Journal of Trauma & Orthopaedics - Vol 4 / Iss 4

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 04 / Issue 04 / December 2016 boa.ac.uk

From:

the B OA

Inside

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

In our Features section you will find out about the value of your membership; Scaling Up; our regular “How I Do…” piece and some festive fun for you and your family

For the latest update on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is hand surgery

News & Updates ––– Pages 02-19

Features ––– Pages 20-47

Peer-Reviewed Articles ––– Pages 48-58

Volume 04 / Issue 04 / December 2016

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JTO News and Updates

From the new Editor

Contents

Phil Turner, Vice President Elect

One of the pleasures of being elected to the Presidential line is the task of editing the JTO. It is an additional pleasure to realise that I share this work with such a talented and enthusiastic Editorial Team. I look forward to providing you with interesting and thought-provoking items for the next two years.

What could be in the festive gift box on the front cover? The benefits of BOA membership; access to the Annual Congress, training courses, podcasts and, of course, your JTO are just a few potential gifts. The article

by Colin Howie provides an excellent overview of the work of the BOA and how this translates into support for our members.

I thought the Congress in Belfast was a great success and this view is supported by the positive feedback from consultants, SAS doctors and trainees in this issue. The inspirational talk from Mandy Hickson was clearly one of the highlights of the Congress.

As Guest Editor, Grey Giddins has provided us with a timely update on some of the key areas in hand surgery and the practical ramifications of “Montgomery” are explored by David Warwick as they apply to the choice of management of wrist fractures and how they can be expressed to patients in a meaningful way.

Once you have had your fill of education and brought yourself up-to-date with all the issues facing us in our profession, turn to the Festive quiz and see if you can solve the questions without reverting to “Google”. You can then finish off the season by sending us the wittiest possible caption for the very worrying photograph of Steve Cannon on page 16.

With best wishes from me, Fred Robinson and the rest of the JTO team.

JTO News and Updates

02–19

JTO Features

20–47

The value of your Membership

20

The use of 3D printing in paediatric orthopaedics for pre-operative planning and bespoke therapeutics

24

Operations we no longer do: Posterior Iliopsoas transfer (Sharrard Procedure)

26

Factors affecting total operating time for a standard surgical procedure

28

Festive Fun

30

Scaling up

32

The Thiel Cadaver: are we entering a new frontier in orthopaedic training?

34

PROMs: are we singing from the same score?

36

How I Do… a Supra- Acetabular Pin Placement for an Anterior Pelvic External Fixator

38

Building on the BONE

40

Being an Orthopaedic Consultant in 2016

42

Montgomery and Wrist Fractures: what should we tell the patient?

44

JTO Peer-Reviewed Articles 48–58

The non-operative management of hand fractures: a review

48

The role of implant arthroplasty in the management of the painful distal radio-ulnar joint

52

Measurement and assessment in modern hand surgery research

56

General information and instructions for authors

60

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JTO News and Updates

From the President Ian Winson, BOA President

So, suddenly you are President of the BOA and you think “I’d better start concentrating”. When I was invited to stand as a Presidential candidate, we seemed to be having a slightly tough time. But, I didn’t expect to be confronted with some of the issues we now face. Top of the list has to be the trainees. The constant demoralisation of the junior staff workforce simply cannot be allowed to continue.

Ian Winson

The BOA continues to make great efforts on the national political front to influence thinking. Much of our efforts seem to fall on stony ground and the question that arises is why the medical profession seems to be uniquely targeted for this treatment. There appears to be a naive belief that because we are caring, we will just keep taking it. I fear the reality is that there is not an infinite line of bright, appropriately skilled people who will be happy to see their quality of life reduced in comparison to their peers. It is some time since we have seen conscription but conscription you pay for is an interesting concept. We, of course, do have to put our own house in order. In general terms we still hear people talking about the feminisation of the workforce as a form of criticism.

Recognising the needs of our trainees is critical and, to a large extent, that means we have to look at service reconfiguration to increase the efficiency of our service and increase the opportunities for training. A great deal of work has been done to get a genuine

curriculum for the early parts of training and we have to reach back further into medical school to inspire the belief that trauma and orthopaedics is an option which is personally and intellectually satisfying.

How we measure what we do is evolving. The growth of registries means that we have the opportunity to observe more of what we do and better understand how to develop our practices. To make this data meaningful it needs to be as complete as possible, to be looked at and reflected upon and, if necessary, acted upon. The BOA Council, as a whole, believes that the public presentation of surgeon specific data is inappropriate and acts as a major barrier to this quality improvement effort. There are far too many variables in individual practice to make this a useful exercise. Unit level data, particularly when accurate, is useful; it provides an opportunity to units that are failing. The analysis of why they are failing and what resources are needed will make this change possible. That is

an argument we do seem to be winning and we will continue to push this as strongly as possible.

That brings me round to the culture in which we live. We had a great Congress in Belfast. We were warmly welcomed; Belfast is a thriving city, and those of us who managed to get out into the countryside were shown some wonderful scenery. There were many highlights but two stood out for me. The Howard Steel lecturer, Mandy Hickson, gave a great talk but the last ten minutes were important where she spoke about the change in culture from a blame culture to a just culture in the aviation industry. There are external forces that hold us in a blame culture and we have to change that. The Presidential lecturer, Professor James Wright, reminded us that there are some internal issues. We are all resistant to change by virtue of our own bias. So, there is a clear message that we should all strive in our professional lives to make change happen and be prepared to innovate.

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Deborah Eastwood - Honorary Secretary 2017-2019 I trained at the University of Birmingham Medical School and was privileged to be part of a truly integrated and continuously assessed clinical courses which taught us the importance of being a ‘good doctor’.

Deborah Eastwood

I was never a DIY type and moments/forces were not my strong points. Nevertheless, due in part to serendipity and some smart mentoring I ended up a paediatric orthopaedic surgeon who splits her time between Great Ormond Street and the Royal National Orthopaedic Hospitals, London.

My training included junior posts in the West Midlands, a quick stint in Brisbane, the Bristol SR rotation and then some specialist training in

Sheffield, Toronto and Melbourne before coming to the Royal Free, London for a general orthopaedic (with an interest!) job.

I have changed consultant posts twice since then and with each move have become more specialist. I still believe that a general training is an excellent, almost essential, foundation for the super-specialist.

I have always enjoyed teaching and mentoring: initially medical students and junior trainees and now at fellow level; so one of my proudest moments was being ‘the also ran’ for the BOTA TOTY 2016!

Outside the day job I have been a bit of a ‘jack of all trades’: I have

recently been elected to the Council of Management for the BJJ; have completed my service to EPOS (European Paediatric Orthopaedic Society) with the 4-year Presidential line post and in the past contributed to the Tertiary Paediatric Services review in London and to the development of the RCS framework for Children’s Surgical Services. I try to keep the research box ticked as well.

I am honoured that you have elected me to serve as Honorary Secretary and I look forward to getting back to my roots. I hope that together we can continue to be good doctors and provide a good service to our patients.

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JTO News and Updates

The New BOA Trustees (2017-2019) Mark Bowditch

Lee Breakwell

My specialist interest is knee surgery, particularly soft tissue.

My mentor, David Dandy, guided me to a fellowship with Greg Keene in Adelaide where I really honed my arthroscopic skills.

Mark Bowditch

I am a Consultant at the Ipswich NHS Trust where I was appointed in 2000. I qualified from Manchester in 1989 after an intercalated BSc in Physiology, knowing that orthopaedics was for me. Surviving Charles Galasko’s HO post, I went to Glasgow University to demonstrate then on to Edinburgh as A&E SHO in perhaps a forerunner of a MTC set-up.

My peri-fellowship BST was in Sheffield. The queue for registrar jobs at Sheffield was long so I applied for the Cambridge registrar rotation, where my parents lived. This became the East of England HST where I first worked in Ipswich.

I was BOTA secretary in 1998 and since being at Ipswich I have pursued my interest in training, becoming TPD for East of England in 2006 until now. It has been an immense sense of pride to have contributed to and follow the progress of new trainees through their achievements on the programme and subsequently in consultant life. I’ve been a FRCS Orth examiner for eight years and served on the SAC for the last five.

I was recently appointed as Chair of the SAC in T&O from January 2017.

I previously sat on BOA Council as President of BOTA, which was a tremendous experience, and I vowed to try and return once grown-up.

I have gained experience in education and management as Director of PGME and Responsible Officer at the Children’s Hospital, and on the Executives of BASS and BSS. I also served as Education Chair for AOSpineUK.

Lee Breakwell

In Ipswich, I have very supportive colleagues who have allowed me to pursue my leadership roles with the mentorship of Clare Marx (PRCS Eng). I have been Chair of the MSC and am currently the Surgical Divisional Director.

I am a full-time Spinal Surgeon at Sheffield Children’s and Teaching Hospitals. I have been a Consultant for 10 years. I am honoured to have the opportunity to represent my colleagues and am grateful to those who voted for me.

I am married to Lucy with four children and relax on our small hobby farm in Suffolk with my vintage MF tractor, six dogs and five alpacas amongst a variety of other animals. Others might say I don’t really relax at all, since I’m a keen triathlete, regularly competing at the 70.3 distance and a past Ironman.

I would seek to offer a balanced view on most things, but specifically I intend to represent the spinal surgery world to the BOA and beyond.

I’m really looking forward to serving as a BOA Trustee and thank you for voting for me.

I graduated from Sheffield, and subsequently worked in the West Midlands, in particular the Royal Orthopaedic, where I got the spine bug, and fellowships in the USA and Nottingham preceded my return to Sheffield.

I was co-designer of the British Spine Registry and administered the system for three years from launch. I still represent the Registry for BSS and am a founder member of the BOA registries group.

I recently joined the UK Spine Societies Board as Secretary, and intend that this is the conduit through which spinal surgery and orthopaedics in the round can communicate for the good of all involved.

I am Chairman of Sheffield Orthopaedics Ltd, one of the largest private practice groups in the country.

I am married to Kim, who works as a GP, and have two teenage kids and a boxer dog. I enjoy fishkeeping and try to stay active playing badminton and tennis.

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Simon Hodkinson

Richard Parkinson

My higher training took me out of the Navy to Edinburgh and Leeds before being appointed a Consultant in the Navy in 1995.

Deployments to Cyprus, Bosnia and the Gulf intermingled with my early career and I then left the Navy in 1999 to join the NHS in Portsmouth.

I started my Consultant career at Wirral NHS Trust in the Mersey Region. I was appointed in 1994 with a primary interest in surgery of the knee. I have developed that subspecialty but I still perform over 100 primary hip replacements per annum. My orthopaedic hero is Professor Sir John Charnley.

In the NHS I developed my fledgling interest in foot and ankle surgery, which rapidly became my chosen speciality as the department expanded.

Simon Hodkinson

I trained in London at St Bartholomew’s Hospital from 1977-82. I was a Royal Naval cadet as a medical student so after house jobs in London and the Navy I spent the next two and a half years on General Duties in the Royal Navy.

After a crash course in all sorts of medical disasters I might face at sea, I went to the Falklands and Antarctica for the best part of a year before spending the second year in general practice in a naval base. I started my surgical training within the Navy in 1986 and in 1990 joined the fledgling HEMS project at the London as one of the original three doctors flying on the helicopter.

After a period as Clinical Director in Portsmouth, my interest in education started as the RCS Tutor and progressed to being the Training Programme Director for T&O in Wessex for eight years and membership of the SAC for five years. I remain on the Training Standards Committee and the Education Committee of the BOA. My wife and I remain on the South Coast and our children have fled the nest; one into the profession, the other to the Foreign and Commonwealth Office.

