Journal of Trauma & Orthopaedics - Vol 1 / Iss 2

The journal OF the British Orthopaedic Association Volume 01 / Issue 02 / September 2013 boa.ac.uk

Mortality Rates: SurgeonS

99.8% CL

National Average

Inside Read the News and Updates section for the latest from the BOA and beyond

Our Features section includes articles from the new NCD for MSK and from a patient perspective on the transition from paediatric to adult services

For the latest updates on clinical issues, see our PeerReviewed Articles which cover a variety of interesting themes

News & Updates ––– Pages 01-16

Features ––– Pages 18-48

Peer-Reviewed Articles ––– Pages 50-72

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News and Updates

BOA Congress Contents Edition 2013 Martyn Porter, BOA President

Welcome to the second issue of the JTO, I hope you enjoy reading it.

The months since the last issue of JTO have been dominated at the BOA by the publication of surgeon level outcomes (cover image; feature article on page 18), the publication of the new T&O curriculum (see page 34), our commissioning guidance work stream (see page 12), as well as preparation for the BOA Annual Congress (see pages 2 and 48). It has also been the first few months for the new NCD for MSK, Peter Kay (see page 22) and a period with new Department of Health policies in procurement and patient safety (see page 12), among others. Looking back it is also one year since the London Olympic and Paralympic Games, which we mark with an interesting feature on sports trauma clinics on page 39.

I appreciate that some readers may be receiving this issue at the Congress and we hope any new readers find the JTO interesting and informative. We encourage you to let us know your thoughts and responses to the articles you read. And, for those who are members and receive a second JTO in the post, we encourage you to give a copy to a colleague who hasn’t had one and suggest they too sign up to receive future issues for free by contacting JTO@boa.ac.uk.

Finally, this issue includes our first letter to the editor. If you would like to contribute a letter to a future issue, I’d be pleased to hear from you.

News and updates

01–16

Features:

18–48

Publication of Surgeon Outcomes: What Happens Now? At Last a National Clinical Director for MSK Schools of Surgery and Surgical Education Providing Value for the Specialist Societies – The Evolving Role of the BOA Making The Transition From Paediatric To Adult Services: A Parent’s And Young Adult’s Perspective On A Long-Term Patient’s Experience Engaging with the Curriculum The First British Sports Injuries Clinic - A Trauma Service for the 1948 Olympics The BOA and the PMI Market BOA Congress Lecture Highlights

18 22 25 28 30 34 39 44 48

Peer-Reviewed Features 50–72

Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation 50 Joseph J Dias The Community Musculoskeletal Service 60 Cathy Lennox and Atle Karstad Femoro-acetabular Impingement: A Reflection 67 Richard E Field

Bookshelf and Letters To Editor 74 Obituary and in memoriam

78

General information and instructions for authors 80 Cover image: Funnel plot depicting mortality rates following hip replacement surgery (see page 18)

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News and Updates

BOA Annual Congress: Hopes and Highlights David Stanley, BOA Secretary

Trauma Boot Camp

As Honorary Secretary of the BOA, it is my privilege to oversee the planning and preparations for the BOA Annual Congress, which this year is being held from 1st to 4th October in Birmingham’s ICC and coincides with the publication of this issue of the journal. This is my third and final Congress as Honorary Secretary, and I hope it will build on the successes of past events. The theme this year is ‘Putting Evidence into Action’, which I believe will provide plenty of opportunity for learning, discussion and consideration of how to put into practice this learning and discussion.

In recent years we have been revamping the Annual Meeting of the BOA so that it appeals not only to Orthopaedic Consultants but also to Specialist Registrars at all levels of their training. We have reduced the number of free paper sessions to promote the dissemination of work of the highest quality, and focused particularly on creating a ‘one stop revalidation facility’ as we are conscious that this is a priority for our members. I hope all attendees at Congress will find ample content of relevance and interest to them, and welcome feedback that I can pass to my successor in this role, David Limb.

For all JTO readers attending Congress, I also offer a few highlights and hints and tips:

Preparing for the Intercollegiate Examination in Trauma and Orthopaedics and Revalidation All of the revalidation sessions kindly provided by the Specialist Societies will also contain valuable material which will be useful for those preparing for the FRCS(Orth).

Delegates are advised to plan the sessions they wish to attend before the beginning of the meeting or very early on at the meeting, which will aid them in ensuring they prioritise those that are most important to them.

Basic Science Course A new development for this year’s meeting is the Basic Science Course which Prof Simon Donell is organising. Simon has for many years been an Intercollegiate Examiner in Basic Science and he has put together this new course. It is different in format to the majority of courses that are undertaken, involves participation

from our colleagues in industry and can be undertaken at the delegate’s preferred time. It therefore does not interfere with any of the fixed sessions in the programme. Essentially what Simon has arranged is for participating orthopaedic companies to provide basic science instruction and information to delegates when they attend their stand in the exhibition hall.

The information provided will build into booklets which can be taken away and studied at leisure. It is hoped that this will be a valuable resource for those preparing for the examination. Simon will give an introduction to the course on Wednesday morning, 2nd October at 8:00am.

This is in the programme for the first time and aims to provide an update on controversial areas of trauma management. It will cover all areas of the body, with upper limb topics on Wednesday 2nd October at 8:00am and all other trauma topics being dealt with during Friday 4th October. The Boot Camp is primarily aimed at Consultants for revalidation but may also be of interest to senior trainees. It is expected that there will be some debate regarding management of some of the injuries that will be discussed but it is hoped that at the end of the session delegates will have a clearer understanding of modern management and why changes have occurred.

Specialist Society Involvement We are always grateful to our Specialist Societies for their contributions to our Annual Congress, particularly the free paper sessions and annual lectures. On page 48 further information about some of the specialist lectures is provided.

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Profile: Prof Tim Briggs – BOA President Elect Prof Tim Briggs, BOA President (2013-2014)

I am looking forward to my time as President of the BOA. My aim is to harmonise the relationship of the Specialist Societies within the BOA so that we can influence the political agenda from a unified standpoint with strong representation.

Given the proposed changes to the NHS and the financial crisis, as well as an ageing population, it is imperative that we stand united in order to continue to deliver high quality care to our patients, something which is under threat as never before.

Tim Briggs

Eurospine Meeting (2-4 October, Liverpool, UK) Eurospine, the spine society of Europe, is on the move. It is a single ‘brand’ of specialists. It has been a significant scientific society since 1998 following the merger of the ESS (European Spine Society) and the ESDS (European Spinal Deformity Society). Spinal surgery is multidisciplinary, and more and more spinal units have dedicated spinal surgeons that may come from a background of orthopaedics or neurosurgery. Fellowships involving both disciplines have produced far more cohesion on spinal topics between the two disciplines. The future of our society is the next generation of leading surgeons; we have engaged with them and wish to encourage more to contribute.

2010 was the end of a decade, and we are moving on, standing on the shoulders of giants of the last generation.

There are two key themes to the Meeting. The first is high value scientific content that represents the cream of spine research worldwide. Podium abstracts are selected by a blinded peer review process, and only about 12% of submissions are accepted. The second theme will be updating members and non-members regarding the ‘Society on the move’. We aim to position ourselves as the society of choice for European spine specialists, with all the multicultural advantages of networking in Europe. For more details, visit our website www.eurospine.org.

High quality Orthopaedic care and ‘getting it right first time’ are the best way to ensure best value for money, and satisfied patients. I believe that we can influence the health agenda by using the quality argument.

Indeed there is evidence that some in the NHS and Government are beginning to listen. An example is the now agreed value of Specialist Hospitals in their own right. I would work to develop the political dialogue further both within the RCS framework but also aim to create a louder voice in our own right.

I am going to work to improve further the training and education needs of our trainees. The current situation of having some welltrained but time-expired trainees with potentially no employment is a situation that needs urgent resolution. I am going to work with the SAC and the Deaneries to resolve this issue.

BREAKING NEWS:

BOA Travelling Fellowships Now Open The BOA Education Committee is delighted to announce that the 2014 round of BOA Travelling Fellowships is now open.

Fellowships offer a unique opportunity to visits to overseas centres of excellence to gain knowledge, experience and different cultural perspectives within Trauma and Orthopaedic surgery.

Various fellowships are available, with values between £1,500 and £10,000. Some have a specified remit, for example focusing on spinal surgery or reconstructive orthopaedics, while others are unspecified and candidates can apply according to their own areas of interest.

For details on the opportunities and how to apply, please visit: bit.ly/BOAtravfell Deadline for applications: 31st October 2013. Interviews for shortlisted candidates: Manchester University Conference Centre 4-6pm, Friday 10th January. Applicants must be current members of the BOA. No awards to ‘top up’ funding already obtained from other sources can be made.

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News and Updates

13th EFORT Congress Istanbul – 5th to 8th June 2013 6,800 Orthopaedic Surgeons gathered from all across Europe to participate in this Congress. Unfortunately, the timing could not have been worse as the city became embroiled in considerable social unrest, starting prior to the event and lasting throughout the Congress and many of the delegates were exposed to the effects of barricades and teargas aimed at the occupants of Taksim Square adjacent to the hotels and Conference Centre.

The Congress itself was only minimally affected as most delegates and faculty did arrive, although some were advised not to travel by their Governments. Where the faculty was deficient, rapid intervention by our Turkish colleagues saved the day in most cases. Only two sessions had to be completely cancelled.

The EFORT Congress format is now really well structured. This year there were 24 Symposia, 23 Instructional lectures and two sessions on evidence based orthopaedics. The highlights were

again interactive expert exchanges, complex case discussions and advances in hip and knee arthroplasty, together with the usual tribology discussion. A new addition session on speaker coaching was well attended. For juniors, the Comprehensive Review Course based on the EBOT examination remains a very attractive feature.

As usual the eponymous lectures proved popular. The Erwin Morscher lecture by Jean Dubousset on 3D dynamics of the spine proved not only informative, but highly entertaining, as was

the Mike Freeman lecture by Katsuro Tomita from Japan on the problems of spinal tumour surgery.

One cannot be anything other than overawed by the achievements of his Unit.

Highlights were reported in the daily congress newspaper and there were excellent presentations on vitamin E enhancement of polyethylene liners. Implant choice and early mobilisation was reported to give optimal results in peri-prosthetic fractures.

The usual strong British contingent saw David Stanley instructing on shoulder and elbow fractures, and Ashley Blom on metal on metal hip replacement. The guest South

and Latin American Orthopaedic Associations gave a powerful lecture on the management of degeneration in skeletal hip dysplasia, and there were excellent presentations on acetabular bone defect reconstruction and on specific treatment of staphylococcal infection in periprosthetic sepsis.

Early feedback was very positive and we thank the European Specialist Associations who enhance the scientific quality of the Congress, and we look forward to an exciting joint Congress with the BOA in London at the ExCeL Centre, 3-5 June 2014, where we expect there will be a strong BOA contribution and attendance.

The Orthopaedic Trauma Society Along with a Royal birth, a new society has also just made its entry onto the scene. The Orthopaedic Trauma Society has been formed and has been launched at this year’s Edinburgh Trauma Symposium.

It will be holding sessions at this year’s BOA meeting, including an instructional course / “Boot Camp”, and will hold its first proper meeting at The Royal College of Surgeons on 6-7 March 2014. This has been thought about for a number of

years by like-minded surgeons all of whom have a primary interest in Orthopaedic Trauma in the British Isles. It has grown out of a desire to have a society that fully and formally represents the subspecialty of Orthopaedic Trauma, which will be:

•

•

•

•

A forum for Orthopaedic Trauma surgery Non-profit making

•

•

•

The focus for Orthopaedic Trauma research The focus for Orthopaedic Trauma education and coordination A focus for Orthopaedic Trauma policies, including injury prevention The organiser of scientific meetings on Orthopaedic Trauma The focus for Orthopaedic Trauma training

•

Advance the practice of excellence in Orthopaedic Trauma.

It is envisaged that membership will be open to anyone, surgeon or otherwise, on application. Details can be found on their website www.orthopaedictrauma.org.uk.

The society will be affiliated to the British Orthopaedic Association and may affiliate to other societies.

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BOA Members’ Free Registration for Congress – Update for 2014 As BOA Members will be aware, the 2013 meeting is the first that has been free to BOA Members as a result of a small uplift in the membership subscription. When we proposed free Congress registration at the 2012 AGM in Manchester we were very clear that we wanted to implement it sooner rather than later: hence its introduction for our Birmingham Congress this year, where it has proved popular with some 1,500 delegates pre-registered.

DON’T FORGET BOA Instructional Course 10-12 January 2014 Manchester Conference Centre For more info: visit bit.ly/boainstructional or email eventsteam@boa.ac.uk

In doing so we always knew that there was likely to be a potential issue with our June 2014 joint meeting with EFORT in London.

Nevertheless, we were reluctant to wait until our Liverpool Congress in 2015 to bring in free registration.

For a variety of reasons it has not been feasible to offer BOA Members registration at a discounted or free level for the joint BOA/EFORT meeting in June; however, we very much hope to see many of our members there.

The programme is already taking shape and looks excellent, featuring some of the mainstays of the BOA Congress, including the Robert Jones, BOA Presidential Guest and other Eponymous Lectures.

In addition to this meeting, the BOA Executive has elected to hold a 2-day meeting in Autumn 2014 at Brighton, and this will be free as part of the BOA membership subscription. The meeting will be in September 2014 for members only and with no industry participation to: •

•

Address other important topics, such as national issues and debates, not covered by EFORT. Focus on the structural changes needed to make the BOA more responsive to member needs: these are likely to be fundamental to the successful future of the Association in the UK’s rapidly changing healthcare environment. They will necessitate debate and extensive changes to our current rules, and will therefore require to be voted upon in order to secure a clear mandate for rapid implementation.

We hope the logic of this approach is clear. Should any BOA Members wish to comment on or discuss any of this with one of the Elected Officers or the CEO

BOA Update on Training & Education Initiatives 2013 Trauma and Orthopaedic Curriculum

The new T&O Curriculum was published in August 2013, and can be viewed online on the JCST website bit.ly/BOAcurriculum.

Read more about it in the feature article on page 34

by Lisa Hadfield-Law, the BOA’s Education Adviser.

Wikipaedics

We are continuing the development of an online eLearning platform entitled ‘Wikipaedics’.

We are grateful to the many authors and editors currently working on content in order to produce a trusted online revision aid and links to other useful online resources.

Training Orthopaedic Trainers

We are holding another Training Orthopaedic Trainers course in January 2014. For more information and how to book please visit bitly.com/BOAtots

you are most welcome to do so: we will of course be presenting further information at the AGM in Birmingham on 3rd October.

The proposed BOA membership fee for 2014 (due for ratification at the Congress AGM) has been abated in part to reflect the reduced Congress component of membership.

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New BOA Council Appointments Tim Wilton (Elected as President for 2015-2016)

David Limb (Elected as Honorary Secretary 2014-2016)

My abiding interest developed in TKR and it is to my first boss in Derby, the late Geoff Newton, that I owe my interest in, and much of my knowledge of, knee surgery.

The first 10 years of my consultant career were spent as Senior Lecturer and this allowed me to develop my passion for medical education. This branched in various directions and by the time I moved to a full time NHS contract I was already leading the Undergraduate course, Programme Director for the orthopaedic rotation, examiner for the FRCS(Tr&Orth) and a member of the Editorial Boards of the JBJS and Current Orthopaedics.

I was delighted to be appointed a consultant in Derby in December 1990 to follow Geoff and continue the research we started together to improve operative technique in TKR. When appointed in Derby it was a large DGH with 6 orthopaedic consultants. Now we are 26 in a huge PFI hospital massively in debt!

Tim Wilton

Following an initial medical degree at Oxford my clinical training was at UCH Medical School. Informed by the Dean at interview that UCH was not regarded as a Surgical, but rather a Physicianly place, nevertheless there I first gained a taste for Orthopaedics.

Peri-Fellowship Training in Cardiff was followed by Nottingham Registrar training where I worked for luminaries such as Chris Colton, John Webb, Nick Barton, Angus Wallace and Bob Mulholland, then on to Derby and Harlow Wood as SR. Travelling fellowships to Ljubljana (Trauma), Bern (AO fellowship), Strasbourg (Hand Surgery) and North America (Knee Arthroplasty and Hand Surgery) helped round my training.

For much of the last 15 years I have been on the BASK executive serving as Treasurer, Secretary and ultimately as President. I was also BASK representative on the NJR steering committee, when we were finally allowed to have one.

My interest in device safety in all aspects is underlined by my current work on the Committee of Safety of Devices, the introduction of ODEP ratings for knees and the knee aspects of the Beyond Compliance programme.

I am greatly honoured to have been elected to be future President of the BOA (2015-2016), and can only hope that I can live up to the expectations and potential of the position.

David Limb

I thank the BOA membership for approving my appointment to the post of Honorary Secretary and now introduce myself. I am based in Leeds and married to Catherine, a part time GP who I met at medical school. We have three boys.

After training at Barts I undertook my SHO rotation in Nottingham before starting my higher surgical training in Trauma and Orthopaedics on the Yorkshire rotation. I have been a consultant since 1996 and my elective practice has always been entirely shoulder and elbow surgery.

However, I remain on the on-call rota for general trauma, though since I work in a very busy unit, even my trauma lists tend to fill with about 90% shoulder and elbow trauma from the more complex end of the spectrum.

This passion has continued to develop and after a term on the SAC, I joined the BOA Education Committee and was subsequently elected to BOA Council, later becoming chairman of the Education Committee and orthopaedic lead for revalidation – positions that entailed close working with the Hon Secretary.

I am now Editor in Chief of ‘Orthopaedics and Trauma’ and Associate Editor for the ‘Bone and Joint Journal’ and ‘Shoulder and Elbow’. I also lead the question writing committee for the FRCS(Tr&Orth) and lead its Standard Setting meetings.

In 2012 I ran the London Marathon to raise money for the BOA through Joint Action (the research fundraising arm of the BOA) and raised over £2,500 for T&O research.

I look forward to the challenges of the role of Honorary Secretary.

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R Adam Brooks Grey Giddins (Elected Member 2014-2016) (Elected Member 2014-2016)

I have spent longer in management as clinical lead than might be good for me, but this has led to my interest particularly in the practice and service delivery aspects of the BOA’s strategy. I have been involved in numerous local service developments, particularly in trying to balance the needs of service delivery while still providing high-quality StR training within the constraints of the EWTD. On a national level, I was chairman of BODS from 2010-12, during which period I served on the BOA Council as an ex officio member, and also represented BODS at the BMA and in various meetings with the Department of Health.

R Adam Brooks

I was born and brought up in Bristol then studied pre-clinical medicine at Cambridge before moving to Oxford for clinical studies, graduating in 1990. After junior posts in London and on the South Coast, I returned to Oxford for my orthopaedic training, which was completed with a Fellowship at St Michael’s Hospital, Toronto. I took up a consultant post at Princess Margaret Hospital, Swindon, in 2002, moving to the new Great Western Hospital a year later.

My clinical interests are lower limb arthroplasty and revision hip surgery as well as young adult hip surgery. I retain a strong interest in trauma, being a regular faculty member on AO courses.

Since stepping down from the BODS chair, I have continued to represent the BOA on the QIPP Implant Procurement group – a subject that I appreciate might seem a little dry to some, but which has often been neglected to the cost of all of our Trusts.

I am married to Alison, a GP, and have three children, Katie, Milo and Harry. I consider myself a lapsed oarsman (there are no rivers near Swindon!), but still enjoy sport, particularly tennis, rugby and Eton Fives, as well as running in the beautiful Marlborough Downs, where I do all my best thinking.

I have previously been Clinical Lead, Head of SpR and SHO Training and Deputy Regional Head of Training. Now I examine for the FRCS (Orth) and the BSSH Hand diploma. My biggest commitment is as Editor in Chief of the Journal of Hand Surgery (European). I also undertake clinical research and some basic science research with a range of collaborators particularly in the department of Mechanical Engineering in Bath but also in other Universities.

