly have access to information from that facility. It is the surgeons’ responsibility to ensure that data is accurate and reflects their practice.

Private medical insurers (PMIs) have changed their processes and practices in numerous ways. Patients have seen a steady increase in the costs of their subscriptions. Despite increased technical complexity, governance and outcome scrutiny, the rates of remuneration for the doctors – upon whose activities the entire IS is based – have been static for many years. Patients would perhaps be surprised that increases in their subscription rates have not been reflected in higher remuneration for their doctor. Indeed, in some cases there has been a reduction in physician remuneration. Many would argue that the existing rate of remuneration do not reflect present costs levied for secretarial and hospital facilities, insurance premiums and assistant support, all of which have increased significantly.

Geographical variation exists with local arrangements that will reflect market forces. However, with a fixed rate of remuneration available, with no ability to reflect experience, expertise, outcomes and technical complexity, many surgeons have felt disenfranchised with existing arrangements. Increased costs with static fees have resulted in a functional reduction in income. Many have felt it necessary to increase their fees to reflect increased expenses. This then leaves many surgeons enforcedly disenfranchised by PMIs, with terms such as ’unrecognised’ used when patients seek to access that specific surgeon in the IS. The situation has deteriorated to a level that the Federation of Independent Practitioners Organisation (FIPO) reports that more recently, appointed colleagues would seem less keen to look to practice within the IS.

Interestingly, with the stated aims of the CMA being to improve patient care – to improve patient choice and to ensure that a clear representation of the costs involved is made available to patients – much of what has happened more recently, with PMIs increasingly determining patient referral pathways, could be seen to have left patients less able to seek out the specific clinician they might wish to be treated by. As such, it could be argued that the net effect of the present arrangement leaves patients with less choice than they have had previously.

How doctors’ views in matters that pertain to the IS are represented is complicated. Discussions that relate to fees and costs are seen to be anti-competitive. As such, colleagues can feel exposed and isolated, with no one able to represent their views and support their interests while maintaining the best care for patients in the IS. More specific to this article, how BOA members are kept informed and how their views are best represented is unclear. A member of the BOA Council represents the BOA in discussions with FIPO. The BOA, among other specialist societies, contributes funding to that organisation which was established in 2000, specifically to represent doctors’ views within the independent sector. Similarly, the BOA has representation with PHIN. The BOA Orthopaedic Committee and Council receive regular reports from that FIPO/ PHIN representative member.

There remains a disconnect regarding how that information is communicated to BOA members and from there, how BOA members’ thoughts, issues and suggestions can then be returned to those with influence. The remit of BOA Orthopaedic Committee does include private practice. The BOA can feed in to the BMA Private Practice Committee, but perhaps orthopaedic views are diluted.

With recent publications in the JTO and communication via the website, the BOA has sought to increase the information available and to seek input from its members. It would be helpful to understand a little more about how BOA members see activities within the IS and what topics they would like the BOA to address. It is important that the BOA understands whether its members would wish to see the organisation more active in the area. Caring for patients, delivering the best possible care while supporting surgeons wherever that care is delivered, fits securely with the BOA’s mission.

We invite and encourage BOA members, plus other colleagues to be in contact with their thoughts and experiences in this area. Any suggestions as to how the present arrangements could be improved, made more relevant to BOA members and effective for our patients, would be very gratefully received. n

References

1. Private Health Information Network (PHIN) and complying with the Competitions and Markets Authority Order: An update for members. JTO Vol 11 Issue 1. March 2023. www.boa.ac.uk

Mark Bowditch is a Consultant and Divisional Clinical Director for MSK & surgical specialties at the East Suffolk and North Essex NHS Foundation Trust. Mark’s specialist interests are in surgery of the knee and all levels of surgical education, and he is currently the Head of School of Surgery in the East of England.

Fergal Monsell has been a Consultant Paediatric Orthopaedic surgeon at the Royal Hospital for Children Bristol since 2005. He is involved in education at all levels, is Visiting Professor at Cardiff University and Director of the Avon Centre for Musculoskeletal Education. Has an active clinical research portfolio and is widely published.

Alterations in commissioning and construction of British Orthopaedic Association Standards

Fergal Monsell, Alex Trompter and Nick Aresti: BOA Clinical Standards Committee

Alex Trompter works at St George’s University Hospital in London and holds the position of Honorary Reader in Orthopaedic Surgery at St George’s University of London. His specific clinical interests are the management of complex fractures, bone infection, non-union, deformity correction and limb lengthening.

This aphorism – frequently but incorrectly attributed to Mark Twain – highlights the perils associated with decisions based on opinion, rather than objective evidence. The introduction of high-level studies and clinical algorithms has substantially improved the orthopaedic evidence base, and the use of an anecdotal methodology to inform clinical decision-making is now effectively redundant.

Each document describes a common clinical scenario, which is associated with a variance in practice, with potentially significant adverse effects on outcome. Each standard is informed by the available evidence, to produce clear, concise recommendations in a uniform and recognisable format. These are now embedded in UK practice and form part of routine clinical care.

Nick Aresti is an upper limb surgeon, focusing mainly on disorders of the shoulder and elbow. He is both a Clinical Lead and the Deputy Network Director at Barts Health. He is the current Vice Chair of the BOA Orthopaedic Committee, having served as a member for two years.

To support this trend, and in an attempt to improve the delivery of orthopaedic care in the UK, the British Orthopaedic Association introduced the first of a series of BOA Standards for Trauma in 2008, and these are generally referred to by the ‘BOAST’ acronym. It was intended that these documents would drive improvements in patient care, set straightforward, auditable standards and eliminate unnecessary variation in practice.

It was recognised that conventional guidance documents were unnecessarily complicated, and from their inception, BOASTs consisted of a single, A4 page executive summary of topics including compartment syndrome, open fractures, paediatric supracondylar fractures and traumatic spinal cord injury.

They are also utilised as reference tools in the national monitoring and audit of major injury, and included in the Trauma Audit and Research Network (TARN) methodology, which benchmarks the performance of major trauma networks, major trauma centres, ambulance services and individual clinicians.

The scope was broadened in 2020 to include elective standards, the acronym was modified to BOA Standards to reflect this change and an additional suite of documents was published. It was recognised that, while containing high-quality information, this rapid expansion would potentially compromise the quality, and relevance of these documents to the general orthopaedic surgeon, who they were intended to serve.

‘It ain’t what you don’t know that gets you into trouble, it’s what you know for sure that just ain’t so.’

The process was, therefore, modified in 2022 to stratify the documents from a temporal perspective, with initial generic management addressed by the BOAST brand and subsequent management covered by a new specialty standards (SpecS) brand.

In practical terms, BOAST documents are intended to be particularly relevant to a nonspecialist practitioner and inform the initial management of a defined clinical scenario.

The purpose of SpecS is to provide more specific advice on index conditions over a longer period. It is anticipated that these will be produced by specialist societies and concentrate on the subsequent management, according to recommendations from experts in this field. Where feasible, this should be based on extant consensus documents or published literature. They are also intended to provide an auditable set of standards, but not act as a definitive description of management.

Since 2002, commissioning, construction, and curation of BOASTs have been overseen by the BOA Clinical Standards Committee, a working group with representation from the BOA Trauma and Orthopaedic Committees, BOA Executive, and ad hoc input from expert stakeholders. This includes specialist society representatives and co-opted, non-orthopaedic experts with skill sets relevant to the topic under consideration.

Future BOASTs will continue with the previous format with title, background and justification, inclusion and exclusion criteria and a list of auditable standards for practice. Some standards are mandatory, and are accompanied with the modal verb must, expressing an obligation. Reassessment of the neurovascular status of the limb after relocation of a dislocated knee illustrates this requirement. Other standards are desirable and are accompanied with the modal verb should, expressing a strong recommendation. Obtaining clinical photographs as part of the initial management of an open tibial fracture illustrates this requirement.

This structural change has led to a parallel stream of documents and while each have a common theme, they are intended to be relevant to different parts of the patient journey and this is illustrated by considering what is currently available, and planned infection standards.

Prior to the change in emphasis, BOASTs dealing with fracture-related infection and paediatric musculoskeletal infection, and specialist society BOASTs dealing with peri-prosthetic joint infection were published. To conform to the new arrangement, a generic PJI BOAST document has been produced, which deals with the initial presentation and it is intended that this is endorsed by relevant special societies. Embedded in this document are links to SpecS, which consist of the previous specialist society BOASTs, providing complementary information that describes the nuances of management in different anatomical locations.

These documents have been interrogated to ensure that they are fit for purpose and do not include information that conflicts with previous published standards. It is planned to introduce these documents simultaneously, to illustrate the characteristics of each type and demonstrate the modifications that have been introduced to conform to the new paradigm.

It is envisaged that commissioning future BOASTs will involve a series of clear stages >>

Figure 1: BOAST Standard - Fracture Related Infections (FRI).

to streamline the process and introduce transparency to the system. Recommendations for new standards will be considered by the Clinical Standards Committee and those considered suitable, presented to BOA Executive for ratification. Proposals are anticipated from a variety of sources, including

individual members, specialist societies, BOA Committees and BOA Executive.

These should include a working title, a statement outlining the proposed subject with inclusion and exclusion criteria, and a draft of the proposed auditable standards. Options

for co-badging should also be considered, and engagement with specialist societies and additional experts secured at the initial stages, before the first draft is submitted.

After acceptance of an initial draft, the proposed BOAST will be reviewed by the Clinical Standards Committee, with assistance from representatives from appropriate specialist societies. The stage will involve clarification of the core clinical content and this is, therefore, primarily the remit of the relevant experts.

The second stage involves editing the document to ensure that it is succinct and corresponds to the accepted style. This also presents an opportunity for reformatting and ensuring compatibility with previous BOASTs, prior to submission to the BOA executive for approval, before publication on the BOA website (www.boa.ac.uk). Previous trauma-related BOASTs have been accompanied by an editorial, published in Injury and it is envisaged that this will continue.

SpecS will be the remit of individual specialist societies and will also follow an agreed format. These documents will typically run to two to three A4 pages, contain more references and will be colour coded to ensure that they can be easily distinguished from a BOAST (see Figures 1 and 2).

This description highlights the origin of the BOAST documents and makes a case for subtle, but important changes in emphasis and the creation of separate SpecS. It is intended that future standards documents will adhere to this formula and as current documents are revised, they will be re-organised to conform to this structure.

This article is intended to inform potential authors and specialist societies of the intended changes, and provide information on how to take proposed standards to publication.

Figure 2: BHS Speciality Standard - Investigation & Management of Peri-prosthetic Hip Joint Infection (PJI).