I am honoured to have been elected as a Trustee and look forward to serving the profession over the next three years.

I have just completed my two year term of office as President of BASK (British Association for Surgery of the Knee).

I have previously served on the Education Committee and the Professional Practice Committee of the BOA. Richard Parkinson

I was fortunate to be born in Ilkley in the county of Yorkshire and completed my secondary education in York. I then attended medical school at the Victoria University of Manchester where I graduated in 1981. My postgraduate training took place in the North West Region under the auspices of Professor Charles Galasko. I did an overseas AO travelling trauma fellowship at Harbour View Medical Centre in Seattle, USA. My knee arthroplasty fellowship in 1993 was with John Bartlett in Melbourne, Australia. I did a further sports medicine fellowship with Dr Kennie Bramlett in Birmingham, Alabama, USA.

I am truly honoured to be able to serve the British Orthopaedic Association in a time period where the orthopaedic profession is facing enormous challenges. The financial situation both in primary care and secondary care is critical.

All of us have had to participate in our own departmental cost improvement programmes while at the same time trying to maintain a first class clinical service and keep waiting times down to the national minimum.

My interests outside orthopaedic surgery are golf, ornithology, fell walking and the history of World War 1.

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JTO News and Updates

BOA Membership UKITE update

The UKITE timetable for 2016 is available online to view, please visit www.boa.ac.uk/training-education/ukite-exam-schedule. All trainees must log in to test their username and password before the exam.

The highest scoring trainee in an invigilated setting from the 2016 UKITE will be recognised at the 2017 BOA Congress in Liverpool.

To find out more about UKITE and other membership benefits, visit www.boa.ac.uk/membership/benefits.

BOA Congress 2017 19th-22nd September | ACC Liverpool

The development of our ‘Quality and Innovation’ programme is well underway.

Don’t forget that abstract submissions open on 12th December. We look forward to sharing this exciting programme with you; keep an eye on the Congress website for programme and speaker updates – www.congress.boa.ac.uk.

The Bone and Joint Journal (BJJ) The BJJ is one of many benefits enjoyed by BOA members, offering a comprehensive compilation of peer-reviewed scientific information in different orthopaedic fields and evidence-based research to enhance the quality of care for orthopaedic patients.

Special offer for SAS surgeons: SAS surgeons who apply for BOA membership before 28th February 2017 will receive the BJJ and BJ360 free of charge for 2017. This offer is open to all SAS surgeons who are not currently BOA members. From January 2018, SAS members will continue to receive the BJJ and BJ360 at a reduced rate incorporated into your BOA membership fee. www.boa.ac.uk/membership/bone-and-joint-journal

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JTO News and Updates

BOA (Zimmer - Adult Reconstructive Orthopaedics in Hips and Knees) Travelling Fellowship Kiran Singisetti I visited Dr (Professor) Alan Gross and the lower limb reconstruction team at Mount Sinai Hospital, Toronto in June 2016. The team has extensive experience in the use of allograft bone in revision lower limb arthroplasty. The unit has the largest series in the world of fresh osteochondral allografts performed for post-traumatic defects of the knee. I was fortunate to see both femoral and acetabular revision procedures during my visit. I was particularly impressed with their experience and finesse in performing trabecular metal cup cage reconstruction. I learnt a lot of tips on the cup cage reconstruction, including how to safely create

a slot for the ischial flange and orientation of the acetabular shell to accommodate the cage.

Clinics were also an enriching experience; seeing complex arthroplasty problems as well as follow-up of younger patients with osteochondral allograft transplants for post-traumatic defects around knee joint. I took part in educational sessions including grand rounds and preoperative planning meetings. I also visited Dr (Professor) Hans Kreder at the Holland Centre campus of Sunnybrook Hospital.

Dr Gross invited me to a social event at University of Toronto and took me to the Blue Jays baseball match. I made a lot of

Kiran Singisetti (centre) with Dr Gross (second from left) and the rest of team at Mount Sinai Hospital, Toronto

friends during this visit and will cherish the memories for a long time. I sincerely thank the British Orthopaedic Association for

awarding me with this travelling fellowship. The experience gained from the visit will go a long way to shape my future career.

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JTO News and Updates

BOA Congress 2016 Reviews Leela C Biant, Consultant

I first attended the BOA Congress 15 years ago as a trainee. The content and format of the BOA Congress has changed beyond recognition over this time, but what is it like now? Usually conference reports are dull, listing endless prominent speakers. Therefore I will try to report the comments of colleagues.

The Political Update on the first day was packed! Perhaps a reflection of the uncertain times we live in. It is clear we face considerable service delivery

challenges, and have orthopaedic leaders who are actively engaged at all political levels.

Mandy Hickson’s Howard Steel lecture was a delight. Mandy was an RAF fast jet fighter pilot.

There wasn’t an orthopaedic surgeon in the room who was not envious - the culture of discipline, teamwork, responsibility, accountability, reflection with continuous improvement.

James Wright gave insights into the lack of evidence for many clinical decisions. He discussed “confirmatory bias” where we

The Clinical Examination Course

only acknowledge sources that confirm our beliefs, even if those beliefs are wrong.

Completion of mandatory training for the non-specialist and specialist were incredibly useful. They are complimentary to the work of the specialist societies and are a one-stop shop for these essential aspects of practice. New sessions included simulation and an excellent medical student session. The Congress App was the best we’ve had.

It worked well for voting at the AGM, ensuring this was a painless experience.

I attended the excellent Clinical and Educational Supervisor session run by Lisa HadfieldLaw. I’ve completed generic courses locally, but an Orthopaedic-specific update was incredibly useful.

Tim Wilton speaking in the Main Auditorium

Quality improvement and service delivery sessions featured highly this year. We heard examples of where achievable changes have effected real improvement in

patient experience. Other sessions included leadership for clinical directors, how to access research funding, how to write fundable grants, how to get published, clinical examination courses, and topical issues such as consent meant that the Congress had something for everyone.

The industry exhibition was somewhat fragmented, but remains popular. I attended an industry dinner meeting and noted the complete shift from sales push to evidencebased innovation.

The social side of the meeting was joyful; the increase in attendance has reached a critical mass and you are highly likely to see friends. As ever, chatting in the bar is just as informative as the meeting.

Practice changing information and career advice is just as likely gained at midnight as at noon. This is why I’ll keep coming to the BOA Congress.

Thanks to the people of Belfast and the BOA team for a great meeting.

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Muhammad S Alam, SAS Surgeon

(SAS: Speciality Doctor, Staff Grade and Associate Specialist)

The BOA returned to the beautiful city of Belfast for its Annual Congress covering the theme of leadership and engagement. It was an enjoyable and informative four days for all the SAS

Surgeons attending. In keeping with tradition, eminent speakers from a variety of specialties talked.

We enjoyed Joe Dias’ Robert Jones lecture and Mandy Hickson, a former Air Force pilot, gave an

inspiring lecture on how to face the problems of the changing NHS. The SAS Doctors particularly enjoyed Tim Briggs’ reflections on GIRFT, as well as the revalidation and the medico-legal sessions.

The SAS Surgeons’ session on Wednesday afternoon, although not as well attended as it should have been, was an excellent review of the SAS Surgeon’s point of view.

Mamdouh Morgan presented a survey on the aspirations of this group of doctors. He gave a longterm plan on how SAS Doctors can be involved in BOA quality improvement programmes, and help deliver safe and efficient care to all trauma and orthopaedic patients.

Ian Winson, this year’s BOA President, attended the session and told the conference how much the BOA values SAS

A busy exhibition at the BOA Congress

Ashtin Doorgakant, Trainee

Like any cash strapped, exam focused and time constrained senior orthopaedic trainee, the idea of travelling to a meeting two months before the FRCS clinicals wasn’t one that naturally appealed to me. But with a poster accepted and an invitation to talk (at the World Orthopaedic Concern UK podium) I felt unable to decline.

My arrears on the ARCP front were additional motivation!

I considered just signing up for the minimum number of days, however, with my presentation being on day three, I bit the bullet and signed up for the whole thing. No sooner had I done that than I received the programme, confirming the date for the Clinical Examinations Course, based on the famous Chesterfield course, was on day four! That course

Doctors. He encouraged us to join the BOA. The concerns of the SAS Surgeons were noted and Mr Winson reassured us that the BOA is looking into why the BOA membership levels, for SAS Doctors in orthopaedic surgery, is not as high as it should be. This is despite the BOA significantly reducing the SAS Doctors’ membership fees. Megan Wilson, JCST and CESR Policy Manager listened and advised on CESR (Certificate of Eligibility for Specialist Registration). Mike Reed, Chair of the BOA Education Committee, also let us know that the BOA clinical leadership programme is open to all SAS Surgeons.

The BOA has welcomed the SAS Doctors with open arms and at the same time SAS Surgeons have recognised that we need to be more involved in future conferences... so here’s to next year!

alone, justified my attendance at the meeting. Concise and to-the-point, it truly is the ultimate one day crash course for the exam - and it’s free!

In the three days before the course, I also managed to attend numerous sessions on a variety of topics relevant to the exams. This was in addition to numerous fascinating orthopaedic updates, not least the launch of Wikipaedics. Even my coffee breaks and evenings proved useful for networking. I managed to secure key viva practice sessions with some top trainers, as well as linking up with other like-minded examinees.

The Congress was also a great time to catch up with old friends, socialise and get a break from the relentless boredom of the books. With hindsight, it was one of the most worthwhile meetings I’ve attended. I would strongly recommend it to all fellow trainees, irrespective of grade.

Traditional Irish dancing at the Welcome Drinks Reception

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JTO News and Updates

BOA Latest News National Clinical Leaders Programme 2017-2018 The Clinical Leadership Programme is now in its third year with a record number of fellows currently in place. The aim of the programme is to: l Develop current and future Orthopaedic Consultant leadership

capability for the NHS

l Accelerate service transformation and quality improvement within

and across trauma and orthopaedic services

The BOA is now recruiting for the 2017-18 programme which is open to senior trainees (ST8 and above), SAS Surgeons and newly appointed consultants who have been in post for less than two years.

There are currently three routes into the programme; either through Trust funding, individual funding or sponsorship from a specialist society to fund a place on the course.

Further details regarding the programme, the application process and information regarding specialist society sponsorship is available on the BOA website www.boa.ac.uk/training-education/boa-national-clinicalleaders-fellowships-programme.

Commissioning Guide Review We have been reviewing four of our NICE-accredited Commissioning Guides. These NICE-accredited Guides aim to set out best practice care pathways and, in so doing, assist Clinical Commissioning Groups to design optimal care for their populations.

The guides being reviewed cover: l Painful osteoarthritis of the knee l Pain arising from the hip in adults l Carpal Tunnel Syndrome (this guide

previously covered other conditions associated with painful tingling fingers) l Painful deformed great toe The revised guides will be available on the BOA website in due course.

National Tariff We have responded to NHS Improvement’s consultation on their tariff proposals for 2017-19, and have engaged further with NHS Improvement since. In our response we acknowledged NHS Improvement’s pragmatism in agreeing to limit price reductions to orthopaedics. Specifically, NHS Improvement limited the reductions in prices to 25% of that implied by their models, following discussions with the BOA and Orthopaedic Expert Working Group.

Our response also raised concerns that the remaining reduction in orthopaedic prices would create significant risk to patients. We fear waiting times may worsen if Trusts cannot provide sufficient crosssubsidy to orthopaedics, if independent sector activity slows, or Trusts choose to carry out fewer privately-paid-for procedures.

