Journal of Trauma & Orthopaedics - Vol 3 / Iss 4

The journal OF the British Orthopaedic Association Volume 03 / Issue 04 / December 2015 boa.ac.uk

Inside

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

In our Features section you will find articles that focus on data validation, the BOA Clinical Leaders Programme and some festive fun!

For the latest updates on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is education, plus our regular “How I…” piece

News & Updates ––– Pages 02-19

Features ––– Pages 20-41

Peer-Reviewed Articles ––– Pages 42-56

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JTO News and Updates

From the Editor

Contents

Ian Winson, BOA Vice President Welcome to the December issue of JTO. There is an air of apprehension as we move into the winter months as to where will we be in the spring. Winter pressures are going to affect many units, the juniors are understandably eyeing up a fight and there is an increasing feeling that the consultant negotiations are panning out like a bad version of Groundhog Day.

JTO continues to target content which looks at our wider professional needs and skills; the guest editorship of Mez Acharya allows expression from one of our active trauma educationalists.

Looking at our front page you could speculate that this is some form of tribute to our spinal colleagues, but could it be some allusion to the “bare to the bone” health service?

Of course, the annual quiz has been carefully engineered to give you an excuse to sit aside from the festivities and do something really vital.

We move forward and having had one excellent deputy in Ananda Nanu, we have managed to target a man of experience and resolution in Fred Robinson to take over. Welcome aboard Fred!

Looking at our data is an important issue both generic and individual. Objectivity in diagnosis and coding issues are also covered.

It remains important that we increasingly take control of our orthopaedic world; we look forward to building upon last year’s successes together in 2016.

Season’s Greetings.

JTO News and Updates

02–19

JTO Features

20–41

Where Goes the BOA? Data validation in the National Joint Registry Lessons of War The BOA Clinical Leadership Programme The JTO Festive Quiz Clinical Coding Explained Over-diagnosis, overscreening & over-treatment: An Orthopaedic Problem?

The Linkmen Roadshow Project: What does good Orthopaedic Training look like on a regional level?

Expert Witness Institute (EWI) Annual Conference - 24th September 2015

20 22 26 28 30 32 34 36 38

JTO Peer-Reviewed Articles 42–57

Maximising Training Opportunities: A handy guide for Trainees and Trainers in T&O Putting the Boot In - intensive simulation based training to prepare surgical trainees for practice Severe Pelvic Trauma in the UK: the trainees experience, needs and expectations How I... maximise opportunity and efficacy with Workplace Based Assessments

In Memoriam General information and instructions for authors

42 48 52 56

58–59 60

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JTO News and Updates

From the President Tim Wilton, BOA President

In the five weeks after the Congress in Liverpool it seems to me that I was very busy. No doubt this seemed very strange to my colleagues in Derby since I was notably absent from there for the month of October! I have however been to various meetings on your behalf including the Australasian annual congresses where there was much discussion about how best to prepare for the onslaught that everyone seems to agree we are due over the next few years. This relates of course to the growing needs of musculoskeletal patients set against the diminishing funds to support them, but the solutions to these problems appear quite different in the various countries.

Tim Wilton

Despite the expenditure of fairly similar amounts of our respective GDPs on health care, the Australian system still supports a largely private and ‘item-of-service’ arrangement for orthopaedics, while the New Zealand system is a mixed economy of ‘health service’, private and compensation (ACC) based payments. The powers that be in those countries believe they cannot afford the orthopaedic services just as they do here, but intriguingly the New Zealand patients and surgeons alike seem to be able to accept a much more overt system of rationing than I think would feel comfortable to us in this country. It seems that the ethos of the NHS style provision of care is an even more ingrained part of our makeup than I might have imagined and this will no doubt govern our own ability to accept proposed changes, just as it does that of the majority of our patients.

In New Zealand there were several papers discussing ways of stratifying patients to identify those who could be allowed onto the waiting list for surgery even after they had been through triage, received conservative treatment, had been referred to a specialist and had agreed with the specialist and their family doctor that they did indeed need the proposed surgery. It is difficult for me to imagine a fair assessment system that could be developed which would adequately correct for the vastly differing needs of people with all forms of musculoskeletal disorder and rank them appropriately, much less a scheme that would do the same for all patients in all specialties requiring secondary care. It therefore surprised me considerably that the surgeons were trying to develop such a system, having found previous scores and international

scores such as the Oxford Hip and Knee scores were not up to the job. It surprised me still more that the patients there would accept with reasonable equanimity being told that they couldn’t go on the waiting list for economic reasons even though everyone they had seen had believed they needed the procedure which they were seeking.

The basis for these decisions whether they are dealt with in this way, or rather by the various methods currently used in the UK, should presumably revolve around the degree to which cost-effectiveness can be shown for whatever treatment is being considered.

Both the Australian and New Zealand meetings produced some interesting and vigorous

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debate in the area of Registries.

The arthroplasty registries are producing more and more diverse and interesting reports and while some may regard this output as no more than elaborate audit, the numbers of cases involved mean that the inferences to be drawn can often be as important as those from more formal research projects, provided suitable and careful adjustment is made to the demographic and other variables.

Research publications have sometimes recently cast doubt on the efficacy of what we do in orthopaedics, such as the ways of treating distal radial fractures, the usefulness of arthroscopy in arthritic knees and the relative values of different types of hip and knee replacement. The answer to these issues is rarely simple, however, and the view derived from a study may depend critically upon the endpoint that has been used: since there are many such end-points for each treatment and condition, it is crucial to avoid simplistic solutions.

Data are likely to be a fundamental plank upon which we fashion our practice for the future whether they be our own audit data, pure research data or those derived from government and other agencies. Data on its own, though, are not enough.

There are already plenty of data sources and we know statistics are often misinterpreted; nor are we necessarily content with the nature or accuracy of data produced by other agencies about us or our activities. The solution to this has to be to have

access to our own data, or at the very least, our own ways of checking that the data produced by others about our patients and activities is appropriate and truthful.

Surrogate outcome measures have grown up in parallel with the push for evidence-based medicine and it is crucial that we are clear in all of our dealings with politicians, regulators and purchasers that when anyone speaks of an outcome of treatments it needs to be a relevant and accurate outcome, using an appropriate measure which is validated for the problem at issue. Sometimes of course such evidence, even when based on inappropriate or surrogate end-points, may come from the medical profession and we must all guard against allowing our treatment choices to be guided by sometimes illinformed evidence. Researchers may also need sometimes to temper their enthusiasm to appear in print, when the main thrust of their argument is based on statistical association with a surrogate measure. Editors and reviewers need to be still more alert to the possibility that a paper may give erroneous or false guidance.

The BOA has moved forwards dramatically in the last few years and has taken on new and greater responsibilities for guiding and supporting professional activities in Orthopaedics. Unfortunately our resources are finite and we will struggle to develop comprehensive costeffectiveness data to support

everything that we do in the near future. Clearly we need help and there are various proposals being worked on to assist with such projects. We will undoubtedly still need to rely heavily on the help and support of the specialist societies to develop this sort of information, starting with the commonest and most effective procedures.

We have started some of these processes and some have made substantial headway. The Exec, PPC and Council have recently produced a suite of documents to allow a pilot of implementation of the GIRFT process based primarily upon arthroplasty work, since that is a major portion of our elective work and because we have much more established national sources of data with respect to arthroplasty. We all appreciate that these data are imperfect, and that any changes that are driven by the data need to be effected with sensitivity to the inadequacies of such data. The GIRFT process was initially based on a series of visits and feedback of local data.

Already in some areas changes in practice have resulted, but we will be looking carefully at how and when a similar round of visits to local hospitals can be arranged in order to assess the effectiveness of the continuous improvement process, based on those changes that have occurred, and to evaluate the concrete benefits for patient care have come out of the whole enterprise.

In this context, there are good reasons to believe that some of the practice in some areas of

orthopaedics could be improved significantly if we are able to move the less good areas in the direction of the better areas.

Monitor Report

The recent Monitor Report on elective care suggests some ways in which this might be achieved but these suggestions are all unashamedly process related and are overtly designed to save money. I believe what we should be doing professionally is identifying ways in which we can improve the clinical outcomes rather than concentrating solely on throughput. This is undoubtedly a challenge, but each unit has areas of excellence in their work and there should be no reason why we cannot disseminate these more universally.

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JTO News and Updates

Our Liverpool Experience Michael Butler, Orthopaedic Surgeon As a Home Fellow and as a trainee before that, I may be part of a small breed of stalwarts that has been to the BOA Congress annually in part or total for more than a decade, partly because of the strong links that the military has with the BOA and partly because of the content to be gleaned. I have seen the content and quality improve year on year and Liverpool was no exception for me - the team picked a great venue and colleagues and friends agreed it was a great Congress both professionally and socially.

I thought the venue handled all of the break-out sessions well and particular highlights for me were the positive weighting applied to Trauma and the OTS sessions. The tips and tricks within the revalidation sessions for Trauma were invaluable and the “avoiding

The drinks reception at the BOA Congress

Lucy Cooper, Trauma and Orthopaedic Registrar (ST7)

The Congress was held in the ACC Liverpool, central and accessible with plenty of hotels and tourist attractions nearby and registration went smoothly, without a glitch.

This year saw the introduction of an interactive app, helping to navigate congress lectures and trade stands and to provide immediate feedback during sessions. The week started with an insightful medico-legal symposium including advice from the medical defence societies and medico-legal experts on avoiding complaints, emphasising the importance of avoiding the mind-set of ‘it won’t happen to me’. The presidential lectures focused on teamwork ‘I’ll get by with a little help from my friends’, highlighting the necessary balance between following guidelines

litigation/complaints” session was interesting and informative.

The continued coverage of the NJR and outcomes make for fascinating sessions and taking part in one of the “Beyond Compliance” sessions I found to be incredibly reassuring for our patients and profession.

The trade stands all seemed to be busy and have lots going on, which I believe is a testament to the organisation and the popularity of the Congress. They provided some good opportunities to meet and sit down with colleagues, although arguably there could have been a little more seating and I chose to eat outside with friends/ colleagues/trainees most days.

Overall, I thought it was a great meeting and I look forward to seeing how Belfast 2016 can improve on it.

whilst maintaining standards and remaining true to our core function.

The Howard Steel lecture was delivered by James Ketchell, the theme being ‘push your limits’.

James described his worldwide adventures and the power of networking, summarising that when pushed from our comfort zone, wonderful things can happen. One of the highlights for me was the paediatric update on the limping child including top tips for pinning a SUFE, the role of the arthrogram and also capsular decompression. The controversial topic of ‘orthopaedics after the election’ was considered throughout the week and the possibility that there may, in the future, be a shortage of surgeons to cope with the ageing population.

The BOA social evening was held on a ‘Ferry Cross the Mersey’, dancing the night away to classic Beatles’ soundtracks and eating traditional scouse - an experience not to be missed.

James Ketchell speaking at the BOA Congress

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JTO News and Updates

Alastair Faulkner, Core Surgical Trainee (CT1)

As a Core Trainee it’s easy to feel overwhelmed by the programme on offer at the BOA meeting and tease out what’s of value for our level. I attended talks on the randomised control trials in trauma management encompassing the ProFHER, DRAFFT and AIM trials.

I imagine these will be quoted in future ST interviews and hearing the lead investigators present these trials was of supreme educational value.

Another important talk I attended was the panel on trauma and orthopaedic surgery after the general election. The standout speaker for me was Labour MP Angela Smith whose eloquence in conveying her personal

experiences in getting a total hip replacement and how it changed her life vindicated my own conviction as to why Orthopaedics is the specialty for me. Additionally, the BOTA session provided an excellent insight on how training varies across the UK providing food for thought when it comes to my own future applications. Shape of Training was a subject that perhaps could have been explored more and the current issue of Junior Doctors’ contracts was only just hitting headlines which I hope will be a topic addressed in future meetings.

The industry stands were excellent and I enjoyed testing how much

Labour MP Angela Smith [far left] on the panel for “T&O Surgery after the General Election”

force was required to tap in a ceramic head! I came away with lots of ideas for audits and research to pitch to Consultants at our local unit such as the use of Fracture Liaison Nurses, and nutritional support workers for hip fracture patients.

Overall, I found the conference varied, interesting and highly relevant to my current stage and would definitely recommend it to those early core trainees seriously considering an orthopaedic career.

The Patient Liaison Group

The BOA Patient Liaison Group actively participated in panel sessions and led a stand-alone session at this year’s BOA Congress. Both clinical and lay members presented on panels.

Navigating the NHS - Nilesh Makwana and Judith Fitch Managing Data Responsibly Judith Fitch Mapping the way forward toward T&O Commissioning - Josephine Fox T&O Surgery after the General Election - Phil Mitchell and Weng Ang Lively discussions during these panels raised issues that the PLG will continue to monitor and highlight, including:

A full session at the BOA Congress

• The positive impact of T&O procedures on patients’ lives • Increasing numbers of T&O trainees looking to leave the specialty • Decrease in the number of trainees applying within the specialty

• Seven day working and junior doctor contract issues • Increased complexity of the NHS infrastructure Our stand-alone session on Toward the Perfect Consultation included a “how-to guide” on shared decision making. Topics addressed by both patients and our clinical colleagues included consultation structure, the variety of methods needed to communicate patient information and the recording of consultations.

A lively discussion on patient consent raised questions on how and when patient consent is actually obtained.

Delegates were encouraged take this discussion back to their own areas to ensure informed consent is a part of their process.

The PLG would like to thank the BOA for (once again) inviting us to participate at the Congress. We look forward to our ever-increasing role in championing patients.

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JTO News and Updates

BOA Latest News BOA responds to NICE Trauma Guideline Consultations Over the past few months, the BOA has responded to a number of recent Trauma Guideline Consultations. These included:

• Complex fractures: assessment and management of complex fractures (including pelvic fractures and open fractures of limbs) • Fractures: diagnosis, management and follow up of fractures (excluding head and hip, pelvis, open and spinal) • Major trauma: assessment and management of airway, breathing and ventilation, circulation, haemorrhage and temperature control • Spinal injury assessment: assessment and imaging, and early management for spinal injury (spinal column or spinal cord injury) • Major trauma services: service delivery of major trauma services.

For further information about these consultations and our wider policy work in this area, please contact policy@boa.ac.uk.

Become a BOA Clinical Champion

CCGs value clinical engagement and working with CCGs is critical to improve patient care. As a result of this, we are pleased to report that approximately 33% of acute trusts in England now have a BOA Clinical Champion. BOA Clinical Champions represent individual trusts and hospitals, and work alongside BOA Regional Advisers to engage with CCGs. Our network is growing in strength and has had success across the country.

If you are interested in becoming a BOA Clinical Champion please contact policy@boa.ac.uk with details of the trust or hospital you would be representing.

There is no formal time commitment to the role. We simply ask that you make contact with your local CCGs to understand their plans for T&O and highlight the BOA’s Commissioning Guidance Documents in the first instance.

Following your initial contact, it will become apparent how much engagement is needed.

National Tariff 2015/16: BOA, Monitor and NHS England provide joint statement

On the 11th September 2015, the BOA released a joint statement with Monitor and NHS England stating that Monitor, NHS England and the BOA were holding “ongoing discussions about relative prices in orthopaedic services” and that “The BOA, Monitor and NHS England were committed to improving the whole process of tariff setting and delivery for orthopaedic services”.

For a full copy of our statement, please visit the BOA website www.boa.ac.uk/latest-news/joint-statement-between-boamonitor-and-nhs-england.

NHFD and NJR Annual Reports Available Both the NHFD and NJR recently published their annual reports, which are available at www.nhfd.co.uk and www.njrreports.org.uk. The NHFD has also published hospital dashboard PDFs regarding hip fracture care for the first time, which are available at the same link.

BOA attends Commissioning in Healthcare 2015

We recently attended Commissioning in Healthcare: an annual conference targeted primarily at commissioners to share best practice and policy updates. This year the conference was organised in association with NHS Clinical Commissioners, the independent membership body for CCGs which boasts over 86% of CCGs being members.

At the event we learned that NHS Improvement, the new body formed between a merger of Monitor and the NHS Trust Development Authority, will aim to apply all competition and pricing legislation as flexibly as possible to support improvements in patient care. Pricing reform will also be a key priority for the new body, to help support the new care models outlined in the NHS Five Year Forward View.

The event also included a valuable session led by NHS Right Care, an NHS England programme to reduce variation and improve patient care. The session warned CCGs not to justify away variations in treatment rates and to avoid using financial indicators as way to identify care pathways to review. Most importantly, NHS Right Care stressed to commissioners that, on the subject of optimising care pathways, that ‘the specialists own the answer’. This last point is particularly exciting given the BOA’s upcoming work to review its Commissioning Guidance Documents.

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Department of Health Consultation on Tariff Objection Thresholds The BOA has responded to a recent Department of Health consultation on proposals which would have made it harder for providers to object to the National Tariff. The BOA argued that the ‘share of supply’ objection threshold, which accounts for the total ‘market share’ objecting providers hold, should remain in place, contrary to the Department’s proposals. The BOA’s view is that ‘share of supply’ gives due consideration to larger providers that often undertake more expensive procedures.