For full details about warnings and precautions read the IFU. For more information and the IFU please visit https://www.arthrosamid.com or contact us at enquiries@arthrosamid.com

Reference: 1. Bliddal, H., et al. (2021). Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: A 6 Months Prospective Study. J Orthop Res Ther. Vol 6(2). 1188. ISSN 2575-8241

Improving breast radiation protection for female orthopaedic surgeons

Hannah Sevenoaks is a ST7 in the North West Deanery (East Sector). As a BOA/BOTA Culture and Diversity Champion, she is interested in addressing barriers to building a more inclusive orthopaedic workforce.

Around 20 years ago, Dr Loretta Chou started noting cases of breast cancer among her orthopaedic colleagues in California. She undertook a series of studies, which indicated an increased prevalence of breast cancer in female American orthopaedic surgeons. Studies by other groups have shown the female breast is inadequately protected by standard radiation personal protective equipment (PPE), leading to concerns that female surgeons are being exposed to a higher risk of developing breast cancer.

In this article, we aim to outline the current evidence and explain how the British Orthopaedic Association are supporting ongoing work to improve breast radiation protection for female surgeons.

Breast cancer

Breast cancer is the commonest female cancer in the UK, with a 1 in 7 lifetime risk1. Radiation is estimated to cause 1% of breast cancers, as breast tissue is highly radiosensitive in a dose-dependent fashion. The majority of female breast cancers develop in the upper outer quadrant (UOQ) of the breast, which extends up to the axilla2,3

Breast cancer risk in orthopaedics

Isobel Pilkington is a Core Surgical Trainee in Wessex. She hopes to train in Trauma and Orthopaedic Surgery and ensure that all women working in healthcare are protected from ionising radiation.

The epidemiological work by Chou et al. showed a 1.9-fold increase in all forms of cancer and a 2.9 to 3.9-fold increase in breast cancer in female orthopaedic surgeons, compared to age matched control populations. While this involved self-reporting, the increase was not seen in plastic surgeons or urologists and remained present even after sensitivity analysis to address selection bias4-6

Robust, longitudinal data pertaining to occupational radiation exposure risk is not available for female surgeons, due to historical low numbers and a lack of focus on data collection in this area. As such, the risks of radiation-induced breast cancer in surgeons is poorly understood7 However, occupational radiation exposure has been associated with an increased prevalence of

female breast cancer in other healthcare cohorts, including US radiology technicians, Chinese radiographers and Finnish doctors 8-10 . Occupational radiation exposure has not been identified as a risk factor for male breast cancer11,12

Standard radiation PPE fails to protect the breast

Studies measuring radiation dose exposure in simulated surgical settings have demonstrated that current standard PPE designs provide inadequate protection to the UOQ of the breast. This is most pronounced with the C-arm in the lateral position and the surgeon standing perpendicular to the table13. Comparison of gown designs showed that traditional tabard gowns or loose-fitting vests made no significant difference in the protection afforded to the UOQ when compared to wearing no gown at all. Significant reductions were seen when formal axillary cover was provided14

Improving breast radiation protection in the UK

With the support of the BOA, a short-term working group was developed in late-2022 to address issues involved in radiation protection, particularly for the female surgeon. This work has involved a number of different avenues – examination of the current evidence, dissemination of appropriate information and working with industry to assess PPE options, which may improve breast protection.

Overall, the key radiation safety principle of time, distance and shielding remains the foremost way to reduce exposure, with PPE as an additional line of defence. Specific recommended behaviours are outlined in Table 1.

• Stand as far back from the source as possible

• Keep arms by side where able

• Stand square to the source to avoid exposing the axilla

• Reduce the use of direct lateral views

Table 1: Techniques to minimise surgeon breast irradiation specifically.

Hannah Sevenoaks, Isobel Pilkington, Lynn Hutchings and Charlotte Lewis

Lynn Hutchings is a Consultant Trauma & Pelvic Surgeon at North Bristol NHS Trust. She is a breast cancer survivor.

Charlotte Lewis is a full-time NHS Trauma Surgeon. She trained in the Wessex region and has worked at Portsmouth University Hospital as a Consultant since 2012. She is currently the Past President of the Orthopaedic Trauma Society.

Prototypes of PPE with improved breast and axilla coverage have been tested for suitability in orthopaedic procedures, looking at comfort, fit, ability to move freely and extent of protection.

Preliminary work has been done to test gown efficacy in simulated settings, with further research planned to establish levels of dose reduction.

What breast radiation PPE should we adopt?

Radiation protection guidance is now available on the BOA website, and we encourage surgeons and departments to reference this to explore the options available. Tabard gowns clearly provide inadequate protection for female surgeons and snapshots of current theatre provision across the country indicate provision will need to be updated in many hospitals. Local working parties may be best placed to consider hospital-level or regional requirements to ensure adequate protection for all surgeons.

Individual surgeons may have different preferences for breast and axillary coverage, based on body habitus, fit and nature of work undertaken. Surgeons should aim for:

• A good, close fit

• Comfortable and free movement of the arms

• Axillary and breast cover are maintained with the arm abducted

Companies have been invited to the 2023 BOA Annual Congress to allow surgeons to trial available products.

Types of enhanced breast radiation PPE

Examples of garment types are:

Vest with wings

Integrated wings on a well-fitted and comfortable-to-wear vest. The additional material fans out anteriorly, but does not wrap around the axilla to provide full coverage. (Made by Infab, USA; UK distribution via Platform 14)

Vest with axillary shields

A detachable shield is applied to the vest, encircling the axilla. Our team worked with industry to develop these, which are comfortable and have no visible gaps in protection. (Made by Rothband, UK).

Bolero

Lead sleeves with a lightweight mesh across front and back, which can be worn under a standard vest. While having the advantage of acting as an adjunct to current gowns, initial testing suggested these were less comfortable and had some gaps in protection, depending on individual shape. (Made by ProtecX, UK and Mavig, Germany).

Beyond T&O

Radiation protection for the breast clearly impacts on many specialities beyond orthopaedics. The European Society for Vascular Surgery has already recommended that female operators consider adopting enhanced protections. We hope that growing awareness across specialities drives industry and governance structures to recognise the importance of protecting the female breast from occupational radiation.

Conclusion

Education for all surgeons, male and female, is key to reducing exposure in theatres. Additionally, our aim is for all female orthopaedic surgeons to have access to suitable PPE to both adequately protect breast tissue and to retain flexibility for orthopaedic operating. We aim to continue evaluating products, to determine degrees of protection and to improve recommendations.

Acknowledgements

Many thanks to Deborah Eastwood, Fergal Monsell, Caroline Hing and Emily James for their ongoing enthusiasm, support and guidance. n

Vest with sleeves

A fully integrated top with sleeves protecting the front and back of the axilla, providing comprehensive coverage. (Made by ProtecX, UK).

References

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

Building a culture of safety and health at work

Hiro Tanaka

The Annual World Day for Health and Safety at Work on the 28th of April promotes the prevention of occupational accidents and diseases globally. It is an awareness-raising campaign, intended to focus attention on the magnitude of the problem, and on how creating a safety and health culture can reduce the number of work-related deaths and injuries. This responsibility lies with each one of us. From government, NHS employers, surgeons in the workplace and our profession. As surgeons, we strive to provide the highest quality of care to our patients. In doing so, we expose ourselves to hazards that have the potential to compromise not only our health, but our ability to deliver the best care throughout our career. The aim of this series of articles is to increase awareness of the guidelines and preventative measures to create the safest possible work environment

What are the hazards?

Most orthopaedic surgeons are aware of the occupational hazards specific to the specialty, which include radiation exposure, infectious organisms, chemical hazards, surgical smoke, noise pollution, musculoskeletal injury and psychological stress1,2. It is easy to acknowledge them as “part of the job that we do”, rather than to consider the long-term effects that they may have. The consequences of repetitive exposure over many years are additive and simple preventative measures can prolong careers. We must also be aware of emerging technologies such as robotic surgery, new biomaterials and nanotechnology, which may pose unidentified risks in the workplace.

The exposure and risk from hazards are not uniform across our profession. They may vary according to subspecialty (eg, arthroplasty and cement fumes),

gender (radiation exposure), racial background (BAME COVID-19 risk), habitus (musculoskeletal injury) and pre-existing disabilities. It is, therefore, essential that safety and health at work is improved within the framework of equity and diversity of our workforce.

Hierarchy of controls

Imagine that a hazardous substance splashes into the eye of a chemical plant operator while taking a sample. The worker is not seriously injured, and the subsequent investigation focuses upon training, personal protective equipment and the circumstances of the event. But did anyone ever ask whether the worker needed to take the sample at all?

The National Institute for Occupational Safety and Health (NIOSH)3 defines five rungs of hazard mitigation, which start with controls that are the most effective to the least effective.

• Elimination – physically removes the hazard.

• Substitution – replace the hazard.

• Engineering controls – isolate people from the hazard.

• Administrative controls – change the way people work.

• Personal protective equipment (PPE) –protect the worker.

PPE is the least effective control and yet it is the area that gains the most attention in healthcare. Jonathan Back from NIOSH said, “You can’t eliminate every hazard, but the closer you can get to the top, the closer you can reach that ideal and make people healthier and safer.”

In light of the previous article by Hannah Sevenoaks et al., this series will start by exploring the principles of radiation safety

Hiro Tanaka is the Editor of JTO and a Council member of the BOA. He co-directs the BOA Future Leaders Programme.

“Everyone has the right to life, to work… to just and favourable conditions of work… Everyone has the right to a standard of living adequate for the health and well-being of themselves and of their family.” - Universal Declaration of Human Rights, UN, 1948

Exposure to radiation

Orthopaedic surgeons have a greater exposure to ionising radiation compared to other specialists, because the use of intra-operative imaging is an essential part of modern trauma and orthopaedic surgery. Despite this, there is no mandatory requirement for surgeons in the UK to undertake formal radiation and protection training. The radiation in orthopaedics study by Raza et al identified that 92% of UK surgeons used intra-operative X-rays at least once per week and yet 38% had received no formal safety training4

There is no safe dose of radiation. Radiation damage occurs at a cellular level. The direct damage may result in breaking of molecular bonds, resulting in cell death or distorted replication, which is believed to be the initial step in radiation-induced carcinogenesis or indirectly through the generation of free radicals.

What is the UK legislation and governance?

Ionising radiation poses a risk to not only the surgeon, but the patient, nursing staff, radiographers and the anaesthetic team. Their safety is covered by the Ionising Radiation Regulations 2017 (IRR17)5 and the Ionising Radiation (Medical Exposure) Regulations

2017 (IR(ME)R17), which are enforced by the Health and Safety Executive (HSE). IRR17 deals with exposure to employees and the public, and IR(ME)R17 to patients.