Our view is that deriving tariff based on unrepresentative and inadequately researched reference costs is flawed and unsustainable. Looking forward, we hope the Orthopaedic Expert Working Group, NHS Improvement, NHS England and NHS Digital can develop a more effective system to determine prices.

Tariff prices are expected to be finalised by the end of the year.

Sustainability and Transformation Plans

Planning Guidance developed by the national NHS bodies for 2016-17 to 2020-21 required the joint development of Sustainability and Transformation Plans by commissioners and providers on a regional basis. These will act as the principal delivery mechanism to implement the Five Year Forward View and will be based around 44 footprints across England. For Orthopaedics, we expect implementation to prioritise: l Implementation of Getting it Right First Time l Roll out of the Right Care programme, which aims to increase value by identifying

unwarranted variation in surgery rates and outcomes, leading to redesigned care pathways from primary to secondary care l Development of the National Orthopaedic Alliance Vanguard, which intends to explore ways of developing a nationwide chain of orthopaedic providers to spread best practice largely drawing on Getting it Right First Time.

Training Orthopaedic Clinical and Educational Supervisors (TOCS & TOES) Course There are still a few places available on the TOCS and TOES course on 19th January 2017. Register now online to confirm your place at www.boa.ac.uk/events/training-orthopaedic-educational-supervisors. The course will provide delegates with a range of learning outcomes, all of which are mapped to the seven domains underpinning the GMC requirement for recognition as educational and clinical supervisors.

Research Committee seeks new members Our Research Committee is seeking new members to help drive forward our Research Strategy and we invite applications for this position. Please email l.rich@boa.ac.uk with your CV by Friday 30th December, expressing your interest and any relevant experience and expertise that you would bring to the committee.

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NHS England Conflict of Interest Consultation In September 2016, NHS England launched a consultation on proposed changes to the way conflicts of interest are declared and managed in the NHS. One of the proposals was to require all clinical staff participating in private practice to disclose the bracket within which their private practice gross earnings fell over the previous 12 month period. The brackets would be: l less than £50K l less than £100K l more than £100K

We responded to the consultation arguing that this specific proposal was unnecessary and intrusive. We also argued that the policy could serve to discourage private practice, thereby undermining patient choice.

Rationing

We have continued to actively oppose the rationing of surgery, with particular reference to BMI and smoker status based referral thresholds for Hip and Knee Replacement. As well as releasing a position statement on the issue, available via our website, we have featured in a number of articles in the national press.

In all of our activity, we have consistently emphasised the cost-effectiveness of orthopaedic surgery and offered support to CCGs via our Clinical Champions network. The Royal College of Surgeons of England has also continued to oppose rationing and, in September, Simon Stevens, Chief Executive of NHS England, explained in an interview that blanket bans on surgery for obese patients or smoking patients were incompatible with the NHS Constitution.

NHFD Annual Report The BOA welcomed the release of the annual National Hip Fracture Database (NHFD) report in September. The report shows that patient care continues to improve but highlights the need for better team work post-operatively.

The report indicates that more patients are surviving after suffering the trauma of a broken hip, with nearly 93% of patients surviving the critical 30 days following their operation. This represents a continuation of the steady improvement in outcomes that the NHFD has helped deliver. Better teamwork is required, however, to improve all aspects of patients’ care, and post-surgical care in particular. Hip fracture patients are amongst some of the frailest patients the NHS treats; we cannot afford to be complacent.

To read the full report, visit www.boa.ac.uk/latest-news/boa-statementnhfd-annual-report-2016.

The Robert Jones 2016 Golf Day

Instructional Course 2017 Saturday 7th - Sunday 8th January Final places remaining!

The 2017 Instructional Course will focus on spine and trauma, with the opportunity for trainees to gain casebased discussions (CBDs) in a number of areas including Physiology of Trauma, Complications of inflammatory spine conditions, and immediate assessment, care and referral of spine trauma.

The Robert Jones 2016 Golf Day was held on Monday 12th September at the Royal Belfast Golf Club. We would like to thank Ian Corry, the local host, for his organisation on the day.

Eighteen golfers took part in the tournament but it was Patrick Robinson who won on the day. Patrick was presented with the Robert Jones Golf Silver Trophy by Past President, Tim Wilton and Ian Corry. Other notable mentions are Richard Lloyd who had the Longest Drive and Mike Foy who was Nearest the Pin. The date of the next Robert Jones Golf Tournament will be Monday 18th September 2017 in Liverpool and you will be able to register via the BOA website in April 2017.

In addition to the CBD opportunities, the BOA Instructional Course provides an excellent platform for trainees to network and attend lectures delivered by expert clinicians. Plenary lecturers this year include Professor Chris Colton, Professor Chris Moran, Professor Amar Rangan, David Limb and Uttam Shiralkar.

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

Training Orthopaedic Trainers (TOTs) Courses

New BOA Podcasts

The TOTs course was established to improve the standard of teaching for those in trauma and orthopaedic (T&O) training and practice. The basic premise of the course is that if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. In addition to the TOTs course being held at the BOA office in December, there will be a TOTs course held in Newcastle on the 22nd-23rd February 2017. If you would like to attend please register via www.boa.ac.uk/events/training-orthopaedic-trainers.

Two new podcasts have recently been published on our website. Episode 9 focuses on reducing toxic stress which can affect surgeons’ decision-making and operative skills. Our most recent podcast (episode 10) will give you an insight into how to maximise your memory unlocking your spatial and visual memory to help with retention and recall. You can listen to both podcasts at www.boa.ac.uk/training-education/orthopodcasts.

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JTO News and Updates

BORS 2016 Annual Meeting, Glasgow The Annual Meeting of the British Orthopaedic Research Society was held at the University of Glasgow Union Building on 5th-6th September. The local organising committee led by Professor Matt Dalby and Mr Dominic Meek

put together an outstanding programme packed with keynote lectures, free papers and breakout sessions.

The society offers a forum for orthopaedic surgeons

Prof John Kenwright receiving the presidential prize from BORS President, Gordon Blunn

and scientists in bone biology, materials and biomechanics to discuss clinically relevant basic science research. In particular, junior researchers and clinicians value the opportunity to discuss their work in an open, knowledgeable and constructive manner. BORS has a strong commitment to promote young researchers. Prizes were given in four categories, including the Andrew Sprowson Prize for Translational Research.

In this spirit, the biannual BORS International Travelling Fellowships Scheme for Young Investigators was initiated in 2007, now sponsored by Bone & Joint Research, British Editorial Society of Bone & Joint Surgery. This year six Fellowships have been awarded; travel starting at the iCORS meeting in Xian, China.

excellent lecture in his distinct style and with inimitable wit exemplifying the ‘seven deadly sins’ of research by his own experiences, incidentally featuring some of our existing BORS members!

A highlight was the President’s Award for outstanding achievements to British orthopaedic research to Professor John Kenwright. He gave an

The meeting concluded with sincere thanks to the local team and we are looking forward to our next meeting; 4th-5th September 2017 at Imperial College, London.

In the evening everybody relaxed over dinner and Professor Gordon Blunn, President, announced Professor Mark Wilkinson as his successor. Into the night plenty of legs and skirts were swung during the energetic ceilidh!

Finally, the invited public engagement lecture by Professor Stuart Reid brilliantly crossed boundaries and connected gravitational waves in space with osteoblastogenesis via nanokicking - a novel stimulus to mesenchymal stem cells!

BSS 2016 Annual Meeting, County Durham The 40th Annual Meeting of the British Scoliosis Society was held at Hardwick Hall, County Durham on 13th-14th October.

The meeting incorporated an Instructional Course and Allied Health Practitioners Meeting, both for the first time. As a niche subspeciality meeting, trainee attendance is often limited, however this year more than 30 trainees attended; a third of all delegates.

The reasonably-priced Instructional Course comprised the pathology and management of spinal deformities. The wellorganised day concluded with FRCS vivas covering the spine curriculum; many of the trainees attended the meeting because of the course. Similar strategies at other specialist meetings might

increase attendance, whilst contributing to trainee education.

The Allied Health Practitioner meeting was attended by over 50 members of the MDT including therapists, specialist practitioners, orthotists and doctors (paediatricians, anaesthetists, surgeons).

The Annual Conference/Scientific Meeting was held on the second day with keynote speeches from esteemed faculty including Dr Tom Errico (New York), Dr Ferran Pelissé (Barcelona) and Dr Pierre Roussouly (Lyon). Best paper prizes were awarded to Matt Newton-Ede (ROH, Birmingham): “The effect of anti-microbial irrigations on osteoblasts and bone formation: an in vitro comparison of Vancomycin, Gentamicin and Povidone-Iodine”

BSS 40th Annual Conference

and to Miss Vasiliki Panagiotopoulou (London Implant Retrieval Centre): “Is corrosion a mechanism of failure in magnetically controlled growth rods?”

featuring professional dancers, a popular dance workshop, as well as an inspired duo performance featuring conference organiser, Mr Raman Kalyan.

The meeting was capped off by an “Exotic Bollywood Dinner”

A well-organised and enjoyable event (with a nice bag)!

Volume 04 / Issue 04 / December 2016

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JTO News and Updates

Caption Competition It is great to see that our Caption Competition is getting your creative juices flowing - thank you to those who entered. Congratulations to Matthew Crane, whose caption was: David Limb: “I said ‘spine’ not ‘wine’.” – your prize will be on its way to you in due course!

We would like to encourage you to send photos to us for future issues whether they are taken at conferences, meetings, work or at social events.

Here is our latest photo which was taken at the BOA Congress in September.

For your chance to win a £20 voucher, simply email your caption to jto@boa.ac.uk with the subject: Caption Competition. You can also send your photos to this email address (if your photo is larger than 5MB please send via www.WeTransfer.com).

Royal College of Surgeons Project 2020 The next year will be critical for the College’s ambitions around developing its Lincoln’s Inn Fields home. The existing college buildings were almost completely rebuilt in the 1950s following extensive bomb damage in World War II. However, they have become uneconomical, inflexible and an obstacle to future progress.

The plan is to transform the London base into a modern, light and flexible facility to provide the best possible education, examination and research facilities for the profession while embracing the prestigious heritage. As well as modernising the inefficient and ageing estate, the redesign will reflect the changing functions as a home for surgical excellence in Britain and across the world in the 21st century.

Work on the project started at the beginning of 2015 and has

instigated a wider programme of work reviewing the operations of the College and how this will advance surgical care. Currently, the project is working towards a detailed internal building design, following on from the planning submission to Westminster City Council.

For the Surgical Specialty Associations, arrangements for the organisational decant are being discussed and plans being made for the return in 2020. The college has been working closely with the associations to ensure that the decant phase happens seamlessly and that in the new building, the associations are accommodated suitably. In the new building, the associations will be situated on their own dedicated floor, and will have a closer working relationship with the college, while maintaining their own specific identities.

A view of the Central Atrium from above

The college understands the need to be at the forefront of advancing surgery and through the implementation of the project and mutual co-operation

and collaboration with the BOA, the RCS will be able to lead in this aim in the best interests of surgeons and the wider public alike.