Grey Giddins

I was a medical student in Cambridge and St Thomas’ Hospital in London followed

by SHO training in and around London. I was a Registrar in Oxford, a Senior Registrar on the Stanmore rotation and a Hand Fellow back in Oxford. I started as a Consultant in Bath in 1995 specialising in Hand surgery.

Since then we have expanded the Hand team within the Orthopaedic department and I now work with two excellent Orthopaedic Hand surgeons as well as a strong team of colleagues in other subspecialties. We undertake a full range of elbow, wrist, hand and nerve surgery, including the treatment of patients with obstetric brachial plexus palsies.

At home, I am married, with three teenagers, a dog and a cat. I keep fit by bicycling to work in almost all weathers (not least as parking is so difficult) and I play tennis and golf occasionally.

I believe that British Orthopaedic Surgeons are undervalued in the NHS and by the research bodies.

The hard work and commitment of our colleagues to patient care and advancing practice is lost in a sea of prejudices based on outdated ideas. I hope to help the BOA continue to highlight the value of modern Orthopaedics both in daily practice but also in advancing and publicising research.

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News and Updates

Ian McNab Philip A Mitchell (Elected Member 2014-2016) (Elected Member 2014-2016)

in the context of changing numbers and working patterns.

UK Hand Diploma Committee and as an examiner. I Chair the AOUK Hand Course. In 2007 I was awarded and undertook the prestigious BSSH Stack Travelling Fellowship in New Zealand, Australia, Singapore and USA.

As a joint replacement surgeon I am very aware of the major issues we as Orthopaedic surgeons face: • •

I have also served on: the BOA Board of Specialist Societies and Professional Practice Committee; as RCS/BOA Regional Specialty Professional Adviser (I proposed the motions at the RCS EGM on the Health & Social Care Act); the BSSH Research & Audit Committee & Council; and as BMA LNC Chair, Regional & National Consultant Committees, and as Chair BMA Orthopaedic Sub-Committee.

Ian McNab

I trained at the London Hospital Medical College and then as an SHO in London, Sussex and Oxford.

My higher orthopaedic surgical training was on the Pott rotation, based on St Bartholomew’s and the Royal London Hospitals. It spanned the transition to SpR training and I was “the last SR”! I undertook my hand and upper limb fellowship training in Oxford and then during a year in Melbourne.

I was appointed in 2000 as a Consultant Hand Surgeon at the Oxford University Hospitals Trust. I work in an excellent integrated team of seven T&O and Plastics hand consultants and closely with my other T&O colleagues, providing emergency care at our Regional Hand Trauma Unit at the John Radcliffe Hospital, and planned and reconstructive surgery at the Nuffield Orthopaedic Centre.

I have a keen interest in teaching as an Honorary Senior Clinical Lecturer in the University of Oxford and at Wadham College.

I am Head of the Oxford Hand Fellowship Programme and have served on the Training Interface Group for Hand Surgery, on the

• • •

Philip A Mitchell My wife Frances is a full-time consultant anaesthetist - with an interest in acute pain (management)! Previously I enjoyed rowing and mountaineering but we now usually undertake more gentle travel and hill-walking.

I believe the BOA must continue to develop strong leadership with pro-active policies and actions and to work collaboratively with other bodies to improve T&O services and training amongst the maelstrom of NHS change - I will focus my energies and experience on helping the BOA deliver.

Educated at Epsom College, then St Mary’s Hospital Medical School, I did my Specialist training on the St George’s rotation in South West London. After a year in Vancouver on the Adult Reconstruction Fellowship, I took up my post at St George’s Hospital starting in 2002.

My practice at St George’s is entirely arthroplasty based. The joint replacement landscape is evolving in South West London, but at the moment I perform primary hip and knee replacement at the Epsom Orthopaedic Centre and revisions, complex primaries, infections and peri-prosthetic fractures at St George’s. I belong to a multi-disciplinary team dealing with infected joint replacements and we are a regional referral centre for these patients. I also run a specialist clinic dealing with the Orthopaedic problems associated with haematological conditions.

My other great passion is education. I am co-director of the South London West teaching programme. We are working with the other London programmes, particularly South East, to maximise the quality of the training

reductions in funding adverse publicity regarding the whole of the NHS public scrutiny of our performance and results the difficult balance between emergency and elective care difficulties with workforce planning and manpower

It is my aim to help bring a focus on quality, getting it right first time and transparency. I intend to make a significant contribution in how our data is presented to the public so that realistic interpretations can be formed, instead of the scaremongering we could be subjected to. We do need to engage the public and gain their support for making changes which will lead to better care in the future.

Getting It Right First Time applies to all aspects of Orthopaedic care. The care of injured patients is vital to restoring function and getting people back to work. By concentrating on our processes of looking after this group and with improved outcome studies we can make huge progress in this area whilst still allowing us to run successful elective programmes.

I am honoured to have been elected as Trustee and look forward to serving you well throughout my tenure.

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Revalidation and Accruing CPD Points David Limb, BOA Education Committee Chair

You may be aware that the standards for revalidation in surgery require that all surgeons participate in 50 hours (points) of continuing professional development (CPD) that is relevant to their own personal development plans.

You may also be aware that the accreditation of some external courses has changed since the introduction of revalidation, and in particular free paper sessions may not be included in the allocation of CPD points to external courses.

However, the GMC encourages self-accreditation of activities that contribute to your personal development that have not necessarily been approved by an external agency. In fact, the 50 points a year is accrued from external sources (courses and meetings), internal sources (at your place of work) and through self-directed activities such as e-learning and journal reading.

Furthermore, it includes not only clinical CPD but also academic and managerial learning.

So, how do you accrue and record evidence for this – particularly self-directed activities for which you don’t receive a certificate? The Pan Surgical Revalidation Project Board has now published the answers you are looking for in the document ‘Continuing Professional Development – Summary Guide for Surgery 2013’. This is available to view or download on the websites of the surgical colleges and the BOA at bit.ly/BOAcpd2013 and should help surgeons compile their CPD records for their annual revalidation appraisals.

For many it will quell their anxiety about how they can obtain 50 CPD points when the number of points allocated to meetings is falling if there are a lot of free paper sessions. It is worth pointing out, however, that the annual BOA congress can provide almost seamless instructional content and tick the box for annual external CPD for most orthopaedic surgeons in the UK!

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News and Updates

Department of Health publishes its new procurement strategy In August 2013, the Department of Health published its new procurement strategy. The strategy outlines the Government’s new blueprint on all NHS spending - from rubber gloves and stitches to new hips, building work, bed pans and temporary staff. The aim is to fundamentally change how the NHS spends its money and to eliminate wasteful and unnecessary spending. It is hoped that this will result in efficiency savings of up to £1.5billion.

Within the new strategy is an initiative focusing on the procurement of orthopaedic implants and the relationship with the device industry. The BOA is particularly supportive of the proposal that will require Trusts to share information regarding the prices they pay for orthopaedic implants. We believe that this has been one of the main barriers to gaining better value from

suppliers. The BOA is hopeful that sharing this information will serve to provide a better insight into each Trust’s costs-to-serve, which could therefore provide an incentive to become a better and more efficient customer. High and variable costs for implants have been of concern to orthopaedic surgeons for some time, and, as a profession, we have not had the appropriate tools to tackle this growing problem.

The BOA continues to work closely with relevant stakeholders on the government’s procurement work stream to ensure that the concerns of the orthopaedic profession continue to be of high priority on the government’s agenda, and we will keep members updated.

Professor Donald Berwick publishes independent report on safety The international safety expert, Professor Donald Berwick published his independent report on patient safety in the NHS in August 2013. Following the publication of the Francis report, Prime Minister David Cameron appointed Professor Berwick, the former health adviser to President Barack Obama, to establish a “zero harm” culture in the NHS.

Berwick’s report identifies key issues and problems inherent within the culture and environment underlining patient safety in the NHS and makes recommendations to address them. At the heart of his report is a call for a significant change of culture within the NHS, which prioritises quality of care and patient safety above everything else, and promotes transparency. Other recommendations range from embracing an ‘ethic of learning’ throughout the NHS, to making ‘wilful or reckless neglect’ a criminal offence.

The BOA broadly welcomes the report and is supportive of many of the recommendations. We are fully committed to patient safety and quality of care and remain dedicated to raising standards through the encouragement and support of all surgeons to practise with the highest integrity, skill and professionalism. As a profession, we look forward to working closely with the government to help shape and lead the future of patient safety in the NHS.

BOA Update on Practice Initiatives Clinical Commissioning Guidance for Orthopaedic Services As mentioned in the last issue, the BOA has been leading on a programme of identifying high volume, high cost procedures within the sub-specialty areas of orthopaedic practice, and commissioning guidance documents have been developed for each of these. The first five of these draft documents were launched for public consultation and peer review in May and June of this year.

We were very pleased with the level of responses to the consultations and are grateful to all those who contributed. Following the input received from the consultations, the guidance is undergoing further development and we expect to see these published in the coming months. Once published, we will work to ensure that the guidance reaches the right clinical, regulatory and political stakeholders.

Getting It Right First Time (GIRFT) The GIRFT team, led by Professor Tim Briggs and funded by the Department of Health, has sent letters to all BOA members and all Trusts in England and is in the process of fixing dates for visits to Trusts wherever possible, over the coming months. We are also in the process of producing the individual provider profile reports for each Trust these will bring together all the national data sets that relate to orthopaedics and provide the basis for discussion during the visits.

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The AXA Whiplash Report: Help or Hindrance to the Medico-Legal Process?

Michael Foy, BOA Medico-Legal Committee Chair

The AXA Whiplash Report (AWP) was launched at a roundtable co-hosted by Jack Straw and Chris Voller (AXA Claims Director) on 16th July 2013. There were other politicians from both Houses, senior members of the insurance industry, representatives from the MOJ, defence lawyers and one representative from the medical profession, your Medico-Legal Committee Chairman.

There were no representatives from the Association of Personal Injury Lawyers (APIL) or Motor Accident Solicitors Society (MASS)… surprise, surprise.

The report provides an analysis of whiplash claims across Europe. It highlights France and Sweden as “instructive blueprints” for success in tackling the escalation in exaggerated or fraudulent whiplash claims. In France there is firm emphasis on “objective proof” with whiplash not recognised unless the assessing medical professional can see objective evidence of injury on X-ray or MRI scan. That would certainly get rid of most claims in the UK! The French have strict rules concerning the qualifications of doctors providing reports/opinion, with requirements to have certain training and qualifications.

In Sweden symptoms arising after 72 hours are disallowed. One can see that Claims Management Companies and PI lawyers would wise up to this fairly quickly and gear their promotional material to ensure that claimants/potential claimants were scuttling off to their GP or Casualty very quickly.

They make a number of recommendations, one of which is that all whiplash claims categorised by experts must use the Quebec Task Force (QTF) scale, with QTF III&IV being compensated but QTF I&II falling below the compensation threshold. The document is worth reading and is downloadable from the AXA website.

Not surprisingly, APIL and MASS have been forthright in their criticism already. APIL described it as “expensive and unnecessary”.

MASS went further labelling it as “highly biased” and “largely based on statistics that are incorrect or out of date.” Watch this space.

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News and Updates

Change of Direction for Joint Action Looking ahead, the BOA is actively exploring changing how the funds for research raised by Joint Action are spent.

Our Research Strategy of 2012 identified the need for a step change in our approach to Trauma and Orthopaedic research and we are currently discussing how best to achieve this through the Research Board and Research Committee, which are led

by Professor Andy Carr and Professor Amar Rangan, respectively. The work is progressing rapidly and focuses principally on how the BOA can best support applications for major T&O clinical trials while developing in parallel strong and productive partnerships with basic science

centres of excellence. Further details will be publicised in the Autumn. In the meantime the annual Joint Action grant call has been put on hold.

We are conscious that many members, as well as the public, donate generously to Joint Action and the BOA has a responsibility to use this money to its greatest effect. We are grateful to all members for your continuing support for research and will keep you updated about the plans as they unfold.

The Best View in the World After an arduous seven-day trek, the team from specialist financial advisers Cavendish Medical successfully reached the summit of Mount Kilimanjaro in aid of Joint Action, the research fundraising arm of the BOA. Late last year, 19 brave climbers – including an orthopaedic surgeon – tackled the world’s highest free-standing mountain and raised over £10,000 in the process.

Consultant orthopaedic surgeon Mr Matthew Oliver, 37, from East Kent Hospitals University NHS Foundation Trust, joined the climb after an appeal for volunteers. He said: “Climbing to the top of Africa (5,895 metres) was an amazing experience.

It was physically very challenging. The final push to the summit was incredible. It was pitch black, -20 degrees Celsius, snowing hard and with strong winds!

The altitude meant oxygen levels were very low and every breath counted. It was a privilege to take

part in this climb with such a great bunch of people. I’ll cherish the memories.”

Cavendish Medical MD Simon Bruce said: “We are very proud of our achievement and would like to thank everyone who supported us during our training programme and on the climb itself, with particular thanks to all those who generously donated to the appeal.”

The BOA would like to thank Cavendish Medical and all those who took part for their support for Joint Action, and welcomes other groups of fundraisers to take on challenges like this to support our research initiatives and grants.

BOA Staff Support T&O Research Two members of staff at the BOA have recently participated in challenges to raise money for Joint Action, the research fundraising arm of the BOA. Information Systems Manager, Daniel Maby, ran the 2013 Virgin London Marathon in April.

He found the challenge tough but exhilarating, especially as he and his brother-in-law, David, decided to wear sumo suits.

“Taking part in the London Marathon for Joint Action was without doubt the most physically challenging and at the same time one of the most rewarding days of my life. I would recommend everyone, no matter what ability, takes part at least once in their life. The crowds, the pain, the euphoria and the fellow runners will never leave my mind.”

Meanwhile, Hayley Oliver, the BOA’s Finance Assistant, decided to take on a bungee jump from a 160ft crane situated in a car park at the O2 in Greenwich to raise funds.

“When I first volunteered to take part in a bungee jump for Joint Action I was extremely excited, this was something that most people say they want to do but never seem to get around to it. By event day I had raised well over my £300 target - an amazing £538.00!

This was a truly fantastic experience that I thoroughly enjoyed and would recommend to everyone; especially if you can raise money for a worthy charity like I did.”

Many BOA Members also support Joint Action, through donations and through fundraising events. Thanks for all your support, and if you’ve been inspired to take on a fundraising challenge like Daniel or Hayley, why not contact Lauren Rich on 020 7406 1767 or at l.rich@boa.ac.uk to find out more.

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Features

Publication of Surgeon Outcomes: What Happens Now? Martyn Porter, BOA President

The story so far:

On the 1st July 2013, surgeon level outcome data were published in orthopaedics – one of nine surgical specialties identified as part of an NHS England initiative to improve quality and better inform patients. In orthopaedics, data on hip and knee replacement activity for the calendar year 2012 and the 90 day mortality funnel plots were published based on records collected by the National Joint Registry (NJR). I would like to reflect on some of the detail leading up to this unprecedented event and then consider the present situation and some of the challenges moving forward and next steps.

The well documented problems at Mid Staffordshire Hospital and the subsequent Francis Report undermined public confidence in the NHS and the fact that 14 other hospital trusts have been identified as being outliers on mortality over the last two years suggests that the problems at Mid Staffordshire were not a one off.

To address some of these challenges, Sir Bruce Keogh, Medical Director of the NHS, announced in December 2012 that surgeon level data would be published by the summer of 2013 and this was further endorsed in the publication ‘Everyone Counts: Planning for Patients 2013’. This document stated, “It is critical that patients and commissioners understand the quality of service being delivered within hospitals and other healthcare settings. To enable this, with oversight from our National Medical Director, the Healthcare Quality Improvement

BOX 1

Martyn Porter

Adult cardiac surgery Interventional cardiology Vascular surgery Upper gastro-intestinal surgery Colorectal surgery Orthopaedic surgery Bariatric surgery Urological surgery Head and neck surgery Thyroid and endocrine surgery

Partnership (HQIP) will develop methodologies for case-mix comparison and in conjunction with NHS Choices, published activity, clinical quality measures and survival rates from national clinical audits for every consultant practicing in the specialties listed [in Box 1]”.

Preparing for the publication From February 2013 onwards, various meetings were organised by relevant organisations to discuss the reporting initiative, including a group established by The Royal College of Surgeons of England, meetings of the Federation of Surgical Specialty Associations (FSSA) and an Outcomes Publication Advisory Group chaired

by Professor Ben Bridgewater (Director of Outcomes Publication, HQIP). The purpose of these meetings was to exchange views, consider the implications, discuss concerns and monitor progress.

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it was important that members at least saw the data that was going to be published in their name.

The British Orthopaedic Association (BOA) formed its own high level committee working closely with all of its specialist associations but particularly with the Hip and Knee Societies to consider views from members and to devise an appropriate strategy and engagement plan.

Concerns, implications and consequences There was a genuine willingness of the audits, in our case the NJR, to be engaged in transparency.

However, there was concern about the NHS Commissioning Board’s (now NHS England) lack of engagement and communication with the BOA prior to the announcement in December 2012.

There were also concerns about the timelines to deliver and genuine issues in relation to data quality (mainly case ascertainment), validation, analysis and applicability at individual surgeon level. The short timelines put considerable demands on the BOA in terms of obtaining consent from individual surgeons. There was also considerable uncertainty over how the political and media channels would interpret the data.

One key area of concern surrounded the publication of mortality data in relation to hip and knee replacement surgery. Mortality is very low (in the region of 0.5 per cent within the first 90 days of elective hip and knee replacement) and many of the factors that explain mortality are related to the patient rather than the surgeon or the surgical team.

This is quite distinct from patients undergoing cardio thoracic surgery or indeed many of the mortality issues surrounding the Mid Staffordshire scandal. For example, it is suggested that social deprivation is a factor that affects mortality events to a greater extent than the surgeon. Members were also concerned that as some surgeons operate on high risk cases (for example, patients with metastatic bone disease where hip replacement occasionally is carried out for palliative purposes), those tackling these sorts of cases could become risk averse if the mortality data identifies the surgeon as a potential outlier.

While some case-mix adjustment can be carried out, several of the important confounders are not present in the NJR dataset which makes full adjustment difficult, if not impossible.

The view of the British Orthopaedic Trainees Association (BOTA) was that consultant surgeons may become less willing to allow trainees to undertake surgery and this would potentially have a negative effect on training opportunities.

Broader issues and challenges Throughout the process, a number of challenges, obstacles and broader issues were identified across the specialties. These included: It was recognised that many of the audits were not set up specifically to deliver the political mandate of publication at individual clinician level.

The audits also differed in scope, compliance and data quality, and varied in terms of “ownership� and integration with their specialty associations.

Most of the data was generally of poor quality and full validation had not been carried out.

There was a variable level of funding of the audits and most of the smaller specialty associations had very modest financial resources and limited staff to comply with the demands of publication by the end of June 2013.

Many of the audits looked at fairly rare conditions where it was unlikely that statistically valid differences could be determined by individual surgeon level reporting, (e.g. acoustic neuroma) but in other specialties complex cases were often dealt within a multidisciplinary team such as head and neck cancer. This creates complexity in terms of assigning responsibility for the outcome.

In relation to outcome indicators, in some audits mortality may be an important indicator but in many others peri-operative death is a rare event and often influenced more by patient factors and social factors than surgical factors. It was felt that if league tables were used (not by the profession but the media) this would not assist patient decision making and choice.

HES data was considered a potentially useful resource but in many specialties coding accuracy is poor for complex procedures; however, the reliability of HES data is probably better for other audits.

Publishing individual surgical performance potentially creates a situation whereby surgeons would be identified as having poor performance without full consideration of the checks and balances and professional mechanisms of dealing with such issues.

The unintended consequences included potentially exposing individual surgeons to reputational harm by the use of poorly validated data, which could result in disengagement of large sections of the surgical profession. However, cardiothoracic surgeons who have many years of public reporting were more positive; they did not experience risk averse behaviour and had not noticed a loss of training opportunities.