Most importantly, however, the BOA stressed that improved engagement with T&O surgeons was essential to improve Tariff and reduce the likelihood of future objections.

The Atlas of Variation

The Atlas of Variation 2015 was recently released and recognises the extent of variation it highlights for hip replacement surgery.

This variation warrants further investigation to ensure patients are given the right treatment, in the right place, at the right time so as to maximise patient outcomes and efficiency in the NHS. The BOA recommends that commissioners identifying high or low rates of orthopaedic interventions in their areas seek clinical guidance from local surgeons, the BOA and the wider MDT to examine this data in the context of a review of relevant care pathways.

Consultant Outcome Publication At the time of this issue going to press, preparations were well underway for the 2015 round of Consultant Outcome Publication, with a planned publication date of 30th November. The published information, covering joint replacement, will appear at the www.njrsurgeonhospitalprofile. org.uk website and through NHS Choices/myNHS. The previous information will be refreshed with the new year of data and a small number of additional indicators added.

These additional indicators are for case-mix information at surgeon level - previously it was thought that surgeon compliance rates would be included in this round but this is still under review.

BOA National Clinical Leaders Programme 2016-2017

The BOA has launched a new leadership programme: The BOA National Clinical Leaders Programme. The first cohort of 25 orthopaedic surgeons has started.

The aim of the programme is to:

The Robert Jones 2015 Golf Day The Robert Jones 2015 Golf Day was held on Monday 14th September at Caldy Golf Club, Wirral. The BOA would like to thank John Ireland for his sterling organisation on the day and his continuous support. The day got off to a wet start with heavy rain but midway through the morning the sun came out and it was a really enjoyable day in Liverpool.

Twelve golfers took part in the golf but it was Marshall Sangster a Trainee member of the BOA, based in Bristol, who won the golf. Marshall was presented with the Robert Jones Silver Golf Trophy by CEO, Mike Kimmons. The next Golf Day will be held in Belfast 2016 - the “Save the Date” for your diary is Monday 12th September. The online registration for the Golf Day will be made available on the website at the beginning of April 2016.

BOA statement on the proposed new junior doctor contract The BOA shares the concerns surrounding the new contract for all junior doctors in England and the effect this will have on our already over stretched workforce. The planned proposals would risk creating a challenging work environment and significantly compromise the training and education needs of our doctors. Please read the full statement on the BOA website www.boa. ac.uk/latest-news/boa-response-to-the-proposed-new-junior-doctor-contract.

• Develop current and future Orthopaedic Consultant leadership capability for the NHS • Accelerate service transformation and quality improvement within and across trauma and orthopaedic services We are now recruiting for the 2016-2017 intake: The programme is open to senior trainees, SAS surgeons and new consultants (all those who have become fellows in the last two years). Many of the fellowships are part funded by host trusts, and specialist societies. Details about the programme, its application process and access to the online application form can be found on the BOA website www.boa.ac.uk/training-education/boa-nationalclinical-leaders-fellowships-programme or by contacting policy@boa.ac.uk.

BOA provides input into Monitor report

Monitor published a report to assist NHS providers to improve productivity in elective care. The BOA is a co-signatory to the report’s foreword as we fully appreciate the scale of challenge faced by the NHS. Indeed, for some time now the BOA has been actively reshaping trauma and orthopaedic practice to ensure that our patients receive the best levels of high quality care within a sustainable NHS. Monitor’s report quite rightly sets challenging, world-leading standards of care, and it also recognises the high performance of many hospitals within the UK NHS. The full report can be downloaded from the BOA website www.boa.ac.uk/latestnews/monitor-helping-nhs-providers-improve-productivity-in-elective-care.

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JTO News and Updates

BOA Membership Benefits BJJ and BJ360 offer for SAS surgeons We are pleased to offer SAS surgeons a subscription to the Bone and Joint Journal for 2016. All SAS surgeons (new and current members) will receive a personal subscription to the Bone and Joint Journal and Bone and Joint 360 (print and electronic access) for 2016. New SAS members must join the BOA before 31st March to qualify. From January 2017 all SAS members can continue to receive the BJJ and BJ360 at a reduced rate of ÂŁ43, incorporated into your BOA membership fee. More details can be found on our website www.boa.ac.uk/membership/ bone-and-joint-journal.

Virgin Atlantic offer for AAOS Conference attendees Are you attending the AAOS conference in Orlando from 1st-5th March 2016? Fly with Virgin Atlantic Airways and receive a special online discount rate of 5% off flights to Orlando and Miami from London and Manchester. Book your AAOS flights at www.boa.ac.uk/ membership/virgin-atlantic.

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BOA Instructional Course 2016 9th-10th January - Final places remaining!

The key focus of the 2016 Instructional Course will be on paediatrics and trauma, and trainees will have the opportunity to gain up to five CBDs. This is an outstanding opportunity for trainees not only to gain a number of CBDs in a range of topics, but to also network and attend lectures delivered by expert clinicians.

The BOA is pleased to confirm that Tim Wilton, Professor Andy Carr, Leela Biant, Deborah Eastwood and David Limb will be delivering the plenary lectures.

For a provisional programme and further information including how to register, please visit the BOA website www.boa.ac.uk/events/ instructional-course.

Confirmed faculty for 2016 Leela Biant

Cyrus Jensen

Paul Partington

Andy Carr

David Johnson

Manoj Ramachandran

Gautam Chakrabarty

Birendar Kapoor

Danny Redfern

Karen Daly

Arun Kumar

Mike Reed

Deborah Eastwood

David Limb

Jurgen Stamer

David Emery

Rex Michael

Hiro Tanaka

Anne Foster

Pete Millner

Raj Verma

Shreekant Gupta

Fergal Monsell

Tim Wilton

Andrew Henry

Badri Naryan

The Lancet Commission on Global Surgery Marie-Caroline Nogaro & Oluwarantimi Ayodele

2015 marked the target for achieving the Millennium Development Goals. These focused on “cost effective”, single disease treatment, such as vaccines. Surgery, however, is perceived as expensive, requiring investment and infrastructure.

Consequentially, global access to surgical services has been poor - the “neglected stepchild of global health”1.

Addressing this, the Lancet’s Commission on Global Surgery was launched this year. The vision: “universal access to safe, affordable surgical and anaesthetic care”2. The key messages are:

• 5 billion don’t have access to safe, affordable surgery and anaesthesia • 143 million additional procedures are needed annually to reduce mortality and disability • 33 million individuals annually face catastrophic health expenditure due to payment for surgery • Surgical services investment is affordable, saves lives and promotes economic growth • Surgery is an indivisible, indispensable part of healthcare2.

Recommendations were proposed to meet the Commission’s vision by 2030. Highlighted was an

understanding that surgery has a role in the treatment of all areas of disease. It should not be seen as competing with, but, as being part of a functional healthcare system. Basic marker procedures of surgical capacity include the management of open fractures.

Atul Gawande, surgeon and author, quoted a former Professor of Surgery at Harvard, “the fundamental act of surgical care is the assumption of responsibility”.

Taking this forward will involve partnerships between surgeons, researchers and governments.

We, as surgeons in the UK, need to pick up the baton and run with it.

References 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008;32:533-36.

2. Meara JG, Leather AJ, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet Commissions 2015;3-58.

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JTO News and Updates

ICUC App Review

Shaun O’Brien

Comprehensive, detailed and intuitive are some of the descriptions given to this iPad app developed by current experts in the field of orthopaedic trauma as a reference aid for both the junior trainee and experienced orthopaedic surgeon who participate in trauma management.

The body is initially spilt into upper and lower limb regions which guide the user to individual areas of that limb. Simple touch screen controls then open up a selection of library tools, reference cases and expert opinions covering that particular area.

The library is a warts and all selection of every case performed by the experts in the field during the registration period, as a result both good and bad results are witnessed with no hiding from the poorly executed case or surgical disaster. The array of cases is quite staggering; for instance the clavicle is divided into three

segments - middle third simple, middle third complex and lateral third each with 15, 16 and 6 clinical case studies for reference.

Every case includes a summary page recording the AO classification, the approach and the surgical highlights as well as a rating for displacement, complexity, reduction and implant position. An overall rating is given before each case is presented in five sections on diagnosis, approach and reduction, implant position, aftercare and a full series of image intensifier pictures. The whole case is annotated by commentary from the expert involved.

The reference cases describe the surgical techniques available and the theory behind them supported by clinical case pictures, animation and imaging.

Images from the app

Finally, the expert opinion gives a selection of tips and tricks for each area under review including approaches, reduction aids, pitfalls avoidance strategies and gems on surgical technique.

Each page reviewed is stored in a brief case for future reference which can be easily deleted at a later date.

The major drawback is that it’s only currently available for iPad and requires access to the internet to be able to explore it fully. It is, however, a remarkable undertaking which will be an invaluable tool to both current and future orthopaedic trauma surgeons.

Highly recommended.

My Travelling Fellowship

Wasim Khan, Post CCT Fellow, Cardiff The 2015 Spring EFORT Travelling Fellowship was held in Croatia for the first time and I was selected by the BOA to attend. The Fellowship started off with attendance at the South-East EFORT (SEEFORT) meeting in Dubrovnik. With over 400 delegates from over 20 countries, this provided a useful educational experience. Mr Steve Cannon attended in his capacity as the EFORT President, and gave an excellent talk on the Stanmore experience with CAD-CAM prostheses.

There was an opportunity to discuss training matters and listen to how EFORT plans to achieve a greater harmonisation of training across Europe.

The Fellowship included visits to public and private hospitals including University Hospital Centre Osijek, Zagreb, and Sestre Milosrdnice, Special Hospital for Orthopaedic Surgery Akromion, Orthopaedic Speciality Hospital St. Catherine and Children’s University Hospital Zagreb. The programme included interesting and interactive talks on a wide range of clinical orthopaedic topics by national leaders in their field. We also had the opportunity to view live surgery and scrub in on cases. We heard from a former Health Minister on the healthcare challenges facing Croatia and the role of the various healthcare institutions.

Wasim Khan performing surgery on his fellowship

The Fellowship allowed a greater insight in to the healthcare system of Croatia, and the challenges faced by a South-Eastern

European country. It was useful to also gain a greater insight into the structure and standards of orthopaedic training across Europe.

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JTO News and Updates

The New BOA Trustees (2016-2018) Stephen Bendall

Karen Daly

Life as a consultant has been one of constant change, I was appointed to a relatively small District General Hospital with three colleagues in a department which has grown into a Major Trauma Centre with over 30 consultants a number which is still growing!

on the South West Thames orthopaedic rotation I worked for many inspirational Consultants.

I experienced world class training doing the GOSH/RNOH fellowship with John Fixsen and Tony Catterall. I still hear their words ringing in my ears as I operate. On a short stay at the Olga Hospital in Stuttgart with Klaus Parsch he showed me how to pace myself in my life and career.

I have always enjoyed teaching and training. I became an examiner for the Intercollegiate Board 10 years ago. I was involved in Standard Setting, the Published Paper and Oral Question committees.

Stephen Bendall

I am a consultant working at the Brighton and Sussex University Hospitals and my subspecialty interest is foot and ankle surgery.

First and foremost I must thank those that voted for me and I am looking forward to serving the BOA membership as a Trustee.

I was appointed in 1997 having qualified from Charing Cross Hospital Medical School, spending my early years at Charing Cross and Stanmore amongst other places.

My specialty training was at Charing Cross and St George’s Hospital.

I spent a very enjoyable Fellowship in Baltimore working in a variety of centres including Johns Hopkins and the Union Memorial Hospital.

I am a HEKSS Training Programme Director and collectively we managed a reshuffle at Deanery level and instigated an innovative series of changes to the training programme.

Within BOFAS I was Secretary then Chair of the Education Committee. I founded the BOFAS Principles Course for Higher Trainees which has been very successful - a fact I gratefully acknowledge is down to my friends and colleagues especially Hiro Tanaka and Chris Blundell.

Last year, I was President of BOFAS which was highly rewarding and involved working closely with members of the BOA team.

I am married to Heidi who works in Family Planning. We have two children who are growing up too fast and share our house with our crazy pets.

Karen Daly

Thank you for voting for me.

At this time rapid and radical change I intend to follow Paul Calvert’s ethos that solutions to problems are found by focussing on what is best for patients and trainees.

In Southampton eyebrows were raised at the suggestion that any student would do surgery let alone one of the “girls”. Undeterred by failing anatomy and everyone telling me how difficult it was I pursued my second choice career with determination.

I was SHO and Surgical registrar in London and Wessex. As Registrar and Senior Registrar

Barrie Parker was my supportive senior consultant at Kingston. He masterminded the introduction of the Consultant of the Week system that undoubtedly improved the quality of patient care, literally overnight. I enjoyed being one of the first COWs. I moved to St George’s and immediately the need to develop a specialist Paediatric network became clear. I am Chair of the Children’s Surgery Group and lead for children’s major trauma and just appointed as Associate MD. I am a member of the London Children’s strategic network group.

I have a strong interest in education and am most proud to have supported generations of PRHOs and F1 trainees many of whom are now surgeons themselves. I have run ATLS courses, been surgical tutor, Core TPD, Assistant to the HoS (QA) and am now on the SAC. When I retire I shall write a comic novel about being a working mother!

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Bob Handley

John Skinner Since 1994 I have been a fulltime consultant on the Trauma Service at the John Radcliffe Hospital in Oxford. During this time my work has been entirely related to trauma. The service is consultant based and for the last 21 years I have been resident when on duty.

Centre, of which I remain a Co-Director. This is one of our proudest achievements and has collected over 6,000 metal hip components from 25 countries worldwide and published over 70 papers with 105 different coauthors. From this work, I have advised the MHRA and FDA in America on this subject. I have chaired the joint BOA/BHS/ NJR/MHRA Expert Advisory Committee on metal hips from 2008 and this is ongoing.

As a trainee my research was related to bone blood flow; as a consultant I have been involved in various practical trauma related trials.

Bob Handley

I was a medical undergraduate in Sheffield where I also did an intercalated degree in physiology.

My first house job was in Lerwick, Shetland. After returning to Sheffield I was a medical officer for the British Schools Exploring Society in Arctic Norway. I worked for the British Antarctic Survey for three years. During this time I spent a year on a 16 man Antarctic base and eight months in the Falklands. The two periods in the Falklands straddled the war.

After a period as a general surgical SHO in Derby, my postgraduate training was based in the North-East around Newcastle and Sunderland. I did a trauma fellowship at Harborview Medical Centre in Seattle.

I have been an examiner for the FRCS Orth for seven years.

I am currently president of the Orthopaedic Trauma Society and a past president of AOUK. I was on the NICE guidelines development group for hip fractures and currently co-chair the NICE groups for complex and noncomplex fractures.

I am married with four children, a setter, a cat and several chickens.

Thank you for electing me.

I am hoping my time with the BOA will be both productive and enjoyable.

John Skinner

I am a consultant at the RNOH Stanmore with an interest in complex arthroplasty and tumour surgery. At Stanmore, I have chaired the Infection Control Committee for 13 years, the Medical Staff Committee for five years and have sat on the Local Research Ethics Committee for six years. I am a reviewer for several journals and was the Editorial Secretary of the British Hip Society for three years. I had the great honour to be President of the British Hip Society in 2014-15.

Much, but not all, of my research interest has been on Metal on Metal bearing hips and in 2007, with Alister Hart we established the London Implant Retrieval

I am now engaged in studies of data linkage to look at the long term health effects of arthroplasty and data validation projects with the NJR. I have been vociferous in challenging the desirability of publishing surgeon level outcome data, until that data is robust enough for it to be meaningful do so.

I remain convinced that this is a bad idea until the NJR is validated and more complete.

Data should be used to inform and improve practice now but is not ready for widespread dissemination until its limitations and meaning are better understood.

I am married with three children who are ‘grown and flown but with periodic returns’, so hope to have time to commit to serving as a BOA Trustee.

Outside of work, I have enjoyed all sports but continue to participate in walking, cycling and gardening.

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JTO News and Updates

Update from the BOSRC The BOA Orthopaedic Surgery Research Centre (BOSRC) is based at York Trials Unit, University of York. The Centre is funded by BOA to support and collaborate with T&O surgeons to obtain funding for significant research projects, in particular randomised controlled trials (RCTs), from large funders such as the National Institute for Health Research (NIHR).

Support can be accessed

by T&O surgeons from any region. Details of the criteria for supporting projects and how to access support can be accessed on the project webpage at www.york.ac.uk/healthsciences/ research/trials/bosrc.

Four grant applications were submitted to the most recent call of the NIHR HTA programme. Three of the submissions were to commissioned calls and one to the researcher-led stream. Of the commissioned calls, two were expressions of interest (outline applications), the third was a full application following a successful expression of interest submitted earlier in the year. The submission to the researcher-led call has also been in development since early 2015 due to the complexity of the study. One of the applications is for a full-scale trial, two for feasibility studies and one is a mixed methods

Thinking of the future The work you do is incredibly important and affects the lives of so many people suffering from musculoskeletal disorders throughout the UK. You selected orthopaedics over any other specialty which means you believe in helping and advancing this field of medicine.