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JTO News and Updates

Wisepress Book Review BOOK OF THE QUARTER

ALSO AVAILABLE

McRae’s Orthopaedic Trauma and Emergency Fracture Management

Orthopaedic Trauma: The Stanmore and Royal London Guide

Author/s: White, T O; Mackenzie, S P; Gray, A J ISBN: 9780702057281 Publication Date: 9th December 2015 Price: £49.99

Author/s: Miles, J; Aston, W; Skinner, J A M ISBN: 9781444148824 Publication Date: 18th November 2014 Price: £49.99

A highly successful ‘survival guide’ for the trainee working in accident and emergency or orthopaedic departments. Retaining the underlying principles of the original editions this comprehensive rewrite and re-presentation provides complete coverage of orthopaedic trauma surgery as relevant to contemporary practice.

Handbook of Foot and Ankle Orthopedics Author/s: Shah, R ISBN: 9789385062230 Publication Date: 13th June 2016 Price: £51.00

Periprosthetic Joint Infection: Practical Management Guide Author/s: Parvizi, J ISBN: 9789350902714 Publication Date: 28th February 2013 Price: £50.00

CONFERENCE LISTING: Organisation

Conference/meeting

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

12-13 January 2017, Coventry

BHS (British Hip Society) www.britishhipsociety.com

1-3 March 2017, London

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

9-10 March 2017, Glasgow

BASS (British Association of Spinal Surgeons) www.spinesurgeons.ac.uk

15-16 March 2017, Manchester

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

23-24 March 2017, Leeds

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

28-29 March 2017, Southport

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

27-28 April 2017, Bath

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

11-12 May 2017, Edinburgh

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org 31 May-2 June 2017, Austria BOOS (British Orthopaedic Oncology Society) www.boos.org.uk

2 June 2017, Newcastle

WOC (World Orthopaedic Concern) www.wocuk.org

10 June 2017, Wigan

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

14-17 June 2017, Germany

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

21-23 June 2017, Coventry

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

7-9 July 2017, Penrith

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

4-5 September 2017, London

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

19-22 September 2017, Liverpool

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

November 2017, TBC

BSS (British Scoliosis Society) www.britscoliosissoc.org.uk

November 2017, TBC

Volume 04 / Issue 04 / December 2016

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JTO Features

The value of your Membership Colin Howie

Each month the BOA Executive Group meet to review each area of business within the BOA and discuss problems, solutions and more often successes within our practice, broadly covering all the subcategories outlined in a “Mind Map” (Figure 1). The Council meets to debate these areas and represent your views on the key matters of the day to be taken into account.

The BOA was originally set up

by Sir Robert Jones and others, following a dinner at the Cafe Royale on 28th November 1917.

The specific intent was to promote general enthusiasm for orthopaedic surgery by encouraging those interested in the practice of orthopaedics through a mutual exchange of experience (the Annual Scientific Meeting) and to develop a training programme for both surgeons and nursing staff to develop orthopaedic services across the country. These key areas were rapidly developed through what were to become the forerunners of the Professional Practice Committee, the Education and Revalidation Committee and a Membership Committee, which has since been subsumed into the central support group.

Colin Howie

These core functions have remained central to the BOA from its official inaugural meeting on the 2nd February 1918 until today. Initially, the Annual Meeting was the only scientific meeting where matters of an orthopaedic nature were presented. It proved extremely popular as a source of

orthopaedic knowledge. As times have moved on, the Specialist Societies have provided more specific scientific meetings, much as the BOA did initially for orthopaedics when breaking away from general surgery.

Consequently, the function and content of the BOA Annual General Meeting has developed dramatically. The success of this process, under successive secretaries, and the recent inclusion of attendance as part of the membership benefits; has seen attendance by qualified surgeons almost double in the space of five years. Moving forward, the online UKITE and the Wikipaedics learning platform will keep British orthopaedics at the forefront with your support.

Our relationship with the Specialist Societies remains key to the performance of the BOA. Trauma and orthopaedics has such a wide remit that a central group cannot provide definitive opinions on all the specific topics coming up in every specialist area. A member of the BOA Executive now attends all of the Specialist Society meetings.

Any issues relating to these societies are directly discussed with the society and their view is reflected in any action. The BOA through the Education and Revalidation Committee maintain the syllabus and curriculum, the training programmes and the specialty exam. The enthusiastic and knowledgeable members of the committee lead internationally, such that the EBOT exam looks very similar to the British exam.

Orthopaedic trainees through BOTA have developed an authoritative voice; both in training and service delivery and they are an active part of the BOA Council.

Again, the over-subscribed annual Instructional Course for trainees and the excellent courses for Training Orthopaedic Trainers and Leaders reflect the input from BOTA and the Education Committee.

The BOA offices, which originally supported membership and the annual meetings, have changed dramatically. Communication advances have been such that the BOA has developed an IT infrastructure that has become more complex, comprehensive and interactive. While we retain highly successful core functions, many staff are policy advisers, and provide an active input to many of the committees that are now encompassed within the BOA. The Patient Liaison Group has developed as part of the communication and advocacy structure, to ensure that trauma and orthopaedics is represented at the highest level and remains relevant. Our policy, reflected in the BOA strap line “Caring for patients; Supporting surgeons” is >>

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JTO Features

Figure 1: BOA Mind Map

a deliberate statement by previous Presidents to shift the agenda towards the needs of our patients.

The remit of the Professional Practice Committee has widened as the healthcare agenda has widened, to include guidance on implementing Duty of Candour, Consent, Private Practice, GIRFT; and several guidelines have been produced in conjunction with the Specialist Societies. Within the wider MSK community, the BOA is part of the Arthritis and Musculoskeletal Alliance (ARMA) and is involved with many of the developments in MSK commissioning, the MSK workforce, including physiotherapy and rheumatology.

Immediately prior to the Second World War, a previous President, Naughton Dunn, ensured that trauma was taken out of general surgery to become a significant partner within orthopaedics.

This has proved hugely effective for the provision of trauma and orthopaedic patients throughout the UK; although it clearly created stresses within our professional support systems. The Trauma Group has taken a major role

in the provision of boot camp sessions at the Congress. These sessions are always greatly appreciated by our members and fellows, setting a new education model for other specialisms to follow. Equally, orthopaedic trauma surgeons have taken an active part, with the Professional Practice Committee, in producing standards of care for trauma throughout the country (BOASTs) and they have also led in the creation of major trauma centres.

the path has not been smooth; many lessons have been learned and there is still some way to go. The National Hip Fracture Audit is an excellent example of how to learn from previous mistakes. Our relationship with NICE has been difficult in the past, but more recently by taking part in the processes and responding positively, there has been a noticeable change in the attitude towards the orthopaedic community.

Perhaps the biggest change in BOA activity has been our interaction with various government departments, moving from a reactive state through the Royal Colleges, to a direct and proactive role. Surgeon outcomes were a top down attempt to improve quality. This remains a high political priority and is therefore difficult to manage. Orthopaedics remains the only major specialty with detailed information on one area of our practice. By adopting a measured, professional approach rather than blanket reactionary objection, together with implant registries, we have influenced the agenda enormously. However,

Government attempts to reduce orthopaedic waiting lists were only successful because of the knowledgeable input of key orthopaedic leaders. The same fiscal pressures remain, but have matured whereby we look to promote good quality orthopaedic care as a method of saving money, within a cash limited environment; the basic premise of GIRFT. The development of MSK commissioning by CCGs has given us the opportunity to introduce musculoskeletal pathways. Because of the myriad of CCGs, it became obvious that we had to set up a network of orthopaedic surgeons around the country who could lead on this

work at a local level. With this network of colleagues, the skills of the speciality associations and central pressure; the BOA has been able to address and improve specific issues for the benefit of all parties.

Bizarrely, but perhaps not surprisingly, we have come full circle. “Ask not what the BOA does for you…” as in 1917, you are the BOA. Our actions and reactions reflect your concerns and problems. We rely on you to keep us informed and perhaps more importantly to help us deliver what is now a huge, active and developing agenda. Any BOA successes are down to the many fellows and members who take an active part in the committees and advisory roles, we (the Executive) just line the pitch. Thank you. n Colin Howie is a Past President of the BOA and continues to work full time as a Consultant Orthopaedic Surgeon in Edinburgh, with a special interest in arthroplasty. His research interests are biomechanical modelling and outcomes research; and he continues to be involved with healthcare delivery.

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JTO Features

The use of 3D printing in paediatric orthopaedics for pre-operative planning and bespoke therapeutics Jim Ballard & Daniel Crawford

Paediatric orthopaedic surgeons regularly carry out a large number of procedures on unusual, congenital and acquired deformities. Traditional radiographic techniques are often employed to plan such surgery.

The 3D printed models have been used to improve diagnosis and enhance pre-operative planning in a number of procedures. This article highlights the application of 3D printing applied to three paediatric cases from the Royal Belfast Hospital for Sick Children.

Developmental Dysplasia of the Hip A late presenting dysplastic left hip in which the hip was not dislocated but contained within

a high volume acetabular socket.

The patient presented at six years old with a leg length discrepancy and discomfort after playing sport.

the anatomy, a CT and MRI scan were performed to determine the volume of the acetabulum and the shape of the femoral head.

An open reduction, capsulorrhaphy and Pemberton osteotomy was performed for containment. The operation was successful, although the acetabulum was still enlarged.

It was decided that the patient required further pelvic surgery.

However, given the complexity of

Additional information on the articulating surfaces of the femoral head and acetabulum was felt to be required; therefore, a 3D model was created (Figures 1 and 2). This gives a much greater understanding of the anatomy of the acetabulum as well as enabling artificial articulation of the scale joint as if it were in situ.

This helped to plan the surgical correction with maximum coverage, in a difficult surgical case1.

Tibial Physeal Bar Resection A young patient presented with knee pain and mild fixed flexion of 10o. Conventional x-ray investigations showed a growth arrest bar in the proximal tibia. Coincidentally, there was a similar asymptomatic bar in the contralateral distal femur.

Jim Ballard

Daniel Crawford

CT and MRI scans were performed to delineate the extent and exact location of the bars so that surgical excision and replacement with bone cement could be planned through a direct transmetaphyseal window.

Figure 1: Close up of degraded acetabulum showing articulating surface in white resin to represent bony anatomy

Figure 2: Proximal femoral head along with dysplastic left hip to accurately assess volume of acetabulum and femoral head condition

From conventional two dimensional images the exact location and extent of the growth arrests were difficult to accurately determine. A 3D printed model was requested and created from the CT scans (Figures 3 and 4). The anatomy and surgical planning were greatly enhanced by the 3D transparent model, which showed the exact three dimensional location of the bar within the tibia.

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Page 25

Figure 3: Proximal tibia with contrasted growth arrest indicating location and volume for preoperative planning

Figure 4: Right medial aspect of proximal tibia showing exact 3D location of bar to use as an intraoperative guide for resection

The model also clearly demonstrated a deformity of the tibial plateau which had been difficult to assess from the twodimensional images. The model was used intra-operatively to guide and check the position of the bar, which was successfully resected2.

Correction of Coxa Vara in Osteogenesis Imperfecta A patient with osteogenesis imperfecta, previously treated with Sheffield rods to both femora to protect against fractures, presented with severe bilateral coxa vara. Walking was significantly impaired.

Staged surgical correction of the varus to protect both the femoral shaft and the femoral head was planned. A one-third tubular plate, bent as a “blade plate” and inserted into the femoral neck, would be used. A Sheffield rod would then be passed antegrade through one of the screw holes providing the equivalent of an adult reconstruction device for the whole femur while protecting the femoral neck physis (Figures 5 and 6).

boa.ac.uk

The unusual femoral geometry, size of the patient and the location of the deformity, necessitated a number of 3D printed models being manufactured. Trial osteotomies with trial fixation were planned and undertaken on the models before surgery.

The models allowed more accurate pre-operative planning than was previously possible with imaging alone3.