Benefits of transparency Despite these concerns, it was recognised that transparency could have many potential advantages. This was an opportunity to demonstrate that surgical performance was good, well audited and, particularly for joint replacements, there were already systems providing feedback on surgical performance and mechanisms of dealing with potential outlier performance. It was also recognised that by looking initially at surgical performance it would be appropriate to look at other medical specialties.

Engaging with members As the June deadline approached, BOA staff ensured that all members affected by the initiative were contacted so that they could review their data and give consent for the publication. We felt it was important that members at least saw the data that was going to be published in their name, particularly the activity data and an indication of mortality within 90 days of surgery.

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Features

the BOA … and … the Specialist Societies believe it is right that the profession is engaged with the principle of transparency and publication of meaningful data that will assist patients in terms of decision-making and choice.

The latter was done in the form of funnel plots rather than a precise figure to avoid the creation of a league table. I, along with Norman Williams and Adrian Joyce, Presidents of the English College and the Vascular Society respectively, undertook a press briefing a week before the information went live. This was carried out to ensure that the media was fully briefed on the data, particularly on its complexity, and the statistics used to analyse the data. Despite this, the vascular audit which was published just before the end of June attracted rather personal and adverse publicity where three surgeons were ‘named and shamed’ in the media. However, the orthopaedic data were presented in such a way that there was very little media interest when the data went live.

Next steps Moving forwards I think there are several lessons to be learnt from the whole process. The first is that the BOA Executive and the Executives of the Specialist Societies believe it is right that the profession is engaged with the principle of transparency and publication of meaningful data that will assist patients in terms of decision-making and choice. The use of the NJR data has been challenging because of the incompleteness of the data set which becomes important at an individual surgeon level. It is hoped that the publication will drive up the quality of the data submission to the NJR but the future probably lies in unit level reporting rather than focusing on the individual surgeon.

It is envisaged that a quality dashboard could be created for every trust, which includes information on patient satisfaction, length of stay, readmission within 30 days, re-operation within 12 months, revision within 12 months, revision within five years and eventually revision within ten years. This can probably be supplemented with other PROMs data. This already occurs within the Swedish Register using the Clinical Value Compass or Spider Plot and this sort of information may be useful for patients to be reassured that the hospital they are being referred to delivers high quality joint replacement where the outcomes are monitored and scrutinised, and variations in performance can be readily visualised. It is important that we reassure patients that we already have a very active stance on individual performance via the clinician feedback mechanism of the NJR but also with the outlier performance management.

I believe that the publication of these data is a critical first step towards greater transparency, and the BOA and specialist societies look forward to leading and shaping the next phase of development whilst ensuring that the concerns of our members and wider profession continue to be addressed.

Articles for Peer-Review Welcome Have you considered submitting an article to JTO’s peer-reviewed section?

JTO is:

available in print and online (with each peerreviewed article available as an individual file) freely available to orthopaedic surgeons across the UK, including all BOA members your journal for instructional articles on latest clinical developments, healthcare innovations and analysis, and excellence in practice, training and education

We’re looking for articles to be peerreviewed for future editions of JTO. For more information, contact: JTO@boa.ac.uk.

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Features

At Last a National Clinical Director for MSK Peter Kay

Three years ago in the dying embers of the last administration, after years of lobbying

by ARMA (Arthritis and Musculoskeletal Alliance) and individually by a number of organisations representing patients and healthcare professionals including the BOA, BSR, AR UK, NRAS as well as many others, we finally got a question asked in the House of Commons that seemed to pave the way for greater recognition and future development of MSK services; it went like this:

Graham Stringer (Manchester, Blackley) (Lab): “If he will appoint a National Clinical Director for musculoskeletal diseases.”

[324908] (30 Mar 2010) The Secretary of State for Health (Andy Burnham): “I am grateful to my hon. friend for the interest that he has taken in this important subject. I can tell him that I am minded to appoint a National Clinical Director, but I am seeking the advice of the National Quality Board, which is currently focusing on the subject of musculoskeletal diseases1.”

But then we were plunged into the paralysis of official purdah that follows the calling of a general election and everything ground to a halt. With a change of government, passage of an extremely controversial green then white paper on health reform and a completely reorganised NHS, it took time to get MSK back on the agenda but the MSK community did so, with a little inside help, and after having had an NCD trauma for a number of years a new NCD post for trauma was announced, along with one specifically for spine and finally one for the broad church that is MSK. Previously (for 4 years) I had chaired the Orthopaedic and MSK 18 week Committee at the old DH, but this functioned very much as an advisory group, with the real decisions taken higher ‘up the DH office’ and all of us on that committee were definitely outside the tent, despite meeting ministers and others. The time spent as President of the BOA, whilst undoubtedly a great honour, was difficult, largely as it was done in my spare time.

Peter Kay

My trust was very supportive, but I constantly felt guilty about the amount of time I needed to take away from clinical activities, even when supported by excellent colleagues who would cover for me. Of course the presidency of the BOA was great fun; with hopefully the profession aligned behind, you could take on healthcare policy head on ‘mob handed’ and occasionally win the day, though often only for a day, with issues such as procedures of limited clinical value, rogue PCTs denying patients treatments, feral CAT services that needed taming.

Of course the DH would be forced to take notice if we fought our way on Radio 4 to savage a PCT3 or the 6 and 10 o’clock news to empower patients to get treatment for OA of the hip and knee4. One could sense we were having some effect when the ‘back channels’ started to warn us to back off from giving the DH such a hard time. The problem was the harder you pushed from the outside the more likely you were to distance yourself and the profession from the centre. But there were those rare moments as articulated in the film Arthur when there was ‘a man worth killing’ at least in reasoned debate if not physically over what we would regard as misguided healthcare policy, or when bullied to the brink, and not giving in saying: “OK, see you in court” and then watch your CEO turn pale as you put the phone down. So, it was a surprise when I was offered the job. Whilst I certainly thought long and hard about the role, a secondment for up to 2 days a week for 3 years at least, there was acknowledged time to perform the role and they hopefully knew what they were getting.

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One could sense we were having some effect when the ‘back channels’ started to warn us to back off from giving the DH such a hard time.

Though I did reflect that perhaps this was the old story of poacher turned game keeper or someone going over to the dark side as the establishment gobbled you up – I hope not – and you must promise to tell me if you sense I have.

Then it hits you, what have you done?

Ms Abbott: “To ask the Secretary of State for Health what assessment (a) his Department and (b) Public Health England have made of the effect on public health of musculoskeletal conditions; and if he will make a statement.” [159522] (17 June 2013) Norman Lamb: “We are aware of the wide prevalence of musculoskeletal (MSK) conditions and their impact on an individual’s quality of life. Local commissioners are primarily responsible for determining what steps are needed to improve the health of people with MSK conditions.

“NHS England is responsible for work on MSK conditions. It appointed the first National Clinical Director for MSK conditions, Professor Peter Kay. The Department’s Mandate to the National Health Service set an objective to improve the quality of life for people with longterm conditions, such as MSK conditions. The NHS Outcomes Framework contains the indicators that are used to hold NHS England to account for making progress2.”

No pressure then, as they say!

So, what has it been like so far?

Well, NHS England has only really been going for 136 days (at the time of writing) and the cynic may say in that time we have seen the failure of primary care to meet demand and the collapse of NHS 111 and A&E services, not to mention an endless wave of failing hospital trusts and community services. With new reports about safety and standards appearing almost weekly, it seems to indicate that the wider NHS is not fit for purpose.

For me there was also the issue that at a point where MSK finally has got a NCD all those other (sexy) areas have moved on (cardiac, kids, cancer) and they now have strategic clinical networks with regional support. Whilst it is true to say I have no budget, share of a very part-time PA in Leeds to look after my diary, no desk and no network, at least MSK is now being represented centrally and we need to build on it.

There are 25 National Clinical Directors with varying roles and we very much work across the patch; as some of the titles indicate they fall into in three domains of the NHS Outcomes Framework (Domain 1 Preventing people from dying prematurely; Domain 2 Enhancing quality of life for people with long-term conditions; Domain 3 Helping people to recover from episodes of ill health or following injury)

D1: Cancer; Cardiac; Stroke; Obesity and Diabetes; Respiratory; GI & Liver; Diagnostics, including Imaging; Pathology D2: Dementia; Mental Health; Renal Disease; Chronic disability and neurological conditions (learning disability); End of life care; Musculoskeletal; Spinal; Integration and frail elderly D3: Children, YP and transition to adulthood; Maternity and women’s health; Rehabilitation and recovering in the community; Emergency Preparedness and Critical Care; Enhanced recovery and acute surgery; Major Trauma; Urgent Care; Rural and Remote Care and Services; Offender Health We have had 3 induction days so far and many other meetings and gradually the new structures are evolving.

In MSK I have identified 47 separate organisations that are involved in MSK (professional groups, patient groups, charities) and am doing my best to meet them all and work with them. I spend one or two days a week mostly in London but also Leeds, and occasionally all week. I have spent time with the various interest groups across the whole of MSK and participate in various Westminster parliamentary groups promoting all aspects of MSK. My role is not to tell people what to do but rather co-ordinate what there is and promote it to the wider NHS, DH but more importantly to CCGs. I have objectives for this year and here they are – very general, but what would you expect:

1. To create a patient-focused common purpose with stakeholders 2. To raise awareness of best practice and commissioning tools 3. To foster integrated services/ pathways 4. To support workforce development 5. To empower patients 6. Implement outcome measures 7. Embed ‘Beyond Compliance’ As part of the role I co-chair the Clinical Reference Groups for specialist Orthopaedics and Specialist Rheumatology services.

There has been a lot of work over the years in orthopaedics with blue books, commissioning guidance through Joe Dias’ work developing High Value Pathways of Care, Tim Briggs’ work on ‘Getting it Right First Time’ and in rheumatology through commissioning support network; as well as many other initiatives. We did produce a Musculoskeletal Framework Document5 that was spawned out of the National Orthopaedic project at the time, which is still relevant today in describing elements of an integrated MSK service. I believe that if we bring together the wider MSK community and all the very positive strands of work on standards, commissioning, research, service design, workforce, training and outcome measures we can help empower the professional groups, patient groups and third sector organisation to improve the lot of the MSK patient, with earlier diagnosis, better information, easier access to service, cost effective services of high value and derive better outcomes.

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I have identified 47 separate organisations that are involved in MSK (professional groups, patient groups, charities).

The first article I wrote for BON as President of the BOA was entitled “The new wind of change – Stepping up to the plate”6 which outlined the need for us as individuals and departments to get involved with commissioning of orthopaedic care locally. This is now still as, if not more, important than ever and now with local engagement, with professional leadership through the likes of Martyn Porter as President and the BOA and now with a foothold in the new NHS, we can achieve the objectives of the BOA of “caring for patients; supporting surgeons”.

Working with our colleagues and patient groups across the wider MSK community we can serve the needs of the often neglected MSK patient. There are, of course, challenges but we like challenges don’t we?!

References: 1. Hansard: 30 Mar 2010: Column 617 Oral Answers to Questions HEALTH 2. Hansard: 17 June 2013, Health Care Debate column 554W 3. “Low Priority Operations” BBC Radio 4 You and Yours 24th November 2010 12:00hrs. www. bbc.co.uk/programmes/p00cbzhs

4. “Surgeons warning over hip and knee operation delays. BBC 6 and 10’O Clock news 5th April 2011” www.bbc.co.uk/news/ health-12979046 5. “Musculoskeletal Services Frame Work – A joint Responsibility Doing it Differently. “ 2006 Crown Copyright ref. Gateway 6857 6. “The new wind of change – Stepping up to the plate” British Orthopaedic News. Issue 46 Winter 2010. Pages 1-3

Conference listing: Organisation

Conference/meeting

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

Annual Scientific Meeting 6-8 November 2013, Belfast

SBPR (Society for Back Pain Research) www.sbpr.info

SPBR Conference 14-15 November 2013, London

BHS (British Hip Society) www.britishhipsociety.com

Annual Meeting 5-7 March 2014, Exeter

OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk

First Annual Meeting 6-7 March 2014, London

Britspine www.britspine.com

Britspine Meeting 2-4 April 2014, Warwick

BASK (British Association for Surgery of the Knee) www.baskonline.com

BASK Annual Conference 8-9 April 2014, Norwich

EFORT (European Federation of National Associations of Orthopaedics & Traumatology) www.efort.org/index.php/events-calendar/efort-event-directory

15th EFORT Congress 4-6 June 2014, London

BOTA (British Orthopaedic Trainees Association) www.bota.org.uk

BOTA Educational Weekend 20-22 June 2014, Chester

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

BOA Annual Scientific Meeting 14-18 September 2015, Liverpool

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Features

Schools of Surgery and Surgical Education Phil Turner

One of my fellow Heads of School recounts the story of sitting at dinner next to an American surgeon who had been attending a meeting in his teaching hospital. The day had consisted of the usual round of presentations by consultants and trainees, prepared and delivered to a decidedly variable standard. The guest asked quite innocently, “So who actually runs surgical training in the UK?” My colleague decided it was not a topic to aid digestion and said he would try to explain later.

So many bodies and authorities seem to have a stake in running surgical education that it is of little surprise that there is a lack of clarity. The GMC – the regulator – lays down the standards.

It approves the curriculum, registers trainees, certifies completion of training and in the near future will approve trainers.

The ‘Colleges’ in the form of the Joint Committee on Surgical Training (JCST), itself a grouping of the now 10 surgical SACs, writes the curricula, develops guidelines for delivering training and gives advice to the GMC as to whether trainees or training programmes have achieved the standards.

Two separate intercollegiate bodies run the examination system. The ICBSE run the MRCS and the Joint Committee for Intercollegiate Examinations (JCIE) is responsible for the FRCS. Both of these bodies report to the GMC and have to maintain standards set by the regulator.

The overarching body that is responsible for education across the NHS in England is the recently constituted Health Education England (HEE). It describes itself on the website as “the NHS engine that will deliver a better health and healthcare workforce for England”. It oversees the regional bodies known as Local Education and Training Boards (LETBs) which roughly correspond to the original Deaneries in England but which now cover the education and training of all healthcare workers rather than just medical and dental staff.

The hospital Trusts actually deliver the training and are labelled the Local Education Provider (LEP).

So where do the Schools of Surgery fit in?

Philip Turner

Development of the Schools The first unified surgical curriculum (Intercollegiate Surgical Curriculum Programme - ISCP) was completed in 2002 and approved by the responsible body at the time (PMETB). The attraction of having a coherent curriculum across all surgical specialties is obvious. It was calculated at the time that the alternative was to approve a total of 56 different curricula. At this time, Foundation training was established to guide trainees from medical school to core specialty training. To ensure standards were maintained across a region, Foundation Schools were set up and their success spurred the development of Specialty Schools for GP, Medicine etc. By 2008, every Deanery had a School of Surgery, with one equivalent body for each of Scotland, Wales and Northern Ireland.

What is a School of Surgery?

The School is the overarching body responsible for the delivery and quality management of all core and higher surgical education within a Deanery or its equivalent.

There are a total of 16 ‘Schools’ and although they all serve more or less the same functions they also have some significant differences, the geographical area served and the number of trainees being the most obvious.

Less obvious is the level of support received, from none at all to a total of eight administrators. There is also significant variation in philosophy, with some acting as a commissioner of education from the LEPs, while others see themselves as predominantly providers of training.

Some Schools hold the budget for education whereas others do not.

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The mismatch between the number of bright young students and core trainees who want to go into surgery and the number of higher surgical training posts is not sustainable.

The Heads of Schools The Heads of School were all appointed in competition and for most it was quite an experience to sit on the other side of the table after many years of asking the difficult questions. All are active clinicians: colorectal and vascular surgeons tend to predominate.

Most receive between two and four sessions from the Deanery and continue to provide up to six clinical sessions a week. My own experience suggests continued clinical work is vital in maintaining credibility with the rest of the team.

What does the School actually do?

Table 1 gives an overview of the responsibilities I have as Head of School in the North Western Deanery. The common theme to all this activity is quality management of surgical education. At one level, I have a quality control function, ensuring that every post and every trainer are able to provide the experience and opportunity necessary to develop a surgeon in the limited time now available.

I also have to quality assure the total product of the programme.

Are trainees achieving the appropriate ARCP outcomes? Are our examination pass rates good enough? Are the trainees being appointed to consultant posts and are they both productive and safe when they get there?

Information about our training programmes is plentiful. We receive trainee feedback at the interim reviews, access the GMC and JCST trainee surveys and, on a regular basis, visit the LEPs where we interview the trainers and trainees and then give direct feedback right up to the level of the Chief Executive.

The Gold Guide is the rule-book we have to apply, but it is open to interpretation. The GMC frequently update their standards and new guidance will come from JCST or one of the SACs. Flexibility and fairness are key attributes!

There is little point in taking in all this information and doing nothing with it. If a post, unit or whole Trust is failing to provide adequate training, we either provide support to develop trainers, re-organise rotations or remove trainees from that environment. Following the Francis Report, it is clear that poor training is a marker for poor clinical performance. There is also evidence that poor patient safety and even increased patient complaints and litigation correlate with a poor training environment.

The trainees can act as the eyes and ears when things are going wrong.

On a more positive note, we must encourage innovation and recognise excellence. Supporting the provision of simulation, both facilities and faculty, is one of our most pressing tasks.

Table 1 : School Functions Core surgery committee Higher surgery committee School Board STCs Surgical tutor appointments ARCP panels Trainer development

Interim reviews Appeals committees TPD appointments Appraisals Trust visits Career advice

CoPSS The Heads of School meet two or three times a year and have formed the Confederation of Postgraduate Schools of Surgery. This is a forum for networking, collaborating and developing best practice. As the immediate past Chairman, I have represented CoPSS on JCST, JCIE, numerous working groups and College Council. Our views and advice are sought on many issues and we support initiatives from these bodies.

Achievements So what have we achieved? We have widespread compliance with the curriculum, we have programmes of quality management and we develop trainers. We continue to produce trainees who are appointable to consultant posts. Most of all, Schools have survived. At a time of austerity and widespread structural change, every Head of School who has left office has had a replacement appointed and there is no intention to remove or replace Schools. This despite the gloomy predictions that there would be no Deaneries and no Schools once the Commissioners and LETBs were established.

Challenges Nevertheless, I think I should end on a note of only cautious optimism. The opportunity that simulation presents must be handled carefully. Having a cadaveric lab is all well and good, but you have to have a trained faculty, an administrator and most of all a curriculum that includes a defined role for simulation training in its broadest sense. At present these are not all on the table.

The mismatch between the number of bright young students and core trainees who want to go into surgery and the number of higher surgical training posts is not sustainable. The number of core trainees is being drastically reduced, leaving Heads of Schools to make difficult decisions over who should lose out, often after years of dedicated support. Sadly, the same applies to higher surgical training numbers and Trusts have to plan how they are going to provide service without relying on a ready supply of trainees.

It is likely that we will no longer be able to appoint LATs to fill gaps in training programmes, making it harder to justify releasing those who want to go ‘out of programme’. The whole question of OOP is being reconsidered as it should not be necessary to go out of an accredited programme just to get to CCT, other than for some very specialised services.

The public expect to be treated by a ‘specialist’, yet the pressure is to produce much more generic generalists who can be moulded into a specialist after CCT. Finally, are our trainees really ‘fit for purpose’? Each reader will have their own opinion.

Reviewing log-books across all surgical specialties can make for uncomfortable reading, yet some do manage to gain the breadth and depth of experience. Are we doing everything to ensure every trainee has the same opportunities whoever they are and wherever they train?

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Providing Value for the Specialist Societies – The Evolving Role of the BOA John Timperley, BOA Honorary Treasurer

At this year’s AGM, all members of the BOA will be presented with and have an opportunity to comment on guiding principles for shaping future proposals to review and consolidate the memorandum, articles and rules of the Association in 2014.

It is important that these reflect - inter alia - the needs of a membership with increasingly specialised clinical interests, particularly as most clinicians wish to have support from, and representation by, specialist societies in addition to membership of an Association representing the interests of patients and the orthopaedic profession at a national level.