We have shifted our focus from funding multiple pumppriming grants to funding one targeted, larger grant with the BOSRC, which we believe will have an even bigger impact, by successfully multiplying available research funds. By doing this,

we hope to achieve a step change in research – with more trials, at more centres, looking at treatments for more orthopaedic conditions. This change means that we need your support more than ever.

To continue this valuable work and to benefit future generations, please consider leaving a legacy in your Will to the Orthopaedic Research Appeal of the BOA. You can make a difference.

For more information visit www.boa.ac.uk/research/ leaving-a-legacy.

study to develop an intervention for a future trial. The total amount of funding requested is approximately ÂŁ3.5 million.

Three of the applications were made with surgeons who are applying as first-time chief investigators, from three different regions of the country, therefore helping build research capacity.

Funding has been secured from Orthopaedic Research UK for a Fellowship based at York Trials Unit to undertake a MD research project. The BOA would like to thank OR UK for their funding and support of this project. This will enable us to advance orthopaedic knowledge.

BOSRC also ran a twoday course on Undertaking Clinical Trials in Trauma and Orthopaedics in April 2015 which was attended by 34 delegates ranging from trainees to experienced consultants.

Feedback from the event was positive and a further event will be delivered in 2016.

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Advertiser’s Content

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JTO News and Updates Wisepress Book Review Book of the Quarter

NOW AVAILABLE

Master Techniques in Orthopaedic Surgery: The Hip

Introduction to Musculoskeletal Ultrasound

Author/s: Daniel J Berry; William Malone ISBN: 9781451194029 Price: £173.00 Publication Date: 2nd October 2015 The 3rd Edition of this superbly illustrated text remains your go-to resource for the most advanced and effective surgical techniques for the hip. More than 1,000 high-quality photographs and drawings guide you step by step through each procedure, and personal pearls from master surgeons provide operative tips that foster optimal care and outcomes.

Decision-Making in Orthopedic and Regional Anesthesiology Author/s: Michael R Anderson; Sylvia H Wilson; Meg A Rosenblatt ISBN: 9781107093546 Price: £64.99 Publication Date: 17th September 2015

Author/s: Jeffrey A Strakowski ISBN: 9781620700655 Price: £56.50 Publication Date: 30th September 2015

Experimental Research Methods in Orthopedics and Trauma Author/s: Hamish Simpson; Peter Augat ISBN: 9783131731111 Price: £76.00 Publication Date: 1st September 2015

Pocket Orthopaedic Surgery Author/s: Jamal Boughanem; Ritesh R Shah ISBN: 9781451185669 Price: £36.99 Publication Date: 25th September 2015

Conference listing:

Organisation

Conference/meeting

BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk

Annual Meeting 10-11 March 2016, Aylesbury

BHS (British Hip Society) www.britishhipsociety.com

Annual Conference 16-18 March 2016, Norwich

BLRS (British Limb Reconstruction Society) www.blrs.org.uk

Annual Meeting (w/ BAPRAS) 16-18 March 2016, Liverpool

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

Annual Conference 30-31 March 2016, Liverpool

BRITSPINE www.britspine.com

Meeting 6-8 April 2016, Nottingham

COMOC (Combined Orthopaedic Associations) www.comoc2016.org

13th Combined Meeting 11-15 April 2016, Cape Town

BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk

Spring Meeting 28-29 April 2016, London

CSOS (Combined Services Orthopaedic Society) www.csos.co.uk

Annual Meeting 13 May 2016, Plymouth

BOOS (British Orthopaedic Oncology Society) www.boos.org.uk

Annual Meeting 20 May 2016, Dublin

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org

17th EFORT Congress 1-3 June 2016, Geneva

CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org

Annual Conference 8-11 June 2016, Japan

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

Educational Weekend 16-19 June 2016, Hinckley

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

Annual Meeting 22-24 June 2016, Dublin

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

Annual Congress 13-16 September 2016, Belfast

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

Annual Meeting 20-21 January 2016, Coventry

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JTO Features

Where Goes the BOA? Ian Winson, JTO Editor & BOA Vice President

Having come to the end of a year full of activity and change in the world of Orthopaedics, I thought it might be time to sit and gaze into the future. This year we have covered a variety of issues in JTO and what is clear is we are going through a period of change in the nature of practice.

To keep pace with this, the BOA itself is adapting and becoming ever more proactive in order to influence that change to the benefit of patients. It is perhaps not often enough recognised that with an ageing population we are the “maintenance team”, we keep working people working and the retired active and contributing.

Ian Winson

This year has seen the emergence of increased registry activity and the publication of the GIRFT report. This might easily be interpreted as some sort of policing of surgical activity. There is, however, an entirely different way of looking at this. We are not all the same as surgeons; there are a few of us who actually need help with our all round skills, but they are the exception. The vast majority are doing a very good job and though we have differing skills, putting those skills together provides a very good service.

This is in the context where the UK’s expenditure on health is 9.1% of GNP where as Switzerland’s is 11.5, Portugal’s 9.7, Norway’s 9.6, and the Netherlands’ 12.9% (all on WHO

2013 figures). Only Ireland in the European arena spends less. It is true that GIRFT illustrates that there are some areas of marked differences in performance both financial and clinical, but we all appreciate that rarely, if ever, it comes down to individual consultant performance. Of particular concern is the variability of complication rates at unit level.

This year JTO commented on how little we really concentrate on the implications of complications both to the service and to society as a whole. They are unpleasant or worse for the patient and cost a lot of money. So the question from GIRFT is what resources do the units that produce the lowest level of complications have that the highest don’t?

It is time that each patient had those resources.

Of course a traditional area of activity in the BOA has been education. Orthopaedically, we have always been at the forefront of this most important part of resourcing surgical activity. Nonetheless we are seeing recruitment to

orthopaedics reducing; the question is why? Some of that may well be seeped in factors that we can only hope to influence such as society perception of surgeons and the reward structure. Other things we can effect more directly related to training starting at the very earliest levels but especially at CT1 and CT2 level.

Of equal importance is the role of research in helping define what we do and to make the innovative moves that will improve on the past. The BOA’s strategy of pursuing resources rather than trying to provide them more directly should bear fruit but takes time to do so.

So what is the BOA’s role and future? It has to be the cement that ties orthopaedic activity together. It is growing as the depository of a set of skills and knowledge that no unit or subspeciality can fully embrace, that are beyond those day to day skills which we do use so well, so often. It continues to pull together that knowledge from colleagues throughout the British Isles and beyond. Happy New Year!

Ian Winson is Vice President of the BOA, current Editor of the JTO and a Past President of EFAS and BOFAS.

TO ADVERTISE YOUR PRODUCT OR SERVICE IN THIS JOURNAL Call Tracy Finnerty on:

0121 200 7820

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JTO Features

Data validation in the National Joint Registry Jeya Palan Co-authors: Paul Gregg, J Mark Wilkinson, Martyn Porter

Arthroplasty registries are well established and are seen to be highly influential in decision-making in clinical care and patient safety.

Underpinning them there needs to be a robust and transparent data validation process (Figure 1).

The National Joint Registry (NJR) of England and Wales data entry system was designed to reduce input errors by using “business rules�. Business rules are processes that demand certain criteria for the entry to be accepted into the database.

The use of a minimum dataset ensures that all the data fields must be completed before the entry is accepted. In addition, there are rules for component entries. If a total hip replacement is recorded then the entry will not be accepted unless all the component parts of a total hip replacement have been entered.

In other words, a femoral stem without a corresponding acetabular component cannot be entered (unless manually overridden) and will remain in an edit stack until the missing data is recorded. The size of the edit stack is monitored at hospital level, as is the frequency of using the override function.

These mechanisms drive some aspects of data quality at the time of data entry but cannot account for missing entries (case ascertainment or compliance) or incorrect data fields.

Jeya Palan

Once the data has been accepted by the database, further automated checks are carried out

to look at implausible entries (e.g. age 209) and the data cleaned (e.g. duplicate entries). The data may be compared to other data sources such as Hospital Episodes Statistics (HES), when further data cleansing may be required prior to final analysis and publication. The NJR records certain elements of data quality by hospital including compliance, consent and linkability. For the data to be used at procedural

level and included in a longitudinal analysis such as survivorship analysis, the record entry must be identifiable, such that it can be linked to a subsequent operation (e.g. revision).

Historically other data sources have been used to assess data quality including linkages to HES. This can provide information on compliance and the details of the procedure. Other audits have been carried out at a local level1,2 and studies to understand NJR data quality have also been carried out by linkage to the London Implant Retrieval centre3.

The lack of a structured validation process has led to uncertainty >> regarding the quality of NJR

Figure 1: Flowchart of data validation process in the NJR - The left hand column identifies the types of data errors that can occur at the different time points (red arrows) during the data collection process from unit to the final data analysis process at the University of Bristol. The right hand column identifies the different methods of undertaking data validation at each of the time points (green arrows).

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JTO Features

data. This was recognised and discussed at several NJR data quality workshops during 2014 and has resulted in the establishment of an NJR data quality subgroup specifically which is charged with addressing this deficiency. The proposed data validation system for the NJR is outlined below (Figure 2).

After pilot and feasibility studies, a national data quality programme has been developed which commenced in August 2015.

This will involve all hospitals that supply data to the NJR and we would like to draw this to your attention so that you can ensure that the hospital or hospitals that you work in are complying with the national programme.

Full details of the audit can be found at www.njrcentre.org.uk but the principles are to validate NJR submissions from your hospital for the financial year 2014-15.

The steps are as follows: 1. NJR contacts Hospital Chief Executive Officer (CEO) to explain audit. It is hoped that trusts would view this NJR audit as a regular, mandatory trust audit 2. NJR Clinical and Data Quality (DQ) leads are being identified in each trust. Trusts that take part would be enrolled into the NJR Data Quality Provider Certification Scheme 3. Information packs and audit tools will be provided 4. Each hospital is supplied with a set of OPCS (Office of Population Censuses and Surveys) codes that represent primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) 5. Hospitals would use these codes to identify patients who have had these procedures from the hospital Patient Administrative System (PAS),

Figure 2: Proposed NJR internal and external data validation process

which should identify the procedures recorded on HES that should have been submitted to the NJR 6. This data is then sent in an appropriate format via an NHS secure link to a dedicated NJR DQ lead 7. NJR DQ lead links the PAS data to the hospital NJR submissions for the same time period.

This creates separate lists of procedures that are on PAS alone and not uploaded to NJR (a compliance issue), NJR alone (potentially not coded - lost income) and procedures on both. These lists are sent to the hospital where the data can be checked against primary source data (Electronic Patient Records, clinical notes, theatre records and internal databases) and corrected as necessary. Any missing entries from the NJR can be uploaded in the normal way and any inaccurate entries can be recalled from the NJR and sent back to the edit stack. The record can be corrected in the edit stack and then resubmitted to the NJR. All alterations and corrections are monitored with an audit tool so that any changes are tracked and any alterations quantified. A separate audit process will involve a random sample check of data fields from primary source data. Such audits could be undertaken by designated trainees, with a consultant lead, potentially using the British Orthopaedic Network Environment (BONE) website (www.bone.ac.uk); an audit and research collaborative network in the UK. Consultants can validate all linked revisions under their name by using clinician feedback. It is not expected that all hospitals will comply or that all missing data will be retrieved and validated but by the end of the audit the

NJR will have a much clearer and more quantifiable picture of data quality for the period under observation. This will provide a platform for better prospective data collection and validation.

A number of NJR external visits will be carried out to validate the internal audit process.

This will provide external governance over the audit process and ensure that audits are undertaken appropriately and with due diligence. The issue of how to validate data in the independent sector is also under consideration and there may be an opportunity to undertake similar internal and external audits as described above, using the Private Healthcare Information Network (PHIN) and Private Health Episode Statistics (PHES) data.

The issue of surgeon outlier analysis and reporting of individual surgeon outcomes data remains contentious. It is clear that for patients and surgeons alike, the necessity of having accurate and complete data is an absolute requirement. Risk adjustment analysis models should take into account differences between straightforward versus more complex cases. For better risk adjustment models, more granularity of data is required together with the ability to link NJR data with other databases.

For example, mortality data from the Office for National Statistics and the NJR or linkage with HES for co-morbidity data.

No data validation process will ever be perfect. Nevertheless, improving the data validation process will enable the NJR to quantify the state of data validation and compare institutions with one another to improve data capture and identify gaps in collection. The NJR

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can provide high level validations but ultimately it is dependent on timely, accurate data submissions. As NJR data is being used for more and more purposes including hospital dashboards, it is imperative that your data is of the highest possible quality. The NJR would very much appreciate your engagement and support, at individual surgeon, departmental and trust level, with this audit and the wider data validation process.

Jeya Palan is a Past President of BOTA. He was the NJR/RCS England Fellow 2013/14 and is

a ST7 trainee in T&O in the East Midlands Leicester rotation. He is an Associate Editor for the Bone and Joint Journal (BJJ) and is undertaking a PhD. His research interests include patient outcomes following hip and knee arthroplasty and the use of joint registry data.

Acknowledgements Elaine Young, Ashley Blom, Richard Armstrong, Maggie Tate, Inez Dunn, Peter Howard, Colin Esler, Linda Hunt, Michèle Smith and Carol Harrison

References 1. Kosy JD, Kassam A-AM, Hockings M. National Joint Registry data inaccuracy: a threat to proper reporting. Br J Hosp Med (Lond) 2013;74(12):691–693.

2. Palmer A, Dimbylow D, Giritharan S, Deo S. HOW ACCURATE IS NATIONAL JOINT REGISTRY DATA? Orthopaedic Proceedings Bone and Joint Journal. 2012;94-B(SUPP XXIX 73).

3. Sabah SA, Henckel J, Cook E, Whittaker R. Validation of primary metal-on-metal hip arthroplasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant ….

Bone & Joint … 2015.

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JTO Features

Lessons of War Colonel Paul Parker L/RAMC Co-authors: Surg Capt Sarah Stapley RN, Professor Sir Keith Porter

“That men do not learn the lessons of history is the greatest lesson that history has to teach”*

Fifteen years of conflict has produced a burden of over 2,500 trauma-injured casualties for the United Kingdom. Five thousand have suffered disease and nonbattle injury related illness (DNBI).

These numbers are small in comparison to the World Wars of the 20th century (0.5% of the 1.6 million UK casualties of the Great War). Yet our casualty survivorship after the devastating ‘unsurvivable’ injuries produced by blast and ballistic trauma has significantly improved - why?

Colonel Paul Parker L/RAMC

94% of combat deaths occur in the first 30 minutes after wounding, mainly from exsanguination. The ability to stem even a fraction of this blood loss after injury is vital and all troops now carry tourniquets. Our Combat Medical Technicians (CMTs) are trained in Battlefield Advanced Trauma Life Support (BATLS), a version of Advanced Trauma Life Support (ATLS®) with its ‘ABC’ approach. BATLS recognises that in military injury - if the airway and breathing are dealt with before major haemorrhage control (the ‘big <C>’), the patient will exsanguinate. BATLS therefore teaches <C>ABC. Our CMTs apply tourniquets (after returning fire), insert surgical airways, decompress pneumothoraces, perform intra-osseous infusions and apply pelvic binders - 40% of blast-related, bilateral above knee amputations have a concomitant pelvic fracture.

Management of junctional trauma remains problematic. These are injuries occurring at the boundary areas of anatomically distinct zones such as the root of an extremity and its adjacent torso cavity. These very proximal injuries often have a perineal component and are not amenable to standard limb tourniquets. If this bleeding had been controlled in some way in the field, a number could have been saved. These were identified by our preventable mortality review process. Prehospital haemorrhage control thus remains challenging: Research into abdominal tourniquets, junctional tourniquets and abdominal foams continues to show promise.

Helicopter-borne Medical Emergency Response Teams (MERT) arrive within an hour of injury. Warmed blood and plasma are transfused, definitive airway control is undertaken, tranexamic acid (TXA) and antibiotics are given. In Afghanistan between 2008 and 2011, 417 casualties received a massive transfusion.

Overall survival increased from 76% to 84%. These results have now influenced UK air ambulance service provision; most carry pelvic binders and several now carry blood and plasma. Yet we first took citrated whole blood forward at the 3rd Battle of Ypres in 1917 and transfused it in the trenches1.

This early military use of tranexamic acid has been shown

to reduce mortality following trauma2. It competitively inhibits the activation of plasminogen to plasmin. Work by the MATTERS group3 demonstrated a significant decrease in mortality associated with its early use in haemorrhage. We give it in the pre-hospital environment, where we also advocated the early use of fibrinogen and cryoprecipitate.

Yet this was the standard surgical practice in the UK campaign in the Dhofar in 1972, where we also liberally used the precursor of TXA, ε-aminocaproic acid (ε-AHX)4.

In-flight the helicopter team snap-brief the Emergency Department (ED) about casualty numbers and injuries. On arrival, a rapid ‘AT-MIST’ report is given for each casualty: Age, Time of injury, Mechanism of injury, Injuries sustained, vital Signs and Treatment given. Patients immediately receive horizontal resuscitation; the ED consultant directs the ‘Orchestra’ with immediate input from specialty consultants in T&O, General Surgery and Plastic Surgery.