Figure 5: Anterior aspect of pelvis and proximal femora in clear resin to show full trail osteotomy and screw placement on cortical bone

Figure 6: Pre-bent third tubular plate inserted into femoral neck as a trial reconstruction device

Conclusion The Core Benefits: l Improved pre-operative planning l Enhanced understanding of existing diagnoses l Reduced operating times l Education of junior surgeons l Improvement in patient understanding Three-dimensional, printed, patient-specific models have a number of applications in many specialties, not just paediatric orthopaedics. The modelling is not only limited to bony applications, as soft tissues can be visualised and 3D prints created for other medical

specialities, including neurology, cardiology and oncology.

Three-dimensional physical models allow a much greater conceptual understanding of the patient’s pathology. A full scale, tangible model of the patient’s anatomy adds an additional element of certainty when planning surgery. This cannot be achieved with conventional, two-dimensional radiography, or even computational 3D multiplanar reconstructions. With the added information that a 3D printed model gives, there are often changes or additions to the original diagnosis and planning of surgery. The use of 3D models for pre-operative planning enhances efficiency by reducing surgical theatre time and the risk of complications.

The physical model also allows better patient information and understanding than an explanation with complex twodimensional CT or MRI scans. n

Jim Ballard is a Consultant Orthopaedic Surgeon at Royal Belfast Hospital for Sick Children in Northern Ireland.

Daniel Crawford is founder and CEO of Axial3D, a UK based 3D medical printing firm providing clinicians with easy access to patient-specific medical models to improve diagnosis and pre-operative planning.

References 1. Full Case Study – Developmental Dysplasia of the Hip: www.axial3d.com/latest/casestudies/developmental-dysplasiaof-the-hip 2. Full Case Study – Tibial Physeal Bar Resection: www.axial3d.com/latest/casestudies/tibial-bar-resection 3. Full Case Study – Correction of Coxa Vara in Osteogenisis Imperfecta: www.axial3d.com/latest/casestudies/osteogenesis-imperfecta

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JTO Features

Operations we no longer do: Posterior Iliopsoas transfer (Sharrard Procedure) Mike Bell

When I was appointed to Sheffield Children’s Hospital in 1986, spina bifida was still prevalent. My predecessor, John Sharrard, had worked extensively with these children.

He was concerned that many children with spina bifida developed hip dislocation and following the study of a large group of patients he came to the conclusion that the cause was muscle imbalance around the hips.

He found that many children with hip dislocation were innervated to L3 and, as a result, the hip flexors and adductors were active, in the absence of opposing muscles.

He designed a modification of the Mustard procedure to rebalance the hips. He transferred the psoas to the posterior aspect of the greater trochanter, via a hole in

the iliac wing. His rationale was to remove the deforming force and provide active hip extension and abduction.

The procedure involved an anterior approach to the hip between the femoral artery and femoral nerve. This is not for the faint hearted! The psoas and the lesser trochanter are identified and psoas is detached from the lesser trochanter with a small piece of cartilage. The iliacus is also mobilised from its femoral attachment. The complete muscle mass of iliopsoas is then mobilised and passed into the pelvis under the inguinal ligament.

successful in containing the hips.

Follow-up also showed that the hole in the pelvis increased in size as the child grew.

Why do I no longer do it?

The incidence of high level spina bifida has decreased significantly, as a result of screening with alphafetoprotein and the realisation of the importance of folic acid supplements in women who are planning to get pregnant.

Evidence from Australia identified that many children with spina bifida who had dislocated hips had a much higher level of neurological impairment with no muscle activity around the hips. They also found that in cases of bilateral hip dislocation the children functioned very well, in spite of the fact that the hips were dislocated. It was also noted that if surgery was unsuccessful on one side, the overall outcome was much worse as one hip would be enlocated, whilst the other remained dislocated. The resulting leg length inequality gives significant imbalance.

Therefore, the Sharrard procedure’s place is very limited and should only be performed in children who have a unilateral hip dislocation with innervation to L3 - now a very rare situation. n

The abdominal muscles and iliacus are mobilised from the iliac wing. A hole is then made in the posterior aspect of the iliac wing.

The iliopsoas tendon is passed through the hole in the pelvis and the abductor muscle mass and attached to the posterior aspect of the greater trochanter. Access to the greater trochanter is via a lateral approach.

Did it work?

Mike Bell

There was doubt as to whether the transfer functioned as an active transfer or merely as a tenodesis. It was by and large

Figure 1: Pictorial representation of Sharrard’s operation

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JTO Features

Factors affecting total operating time for a standard surgical procedure Yu-Chuan Chong Contributing authors: Colin Howie, David Ray, Deborah MacDonald, Hamish Simpson

There is increasing pressure to optimise the use of operating time. The aim of this research was to determine what effect factors such as age, ASA status, anaesthetic technique, operating surgeon and anaesthetist had on the total operating time and their implications for the number of surgical cases done per list.

In order to reduce confounding variables, the analysis was restricted to a common, standard surgical procedure: Primary elective total hip replacement. The study showed that age, ASA status and anaesthetic technique have minimal clinical significance on the total operating time.

Figure 1 depicted that spinal anaesthesia required the shortest time to set up compared to the other anaesthetic technique. In the same figure, the outliers of spinal anaesthesia were found exceeding the mean APT by twice the duration.

Yu-Chuan Chong

In Figure 2, outliers were also identified amongst the surgeons performing primary elective THR. Given that the Royal Infirmary Edinburgh is a teaching hospital, education is likely the cause for these delays. There was a similar variation between the anaesthetist and anaesthesia preparation time, and the surgeon and length of surgery. The exact cause for the variation was not identified.

Even with the fastest surgeon and anaesthetist working together, the total time for five cases requires 490 minutes which is difficult to accommodate in an eight hour

Figure 1: Boxplot of anaesthetic technique against APT

list. Even though maximising the resources of the operating unit would be beneficial, patient safety must still be the top priority in carrying out a procedure and there is a fine balance between speed and safety. The total time per total hip replacement case suggests that four cases in an 8-hour workday is appropriate as recommended by the British Orthopaedic Association. n Yu-Chuan Chong is working as a Foundation Doctor in Ninewells Hospital, Dundee. His main wish is to improve the quality of life of his patients. He aspires to be a Trauma and Orthopaedic Surgeon.

The full version of this article can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

Figure 2: Boxplot of surgeon against ST

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JTO Features Festive Fun

JTO Festive Fun 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 our festive puzzle and quiz.

Solve the Puzzle

Unscramble each of the clue words (related to your profession).

Copy the letters in the numbered cells to complete the message below.

SENBO

21 10

LYRPOSTAATRH

32 24

26

LUCLUELEMAKSOST

15

20 16 33

GYSUERR

11

SERCERHA

17

9

F

2

3

25 26

4

39

27

7

8

3

18

14

9

36

4

7

6

37

38

8

5

5

1

27 23 30 2

MUARAT AICOHPORDET

28

6

40 19

RINIGTAN

1

35 13 25 34

29

NATSITPE

12

10

28 29 30 31 32 33 34

11

F

22

12

13

35 36

31

14

F

15

37 38 39 40

16 17

18 19 20 21 22 23 24

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Festive Quiz 1. The song ‘White Christmas’ was first performed in which 1942 film?

2. In the song The Twelve Days of Christmas, “...my true love gave to me; nine...” what?

3. What Christmas item was invented by London baker and wedding-cake specialist Tom Smith in 1847?

4. From which country does the poinsettia plant originate?

5. The character Jack Skellington appears in which 1993 Tim Burton film?

6. Who wrote ‘How the Grinch Stole Christmas’?

7. In which country does Santa have his own personal postcode HOH OHO? 8. Who was the first British monarch to broadcast a Christmas message to the nation?

9. In the inspirational 1946 film ‘It’s a Wonderful Life’, what’s the name of George Bailey’s guardian angel?

10. Who is officially credited as the writer of Auld Lang Syne?

Answers on page 58.

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JTO Features

Scaling up Mike Reed

Scaling Up Improvement is a £4.3 million improvement plan funded by the Health Foundation, which supports project teams in taking successful health care improvement interventions and approaches and delivering them on a larger scale. The aim is to deliver demonstrable improvements in health care and/or the way individuals manage their own health, through the redesign of process, practice and service delivery models.

Background Hip fracture is very common and very serious. Nearly a third of the 65,000 people admitted to hospital with a fractured hip will die within the year and a further fifth of patients won’t return to their own home. The cost of care is high and set to rise sharply as the population ages. There is variation in mortality nationally ranging between 2.5% in some trusts and 14% in others.

Mike Reed

High quality, safe care requires the coordinated approach of a multidisciplinary team who are committed to implementing evidence-based care to deliver the best outcomes. The purpose of our safety partnership is to improve the quality of care delivered to patients with a hip fracture through system redesign using proven, evidencebased practices. Northumbria Healthcare NHS Foundation Trust’s hip fracture quality improvement programme (HIP QIP) has been running for five years and hip fracture patients at the Trust have faster access

to information, imaging and surgery, and receive better pain management with early physiotherapy, which is available seven days a week.

What is the HIP QIP Programme and how is the BOA involved?

Northumbria’s award-winning hip HIP QIP was one of seven projects supported in round two of the Scaling Up Improvement programme, which runs from April 2016 through to late 2018. It is being led by Northumbria Healthcare NHS Foundation Trust, in partnership with the British Orthopaedic Association, Academic Health Science Network for the North East and Cumbria with the Royal College of Physicians as evaluation partners.

The HIP QIP Scaling Up Improvement programme is a safety collaborative across six UK NHS Hospital Trusts, aiming to improve care and reduce mortality following hip fracture

in a multidisciplinary pathway approach. This work involves replicating the learning from HIP QIP.

What are the aims and objectives of the programme?

The aim is to improve safety and care for hip fracture patients and save 100 lives by December 2018 across six NHS organisations in the UK. The fundamentals are: l Safer care through improved

attainment of best practice tariff standards l Increasing nutritional support after surgery l Improved access to surgery within 36 hours l Improved access to nerve blocks on admissions l Patients supported to mobilise as early as possible after surgery l Better access to specialist care for elderly patients with complex medical problems l Better access to information to enable patients to manage their own care l Better access to guidance helping patients and families know what good care looks like l Better patient reported pain management l Improved patient experience.

For more information, please contact Mike Reed on mike.reed@nhs.net. n Mike Reed is an Orthopaedic Surgeon for Northumbria and a Senior Lecturer with the University of Newcastle.

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JTO Features

The Thiel Cadaver: are we entering a new frontier in orthopaedic training?

Alastair Faulkner & Peter Davies

Cadavers have been used in the training of surgeons for centuries. With changes to legislation including the Human Tissue Act (England, Wales and Northern Ireland) and the Anatomy Act (Scotland), performing surgical procedures on cadavers has become more widespread.

Numerous cadaveric courses exist throughout the country. We use the Thiel embalming method, which we believe offers advantages to the orthopaedic trainee.

What is the Thiel embalming method?

The Thiel technique is a ‘softfix’ embalming method first described in 1992 and pioneered in the University of Graz, Austria. Initially, the cadavers are submerged in high concentrations of preservative chemicals known as the ‘perfusion stage’.

Alastair Faulkner

Peter Davies

The cadavers are then immersed, for at least three months, in an embalming fluid containing water, glycol and various salts in addition to preservatives including low concentrations of formalin1. The resultant specimen is almost odourless, with life-like flexibility and colour. Importantly, it is safer for trainees to handle.

The Centre of Anatomy and Human Identification at the University of Dundee is the first centre in the UK to utilise this method to preserve cadaveric specimens.