Radiation exposure should comply with a concept known as ALARA which means “as low as reasonably achievable”. It is synonymous with ALARP (practicable). The optimisation principle requires consideration of its use at all, its application during surgery, engineering and design to reduce exposure, and adequate PPE.

Hospitals appoint Radiation Protection Supervisors (RPSs) to ensure local compliance with regulations and undergo training courses, with refresher courses every 3-5 years.

All workplace-related deaths, accidents and occupational diseases including cancer must be reported by the employer to the HSE via Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR)

What is the statutory occupational exposure limit?

The occupational dose limits are set by the International Commission on Radiological Protection (ICRP) and defined by IRR17. The effective dose is the tissue-weighted sum of all the equivalent doses in all body organs and

represents the probability of cancer induction. Some body tissues have a higher sensitivity to radiation relative to body mass and, therefore, are given a higher weighting. For example ICRP103(2017) has a weighting of 0.12 for breast, 0.08 for gonads, 0.04 for thyroid and 0.01 for skin.

The maximum effective dose limit in IRR17 is:

• 20 mSv per year

• Or 100 mSv in any consecutive five years with a maximum of 50 mSv in any single year.

Once a pregnancy is confirmed and the employer notified, the employer must ensure that the equivalent dose to the foetus will unlikely exceed 1 mSv for the remainder of the pregnancy.

There are separate equivalent dose limits for the eye and thyroid.

To put things into perspective, we are all exposed to background radiation in our everyday lives and most people are exposed to 3 mSv of radiation per year. A chest X-ray exposes a patient to 0.1 mSv, a CT of the abdomen is 10 mSv.

What is the risk to my health?

Increased rates of malignancies in orthopaedic surgeons compared to the normal population have been reported6, as well as higher prevalence of breast cancer among female surgeons7. In addition, there is a significantly higher risk of complications during pregnancy8 and even congenital abnormalities among the offspring of surgeons9

It is important to be mindful that these selfreported studies do not attribute causation to radiation exposure, but it does highlight the need to take safety at work seriously.

What should I do with the C-arm?

Most of the radiation exposure from a C-arm comes from scattered radiation, which is significantly less than the primary beam. Therefore, awareness of good fluoroscopy practices can dramatically reduce radiation exposure over time. The exposure rate from the primary beam from a standard C-arm can be as high as 12-40 mSv per minute, while the scatter is about 0.05 mSv at 2 feet and 0.01 mSv at 4 feet.

There are four recommended methods of reduce radiation exposure from scatter:

• Positioning / contamination control

• Increasing distance

• Shielding

• Decrease time. >>

Figure 1: Correct orientation of a C-arm to minimise scatter.

Features

Positioning tips

1. Radiation levels are highest where the beam enters the surgical site, therefore it is important to be aware of the design of the C-arm. The radiation beam is emitted from the “Hammerhead” and the intensifier (receiver) is flat (Figure 1).

2. Vertical positioning. When vertically orientated, the optimal position to minimise scatter would be to position the radiation tube/emitter under the patient and the image intensifier above the patient. This would decrease the scatter delivered to your upper body and eyes.

3. Lateral positioning. Where possible, avoid the use of a horizontally orientated C-arm, for example, in hip or spine surgery. Standing on the emitter side can result in a four to eightfold increase in radiation exposure10 Instead, consider the 70-degree oblique view.

4. Oblique positioning. Stand on the side of the patient (on the side of the intensifier) and tilt the intensifier towards you. Tilting the intensifier towards your legs reduces exposure to your upper body and neck.

5. Distance. During orthopaedic trauma procedures, your hands are most vulnerable to exposure. Spinal surgeons are particularly at risk of hand exposure during insertion of pedicle screws. Stepping away just 1 foot from the beam can reduce scatter radiation by 300 times11 and 2 meters by 4,000 times.

6. Collimation. Most C-arms are designed to use collimation, which serves to narrow the beam of radiation and control scatter (Figure 2).

7. Laser guide. This allows centering of the beam and avoids unnecessary inadequate images.

Shielding

With shielding, 0.25mm lead gowns will attenuate 90% of the radiation, whereas 0.5mm will attenuate 99% at the cost of added weight and potential problems with musculoskeletal strain. Many units provide 0.35mm gowns as a balance of benefits.

For surgeons with pre-existing musculoskeletal problems, modern lead-free gowns are available, which are 30% lighter. The limitations of standard gown design in the protection of breast tissue have been highlighted in this issue.

Thyroid shields of 0.5mm thickness achieve 90% of exposure reduction, as well as leaded glasses which provide better protection than ordinary glasses.

A single dosimeter under a protective gown is not sufficient to measure the radiation doses to other parts of the anatomy such as the eyes, hands and neck. Better practice would be to use one above and one below the apron for surgeons at risk.

Is a Mini C-arm better?

The Mini C-arm has gained popularity among hand and foot/ankle surgeons because they have 1/10th of the radiation scatter of a standard C-arm. However, the same radiation protection principles should be applied in its use. There is a danger that the ultimate radiation absorption may be higher for a Mini C-arm due to increased fluoroscopy time, and decreased distance between the surgeon and the emitter. In one study, its use resulted in a

10-fold increase in the output and double the absorption to the surgeon’s hand12 Therefore, while it is theoretically safer, it may not necessarily be a better alternative in practical use.

Key learning points

1. Always consider the radiation principles of positioning, distance, shielding and time.

2. Ensure correct orientation of the C-arm. Emitter at the bottom.

3. Be aware of scatter when radiation is deflected from the patient or surfaces.

4. Step away from the beam when screening, if able to do so.

5. Avoid the use of the C-arm in the true lateral position where possible.

6. If a lateral view is required, consider a 70-degree view, with the beam directed away from the operating surgeon.

7. Consider the additional value of each image to the success of the procedure and minimise the overall number of images.

8. Avoid live screening.

9. Wear appropriate, correctly fitting PPE. References References

Figure 2: Mini C-arm views obtained with Standard 6” vs 4” collimation. Narrowing the field increases magnification but reduces scatter.

“The Mini C-arm has gained popularity among hand and foot/ankle surgeons because they have 1/10th of the radiation scatter of a standard C-arm.”

Non-selective state schools engagement programme: The British Hip Society Experience

Marieta Franklin, Joanna Maggs and Vikas Khanduja

Marieta Franklin is an ST7 registrar in Mersey where she is on the Specialty Training & Education Committee. She is on the BOTA committee as the Specialty Advisory Committee Representative and forms part of their Culture & Diversity subgroup. Representing BOTA on the British Hip Society’s Culture & Diversity Committee, Marieta is Project Lead for their Schools Engagement Programme.

Medical school applications are disproportionately skewed towards the more affluent end of society. When using the National Statistics Socio-economic Classification, a self-reported system based on parental occupation with a range of options, 72% of applications came from the category of ‘managerial/professional occupations’, while only 11% identified as being from either the ‘lower supervisory and technical occupations’ and ‘semi-routine and routine occupations’ groups1

In the book The Class Ceiling2, Friedman and Laurison deliver an analysis of earnings data from the Office of National Statistics Labour Force Study3. They note that the children of doctors are 24 times more likely to enter the profession than those without a doctor parent. If individuals are not exposed to surgical careers, how will they be inspired to pursue them?

The UK undergraduate curriculum for medicine provides variable – and at times

limited – exposure to surgery, and in particular trauma and orthopaedic surgery (T&O)4. Some medical schools no longer have formal placements in T&O at all. This, despite Hospital Episode Statistics (HES) data showing that T&O sees the highest number of outpatients of any surgical specialty and is second only to general surgery in number of hospital admissions4,7. The loss of the firm structure and changes to working schedules, means that doctors who had little exposure to T&O in medical school, may not have very much more in their early years of qualification unless this is something they actively pursue. Studies have demonstrated that some of the most powerful and valuable aspects of surgical learning are personal, and positive practical interactions with surgeons5,6. If we want the best people to join our specialty, we need to sow inspirational seeds early. Therefore, why not begin this process prior to entry into medical school?

We outline a simple, free, reproducible and effective way to address the issues around widening participation in medicine and surgery.

Joanna Maggs is a Consultant orthopaedic surgeon at Torbay Hospital specialising in trauma, lower limb arthroplasty and revision hip surgery. She completed her undergraduate studies at University College London, intercalating with a BSc in the history of medicine and later completed an MSc in musculoskeletal science at University of Oxford, awarded with distinction. She is chair of the British Hip Society Culture and Diversity Committee.

Engaging with schools

As part of the British Hip Society’s (BHS) ongoing work on Diversity, Equity & Inclusion, our Culture & Diversity Committee formed a working group to develop an engagement project with non-selective secondary state schools. The American Academy of Orthopaedic Surgeons runs a ‘Playground Build’ programme during their annual meetings 8 We decided on a similar approach in the hope of giving something back to the local community. With our annual meeting in Edinburgh fast approaching, we contacted all the nonselective state secondary schools in Edinburgh and Lothian, offering the opportunity to attend our schools engagement session: ‘Do you want to be a surgeon’? Twenty-eight young people along with an accompanying adult from each school availed themselves of the opportunity. BHS funded their transport to and from school, and provided refreshments throughout the morning and lunch.

Vikas Khanduja is a Consultant Trauma and Orthopaedic Surgeon at Addenbrooke’s - Cambridge University Hospital NHS Foundation Trust. He is the President of the British Hip Society and Trustee of NAHR. He has been involved in the conception, initiation and development of Schools Engagement Programme run by the BHS.

We devised a programme with the goal of being engaging, interactive and beneficial (see Figure 1). We ensured that our working group was a team of individuals with diverse characteristics with respect to gender, age, background and location of work – after all, diverse teams perform best9. With the awareness that hip surgery would be a niche career option for a secondary school pupil, we were keen to expose our school students to as wide a breadth of our work as possible. The tone for the day was set brilliantly by an informative set of talks from third year medical students. They talked about ‘life as a medical student’ and ‘accessing medicine’, including discussing routes into medicine designed to widen participation and the eligibility criteria for these. We had fabulous engagement from industry with practical workshops on stems, and cementing and demonstration of new technologies and robotics. Extended scope physiotherapists were recruited to run a workshop using goniometers and dynamometers – opening the students’ minds to allied health professional roles. Laparoscopic box and radiograph sessions run by surgeons were well-received. Groups were also allowed time to wander the stands with a surgeon host and to experience the environment of a professional conference.

To the best of our knowledge, this is the first project of its kind to run at a UK orthopaedic conference. It was a step into the unknown and we were unsure as to how interactive our students would be. Our reward was the privilege of engaging with a room full of enthusiastic students and to see these young people get hands-on in workshops, excited and happy.