An anaesthetic consultant takes the lead on the airway. Damage control resuscitation algorithms allow three choices; the operating theatre, the CT scanner or the ITU. Prevarication kills and the team will all have trained together in the UK prior to deployment.

Civilian best practices are rapidly adopted: We do not fear change.

Karim Brohi coined the term ACOTS - acute coagulopathy of trauma, noting however that it had been postulated in an original paper from the Vietnam War in 19695. This syndrome increases transfusion requirements, organ dysfunction, length of stay in ITU, morbidity and mortality.

Our current military response6 is

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didactic following an initial massive transfusion protocol7.

There are four key elements; a. recognition of the requirement using the incoming casualty reports; b. reactive logistics with pro-active laboratory production of ‘4+4 shock packs’ - each contains four units of O-Negative blood and AB Fresh Frozen Plasma (FFP); c. continual communication between clinicians, nursing staff and lab staff; d. monitoring the state of the patient, product usage and blood stocks remaining.

Later transfusion is finetuned by the use of Rotational Thromboelastometry or ROTEM. This technique allows for rapid near-patient assessment of the patient’s coagulation status8.

Admission samples demonstrate the severity of the coagulopathy and provide indicators of which aspects of the clotting cascade need supporting. Thus treatment is individualised and goal directed.

One of the significant advances

we have introduced has been the ability to deliver platelets early to these casualties. ROTEM produces a simple coloured graph of clot formation, strength and lysis9. This advanced knowledge of trauma physiology may not be common to all orthopaedic surgeons, but in the polytrauma patient it helps inform surgical management.

Communication between the different members of the team is key. Knowledge of the patient’s physiology allows surgical time to be reduced or extended, with monitoring of lactate trends in particular. Debridement and external fixation are undertaken concurrently with general surgical procedures. This shortens theatre time, allows for emergent haemorrhage control, rapid stabilisation of fractures and rapid revascularisation of limbs, often with shunts. No definitive fixation surgery is performed. As many as five to seven surgeons and three anaesthetists may simultaneously be involved in the care of a single

“Where’s the patient?” The five surgeon, three anaesthetist approach to blast and ballistic trauma

casualty. Thomas splints, which were introduced in 1916 during the Great War, and plaster of Paris casting are still used. Our predeployment training for ‘modern’ orthopaedic surgeons (even in 2015) includes a session on the application of a Thomas splint.

Human physiological response to these massive injuries, such as triple limb amputation, provides a relatively short window of opportunity to return them to the UK, before they start to develop multiple organ failure. Most leave the overseas Rôle 3 Hospital by 18 hours post injury and arrive in Birmingham within 36 hours, accompanied by highly specialised critical care in the air transfer teams (CCAST) on C17 transport aircraft.

On arrival at our UK Rôle 4 Hospital, the Royal Centre for Defence Medicine at the Queen Elizabeth Hospital, Birmingham, casualties are met, day or night, by a multidisciplinary team, backed up by a ready theatre of consultant orthopaedic and general surgeons, fertility and semen harvest team, intensivists and nurses. A full examination of all wounds is undertaken immediately. Many injuries sustained in the cultivated ‘green-zone’ areas around the Helmand River in Afghanistan produced unrecognised fungal wound infections. This was initially thought to be a novel problem, yet a later review of the literature relating to infection in military personnel showed that the Israelis had described this well over a decade earlier in fruit market bombings.

Fungal biopsy and anti-fungal therapy on arrival in the UK rapidly became standard practice10.

An operating department uplift, relevant ITU facilities and the development of a “Bunker” as a

co-ordination cell in order to maintain communications throughout the whole multidisciplinary team were all required over the period of the conflict. At the height of war-fighting this “Bunker” team met three times a day in order to ensure that all patients were treated optimally. As an example, a single casualty may require twenty trips to theatre with one-hundred hours of surgical time and over a month in ITU. Our simple take-home message?

Well-resourced, communicative teams who train together to develop shared mind-sets in conjunction with the best ‘kit’, will always produce the best results.

We must not (again) forget these lessons of history. *Aldous Huxley, Collected Essays 1958 Colonel Paul Parker joined the British Army in 1983. A Consultant Trauma and Orthopaedic Surgeon at the Level 1 Trauma Centre at the Queen Elizabeth Hospital in Birmingham. He is Defence Senior Lecturer in Trauma Physiology. He has deployed often to Northern Ireland, Central America, the Balkans, the Gulf, Africa and Central Asia. His research interests include whole blood transfusion in trauma and surgical resuscitation at altitude.

References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Features

The BOA Clinical Leadership Programme Mike Reed Co-author: Rayshum Notay, BOA Director of Policy & Programmes

The first BOA Orthopaedic Clinical Leadership Programme commenced in October 2015, which included 25 surgeons who had been selected following a competitive application process.

What are the objectives and outcomes of the Programme?

OBJECTIVE

OUTCOMES

To develop Trauma and Orthopaedic leadership capability

Demonstrate self-awareness and enhanced leadership presence and impact to lead multidisciplinary teams as Trauma and Orthopaedic surgeons

To accelerate service transformation and quality improvement within and across Trauma and Orthopaedic services

Deliver and share quality improvement project outcomes demonstrating tangible results through proactive clinical leadership using core skills in improvement methodology and knowledge from improvement science

To sustain a skilled, prepared, energised, engaged and motivated talent pool of Trauma and Orthopaedic surgeons

A vibrant learning and support clinical leaders network in Trauma and Orthopaedics

The Programme

Mike Reed

The BOA National Clinical Leaders Programme is supported by best evidence from healthcare and industry. Its central focus is to lead improvement and transformation in Trauma and Orthopaedics through: • improving quality and safety • driving efficiencies and productivity • integrated partnership working and integrated care

• clinical and managerial alignment • motivating and leading teams • engaging colleagues • delivering results • creating clinical networks for trauma and orthopaedic service improvement The Programme is delivered through a combination of master classes, tutorials and coaching sessions with experts in their

field. The legacy of this one year development programme is a significant innovation and improvement project delivered by each clinical leader to their Trust’s strategic change agenda and improvement of Trauma and Orthopaedic services.

During the Programme, clinical leaders will attend four TWO day modules that will take place in Newcastle upon Tyne. The modules will cover the following content: Leadership effectiveness: self-awareness, leadership diagnostics, breakthrough personal effectiveness, leadership development plans, coaching objectives, personal impact, coaching for improvement, aligning clinical and managerial agendas.

The context for improvement in Trauma and Orthopaedic services: leading safety, reducing harm, the human factors, quality and efficiency, patient experience and expectations, innovation and new approaches in Orthopaedics, NHS policy context, Trust strategy and improvement agenda.

Quality improvement tools and methodology: principles of Quality Improvement, LEAN methodology, Kaisen, Toyota, process review and redesign, demand management, workforce planning, measurement of improvement, statistical process control, creativity tools, problem solving tools, project management, applications in healthcare.

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Inspirational leadership: leading teams, engaging and motivating colleagues, influencing, leading change, negotiating, difficult conversations, high performing individuals and teams, coaching for complex change.

Over the course of the year between modules, clinical leaders will be supported by telephone coaching, podcasts, ebooks and 24/7 access to module based online leadership and management resources for self-study. At the end of the Programme, the clinical leaders’ improvement work is prominently displayed at the BOA Annual Congress and all posters will be available online as a developing library of improvement in Trauma and Orthopaedic services on the BOA website.

In addition to the main programme, the below opportunities are also offered to clinical leaders: Journal Review Training The Bone and Joint Journal’s editorial team has engaged wholeheartedly to support the Programme and all clinical leaders will receive reviewer training.

Each participant will be mentored through four reviews over the year by a senior member of the Journal team. During the 12 month programme, clinical leaders are strongly recommended to attend a Journal Reviewer’s day event at the reduced rate of £35.

TOES (Training Orthopaedic Educational Supervisors) A one day programme aimed at engaging trainers.

Who is this programme for?

There are four main routes into the programme: 1. BOA National Clinical Leaders Fellowships - recruited by Trusts hosting National Clinical Leaders Fellowships 2. Specialist society fellows (for example British Elbow and Shoulder Society) 3. Individual applicants: a. Newly appointed consultants or senior SAS surgeons (FRCS Tr & Orth) b. Senior trainees (ST8 or above when the programme runs) The price of the 2015/2016 programme was £2,760 including VAT. This cost includes all fees, learning materials and day delegate hospitality. It does not include travel and accommodation.

Funding for the programme comes from a variety of sources: Host Trusts, specialist societies, and the individuals. Further detail on how to apply for the 2016/2017 Programme is available on the BOA website www.boa.ac.uk/training-education/ boa-national-clinical-leadersfellowships-programme.

Who delivers the programme?

Karen Picking and Associates www.karenpicking.co.uk Bone and Joint Journal BOA Educational Advisor - Lisa Hadfield-Law Mike Reed is an orthopaedic surgeon for Northumbria and a Senior Lecturer with the University of Newcastle.

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Festive Fun

The JTO Festive Quiz After filling up on food over the festive season, here’s something else you can get your teeth stuck into. Gather the family around and complete this fun festive quiz.

Around the world at Christmas

Match the tradition to its country (watch out for the red herrings) Q1. On 5th December; cakes, biscuits or chocolate in the shape of the first letter of people’s names are given as gifts or eaten at Sinterklaas parties. Good children will get presents but bad children will be put in a sack and the “Zwarte Pieten” takes them to Spain for a year to teach them how to behave.

Q4. New Year’s Eve/Day is one of the most important nights in this country’s calendar.

Several magical traditions are supposed to happen! Cows are meant to be able to talk, seals take on human form, the dead rise from their graves, and the Elves move house.

Q2. A Christmas Eve night tradition is ‘globos’, paper decorations with a light inside that float into the sky (like Chinese Lanterns). The sky is filled with them on Christmas Eve after midnight.

Q5. Epiphany (6th January) is important in this country. Children will receive their main presents on this day. An old lady called “Befana” puts their presents in their stockings. Children will still receive small gifts on Christmas Day from “Babbo Natale”.

Q3. On Christmas Eve, children go into the streets to sing carols, playing drums and triangles as they sing. They sometimes carry model boats decorated with nuts and painted gold. Presents aren’t given to children until 1st January.

Greece

Argentina

Italy

Hungary

Q6. The traditional Christmas meal which is also eaten on Christmas Eve is fish, cabbage and a special kind of poppy bread/cake called “Beigli”.

The Netherlands

Jamaica

Sweden

Iceland

Romania

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Orthopaedic Milestones Match the orthopaedic milestone to the correct year

1768

A. Nicolas Andry published Orthopédie about childhood deformity correction.

He is credited as the first to coin the term “orthopaedics”. An illustration in the book bore an engraving of a sapling being splinted with a stake, a symbol now referred to as the Tree of Andry and adopted by many orthopaedic associations internationally

1940

B. Paul Lauterbur and Sir Peter Mansfield were awarded the Nobel Prize in Physiology or Medicine for their “discoveries concerning magnetic resonance imaging”

2005

C. Sir John Charnley performed the first total hip replacement

1918

1954 2003 1741

D. The BOA was formed E. David Hamblen became President of the BOA F. Küntscher first described use of cloverleaf nail for fixation of long bone fractures

G. Current BOA President, Tim Wilton, was born

1962

H. Robert Jones and Alfred Tubby founded the British Orthopaedic Society but it disbanded after four years due to lack of commitment from orthopaedic surgeons

1894

I. Percivall Pott published his book Some Few Remarks upon Fractures and Dislocations, following his compound femoral fracture, on the use of splinting to avoid amputation

1990

J. Ian Leslie became President of the BOA Answers on page 60.

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JTO Features

Clinical Coding Explained Ro Kulkarni Co-authors: Rhodri Gwyn, Hallam Amos, Jayne Harding

Clinical coding is the translation of medical terminology, as written by the clinician to describe a diagnosis, treatment or reason for seeking medical attention into a coded format, which is nationally and internationally recognised.

The NHS requires accurate data to reflect clinical activity and support statistical and epidemiological analyses; in addition trusts have a financial incentive to ensure that coding is accurate, comprehensive and timely as coded data underpins the NHS payment system1.

The Health and Social Care Information Centre - Clinical Classifications Service (CCS) is responsible for two national standards used within the NHS: â&#x20AC;˘ ICD-10 classification which codes diagnoses. â&#x20AC;˘ OPCS-4 classification which codes procedures.

Ro Kulkarni

ICD-10 and OPCS-4 are central components of the national datasets. Hospital Episode

Statistics (HES) in England, Patient Episode Data for Wales (PEDW) and Scottish Morbidity Records (SMR). Guidelines regarding national clinical coding standards, which must be adhered to in England are found in the clinical coding standards reference books2 and Coding Clinic3 publication.

The WHO International Statistical Classification of Diseases and Related Health Problems (ICD) is a comprehensive classification of causes of morbidity and mortality. The classification is mandatory for all Admitted Patient Care Commissioning Data Sets (CDS). The WHO publishes ICD-10 and is the copyright holder. ICD-10 is used under licence by the

United Kingdom government.

The World Health Organisation (WHO) is currently developing a revision to the ICD classification - ICD-114. Field trials of ICD-11 at country level will commence in 2016/17.

ICD-10 has 22 chapters.

Chapter 13 represents diseases of the musculoskeletal system and connective tissue and have the prefix M. Chapter 19 represents injury and poisoning, with the prefix S or T. For example a rotator cuff tear (nontraumatic) has an ICD-10 code of M75.1, whereas a rotator cuff tear (traumatic) is coded S46.0, injury of muscle(s) and tendons(s) of the rotator cuff of shoulder.

Chapter 20 is for external causes of morbidity and mortality and allows for the classification of environmental events and circumstances causing an injury, for example W19.9 is for an unspecified fall.

OPCS-4 is the Office of Population, Censuses and Surveys classification of Interventions and procedures.

It is a UK procedural classification, which is governed by Crown Copyright. The classification enables the provision of data on surgical procedures and interventions. The classification is mandatory for Admitted Patient Care CDS. There are 24 chapters in the OPCS-4 classification. Orthopaedics is

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mainly represented in Chapter V - Bones and joints of skull and spine, Chapter W - other bones and joints, and Chapter T - soft tissues.

The CCS develops and supports these classifications for UK implementation. A three year release cycle was determined by the Department of Health. Each release is subject to approval by the Standardisation Committee for Care Information5. The most update of ICD-10, the 5th Edition, will be implemented on 1st April 2016. The next update to OPCS-4 - OPCS-4.8 - is proposed for implementation on 1st April 2017.

The NHS payment system, a set of prices and rules regulating how hospitals and other providers are paid for the care they give patients, means that all English trusts will use a fixed price tariff for specific treatments. At the heart of this is coded clinical information provided by clinical coders.

Trusts have to ensure that their coding is accurate as errors will impact on their income. Unless trusts take actions to ensure coding is accurate the adage ‘rubbish in - rubbish out’ will ensue.

The role of the clinician in coding is vital to optimise clinical datasets and payment. Many coders code from the discharge

summary alone. These summaries often lack the information to assign an appropriate code.

For example patients with complications and co-morbidities often require greater resources for their treatment. If documented clearly within the medical record and coded appropriately they generate a higher funded Healthcare Resource Group (HRG).

SNOMED CT is the standard clinical terminology for clinicians recording clinical information in a way that supports data management and analysis. As we move to electronic care records, it is important that this information is consistent and transferable across all the healthcare settings where a patient may be treated.

Cross-maps link SNOMED CT to ICD-10 and OPCS-4. The mappings are semi-automated, with default and alternative codes, where appropriate. This allows the coding professional to include context, if available in the medical record, in the final target code(s) assigned. The CCS develops and maintains these maps, which are updated twice a year.

Editor’s Comment In the financial world we now live in I think we are all aware that understanding how the funding stream is generated based on the work we do is important. There is no doubt there is a downward pressure on HRG’s and there is a growing theme of decreasing trust hospitals ability to object to or appeal against these changes. It remains the situation where change sometimes occurs without particular rhyme or reason. However, there are things to be aware of. Firstly there is the rule of unforeseen circumstances, some of the automatic or semi-automatic imposition of default codes can lead to punitive effects which are difficult to get rid of. When services are updating or new services evolving the available codes may not do justice to the complexity and ultimate value of what is being achieved.

Knowing real costings of such treatment and comparing that with the end result of a legitimate coding exercise can be helpful but changing value on the basis of that evidence can be very difficult. There is an appeal process but it requires specific evidence and potentially from more than one source. Ultimately, being aware of the above processes and the pitfalls therein do help to secure funding more reflective of activity whilst also improving data on true activity.

Ro Kulkarni is a Shoulder and Elbow Consultant at the Aneurin Bevan University Heath Board, Newport. He is the Immediate Past President of the British Elbow and Shoulder Society and Expert Advisor in Orthopaedic Surgery to the Clinical Classifications Service, HSCIC.