How is it different other forms of cadaveric preservation?

Traditional methods of preserving cadavers involve high concentrations of formaldehyde and phenol resulting in a characteristic grey appearance and smell that is only too familiar from medical school anatomy sessions. The potential carcinogenic properties of formaldehyde have resulted in a trend to minimise exposure in recent years. Another drawback is that formaldehyde preserved bodies have been criticised as a result of the hardness and lack of tactile feedback.

Fresh frozen cadavers are an alternative to the Thiel method and offer similarities in terms of realism of tissue handling.

The main disadvantages with fresh frozen cadavers are that the specimens have to be used within days and carries a greater infection risk to trainees2.

The Thiel method is ideal for trainees as a result of the low concentration of formaldehyde, which minimises the risk of

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exposure. Additionally, the feedback from trainees from several courses, across a number of specialities including ENT, urology and orthopaedics3 includes praise for more realistic tissue handling. Finally, the specimens can be preserved over a longer period of time2,3.

The main drawbacks of the Thiel method are logistical and financial. The set-up is expensive requiring appropriately trained personnel, equipment and chemicals in order to ensure correct preservation.

Thiel cadavers are already being used in a number of orthopaedic courses, including soft tissue knees, foot and ankle and most recently hand and forearm4.

An excellent example of the advantages of the Thiel method was seen in the well-run Dundee ‘Principles of Hand and Forearm Surgery’ course. The faculty included a number of upper limb, hand and plastic surgeons based in the Tayside and surrounding regions including Consultants Mr Simon Thomas, Mr Alastair Lowrie, Mr Pete Rickhuss, Mr Amit Putti, Specialty Registrar; Mr Mike Reidy, Specialty Registrar and Professor Tracey Wilkinson, Principal Anatomist and Cox Chair of Anatomy at the University of Dundee. The delegates mainly consisted of early year Core Surgical trainees (CT1-CT2), specialty trainees in

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Trauma and Orthopaedics (ST1ST2) and Clinical Fellows.

The main appeal of this course was that the soft ‘feel’ of the specimens was a particular advantage in a cadaver course involving peripheral structures and allowed for more realistic tissue handling. The faculty commented how carefully the delegates handled the soft tissues as a result of their lifelike feel.

What’s in it for trainees?

The Thiel cadavers provide better simulation for operating on living tissue compared with non-Thiel cadaveric courses. The need for procedural repetition is essential in performing surgery competently and safely and courses using specimens preserved using the Thiel technique provide an excellent means of doing this.

Additionally PBAs and DOPs can be completed in the cadaver lab to increase logbook numbers.

Conflict of Interest Declaration The authors have no competing interests to declare. n Alastair Faulkner is a Specialty Trainee based in the East of Scotland). He is also the current BOTA Web Editor.

Peter Davies is a Specialty Trainee based in the East of Scotland.

He is also the BOTA Scottish Representative.

References 1. Eisma R, Mahendran S, Majumdar S, Smith D, Soames, RW. A comparison of Thiel and formalin embalmed cadavers for thyroid surgery training. 2011. The Surgeon. 9 (2011) 142-146.

2. Eisma, R, Wilkinson T. From “Silent Teachers” to Models. 2014 PLoS Biol Oct; 12(10): e1001971 3. Healy S, Rai B, Biyani C, Eisma R, Soames RW, Nabi G, Thiel Emblaming Method for Cadaver Preservation: A Review of New Training Model for Urologic Skills Training. 2015 Urology 85(3) 499504 4. Sadoghi P, Borbas P, Friesenbichler J, Scheipl S, Kastner N, Eberl R, Leithner A, Gruber G. Evaluating the tibial and femoral insertion site of the anterior cruciate ligament using an objective coordinate system: A cadaver study. Injury. 23(2012) 1771-1775

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JTO Features

PROMs: are we singing from the same score?

B. Michael Wroblewski

Patient reported outcome measures (PROMs) were introduced to: l Assess the quality of care

delivered to NHS patients from the patient perspective l Calculate health gains after treatment using pre- and post-operative surveys l Measure a patient’s health status or health related quality of life at a single point in time.

PROMs are collected through short, self-completed questionnaires and have been hailed as “a more rounded way of measuring treatment outcomes”.

The first PROM studied was for total hip replacement (THR). Why, after fifty years is THR of such interest? The clinical success of THR has uncovered the demand, extended the indications and increased patients’ expectations.

In the early days, patient selection was strict: hip pain at rest, matching clinical picture confirmed by the radiograph of a destroyed joint.

Qualitative and quantitative assessment of severity of pain continues to be a complex problem that cannot be solved by a sliding scale: pain is very personal! Relief from pain has a very liberating effect; it manifests in a change of mood and activity level. Pain is quickly forgotten while activity level advertises the success of the operation to potential patients.

B. Michael Wroblewski

Total hip replacement is technically demanding. As Charnley stated, it “… demands

training in mechanical techniques which, though elementary in the practical engineering, are as yet unknown in the training of a surgeon”1. As well as the technical skills, knowledge of materials, design and the consequences of mechanical construct functioning within the human body, are required by the surgeon. Standards of manufacture, testing and sale of implants, regular assessment of the results and the study of failures were all essential. The manufacturer was involved in training surgeons in the hope that the surgeons would become the customers. The acquired skill could not be sold at a profit and yet it had to be nurtured and reinforced.

The changes came about gradually. Failures were not attributed to surgical technique but to the cement used for fixation and tissue reaction to wear particles. Cement disease cleared the way for cementless fixation; a move away from the technical skill of the surgeon to implant technology and design. Furthermore, osteolysis started the search for new and more expensive articulating materials. Cementless fixation was accepted without questioning or understanding the method or the reason for the immediate freedom from pain. The surgeon was assured that the ‘bone will grow in/on’ and was instructed to follow a predetermined technique with the ‘final hammer blow’ as the end point (a new complication emerged: intra-operative fracture of femur).

The patients still had immediate pain relief – both they and the surgeon were happy. Treatment was complete. The natural, symptomatic was replaced with neuropathic. Failures would become symptomatic, and therefore, follow-up was discouraged and at times abandoned (‘everybody operated and everywhere hardly a single surgeon has had the opportunity to follow-up his cases’2).

Surgical skill, a commodity that could not be packaged and sold at a profit was replaced by the implant – a marketable item.

When the indications for THR moved from pain relief to increased activity level, demanded by the patient, and at times even implied by the surgeon, a new generation of implants was introduced and these claimed superiority over the existing3. The use of a resurfacing technique requires a sound subsurface. This has led to an earlier intervention, with the terms; ‘end stage arthritis’ and ‘end stage hip disease’ 3,4.

Over time the financial implications of this change from surgical skill to implant cost have become clear. The healthcare provider who pays the bill demands evidence of cost/benefit ratio, quality of care, health gains and health related quality of life. Hip pain; the indication for surgery has been forgotten and superseded by improvement quality of life.

When considering ‘quality of

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life’ we must distinguish between appetite and starvation.

is being done at the right time or on the right patients”6.

the quality and the cost – the real objective of the PROMs.

We must accept that THR as a method of treatment has survived 50 years of clinical application. It has been very welldocumented that clinical results do not reflect the mechanical state of the arthroplasty5. A failing implant can only become symptomatic when living tissues become involved. Assessment of outcomes by completing questionnaires cannot be a substitute for objective, regular assessment of the mechanical aspects of the operation by knowledgeable individuals. A survey of 34,960 THAs, published in 2011, highlighted this, stating: “we cannot tell...whether surgery

For THR to be truly scientific every effort must be made and every opportunity taken, to separate the mechanical from the clinical aspects of the treatment.

Increasing the size or the complexity of the implant is not a solution to dwindling bone-stock.

If without understanding the complexity and accurate documentation, the objective may become just an ‘unfinished symphony’. n

What about PROMs; are we singing from the same score? Not yet. The composer has written the score, the conductor is in charge and the singer is expected to join. The score will no doubt become more refined, the conductor stricter in selecting the would-be singers, as well as the tunes to be sung, thus controlling

Professor Wroblewski is a Consultant Orthopaedic Surgeon and Director of John Charnley Research Institute at the Wrightington Hospital. The John Charnley Research Institute was established to continue Professor Sir John Charnley’s work; training surgeons and studying the longterm results of his operation. An author of over 180 peer review publications, Professor Wroblewski’s most recent work (with PD Siney

& PA Fleming) is a book entitled “Charnley Low Frictional Torque Arthroplasty of the Hip: Practice and Results”, which reviews the original work of Charnley, the design and materials of the implants, the principles of surgical technique and the results of nearly 50 years of regular follow-up.

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

How I Do… a SupraAcetabular Pin Placement for an Anterior Pelvic External Fixator Andrew Carrothers As an adjunct to pelvic binders, applying a stable anterior pelvic external fixator is a skill that should be mastered by all orthopaedic surgeons who treat acutely injured patients. Stabilising a pelvis during resuscitation allows clot formation and can help to reduce the volume of the true pelvis.

Supra-acetabular (SA) Pin placement (slightly superior and lateral to the anterior inferior iliac spine (AIIS)), is less familiar to orthopaedic surgeons than iliac wing pins, but provides a more reliable pin-bone interface and allows improved reduction in

the plane of the deformity, with fewer soft-tissue complications.

In addition, SA pins are better tolerated than iliac crest pins in the definitive management of pelvic ring disruption.

Kit: l Image intensifier (II) and radiolucent table l Two large (6.5 mm) hydroxyapatite-coated AO Schanz pins l “MRI compatible” large AO ex-fix bar and connectors l 4.5mm drill.

An oblique 2cm skin incision is made at the level of AIIS. The lateral femoral cutaneous nerve is identified and protected. An ‘obturator outlet’ view (Figure 1) is used to identify the entry point. This will show the safe corridor as a teardrop. The obturator oblique view shows the pin insertion site 2cm above the hip.

The outer cortex is broached with 4.5mm drill in the identified SA zone, checking progress with an ‘iliac oblique view’ to ensure the appropriate trajectory just above the sciatic notch (Figure 2), where there is dense bone.

The obturator inlet view assures that the pin is contained within the bone for its entire length.

Andrew Carrothers

The “MRI compatible” bars for the fixator are placed with the

Figure 1: Obturator outlet view identifies ‘teardrop’ entry point

apex slightly distal and asymmetric to one side to allow the patient to sit up and be nursed.

Tips and Cautions: l Hydroxyapatite-coated pins are favoured as they appear to confer better longevity of the pins and potentially reduce local soft tissue infection l Meticulous pin site l Image intensification to avoid intra-pelvic or sciatic notch pin placement l Insertion of pins at least 2cm above the hip avoids hip capsule penetration l The fixator can be placed with a pelvic binder in situ.

Andrew is a pelvic and acetabular surgeon working as a full time Consultant at Addenbrookes, Cambridge University Hospital NHS Foundation Trust. In addition he is a Trauma and Orthopaedic

Figure 2: Iliac oblique view to ensure the appropriate trajectory in the direction of the sacroiliac joint above the sciatic notch

Surgeon in the Royal Army Medical Corps (V), having served in both Iraq and Afghanistan.

He is an Associate University Lecturer at the University of Cambridge. Recently, he has been awarded an NIHR RfPB grant, as chief investigator for a feasibility RCT in the management of elderly acetabular fractures (AceFIT).

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

0121 200 7820

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JTO Features

Building on the BONE Jamie McConnell

Hopefully, readers will already be aware of BONE.ac.uk; a trainee-led orthopaedic audit network. Perhaps you are one of the 1,030 members (and counting) who have already registered?