What did we learn?

A number of learning points emerged from this session. These will help us to refine our approach next year, and we hope will be of use to others considering setting up a similar initiative:

• We approached more than 100 Edinburgh and Lothian non-selective state schools, and uptake was lower than we had anticipated. This was in part due to school policies regarding senior pupils not going on school trips close to national exams (Scottish Highers commence at the end of April).

• We stipulated that a member of staff/suitable guardian accompanied the pupils from each school. Some schools reported that they didn’t have a free staff member and could not easily arrange another accompanying adult with the appropriate Disclosure and Barring Service (DBS) clearance.

• Our workshops lasted for 15 minutes, but we felt that in future we would allow a little more time, as the groups tended to still be really engaged at the 15-minute mark and had to be cajoled into moving onto the next station!

• A friendly familiarity developed between the pupils from different schools over the course of the morning, and our group sizes of around 8-12 students seemed to work well, allowing everyone to feel involved, but not under undue pressure.

• We received some interesting feedback from one tutor – she explained that she had taken a group to another industry event for school children a year or so previously. At that event, there were children from both private and state education. She had observed a tendency in her students >>

Figure 1: Running Order - Schools Programme.

on that occasion to defer to the somewhat more confident children from private schools and remarked that the students at this event had felt more comfortable, due to their similar schooling backgrounds.

• We were fortunate that our self-selected group were similar in age, ranging from 15-17 years old. This meant that workshop hosts and faculty could deliver teaching at a similar level for all students, and peer to peer interaction happened naturally.

• The awe and excitement of the school students was infectious! Word spread about how much fun the faculty and members of the BHS Executive committee

were having, and some very senior FRCS examiners rolled up their sleeves and came to join in with demonstration and hosting.

• This positivity continued for the subsequent days of our largest ever, 700-strong conference. Word spread, and colleagues from far and wide came to find us to enquire about the session, and how they could get involved in future events.

Future plans

We plan to make the schools engagement session a permanent feature of the British Hip Society annual meeting. In addition, we are hoping to collaborate with the British

Orthopaedic Trainees Association (BOTA), the British Orthopaedic Medical Student Association (BOMSA), and the British Orthopaedic Association (BOA) to run a similar session at this year’s BOA meeting. Next steps will also include our members reaching out to pay schools visits, with supporting materials provided by our working group. The British Hip Society Culture & Diversity Committee would welcome all thoughts and ideas around schools’ engagement to cd.com@britishhipsociety.com n

References

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

Jig-guided hip revisions

For the first time, Gomina has developed an extraction set that allows a hip revision to be done with minimal bone loss. Thanks to innovative production technologies, it is possible to manufacture dimensionally rigid chisels with different radii. The precision ground, sharp cutting edges of the chisels are the result of Gomina’s many decades of expertise.

The bespoke crafted jigs manufactured by Gomina ensure the application of a precise separation of bone and prosthesis. This innovative pioneering extraction set from Gomina makes surgeon’s work far easier, leading to shorter operating times. Entirely for the patient’s benefit.

of the European Bone and Joint Infection Society

Theme From the beginnings of the AO foundation to modern treatment concepts in implant-related infections

Topics

• Animal models in biofilm research

• Antimicrobials

• Biofilm and beyond - translation from in-vitro data to in-vivo strategies

• Diabetic Foot Infection and Diabetic Foot Osteomyelitis

• Genetics in implant-related Infections

• Infection prevention

• Orthoplastic Surgery – from split skin to tailored tissue engineering? …and much more!

Clinical guidelines and the standard of care: Part 1

Many clinical negligence lawyers have seen some use of clinical guidelines in their cases to assist the court in determining what constitutes reasonable care1. It has been proposed that when using a guideline to inform the standard of care, the guideline must be Bolam-defensible, Bolitho-justifiable, Daubert-valid, and also relevant to the specific case in question2

Simon Britten is a Consultant Trauma & Orthopaedic Surgeon in Leeds specialising in lower limb reconstruction and he is the President Elect of the British Limb Reconstruction Society. He has been awarded the taught degree of Master of Laws with Distinction in Medical Law and Ethics by De Montfort University Leicester. He is the chair of the BOA Medico-legal Committee and faculty member of the BOA course ‘Law for Orthopaedic Surgeons’. Last year he was elected to Membership of the Faculty of Forensic and Legal Medicine of the Royal College of Physicians of London. Mr Britten is grateful for the assistance of Bob Handley and Chris Moran, who both gave up time to discuss the origins, formulation and ethos of BOAST guidelines.

That is to say, in adhering to the guideline, the doctor was providing treatment which was considered reasonable by a responsible body of medical opinion3; the body of medical opinion has a logical basis and has involved the weighing of risks against benefits 4; the guideline is admissible as evidence, with scrutiny of the guideline’s development and the extent of its adoption within the relevant medical community5; and the finding of fact as to whether the guideline has been followed when providing care in the specific case or not, coupled with expert evidence considering the standard of care within the parameters of the guideline.

In Montgomery v Lanarkshire Health Board6, the well-known pivotal case in the consideration of clinical negligence by the courts, it has been argued by some that the Supreme Court chose to overlook the relevant guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG)7 and the National Institute for Health and Care Excellence (NICE)8 that were in existence at the time of Nadine Montgomery’s obstetric care9. The Supreme Court’s decision in Montgomery indicating that compliance with professional guidelines does not necessarily protect the clinician from the accusation of clinical negligence, means that broadly the clinician must try to figure out whether aspects of a particular clinical guideline will or will not be acceptable to the court.

In broad terms, the Claimant’s lawyers may argue that the surgeon followed the relevant guidelines, but in the specific case under consideration they should have deviated. The Defendant’s legal team may contend that the surgeon followed the guidelines, so it must have been reasonable. On another occasion, the Claimant may argue that the surgeon did not follow the relevant guidelines, so the care on balance must be negligent; while the Defence would reply that while the surgeon did not follow the guidelines, there was a clinical reason to deviate on that occasion.

When considering what is reasonable treatment, both from the clinical point of view and also from the medico-legal point of view, the surgeon may wish to:

i. Take into account the relevant clinical guidelines

ii. Consider any circumstances specific to the individual case which may influence treatment options

iii. Appreciate that rigid adherence to guidelines may occasionally be unwise and potentially negligent

iv. Recognise that intentional deviation from existing guidelines may be reasonable if there are case-specific factors which warrant departure from the guidelines.

In other words, from both the clinical and medico-legal perspectives, each individual case should be considered on its own merits. In the end, they are only guidelines after all.

Sources of clinical guidelines

There are several sources of clinical guidelines of relevance to orthopaedic practice in the UK, covering both acute trauma and elective practice, which ought to be familiar to orthopaedic specialists for the purposes of clinical practice and medico-legal practice.

Simon Britten

The National Institute for Health and Care Excellence (NICE) has several guidelines of relevance to both acute trauma and elective orthopaedics10. Over the last 10 years or so, the BOA has developed a series of clinical guidelines covering trauma and fracture care, including British Orthopaedic Association Standards in Trauma and Orthopaedics (BOAST) guidelines11; and running alongside this work has been collaboration with the British Association of Plastic, Aesthetic and Reconstructive Surgeons (BAPRAS) to produce clinical guidelines on the orthoplastic management of open fractures12

On the elective side, the BOA has worked in collaboration with NHS England, NHS Improvement and the Royal National Orthopaedic Hospital Stanmore, on the Getting It Right First Time (GIRFT) programme13 . There has been collaboration between GIRFT and NHS Resolution, along with the British Hip Society [BHS] and British Association for Surgery of the Knee (BASK) to produce guideline documents for best practice in documenting hip and knee arthroplasty procedures, published in 201914

While not strictly offering clinical guidelines, another source worth considering on whether treatment provided in cases of orthopaedic trauma has reached a reasonable standard is the influential text book Rockwood and Green’s Fractures in Adults15. For certain injuries the text can be very prescriptive in what treatment should (and as importantly, should not) be followed. This can guide the treating clinician, and on occasion it can add significant weight to the orthopaedic expert’s evidence when assisting the court as to whether treatment provided has been reasonable.

BOAST guidelines

This series of compact and versatile documents sets out auditable standards in trauma care, and more recently for elective orthopaedic practice, and were originally developed by the BOA’s Trauma Group16

In 2007-08, under the chairmanship of initially Professor Keith Willett17 and subsequently Professor Chris Moran18 , the BOA Trauma Group wanted to express succinctly their view on assorted aspects >>

“In medico-legal practice it can be useful for the expert to append the relevant BOAST to their medical report, as a succinct summary of the relevant clinical considerations and potential actions – perhaps more as a background summary than as a one-size-fits-all recipe to determining what constitutes reasonable treatment.”

of orthopaedic trauma management for the general benefit of trauma patients. They appreciated that overly long guidance documents generated by professional groups were both time-consuming to prepare and in reality, unlikely to be read. The group began to produce single page executive summaries – BOASTs – on such topics as compartment syndrome, open fracture management, treatment of supracondylar fractures in children and the management of traumatic spinal cord injury. Each topic was selected on the basis that it represents a clinical entity which may be difficult to treat well, with potential pitfalls lurking, and at significant risk of attracting litigation if poor outcomes ensue.

Each BOAST was written on the basis of the contemporary evidence base, to set out auditable standards and to enable different solutions in different places to achieve the same standard of care19

While the BOASTs are not formally part of the higher surgical training exit examination FRCS (Tr & Orth) syllabus, most orthopaedic trainees know them for the examination, thanks to their succinct and functional nature. Furthermore, several BOASTs are referred to in the methodology of the Trauma Audit and Research Network (TARN), the UK nationwide monitoring system for moderate to severe injury20. TARN benchmarks the performance of major trauma networks, major trauma centres, ambulance services and individual clinicians.

This wide range of BOAST guidelines applications include in day-to-day clinical practice, concise revision aids for trainee orthopaedic surgeons. Through their use as reference tools in the national monitoring and audit of major injury, they demonstrate their considerable usefulness and functionality.