References References can be found online at www.boa.ac.uk/publications/ JTO or by scanning the QR Code.

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JTO Features

Over-diagnosis, overscreening and over-treatment: An Orthopaedic Problem?

Robin Paton

MRSA Screening

One of the first tenets of medical education is ‘first do no harm’.

There is an increasing tendency in the Western world to overdiagnose ‘abnormalities’. In the USA, it is estimated that over $200 billion is wasted on unnecessary treatment1. ‘The over treatment of the healthy and the under treatment of the sick are the conjoint twins of modern medicine’2.

The problem of over-diagnosis in medical specialities has been highlighted recently in the British Medical Journal3. Areas of concern highlighted included: over-diagnosis in breast, thyroid and prostate cancer, gestational diabetes, osteoporosis, chronic kidney disease, and pulmonary embolism.

‘The ability to detect trivial abnormalities axiomatically tends to increase the prevalence of any given disease’4. The drivers of over diagnosis are: a faith in early detection unmodified by the risks, a health system favouring more tests and treatments and legal incentives that punish under-diagnosis but not over diagnosis3. Recently, in the UK, a Health Minister has promised to ‘name and shame’ doctors who ‘miss’ diagnoses. Certain protocols and guidelines may lead to over-diagnosis, over screening and over-treatment2.

Screening

Robin Paton

The principles of effective screening were outlined by the World Health Organisation5.

Unfortunately, most Orthopaedic

conditions do not lend themselves to effective screening. Screening has been used in Orthopaedic practice for many decades and includes screening for Developmental Dysplasia of the Hip (DDH), scoliosis, and more recently MRSA. The effectiveness and validity of these programmes has been questioned6,7.

Hip Screening Clinical hip screening has been advocated in the UK since 1969. The addition of ‘at risk’ hip screening and selective sonographic hip imaging has not resulted in a significant decrease in the presentation of ‘late’ irreducible hip dislocation8. A Cochrane review9 noted that there is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone.

Following universal sonographic screening of the hip joint, up to 7% of the population may be treated with hip joint splintage, a considerable over-treatment of the ‘truly’ pathological hip10.

In a series of 8,867 adults swabbed in an Orthopaedic unit over a calendar year in the North West of England there were 42 cases of a positive MRSA skin swab (0.47%) of which 18 were successfully decolonised following therapy6. There were no cases of surgical site infection.

MRSA colonisation is not a disease process but in many cases may be a harmless skin commensal. MRSA bacteraemia had decreased considerably over the five years prior to the implementation of the MRSA screening programme due to better hand washing, deep cleaning of wards and more judicious antibiotic prescribing.

A Cochrane review11 showed that there was no evidence that systemic or topical therapy results in eradication. This review and the change in practice prior to the introduction of the screening programme have questioned the validity of the MRSA screening programme. This suggests that widespread MRSA screening in low risk cases (without metal implantation) is a waste of resource.

Scoliosis (National Screening Committee 2011) The National Screening Committee12 reviewed the evidence for scoliosis screening.

The introduction of clinical scoliosis screening resulted in an increase in investigations (including ionising radiation) and treatment.

This policy did not improve the

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treatment or outcomes of the condition in the majority of cases and potentially may have increased patient and parental anxiety.

Evidence Based Medicine (EBM) & referral methods EBM has some serious flaws: the volume and source of evidence (NICE), statistical significance may not result in clinical benefit and algorithms have replaced patient centred care. In addition, EBM guidelines struggle to contend with multiple morbidities and there is evidence of Industry and Government interference/ bias13. This may result in ‘healthy’ individuals being treated as ‘sick’.

How is over-diagnosis being tackled?

Choosing Wisely®15, ‘Less is more’16, and ‘Too much medicine’17 are initiatives that have been developed in North America and the UK to tackle potential over-diagnosis and overtreatment. In North America the Speciality of Orthopaedic surgery was asked to select five ‘useless’ treatments that could be shelved.

The following were chosen:

Unfortunately, in surgical specialties, many of the procedures undertaken are based on poor ‘Levels of Evidence’ often at levels III to V. This makes orthopaedic surgery particularly vulnerable to the claim that many surgical interventions are at best useless and at worst harmful.

• Avoid needle lavage in symptomatic OA of the knee for long term relief • Avoid glucosamine and chondroitin in the treatment of symptomatic OA (knee) • Avoid routine post-operative DVT ultrasonography screening in elective TKR and THR • Avoid lateral wedge insoles in patients with symptomatic medial compartment OA (knee) • Avoid post-operative splinting of the wrist after carpal tunnel release for long term relief

To control the problem of increasing numbers of referrals to orthopaedic clinics, triage clinics have been developed. The entry level to these triage methods is that of the novice: learns basic rules and applies mechanically with no attention to context. Merely following rules will produce poor performance in the real world14. Close supervision, education and timely advice from ‘experts’ could raise the triage standard (Figure 1), resulting in fewer referrals and ultimately the potential for over-treatment.

There appears to be a lack of ambition with ‘low hanging fruit’ being picked rather than the more difficult decisions that may ruffle feathers within the profession (vested interests) or in industry (equipment sales). If Orthopaedic surgeons fail to analyse objectively the surgical procedures that we routinely undertake, others who are less knowledgeable will dictate to us. Some CCGs and insurance companies are actively advocating that much of elective

Figure 1: Dreyfus model of learning (after Dreyfus 2004)

surgery should not be funded due to a lack of evidence.

This could result in the opposite problem of under-treatment (not over-treatment). Even where there is evidence of surgical benefit, CCGs may insist that surgical treatment be avoided e.g. carpal tunnel syndrome should be treated with multiple injections of steroid or prolonged splintage of the wrist despite a lack of evidence of lasting benefit18. There is reasonable evidence that several common orthopaedic procedures are likely to be ineffective and should only be used rarely, if at all. These include: arthroscopic washout of advanced OA of the knee, arthroscopic debridement of degenerative meniscal tears, some arthroscopic shoulder procedures and vertebroplasty vs. sham surgery for pain in vertebral compression fractures19,20,21.

In Paediatric Orthopaedics, orthotics for the treatment of flexible flat feet, curly toes, intoeing and varus or valgus knees have been abandoned due to evidence based research22.

The Ponseti method in Congenital Talipes Equinovarus has resulted in the abandonment of radical surgery in the majority of cases23.

The headlong rush into fixing distal radial fractures in adults (with locking plates) and even the increasing use of K wires and fixation in children’s distal radial fractures has resulted in surgical surgical complications such as carpal tunnel syndrome, tensosynovitis, flexor and extensor tendon rupture, pin tract infection and neuropraxias24,25.

Fortunately, there has been recent orthopaedic qualitative research on the efficacy of certain common surgical procedures.

Examples include the multicentre RCT studies in the treatment of adult distal radial fractures26 and proximal humeral fractures27.

In elective surgery, the recent serious complications arising from the rapid adoption of metal on metal and re-surfacing

techniques in hip arthroplasty has raised considerable concern. Increased scrutiny of new techniques and implants is clearly required along the lines of the introduction of new drugs28. The introduction of ‘Beyond Compliance’29 is a welcome step in the safe and stepwise introduction of new or modified orthopaedic implants.

Summary Do not classify healthy individuals as ‘sick’! Control ‘screening’ in orthopaedics.

Avoid the herd instinct of undertaking new fashionable operations, before appropriate evidence is available.

Orthopaedic departments must produce high quality evidence on the efficacy of surgical treatments or be dictated to by other groups with financial and political interests at heart.

Robin Paton is a Consultant Orthopaedic Surgeon at East Lancashire Hospitals NHS Trust with a special interest in Paediatric Orthopaedics. He has served on the BSCOS national committee and the National Screening sub-committee (NIPE hip screening). He has an interest in education and has been involved in the development of the undergraduate medical school and an MSc in MSK at UCLAN. He has twice been voted the Northwest Orthopaedic Trainer of the year by the Northwest Orthopaedic Trainees Association (NWOTA).

References References can be found online at www.boa.ac.uk/publications/ JTO or by scanning the QR Code.

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JTO Features - Trainee Section

The Linkmen Roadshow Project: What does good Orthopaedic Training look like on a regional level?

Mustafa Rashid, BOTA President

During my tenure as BOTA Vice President, I organised and coordinated a very ambitious project to conduct a qualitative analysis of all 30 regional Trauma and Orthopaedic Surgery training programmes in the United Kingdom.

Mustafa Rashid

The past BOTA President (Mr Peter Smitham), the BOTA Regional Trainee Representatives (BOTA Linkmen) and I conducted Skype conference calls using a structured 21-point agenda.

Nine months of hard work, over 1600 Skype minutes, and 127 emails later, we had completed the project. The premise was to discover the unique and innovative ways in which various regional training programmes were providing excellent training opportunities, covering a wide range of areas from simulation training access to quality assuring individual training posts.

Regional Teaching Programmes

Unfortunately, the sheer breadth and depth of the project precludes reporting in this article in its entirety, but I will attempt to highlight some of the salient points we encountered regarding high-quality training. The full report is available in JOINT, the annual BOTA yearbook, and can be found online at www.bota.org.uk.

The two stand-out programmes were Oswestry and Manchester.

The major features that made the Oswestry teaching programme so unique were a combination of high volume, quality teaching with well-integrated simulation training every week. Similar to a number of rotations in the UK, Oswestry run two mock

The structure and format of different regional teaching programmes varied significantly.

Whether it was held on a weekly basis on one afternoon (usually Friday), or a whole day organised fortnightly, trainees certainly appreciated high quality, regular, FRCS-focused teaching. Most were structured into terms or blocks. Several regions appointed a deputy TPD or Educational Programme Director to oversee and organise the teaching elements.

FRCS examinations during the year. The four highest scoring candidates are put into the “hot seats” at teaching for the next 6-12 months. Every Friday afternoon, patients are brought in for case conferences in a simulated FRCS clinical environment. This is usually followed by a one hour lecture from either a local, or external, Consultant speaker. Patient case conferences in an FRCS style are a form of simulation, and are well received, as they result in trainees becoming “desensitised” when it comes to the real exam.

In addition, Oswestry cultivates a proud culture of providing exemplary teaching. Many consultants regularly spend early morning or weekend time teaching trainees who wish to receive extra exam practice. Each morning, in the plaster room, there is teaching before the day starts. Days are themed, for example Paediatric Orthopaedics, Tumours, Basic Science and Lower Limb Arthroplasty. Trainees also have access to the on-site cadaveric dissection lab, where surgical approaches can be honed both ‘ad hoc’, and as part of organised educational courses.

An honourable mention goes to Manchester, which was the

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only programme that runs four simultaneous streams matching the varying learning needs of different levels of trainees. At the beginning of the year, the new ST3 trainees have an 8-week introductory module, whilst the post-exam FRCS trainees cover professionalism, management and clinical leadership skills.

The rest of the trainees will attend main teaching, which is structured in terms based around FRCS topics. Finally, around the time of the FRCS exam, the peri-FRCS trainees have specific exam-focused viva practice and teaching.

Quality assurance and Allocation to training posts Several Linkmen discussed methods employed by their programmes to quality assure training posts. These include regular logbook reviews and systems to allocate trainees to posts that best meet their training needs. The Northern (Newcastle), Mersey, and Leicester programmes employ a ranking system; trainees accrue points which subsequently are used to help determine the preference and allocation of posts every 6-12 months. Most programmes used seniority as a key determinant of rank, and some even provided a list of jobs with profiles of what was to

be expected from each job in terms of clinical activity.

Manchester managed to further improve the posts that trainees rotate through by developing an in-house, anonymous, survey run by the TPD. Trainees are asked to feedback honestly and candidly without fear of discrimination as to the quality of training. This works well, as trainees are confident in the process. Their feedback will be collated over two to three years and used to exclude jobs with less emphasis on training from the programme.

Trainees appreciate being given a “roadmap” of where they can expect to work over a two to four year period. Additionally, The Kent, Surrey and West Sussex programme runs a structured programme, with ST3s undertaking one year as a “Trauma reg” to complete all their Index Operative Procedures in trauma, followed by a year training in elective lower limb arthroplasty.

Out of Programme Placements (The Resurgence of the Pre-CCT fellowship) Several years ago, BOTA was informed of the unanimous decision by the SAC to

recommend removing all preCCT fellowships. This was hotly debated within BOTA at the time.

BOTA initially felt that it may help level the playing field, as some regions allowed their post-FRCS trainees to go on fellowship for a year prior to CCT, whilst others did not. A third of BOTA Linkmen reported that, in their region, pre-CCT fellowships were being undertaken, whilst other stated that this was explicitly banned. Some trainees were even allowed to undertake fellowships abroad, in places such as Australia, Malawi, New Zealand, and South Africa.

BOTA’s position has always been about equality and fairness. We feel that if a trainee has completed the FRCS examination, achieved an Outcome 1 at ARCP (end of ST7), and is on track to achieve CCT, they should be allowed to explore an area of sub-specialist interest within the UK, and perhaps outside their own region. This decision should be on a caseby-case basis with support from the TPD, dependent on having successfully completed the majority of the CCT requirements.

Take-home message This was a rewarding and fascinating project to have undertaken. We have gained

insights into novel and innovative ways in which programme directors have improved key areas of the training being offered in their region. The overwhelming sentiment is of tremendous variability between the regions, and across all areas of training.

One key aspect that is always linked to a strong training programme is a culture of pride in that training programme.

In regions where the TPD and deputies have developed an ethos of delivering high quality training the trainees will benefit greatly from a strong educational programme. When the programme and its leaders believe that an investment in trainees is a worthwhile endeavour, the trainees will ensure that this commitment is recognised and valued.

What is “good Orthopaedic training”? We believe it is “the alignment of the right trainee, with the right trainer, in the right environment, at the right time.”

Mustafa Rashid is a ST5 Orthopaedic Specialist Trainee in North East Thames on the Percivall Pott Orthopaedic Rotation and the President of the British Orthopaedic Trainees Association (BOTA). He is currently reading a PhD at the University of Oxford investigating predictive modelling for rotator cuff repair integrity.

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JTO Medico-Legal Features

Expert Witness Institute (EWI) Annual Conference 24th September 2015 Michael A Foy

The EWI was founded in November 1996 to improve the quality and standards of the provision of expert evidence in the both civil and criminal cases. It is a multidisciplinary organisation with representation from the legal profession and a variety of disciplines from which expert opinion might be requested.

The medical profession is well represented among the membership with 45-50% of the 992 members belonging to it.

However, there are also members from diverse disciplines ranging from building/surveying to DNA, fingerprinting and phonetics. In addition to the Annual Conference the EWI runs training courses for experts, has meeting rooms for rent at its London offices and offers a mediation service.

Michael A Foy

Professor Colin Howie, was asked to form part of a panel for a discussion on the subject of, “Experts and the Rule of Law: Was Runnymede 1215 the first hot tub?”. Colin asked me as Chairman of the Medico-Legal Committee to represent him and the Association and I thought it might be useful to provide some feedback on the day’s activities for members through the columns of the JTO. There were 190 people present at the conference and looking at the

delegate list I noted that there were nine orthopaedic surgeons in attendance.

The conference was chaired by Amanda Stevens, ex NHS manager, latterly solicitor and now a partner at Irwin Mitchell solicitors and a Governor of the EWI. The panel for the Runnymede discussion was chaired by solicitor Michael Napier with myself and two barristers, Theodore Huckel QC (Counsel General for Wales) and Graham Aldous QC. The Runnymede theme was topical as we are now in the 800th year since the sealing/signing of the Magna Carta by King John.

The hot tubbing issue was dealt with fairly speedily. As you will be aware, this is an innovation arising from the Jackson CPR reforms introduced in April 2013. Essentially it involves witness conferencing with judge and counsel able to cross examine expert witnesses less formally outside the Court room in order to resolve differences that

have proved irresolvable following joint discussions and preparation of Joint Statements. It was introduced following experience in the Australian legal system. It soon became evident after a show of hands among the delegates that there was very little experience of hot tubbing amongst the attendees with only a handful of the 190 present having any experience of it. The majority of these appeared to be non-medical. It may be that the type of cases that we are involved in do not lend themselves to this process. If any of the JTO readership has experience of hot tubbing or can relate any experiences that we can usefully learn from, I would be interested to hear from them. While the legal profession speak enthusiastically on the subject it seems to be something of a damp squib for orthopaedic and medical experts at the present time.

During this session there was also debate about the role of the medical expert in relation to the Court and to the claimant/patient. The point was made that from time to time one still sees cases where the expert is recommending treatment as part of his/her opinion and then carrying it out. The prevailing view was that this represented a conflict of interest and potentially subjected the expert to criticism and should be discouraged.

In my own practice I have come across this most commonly with Pain Management experts. There was also discussion about how we might try to better educate patients/claimants and GPs about the nature of the legal process

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given that in some cases the legal process overtakes the investigation and treatment of the underlying condition. There sometimes appears to be a misunderstanding by the claimant and his/her GP that various investigations (MRI in particular) and specialist appointments for the legal process are not a direct part of the clinical investigation and treatment of the underlying problem. However, common sense would dictate that any investigations carried out for the purposes of the claim could/ should be made available to the treating consultant rather than be duplicated. There were also discussions on when experts

should hang up their boots with the issues of appraisal and revalidation raising their heads again.