If not, perhaps this article will inspire you to join.

The past year has been a whirlwind of activity.

Trainee and medical student collaborators throughout the UK contributed to two large snapshot audits. The first was the “Lost Tribe Audit”, a study of working patterns and clinical activities among the Trauma and Orthopaedic first-on-call tier. With 221 participants, this study had the distinction of being the largest trainee-led audit ever performed in the UK. It was rapidly knocked off that pedestal by its successor, the Paediatric Orthopaedic Trauma Snapshot; a study into current standards of trauma management. A staggering 361 collaborators contributed to this week-long audit, eclipsing our most optimistic predictions.

Such success is the result of the BOTA Committee’s yearlong efforts to promote simple audits, which appeal to those who have never engaged in collaborative audit before.

Jamie McConnell

Having attracted the interest of so many new users, the BONE project is now a strong platform from which to launch further studies. BONE is stronger as it is a network

with many individuals already engaged. These individuals are also motivated, having seen the success of these recent projects. We trust that the results of these audits will make their way to print in the near future, further bolstering the enthusiasm of future project collaborators.

Any BONE user may post a project of their own, although it is not simply a case of “if you build it, they will come”. Our experience has shown that projects are more likely to attract collaborators if they are topical, easily understood, and include a concise data-collection spreadsheet. The audit projects that have succeeded on BONE all started with small-scale pilot studies at single hospitals and were refined before being more widely launched. Given that collaborators are responsible for getting approval from their local audit department, it’s important to make this application simple.

Going through this process at your local trust gives you a chance to optimise the supporting documentation.

Some publicity also helps, and BOTA would be happy to help, where appropriate.

What next for BONE? One goal is to expand from audit to clinical research. We hope that external researchers will be encouraged to recruit site investigators from amongst our membership.

We envisage that this will be attractive to either established research centres, or individuals in collaboration with one of the regional Clinical Trials Centres.

Certainly, the recruitment process to a research trial is vastly more complex than that of an audit, but we have already shown that our membership is a selfselected cohort of motivated individuals. Where better to begin your search? n Jamie McConnell was previously the BONE project coordinator for BOTA. He is currently the DePuy Arthroplasty Fellow in Warwick.

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JTO Features - Trainee Section

Being an Orthopaedic Consultant in 2016 Nick Peterson & Karen Daly

This article expresses the opinions of the two authors and is not representative of the views of any of the organisations with which they are connected. Karen Daly’s comments are informed by her breadth of perspective and experience and represent her views on the wider secondary care sector and not necessarily her own Trust. The authors did not confer before writing this piece.

What is the most exciting part about becoming a Consultant?

NP: Becoming a consultant primarily marks the transition from training to becoming an independent practitioner, and therefore represents autonomy.

In my opinion, the most exciting thing is the chance to incorporate all the good aspects of practice that you have been exposed to during training, while choosing to avoid things you have seen, done badly or unnecessarily. This is a time when you can help to change an existing service, or develop a new one. It is an opportunity to provide treatment in a way you feel is best for your patients, based on their needs and your accumulated experience.

Nick Peterson

Karen Daly

KD: It is great being one’s own boss and being able to take responsibility for the whole patient pathway. It really brings

home how orthopaedic surgery can transform lives, and what a privilege it is to have a part in that. Consultants coming through modern training schemes are better equipped than those of my generation; to be able to influence and improve care for their patients, although they are often surprised how difficult it is to change things.

My advice would be to engage with management and look after your professional development, right from the start. Surgeons and managers think really differently. It really helps to understand that.

What is the most challenging aspect of being a Consultant?

NP: I feel the most challenging aspect will be to remain safely within the limits of your competence, in terms of decision-making and surgical practice. The early years of being a consultant are a point at which you are vulnerable, due to lack of experience, but you will also be exposed to pressures that you rarely worry about as a trainee (management, complaints, administration etc.).

Maintaining a collaborative and mentoring relationship with senior colleagues, so as to prevent isolation is probably the best way to avoid biting off more than you can chew, while still ensuring progression and development.

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KD: There are some days when it is really hard work, just to keep the patient safe in theatre. We sometimes work with unfamiliar teams, inexperienced or temporary staff, and often competing demands for our attention, while trying to meet expectations of a certain throughput in theatre. It can be exhausting trying to keep control of the basics of safe patient care.

It is most important, particularly for the new consultant, to recognise when the surgical environment is becoming a risky one, and to take steps, even perhaps cancelling a patient, when the risk is too high. That’s a really difficult call.

What do you think are the main differences between being a consultant today and 10 years ago?

NP: Ten years ago, the term ‘consultant’ was more applicable to the role than today. In my opinion, the job is now more hands on, with consultant led service being the norm. Stories of the consultant ‘supervising’ from the golf course or the private hospital have been consigned to the past, probably due to the lack of trainee experience, since the introduction of working time directives. The scope of practice is also limited today by financial pressure and evidence based medicine. This potentially restricts innovation, but also

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ensures that care is safe and it reduces outliers in terms of performance.

KD: Newly appointed consultants today are much more likely to be joining specialty teams, rather than working independently. This should provide a degree of support that is welcome in the early years of consultancy. A decade ago, a new consultant could carve out their own niche, whereas today they are much more likely to be appointed with a specific remit. Job planning with objectives is becoming much more common, emphasising that the consultant is expected to adjust their working patterns to meet the needs of the department, and the wider healthcare system.

What do you think it will be like to be a consultant in 10 years’ time?

NP: The current political situation makes prediction difficult, with sustainability and transformation plans threatening to fundamentally change the structure of the NHS. The recent contract negotiations have strained the relationship between doctors and government, but may also potentially affect relationships between future consultants and their trainees. I believe that in ten years’ time the service

will be increasingly consultant delivered, probably with shift work. If privatisation selects out profitable subspecialty areas, the role of consultants may differ within the same specialty. I anticipate that scope of practice will be progressively limited by financial and political pressure.

KD: It’s really difficult to see what the future looks like for the NHS, but there is no doubt that there will be increasing numbers of patients in need of orthopaedic care. I think it’s likely that orthopaedic care will be delivered in a variety of different settings. It’s becoming clear that some degree of separation of elective and emergency care is a safer and more effective way to work, (ironically as it was delivered that way in many places in the UK 30 years ago). Elective centres may employ staff surgeons and it’s possible that there will be more competition for what we would now think of as ‘consultant posts’. I would hope that increasing numbers of orthopaedic surgeons will be closely involved in the design and delivery of orthopaedic services. Where there is clinical leadership, the design and delivery of services is more patient focused and effective. n

Nick Peterson is an ST6 in Trauma and Orthopaedics in the Mersey Deanery. After graduating from Liverpool in 2008 and completing Foundation training, he spent a year in Melbourne, Australia.

He ran the Mersey Orthopaedic Trainees Association from 2014-16 and is co-designer of the mobile app ‘OrthoFlow’.

Nick aspires to a career in adult and paediatric limb reconstruction surgery.

Karen Daly is a Paediatric Orthopaedic Surgeon at St Georges University Foundation Trust where she is Associate Medical Director for Human Resources. She is an elected member of the BOA Council and an appointed member of the SAC.

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JTO Medico-Legal Features

Montgomery and Wrist Fractures: what should we tell the patient?

David Warwick

In 2015, the UK Supreme Court made a ruling based on an obstetric case that will have implications, quite profound implications, on our clinical practice as orthopaedic surgeons.

The ruling is already starting to open new avenues for medical negligence claims, which may incur extra liabilities for a service already strained by the litigation burden.

The reason is that, whereas prior to Montgomery vs Lanarkshire it was a medico-legal defence to use a treatment that would be regarded as reasonable and responsible by one’s peers (the Bolam test), now there must be evidence that the options for treatment have been discussed with the patient and consented prior to treatment.

The Montgomery Judgement: what it says

David Warwick

The Montgomery vs Lanarkshire Health Board Supreme Court Ruling (2015 UKSC 11) states: “A doctor has a duty to take reasonable care to ensure that the patient is aware of any material risk involved in any recommended treatment and of any reasonable alternative or variant treatments.”

Furthermore “It requires that the test of materiality is whether in the circumstances of the particular case a reasonable person in the patient’s position would be likely to attach significance to it.”

In fact, the law has now merely enshrined what we have been advised by the GMC for many years: l Work in partnership with

patients;

l Listen to and respond to, their

concerns and preferences;

l Give patients the information

they want or need in a way they can understand; l Respect patients’ rights to reach decisions with you about their treatment and care.

More recently, similar requirements have appeared in the Royal College of Surgeon’s Good Surgical Practice (2014): l Seeking consent for surgical

intervention is not merely the signing of a form; l You should discuss information about the options for treatment, including non-operative care and no treatment; l The likelihood of success; l The risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications.

The consequences of non-operative alternatives should be explained.

Distal Radius Fractures who should give consent?

Distal radius fractures (DRFs) are common and are managed by people with a range of training and experience, from Nurse Practitioners through Orthopaedic Registrars to Hand Surgery Consultants. So, different health carers may need to provide different levels of consent. In the Emergency Department the patient needs to be advised of the suitable options for first aid (pain relief, manipulation under anaesthetic if displaced, the options for follow-up and the possibility of surgery). In the fracture clinic the

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patient needs to be aware of the advantages and disadvantages of operative or non-operative measures and the risks and benefits of the various surgical options should be discussed. In the surgical ward, signed consent for the patient’s well-informed choice is finally procured.

The options for treatment, and thus the options to be presented to the patient, may vary as time passes; for example when an undisplaced fracture becomes displaced.

What should we tell the patient to involve them in making their own decision?

An experienced surgeon might advise that, notwithstanding all the options available, a particular DRF is best served by a certain treatment; some cases need just a removable splint, others might need complex surgery with double plating and bone grafts. Yet sometimes the patient’s choice may seem irrational - an undisplaced stable fracture could be fixed if the patient insists; a substantially displaced intra-articular fracture probably should be fixed yet some patients may refuse. Informed consent must be sufficient that the patient understands how their best interests are served.

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If an “irrational” decision is in fact because the patient has misunderstood the benefits and material risks presented to them, then inadequate explanation might have been the cause, for which inadequacy the Doctor could be liable.

The assertions of those who are more enthusiastic in encouraging surgical fixation should be tempered by proper sharing with the patient of some facts. l The risk of arthritis is low with

modestly displaced fractures: the orthopaedic mantra that joint line displacement leads to arthritis has not been established reliably for the DRF1,2,3,4,5,6

l Anatomy does not correlate

particularly well with outcome: studies have consistently shown at best a weak correlation6 between anatomy and outcome, and no particular advantage for surgery over non-operative treatment8 over the age of 60 l Surgical fixation is not without

risk. Volar locking plate fixation and k-wires have a material complication rate of at least 8% 9,10.

The risk is probably to some extent dependent on experience and talent of the surgeon and DRF fixation may be delegated to more junior orthopaedic surgeons. Consent should,

ultimately, include details of the surgeon’s talent and experience l Sometimes we just know what

treatment works best: for some fracture configurations, no trial is needed since there is no logical comparator. Instead, we rely on the surgeon’s art - an undisplaced stable fracture is treated with a cast, a displaced Barton’s fracture is treated with a volar plate, a highly comminuted impacted fracture is treated with a rigid distraction device.

Experienced surgeons each have their own preferences, which give a better outcome in their hands. The surgeon should be mindful that they need honest insight into their own craftwork when consenting

l Sometimes we just do not

know what treatment works best: for a “standard” DRF where the patient duly consents for surgery, the ideal technique is unknown.