BOASTs were set up as auditable standards, as opposed to specifically a gold standard or a reasonable standard. Each BOAST contains numerous auditable potential interventions for any given clinical entity. For any given item within a BOAST, each must be considered on its own merits with reference to the reasonable standard of care by the Bolam test. Some interventions are mandatory, such as reassessing the neurovascular status after relocation of a dislocated knee. To fail to do so would be considered by an orthopaedic expert to have fallen below a reasonable standard of care. Other interventions may be desirable, for example taking photographs of the open wound when first exposed for clinical care when managing an open tibial fracture. Not to do so in isolation would not fall below a reasonable standard of care, although in conjunction with other omissions it may give the orthopaedic expert an overall impression of care which has fallen below a reasonable standard. Sometimes a listed intervention may not be required, for

example measurement of pressures in a case of compartment syndrome, where on clinical grounds the diagnosis has already been made, emergent surgery to perform fasciotomies has been arranged, and to measure the pressures would simply delay surgery 21

It can be argued that if care is offered to a patient which is not in line with standards set out in the relevant BOAST guideline, then the patient should be made aware of that 22

In medico-legal practice it can be useful for the expert to append the relevant BOAST to their medical report, as a succinct summary of the relevant clinical considerations and potential actions – perhaps more as a background summary than as a one-size-fits-all recipe to determining what constitutes reasonable treatment. The orthopaedic expert should anticipate assisting the court by placing such a document in clinical context to consider whether specific aspects of treatment recommended in a BOAST constitute the auditable standard of care, or the gold standard, or the reasonable standard. Of course care given only has to be reasonable to avoid being negligent.

BAPRAS / BOA guidelines on open fractures

The British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British Orthopaedic Association first published guidelines on the joint orthoplastic management of open fractures in 1993 and since then, several updates of this document have been produced23

Unlike NICE guidelines, the BAPRAS / BOA guidelines have yet to make a significant appearance in reported case law, despite their considerable relevance to the standard of care provided in the treatment of open fractures.

Open fractures are severe injuries, that can lead to significant rates of bone infection, non-union, post-traumatic deformity, joint stiffness and arthritis, plus permanent functional limitation. If an individual goes on to develop one or more serious complications of their open fracture leading to a poor outcome, it can be very difficult to demonstrate that this has been caused by negligent treatment, rather than as a consequence of the original severe injury itself. Several departures from the guidelines overall may constitute breaches of duty of care, but the defence may simply be that the poor outcome would on balance have occurred in any event, irrespective of those breaches, as the injury was so severe from the outset.

It is worth bearing in mind that clinical guidelines from different sources may overlap, both in terms of clinical scenarios covered and also differing in time of latest edition. BOAST, BAPRAS / BOA and NICE guidelines all cover open fractures and compartment syndrome for example. As these documents are sequentially

revised at different times, this may give rise to the potential for some ambiguity and inconsistency. Having said that, the national experts responsible for each set of guidelines tend to be drawn from the same pool and more recently efforts are made to ensure continuity across these platforms.

Next time in Part 2 (which will be published in the September issue), I will be considering other useful sources of clinical guidelines available, which help to inform the standard of care in trauma and orthopaedic surgery – including a more detailed consideration of guidelines from NICE, GIRFT, and Rockwood and Green. There will also be comment on what may be yet to come in terms of medico-legal jeopardy, after the COVID-19 pandemic spawned clinical guidelines for the orthopaedic surgeon acting as the medical registrar treating respiratory patients, outside their usual area of expertise. In addition, guidelines for how to treat a variety of acute musculoskeletal injuries non-operatively. This was in anticipation of a considerable reduction in anaesthetic support, due to redeployment to intensive care units, the need to protect patients from hospital admission and the risk of nosocomial COVID-19 infection. n

References

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

This article is based on the following book chapter: Clinical Guidelines in Trauma and Orthopaedic Surgery in Clinical Guidelines and the Law of Medical Negligence: Multidisciplinary and International Perspectives, ed. by Samanta A and Samanta J. (Edward Elgar Publishing, Cheltenham, UK & Northampton, MA, USA, October 2021). All excerpts reproduced with kind permission of the publisher.

Anna Clarke

Paediatric orthopaedics update: what’s new with the ‘Big Three’?

For most orthopaedic surgeons that have an adult practise by day, but look after paediatric patients on call, there are three conditions that historically may have caused a flutter in the chest: the paediatric supracondylar fracture, the child with infection and open trauma.

In this paediatric special edition, we will examine all three of these conditions in the hopes of updating traditional knowledge, and with some potentially new insights into current practice.

Anna Clarke is a consultant paediatric orthopaedic surgeon from Bristol. Her special interests include trauma, upper limb surgery and neuromuscular conditions. She is the clinical lead of the Bristol Paediatric Major Trauma centre, avid AO educator and examines for the FRCS. She remains enthusiastic towards the generality of orthopaedics that paediatrics provides.

The joy of paediatric orthopaedic surgery is its diversity, complexity and variety. Even in trauma (unlike our adult colleagues) who may subspecialise in limb reconstruction or hip arthroplasty for example, our trauma lists meander through the likes of orthoplastics in open trauma, complex intraarticular adolescent distal humeral fractures, back to manipulation under anaesthesia of simple wrist fractures, within the space of a Saturday on call.

I am lucky enough to work in one of the few ‘standalone’ paediatric major trauma centres in the UK. I am surrounded by people whose experience is centred around the care of children, and I can tap into their knowledge and paediatric specific resources whenever required, but am mindful of those who do not have these advantages.

I would, however, point out that there is much benefit to be gained by being treated in a centre where adult and paediatric surgeons co-exist. Adult polytrauma cases are commonplace, and the protocols and pathways of management are innate in the doctors dealing with them. In children, thankfully, these cases are rare – meaning we face different challenges in terms of access to, for example, whole body CT scanning, and the management of rare ‘more adult’ conditions such as hip fractures or pelvic trauma, without necessarily having immediate access to an onsite pelvic team.

The point of a publication such as this is to help all of us maintain our knowledge and make us the best possible surgeons across the breadth of the specialty, in the context of our individual unique units.

I hope the information relayed will not only be interesting, and potentially provocative, but, more importantly, relevant to all of us that are fortunate enough to work with children as part of our practise. n

“I would point out that there is much benefit to be gained to being treated in a centre where adult and paediatric surgeons co-exist. Adult polytrauma cases are commonplace, and the protocols and pathways of management are innate in the doctors dealing with them.”

Evolution and current management of the paediatric supracondylar fracture

James Hunter has been a consultant in Nottingham since 1995. He was president of BSCOS from 2010 to 2012 and chair of the AO Paediatric Group from 1997 to 2016. He was one of the authors of the BOAST on supracondylar fractures and one of the developers of the AO Paediatric fracture classification.

The supracondylar fracture of the humerus is still quoted as the case most trainees would like least on their first on-call consultant night. Mercer Rang prefaced his chapter on elbow fractures with the quote “pity the young surgeon whose first case is a fracture around the elbow”. He maintained it was an ancient saying, but searching for the reference is fruitless, leading to the possibility that he was quoting himself. This really does not need to be the case as we approach the end of the first quarter of the 21st century, and here we will try to summarise the tips and techniques that make the management of this fracture much easier.

As a registrar in the 1980s, the expectation was that one would manage a displaced supracondylar fracture by closed reduction and immobilisation, in either a cast or more traditionally a collar and cuff. This immediately exposed one to the conundrum of elbow flexion, whereby hyper flexion was required for stability, but was the very thing that endangered the vascular supply and could cause the compartment syndrome that resulted in Volkmann’s ischaemic contracture – the very worst results that could be obtained. Various alternative treatment methods were available; skin or skeletal traction, open reduction and K wiring (strongly recommended by several senior surgeons of that era) and closed reduction with percutaneous Kirschner wiring, which had been described a decade earlier. It is this latter method which is now the standard. Traction produces excellent results, but lengths of stay in hospital are between 10 and 25 days. Routine open reduction can lead to unacceptable levels of stiffness and modern equipment, especially image intensifiers, have facilitated the performance of close reduction and percutaneous pinning (CRPP).

Classification

Five percent of supracondylar fractures are of the flexion type, which if displaced is particularly difficult to manage (Figure 1).

The classification of extension type supracondylar fracture has been made unnecessarily complicated by adherence to the method of Gartland, which requires considerable modification to work.

Gartland originally described mild, moderate and severe displacement of the supracondylar fracture, and this became modified to:

1. Undisplaced

2. Angulation with an intact posterior cortex

3. Complete displacement.

This version of the classification has been shown to have good reproducibility, but fails to distinguish between some type 2 fractures that can be managed non-operatively, and others that are less stable and require fixation. Most of the fractures that defy classification have an element of rotation at the fracture site. Von Laer introduced the concept of fractures that were rotated being distinct from those that were not and created a classification with four groups (Figure 1). There are other four group classifications, such as that of Lagrange and Rigault, and that of the AO group. Whichever one is used, the key is to distinguish unstable fractures requiring reduction and fixation from those that can be managed in a sling, possibly after a nudge straight.

What treatment when?

Undisplaced and angulated fractures can be managed in a collar and cuff or cast. The former is preferable, as one can achieve more flexion without anything at the front of the elbow. X-rays are easier to perform and the sling can be removed easily at the end of treatment.

James Hunter and Anna Clarke

Anna Clarke is a consultant

paediatric orthopaedic surgeon from Bristol. Her special interests include trauma, upper limb surgery and neuromuscular conditions. She is the clinical lead of the Bristol Paediatric Major Trauma centre, avid AO educator and examines for the FRCS. She remains enthusiastic towards the generality of orthopaedics that paediatrics provides.

The primary treatment for displaced fractures should be closed reduction and percutaneous K-wiring.

Traction can be used for displaced fractures, particularly in younger children with better remodelling capacity and is a useful ‘get out of jail’ technique which is useful to be familiar with. The rare fracture that will not reduce is better placed on traction, rather than attempting open reduction on an elbow swollen by multiple attempts at closed reduction. Skin traction is also used as overnight immobilisation in some units; the advantage being that it can be applied under simple analgesia without sedation or an anaesthetic. (Figure 2)

Timing of treatment

More than 20 years ago, the group from Cincinnati described leaving the formal treatment of supracondylar fractures until the next day in the majority of cases. Obviously, they excluded any cases with vascular compromise and they did perform a provisional reduction, under ketamine, in many of their cases. The complications were less in the group with delayed treatment. Multiple further investigations have been performed, albeit mainly retrospective and the evidence was summarised, in the systematic review from Aberdeen, which found no difference in outcome for a variety

of endpoints from the need for open reduction to post-operative deformity. The key is to not delay fractures with vascular compromise. The recommendation in the latest version of the BOAST (2020) is that an absent pulse should be an indication for early surgery.

How to do a closed reduction

Views on how to reduce and K-wire the supracondylar fracture are relatively diverse and often entrenched. There is no need to change someone’s successful method, but when it is proving unsuccessful there are some useful tips. The method described on AO surgery reference is essentially a synthesis of the views of faculty members on paediatric courses over the last 20 years and is not contentious. It varies little from the method of Charnley described in his Closed Treatment of Common Fractures

For the standard posteriorly displaced supracondylar fracture (AO type 4, displaced Gartland 3) the following tips should be helpful.