There are now 20 different bodies represented on the board of specialist societies of the BOA.

Their structures, aspirations and needs are diverse and the Presidents of each society were recently asked about their present relationship with the BOA, the support currently given by the Association and their wishes for what they would like the BOA to deliver for them. The aim of this exercise is to guide the restructuring of the BOA so that the Association can provide more up to date infrastructure, relevant support and better value to each of the societies.

It can be seen from the matrix that improvements and changes are being considered for office support, information systems and communications support, help with organising congresses, media training/representation as well as support for research and specialist registers. On-going changes within the BOA offices and the creation of a new IT platform with a consolidated membership database have had profound changes on the value the BOA can provide its membership and affiliated societies.

Several initiatives have already been implemented recognising the important contribution of the specialist societies. At Annual Congress the societies now organise the content and free paper sessions of their specialist days as well as providing sessions of educational value for all BOA members as required for revalidation. In addition, the specialist societies are able to be involved, from 2014, in commissioning articles for their members in “badged” sections of the new Journal of Trauma and Orthopaedics.

John Timperley

With the improvement in IT capability at the BOA there is potential to help specialist societies develop and host websites in subdomains, advice on Apps and help with communications consistency between applications such as Twitter, Facebook etc.

The BOA website has an average of 20,900 unique visitors per month and an average of 7,900 page views per day, via social media/app the BOA communicates with over 10,700 people, and the JTO online has made over 16,100 impressions since launch. By collaborating, the Specialist Societies can leverage on these new capabilities and increase the influence of the profession.

Financial modelling for how to pay for these services is being carried out, but as the BOA is restructured, and with growing BOA membership, it is envisaged that much of this support can be provided free for specialist society members who are also BOA members. As is only fair and proper, it is likely that a charge will have to be made to cover the cost of delivering services for specialist society members who do not belong to the BOA. You are urged to join the discussions at the AGM; the BOA is run by BOA members on behalf of the membership and we are all responsible for guiding the development of the Association to fulfil our objectives.

The ultimate aim of this initiative is to develop and work on members’ ideas with the objective of bringing developed proposals, the associated rule changes and a revised Document of Association for final consideration at a closed BOA Congress (for members only) in September 2014.

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Making the Transition from Paediatric to Adult Services: A Parent’s and Young Adult’s Perspective on a Long-Term Patient’s Experience Ruth Reavley

A diagnosis of proximal focal femoral deficiency at 20 weeks into her second pregnancy radically changed Ruth’s experience of hospitals. Four Ilizarov frames (one double), a couple of tendon releases, three epiphiysiodeses and lots of physiotherapy later (not to mention numerous childhood breaks of other bones owing to stumbles and falls), David is 17, about to start A2 courses, has been on crutches now for 4 years owing to knee subluxation, and is hoping that a knee replacement after exams next summer will regain his independence in walking. Ruth is a member of the BOA Patient Liaison Group

Ruth Reavley

Teenage patients move from paediatric to adult orthopaedic services around the age of 16.

Some have built up life-long experience and networks with clinical teams and physiotherapists in a paediatric service setting. The transition typically severs those personal relationships. Managing the transition from these familiar setting to new and unfamiliar adult settings involves careful planning by healthcare professionals, and adaptation by the patient and the parent/carer. The tone and pace of consultations are different. The support role of the parent changes.

The biggest surprise came in the impact that a change of clinical team and setting had on our son’s capacity to deal with new situations emotionally. Rationally he was ready to move. A great deal of care had been put into planning the best point in treatment to make the change. But the simultaneous experiences of unfamiliar adult settings, a clinical team he was just getting to know, some pretty big decisions to be faced, and the first experience of signing the consent form (rather than countersigning a form I had signed), had huge impact on his emotional capacity to cope. Reflecting, several months on, we realised that for some months immediately following the transition, he felt more vulnerable than either of us had appreciated.

For many years, my roles in relation to our son’s treatment have centred on understanding the condition and proposed treatment (sharing the task of explaining in age-appropriate ways when he was very young), and motivating him on physiotherapy. The transition to our son taking primary responsibility for understanding his condition and treatment was made over a number of years. Encouragement to do the physiotherapy is a perennial parental responsibility.

Acknowledging that one family’s reflections merely make a unique case, I nonetheless invite readers to consider the wider and deeper picture. Virtually everything is changing for the young adult long-term patient except their underlying condition. As a result of these experiences, I led the development of a document on ‘Managing the transition from paediatric to adult services’ by the BOA’s Patient Liaison Group, of which I am a member. The document has recently been published online and is reproduced in full for JTO readers on page 32.

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Making the transition By the time a long-term orthopaedic patient reaches sixteen, they have probably had enough of the dressing up corner, the Lego, play kitchen and children’s comics, which are staple offerings in the waiting room. However the absence of graduated ‘in-flight’ waiting room entertainment is, in our experience, more than ably offset by the steady adaptation in the manner of treatment by staff in the paediatric unit.

Everyone at the clinic should be aware that adolescent patients who may be relatively tall and, if male, deep voiced, can be quite intimidating to the smaller patients.

The ‘good practices’ we experienced in the run-up to transferring to an Adult Unit were: 1. Age and developmentappropriate involvement of the patient in discussion about treatment and risk factors 2. Encouragement to countersign surgery consent forms as a patient approaches 16 years old 3. Information about the name and specialism of the adult services consultant who is to pick up care 4. Age-stratification of bays in wards 5. The offer of high-tech distractions such as GameBoys (to complement any ‘musthave’ items brought in e.g. the iPhone/iPod, which incur extra insurance cover for parents) 6. Age and developmentappropriate vocabulary used in explanations

What is it like for a parent to shift from being essential to being an optional extra in consultations?

Until a child is 16 they have to be accompanied by an adult who will give consent to treatment.

As a parent I had to be at every clinic. Suddenly – overnight – I am considered an optional extra.

However, as my 17-year-old says: it’s crazy not to have me in clinic appointments as I’m the one who does the caring, the transportation, the reminding about routines, the negotiation with school about time off the premises, and he relies on me to share an understanding and perspective on proposed treatment. So it’s essential that there is a gradual transference of responsibility and autonomy to allow the pending adult to acclimatise to the extra responsibility!

I have found it good practice to always ask our son before clinics whether he wants me to be in the session with his consultant. I always say on arrival that our son has asked me to be present. And I’ve taken to asking when it’s clear the consultation is rounding off, whether our son has anything he wants to raise without me being there. I’d leave if he wanted me to.

Passing responsibilities over to the patient We’d agreed, from about age 15, that our son would announce himself to the reception desk in clinics and had responsibility for taking the clinic letter.

From about age 12, we discussed the advice given in clinics and wrote down a shared understanding in a book which the whole family could look at.

(Previous to that, I’d kept a record, but not one based on explicitly shared understanding.)

I gradually withdrew myself from physiotherapy appointments from about age 14 (puberty alters the mother-child dynamic, and this seemed like a good way to demonstrate that I was truly offering independence). I was present, but disengaged from the conversation (reading, in the same room). If my involvement was sought (by son or physiotherapist), then I was there and immediately available. I don’t go into physiotherapy appointments in the adults’ services provision, but, as transport provider, am on hand should I be wanted.

What does a smooth transition to adult services look like?

1. Appointments coming through promptly – with continuity and good communication between the two clinics 2. Some level of negotiation on physiotherapy to adapt to free periods and school hours (rather important alongside A2s and AS level public exams) 3. A willingness from all parties to respect the non-obligatory role of a parent in clinic discussions

What has surprised us so far?

Visiting hours are different in adult wards – typically being much more limited. Whereas it had been routine for me to attend ward rounds in the Children’s Hospital it’s not necessarily possible to turn up to early ward rounds at an Adult Unit. This represents a real change in support for the patient.

On the morning of the first new surgical procedure as an adult the ward round took place before I got to the hospital. Having signed the consent form at pre-op clinic when I was present, the experience of checking it and re-hearing the risks list whilst on his own, on the ward, just before surgery, caused unanticipated high levels of anxiety. It seemed that all the times they’d been recited before (a surgery list going well into double figures), our son had ‘zoned out’ as it was something I was signing for. The risks on this occasion were no different.

His being the sole participant in considering them was new – and personally challenging. Young adults may need additional help to manage this step in independence.

The clinicians involved in the conversation may not have thought about the impact of their words on a young adult taking sole responsibility for signing consent for the first time, and may not ‘read’ the patient’s anxiety proficiently.

Department of Health Policy guidelines are summarised in You’re Welcome (March 2007).

The introduction states: All young people are entitled to receive appropriate health care wherever they access it. The You’re Welcome quality criteria lay out principles that will help health services – both in the community and in hospitals – to ‘get it right’ and become young people friendly. http://webarchive. nationalarchives.gov. uk/20130401151715/https://www. education.gov.uk/publications/ eOrderingDownload/275246.pdf More recently the Department of Health has published Quality criteria for young people-friendly health services (April 2011) as an extension of this initiative. This paper reflects on paragraph 8.3. https://www.gov.uk/government/ uploads/system/uploads/ attachment_data/file/152088/ dh_127632.pdf

Summary:

Adolescents need managing differently from pre-teenagers.

Waiting rooms and wards need to reflect the needs of postpubescent patients.

Health care professionals should ensure they treat post-pubescent patients appropriately.

Patients and Parents need to adapt the way they discuss and manage hospital visits as the patient approaches the transition to Adult Services.

This may be problematic where the parent has no personal experience of adult units.

Children’s Hospitals need to ensure they prepare patients for the transfer to an Adult Unit.

The Adult Unit (Clinic or Ward) needs to ensure the patient and their family are aware of, and comfortable with, the different practices.

The Adult Unit needs to understand that young adults may feel vulnerable when they first attend an adult clinic or have their first adult ward admission.

The ‘Managing the transition from paediatric to adult services’ document by the BOA’s Patient Liaison Group was published in Summer 2013 and is available online at www.boa.ac.uk/PI/Pages/plg.aspx

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Engaging with the Curriculum Lisa Hadfield-Law

The latest T&O curriculum submission went live on 7th August 2013. The Training Standards Committee (TSC) at the BOA have spent over a year working on this document, which is aimed at making learning and teaching easier and more effective for trainees and trainers. The TSC comprises trainers and trainees from different backgrounds, from all over the country, who donate their time generously.

We want to make the shift from the 2010 to 2013 curriculum as straightforward as possible for everyone. You should find the latest version a more coherent structure built on experience and feedback from trainers and trainees. The T&O curriculum is now delivered through ISCP, so many of the wrinkles remaining from the previous merging of ISCP and OCAP, should have been ironed out. The major changes you need to be aware of fall into six categories:

Applied Clinical Knowledge The Applied Clinical Knowledge (ACK) requirements for each regional anatomical area stay the same. We have however changed the layout to make headings more consistent and to group detail under broader headings. It should be easier to use and map against courses, exams and other educational activities.

Critical Conditions The most notable addition to the ACK syllabus is the inclusion of ‘critical conditions’. This small group of conditions requires focused learning and assessment, as they can be associated with significant risk to patients if not identified early. A case based discussion (CbD) workplace based assessment tool (WBA) on a simulated scenario can be used to assess such critical conditions e.g. cauda equina. Trainees may complete training having not come across such conditions in practice, but they must be able to recognise, manage and appropriately refer such cases.

Lisa Hadfield-Law

Applied Clinical Skills The required skills stay much the same. Trainees won’t be expected to attain the highest levels of competency for all procedures.

So, we have removed the ‘s’ component at level 4, but added a level 5 and modified the definitions for a trainee in the generality of T&O (4), as against requirements for training in an area of specialty interest (5).

The skills and procedures have 5 defined levels now (excluding level 0): 0 No experience expected (for core trainees) 1 Has observed or knows of 2 Can manage with assistance 3 Can manage whole but may need assistance 4 Can manage without assistance including common complications 5 Can manage complex cases & associated potential complications All index/primary procedures assessed by primary Procedure Based Assessments (PBAs) must be mastered to level 4 and the remainder at the level indicated in the syllabus, depending on the stage of training and specialisation.

Remember, that to achieve levels 4 and 5, management of complications is not necessarily possible or required. Trainees should be able to anticipate potential complications and discuss options for avoidance and management should they arise.

Competence in this area may be tested through a CbD or as part of the PBA, as long as it is recorded appropriately in the text boxes.

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To improve patient safety, many surgical/procedural, clinical and communication skills can be practiced in a simulated environment.

Quality Improvement Completing a full audit cycle and closing the loop, leading to a change in practice and improved quality of care, has become part of the revalidation process for consultants. To date, trainees have only been expected to take part in regular audit and demonstrate that activity in their portfolio. This revision requires all trainees to undertake at least one audit per year with two audits where the loop is closed during ST3-ST8.

The completed audit cycle should be presented at a local, national or international meeting.

Simulation The future curriculum will include simulation. To improve patient safety, many surgical/procedural, clinical and communication skills can be practiced in a simulated environment. This will shorten the learning curve for trainees and allow us to focus learning on specific needs.

We aspire to provide opportunities for all trainees in simulation, but we must accept that cost and availability of some high tech facilities such as human simulators and cadaveric labs may have limited access locally, but some will be provided at national or regional centres. There is scope for a range of simulations from low to high fidelity and low to high technology. Our main focus will be on integrating simulation into day to day surgical training and practice.

Novel, accessible and cheap simulation models/trainers, using recycled and reusable items, will help trainees to fully integrate simulation into learning and achieve the deliberate practice and distributed simulation to accomplish automaticity.

Example of Scarf Osteotomy for Hallux Valgus Take a peeled banana and plastic knife (available in the canteen) and make the scarf osteotomy cuts. Rotate the two pieces of banana to simulate straightening of the metatarsal. Use two cocktails sticks to pin the newly straightened banana in place and cut off protruding edges of the “bone� (banana).

These high impact simulations can be conducted whilst waiting for a delayed patient in theatre, during the lunch break in clinic or indeed any other variable period of downtime. Trainers and trainees should encourage each other to maximise every opportunity.

Example of a patient with back pain One trainee/ trainer to play the part of a patient with a large set of notes and chronic back pain for which no cause can be found, the other to assume the role of the surgeon in clinic. To explore options for handling breaking bad news: 1. I am really sorry but you have a condition for which medical science has no answer at present.

2. Your symptoms may worsen or improve over time - and if you still have symptoms in 2 years’ time we may have some answers.

3. Is your condition bad enough to warrant an operation?

4. Are your symptoms the same as you had on the other side? (in bilateral problems) 5. Can you put a % figure on how much better you are after your surgery/treatment?

6. For CRPS patients (who have a diagnosis). You have a poorly understood problem for which there is little that we can do apart from physiotherapy. After any trauma you get swelling, pain and stiffness of your joints.

CRPS patient suffer from those symptoms much more and for much longer but by 2 years most of them will abate.

Different levels of trainee practicing reduction of Colles fracture

Trainers and trainees completing assessments on tablets and phones after fixing fractures on bone models

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It seems for some, that ISCP and the curriculum are constantly changing, making the training environment appear uncertain and unstable.

Index Procedure Based Assessments (PBAs) A modified set of the original index PBAs remain as primary PBAs and are required for all trainees to complete to level 4, prior to the intercollegiate examination. Individual PBAs remain formative assessments and a way of recording progression in competency. The range of primary PBAs has been changed to reflect current practice and a realistic view of available opportunities.

A secondary PBA will be used to assess trainees in the generality of T&O in skills other than those in the index group.

A tertiary PBA will be used to demonstrate competency in a specialty interest area.

The 2013 curriculum will focus more heavily on the use of other WBA tools. For example, casebased discussions (CbDs) will be used to assess competency in critical conditions. Direct Observation of Practical Skills (DOPs), Clinical Evaluation Exercise (CEX). and CbDs will be used in a more balanced way.

All WBA will require entry of a narrative about feedback between trainers and trainees, along with the trainee’s reflections on the event being assessed.

It is worth repeating that to achieve a score of 4 at PBA, management of complications is not necessarily possible or required. Trainees should be able to anticipate potential complications and be able to discuss options for avoidance and management should they arise. Competence in this area may be tested through CbD WBA tool.

Changeover to the latest version of the 2013 T&O curriculum is mandatory for all trainees and trainers, irrespective of when they were appointed, with the sole exception of those in their final year of training. We hope to make the transition as easy as possible by ensuring access to the relevant and useful parts of the curriculum by: Cascade briefing through training programme directors Exploring the possibility of an ‘app’ Trainees are being offered WBA as part of AO, ATLS instructors and cadaveric courses Integration into programmes including Training Orthopaedic Trainers (TOTs), Training Orthopaedic Educational Supervisors (TOES) & Training Orthopaedic Clinical Supervisors (TOCS) Direct links to Wikipaedics Access to an E-learning module via the BOA website aimed at helping trainers and trainees create useful pieces of reflective writing.

It seems for some that ISCP and the curriculum are constantly changing, making the training environment appear uncertain and unstable. We hope that continued efforts by the Training Standards Committee, the SAC, ISCP, trainers and all those concerned, will help T&O trainees to complete training which will prepare them for safe, effective and rewarding practice.

Any feedback or suggestions will be gratefully received and considered by the Training Standards Committee through the British Orthopaedic Association.

So… if the TSC and others are endeavouring to make the transition as easy as possible, we must rely on you as trainers and trainees to support our efforts.

The clear message from the ISCP evaluation last year is to strive for commitment rather than compliance. With constant harping on about ‘tickbox exercises’, such achievement is unlikely. ‘Not allowed’ and ‘must’ could fade into insignificance if we look at exciting and creative ways of making the curriculum work. If we can think beyond filling the boxes on a PBA form, to exchanging feedback which will influence practice and capturing learning through CbD, CEX, OOTs and the much wider range of tools we have available then the suggested 40/80 WBAs

per year will become a motivator rather than a source of irritation and anxiety.

Our curriculum could save huge amounts of time and effort, making sure that trainees are learning and trainers are teaching what is needed. But, it must be knitted into the fabric of T&O practice and it’s up to us to link all educational efforts along the spectrum from courses to opportunistic teaching, to the curriculum.

Unless someone has a better option, we must make this work.

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The First British Sports Injuries Clinic - A Trauma Service for the 1948 Olympics Michael Edgar & Fares Haddad

The recent report in BON 54 about the new Institute of Sport and Exercise Health considered the challenge of maintaining the positive impact of the 2012 Olympics, from the medical aspect. This article, by contrast, looks at a much earlier development following the London Games of 1948, which interestingly coincided with the advent of the NHS. This close link between the London Olympics and the NHS in 1948 was again reflected in the spectacular 2012 Opening Ceremony with a ‘Cirque de Soleil’ style presentation of the Great Ormond Street Children’s Hospital to highlight the achievements of the NHS since 1948.

In contrast to the sophisticated medical services at the recent Olympics, only the bare essentials of a first-aid provision existed for the post-war ‘Austerity Olympics’ at Wembley 64 years ago. But there was one exception, which was the brainchild of Dr Ben Woodard, an Accident Officer (orthopaedic registrar with trauma responsibilities) at The Middlesex Hospital, London W1, then a leading London teaching hospital. Dr Woodard was a keen athlete and a prominent member of the AAA (Amateur Athletic Association). With the support of his consultant, Mr Philip Wiles (later – 1956/57 – to be President of the BOA), Woodard gained permission from the Department of Health to set up a trauma service for athletes injured in training or competition at the Wembley Games under the auspices of the newly-founded NHS. Its uniqueness at that time attracted media coverage.

Interestingly after the ‘48 Games, this facility known as ‘The Athletes Clinic’, continued spontaneously and uninterruptedly at The Middlesex, twice weekly and, without any formal publicity, recorded an attendance of between 400 and 800 new patients and over 1,000 follow-ups annually.

In later years, attendees were required to provide a letter from their GP or sports club secretary.

The clinic was conducted by someone of registrar status supported by a physiotherapist and was held alongside the main Orthopaedic Out-patients Clinic with consultant advice to hand.