There were presentations from John Sorabji, legal adviser to the Ministry of Justice (MoJ) and David Marshall from the Law Society. Both focused on the effect that governmental cuts in funding would have on the legal process as we experience it. The latest round of savings cuts £249 million from the MoJ budget. Much of the savings are planned to come from closure of Courts and tribunals on the basis that they are underused and there should be greater use of modern IT methods, such as video links in the process. There has been

(L-R) Mike Napier, Mike Foy, Theodore Huckle QC & Graham Aldous QC

a suggestion that for claims under £25,000 (the current fast track limit) a system should be established for Online Dispute Resolution (ODR).

However, with Medco (see later) this will probably not have a great effect on us as orthopaedic surgeons. The legal experts expressed concerns that the adversarial system that exists at present may be replaced by an inquisitorial system. It was felt that advocates of the adversarial system must engage with austerity, IT and proportionality rather than fighting for the status quo.

Judge Allen Gore spoke on, “Current Expert Evidence Issues: A view from the bench”. Much

of what Judge Gore said went over my head but he made some interesting points. He reminded me that part 35 questions are merely for the purpose of clarification. It is worth remembering that the Chancery guide indicates that, “If questions are oppressive in number or content” and are not agreed with the other side the Court will disallow them.

This was timely as far as I was concerned having very recently received part 35 questions running to 56 pages from a claimant solicitor effectively exploring every avenue possible to get me to change my opinion as it was not particularly supportive of the claimants case.

Judge Gore also made the point that in high value/complex cases the expert should be involved in drafting the agenda for the joint discussion with his/ her opposite number as laid down in the 2014 Guidance.

I found this interesting as I would estimate that 90% of the joint statements that I am involved in preparing have no agenda! I am probably asked for advice/input into the agenda in 20/25% of the 10% where there is an agenda.

Judge Gore indicated that there were three common reasons why an experts’ opinion would be rejected: 1. Descent into advocacy i.e. taking sides or lacking impartiality 2. Expression of opinion outside expertise 3. Demonstration that factual assumptions on which the opinion is based are incorrect. >>

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JTO Medico-Legal Features

The point was also made that it is reasonable and acceptable for an expert to change his/her opinion as long as there is a clear reason for the change, for example receipt of additional information.

We were then, I thought, about to be entertained by Stephen Webber, Chairman of the Society of Clinical Injury Lawyers (an organisation that I had never heard of) speaking on the provocative subject of, “What Solicitors really think about Experts”. In fact this was more of a practical and pragmatic offering on how to be a good expert and keep the instructing solicitor happy with advice including: 1. Check carefully that the matter falls within your area of expertise (clinical practice) 2. Check for conflict of interest 3. Read the letter of instruction carefully and ensure that any specific questions within that letter are answered. Don’t just produce a generic report 4. If there is more than one factual scenario provide your opinion on the alternatives.

Don’t argue the case for which is correct, that is for the Court to decide 5. The judge is not a doctor.

Make the report understandable to a lay person, even a professional lay person 6. Have a proper administrative set up and point of contact.

Respond to letters and emails, don’t ignore them 7. Prepare thoroughly for conferences and joint discussions 8. Solicitors have to provide a

EWI Chairman, The Rt. Hon. Sir Anthony Hooper

budget for all costs including expert fees therefore experts have to be prepared to provide a budget if requested 9. Adhere to agreed timetables and particularly timetables set out in Court directions.

It seems that the Society of Clinical Injury Lawyers has been formed this year by leading clinical negligence lawyers, who are concerned that recent legal changes will make it more difficult for victims of medical accidents to obtain full compensation for their injuries and financial losses.

Moreover the Society’s members

believe that the bigger picture is that medical accidents in England and Wales will increase if medical negligence claims decrease since there will be less financial incentives for medical professionals to commit enough resources to ensure such accidents are avoided. Perhaps it is time to revisit the question of a no fault compensation scheme for medical accidents, as exists in New Zealand, Sweden, Finland and Denmark. The Scottish Government have been investigating such a scheme for the last five years and as

I understand it now intends to proceed with caution and further explore how the system may work.

There was then a joint presentation from Senior Costs Judge Peter Hurst and Nicholas Bacon QC on costs with more focus on the state of play with austerity and reduced MoJ funding. The matter of proportionality raised its head again. This is something highlighted recently by the MPS in their briefing paper where they discussed two recent negligence cases:

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from time to time one still sees cases where the expert is recommending treatment as part of his/ her opinion and then carrying it out. The prevailing view was that this represented a conflict of interest and potentially subjected the expert to criticism and should be discouraged.

1. A cosmetic surgery case where damages of £17,500 were agreed within five months of notification of the claim by which time legal costs in excess of £50,000 were being claimed 2. In a second case relating to delayed diagnosis of skin cancer damages of £30,000 were again agreed within five months of claim notification by which time legal costs had risen to £60,000.

Obviously as experts instructed by solicitors for the claimant we don’t usually have a clear idea of the bigger costs picture. In over 25 years of providing expert reports in PI cases and 14/15 years in negligence, I haven’t had my fees reduced during or after the case.

Perhaps I’m not charging enough or perhaps the expert fees are more protected than other areas of expenditure.

The fixed cost medical report through MedCo was discussed.

The first report, whoever provides it, will carry a fee of £180. This will presumably be considerably reduced if the expert is instructed by a Medical Reporting Organisation (MRO). A further report, where justified, will carry a fee of £420 (consultant orthopaedic surgeon), £360 (A&E consultant) or £180 (GP or physiotherapist). Finally, in this session there was a discussion on conditional and contingency fees.

These are strongly discouraged.

The impartiality of the expert is called into question if the nature of the expert opinion might be influenced by payment dependent on the outcome of the case.

The final session directly relevant to JTO readership was titled “Whiplash Reforms: MedCo-Improving the quality and independence of medical reporting”. Again there was a double act presenting with Patrick Allen (Managing partner Hodge Jones and Allen solicitors) and Donald Fowler (CEO, Premex). Those of you who attended the Medico-Legal session at the BOA Congress in Liverpool the previous week will know that we ran a MedCo session with a representative from APIL, an orthopaedic surgeon and the MedCo Chairman to try to and establish some balance and perspective.

Therefore, I was interested to see where we got to with two senior figures in the provision of reports in whiplash cases and no balance from MoJ or MedCo. Predictably, MedCo, set up on 6th April this year was castigated

by Messrs Allen and Fowler.

They believed that following the MoJ consultation last year MedCo was rushed without proper thought or consultation because of the impending general election. The principal complaints/criticisms were: 1. There is no longer any freedom of choice for solicitors in choice of experts. It is now a random allocation process based on post code 2. Accreditation of experts will be necessary by 1st January 2016, although there is no agreed means of accreditation at the present time. However,

since the meeting MedCo have announced two means of accreditation and this has been passed on to the membership via the e-newsletter and elsewhere in this edition of JTO 3. MoJ aim was to improve quality of medical reporting – there is no evidence that this has been achieved 4. “A complete mess and a retrograde step all round”.

I believe that we had a more proactive discussion session at the BOA Congress, although the orthopaedic audience were critical of the set up and the fact that there was a lack of clarity on whether second reports were to be commissioned through the MedCo site. Obviously it will be interesting to see whether MedCo stays the course or is consigned to the scrap heap.

At the time of writing it has still not been up and running for six months so we will have to see how the situation evolves.

All in all this was an interesting day at the EWI Annual Conference with some useful issues aired. Consent and Montgomery were not really discussed. However, it seems that with Montgomery and the Society of Clinical Injury Lawyers, Bolam is coming under increasing attack from the legal profession. They really don’t like us having much say in our own regulation.

Interesting and perhaps worrying times for trainees and newly appointed consultants.

Michael Foy is a Consultant Orthopaedic and Spinal Surgeon, is Chairman of the BOA’s Medicolegal Committee, Co-Author of Medico-Legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.

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JTO Peer-Reviewed Articles

Maximising Training Opportunities: A handy guide for Trainees and Trainers in T&O Mustafa Rashid & Simon Fleming

Being a T&O Trainee has changed dramatically over the last few decades. This is most starkly represented when considering the history of the term, ‘Registrar’. In pre-Calman training, the Registrar was the boss’ right hand man (or woman!). They kept a register of all the patients that were under the care of the consultant.

They lived in the hospital, seemingly night and day; working to ensure the firm kept track of who was awaiting surgery, who was post-op, and where in the hospital they resided. During the firm’s take, the first job of the registrar was to go around the wards and ask Matron how many beds were free so that they could place patients being admitted (whilst keeping a register of whom and where they were). The firm structure worked well, to build a sense of community, teamwork, and apprenticeship.

Whilst it is easy to romanticise this method of training, it did lead to exhausting hours, operating in the middle of the night and being “supervised” remotely.

Mustafa Rashid

Simon Fleming

Thankfully, some may say, we don’t live in those days. We must embrace the present system and say to all the new recently

appointed ST3s, “Welcome”.

We are in a climate of increasingly robust assessment, appraisal, and reporting of competence within surgical training. Here are a few thoughts from people who have only recently been where you are (stood at the front of a trauma meeting, wishing you hadn’t stopped reading the moment that interview was over)…

Let’s begin with a definition of “good” training: Good Orthopaedic Specialist Training is the alignment of the right trainee, with the right trainer, in the right environment, at the right time.

Thinking about that definition, there are obviously some things you, as a trainee, can control >>

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JTO Peer-Reviewed Articles

Practice doesn’t make perfect.

Perfect practice makes perfect.

and others you can’t. Any aspect of your training you can mould to your own needs, you should. Equally, as a trainer, you can influence some aspects and not others. Together, the trainer/trainee relationship can be, at best, a thing of (platonic) beauty or, at worst, a waste of everyone’s time.

1. Pre-Job This one is for both trainer and trainee alike; meet before the start of the job.

Trainees: introduce yourselves; make yourself known to the ward, clinic nurses, and theatre staff. Most importantly, get to know your new trainer. What makes him/her tick? What are their expectations, their pet hates? What is their timetable like?

Trainers: what expectations does your new team member have?

What do they need (not want) to move forward in their training and is this achievable? Be clear to outline what you expect from them whilst they are working for you. Be flexible if their training needs cannot be met by solely working with you and help them achieve these by organising extra training opportunities, perhaps with other consultants.

A trainer who is familiar with navigating the trainer profile on ISCP makes the administrative side of validating portfolio assessments significantly less laborious.

2. Administration Working in the NHS is full of administration, forms, and paperwork. Be a help, not a hindrance to each other.

Trainees: look ahead to operating lists in the coming weeks; ask your trainer if they want you to order any kit, or anything special for the cases. Look at the forthcoming clinic lists, prepare the clinics if possible, read the patients’ electronic notes and review their imaging prior to the clinic. Learn how your trainer likes the clinic letters and operation notes to be laid out, and adjust your dictation style accordingly.

Trainers: your trainee has lots of admin too (see ISCP/ARCP).

Please help them with their WBAs and Learning agreements etc.

They are only valuable learning tools if both sides engage in the process. It is important that trainers should be familiar with the ISCP website, and please validate assessments in good time.

3. Clinics Trainees: clinics can take a variety of forms in terms of how busy they can be, how consultations are undertaken (trainer and trainee in separate rooms, or trainee observing trainer, or even trainer observing trainee), and the patient mix (new, follow-up, post-ops etc.).

Every clinic is an opportunity to further your knowledge, skills, and experience, as well as complete CBDs and CEXs.

Trainers: it is important to understand that all trainees are different. Some trainees may never have done a particular sub-specialty before. Taking the time to explain how you manage common conditions or even writing down how you follow up your common elective cases would be of great help.

4. Theatres Both trainees and trainers enjoy operating. The privilege of being allowed to put scalpel to skin is what motivates a lot of surgical trainees. However, it is really important to ensure that the operating theatre is not merely a production factory but an arena where learning and training should be nurtured.

Trainees: read up beforehand.

There is no excuse for not having read up before an elective list.

Don’t be upset if your trainer will not let you do something, from start to finish, on day one. Don’t be afraid of learning steps of an operation over time, before putting them all together. Your trainer is aware that you have indicative numbers to achieve, but surely you want to be an excellent surgeon, rather than a high volume, mediocre one. Also, don’t push for “independent operating”. Having your trainer scrubbed in with you or in the room is how you improve.

Operating solo without supervision and feedback is not training!

“Practice doesn’t make perfect.

Perfect practice makes perfect.”

Trainers: your trainee wants to learn from you. They want to be better. But they also have index numbers and ARCPs. Please understand that, within safe and appropriate boundaries, trainees will push to operate…and if they don’t, then they should be encouraged to do so. The best trainers use every case as a training case, regardless of complexity. All subspecialties whether surgical or non-surgical have trainees who need to be trained and it is important not to lose these training opportunities.

5. ISCP/ARCP/WBAs etc.

The ISCP and using it to record WBAs as well as achievements, is a vital part of training. Some trainees may not be keen to submit WBAs or input things into the virtual portfolio. However, it must be remembered that it is currently the most robust way of recording one’s progression and achievement of competencies.

It will be scrutinised during the ARCP and the accumuled evidence is used when awarding the Certificate of Completion of Training (CCT).

Trainees: Use the ISCP properly – record everything you can in the Portfolio section. This will be assessed critically by the SAC both during and at the end of training. Keeping it up to date is so much easier than a frantic uploading session before an ARCP. Similarly, WBAs are a very good way to get and record feedback, as well as monitoring

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Š 2015 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 03, Issue 04, pages 42-46 Title: Maximising Training Opportunities: A handy guide for Trainees and Trainers in T&O Authors: Mustafa Rashid and Simon Fleming

your progression towards competency. Submit WBAs appropriately - discuss with your trainer if they are happy for you to send them an assessment and then make sure you do really reflect; think about what you did well and what you could do better. Equally, use the ARCP process for what it is, a chance to look back over the last year and identify areas where you are excelling and areas where you need further development.

Trainers: Please, please engage with ISCP. If sent an assessment, please have a look at it and, if appropriate modify it or give feedback. Trainees appreciate it can be seen as an onerous task, but it is much better and probably a more accurate reflection when assessments are completed regularly rather than numerous assessments just before the ARCP.

6. On Calls On calls are important training opportunities as much as they are service provision. There can be a huge variation between working in a Trauma Unit and a Major Trauma Centre both in terms of numbers of admissions and complexity of cases.

Each patient/case should be taken as a training opportunity to find out more about that particular presenting problem or gain further experience in managing that patient in the hospital setting. Other on call duties involve patient reviews

and working patients up for theatre, taking referrals from colleagues, consenting pre-op patients, operating on patients and reviewing post-operative imaging. All of these are important technical and nontechnical skills which need to be developed into training opportunities.

Trainees: It is extremely important to be organised and efficient. Be punctual for the ever-important handover process. Keep a list of all admissions and ensure that a trainee has seen all new patients. Be supportive to the junior members of the team, and ensure that all important and relevant information is relayed to the on call consultant.

All patients should have a management plan and patients requiring surgery should be prioritised and added to the theatre list appropriately.

Trainers: There will be times when your trainee gets it wrong, gets a complaint or even gets bullied whilst on call. It is important for trainers to be supportive of trainees. Errors of judgment or practice can be used constructively to highlight an area of improvement using non-judgmental feedback in a private setting.

7. Teaching Teaching is important both in terms of overall knowledge acquisition and for

consolidating what is already known. Regional teaching and training programmes have been organised for trainees. It is imperative that trainees attend as many sessions as possible.

Some Deaneries have attendance at a minimum number of sessions stipulated. Teaching could take the role of providing knowledge or training to juniors or members of the multidisciplinary team.

Surveys of trainees opinions on regional teaching programmes shows that a multi-modal approach with patient case conferences, mock FRCS vivas, cadaveric dissection sessions, and consultant-level lectures focused towards the FRCS exam are best received by trainees.

A grand round, journal club or regular consultant led teaching can also be very beneficial.

8. Research and Audit Research and audit are important components of the T&O curriculum and experience/ knowledge of how they should be conducted is expected for the attainment of a CCT. The T&O Specialty Advisory Committee (SAC) were the first to appreciate the importance of experience in recruiting surgical patients into a registered clinical trial, whilst others have purely focused on number of peer-reviewed publications.

Clinical audit can become an afterthought for many trainees however it is expected that T&O trainees complete six audits in

their specialist training with two being re-audit, to complete an audit loop. It is important to register the audit with the audit department as this provides a log of the work that has been completed. The audit department may also be able to provide help, with a list of patients and by obtaining patient notes. Trainees are required to either recruit five patients OR produce two peer-reviewed publications within six years of specialist training for CCT. Trainees: BOTA has created a platform for conducting audit and research that provides you with toolkits, project ideas, template data collection forms, and a means to recruit/share ideas amongst fellow doctors. Sign up to www.bone.org.uk and utilise this platform to make completion of audit/research smooth and pain-free - itâ&#x20AC;&#x2122;s free! If you recruit a patient into a registered clinical trial, make sure you get evidence of this from your research department. Involve juniors (medical students to SHOs) they are a great resource.