1. Longitudinal traction with the elbow slightly flexed for at least five minutes gets most fractures out to length with interposed soft tissues released. Milking manoeuvres may be required for puckeredin soft tissue, but these mostly release with traction. >>

Figure 1: Classification algorithm.

2. Correct the medial lateral displacement using the image intensifier while maintaining traction.

3. Flex the elbow with a thumb on the olecranon, pushing the distal fragment forwards. One should feel reduction.

4. If the elbow will not fully flex, the fracture is not reduced. In full flexion, the hand may go white – do not panic.

5. Check the shoot through AP. Rotate the arm at the shoulder to check the oblique views, which will show the medial and lateral columns.

6. Maintaining full flexion, rotate the whole arm to get the lateral view, medial side up. The fracture will be stable if the posterior periosteum is intact and the elbow fully flexed.

7. Place your K-wires.

8. Check the alignment of the arm and carrying angle against the opposite arm.

For the flexion type a different approach is required.

1. Firstly positioning must allow full extension and hyperextension of the elbow.

2. It must be possible to get the image intensifier into the lateral position without moving the arm.

3. Pre-insertion of the K-wires into the distal fragment before reduction may be necessary, as inserting them with the arm fully extended can be difficult.

4. External fixation can be useful as the pins can be used as joysticks to reduce the fracture.

What wire configuration?

For all but the smallest children (under four) one should use 2mm K-wires. Why? They are stronger and will hold the position of reduction reliably for three weeks. They deviate less in the bone on insertion. They do not cause growth arrest. Multiple punctures with 2mm wire will not cause growth arrest.

For standard transverse fractures, it is reasonable to use two lateral wires to avoid the ulnar nerve. The entry point is on the capitellum. The wires should be divergent. If the wires cross outside the skin they will diverge in the bone. After placing the wires stability should be tested and if in doubt, then a third lateral wire or a medial wire can be added.

If using a medial wire, then one needs to take precautions to avoid the ulnar nerve; check the uninjured side for a subluxing ulnar nerve (one in 20). Make a small incision to directly place the drill guide on the medial epicondyle, then put the wire in on oscillate and press on the ulnar nerve so that you cannot get it without drilling your thumb. Some fracture configurations demand a medial wire, so it needs to be within one’s skill set (Figure 3).

Whatever wire configurations is used, the construct must be tested under fluoroscopy at the end of the procedure. The fracture

needs to remain stable through flexion and extension of the elbow, and be resistant to varus and valgus stresses. Stability and alignment are more important than accuracy of reduction. Unni Narayanan reported to EPOSNA in 2017 that the limits of acceptability for reduction were quite wide:

• Medial displacement 30%

• Lateral displacement 15%

• Posterior displacement 37%

• Anterior displacement 25%

• Baumann angle 59o to 83 o

• Anterior humeral line through capitellum.

Aftercare

The wires should be left outside the skin and removed in clinic. Three weeks is long enough for the majority of fractures. Four weeks is the absolute maximum and the elbow should be mobilised straightaway, not put back in a sling.

An above elbow backslab should be applied in 45°-60° of flexion. The slab is of sufficient size that it encompasses between two-thirds and three-quarters of the arm circumference, open at the front.

Physiotherapy is not required for the majority of supracondylar fractures, but it is worth warning parents that full extension of the elbow can take many weeks to return.

Nerve injuries

The neurovascular status must be carefully documented, before and after surgery. Testing of the individual nerves must be complete and documented. N/V ‘tick’ is not adequate documentation. The preoperative documentation is essential because new nerve lesions after the operation are a concern, and require discussion with the responsible consultant and the operating surgeon as a minimum (PNI BOAST). The combination of median nerve deficit and absent pulse potentially indicates entrapment at the fracture site, and is best released before the onset of healing.

Vascular problems

These can be a huge cause of concern. Some simple principles can guide decisionmaking:

• There is an excellent collateral circulation around the elbow. The majority of vascular impairments associated with supracondylar fractures resolve with reduction of the fracture.

• Volkmann’s ischaemic contracture is caused by a compartment syndrome in the flexor compartment.

Figure 2: Patient in traction.

It therefore follows that:

• The immediate treatment of a poorly perfused hand below a displaced fracture is to reduce the fracture urgently.

• If the hand is well-perfused after reduction, exploration of the artery is not required, whether the pulse can be palpated or not.

• If perfusion is worse after reduction the artery may be entrapped. In this situation the reduction is normally incomplete. Re-displace the fracture, pull on the arm and try to milk soft tissues from the fracture. An open approach to the interposed soft tissues may be required.

• A white hand that remains white after reduction clearly requires exploration, possible reconstruction of the artery and fasciotomy. Exploration and fasciotomy are well within the remit of the orthopaedic surgeon, but arterial reconstruction is not, so it is best to decide in advance who is available (vascular/plastic surgery).

Conclusion

In summary, with a sensible plan, displaced supracondylar fractures can be managed satisfactorily without stress. n

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Spine

1 ACDF – 319 patients (IDE RCT)

“i-FACTOR subjects demonstrated higher overall success rate than control (autograft) subjects (68.75% and 56.95% respectively, p = 0.0382)”

2 PLF – 98 patients (RCT)

“This RCT indicates i-Factor being signi cantly superior to allografted bone in enhancing intertransverse fusion (p = 0.000)”

3 ALIF – 110 patients

“…high fusion rate and clinical improvements comparable to the published results for ALIF using autograft or BMP”

4 PLIF – 40 patients

“i-FACTOR is associated with faster formation of bridging bone when compared to autologous bone in patients undergoing PLIF”

Orthopedics

5 Long bone non-union and delayed union 22 patients –90% bone consolidation

“P-15 appears to o er a safe, economical, and clinically useful alternative to autograft in the repair of ununited fractures”

6 Foot and ankle – 170 patients

i-FACTOR yields 92% fusion at 12 months post-op across fore-, mid- and hindfoot joints

7 Foot and ankle – 16 patients

100% fusion at 12 months in hindfoot and ankle fusion revision procedures

8 Peri-acetabular osteotomy – 51 patients

Patients treated with i-FACTOR were 3x more likely to attain a partial or complete fusion at 6 months post-op compared to allograft

Figure 3: Fracture configuration with medial wire.

Open tibial fractures in children: are they really just little adults?

Jonny Jeffery studied medicine at Imperial College London, completed his CCT in trauma and Orthopaedics in the Oxford deanery and is currently the Senior Fellow in Paediatric Orthopaedics at the Bristol Royal Hospital for Children. He has a specialist interest in child and adolescent sports and soft tissue knee injuries and paediatric lower limb deformity correction.

Should open fractures in children be treated differently to those in adults? It is often thought that while anatomy might be similar, physiology might be different and a more cautious approach is taken with children following such trauma. National standards of care have been published, which include the care of children. The fact remains that the incidence of open long bone fractures in children is less than 10% than that seen in adults and as such, very few centres can declare an extensive experience.

We can reflect on a typical case example to illustrate standard management of open lower limb trauma in our centre, according to NICE Guidelines1 and the BOA / BAPRAS Standards of Care2, and discuss the evolution of orthoplastics management in this population.

Case Presentation

A 9-year-old boy was brought by ambulance to our Paediatric Major Trauma Centre (PMTC), having fallen two metres from a tree while on a camping trip. He sustained an open tibia fracture that was reduced under sedation at the scene by paramedics. On arrival at the PMTC, he was given prophylactic intravenous Co-Amoxiclav; his wound was inspected and photographed (Figure 1) prior to application of a saline-soaked gauze dressing and a plaster cast.

His foot was well-perfused with normal sensation. Plain X-rays confirmed a diaphyseal tibial fracture with some comminution (Figures 2 and 3). No other injuries were identified on clinical assessment and this was confirmed with a trauma CT series, including a CT angiogram. This is routine practice in our unit to assess the vascular anatomy of the limbs and to plan reconstructive options.

Thomas Wright is a consultant plastic surgeon in Bristol, UK. His main interests are extremity reconstruction for trauma, infection and soft tissue sarcomas. He has published extensively on the orthoplastic management of open fractures and teaches regularly on this subject both nationally and internationally.

Jonny Jeffery, Thomas Wright, Anna Clarke and Umraz Khan

Figure 1: Open tibia fracture prior to application of a saline-soaked gauze dressing.

Umraz Khan is a renowned plastic surgeon and has been undertaking extremity reconstruction for over 20 years. He has established and leads a world class orthoplastic service in Bristol where over 200 cases are managed each year. He has co-authored many leading articles as well as national guidelines in trauma and PJI.

The next morning he underwent a first stage wound excision, extension and washout of the wound, with both consultant orthopaedic and plastic surgeons present. The guidelines recommend dual senior surgical input at this stage, as it allows thorough excision of compromised tissue in a planned fashion that enables preparation for future soft tissue management, but also allows for discussion of bony stabilisation options. Historically, there may have been a tendency to believe that the wound excision need not be as thorough as in adults, but this is not evidence-based. Degloved skin is assessed and is excised as it will take several days to fully declare, potentially leading to an exposed fracture and even metalwork3

At stage one, the comminuted bone fragment was loose and devitalised, so was removed leaving two-thirds remaining cortical contact. (Figure 4). A monolateral external fixator was applied in this case, along with a vacuum dressing (Figure 5). The choice of temporary stabilisation is down to the surgical preference of the orthopaedic and plastic surgical team, while bearing in mind the characteristics of the fracture and planned future definitive fixation.

The patient continued intravenous Co-Amoxiclav as an inpatient. He returned to theatre within 72 hours for definitive surgery in the form of further washout and debridement, redelivery of the bone ends, and exchange of the monolateral external fixator for a Taylor Spatial Frame (TSFSmith and Nephew) and free flap soft tissue coverage (Figure 6).

When using a ring fixator for open fractures, combined pre-operative planning between orthopaedic and plastic surgery specialists is vital to ensure the frame can be partially deconstructed once applied to allow sufficient access for microvascular free tissue transfer. Where possible, we will position and prepare the patient so that our plastic surgery colleagues can begin harvesting the free flap, while orthopaedic surgeons complete the skeletal stabilisation, to minimise total anaesthetic time. >>

Figure 2: Diaphyseal tibial fracture...

Figure 3: ...with some comminution.

Figure 4: Comminuted bone fragment removed.

Anna Clarke is a consultant paediatric orthopaedic surgeon from Bristol. Her special interests include trauma, upper limb surgery and neuromuscular conditions. She is the clinical lead of the Bristol Paediatric Major Trauma centre, avid AO educator and examines for the FRCS. She remains enthusiastic towards the generality of orthopaedics that paediatrics provides.