Michael Edgar

Fares Haddad

Figure 1 - John Fairgreve at the 1948 Olympics

This Sports Injury Service for the ‘48 Olympics was well remembered by the late Sir Rodney Sweetnam (BOA President 1985), then a clinical student at The Middlesex, who himself went on to become Accident Officer & eventually Consultant in Charge of the Athletes Clinic. John Fairgrieve (now a retired vascular surgeon), also has clear recollections. Not only was he a Middlesex student at the time but also an Olympic competitor representing Great Britain in the 200 metres (Figure 1).

Later he presented to Ben Woodard in the Athletes Clinic with a meniscal injury of the knee.

An independent study has now confirmed that The Middlesex Athletes Clinic was the first hospital based sports injury service to exist in Great Britain2.

The Sports Council was formed in 1965. Part of its policy from 1972, was to set up NHS Sports Injury Clinics, using the Middlesex Athletes Clinic as a prototype3.

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one only has to look at the publications that originated from the Clinic to realise that it made pioneering contributions on a number of fronts.

The post-war era also saw a marked and rather unregulated expansion of private sports medicine and trauma facilities for the major professional sports clubs, league football being a prominent example.

During this period, a number of other national bodies were formed to promote the specialist status of sports medicine and sports injury services. BASM, later BAS(E)M (British Association of Sport and Exercise Medicine) was probably the leading example. Following a recommendation by BASM, it was agreed to start a trial of Saturday evening clinics at the Middlesex in 1957 to provide a more acute sports injury service for the many weekend sportsmen, as opposed to the rather elective weekday clinic. Surprisingly this weekend venture closed after a year due to lack of patients4.

Other organisations included the British Association of Trauma in Sport (BATS) which was formed in 1980 by a group of dissenting BASM members. Another, the Institute of Sports Medicine, has aimed to encourage quality research and has recognised achievements in Sports Medicine Research with the award of its ISM Fellowship. In the last two decades more specialised societies have formed not with the object of being pressure groups for Sports Medicine but rather with the aim of sharing expertise: e.g. – British Orthopaedic Sports Trauma Arthroscopy Association (BOSTAA) Despite a fairly turbulent sports medicine world which surrounded it in the three or four decades that followed 1948, The Middlesex Athletes Clinic remained almost unchanged in its style over the years and it was tempting to think that it had become lost in a time-warp. However one only has to look at the publications

that originated from the Clinic to realise that it made pioneering contributions on a number of fronts. The first batch of these publications occurred in the 1950s when Mark Devas, working with Rodney Sweetnam and others, confirmed what is now taken for granted, that ‘shin splints’(excluding those arising from compartment syndromes) are mainly due to missed stress fractures of the tibia and occasionally the fibula5,6,7,8.

Philip Newman’s classic work on the classification of spondylolysis and spondylolisthesis9 undoubtedly included details of patients attending the Athletes Clinic10. The causes and evaluation of back pain among 197 sportsmen presenting to the Clinic, published in 1984, was at that stage the largest review of its kind and became influential in the management of back pain11.

A third group of studies emerged when the Middlesex acquired one the first Watanabe arthroscopes in 1970. Arthroscopy became quickly recognised as a useful and prompt diagnostic tool for knee injuries and early studies from the Clinic supported this12,13.

Of course the predominantly therapeutic value of arthroscopy subsequently became established.

After a period of 39 years, from 1948 to 1987, this landmark service in its original form ceased with the transfer of The Middlesex Trauma Service to University College Hospital, and the ‘Athletes Clinic’ became absorbed into UCH’s own Sports Clinic. Since then, as stated in the previous article, this has now metamorphosed to a state of the art Sports Injury Centre in the ‘Middlesex Tower’ at the new UCH, with full gym access and physiotherapy support. Post-2012 Olympics, this Sports Clinic will now expand into a new facility at 170 Tottenham Court Road where co-location of teaching, training,

3 Heggie,V (2010) Specialisation without the Hospital: The Case for British Sports Medicine ‘Sports Injuries Clinics’ Med. Hist. 54 (4) 457 – 474 4 Heggie,V (2010) Specialisation without the Hospital: The Case of British Sports Medicine ‘Regulating Sports Medicine: Insurance and BATS’ Med. Hist. 54 (4) 457-474 5 Devas MB & Sweetnam R (1956) Stress Fractures of the Fibula – A Review of 50 Cases in Athletes. J Bone Joint Surg 38B 818 Figure 2 - 1948 Olympic Games

rehabilitation and research in sport and exercise medicine comes together in the form of the Institute of Sport, Exercise & Health. This is a unique academic and clinical collaboration whereby the NHS care will be provided for sports injuries at the same time as care for the very best of our athletes and against a background of research teaching training in sports injuries.

We hope it is a fitting legacy to the superb work that was undertaken in those early days at the Athletes Clinic of The Middlesex Hospital and that it will now support a new generation of athletes.

References 1 Haddad F (2012) The Institute of Sport and Exercise Health – a legacy from 2012 BON (54) 11-12 2 Heggie,V (2010) Specialisation without the Hospital: The Case of British Sports Medicine ‘The Sports Council and Sports Medicine before 1972’. Med. Hist. 54 (4) 457-474

6 Devas MB (1958) Stress Fractures of the Tibia in Athletes or ‘Shin Soreness’. J Bone Joint Surg 40B 227-239 7 Devas MB & Sweetnam DR (1958) Runners Fracture. The Practitioner 180 340-342 8 Devas MB (1960) Longitudinal Stress Fractures J Bone Joint Surg 42B 508-514.

9 Newman PH & Stone KH (1963) The Aetiology of Spondylolisthesis J Bone Joint Surg 45B 39-59 10 Newman PH, Thomson JPS, Barnes JM & Moore TMC (1969) A Clinic for Athletic Injuries Proc R Soc Med 62 939-943 11 Cannon SR & James SE (1984) Back Pain in Athletes Brit J Sports Med 18(3) 159-164 12 Elliott B & Henry A (1972) Arthroscopy of the Knee J Bone Joint Surg 54B 749 13 Edgar MA & Lowy M (1973) Arthroscopy of the Knee – A Preliminary Review of 50 Cases Proc R Soc Med 66 512 515

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The BOA and the PMI Market Ian Winson, BOA Council Member

In being asked to write this article I realise that, in many ways, I was never entirely comfortable discussing the nature of commercial organisations. Though contrary to the popular belief that doctors aren’t good at management, I think we are trained to make difficult management decisions on a regular basis, which, in some cases, is far removed from the commercial practice of companies. Currently we seem to be seeing business practices that reflect a much more commercial world. There are concerns that the interest of the patient is perhaps not being prioritised by all parties in an equal manner. In many ways the biggest problem we have, as orthopaedic surgeons, is the inconsistency of the behaviour of the spectrum of companies and the inconsistency of individual companies in the long-term.

Ian Winson

Following recent changes made by some of the companies which compile lists of surgeons based on a concept of fee assurance, I am, somehow, reminded more of my local public house than I am of the care of patients. My local pub actually serves quite reasonable food as part of a large commercial chain. The menus are defined by a central office but one of the things I have always struggled to understand is the nature of the chicken dishes they produce. Those dishes are always described as being farm-assured.

At first glance you may think that this is organic chicken or chicken that has been free-range, or at least chicken that has been fed on good food such as corn. However, talking to my local landlord, he confirmed what I had expected: farm-assured chicken merely means that it comes from a farm!

The nature of that farm, how it produces its chickens and quality of care of the chickens are not part of that assurance.

We now seem to have PMI insurance companies using the same phraseology and trying, initially, to pretend that it means many things. When backed into a corner, they still try and pretend that their insurance is not really driven by one thing, i.e. the money.

So in this article I hope to show you the present BOA Council stance on these matters to give you some information about the PMIs and to explain the way in which Council intends to continue to pursue these matters.

Ultimately it has to be clearly understood that the BOA is a charitable organisation whose remit is to educate and support orthopaedic surgeons, to support orthopaedic research and to provide an organisation that people can look to for leadership in matters of orthopaedics. All of these aims are intended to be for the benefit of our patients.

Historically, over the years, the BOA has chosen not to comment on the behaviour of commercial companies. However, there is a growing and sustained feeling that part of the leadership role of the BOA is to consider and report on these matters.

The PMI Market So what do we actually see among the private medical insurance companies? In truth, part of the issue is that an individual company’s behaviour is very much based on its own corporate nature, and this naturally differs across the whole of the market. It is clear that some of the companies which provide private medical insurance are straightforward commercial enterprises which hope to make a profit out of their activity to then be distributed to their shareholders (or perhaps, in this day and age, to the bonus payments of employees, particularly senior employees!).

Some of the companies involved in this commercial profile are relatively small and command a relatively small part of the market. Others have a much more substantial share of the PMI market, the most obvious being AXA PPP, and are clearly a subsidiary of an extremely large commercial organisation.

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there is a growing and sustained feeling that part of the leadership role of the BOA is to consider and report on the behaviour of commercial companies.

At the other end of the spectrum we have the provident associations. The essential structure of these is to charge a regular fee to be a member of the association and to accrue funds that are sufficient to cover the medical treatment needs of those members within certain defined limits. As a provident association they have a duty to accumulate sufficient funds to cover their liabilities. This inevitably means they will, in balancing the books, try to be in a reasonable level of positive balance at all times.

Probably the best example of this form of company is WPA. We then have companies which are rather more difficult to define.

The largest in terms of the current market is obviously BUPA, which is also a non-profit-making provident association. However, BUPA function on a multi-national level with subsidiary companies in many countries around the world in various areas of the provision of medical care and medical insurance. For many people it is difficult to understand their business structure and to see exactly where they fall in the spectrum of those companies providing PMI. I am sure most of you reading this article will know that historically BUPA have been the largest company in the PMI market and certainly, until recent times, had 42% of the market. The next biggest company with about 20% has been AXA PPP and then you move down to the companies with a much lesser share of the market.

The recent stance of BUPA, in particular where they have radically reduced their fees in so many areas of practice, where they have restricted the access of patients to a much smaller group of consultants who are willing to be fee-assured, seems in many ways very odd. I am no expert on business practice overall but if you have 42% of the market it would seem to me that your priority is to ensure that the service you provide remains of the highest level. To create a scenario in which clients have a restriction on what their insurance covers and to simultaneously ask that those people who are providing the service should provide it at anything up to 50% less than its previous value seems to be taking somewhat of a commercial risk.

If I were the CEO of a company which had 10% of the market and was looking at my profit base, I would very quickly try and analyse whether, if by providing better access and a better level of remuneration, I could increase my share of the market to 20% and ultimately increase my profit.

We can now see evidence of this approach starting to emerge.

Cigna, as an insurer in many areas of practice, has recently increased its fees, WPA have sought to reassure people that they will not interfere with normal medical practice and care pathways and, as I understand it, they have even taken the opinion of a QC about the liability risk of an insurance company effectively directing patients rather than leaving that up to the patient’s primary medical adviser, their GP.

It is also a relief that other insurers are looking at the possibility of guaranteeing a surgeon’s fees provided that the surgeon has made their own quality assurance and standards of practice available to the insurer, preferably in the public sphere. When you look at all of this, it does seem fairly certain that the consequences of trying to change the nature of the relationship between patients and doctors on a commercial basis may well have unpredictable effects for the companies themselves.

However, it is the general feeling of the BOA Council that it is not the role of an orthopaedic surgeon or indeed of the Association to try and influence the commercial practice of any one organisation.

It is entirely a different matter to ensure that the interests of the patient are protected in the widest possible sense while these commercial machinations continue.

The nature of independent practice Ultimately, it is obvious that it is not up to the BOA to tell surgeons at what level to set their fees. However, in the interests of our patients, there is general agreement throughout the BOA Council, the BOA in general and, I should imagine, all orthopaedic surgeons about how to behave in a responsible manner when setting fees in the private sector. The simple principle to which all seem to wish to adhere is to keep the patient thoroughly and completely informed of their personal liability and to supply them with as much information as they need to cover as much of that liability as possible through their insurance scheme if they are a member of one.

Letting patients know in writing what their care is going to cost them before they are financially committed is obviously now regarded as straightforward good practice. The PMIs have in the past tried to argue that GPs cannot know the financial implications for their patients when they refer them.

But should anyone, let alone the GP, make a clinical judgement on this basis? It does, however, seem entirely reasonable for surgeons, or the organisations that support their practice, to tell patients at the earliest opportunity about the potential costs and indeed, if the patient feels that they are in a position where they won’t be able to meet those costs, at least to let their GP know and preferably try and direct the patient down a path of treatment that will be protective of their interests.

On the other hand, it seems fairly clear that the provision of information to patients by private medical insurers is far from consistent. Many will not, for example, reliably tell patients about their financial arrangements with different independent hospital chains. They do not differentiate between hospital fees and consultant fees, despite the former being substantially greater.

They will rarely, if ever, explain to a patient the difference between what they will pay and what a consultant is known to charge before the referral arrives on the consultant’s desk. They may imply that the patient is going to end up with extensive further charges.

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Features

Many patients who have PMI insurance do not understand the detail of how it works and do not understand the restrictions that have been placed on their particular policy. With the present and past scandals involving the mis-selling of insurance, one wonders whether if it is only a matter of time before a group of patients, or a corporate body, challenges one of the insurance companies.

It is actually very difficult to get to the bottom of what insurance companies do to define their schedule of fees. Ultimately, it seems to be that they adopt the principle of a basic hourly rate and play around with the figures from there. This seems to take no account of required expertise; it seems to take no account of quality and experience; it seems to take no account of the increase in costs of running a private practice.

Though it is often said that certain fees haven’t increased for many years, this isn’t strictly true. What is true is that the fees have not kept pace with either inflation in society as a whole or the inflation specific to running a private practice. In an era when our standards of practice are becoming increasingly open and available to patients, it would appear that many parts of the PMI market do not actively practise the same level of openness.

So ultimately what does this all mean for the BOA and for its membership?

Having looked at the present situation, it is the opinion of BOA Council that the position of some of the commercial companies and the general lack of clarity and instability in the private insurance market are not ultimately in the best interests of patients. Council believes that the pathway from primary to secondary care which ensures that the right patient is treated by the right person at the right time remains the priority in the private medical market just as it is in the NHS.

BOA Council believes that it should be drawing up a list of expectations that both patients and orthopaedic surgeons (and doctors in general?) should reasonably have of a PMI company. It is their belief that the Chief Medical Officers and the CEOs of commercial organisations should feel beholden to sign up to these standards of practice and that it is in the best interest of patients to pursue matters in this manner. The task of further analysing this and drawing up the statement to this effect is being handed over to the BOA’s private practice committee.

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Features

BOA Congress Lecture Highlights

John Charnley Lecture – Ethics, Probity & Science: The History of Thromboprophylaxis in Hip and Knee Replacement Surgery (BHS)

Naughton Dunn Lecture – Evidence Versus Anecdote in Foot and Ankle Surgery (BOFAS) Judith Baumhauer [US]

Robert Barrack [US]

Adrian Henry Lecture – Ligament Balancing with Computer-Aided Surgery (BASK) James Stiehl [US] Computer-aided surgery has not been adopted as routine in the NHS. It is clearly useful for training purposes, and is used as a research tool.

One new area is in garnering data about ligament tensions and balance in vivo. This raises the possibility about understanding ligament balance in the replaced knee, and whether we can match this with the normal knee. This requires us to believe that achieving normal knee kinematics is possible after osteoarthritis and then an arthroplasty.

Despite decades of clinical experience the ideal method of venous thromboembolism (VTE) prophylaxis after arthroplasty remains controversial. The role of the Pharmaceutical Industry in influencing clinical practice guidelines has been profound. The majority of RCT studies performed have been Industry sponsored using venographically proven DVT as a surrogate endpoint rather than clinically symptomatic events and the avoidance of bleeding complications. Authors of bodies drawing up the original guidelines had often a declared conflict of interest with Industry.

In the US, the guidelines have changed significantly and there is now widespread recognition of all major options for prophylaxis including aspirin and intermitted pneumatic compression devices. Dr. Barrack will describe these changes in the Charnley lecture.

Professor Baumhauer is an internationally renowned researcher, foot and ankle clinician and lecturer and we are delighted that she is giving the Naughton Dunn Lecture for BOFAS this year. She is the Professor of the Department of Orthopaedics in Rochester and is a reviewer for many journals including the JBJS and the American Journal of Orthopaedics.

Judy is the immediate past President of the American Orthopaedic Foot and Ankle Society. With a wealth of experience of setting up and running Phase III FDA guided clinical trials, Professor Baumhauer will be able to illuminate us as to the pragmatic reasons whether this struggle is necessary or whether anecdote is a rational alternative to evidence.

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Peer-Reviewed Articles

Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Joseph J Dias

This article looks at salvage surgery of the wrist after a scaphoid fracture non-union or a scapholunate dissociation cause arthritic change in the radioscaphoid joint.

All motion-preserving alternatives are discussed. Of the common ones of scaphoid excision and a four-corner fusion or a proximal row carpectomy, in the medium term a proximal row carpectomy retains more physiological movement and therefore better function but long-term results are less certain. In such cases the orthopaedic surgeon must discuss alternatives and tailor a specific solution to the patient.

Joseph J Dias

Injury to the wrist is common and usually affects young men.

The two injuries that can result in early secondary osteoarthritis are a scaphoid fracture1 that does not heal and a scapholunate dissociation2, which causes instability.

Once degenerative change has set in salvage procedures may be needed if symptoms intrude on the patients’ ability to perform activities of daily living or activities at work.

Both injuries disrupt the continuity of the proximal carpal row. This row is then broken into two unequal parts, the smaller radial segment made up of a part or whole of the scaphoid and the longer ulnar segment of the lunate and triquetrum with or without the proximal part of the scaphoid. The extent of degeneration reflects the size of the radial segment of the proximal carpal row, which flexes after the non-union or dissociation.

There is point loading between the radial segment of the proximal carpal row and the dorsal rim of the scaphoid facet of the distal radius.

This, in a very quick time, leads to loss of joint cartilage. After a scaphoid non-union (Figure 1) there is a loss of wrist cartilage which is noted on wrist radiographs within five years in most patients3. The arthritis initially occurs between the radial segment of the proximal carpal row and the styloid and dorsal rim of the distal radius.

It rapidly extends to involve the articulation between the radial segment of the proximal carpal row and the scaphoid fossa of the distal radius. The next joint to get involved is that between the capitate and the proximal scaphoid with the degeneration slowly progressing (Figure 2). The radiolunate joint and that between the proximal scaphoid and the radius is preserved until very late4.

The symptoms from the degenerative arthritis do not usually reflect the radiological findings. Patients can present with episodic sharp catching or painful giving way, especially on gripping forcefully. Persistent aching is uncommon and, although patients have restricted movement, what is left permits most daily activities.

Patients cannot push up taking weight on their palm. Once the symptoms have become intrusive and cannot be managed using non-surgical methods (rest, splints, analgesics NSAIDs or injections), the surgeon needs to consider possible intervention.

Surgical Options The options the surgeon may consider include advice, debridement of osteophytes, denervation, and partial excision arthroplasty. Excision arthroplasty commonly involves excision of the scaphoid and midcarpal fusion or a proximal row carpectomy. It is very uncommon, in my experience, to need total wrist arthroplasty5 or a full wrist fusion6.

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Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58 Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Authors: Joseph J Dias

Figure 1 - This radiograph demonstrates the features of a late result of a scaphoid fracture non-union. The Scaphoid Non-union Advanced Collapse (SNAC) wrist shows arthritis between the distal scaphoid and the scaphoid facet of the distal radius. The radiolunate joint and that between the proximal scaphoid and the radius is preserved. Note the hatching on the radial aspect of the proximal capitate where there is point loading. There is also arthritis between the capitate and the lunate. In this case a proximal row carpectomy is contraindicated so a scaphoid excision and a four corner fusion would be a reasonable alternative.