Trainers: Many of you have excellent research/audit ideas.

Make sure you discuss the traineesâ&#x20AC;&#x2122; goals for audit/research during the initial meeting. Bear in mind that trainees often find it very hard to say no to a project, so as to not let anyone down.

Be supportive both in advice and your time to ensure your trainee has ample opportunity and time to conduct audit or research during their placement. >>

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Developing a strong mentor-mentee relationship can take time and sometimes a stroke of serendipity. Mentorship is important to motivate others to follow their passion, to giving back to the orthopaedic community, and for shaping an enjoyable career path.

9. Mentoring and Career Advice Developing a strong mentormentee relationship can take time and sometimes a stroke of serendipity. Mentorship is important to motivate others to follow their passion, give back to the orthopaedic community and shape an enjoyable career path.

Trainees: Always be on the lookout for mentors. Seek out people who inspire you and let them know that you are keen for their advice and support. Pass on the same advice and support to juniors who are coming up.

Remember why you chose the specialty and make sure that you and your peers see the enjoyable aspects of the career. Juniors these days are demoralised about their career progression and the light at the end of the tunnel – “the ideal consultant job”. It is important to be proactive and realistic in identifying appropriate subspecialty and fellowship training.

Trainers: Your actions and examples can inspire your trainee to achieve above and beyond any expectations. Training in Trauma and Orthopaedics to how it was five years ago. Take time to learn the challenges faced by the new generation and consider how you can help them overcome these.

Our top tip for careers fulfilment is to have a clear plan, with set, time-based goals. If you do not know what subspecialty you want to pursue, then go and find

out! Attend extra clinics and lists to see if you fancy that brand of orthopaedics. Ask consultants about their fellowship experiences and start planning early. Avoid meandering through your training and hoping to stumble upon your dream job.

Be proactive, seek advice, stay dynamic, and remain insightful about the challenges ahead.

10. Feedback A very clever man once said that “feedback is the breakfast of champions” - it is true. As both trainee and trainer, although sometimes a bitter pill to swallow, we must hear, accept, reflect and action feedback to improve.

Trainees: Feedback is what you need. You can never have enough. Your trainer may or may not be very good at giving it, but be aware that any time someone is commenting on what you did, whether well or badly, whether in a formal setting or over coffee, it’s feedback. Take it on board and reflect on it. Have the insight to realise that you have six years of being told what you are doing well and what you are doing less well, both are equally valuable.

Trainers: Learn how to give feedback and, regardless of how pointless an exercise you might think it is, let us know it’s coming just before you deliver it. Often, if we are either on top of the world or feeling hugely self-critical, we may not recognise feedback for what it is.

Summary

Correspondence:

This article does not pretend to be exhaustive, nor does it cover all aspects of training.

The simple take home message is that as a trainee or a trainer, we must work together with a single goal in mind; to create an environment whereby patient, trainee and trainer all get what they want; the best care, the best training and the best working environment.

Email: mustafa.rashid@doctors.org.uk Email: simonsfleming@doctors.org.uk

Mustafa Rashid is a ST5 Orthopaedic Specialist Trainee in North East Thames on the Percivall Pott rotation and the President of the British Orthopaedic Trainees Association (BOTA). He is currently reading a PhD at the University of Oxford investigating predictive modelling for rotator cuff repair integrity.

Simon Fleming is an Orthopaedic trainee on the Percivall Pott rotation and a keen educator.

He is the Vice-President of BOTA and is working towards his PhD in Medical Education. When not training or being trained he enjoys good food and better company.

References: www.jcst.org/quality-assurance/ documents/certificationguidelines/trauma-andorthopaedic-surgery-certificationguidelines

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Putting the Boot In - intensive simulation based training to prepare surgical trainees for practice Richard Bamford Co-author: Mehool Acharya

Simulation Training

The National Health Service is changing rapidly with increasing numbers of patientsâ&#x20AC;&#x2122; requiring rapid assessment and decision making1. This is coupled with the European Working Time Directive (EWTD) dramatically reducing training time availability.

It is important that adequate training time is balanced against the need for service provision2,3.

As a profession, surgeons are becoming more accountable to the public and surgical outcomes are now available in a range of specialties on a yearly basis4. All of these factors contribute to the traditional apprenticeship model of training no longer being feasible or educationally acceptable1,5.

Richard Bamford

Progressing through training from medical student to senior specialist can be a stressful time for trainees as they develop concerns related to their clinical skills, responsibilities and expectations6,7. This is most evident during the August handover period where new graduates start their training and

the majority of trainees rotate to new programmes. During this time there is evidence that patient mortality can increase and Hospital efficiency reduce8,9.

Simulation offers one potential answer to the challenges faced in the modern work place.

Intensive, simulation rich training programmes or â&#x20AC;&#x153;Boot Campsâ&#x20AC;? have been postulated as a way to develop such skills and may be of benefit to trainees during their handover period10.

This article will explore the use of simulation in the development of surgical skills and its use in a Boot Camp environment.

Simulation training recreates realistic environments to allow for safe, reproducible and effective training of technical and nontechnical skills11,12. The use of simulation in medical education is now well established and in surgery, simulation is often seen as a technique to safely improve procedural skill13,14.

The UK Department of Health and The General Medical Council support the use of simulation in medical training15,16. The Joint Committee on Surgical Training (JCST) and the Intercollegiate Surgical Curriculum Programme (ISCP) have incorporated it into their syllabus and simulated work based assessments can be used to evaluate progression17. In the United States, the Accreditation Council for Graduate Medical Education requires all training centres to provide a simulation and skills lab and the American Board of Surgery mandate that general surgical residents must complete and pass the Fundamentals in Laparoscopic Surgery Programme to become eligible for Board Certification18. Surgical trainees argue that simulation is beneficial

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as an adjuvant to clinical practice and value the skill acquisition it provides19,20,21.

Boot Camps Surgical Boot Camps are innovative, simulation rich environments that allow the acquisition and development of key technical and non-technical skills. A variety of studies have suggested a benefit to trainees prior to commencing their first clinical rotation6,22. National or regional boot camp training programmes for higher specialist trainees in neurosurgery23,24 and cardiothoracic surgery25 have shown benefits to their trainees.

The Royal College of Surgeons in Ireland run a surgical boot camp for core trainees and have found it to be an effective way to rapidly acquire knowledge, technical skills, and confidence26. A similar training programme is available in Scotland27.

Trainees report boot camps to be a useful adjunct to their training and describe them as relevant to clinical training.

Faculty assessments identify improvements in patient assessment, team-working, communication skills, confidence and patient care28.

Meta-analysis of the effects of post-graduate Boot Camps have highlighted that this relatively new concept consistently demonstrates improvement in clinical skill, knowledge and confidence and may be of benefit during a trainees career transitions29. Overall it would appear that Surgical Boot Camps are useful in the acquisition and development of technical and non-technical skills, knowledge and confidence.

If placed at an appropriate time in training these skills may be beneficial to patient safety10.

Surgical Skills Bench models to teach basic surgical skills are commonplace and may use either synthetic or animal tissue (Figure 1).

Porcine bench models have been validated for compression plate application and can be argued to be a realistic and costeffective form of training30. Within laparoscopic surgery it has been demonstrated that low and high fidelity models can successfully be used to develop skills that can be transferred to the operating theatre31,32 and develop the skills required in arthroscopy33.

Studies have demonstrated improvements in the psychomotor skills for arthroscopic surgery using simulators34,35. Howells et al have shown that these skills can be transferred to the operating theatre36. As well as using synthetic models, cadaveric models have been used. While cadaveric bone may be considered less realistic due to the high degree of variability in its biomechanical properties, cadaveric models may be useful for the soft tissue aspect of orthopaedic procedures and have demonstrated improvements in accuracy amongst orthopaedic trainees37. High fidelity virtual reality simulators are also available and include The Knee Arthroscopy Surgical Trainer (KAST), supported

by ABOS, and The Sheffield Knee Arthroscopy Training System (SKATS) have demonstrated both construct, face and predictive validity38,39. Virtual reality simulators have been shown to offer valid, reliable and feasible assessments of a trainee’s skills level40.

While these simulation models are encouraging tools that can be used to develop and assess surgical trainees, access to simulators alone is not the solution to developing surgical skills. Ericsson suggests that

Figure 1: Core Trainees using pork belly to develop suturing skills as part of a basic surgical skills workshop.

successfully learning a new skill requires a mechanism for feedback and repetition of the task41.

Regular repetition and aiming beyond basic levels of achievement are also important to prevent the deterioration of a skill42,43. This may explain why some studies fail to show sustained improvement in performance after initial simulator training44, whilst those who offer repetition in learning are more likely to retain the skill45.

The development of surgical skills using simulation is possible, effective and can transfer skills to the operating room. However, the process must have well defined, specific outcomes and aims and allow for feedback with repeated practice beyond that of the initial training opportunity. Their inclusion in a Boot Camp environment should be encouraged but, to be effective, must not end there and further exposure to practise and simulators must be available.

Non-Technical Skills Technical skills are only one part of surgical training. Clinical judgment,

communication, decision-making, patient interaction and teamwork are essential components required in trainee surgeons46.

The complexities associated with these skills are often the cause of surgical errors. Increased risk of complications and mortality has been demonstrated in teams who do not share information effectively47. Communication and team work issues have been identified as the root cause for up to 70% of adverse events and a contributing factor in 24% of malpractice claims48,49. These non-technical skills are “the critical cognitive and interpersonal skills that underpin technical proficiency”50. A number of assessment tools have been designed and validated to assess team and individual surgeons in these areas50,51. It has been argued that these assessment tools should be integrated into the UK surgical trainee work based assessment scheme52.

Simulation offers the opportunity to train individuals and teams in these skills and does not depend on expensive or complex models to reduced rates of surgical morbidity >>

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Cognitive research suggests that increased confidence is associated with a higher level of motivation and that high levels of motivation are required for the development of a skill62,63. This may demonstrate the importance of confidence but is unproven.

One study has identified a strong relationship between confidence and competence in medical students after training in basic surgical skills, perhaps suggesting that novices are not yet aware of their skill level64.

and increase efficiency53. In situ simulation (Figure 2), where training occurs within the normal working environment has been shown to be beneficial in reducing patient harm when compared to didactic training sessions54. While in-situ training tends to occur with the usual working team, other simulated training opportunities such as those found in trauma tend to be in different teams. The benefit of simulation based training in each setting appears to be equal55.

Simulated trauma training can significantly reduce the errors associated within these highly stressful situations including medication and transfusion errors and significantly improve the efficiency of trauma management56,57. High fidelity manikins can be used as trauma patients during simulated in-situ trauma calls allowing for a realistic situation for the trauma team to manage. Adaptations can be made to the manikins to simulate the physical and physiological impact of trauma and the effect of treatment. This can occur as part of a normal working day in the resuscitation room of an emergency department, as part of a course or in the pre-hospital setting. Figure 3 demonstrates how these models are used during military trauma training in a simulated combat zone. Improvements in teamwork developed during in-situ multidisciplinary simulated trauma cases have been shown to transfer to the real world setting and as such are a hugely valuable resource58.

More recently, there has been recognition that the surgical ward round is a highly important yet variable entity with increased morbidity if undertaken poorly59.

Simulation-based ward round training can assess and improve performance in this area and may therefore benefit patient outcomes60.

Figure 2: The debrief of an in-situ theatre multidisciplinary team simulated training event.

However, the relationship manifests, surgical trainees need to be confident enough to succeed within a highly competitive and challenging environment. Simulation training has been shown to enhance confidence and the Boot Camp is possibly the safest environment to explore the boundaries associated with it.

Knowledge

Figure 3: SimMan 3G Trauma being used for in-situ trauma training on a simulated battlefield. The same principles can be used to develop trauma team skills in an Emergency Department Resuscitation Bay.

The development of non-technical skills is essential for surgical trainees. Many trainees will need to develop these skills rapidly and with limited experience while they attempt to simultaneously master technical skills. By introducing these components at an early stage of training and reinforcing their value, trainees will have long lasting tools at their disposal.

Confidence The relationship between confidence and surgical performance is complex and this is reflected in the limited data available on the subject. Despite this, a wide range of evidence exists demonstrating that simulation training increase confidence in surgical skill32, knowledge61 and non-technical skills50.

The acquisition of knowledge has not traditionally been associated with simulation training, however, an integrated framework of simulation design allows for knowledge to be obtained alongside technical skill65. This can take the form of identifying anatomical structures during a simulated procedure or explaining the reason behind choices of surgical equipment and approach. Further knowledge can be derived by the need to justify decisions and explain the physiological or mechanical impact this will have. Webbased pre- and post-simulation assessment and computer based simulated patients allow for trainees to work through their decision making process and understand the impact of their decisions. Van Heest demonstrated this successfully as

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part of an integrated carpal tunnel training programme61. More often, simulation is a tool by which the application and refining of clinical knowledge can be developed66,67.

Expectations and requirements for knowledge will vary amongst trainees according to grade and experience. For simulation to be successful in the acquisition and application of knowledge, it must be aimed at the correct end user.

Boot Camps for trainees of the same seniority and during periods of transition between grades therefore seems an appropriate way for this

to be accomplished, highlighting the level of knowledge that can be expected in their new role.

Summary Simulation offers opportunities to develop skills in all the suggested areas of a Surgical Boot Camp.

By providing an appropriately timed intensive simulation rich induction course, trainees will quickly develop the core technical and non-technical skills required for safe practice. In doing so patient safety may be improved

and there may be a significant reduction in the “August effect”.

Richard Bamford is a Surgical Trainee within the Severn Region and is the inaugural Health Education South West Severn School of Surgery Simulation and Non-Technical Skills Fellow and Honorary Senior Lecturer at the University of Bristol. His main educational areas of interest are in teaching postgraduate trainees, using simulation, virtual patients and technology enhanced learning, to develop technical and non-technical skills.

Correspondence: Email: richardbamford@doctors.org.uk

References: References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Peer-Reviewed Articles

Severe Pelvic Trauma in the UK: the trainees experience, needs and expectations Mehool Acharya

Major pelvic fractures are usually the result of high energy motor vehicle accidents. The fracture incidence has been estimated as 3 per 100,000 (population). These injuries are commonly part of a multisystem injury. A mismanaged pelvic injury can lead to early death from haemorrhage or later death and disability from complications or sequelae of multisystem organ failure1. Open pelvic fractures account for approximately 3-5% of all pelvic injuries and are at the more severe end of the spectrum. They are associated with a mortality rate of between 30-50% and high levels of morbidity2,3.

Reconfiguring of major trauma to establish major trauma centres (MTCâ&#x20AC;&#x2122;s) in the UK has seen a 20% increase in patients surviving major trauma.

Pelvic binders are the first line management for any patient presenting with hypotension and a suspected pelvic ring injury.

Rapid resuscitation and damage control surgery are strategies to prevent the lethal triad of hypothermia, acidosis and coagulopathy4.

Mehool Acharya

All MTCâ&#x20AC;&#x2122;s should have a protocol in place for dealing with patients that continue to remain haemodynamically

unstable even after the initial period of aggressive resuscitation.

The establishment of MTCâ&#x20AC;&#x2122;s is considered by some to have also had an effect on general and complex trauma training for orthopaedic trainees. It is currently not compulsory to rotate through the MTC as part of orthopaedic surgical training (ST) and thus trainees may never be exposed to managing patients with severe pelvic fractures and multiple injuries.

The aim of this study was to determine whether

orthopaedic trainees felt that they had adequate training in the management of a haemodynamically unstable patient with a pelvic fracture and to identify any possible deficiencies in training.

Study design and methods All BOTA trainees were sent an online questionnaire to complete. There were 21 key questions all relating to the management of a haemodynamically unstable patient with a pelvic fracture (Appendix 1*). Responses were either Yes, No or unsure. All trainees were sent a reminder email a few weeks after the initial questionnaire to increase the response rate. The results were collated and analysed.

Results 154 members of BOTA (approximately 18% of all members) responded to the questionnaire. This ranged from foundation year 2 doctors to individuals in a substantive orthopaedic consultant post.

Nearly 90% of respondents were in specialist training years with 16% ST3, 16% ST4, 15% ST5, 10% ST6, 13% ST7 and 20% ST8. 56% of trainees

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Š 2015 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 03, Issue 04, pages 52-54 Title: Severe Pelvic Trauma in the UK: the trainees experience, needs and expectations Authors: Mehool Acharya

were working in a hospital that managed patients with pelvic trauma. 45% of trainees reported that their hospital had a management protocol for dealing with the haemodynamically unstable patient with a pelvic fracture.

20% of respondents reported that there was no such protocol available for dealing with these injuries and the remaining 35% reported that they were unsure whether there was a protocol available in their hospital.

comfortable applying a pelvic external fixator and had actually applied an external fixator to the pelvis (Figures 1 & 2).

Figure 1: Have you ever applied an external fixator to the pelvis?