For this case, the frame was applied in the supine position and then augmented laterally with Ilizarov rods before removal of the medial three struts and the medial half of the rings. The patient was then turned to the lateral position (injured side down) to allow access to both the posterior tibial vessels and elevation of a scapular free flap. The flap was anastomosed to the posterior tibial artery (end to side) and its vena comitans (end to end). Once free tissue transfer has been completed, the TSF was reconstructed and the lateral Ilizarov rods removed.

The patient was then treated on the high dependency unit as per our department free flap protocol. This involves a period of four days’

bed rest under a warming blanket with fluid balance monitoring via a urinary catheter. Nursing staff are trained to monitor the flap regularly for signs of vascular compromise. The patient has their first change of dressing on day five and is allowed to mobilise non-weight bearing initially. The majority of our patients will be discharged on day seven.

Our patients are then followed up in a specialist orthoplastics multidisciplinary clinic, their pin site care is managed and maintained in clinic and with local district nursing input, and they are monitored until soft tissue healing and union has occurred. This child went on to have solid union at the fracture site, no bony deformity, and soft tissues as shown (Figure 7).

Enneking functional outcome scores are collected for all our patients throughout their recovery.

Choice of soft tissue coverage

The choice of flap reconstruction is dependent on surgeon preference, but also patient factors. In our centre, we have found that free fasciocutaneous flaps afford better functional outcomes than local flaps4. Local flap options may also be compromised by the zone of trauma. We prefer to use fasciocutaneous flaps rather than muscle flaps, as we find post-operative monitoring more reliable, and the skin flap is easier to re-raise for secondary

surgery (namely removal of metalwork).

Although the anterolateral thigh flap (ALT) is our most commonly used flap in adult open tibial fractures, we use the scapular flap most commonly in children, as it has extremely consistent and reliable vascular anatomy compared to the perforator-based ALT flap. However, the patient must be placed in a lateral (or prone) position to raise a scapular flap.

Figure 5: Monolateral external fixator applied, along with a vacuum dressing.

Figure 6a: Taylor Spatial Frame.

Figure 6b: Free flap soft tissue coverage.

Figure 7a: Solid union. Figure 7b: No deformity.

Acute shortening or intentional deformation of tibial fractures has been described, in order to allow direct primary closure and later slow deformity correction with programmed hexapod fixation5

Although these techniques avoid the need for microsurgical reconstruction, they require extended periods in ring fixators, multiple procedures and associated morbidity. We have not needed to use these methods, but could perhaps consider them in the unlikely event that flap coverage was not possible or unsuccessful.

Choice of fixation

The choice of skeletal fixation will depend on patient age, fracture configuration and associated soft tissue injury. In the child with significant growth remaining, our preferred options are external fixation with a hexapod device or internal fixation with extra-physeal plates. TSF fixation has been shown to have good outcomes in high energy open fractures of the tibia in children with a low complication rate6

Hexapod fixators are commonly used as definitive treatment for paediatric open lower limb trauma in our department, and our practice is to use a combination of hydroxyapatite-coated half-pins and trans-osseous wires to obtain at least two points of fixation above and below the fracture zone. The advantage of this form of fixation is stability, and the ability to easily monitor the soft tissues. In cases where bone loss has occurred or there is imperfect reduction, the frame can be programmed to potentially correct for this once

the soft tissues are adequately stable. It also means the physes are not violated in any patient with sufficient growth remaining.

Modern locking plates are very versatile and occasionally the soft tissue defect resulting from injury and initial debridement provides adequate exposure for plate fixation without the need for further incisions, while also remaining extra-physeal (Figure 8). When combining this with robust free tissue coverage, we have had no issues with infection, metalwork failure or non-union.

When treating an older child with minimal remaining growth and sufficient tibial canal diameter, there is the option of using adult intramedullary nails (Figure 9). Violating the tibial tubercle apophysis with an adult nail can cause later recurvatum deformity, which can be difficult to correct and is therefore best avoided if doubt remains as to the patency of the physis.

Titanium elastic nails can also be considered, but have historically been associated with high complication rates, particularly in older, heavier children with unstable fracture configurations7,8 The triangular cross section of the tibia makes their insertion technically challenging and prominence of metalwork can be an issue, leading to a higher rate of further surgery when compared to other forms of fixation. The use of end caps can increase their indication and in many units – particularly in Europe – these implants are widely used with good effect.

Summary and conclusion

The management of open lower limb trauma in children in the UK is still evolving. Unlike in adults where the guidelines are well-accepted and largely followed, in children the nature of their developing skeleton could mean there is a belief that their outcomes are inherently better than adults due to favourable biology, and the more limited choice of physis-friendly implants can influence management.

We ascertain that in cases of severe open trauma in children, the management should still be guided by the severity of the soft tissue injury, the nature of the fracture, respect for open physes and to a lesser extent, the societal circumstances of the child. An orthoplastics approach is vital to address all of these factors, to achieve a healed fracture with stable soft tissues and no deep infection, thereby allowing the child to return to their pre-injury level of activity. We have previously demonstrated that timely and comprehensive orthoplastics management of children with open tibial fractures can result in high union rates, low infection rates and excellent functional outcomes9 n

References

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

Figure 8: Versatilty of modern locking plates.

Figure 9: Adult medullary nails.

Paediatric Infection Update –Sticks and stones may break my bones, but infection makes me sicker

Asix-month-old baby is brought to the Children’s Emergency Department by their parent. They report that for the last 24 hours, the infant has not been using their right arm and it has become ‘limp’. The parents have recorded a low-grade fever with a home thermometer and report that the baby has ‘gone off’ their feeds. There is no history of trauma. The child was born at term with an unremarkable birth and developmental history.

Katie Hughes is a ST4 T&O registrar on the South East Scotland rotation. She has a keen interest in paediatric orthopaedics and medical education. She will be coming out of programme next year to undertake a Lothian Medical Education Fellowship and a MD focusing on hip displacement in cerebral palsy.

This is a fairly common presentation to the orthopaedic on call team. Often trauma or injury is considered first when a child has an acutely irritable upper limb. This differs from the limping child, whereby our colleagues in the emergency department will tend to consider a potential infection. However, osteomyelitis or septic arthritis (SA) can affect any limb or joint. Incidence figures vary, but it is estimated the shoulder is affected in 2%-12% of cases of SA, compared to the hip in 32%-39% and knee in 26%-47%1

Bone and joint infection (BJI) in children has changed noticeably in the post-COVID-19 western world. It is a fascinating, challenging area of paediatric orthopaedic care that should always quicken the pulse and incite heightened clinical suspicion. This editorial utilises this clinical case in order to illustrate various aspects of investigation and management of acute bone, and joint infection in children, including:

1. The new BOAST paediatric infection guidelines

2. Imaging in BJI and the PICBONE study

3. An update on what orthopaedic surgeons should understand about the organisms implicated in BJI

On examination, the infant is unsettled and has a temperature of 39oC. There is no obvious erythema, warmth or deformity around the shoulder girdle. They seem irritable with movement of their right shoulder and abduction is limited to 90 degrees. They have a warm hand and a strong radial pulse. Their ear, nose, throat, abdominal and cardiovascular examination are unremarkable. Radiographs of their right humerus are shown in Figure 1. Bloods demonstrate a CRP of 26 and WCC of 7 × 109/L with a normal neutrophil count. Blood cultures are taken.

Examining a listless infant is challenging. They are unable to give a history and sometimes the clinical signs can be subtle. A ‘pseudo paralysis’ of a limb may be the only clue of an underlying BJI. Differentials include first presentation of juvenile idiopathic arthritis (JIA), a humeral or clavicle fracture, chronic recurrent multifocal osteomyelitis (CRMO), brachial plexus injury, or, rarely, malignancy. As always, vigilance is required for the potential of non-accidental injury and a top-to-toe examination is indicated. CRP may not be significantly elevated even in acute SA, especially in the infant population2

The next question that maybe reasonably asked is whether to commence antibiotic therapy.

A new British Orthopaedic Association Standard (BOAST) on the Management of Children with Acute Musculoskeletal (MSK) Infection was published in May 2022. It gives clear, comprehensive guidelines on how to assess, investigate and treat children with suspected MSK infection. It touches on the importance of agreed referral pathways to specialist centres, to support local hospitals and transfer complex cases. It acknowledges the diagnostic

Katie Hughes, Emily Baird and Anna Clarke

Emily Baird has been a Paediatric Orthopaedic Consultant at The Royal Hospital for Children and Young People in Edinburgh since 2015. She trained in the South-East and West of Scotland, and underwent Fellowship training in Edinburgh and Toronto, Canada. Emily has a particular interest in paediatric trauma and conditions of the immature hip and foot, and how children with developmental dysplasia of the hip and congenital talipes equinovarus are looked after by the MDT.

uncertainty in these cases in that no single investigation algorithm is completely reliable. It supports empirical antibiotic treatment in children who meet the NICE high-risk sepsis criteria, but acknowledges that treatment can be delayed until tissue sampling in stable children.

Anna Clarke is a consultant paediatric orthopaedic surgeon from Bristol. Her special interests include trauma, upper limb surgery and neuromuscular conditions. She is the clinical lead of the Bristol Paediatric Major Trauma centre, avid AO educator and examines for the FRCS. She remains enthusiastic towards the generality of orthopaedics that paediatrics provides.

Radiographs (Figure 1) are reported as showing no fractures, but possible osteomyelitis due to the lucency seen in the proximal humerus which may represent a Brodie’s abscess or subperiosteal collection.

In acute osteomyelitis there are often no radiological changes initially and this should lead to consideration of further imaging. Ultrasound (USS) is quick, requires no irradiation or sedation and in many centres, can be performed out of hours in the Emergency Department3 . USS can identify the presence and volume of a joint effusion, any tissue inflammation and may even identify a subperiosteal collection. The disadvantages are that it cannot accurately distinguish between sterile, purulent and haemorrhagic effusions, and that it is user-dependent in nature1 Magnetic resonance imaging (MRI) with contrast may be the gold standard diagnostic imaging modality, but it can be a logistical challenge to perform in young children that often require sedation or anaesthesia.

The PICBONE study started recruitment in December 2022. It is a multi-centre cohort study from Oxford to understand the diagnostic accuracy of MRI and USS in acute

haematogenous osteomyelitis in children. Their study also aims to create a BJI diagnostic pathway for use in the Emergency Department.

A USS (Figure 2) showed general inflammation around the proximal humerus. A 6-10mm deep joint effusion was identified with a small quantity of fluid seen along the cortex of the proximal humeral metadiaphysis. Collectively, appearances were concerning for SA with or without osteomyelitis of the proximal right humerus. A MRI (Figure 3) showed appearances in keeping with right shoulder septic arthritis with small subperiosteal collection.