Denervation Denervation7 involves a careful dissection of the branches from the superficial division of the radial and ulnar nerves from the extensor retinaculum and the identification and excision of a segment from the posterior and interosseous nerves, the latter distal to the pronator quadratus8. Preoperative local anaesthetic blocks of the nerves to be divided may help identify patients who may benefit but this is not routinely done. The risks of infection on complex regional pain after surgery are very low and recovery of function is rapid, as patients do not need immobilisation in a plaster cast or splint.

The advantage is that recovery time is very short and risks are low but the benefits from this procedure are difficult to predict. At nine years 54% of patients retained benefit after such surgery and 85% of patients did not need to change their occupation7.

Debridement If there are large osteophytes on the dorsum of the radius and the contiguous part of the waist of the scaphoid these can be excised via an arthrotomy or arthroscopically to prevent osteophyte impingement. This usually improves the range of movement but relief of pain is unpredictable.

Figure 2 - This radiograph demonstrates a Scapho-Lunate Advanced Collapse (SLAC) wrist with radioscaphoid and midcarpal osteoarthritis. Note on the lateral radiograph that the lunate is tilted to face backward- the Dorsal Intercalated Segment Instability (DISI) pattern

The two common options to salvage a painful wrist with a high chance of improving symptoms and still retaining some wrist movement are the excision of the scaphoid and a four corner fusion of the mid carpal joint or alternatively a proximal row carpectomy excising the scaphoid and along with it the lunate and triquetrum.

Scaphoid excision and Four Corner Fusion When the arthritis between the scaphoid and the radius is severe and painful the surgeon can consider excising the scaphoid distal part. This therefore is an excision arthroplasty similar to a trapeziectomy. The main risk of carpal collapse into a dorsal intercalated segment instability (DISI) pattern with the lunate tilting to face dorsally is mitigated by performing a midcarpal fusion.

The articulation preserved for wrist motion is the radiolunate joint.

If this joint is involved then the surgeon must consider whether this procedure is appropriate.

This joint is usually preserved in scapholunate dissociation (SLAC) or scaphoid non-union (SNAC).

Choice

Clinicians have considered this for a SLAC or SNAC wrist because it maintains carpal height, This maintains the best length of the muscle tendon units across the wrist so there is no weakening of the muscles used to perform tasks.

So surgeons have traditionally considered this option when they have wanted to retain maximum strength in the hand9.

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Peer-Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58 Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Authors: Joseph J Dias

Advice

Patients are told that the scaphoid will be excised and the mid-carpal joint will be fused. They will be immobilised in a plaster cast for a while between six and 12 weeks.

Patients are informed that their wrist movement will be reduced and that the procedure does not restore normality. They are warned of the other risks of non-union, malalignment of the wrist joint, ulnar sided pain in addition to the usual surgical risks of infection, stiffness, algodystrophy and nerve injury. All other alternatives are discussed and a shared decision is made.

Technique

My preference is to do this procedure through a dorsal longitudinal incision centred over the middle finger ray. The extensor retinaculum is divided transversely and the stout septum between the third and fourth extensor retinaculum is divided. This allows the distal part of the retinaculum to be retracted, exposing the Extensor Pollicis Longus tendon and the tendons of the fourth compartment. These are retracted radially and ulnar-wards to expose the dorsum of the wrist capsule.

The posterior interosseous nerve is identified as it courses to the dorsum of the wrist. A onecentimetre section is excised from as proximal as the incision permits. Once the nerve is divided the radiocarpal joint is entered distal to the Lister’s tubercle and the capsulotomy extended radially to the styloid. On the ulnar side the incision is oblique through the middle of the dorsal radiotriquetral ligament towards the triquetrum and then distally for one centimetre.

The incision into the capsule then goes radially to the scaphoid and the dorsal radially based flap is elevated from the carpal bones fully exposing the mid carpal joint.

Figure 3 - This intra-operative photograph shows the scaphoid excised and the midcarpal joint stabilised with a circular plate.

The scaphoid is then mobilised and removed using sharp dissection and a periosteal elevator. The palmar ulnar corner of the scaphoid tuberosity can at times cause a problem as it is very strongly attached. Sometimes the scaphoid is large and may need to be divided using Lambotte osteotomes. Bone nibblers are used to complete the excision. When dealing with a SNAC wrist we usually retain the proximal scaphoid. The area is washed and any debris removed.

Attention is turned to the dorsal osteophytes, which are trimmed back, and the radial styloid is trimmed with osteotomes to present a rounded surface and avoid impacting on the trapezium on radial deviation.

Attention is then turned to the mid carpal joint, which is usually unaffected. The surfaces of the capitate, hamate, triquetrum and lunate are cut back to good bleeding bone using a combination of rongeurs, osteotomes and a 4 mm burr. The area is washed to remove debris, and packed with cancellous bone. We prefer to obtain good quality cancellous bone from the patient’s opposite iliac crest. This is morcellised using a bone cutter and packed into the mid carpal joint. The joints are stabilised using 1.1 mm Kirschner wires, with attention being paid to correct any dorsal tilting of the lunate. The position is checked on image intensifier.

Once a satisfactory position is obtained we prefer to hold position using a circular plate (Figure 3).

There are many alternative ways of holding the bones in position10 and the surgeon needs to be familiar with a few of these techniques.

The capsule is then closed with a few interrupted sutures. The transverse split in the extensor retinaculum is quickly closed with a running absorbable suture.

The wound is infiltrated with a long acting local anaesthetic.

The longitudinal skin incision is closed and the wrist bandaged.

We routinely apply a plaster of Paris cast on the palmar surface to immobilise the wrist.

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Peer-Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58 Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Authors: Joseph J Dias

Outcome

This procedure needs the midcarpal bones to fuse. This takes up to 12 weeks and the wrist requires immobilisation in a plaster slab or wrist support. It requires the fusion of normal joints; around 5% of cases have failure of union and may need re-arthrodesis11. It is usual to retain 60% of movement but this is not predictable and some patients can lose much more than this. Most patients retain 80% of grip strength but around 25% continue to experience some pain even after solid midcarpal fusion.

Salvage for a failed four-corner fusion is a total wrist replacement or a total wrist fusion.

Figure 4 - This patient had midcarpal fusions on both sides using stout Kirschner wires. Note the solid fusion and the preservation of radiolunate joint height. Note that on the right the radial styloid has been excised to avoid impingement between the trapezium and the radial styloid on radial deviation.

The immediate aftercare is to elevate the wrist and hand for a few hours and start early exercises to recover hand and finger movement. The plaster of Paris slab is retained for a few weeks and then the wrist is supported in a removable splint. Union is assessed on radiographs at six and 12 weeks (Figure 4). Any uncertainty about union is resolved using a wrist CT scan to establish whether there is bridging bone.

Tricks and tips

There are three problems that can be avoided by attention to technical detail: 1. Range of wrist movement is retained if the DISI is corrected. So careful attention to this and checks before stabilisation using intraoperative fluoroscopy helps avoid a fusion in persistent DISI position.

2. Radial tilting of the hand can be avoided by allowing the capitate to find its neutral position and by not trying to locate the capitate into the cup of the lunate. This causes a fusion where the carpus will assume a position of radial deviation as the radiolunate ligament is rendered slack in this manoeuvre. So, as it regains its taut position, the lunate tilts radially.

3. The third problem is the pain on the ulnar side. This needs attention to ensure that the triquetrum is not fused so it protrudes towards the ulna leading to secondary impaction after the four-corner fusion.

Proximal row carpectomy This is an arthroplasty that excises not just the scaphoid but also the remainder of the proximal carpal row and includes excision of the lunate and the triquetrum.

This needs the articular cartilage on the proximal capitate and the lunate facet of the distal radius to be preserved. Low-demand patients are considered suitable for this. The concern about a proximal row carpectomy is that the carpal height is reduced thereby weakening the muscle tendon units of the long flexors and extensors of the fingers and wrist. In addition there is concern about rotational stability of the new joint. This procedure has been considered for those not needing forced grip in their daily and work activities9.

Advice

Patients are advised that they will need to protect the hand from forceful use for a few weeks. They are told that the weakness in their hands will persist and that a proportion of them will continue to have some pain in the wrist. They are also warned of weakness in tasks needing forearm rotation, such as opening doors.

Technique

The approach to the wrist is exactly the same as for four-corner fusion.

After the scaphoid and radius osteophytes are excised the lunate and the triquetrum are removed.

Care is taken to retain the radioscapho-capitate ligament when dealing with the radial styloid. The capsule closure is as before.

Tricks and tips The surgeon needs to be aware of the shapes of the capitate12.

Those with a distinct ridge are more likely to have point loading and early degenerative change in the new joint between the capitate and radius.

Aftercare The hand is elevated initially and the wrist may be immobilised in a plaster of Paris slab for the first week or so and then the wrist supported by a wrist splint. Full activities, which are not forceful, are permitted from the outset.

Radiographs are obtained and follow-up is arranged for six and 12 weeks.

Outcome

The wrist movement surprisingly does not improve significantly after a proximal row carpectomy. Once again patients usually retain twothirds their range of movement and 80% of their maximal grip strength.

However 5% need salvage surgery and around 25% continue to experience some pain, even after a proximal row carpectomy.

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Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58 Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Authors: Joseph J Dias

Salvage for a failed proximal row carpectomy is a capitate hemireplacement or a total wrist fusion.

So on the current evidence whether the patient is offered one or the other procedure very often comes down to the preference of the surgeon.

Outcomes in comparison We investigated the function of the wrist and hand after a fourcorner fusion and proximal row carpectomy and found that pain relief was comparable but the axis of wrist movement13 14 was parallel to that of the normal wrist after a proximal row carpectomy and was more vertical after a four-corner fusion. Function as assessed by the timed Sollerman hand function test15 was better and quicker after a proximal row carpectomy but tasks needing forearm rotation were more compromised after a proximal row carpectomy. We used two patient reported outcome questionnaires, the Patient Evaluation Measure16 and Michigan Hand Questionnaire17 18 . Both have been validated for wrist disorders. Patient were more satisfied, and had better pain relief and function after a proximal row carpectomy. A systematic review of the literature comparing the two techniques demonstrated no difference between the two techniques although the risk of delayed arthritis in the joint between the capitate and radius was much greater after a proximal row carpectomy19. Another study comparing the two procedures in 20 patients also found no difference20.

At six years after a proximal row carpectomy in 23 patients, patients had 61% of range and 79% of strength21. Another study in 24 patients at 10 years found similar range and strength but noted radiographic arthritis in 52%22. But at 15 years 46 of 61 patients had persistent pain and were dissatisfied and arthritis between the capitate and radius was observed on radiographs and 12 of 61 (19.6%) needed full wrist fusion23.

After midcarpal fusion 37 patients were reviewed at 8 years and had range and strength that was similar to that seen after a proximal row carpectomy but 10/37 (27%) had developed radiolunate arthritis24.

However, after either of these two procedures my clinical experience is that the need for further surgery after a successful operation is very low.

Other options: Total Wrist Fusion, Total Wrist Arthroplasty In those patients with persisting disabling pain after these motionpreserving procedures or in those where the extent of arthritis precludes these operations, the surgeon may consider a total wrist arthroplasty or total wrist fusion.

Both these procedures improve pain.

Fusion of the wrist gives more certain control of wrist pain but has a profound impact on the function of the arm6 25 26. The risks of fusion surgery are well established27. Nonunion is unlikely but complications were noted: 50 of 71 (70%) wrists fused, with reoperation to remove the fusion plate needed in 20%.

Eighteen wrists were left with permanent problems. 55 of 71 (77%) wrists fused had a stable pain-free wrist after a total wrist fusion27. Total wrist fusion is a reliable procedure but has a high problem rate and 1:4 will continue to have problems.

The other alternative is to perform a total wrist arthroplasty. Total wrist arthroplasty has evolved over recent decades and we now have experience and information on indications, techniques, complications and their salvage28-30. As our knowledge and experience of wrist arthroplasty in patients with post-traumatic arthritis increase31 32 this may become the intervention of choice especially when motion-preserving procedures fail.

Conclusion We found that patients with a proximal row carpectomy had restricted movement, but retained the dart-throwing axis. Patients having a scaphoid excision and four-corner midcarpal fusion lost the dart-throwing axis of movement. There was nearly 65% loss of area of circumduction compared to the opposite wrist.

Peak strength was similar after each of these operations. Patients reported better outcomes (PEM, MHQ) after a proximal row carpectomy but took longer to perform activities requiring forearm rotation. Based on our findings, a proximal row carpectomy is better, at least in the medium term.

If pain relief is inadequate the surgeon can consider either a wrist arthroplasty or a full wrist fusion using a custom fusion plate.

In summary, wrist salvage surgery for post-traumatic pain due to degenerative change needs to be specifically tailored to each patient.

There are many surgical options and good shared-decision-making and technical execution are the key to obtaining a satisfactory outcome.

Of the two procedures that preserve motion, the proximal row carpectomy is superior in the medium term as it retains the natural axis of wrist movement. But late reviews suggest that 1:4 cases will continue to have or develop wrist pain after either of these two common motion-preserving procedures.

References 1. Hidaka Y, Nakamura R. Progressive patterns of degenerative arthritis in scaphoid nonunion demonstrated by threedimensional computed tomography. J Hand Surg Br 1998;23(6):765-70.

2. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9(3):358-65.

3. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am 1984;66(4):504-09.

4. Moritomo H, Tada K, Yoshida T, Masatomi T. The relationship between the site of nonunion of the scaphoid and scaphoid nonunion advanced collapse (SNAC). J Bone Joint Surg Br 1999;81(5):871-76.

5. Anderson M, Adams B. Total wrist arthroplasty. Hand Clinics 2005;21(4):621-30.

6. Houshian S, Schrøder HA. Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases. J Hand Surg Br 2001;26(4):355-59.

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Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 50-58 Title: Motion-preserving salvage surgery of the wrist after a scaphoid non-union or scapholunate dissociation Authors: Joseph J Dias

7. Schweizer A, von K, Kammer E, Meuli S. Long-term followup evaluation of denervation of the wrist. The Journal of hand surgery 2006;31(4):559-64.

8. Foucher G, Da Silva JB. [Denervation of the wrist].

[French] La dénervation du poignet. Annales de Chirurgie de la Main et du Membre Supérieur 1992;11(4):292-95.

9. Dacho AK, Baumeister S, Germann G, Sauerbier M. Comparison of proximal row carpectomy and midcarpal arthrodesis for the treatment of scaphoid nonunion advanced collapse (SNACwrist) and scapholunate advanced collapse (SLACwrist) in stage II. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS 2008;61(10):1210-18.

10. Richards AA, Afifi AM, Moneim MS. Four-corner fusion and scaphoid excision using headless compression screws for SLAC and SNAC wrist deformities. Techniques in hand & upper extremity surgery 2011;15(2):99-103.

11. Unglaub F, Manz S, Leclere FM, Dragu A, Hahn P, Wolf MB. Clinical outcome of rearthrodesis in cases of non-union following fourcorner fusion. Archives of Orthopaedic & Trauma Surgery 2011;131(11):1567-72.

12. Yazaki N, Burns ST, Morris RP, Andersen CR, Patterson RM, Viegas SF. Variations of capitate morphology in the wrist. J Hand Surg Am 2008;33(5):660-6.

13. Singh HP, Dias JJ, Slijper H, Hovius S. Assessment of velocity, range, and smoothness of wrist circumduction using flexible electrogoniometry. J Hand Surg Am 2012;37(11):2331-9.

14. Singh HP, Dias JJ. How Does Four Corner Fusion Effect Circumduction of Wrist? Journal of Bone & Joint Surgery, British Volume 2012;94-B(SUPP XVIII):101.

15. Sollerman C, Ejeskar A. Sollerman hand function test A standardised method and its use in tetraplegic patients.

Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery 1995;29(2):167-76.

16. Dias JJ, Bhowal B, Wildin CJ, Thompson JR. Assessing the outcome of disorders of the hand Is the patient evaluation measure reliable, valid, responsive and without bias? The Journal of bone and joint surgery. British volume 2001;83(2):235-40.

17. Chung KC, Hamill JB, Walters MR, Hayward RA. The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to clinical change. Ann. Plast.

Surg. 1999;42(6):619-22.

18. Dias JJ, Rajan RA, Thompson JR. Which questionnaire is best? The reliability, validity and ease of use of the patient evaluation measure, the disabilities of the arm, shoulder and hand and the michigan hand outcome measure. The Journal of hand surgery European volume 2008;33(1):9-17.

19. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur Vol 2009;34(2):256-63.

20. Bisneto EN, Freitas MC, Paula EJ, Mattar R, Jr., Zumiotti AV. Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study. Clinics (Sao Paulo, Brazil) 2011;66(1):51-5.

21. Tomaino MM, Delsignore J, Burton RI. Long-term results following proximal row carpectomy. J Hand Surg Am 1994;19(4):694-703.

22. Richou J, Chuinard C, Moineau G, Hanouz N, Hu W, Le D. Proximal row carpectomy: long-term results. Chirurgie de la main 2010;29(1):10-5.

23. Ali MH, Rizzo M, Shin AY, Moran SL. Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up. Hand 2012;7(1):72-8.

24. Kitzinger HB, Löw S, Karle B, Lanz U, Krimmer H. The posttraumatic carpal collapse--long-term results after midcarpal fusion.

Handchirurgie Mikrochirurgie plastische Chirurgie : Organ derDeutschsprachigen Arbeitsgemeinschaft für Handchirurgie : Organ derDeutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie derPeripheren Nerven und Gefässe : Organ der Vereinigung der Deutschen 2003;35(5):282-87.

25. Field J, Herbert TJ, Prosser R. Total wrist fusion. A functional assessment. J Hand Surg Br 1996;21(4):429-33.

26. Meads BM, Scougall PJ, Hargreaves IC. Wrist arthrodesis using a Synthes wrist fusion plate. J Hand Surg Br 2003;28(6):571-74.

27. Zachary SV, Stern PJ. Complications following AO/ ASIF wrist arthrodesis. The Journal of hand surgery 1995;20(2):339-44.

28. Adams BD. Total wrist arthroplasty. Techniques in hand & upper extremity surgery 2004;8(3):130-7.

29. Adams BD. Complications of wrist arthroplasty. Hand Clinics 2010;26(2):213-20.

30. Krukhaug Y, Lie SA, Havelin LI, Furnes O, Hove LM. Results of 189 wrist replacements.

A report from the Norwegian Arthroplasty Register. Acta Orthopaedica 2011;82(4):405-9.

31. Levadoux M, Legré R. Total wrist arthroplasty with destot prostheses in patients with posttraumatic arthritis. The Journal of hand surgery 2003;28(3):405-13.

32. Nydick JA, Watt JF, Garcia MJ, Williams BD, Hess AV. Clinical Outcomes of Arthrodesis and Arthroplasty for the Treatment of Posttraumatic Wrist Arthritis.

The Journal of hand surgery 2013;38(5):899-903.

Correspondence: Prof. J J Dias Clinical Sciences Unit, Off Ward 11 Leicester General Hospital Gwendolen Road Leicester LE5 4PW Email: jd96@leicester.ac.uk

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The Community Musculoskeletal Service Cathy Lennox FRCS(Orth)Ed, Consultant Orthopaedic Surgeon Atle Karstad MBA, BSc Hons, MCSP, HPC, Consultant Physiotherapist

After retirement from a full-time Consultant post in Trauma and Orthopaedics, I have spent the past 5 years in what has been, for me, an entirely new venture: as Clinical Lead/Adviser in a community MSK service.

Working with a batch of enthusiastic, competent and highly professional nonmedical professionals has been a privilege and an ‘eye-opener’. I recognise the potential for the huge benefit it offers to the patients, the GPs and most of all to the Orthopaedic secondary care teams, in addressing the overwhelming work-load, by sharing that load and ensuring the patient is seen by ‘the right person, at the right time, in the right place’.

Improving the pathway for Orthopaedic patients: A model of care developed in the North Tees and Hartlepool NHS FT Background The term ‘Musculoskeletal’ (MSK) entered common parlance only recently, and represents the wide spectrum of conditions affecting the soft tissues, skeleton and joints; all age groups and causes; and includes systemic diseases.