Pelvic Packing - 23% percent of trainees have been involved in the management of a patient that required emergency pelvic packing. However, only 10% of trainees would be happy to perform emergency pelvic packing for a patient with a pelvic fracture and heamodynamic instability (Figure 3).

90% of trainees reported that there was a massive transfusion protocol in their hospital, 9% were unsure and the remaining 1% reported that there was no such protocol in their unit.

When asked whether trainees were comfortable dealing with a haemodynamically unstable patient with a pelvic fracture, 60% reported yes, 19% reported no and the remaining 21% were unsure.

Figure 2: Do you feel able to apply an external fixator to the pelvis?

Pelvic binder - 97% of respondents were comfortable applying a pelvic binder. However, only 88% of respondents had actually applied a pelvic binder.

Pelvic External Fixator Almost 50% of trainees were

C Clamp - 13% of trainees reported that their hospital had a C Clamp, 32% reported that there was no C clamp in their hospital and the remaining 55% were unsure. Only five of the respondents were comfortable applying a C Clamp and only four had actually ever applied one.

Figure 3: Do you feel able to perform pelvic packing?

Pelvic fracture and urethral injury - 60% of trainees had managed a patient with a suspected urethral injury. Nearly 36% of respondents were happy to perform a cystourethrogram in patients with a pelvic fracture and a suspected urethral injury. However, only 18% of respondents had actually performed a cystourethrogram.

Open pelvic fracture - Less than half of all respondents reported that they had been involved in >>

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JTO Peer-Reviewed Articles

95% of respondents reported that they would be very keen on standardised pelvic and acetabular trauma training during the ST years.

the management of a patient with an open pelvic fracture (Figure 4).

knowledge, performing a skill and developing experience.

General Pelvic trauma training 27% of respondents reported that they had completed a specific pelvic and acetabular trauma post in their training to date.

However, nearly 70 % had had some structured training in the management of pelvic fractures.

The trauma and orthopaedic curriculum suggests that a level 4 competency (knows specifically and broadly) should be attained for ST3-8 in applied clinical knowledge for pelvic fracture stabilisation. It also suggests that ST3-8 should have the applied clinical skills to apply an external fixator to the pelvis5.

95% of respondents reported that they would be very keen on standardised pelvic and acetabular trauma training during the ST years.

Discussion This is the first study of its kind in the UK where a survey of orthopaedic traineesâ&#x20AC;&#x2122; experience, ability and technical skill in managing patients with severe pelvic trauma has been conducted. There has been no attempt to demonstrate the knowledge associated with these technical tasks and skills. However, it is appreciated that there exists a complex relationship between acquiring

The results of this study show that just over 50% of trainees have been involved in the management of a patient with a pelvic fracture and haemodynamic instability and that just under 50% of trainees were aware of the existence of a departmental protocol for the management of these patients.

Only 50% of trainees felt they had the skill and experience to perform specific tasks essential in the management of a patient with severe pelvic trauma. This may be in part related to the training that trainees are exposed to and whether or not they rotate through the MTC during their training. One of the ways of

potentially increasing exposure in dealing with these patients would be for all orthopaedic trainees to rotate through the MTC during their surgical training. However, it may prove to be impossible for all trainees to rotate through an MTC as part of their orthopaedic surgical training and thus it may be more appropriate to ensure that all orthopaedic trainees whether they work in an MTC or not are provided with the opportunity to access standardised training.

Conclusion The results of this survey show that amongst orthopaedic trainees in the UK there is a variation in skill, ability and experience in the management of patients with severe pelvic trauma. Over 95% of trainees would like standardised pelvic and acetabular training during the ST years. Standardised training related to the emergency management of patients with severe pelvic trauma should be available to all orthopaedic trainees. This is probably most beneficial for both trainees and patients if it is in the early years of orthopaedic surgical training (ST3-5). Formal assessment should be undertaken to ensure that appropriate levels of competencies are achieved.

Acknowledgements

Figure 4: Have you managed a patient with an open pelvic fracture?

I would like to thank Mr Jeya Palan (a former President of BOTA) for help with sending out the questionnaire.

Mehool Acharya is a Consultant Orthopaedic Trauma Surgeon in Bristol. His subspecialty interests include pelvic and acetabular trauma and hip and knee arthroplasty. He is the Deputy Chair of the Severn School of Surgery Training, Skills and Courses Committee. He has been involved in setting up and running numerous courses in the UK, Europe and Australia.

Correspondence Email: mez001@hotmail.com

References *The appendix and references can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

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© 2015 British Orthopaedic Association

How I... maximise opportunity and efficacy with Workplace Based Assessments Alex Trompeter & Paul Fearon Contributing Author: Lisa Hadfield-Law The last few years have heralded significant changes in the way medical education is delivered, assessed and recorded. Surgical specialties, including trauma and orthopaedics have been at the forefront of this change and embraced the concept of workplace based assessments (WBA’s), using the Intercollegiate Surgical Curriculum Programme (ISCP) as the web-based educational platform.

Concern remains amongst trainees and trainers as to the target number of WBA’s a trainee is expected to achieve per year (Hunter, Baird & Reed 2015).

Targets of 40 to 80 WBA’s per trainee, per year, potentially has a significant impact on resources.

Completion of WBA’s should not be considered a burden, but a means to maximise learning opportunities. For an assessment to have an impact, rather than just be a tick-box exercise, it is vital that it is discussed soon after it is undertaken. After a constructive

discussion with their trainer, the trainee should complete the relevant forms, including reflective comments. Blank forms or forms sent to a trainer, after a significant delay, should be rejected. We suggest that after 48 hours the educational benefit of the WBA wains, without focused discussion, recording and validation.

Importantly, the effort should focus on the learning event, rather than the form filling. For all clinicians, the challenge revolves around time to integrate WBA activity in to a standard working day.

Nevertheless, there is unused time in the typical day which could be used for educational opportunities.

Imagine a normal working day.

The trauma meeting is an excellent platform for a case-based discussion (CBD). The trainee must engage with and reflect - how they could better structure an answer next time; how they could follow up with self-study.

Furthermore, a trainee could present an overview of a topic previously

discussed - an opportunity for an observation of teaching (OOT) WBA. Senior trainees, post FRCS, could run the morning meeting.

If they have the required number of WBA’s, they could complete an OOT, to demonstrate improvement in teaching skills related to running the morning meeting and asking questions.

Paul Fearon is a Consultant Orthopaedic Trauma Surgeon based at RVI Newcastle. He trained in Belfast, Scotland, NE England and North America.

Clearly there remains a range of opportunities for assessment when the day’s clinical activities are Time

Activity

WBA

Example

08:00 – Trauma 09:00 meeting

CBD OOT

Discussion on distal radius fractures Senior SpR leading questioning; Short presentation on a topic previously discussed

09:00 – Clinic 12:30

CBD CEX DOPS

Case based discussion and presentation Examination of patient Application of cast

12:30 – Governance/ OOT 13:30 Audit CBD

Presentations made at Grand Rounds etc.

Audit methodology and presentation

13:30 – Theatre 17:00

NOTSS Theatre set up; WHO time out CDB Specific discussion related to case; ‘Talk-through of surgical steps’ while scrubbing; Case planning and templating CEX EUA of knee DOPS Application of cast; Suturing of wound PBA Index procedures; Generic PBAs OOT Supervision of junior

17:00 – Journal club 18:00

OOT CBD

Presentation of paper Engaging and leading on discussion

18:00 – On call 08:00

CBD DOPS CEX

Presentation of case to senior Reduction of dislocated joint Neurological examination; Trauma call lead

CBD

Research methods; Communication skills; Management and Leadership experience; Reflective CBD for challenging event Simulated PBA on sawbones (courses)

PBA Paul Fearon

Alex Trompeter is a specialist complex trauma and limb reconstruction consultant working at St George’s hospital in London.

This is a level 1 major trauma centre and tertiary referral centre for complex orthopaedic conditions.

Table 1 highlights the opportunities to complete a WBA typically found in a working day and specifies which types can be allied to certain clinical activities.

Other

Alex Trompeter

realised for their true educational potential. Remember, time spent discussing performance and recording reflections and feedback are invaluable for trainees and the training process.

Table 1: Opportunities to complete a WBA

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In Memoriam

Leslie Klenerman

1st May 1929 - 20th July 2015 Before 1994 many South African surgeons left for Europe or North America for a more liberal regime. Many made an outstanding contribution in their adopted countries but few made a greater contribution than Leslie Klenerman.

Leslie had been an outstanding swimmer in his youth and even planned to swim the 18 kilometre length of Windermere in the English Lake District long after retirement. The same degree of determination and dedication characterised his orthopaedic career. He never ceased to read, write and think about the human body and almost until the end of his life taught in the Anatomy Department of Cambridge University.

Leslie Klenerman

His special interest was the foot and ankle. He was a founding member of the British Orthopaedic Foot and Ankle Society and acted as secretary for many years.

He was elected president of this society as well as the British Orthopaedic Research Society. From its inception he was a leading figure in the European Society of Foot and Ankle Surgeons and was instrumental in the union of this society with the European Federation of Foot and Ankle Surgeons. The new society, the European Foot and Ankle Society, was established in 1998 and, before this, Leslie was appointed as the first Editor in Chief of Foot and Ankle Surgery in 1996.

Subsequently he resigned from this post but in 2008, as a mark of respect for his contribution to foot and ankle surgery, he greatly enjoyed returning as a guest editor for a special volume.

He was always more academic than most European orthopaedic surgeons and in 1970 moved from a routine post in North London to work at Northwick Park Hospital which then had a close relationship with the Medical Research Council. In 1987 he moved to the prestigious chair of orthopaedic surgery in Liverpool. This was a famous department with a tradition going back to Sir Robert Jones and a training program leading to a higher degree in orthopaedic surgery. The degree of MCh Orth (Liverpool) was highly regarded and its reputation was enhanced during Leslieâ&#x20AC;&#x2122;s tenure.

His research interest never flagged. After retirement he had a plan to continue research with his friend Henry Mankin in Boston USA. This never happened but he did publish five books after retirement and was working on an introduction to anatomy

at the time of his death.

Typically he died soon after travelling to London to hear a lecture at the British Museum.

For a man of such distinction and achievement Leslie was never one for self-promotion.

His achievements speak for themselves, as do the number of foot and ankle surgeons who were trained and inspired by him.

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In Memoriam

Max Henry Montague Harrison 16th March 1922 - 22nd January 2015 Max Harrison was educated at Leeds Grammar School and Leeds University, and graduated in Medicine in 1942. His orthopaedic training in Oxford, under Sir Herbert Seddon and Joseph Trueta was completed at the Westminster Hospital, London and in the United States.

In 1958 he was appointed Consultant Surgeon to the Royal Orthopaedic Hospital and General Hospital, Birmingham.

Max Henry Montague Harrison

His ChM thesis on the blood supply of femoral head stimulated a lifetime commitment to the treatment of Perthes’ disease, numerous publications

on conditions related to hip development in childhood and a Hunterian Professorship in 1976.

Max was an outstanding and inspiring teacher of undergraduates and trainee orthopaedic surgeons, and a man of firm moral and religious conviction who influenced a generation of trainees by example. He developed links with colleagues in Israel and trained their young surgeons who went on to form a network of centres in that country.

He was a founding member of the British Orthopaedic Research

Society, a member of the JBJS Editorial Board and BOA Executive (1965-1966) and a past President of the Naughton Dunn Club (The West Midlands Orthopaedic Association).

After retirement he continued with medico-legal work and was a regular user of the hospital library into his 90s. He was dedicated to the wellbeing of the Royal Orthopaedic Hospital and was Founder Member of the Board of Trustees.

He married Valerie in 1950, with whom he had two daughters, Ruth and Judith, and a son Barney.

Peter Leo Frank

26th December 1928 - 19th November 2014

Peter Leo Frank

Born in Prague in 1928, Peter was incarcerated during the war in concentration and slave labour camps. His proficiency in languages meant he could translate for a French doctor providing care to inmates. This engendered a love for medicine, and helped him survive. Rescued to England in 1945, Peter returned to formal education qualifying from Manchester in 1956. He trained in orthopaedics in Manchester and Salford, and was a consultant at Salford Royal, Hope Hospital, and Manchester Children’s Hospital, with a thriving private practice in the North West, London and the Channel Islands.

In memoriam

It is with great sadness that we report the death of Frank this time. A full obituary will appear in our next edition.

An honorary lecturer and fellow at the Universities of Manchester and Salford respectively, Peter’s research included: the normal and abnormal lower limb development in children, whiplash, portable traction, and joint replacement and bone graft techniques. Peter strongly supported the orthopaedic academic department in Salford, campaigning for the establishment of a University of Manchester Chair in Hope hospital, and its continuation.

He introduced several techniques into Salford including total hip and knee

joint replacements and silastic hand implants, and was an acknowledged expert in spinal surgery. Peter retired from the NHS at 60 to concentrate on medico-legal practice and was a highly sought-after expert witness. At the time of his death after a severe stroke he had just completed his last cases, exasperated as ever at delays from repeated court postponements. He was foremost a ‘general orthopaedic surgeon’ building on diligent learning from the modern specialties founders, and passing this expertise onto those following him.

Horan shortly before the JTO went to press. Our thoughts are with his family and friends at

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Imprint

JTO: Information for readers, advertisers & potential authors

Instructions for authors

Future publications

Authors wishing to submit a news item, feature article or peer-review article for the JTO should, in the first instance, submit a synopsis of 120 words explaining what the article is and its relevance within the JTO. This should be emailed to JTO@boa.ac.uk. This will then be passed on to the Editorial Team for confirmation that the subject matter will be appropriate for publication. You will receive an email from the JTO team indicating their decision. The JTO does not publish audits or case reports.

JTO is published quarterly.

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JTO Editorial Team l l l l l

Ian Winson (Editor) Fred Robinson (Deputy Editor) Michael Foy (Medico-Legal Editor) Mustafa Rashid (Trainee Section Editor) Mehool Acharya (Guest Editor)

BOA Executive Tim Wilton (President) Colin Howie (Immediate Past President) Ian Winson (Vice President) Ananda Nanu (Vice President Elect) Don McBride (Honorary Treasurer) David Limb (Honorary Secretary) l Mike Kimmons (Chief Executive)

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Tim Wilton (President) Colin Howie (Immediate Past President) Ian Winson (Vice President) Ananda Nanu (Vice President Elect) Don McBride (Honorary Treasurer) David Limb (Honorary Secretary) Gordon Matthews Ananda Nanu Alistair Stirling R. Adam Brooks Grey Giddins Ian McNab Philip Mitchell David Clark Simon Donell Mike Reed Fred Robinson

Registered Charity No.1066994 Company limited by guarantee Company Registration No.3482958

BOA Staff Executive Office Chief Executive.............Mike Kimmons CB Personal Assistant to the Executive........................ Celia Jones Education Advisor ........ Lisa Hadfield-Law

Policy & Programmes Director of Policy & Programmes ..................Rayshum Notay Policy & Programmes Officer ................................Matthew Barker Policy & Programmes Officer .................................. Phoebe Jones

Communications & Operations Director of Communications & Operations ........................ Emma Storey JTO & Joint Action Officer ..... Lauren Rich Office Co-ordinator......Natasha Wainwright

Quality Outcomes Programme Director ............... Julia Trusler

Finance Director of Finance ...........................Liz Fry Deputy Finance Manager.................. Sherrine Wilson-Smith Finance Assistant . .................Hayley Oliver Finance Assistant (Membership) ..................... Miranda Boyce

Events & Specialist Societies Director of Events Management ....................... Hazel Choules Exhibition Manager ....................Janet Mills UKSSB Executive Assistant ............................Julia Bloomfield

Information Systems Director of Information Systems . .............................Melanie Knight Information Systems Assistant.................................Claire Wilson

News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 and must include an image.

We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 200 words and should include a photo. Feature articles and Peer-Review articles should be no longer than 1,500 words.

Please be aware that the Editorial Team reserves the right to reduce the content where appropriate.

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All articles should include images, illustrations, graphs, tables etc. where possible – this is strongly encouraged.

These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title.

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Peer-Review articles will be reviewed by two or more (where appropriate) independent reviewers following a review by the Editor. You may be asked to revise your article following this process and you will be provided with the reviewers’ remarks to help you with this.

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You must submit with your article and images; a photo of yourself and a short bio in the third person (no more than three sentences).

You will be sent a Copyright Form following your article submission and this should be returned by email (signed, dated and scanned) to JTO@boa.ac.uk or posted to JTO Team, BOA, 35-43 Lincoln’s Inn Fields, London WC2A 3PE.

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Advertising All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820

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.

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Tom Smith, Barney Harrison, Alistair Thompson, Patrick Mulligan, Mark Gabbay & Charles Galasko.

Copyright Copyright© 2015 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

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

Festive Quiz Answers Answers to: Around the world at Christmas – 1. The Netherlands; 2. Argentina; 3. Greece; 4. Iceland; 5. Italy; 6. Hungary Answers to: Orthopaedic Milestones – A. 1741; B. 2003; C. 1962; D. 1918; E. 1990; F. 1940; G. 1954; H. 1894; I. 1768; J. 2005