Blood cultures grow Staphylococcus aureus. Is this the most common causative organism?

S. aureus remains the most common organism in paediatric BJI, but others should be considered. It can be infamously difficult to identify the organism causing a BJI. Around 20% to 50% of children with BJI remain culture negative4 Staphylococcus aureus is the most commonly cultured organism. Other common pathogens are Kingella kingae, Streptococcus pyogenes and Streptococcus pneumoniae and Salmonella1,5 Kingella tends to affect children under 2 years old and often behaves in an indolent manner, although is one of the only organisms that will cause an abscess in the epiphysis. It is notoriously difficult to culture, but can be detected by polymerase chain reaction (PCR). Where available, a prompt request for PCR may aid in diagnosis and help tailor antibiotic therapy5 >>

Figure 1: Annotated anterior-posterior and lateral radiographs of the right humerus and shoulder. The enhanced image of the shoulder shows lucency in the proximal humerus (yellow circle).

Invasive Group A Strep (iGAS) infection has caused significant anxiety in recent months. iGAS infection rates in the 1 - 9 year age group have increased fourfold this year compared to pre-pandemic. Fortunately, there have only been five recorded deaths within seven days of iGAS diagnosis in children aged less than 10 years old6

The infant was taken to theatre for an open washout of the right glenohumeral joint. Turbid fluid was drained and purulent material in biceps tendon sheath was incised. Tissue samples sent for microbiology also grew S. aureus. Histopathology showed necroinflammatory debris with no evidence of malignancy. They were treated with two weeks of intravenous (IV) flucloxacillin and ceftriaxone via a central line, before being discharged on six weeks of oral co-trimoxazole. They made an excellent recovery and rapidly regained full painless use of the right arm. They will remain under close clinical and radiographic follow up to monitor for growth arrest of the proximal humerus, a recognised complication after SA7

Increasingly, shorter courses of intravenous therapy are given with an ‘early oral switch’.

In many units, outpatient antibiotic therapy services allow IV antibiotics to be given in the community. If surgical intervention is required, and facilities and skill mix allow, consideration should be given to insertion of mid-term IV access under the same general anaesthetic. Shared decision-making will guide empirical and definitive antibiotic choice, duration and when to switch to oral therapy.

Musculoskeletal infection in children remains a diagnostic challenge, particularly in the upper limb. It is our experience that new-onset pseudoparalysis in the upper limb of a child is likely to be due to infection if the clinical signs and appropriate investigations support this. It is important to consider other diagnoses such as non-accidental injury and when sending samples to microbiology, send tissue for histopathology to aid the diagnosis of synovitis in the setting of JIA or CRMO. A multi-disciplinary approach to management involving our paediatric infectious disease and microbiology colleagues is essential. n

References

1. Donders CM, Spaans AJ, van Wering H, van Bergen CJA. Developments in diagnosis and treatment of paediatric septic arthritis. World J Orthop. 2022 Feb 2;13(2):122.

2. Danilov C, Ihle C, Fernandez FF, Blumenstock G, Wirth T, Eberhardt O. Pseudo paralysis of the shoulder and increased C-reactive protein are predictive factors for septic shoulder in children superior to other clinical symptoms: a retrospective case series of 25 patients. J Child Orthop. 2020 Feb 1;14(1):85–90.

3. Hosokawa T, Tanami Y, Sato Y, Deguchi K, Takei H, Oguma E. Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review. World J Pediatr 2023 Jan 1;19(1):20–34.

4. Searns JB, DeVine MN, MacBrayne CE, Williams MC, Pearce K, Donaldson N, et al. Characteristics of Children With Culture Negative Acute Hematogenous

Musculoskeletal Infections. J Pediatr Orthop 2022 Feb 1;42(2):E206–11.

5. Khattak M, Vellathussery Chakkalakumbil S, Stevenson RA, Bryson DJ, Reidy MJ, Talbot CL, et al Kingella kingae septic arthritis. Maintaining a high level of suspicion in children with atypical presentation. Bone Jt J. 2021 Mar 1;103-B(3):584–8.

6. GOV.UK. Group A streptococcal infections: report on seasonal activity in England, 2022 to 2023 [Internet]. [cited 2023 Feb 20]. Available from: https://www.gov.uk/government/ publications/group-a-streptococcal-infectionsactivity-during-the-2022-to-2023-season/groupa-streptococcal-infections-report-on-seasonalactivity-in-england-2022-to-2023#table2

7. Peters W, Irving J, Letts M. Long-term effects of neonatal bone and joint infection on adjacent growth plates. J Pediatr Orthop 1992;12(6):806–10.

Figure 2: Annotated USS of right shoulder showing glenohumeral joint effusion.

Figure 3: Annotated coronal and axial MRI sections of the right shoulder. This shows a joint effusion and subperiosteal collection of fluid tracking down the proximal humeral diaphysis anteromedially measuring up to 2mm in depth.

Timothy Rowland Morley

18th March 1939 - 11th January 2023

Obituary by Michael Edgar and Michael Sullivan

Tim Morley was a distinguished Spinal Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, recognised for his contribution to advances in scoliosis surgery. In addition to his surgical reputation, he was gifted with discerning independence of mind, a timely sense of humour and a gracious manner.

Tim was educated at Wellington College, Downing College Cambridge and University College Hospital Medical School. After gaining FRCS Eng, he trained in Orthopaedics at the RNOH and was appointed Consultant to Kings College Hospital in 1974.

From 1978, Tim partnered Charles Manning on the Scoliosis Unit, Stanmore, succeeding him in 1981 and taking over his commitment to the Chailey Heritage Home, Sussex.

Tim was joined by Peter Webb at Stanmore. They pioneered the Webb-Morley Instrumentation, improving correction and stability in spinal deformity surgery. With Mike Edgar, Andrew Ransford and Steve Jones (from the Institute of Neurology, Queen Square) he assisted in the development of a sensory spinal cord monitoring system, which was adopted internationally. Tim gave a good deal of time in building up a scoliosis service in Malta, for which he was honoured with the Maltese Medal.

The ‘Home Office’ was Tim’s endearing term for his wife Mary. They have a daughter, Nicky, and a son, Mark.

Tim’s interests included his 47ft sailing boat Kwa Heri, unsurprisingly registered in Malta. Many colleagues enjoyed his hospitality sailing in the Mediterranean. His other love was game shooting in the UK and abroad.

He also belonged to a small orthopaedic society, formed from those who had been registrars together at the RNOH. They met every year from 1972-2022. With his love of sailing, Tim always took his turn hosting on an island, be it Malta, Isle of Wight or the Scillies. n

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The conference will be an impactful learning and networking opportunity for the orthopaedic community. It will address issues affecting orthopaedics and MSK, giving members an insight into national solutions and initiatives as well as opportunities to collaborate and share best practice. For the second year running, the award ceremony will shine a light on excellence in orthopaedics.

Colleagues from NOA member organisations can find out more and register to attend the conference by scanning the QR code or by emailing info.noa@nhs.net

Download the App

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Arthroplasty and high-risk patients

How can results for patients at risk from infection be improved in a sustainable manner?

The main goal of arthroplasty is to relieve pain, improve and restore joint function and recover quality of life.

Periprosthetic joint infection (PJI) remains a complication that has to be taken seriously for those receiving arthroplasty surgery. The risk of infection for those receiving primary resection is up to 2%, rising to up to 5% for those undergoing revision.

There are many reasons why PJI can occur; it is sometimes down to the patient themselves. Patients each possess their own risk factors, which can increase the likelihood of developing an infection, both for those receiving primary and revision arthroplasty. For every ten patients over the age of 65, six will display at least two risk factors for infection. The latest studies suggest that individual risks or complications that can lead to PJI should be examined in relation to defined patient profiles. They provide initial findings that can be used, in the future, to develop promising arthroplasty treatment strategies that are geared towards different patients.

Approaches to arthroplasty surgery should be tailored to the patient

In clinical practice today, you can find different approaches aimed at avoiding complications and revisions in arthroplasty, such as PJI, periprosthetic fractures, dislocations and aseptic loosening, in an effective manner. What these all have in common is that the patient, with their individual risk profile, should be considered

in a situational manner to include the following in their treatment plan: the patient’s current comorbidities and the surgeryassociated risks.

Taking the patient-related risk factors into consideration

For example, patients that suffer from risk factors such as obesity, diabetes or cardiovascular diseases have a disproportionate risk of developing acute or chronic infections in the area surrounding the joint prosthesis following arthroplasty surgery. Many studies have shown there is a correlation between an increased Body-Mass-Index (BMI) and an increased risk of infection. Compared to non-obese patients, the rate of polymicrobial infection is higher in obese patients (60.3% compared to 33.3%, p<0.001). Uncontrolled diabetes is a known separate risk factor in the development of periprosthetic infection. For patients suffering from cardiovascular diseases, chronic blood vessel damage and medicines that influence clotting and thrombocyte function can all increase susceptibility to infection.

As many of these risk factors cannot be reduced in the short-term before surgery, targeted infection prophylaxis strategies are vital to help prevent infection. This also goes hand in hand with the decision to use antibioticloaded bone cement when fixing prostheses.

Indication-based treatment strategy: risk classification in primary arthroplasty

A patient’s individual comorbidities have a considerable influence on their risk of infection and should be considered when

selecting the optimal treatment algorithm. The first steps when deciding on the treatment and therapy to be deployed are to identify the patient’s comorbidities. When possible, this will go hand-in-hand with preoperative comorbidity optimisation.

Classifying patients at risk of infection, even for primary procedures

To prevent periprosthetic infection in patients at risk of infection in an effective manner, including during primary arthroplasty, a definition should be established to identify which patients can be classified as being at risk of infection. One approach from Spain takes the combination of a number of different risk factors into account, including comorbidities, the patient’s various pre-existing conditions and surgery-related risks. For example, in elective primary hip arthroplasty (TEP) and hip arthroplasty following trauma, a patient is classified as being at-risk if they have a combination of at least three risk factors, whereas for elective primary knee TEP, patients are classified as at-risk if they show at least two risk factors.

Infection reduction with dual antibiotic-loaded bone cement

It has been shown that for patients at risk of infection with a selected risk profile, the risk of developing PJI following primary hip or knee arthroplasty surgery can be additionally reduced through the application of dual antibiotic-loaded bone cement. A further report from Spain has shown a PJI reduction of 34% from 3.7% to 2.45% for primary hip and knee arthroplasty in high-risk patients through the use of a dual antibiotic-loaded bone cement, compared to the use of a single antibiotic-loaded bone cement. n