The percentage of MSK cases on GPs’ workload is 30% (and 50% in over 75 year olds).1 Until the introduction of multiprofessional services, GPs had little alternative other than to refer all of this wide spectrum to the Orthopaedic Service, which was therefore overloaded; cases who were most in need of Orthopaedic specialist attention were often significantly delayed.

A framework for the delivery of Musculoskeletal Services was published by the Department of Health in 2006.2

Cathy Lennox

It described the extensive and multi professional (and often disparate) provision of care across primary and secondary care.

Specifically, it acknowledged the problem of access to specialist Orthopaedic and Rheumatology services, in providing timely assessment, investigation and treatment for appropriate cases, within this ever-increasing spectrum of MSK conditions.

Since its publication, demand for MSK services has continued to increase; therefore the need for reliable, robust, consistent, and effective referral patterns and clinical pathways is now all the more pressing to ensure that patients are directed to the most appropriate professional without a lengthy wait and without duplication of effort.

Professor Briggs’ recent report ‘Getting it right first time’ (2012) emphasises the fact that low priority is afforded to training at Medical School in musculoskeletal conditions (maybe as little as 5 weeks during under-graduate training), and indeed this is also true of junior doctor Foundation Training.1 Consequently, in General Practice, there has been a reliance on referral into secondary care for all manner of MSK problems, both surgical and non-surgical.

As a result, a large number of such referrals to a specialist Orthopaedic clinic are considered of ‘low value’ (43%) in terms of their suitability for specialist (including surgical) involvement.2 As a consequence, the secondary care Orthopaedic out-patient service is heavily over-subscribed; patients and their referring GPs have become resigned to lengthy waits for first appointment, which is then often rushed, with inadequate time for explanation and discussion. Then there is a further wait for imaging investigations and frequently only then a forward referral; and yet another wait for those who need a more appropriate professional e.g. physiotherapist, podiatrist, pain management team etc. It is frequently impossible to achieve the 18 week referral-totreatment target.

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Therefore, the process may be considered of ‘low value’ by the secondary care team, but even more so by the patient and GP! A majority of such cases are managed far more effectively by Allied Health Professionals and so the design of a comprehensive MSK service ought to centre on a community-based ‘hub’ for referrals, where triage is applied, and the patient is allocated to see the most appropriate professional, in a multidisciplinary team and, where indicated, referred to specialist secondary care. This ensures that the expertise of the Orthopaedic Surgeon is accessible to the most appropriate cases, i.e. those for whom experienced assessment, diagnostic skills and surgical input are indicated.

It is also important that we in the Orthopaedic Surgery profession accept that it is not necessary for us to see all MSK referrals but to recognise and acknowledge the skills and experience of other professions.

Referral pathways Many attempts have been made to design referral pathways which would be seen as “user-friendly” by the referring GP clinician, and therefore likely to be adopted nationally.

The fact that there are no universally-accepted MSK referral pathways is a reflection of many factors: lack of consensus amongst clinicians, and the involvement of so many sub-specialty teams who require their own pathways. Not the least of the factors is the demand on GPs’ time, overwhelmed as they are with requirements relating to targets, preventive medicine and of course referral pathways produced by every other secondary care specialty!

Thus, in order to bridge the divide between Primary Care and achieving timely advice, treatment and forward referral as required, there is a strong case for harnessing the skills and experience of senior physiotherapists and other allied professionals in a Communitybased MSK service.

Nevertheless, it is still of vital importance to continue to develop such formal pathways and to integrate them into seamless clinical pathways from primary to secondary care. Hopefully the introduction of Clinical Commissioning Guidance will prove useful in that respect.

The Development of a Community MSK Service Several models of a community MSK service have emerged in the UK, with the aim of improving the quality of those referrals into secondary care: The role of the GP with a special interest (GPSI) – was developed as a means of providing MSK expertise in the community, and it has been very successful in some areas, especially in areas of large population density, where patients can travel a short distance to an MSK service staffed by GPSIs. The role was also intended to provide credibility to the MSK service and attract other practices to refer. There are obviously training and cost issues.3 Some General Practices have been able to allocate responsibility for MSK patients to one GP per practice (some of whom have completed formal GPSI training).

Employing a physiotherapist within a practice is a popular move with GPs and with patients but has proven difficult to sustain.

A musculoskeletal triage service (MTS) may be staffed by physiotherapists and/ or GPSIs, and their main role is to decide on the most appropriate forward referral.

Others CAS, CATS, ITC etc.

All of these options have training and cost-effectiveness issues and may delay the forward referral for those needing specialist care.2

The Community Musculoskeletal Triage, Assessment and Treatment Service North Tees and Hartlepool NHS FT serves a population of 360,000.

This MSK service was initiated as a small pilot in a GP surgery nine years ago and has developed into its present form, which is a multiprofessional service located centrally in Community Health Centres (on two sites to serve the two towns of Stockton and Hartlepool).

The service developed in The North Tees and Hartlepool Community Directorate of the FT differs from other models in several important respects: The harnessing of the skills and experience of senior physiotherapists and other allied professionals is the key to its success.

The members of the team were all already employed within the Trust and have now re-located centrally within the Community Health Centres. This is an ideal scenario to allow interprofessional working. These existing Physiotherapy and Podiatry staff were recruited onto the preceptorship programmes to take on the extended role.

Their role is far more than simply triage.

The following is a description of the process of referral into the service from the GP: GPs are offered the option of referral directly to the Community MSK service rather than to Orthopaedics in Secondary Care.

All referrals (most of which are now made electronically) from GPs to the Community MSK service are read immediately by one of a team of Extended Scope Practitioners – (ESP Physiotherapists Band 7, and Highly Specialised Podiatrists, HSP, Band 7) and depending on the content of the referring information, the patient is allocated to one of the triage options below (if referral information is inadequate then direct contact is made with the referring GP to request more specific information). Of critical importance is that these professionals are very well able to recognise a ‘red flag’ and that they should refer such cases immediately to secondary care by direct communication.

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Triage options 1. Consultant Physiotherapist Mr Atle Karstad: who has an overseeing and mentorship role, and also has his own clinical workload within MSK. Cases with a more complex history are often triaged to his clinic. He has responsibility for the education programme within the service and has been involved in research at the University of Teesside.

He is also responsible for the selection of senior professionals to undertake the preceptorship programme for the ESP role.

2. ESP physiotherapist (band 7): for assessment, investigations, treatment plan including injection techniques and subsequent forward referral to Orthopaedics or Rheumatology if and when required and without delay.

There are core physiotherapy staff on site to whom the ESPs can refer patients for specific courses of treatment.

3. ESP physiotherapist – Joint Replacement: These ESPs assess potential THR/TKR patients, and for those who meet the criteria, liaise with a Senior Sister from the secondary care team who does a clinic in the Community Clinic weekly and who does the initial pre-assessment work and then allocates that patient to an appropriate lower-limb arthroplasty clinic in Secondary Care.

4. HSP Podiatrist: including biomechanics, gait analysis, treatment plan including injection techniques, orthotics made on site.

5. ESP Paediatric Physiotherapists who work with infants and up to 16 years old, for advice, reassurance and treatment as required and, where indicated, liaise directly with Paediatric Orthopaedic teams at the specialist centres in the North East.

6. HSP Paediatric Podiatrists have their own patients from the triage process, and also share the care of many cases with the ESP Paediatric Physiotherapist. They have access to the orthotics laboratory on site for simple inserts and appliances; and to the Orthotist who has a clinic within the service once weekly for more elaborate work and for bespoke footwear.

7. ESP Hand Physiotherapists.

8. Consultant Hand Surgeon (weekly clinic held in conjunction with the Hand ESPs who also have their own clinics).

9. Triage may refer directly to secondary care if indicated by referring information.

10. Counselling Psychologists are part of the team and available to take referrals from the ESP/ HSP staff.

11. Orthotist who has a clinic once a week and takes referrals from the Podiatry or ESP teams for bespoke shoes and supports (adults and children).

12. Podiatric Surgeon: a full team of Podiatric Surgeons, Senior Podiatrists with access to a fully equipped and staffed Community Operating Theatre is well established on site; receiving referrals directly from GPs as well as from the MSK Podiatry team.

Immediately after triage, the patient is contacted and offered an appointment within 2-4 weeks (on a date agreed between patient and clinician).

The initial appointment of 40 minutes involves history, assessment, clinical examination and a treatment plan outlined.

X-Rays are performed on site at the first attendance and can be viewed by the ESP electronically (a subsequent Radiologist’s report is viewed as soon as it becomes available). Further imaging e.g.

Ultrasound and MRI scanning, can be arranged by the ESP and the reports are shared with the patient at a review appointment shortly after. If haematology, biochemistry and immunology blood tests are ordered by the ESP/HSP, bloods are taken by trained HCAs and results available for ESP to review electronically within few days.

If the treatment plan includes a course of physiotherapy treatment, this is provided on site by the core physiotherapy team (Band 5).

Injection techniques into joints/soft tissues are performed as required by suitably trained ESPs/HSPs either at the first appointment or in a designated injection clinic within the MSK service. A strict protocol for consent and aseptic technique is followed.

Review by the same ESP/HSP is arranged to discuss test and X-ray results and reports and to assess progress.

Internal referral to other ESPs is common e.g. ESP Physiotherapist to Biomechanics; ESP Paediatric Physiotherapist to HSP paediatric podiatrist; ESP to Clinical Psychologist, etc.

Some of the ESP Physiotherapists have a regular contribution to Specialist Orthopaedic clinics in Secondary Care (e.g. joint replacement, knee injury, shoulder and spine); an excellent mutual learning experience; and an opportunity for the ESPs to discuss with Orthopaedic staff any unusual cases they have seen in the Community setting.

This also allows Orthopaedic surgeons to update the ESPs but also to appreciate the skills and techniques that the physiotherapy/ podiatry staff offer.

Other members of the team Podiatric technicians who are trained in the manufacture of custom-made orthotics, made in a laboratory on site.

HCAs who act as phlebotomists, chaperones, clinic support and assistants in injection techniques and theatre assistants.

Administration staff (12 team members)

Clinical Governance There are regular clinical audits performed, some in conjunction with the Secondary Care teams.

These include: Infection control issues Injection technique training and audit Consent audit Patient satisfaction surveys regularly performed; results discussed and acted upon Case notes audits (there are no paper case notes, records are kept electronically)

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Basic Life Support training and updates for all staff and Intermediate Life Support training with regular updates for staff involved in any invasive techniques, e.g. injection work.

Teaching sessions with clinical presentation and Case reviews

Performance data The success and efficacy of this model can be demonstrated by monitoring throughput numbers, the numbers seen treated and discharged from the MSK service, and the numbers referred on to secondary care.

Future Developments There are obviously teaching opportunities within this service For GPs For undergraduate medical students and FY doctors.

The Band 7 Physiotherapy and Podiatry staff are very experienced in doing a thorough assessment at the initial visit. Their history-taking and clinical examination skills are very competently done and present an opportunity for students to refresh and/ or learn those skills in an unhurried situation.

Conclusion

The benefit to the secondary care Orthopaedic Service

This model of care addresses the issue of service provision by acknowledging the competence and potential of senior AHPs.

is very significant, ensuring that cases sent on to Orthopaedics (after initial assessment and investigation in the MSK service) are appropriate, as evidenced by the high conversion rate to surgery.

Since the patient has had imaging and other investigations already done in the MSK service, the Orthopaedic Surgeon may be in a position to make a treatment plan at the first visit, including a surgical procedure if appropriate, so the patient’s name may be entered onto the waiting list without delay.

There are fewer steps in the care pathway, and referral-to-treat times are improved.

It effectively identifies which cases are unlikely to need a surgical opinion or intervention and allows those to be assessed, investigated and treated within the MSK service.

The benefit to the GP is the provision of an option for referral of those cases where it is unclear whether Orthopaedic Surgical opinion is necessary or for chronic and long-term conditions, or where there is no useful referral pathway.

The GP will still refer directly to Orthopaedics those cases where the diagnosis is clearer.

The benefit for the patient is that it provides timely access (four weeks) to an appropriate professional competent in assessment, examination, investigations and arrangement of a treatment plan, including followup. Patient satisfaction levels are very high, particularly as their care pathway starts within four weeks; they see the same professional at each subsequent visit.

Advice for others considering setting up such a service is that it requires the existing staff of allied health professionals to be re-located to work in a team and that may take some time to set up, as well as suitable premises, and that gradually the critical mass of staff to meet the demand will be assembled. The extended role of the AHPs is of great importance and a preceptorship programme with University backing will be needed. Strong clinical leadership will ensure support and guidance for the staff and credibility amongst the referring GPs.

An essential requirement is to have the support and clinical advice provided by members of the Consultant Orthopaedic staff from secondary care to ensure good liaison and contribute to the teaching programmes.

The cost of setting up such a service is minimal in terms of staff costs other than the training for the extended role and appropriate re-banding.

In terms of cost effectiveness, the MSK service is well-supported by the Clinical Commissioning teams, based on GPs’ confidence in the service and outcomes but, also the comparison of the salary of a Senior Physiotherapist with that of a Consultant Surgeon.

The recently published Clinical Commissioning guidelines emphasise the need for commissioners to expect an integrated service. This service represents a reliable and costeffective means of achieving that, and will provide commissioners with confidence in recommending the use of the Community MSK service.

Figure 1 - Referral patterns from GPs in the North Tees and Hartlepool catchment area to Orthopaedics and into MSK - 3 year trend

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The proportion of GP referrals to Orthopaedics and to MSK is shown, with some annual variation, but the latter service may see an increase in referrals as it attracts more confidence from GPs in its present format. Of the numbers referred from GPs to MSK, those subsequently referred to Orthopaedics for specialist attention is an average of 16.6%. Therefore, the other 83.4% are seen within 4 weeks of referral, investigated and treated in MSK, and discharged from there. These are cases which would otherwise have added to the numbers waiting for an initial Orthopaedic assessment.

Figures 2 to 4 show the referral and surgery rates for GPs and the MSK service. There is a higher conversion (average 76%) amongst those who had been referred initially for MSK assessment before referral to Orthopaedics. Those referred directly to Orthopaedics have a conversion rate to surgery of 55%. A large proportion of those referred directly from GP to Orthopaedics are not subsequently selected for a surgical procedure, i.e. many could have been more appropriate for initial assessment by the MSK team.

Figure 2 - The numbers of patients referred by GPs to Orthopaedics and the numbers converting to surgery.

Figure 3 - The numbers of patients referred by MSK to Orthopaedics, and the numbers converting to surgery.

References 1. “Getting it right first time” Prof T.W.R. Briggs 2012 2. A Framework for the delivery of Musculoskeletal Service Department of Health 2006 3. Department of Health Briefing Paper “An assessment of the clinical effectiveness, cost and viability of NHS General Practitioners with Specialist Interest (GPSI) services.” – Department of Health 2006

Figure 4 - The comparison between conversion rates to surgery in the 2 groups

Correspondence: Ms C M E Lennox Email: JMCMEL@aol.com

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Femoro-acetabular Impingement: A Reflection Richard E Field PhD FRCS FRCS(Orth) Professor of Orthopaedic Surgery, St George’s University of London Director of Research, The South West London Elective Orthopaedic Centre Consultant Orthopaedic Surgeon, Epsom & St Helier NHS Trust

Earlier this year, a well-known figure from the popular music world cancelled the 21date, US leg, of her world tour in order to undergo surgery to repair a labral tear, of her right hip joint.

Ten years ago, a labral tear was an almost unknown diagnosis. It was certainly not recognised outside a small clique of orthopaedic surgeons. Its pathogenesis was unknown. It was not clear whether a torn labrum was a clinical problem. There were no recognised strategies for treating the condition and no-one had proven that surgical intervention would be advantageous. So how is it that, in less than ten years, an orthopaedic curio has developed into a major show-stopper, a condition that is familiar to the mainstream press and one that can be treated with increasing confidence?

We know that a healthy hip must satisfy the conflicting requirements for movement and stability. The forces and strains on the hip depend upon the size, shape and orientation of the articulating surfaces, the balance and strength of the surrounding soft tissue envelope, body morphology and the activities that an individual undertakes. The interplay of these variables makes every hip a unique structural and stress environment. The rim of the acetabular socket, known as the labrochondral complex, augments joint stability and helps retain synovial fluid between the bearing surfaces2,3,4,5 (Figure 1).

Richard E Field

Figure 1 - The labrochondral complex.

Over a lifetime, the human hip will be subjected to over 200 million loading and movement cycles. This equates to walking more than two circuits of the earth’s equator. Any structural incongruity or instability between the femoral head and acetabular socket will stress the labrochondral rim and initiate a damage cascade that results in degenerative joint disease.

In July 2005 the British Journal of Bone and Joint Surgery published an article, from Ganz’s team in Berne. The title of the article was ‘Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip6. If I were selecting my ten ‘Desert Island’ papers, it would be near the top of the list.

Publication of this article was the tipping point that disseminated the concept of femoroacetabular impingement (FAI) from a small group of hip specialists to the wider orthopaedic community and beyond. I first saw the paper a few months before its publication and subsequently wrote a ‘further opinion’ piece for the JBJS’s online version7. Being anxious not to make a complete idiot of myself, I spent a long weekend reading papers that Ganz’s team had published in the preceding few years8,9,10,11.

It was one of those occasions when you realise that if you’d only been a bit less lazy and read the papers being written by the thinkers of the orthopaedic world you wouldn’t have missed out on one of the most important discussions to occur during your career.

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Sponsored Content

Joint decision: Why collaboration is key to the future of orthopaedic procurement Deliver cost savings or ensure clinical choice?

Traditionally, this has been a decision that NHS trusts have had to make in response to the government’s public sector austerity programme and commitment to driving improvements in patient care. However, greater collaboration between trust procurement departments and clinicians throughout the product procurement process, as well as closer links with procurement intermediaries such as NHS Supply Chain has shown that trusts are realising they can achieve both.

The Department of Health’s Procurement Strategy, launched back in August, highlighted orthopaedics as one clinical area with huge potential for efficiency savings. The strategy states that up to 40 per cent of the cost of orthopaedic supplies is associated with ‘costs to serve’ such as consignment stock and sales support staff – more than twice the profit margin of many other clinical products . The message from the Procurement Strategy is both logical and clear; things must change.

The greater use of procurement intermediaries such as NHS Supply Chain and the development of more focused and committed relationships between them and trusts is cited in the strategy as a crucial tool in driving efficiency savings across the NHS. NHS Supply Chain has already started to develop such relationships with trusts across the supply of orthopaedic products with some outstanding results – such as achieving total savings of over £450,000 at County Durham and Darlington NHS Foundation Trust (CDDFT) over two years.

CDDFT is one of the largest integrated care providers in England. In early 2012, the trust looked to achieve cost efficiencies across their orthopaedic procurement and decided to work with NHS Supply Chain using the mini-competition process.

With a focus on achieving improved savings whilst maintaining the status quo in terms of product choice, NHS Supply Chain worked with the procurement and clinical teams within the trust to secure a lower pricing structure across the range of hip and knee products available, within just a three month window. The initial mini-competition has so far achieved revenue savings of over £220,000 for the trust orthopaedic department alongside improved supplier relationships for the future.

Fast forward one year and CDDFT identified the potential for further savings by reviewing the procurement of knee joints on contract. Due to the success of the previous mini-competition process, the trust approached NHS Supply Chain once again to use their procurement leverage to negotiate more competitive pricing with suppliers.

“Delivering savings and clinical efficiency were once again the main drivers behind this choice” explains Lindsay Harris, Procurement Specialist at CDDFT. “Clinical staff from the orthopaedic department and the procurement team worked alongside NHS Supply Chain to identify requirements and develop a bespoke mini-competition that successfully delivered savings to CDDFT of almost £230,000 over a 12 month period. This was great news, and we’ll be looking to follow suit with hip implants in the near future.”

As the work with CDDFT clearly demonstrates, significant savings across orthopaedic departments are possible if trust clinical and procurement teams work together to identify the best products for delivering the best patient care. Working with procurement intermediaries such as NHS Supply Chain to secure the best pricing on these products with suppliers is the final piece of the puzzle.

With the DH Procurement Strategy setting a clear path for the future of NHS procurement, success through collaboration is arguably the only way forward.

Visit NHS Supply Chain at the BOA Annual Congress 1-4 October 2013. Stand 118 (Hall 3) Follow us on Twitter for updates @nhssupplychain

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Figure 3 - Labral compression and ‘wave sign’ articular cartilage delamination caused by ‘pincer’ type impingement

Figure 2 - Labral eversion, labrochondral splitting and articular cartilage damage caused by ‘cam’ type impingement

I realised that Ganz’s group was creating a vocabulary that would allow us to visualise and describe mechanisms by which the hip can become damaged. Once the concepts were grasped, it seemed so obvious and somewhat bizarre that we hadn’t got it sooner. This was eight years ago. A mere blink in orthopaedic history. Yet, in just a few years, the management of pre-degenerate hip disease has been transformed. Surgeons specialising in joint preserving hip surgery have developed a range of new surgical techniques and people from all walks of life can be treated successfully, with minimal soft tissue trauma.

What is a labral tear and why do they occur?

Most orthopaedic surgeons are familiar with meniscal and labral pathology in the knee and shoulder.

In the hip, ‘labral tear’ is a succinct term that is accepted by patients and the media. However, it is an oversimplification that may hamper our understanding of labral pathology.

The labrochondral complex can be damaged by compression (being squashed), tension (being stretched) torsion (twisting) and shear (sliding) forces. The combination of stresses on the labrochondral complex differs for a degenerate hip, a dysplastic hip, a cam hip and a pincer hip.

Patients with degenerate hip disease are referred for orthopaedic review with a spectrum of osseous changes; ranging from relatively mild joint thinning and early subchondral changes to complete joint space obliteration, extensive marginal osteophyte formation, subchondral sclerosis and subchondral cyst formation.

While healthcare funders may deem the degree of radiological degeneration to be an appropriate criterion for joint replacement, orthopaedic surgeons recognise that any correlation between clinical symptoms, disability and radiological changes is far from linear. Indeed, patients with evidence of advanced radiological joint degeneration often report a relatively short duration of pain. Although this phenomenon is unexplained, it is interesting to note that antero-superior labral swelling and separation is usually present in such cases. It may be speculated that entrapment of the richly innervated12,13, unstable labral segment is the cause of the patients’ increased symptoms and this would also explain why some patients experience such severe symptoms in the presence of relatively mild radiological deterioration.

In dysplasia, overload of the hypertrophied labrochondral complex provides a readily understood explanation for labral separation and the poor clinical outcome of labral resection or repair is widely recognised.

Ganz’s team proposed that FAI could occur by one or more mechanisms. In cam-type impingement, the femoral head is not round. Any segment that sits proud of the surface of rotation will bump into the socket rim. As the prominent segment passes into the joint, the labrum will be levered outwards and a grinding force will be applied on the adjacent hyaline cartilage. With time, the labrochondral junction splits and the adjacent chondral tissue delaminates or breaks down (Figure 2). As damage progresses, subchondral rim cysts develop; either by repetitive trauma or pressurised synovial fluid erosion.

In pincer impingement the femoral neck impacts upon and compresses the labrum (Figure 3).

This can occur if the acetabular socket is deep (coxa profunda), if the front of the acetabular socket is prominent (acetabular retroversion), if the femoral neck is retroverted, if the individual has sufficient ligamentous flexibility that they are able to move their joint to an osseous limited endpoint or if the joint is forced into such position.

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Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 67-72 Title: Femoro-acetabular Impingement: A Reflection Authors: Richard E Field

What can we do about FAI? As Personal Trainers, Physiotherapists, General Practitioners and Orthopaedic Surgeons become more attuned to the symptoms and physical signs of FAI lesions; our first priority is to identify whether patients symptoms will settle with modification of activities, physiotherapy or steroid injections. Professor Damian Griffin is currently coordinating the ‘UK FASHION’ study to determine a whether patients deemed suitable for surgical treatment can be treated by non-surgical means. If this proves to be the case, a burgeoning branch of Orthopaedic practice will be arrested. Alternatively, if the ‘UK FASHION’ study does lend support to the premise that surgical intervention can be advantageous, our task is to ensure that the appropriate intervention is undertaken in each case.

Plain radiographs usually signpost the type of impingement that a patient may be experiencing. The AP standing view provides an abundance of useful information including: joint space narrowing, saucil angle, centre-edge angle, subchondral sclerosis, marginal and saucil subchondral cyst formation, cross-over sign, ischial spine sign and labral calcification or ossification. Augmented by turned lateral and cross-table true lateral views it is usually possible predict the findings of further imaging studies such as MR, MR arthrograms and CT reconstructions. Plain radiographs also enable a surgeon to provide patients with rapid feedback on the structure and condition of their hips with appropriate guidance for further investigations and treatment. The value of these simple radiographic views cannot be over emphasised.

Over the last few years, a number of research groups have developed motion analysis software using CT data to analyse the geometry of a patient’s hip and compare the potential ranges of joint movement against known population norms14,15,16 (Table 1).

Such software also enables surgeons to understand the location and quantity of bone that would need to be removed to provide impingement free movement during activities of daily life (Figures 4 and 5)17.

Future refinements of these tools should incorporate the additional complexity of ambulation as well as the orientation and movement of adjacent and more distant joints.

Surgical treatment of FAI is increasing. When surgery works well, the patients are able to return to competitive sport, at the highest level18,19,20. Joint replacement cannot achieve this goal. However, we do not yet know whether such individuals are being provided with a license to further damage their natural joints or the prospect of prolonged healthy joint function.

TABLE 1 Motion Test Target

This Hip

120o 50o 60o 60o 40o 30o 50o 40o 30o 15o

106o 67o 101o 87o 36o 20o 78o 33o 12o 16o

Maximum flexion Maximum abduction Max internal rotation Max internal rotation at 30o flexion Max internal rotation at 60o flexion Max internal rotation at 90o flexion Max internal rotation at 30o flexion + 20o adduction Max internal rotation at 60o flexion + 20o adduction Max internal rotation at 90o flexion + 20o adduction Maximum extension at 15o external

Figure 4 Acetabular resection option to restore a normal ROM

Table 1: The figures in the left column show normal ranges of hip movement.

The figures in the right column are those of a patient with cam type FAI.

Figure 5 Femoral resection option to restore a normal ROM

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Peer-Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 01, Issue 02, pages 67-72 Title: Femoro-acetabular Impingement: A Reflection Authors: Richard E Field

There is growing evidence that open FAI surgery causes more iatrogenic morbidity than miniopen and arthroscopic procedures.

However, arthroscopic FAI hip surgery is not easy. To be undertaken successfully, special equipment and new surgical skills are essential. Great strides have been made to develop a community of UK surgeons with the expertise to undertake and develop FAI surgery and these individuals deserve our encouragement and support to ensure that they provide safe and effective interventions.

Most importantly, FAI affects the lives of young people whose ability to work, pay tax and play an active role in our community may be compromised by the sequelae of FAI. In the case of the popular music star, cancellation of her US tour dates meant that the concert promoters were obliged to refund some $25M to disappointed ticket holders.

References 1 www.bbc.co.uk/ newsbeat/21458325 2 Takechi H et al. Intra-articular pressure of the hip joint outside and inside the limbus. NSGZ. 1982; 56:529 - 36.

3 Terayama K et al. Joint space of the human knee & hip joint under a static load. Eng Med. 1980; 9:67 - 74.

4 Ferguson SJ et al. The acetabular labrum seal: a poroelastic finite element model. Clin Biomech (Bristol, Avon). 2000; 15:463 - 8.

5 Song Y et al. Articular cartilage friction increases in hip joints after partial & total removal of the acetabular labrum. 55th –Meeting - ORS; 2009 Feb 22 25; LasVegas, NV. Poster 1153.

6 Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip.

J Bone Joint Surg Br. 2005 Jul;87(7):1012-8.

7 www.bjj.boneandjoint.org.uk/ content/suppl/2005/06/28/87 -B.7.1012.DC1/1012.pdf 8 Ito K, Minka-II M, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset J Bone Joint Surg Br March 2001 vol. 83-B no. 2 171-176 9 Ganz, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock K. Femoroacetabular Impingement: A Cause for Osteoarthritis of the Hip Clinical Orthopaedics & Related Research: December 2003 - Volume 417 - Issue pp 112-120 10 Lavigne M, Parvizi J, Beck M, Siebenrock K, Ganz R, Leunig M. Anterior Femoroacetabular Impingement: Part I. Techniques of Joint Preserving Surgery Clinical Orthopaedics & Related Research: January 2004 - Volume 418 - Issue pp 61-66

11 Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior Femoroacetabular Impingement: Part II. Midterm Results of Surgical Treatment.

Clinical Orthopaedics & Related Research: January 2004 - Volume 418 - Issue pp 67-73

18 Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: A preliminary report.

J Pediatr Orthop 2008;28:705710

12 Kim YT, Azuma H. The nerve endings of the acetabular labrum. Clinical Orthopaedics and Related Research 1995(320):176-181

19 Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ. Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players.

Am J Sports Med 2010;38:99104.

13 Shirai C, Ohtori S, Kishida S, Harada Y, Moriya H. The pattern of distribution of PGP 9.5 and TNF-alpha immunoreactive sensory nerve fibers in the labrum and synovium of the human hip joint. Neuroscience Letters Volume 450, Issue 1, 23 January 2009, Pages 18–22

20 Singh PJ, O’Donnell JM. The outcome of hip arthroscopy in Australian football league players: A review of 27 hips.

Arthroscopy 2010;26:743-749.

14 Boone, D. C., Azen, S. P. 1979.

Normal range of motion of joints in male subjects. J Bone Joint Surg 61 (5), 756–759.

15 Roaas, A., Andersson, G. B. Normal range of motion of the hip, knee and ankle joints in male subjects, 30-40 years of age. Acta Orthopaedica Scandinavica 1982. 53 (2), 205–208.

16 Soucie, J. M., Wang, C., Forsyth, A., Funk, S., Denny, M., Roach, K. E., Boone, D. Range of motion measurements: reference values and a database for comparison studies.

Haemophilia the official journal of the World Federation of Hemophilia 2011. 17 (3), 500–507.

17 www.clinicalgraphics.com

Correspondence: Richard E Field The South West London Elective Orthopaedic Centre Dorking Road Epsom Surrey KT18 7EG Email: richard.field@eoc.nhs.uk

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Bookshelf and Letters To Editor

The JTO Bookshelf Book of the Quarter

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Letter to the Editor Dear Martyn,

Re: The Francis Report (Vol. 1, Issue 1)

My congratulations to you on producing an excellent ‘first edition’ of the new JTO.

For me, the most frightening feature of the Francis Report was the acknowledgement that a ‘culture’ had been allowed to develop whereby professional standards became subservient to the demands of ‘management’ to meet financial and political targets.

It is the primary duty of every doctor or nurse (indeed, all healthcare professionals) – from the most junior to the most senior – to ensure the safe and proper care of their patients.

It is their duty to report any concerns where the proper care of patients is put in jeopardy. In the case of juniors, this should be to their professional seniors – consultant or ward sister (now named ‘ward manager’!); in the case of seniors this must be to ‘management’. Those with the power to do so may have to insist that a ward be closed, or no new elective patients admitted, if staffing levels (both in terms of numbers and expertise) are inadequate – the safety of patients must be paramount.

If their professional advice is being ignored, they should put their concerns in writing – with a copy to the Trust Chairman, if necessary.

The profession cannot, and must not, allow the respect and trust of the public (our potential patients), which we still command, to be undermined. We must be seen to be the protectors of our patients.

Yours sincerely,

Malcolm Morrison Retired Orthopaedic Surgeon

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Š 2013 British Orthopaedic Association

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Volume 01 / Issue 02 / September 2013

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Obituaries

Sir (David) Rodney Sweetnam: 5 February 1927 – 17 May 2013 Sir Rodney was undoubtedly the doyen of Orthopaedic Surgery in his generation.

He had many talents. Foremost he was a natural, very gifted operative surgeon. He was also a pioneer in the research and management of bone tumours and a brilliant committee chairman and strategist. His sprightly manner and careful but resolute decision making were balanced by a warm and sensitive personality and a youthful sense of humour.

He was Honorary Secretary of the British Orthopaedic Association (1972-3), President (1985) and granted Honorary Fellowship (1998).

He became Secretary/Treasurer of the British JBJS Council of Management in 1975, when David Evans was made Chairman. This partnership was to last 17 years after which Rodney took over the Chairmanship. He relinquished this when elected President of The Royal College of Surgeons of England in 1995, only the second orthopaedic surgeon after Sir Harry Platt to have achieved this position.

Rodney was born into a medical family. His father, William, a graduate of Trinity College, Dublin was a well-loved general practitioner in Wimbledon. He was educated at Clayesmore School, Peterhouse Cambridge (where he was an open scholar, took a first and later was made Honorary Fellow in 2003) and The Middlesex Hospital Medical School, London. He spent two

The subsequent development of massive replacement prostheses with Professor John Scales, from Stanmore, enabled radical tumour excision to be achieved with limb salvage even in hemi-pelvectomy.

This technique was probably Rodney’s most notable achievement and one which, combined with steadily improving chemotherapy regimens, vastly improved both life expectancy and its quality.

years National Service as surgeonlieutenant in the Royal Navy where he served on the flagship HMS Vanguard. He trained under many of the great orthopaedic surgeons of the day including Wiles and Newman at The Middlesex, WatsonJones and Osmond-Clarke at the London and Seddon at the Royal National Orthopaedic Hospital. He was appointed Consultant at The Middlesex Hospital in 1960 aged 32.

Following on from Philip Wiles, Rodney continued a major interest in bone tumours. Working with Sir Stanford Cade, he demonstrated that in a series of adolescent lower limb bone sarcomas, local radiotherapy followed six months later, if free of detectable metastases, by amputation led to a similar if not slightly better survival rate (then only 20%). Thereby, untimely amputation compounding a tragic terminal illness was largely avoided. This study was awarded the Jacksonian Prize, 1967.

Sir Rodney Sweetnam

He chaired the MRC working party on bone sarcomas from 1980-85. As Consultant Adviser in Orthopaedic Surgery to the Department of Health (1981-1990), his committee recommended that all joint and other implants should be subject to a period of surveillance before general release. Had the Department implemented this, many implant failures might have been avoided, including recent ones.

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Obituaries

Lt Col Mike McErlain: 18 March 1968 – 6 June 2013

Sir Rodney Sweetnam as Royal College of Surgeons President

Under Rodney’s leadership and with adequate funds to hand, the Council of the British JBJS made the bold decision to withdraw from the College of Surgeons and become independent, setting up their own freehold premises in Buckingham Street, a decision fully justified with time. Conversely, as BOA and College President, he was keen for the BOA to remain within the College as an influential body, Musculoskeletal Surgery being the largest subspecialty.

Among his many other honours Rodney was appointed Orthopaedic Surgeon to the Queen and Royal Household in 1982, a post he held for ten years with a commitment to ensure that he was almost always available if needed.

Reputedly, when the Queen phoned him he always stood to answer. During an early visit to the Palace, some junior members of the Household secreted several valuable ornaments into his Gladstone bag which fortunately he noticed just in time before leaving.

Rodney came to love The Middlesex Hospital dearly (he insisted on a capital ‘T’ for ‘the’) and he was the central figure in organising the many Orthopaedic Department alumni or ‘Snowball’ gatherings. For him and many other colleagues it embodied the highest standards of teaching and clinical practice in a disciplined yet friendly atmosphere within its multi-specialty setting. Rodney epitomised this ethos and viewed Orthopaedics as best developed within a multi-specialty context.

Rodney was part of a close knit family. His lovely wife Pat was a nursing sister at The Middlesex and his daughter Sarah trained in nursing there. David, his son, is an established Orthopaedic Surgeon.

Rodney, always trim, kept fit by brisk walking (which included ward rounds up and down the six floors of The Middlesex) and by gardening. In ‘Who’s Who’ he described himself as a ‘garden labourer’ in deference to Pat’s horticultural talents. Her recent declining health, for which he has given her much support, greatly saddened him, second only to which was the closure of The Middlesex.

Lt Col Mike McErlain, a skilful and dedicated Army Spinal surgeon, died on the 6th June 2013. He was running the D-Day 44, an ultramarathon that he organised in support of the charity British Limbless Ex-Service Men’s Association (BLESMA) for whom he had raised in excess of £100,000 since its inception six years ago.

He was highly decorated having served with distinction in Northern Ireland, Bosnia, Iraq (during the second Gulf War) and multiple tours of Afghanistan where he had operated on hundreds of casualties including civilians and children.

He was passionate about the military and caring for soldiers.

On returning from deployment, he worked closely with Headley Court, the Army rehabilitation unit near Leatherhead. He was extremely humble and remained in awe of the sacrifices these soldiers had made.

He was also passionate about music and showcased his self taught talent on the piano and guitar at dinner parties for anyone prepared to listen. This, coupled with a keen sense of humour, made him fantastic company and a great entertainer. Despite many other passions, his over-riding passion was his family. His love and devotion for his wife Joanne, and his three children Paris (10), Venice (9) and Lucius (7) was immensely strong. He will be deeply missed by all who had the privilege of knowing and having served with him.

Born in Singapore, he subsequently grew up in Scotland and completed his medical degree in Aberdeen.

His surgical training was conducted in Wessex, Bristol, Exeter and Melbourne, Australia, following which he was appointed Consultant at Frimley Park Hospital in 2008.

He had an illustrious military career, having joined the Royal Army Medical Corps in 1989. He served with 1st Battalion The Parachute Regiment, having earned the coveted maroon beret.

Lt Col Mike McErlain

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Imprint

JTO:

BOA Executive Martyn Porter (President) Joe Dias (Immediate Past President) Tim Briggs (Vice President) Colin Howie (Vice President Elect) John Timperley (Honorary Treasurer) David Stanley (Honorary Secretary)​

Information for readers, advertisers & potential authors

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Instructions and information for authors [Note: these instructions are for general guidance; prospective submitters should consult the full instructions on the BOA website before submitting any article.]

News and feature articles Authors wishing to submit news items (of up to 250 words) or feature articles (up to 1500 words) should, before submission, contact the Editorial Team (JTO@boa.ac.uk) for confirmation that the subject matter will be appropriate for inclusion. Illustrations, such as photographs, x-rays, graphs, tables and other figures are encouraged for all articles. [Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.]

Instructional articles for the peer reviewed section The usual length of an instructional article in any one edition is up to 2,500 words. Longer articles may be edited or published in more than one part, if they can be segmented into shorter selfcontained pieces. The article must be fully referenced, and illustrations, such as photographs, x-rays, graphs, tables and other figures are encouraged.

Each instructional article is reviewed by the Editor. If judged suitable, it will be sent to three independent peer reviewers.

The Editor will then decide, based on their recommendations, whether the article should be accepted as is, revised or rejected. If revision is required, the manuscript will be returned to the author, with the reviewers’ remarks. The Editor’s decision will be final.

Copyright Agreement & Patient Identification We require the authors of articles accepted for publication to sign an Assignment of Copyright before the article can be published. The form will be sent with the acceptance email.

If a patient is identifiable from the text or any images used in an article, a consent form must be signed by the patient or their guardian/relative – these forms are available from the BOA and must be made available to the BOA on request.

Future publications JTO is published quarterly

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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. Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations. Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.

Copyright Copyright© 2013 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C Regent Court 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 608 2300

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Stephen Cannon, Simon Donell, Chris Blundell, David Hinsley, John Timperley, Mike Edgar, Philip Sell.

BOA contact details The British Orthopaedic Association 35-43 Lincoln’s Inn Fields London WC2A 3PE Telephone: 020 7405 6507 Fax: 020 7831 2676

Volume 01 / Issue 02 / September 2013

boa.ac.uk

Page 81

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Volume 01 / Issue 02 / September 2013

boa.ac.uk

Page 82

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