There is no consistent evidence for one treatment over another; the recent randomised, level 1 DRAFFT study11 suggested that a distal radius fracture fares as well with percutaneous wires as a volar locking plate. However, the cases were selected and the generalisability is not clear12; meta-analysis of other studies shows a trend in favour of plating13,14. Early return to work with uncomplicated volar plating

may render a significant socioeconomic benefit regardless of any medium term equivalence with k-wires; a self-employed patient would expect this advantage to be explained as part of the consent process.

The fact that the DRAFFT study was approved by an Ethics Committee, and that patients consented to be included, demonstrates equipoise for surgeons and patients; this might be a reasonable defence against any retrospective medico-legal contention that a patient would have chosen one over the other in the event of a complication15.

Consent for a fracture that may or may not benefit from fixation Some fractures are so displaced initially, or due to their inherent instability displace so rapidly and markedly after an initial closed reduction in the Emergency Room, that failure to tilt the consent process towards surgical stabilisation would expose the patient to a predictable risk of a poor result.

However, there is a paucity of information upon which to base informed consent as to the best procedure and the real benefit of anatomical reduction. >> Additionally, we do not really

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JTO Medico-Legal Features

SOME FRACTURES ARE SO DISPLACED INITIALLY, OR DUE TO THEIR INHERENT INSTABILITY DISPLACE SO RAPIDLY AND MARKEDLY AFTER AN INITIAL CLOSED REDUCTION IN THE EMERGENCY ROOM, THAT FAILURE TO TILT THE CONSENT PROCESS TOWARDS SURGICAL STABILISATION WOULD EXPOSE THE PATIENT TO A PREDICTABLE RISK OF A POOR RESULT.

know, for many fractures, what amount of angulation or shortening can be accepted, or should prompt surgery. We do know that, in fact, most patients with modestly displaced extraarticular DRFs do well regardless of the final anatomical position, especially in older and lower demand patients. Conservative treatment can fare as well as surgical treatment16. We also know that volar plate fixation is expensive and not without risk. Finally, we also know that distal radial osteotomy for an extra-articular fracture is a reliable operation with good results when performed17 before secondary changes develop in the mid-carpus and the distal radio-ulnar joint.

So, what do we do with a mildto-modestly displaced DRF, with say 3mm of shortening and 20 degrees of dorsal tilt at the two week x-ray? Do we accept or do we operate? If the fracture is left and then goes on to a symptomatic malunion they will be dissatisfied and may even litigate. But supposing a volar plate is used and they then have a tendon rupture or infection, they might be equally dissatisfied and litigate, once again. Informed consent, involving the patient and documenting the matters discussed and the conclusion reached, is essential. But the

Montgomery judgement actually helps us to deal with this dilemma, framing the discussion with the patient something along the following lines: If we operate now for this mildly displaced fracture, there is about an 8% chance of a significant complication which would probably make you regret the decision to undergo surgery.

But, if we avoid surgery now, and wait and see instead, there is only about a 20% chance of actually needing an operation.

That operation will be almost the same as if we performed surgery now. Surgery would involve a cut at the front of the wrist and the insertion of a metal plate. You may also need a small incision in the edge of the hip for a bone graft or perhaps some artificial material will be inserted into the gap. This may take a few weeks longer to recover.

This consent model can mollify our unease in the grey areas we face in trauma management, sharing our uncertainties with the patient, explicitly in the consent process. A medical negligence claim may emerge when a DRF is not operated on initially and then an osteotomy is eventually performed. If better consent had been undertaken and documented, the claim may well never have been viable. Fortunately,

the causal losses tend to be relatively small when the claim is settled, because the outcome of osteotomy is usually good and the patient would have had an operation in any event.

Correspondence

Conclusion

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

We orthopaedic surgeons dealing with distal radius fractures have to be meticulous in the consenting process with a full and balanced explanation of options and risks and outcomes. This has always been so professionally, but now, in the post-Montgomery era, the medico-legal perspective is the same. Nevertheless with real uncertainty about the advantages and disadvantages of any treatment despite years of research, the information upon which to base informed consent is itself uncertain. In the consent process we must clearly share and document the uncertainty. n

Acknowledgements: Thanks to Andrew Clarke and Mike Foy of the BOA Medico-legal Committee for their input into this paper.

Professor David Warwick is a Hand Surgeon at University Southampton and member of the BOA Medico-legal Committee.

Email: davidwarwick@handsurgery.co.uk

References

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JTO Peer-Reviewed Articles

The non-operative management of hand fractures: a review Grey Giddins

Most hand fractures can be successfully treated non-operatively9.

Some injuries such as contaminated open fractures or combined injuries e.g. requiring flexor tendon repair need operative treatment. The blood supply of the hand means that almost all fractures treated non-operatively heal with bone and most of those that do not are minimally symptomatic as the hand is not primarily weight bearing.

The aim of this paper is to identify and highlight some hand fractures which are often treated operatively but where the published evidence suggests that non-operative treatment is so good that surgery is rarely indicated.

Spiral or long oblique metacarpal fractures

Grey Giddins

Spiral or long oblique metacarpal fractures can be treated with a range of surgical techniques; comparably good results have been reported with operative1,2 and non-operative treatment3.

All spiral metacarpal fractures, even with initial malrotation, can be treated non-operatively with very good outcomes and minimal morbidity4. The patients were treated with early mobilisation without a splint or plaster

and specifically encouraged to make a fist from the first outpatient visit to correct any malrotation and ensure early mobilisation. Twenty-five of 30 patients reviewed at a minimum follow-up of six months had full movement, grip strength of at least 90% of the other hand and only minimal malrotation in one patient and mild discomfort in another.

Malrotation following spiral metacarpal fractures almost always corrects with finger flexion. If it does not, then encouragement or manipulation under local anaesthetic would be appropriate, as the key aims of treatment are full movement avoiding rotational malunion.

The risk of dysfunction caused by shortening of the metacarpals with non-operative treatment

has been raised5,6,7. A recent biomechanical study has suggested that shortening up to 5mm is not significant8; this fits with the results of Khan and Giddins4.

Transverse metacarpal fractures of the fingers Historically, patients with transverse metacarpal fractures of the shaft and especially the neck (boxer’s fracture) were left to mobilise freely. They usually healed with some deformity but good function. Barton9 established the role of a short plaster or splint to reduce the angulation of transverse metacarpal shaft fractures. The results of surgical treatment are also typically very good. There is a trade-off of angulation (non-operative treatment) versus the risks of surgery and a scar.

A key question is therefore: “what degree of malunion is ‘acceptable’?”. The answer is unclear. For metacarpal neck (boxer’s) fractures there have been various recommendations: 50° to 60° flexion10; 30° 11,12 and 20° 13,14. For little finger metacarpal shaft fractures, 30° has been considered acceptable10,15. But these are only expert opinion. A Cochrane review has shown there is no good evidence that more marked malunion causes reduced hand function or creates unacceptable deformity16.

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Journal of Trauma and Orthopaedics: Volume 04, Issue 04, pages 48-51 Title: The non-operative management of hand fractures: a review Author: Grey Giddins

Westbrook et al.17 compared 105 metacarpal neck fractures treated non-operatively vs 18 treated operatively (13 with intramedullary k-wiring and five with plating); and 113 metacarpal shaft fractures treated non-operatively vs 26 treated operatively (four with k-wiring and 22 with plating).

At a minimum follow-up of two years there were no differences in DASH score, grip strengths or aesthetics but a significant complication rate following surgery. Follow-up rates were, however, low (17% for nonoperative treatment and 54% for operative treatment). A randomised study on metacarpal neck fractures18 has suggested that surgery may be very slightly better than non-operative treatment, primarily in giving better cosmesis due to less angular malunion. Strub et al.18 reported two groups of 20 patients who were pseudorandomised to intramedullary (bouquet) wiring (requiring two operations each for insertion and removal of the wires) or non-operative treatment with early mobilisation. The only complications were in the operative group which had more dissatisfied as well as more very satisfied patients. This study did not address patient inconvenience or patient/ healthcare costs.

Finger proximal phalanx collateral ligament avulsion fractures

Thumb metacarpophalangeal joint avulsion fractures

Bekler et al.19 noted that avulsion fractures of the bases of the phalanges are challenging injuries to treat but also stated that: “Avulsion fractures (of the bases of the phalanges) are intraarticular according to their configuration and need anatomic reduction� (a common but largely unproven myth in the hand). Other authors have also recommended that all base of finger avulsion fractures should be treated surgically because of the high rate of symptomatic non or delayed union20,21,22,23,24,25, yet early protected mobilisation gives very reliable results at a mean follow-up of 57 (range 8-94) months26. The available data are limited as these are small series often with limited follow-up. The dichotomy with the experience of Shewring and Thomas24 who reported symptomatic delayed union in eight consecutive patients and the excellent results of Sawant et al.26 in seven patients may be that many of these injuries often do not unite with bone (as for thumb metacarpophalangeal joint ulnar collateral ligament avulsions27) but heal with sufficient stability that surgery is not required. Currently, the evidence suggests the results with non-operative treatment are reliable so that should be the first line of treatment.

Ulnar collateral ligament injuries: The outcome of thumb metacarpophalangeal (MP) joint avulsion fractures is disputed.

A Stener lesion whether or not there is a bony avulsion will give a poor outcome with nonoperative treatment28. Some authors have reported poor outcomes with non-operative treatment of ulnar collateral ligaments avulsion injuries: Dinowitz et al.29 reported on nine cases with minimally displaced fractures treated in plaster within six days; all reported persistent pain which largely resolved following surgery. Kuz et al.30 reported 30 patients treated nonoperatively. All were reviewed by questionnaire; 20 were seen in person. Nineteen of the 30 had no pain; all reported being satisfied by their treatment and none had changed jobs. The 20 assessed in person had no reduction in pinch or grip strength but two had some instability. They reported a non-union rate of 25% (5 of 20).

Sorene and Goodwin27 reported 28 cases of avulsion fractures stable at original assessment treated with immobilisation in plaster for six weeks and followed up for a mean of 2.5 (range 1-4) years. They reported that 26 of the 28 had no pain on movement and no reduction

in pinch and grip strength yet radiologically 60% had nonunion. Comparable surgical results have been reported31.

Current evidence indicates that stable bony avulsions can be safely immobilised in plaster with the expectation of a good outcome.

The treatment of unstable injuries is less clear with surgery the current default position.

But, as so often, the data are inadequate. There are a range of different types of thumb ulnar collateral ligament avulsions injuries from small bony avulsions i.e. primarily a soft tissue problem to large rotated bony avulsion fragments. This is likely to be an injury with subtypes that will benefit from surgery and others that will not; this remains unproven.

Radial collateral ligament injuries: There are fewer reports of the treatment of radial collateral ligament (RCL) injuries. As there is no adductor hood to cause a Stener-type lesion non-operative treatment should work well, i.e. immobilisation in plaster for 4-6 weeks. The role of surgery is debated12, 32-34. Mildly displaced RCL avulsion fractures treated non-operatively usually achieve a very good outcome35. The role of surgery for more widely displaced or unstable injuries is unclear.

Some authors believe that surgery is required on the basis >>

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MALROTATION FOLLOWING SPIRAL METACARPAL FRACTURES ALMOST ALWAYS CORRECTS WITH FINGER FLEXION. IF IT DOES NOT, THEN ENCOURAGEMENT OR MANIPULATION UNDER LOCAL ANAESTHETIC WOULD BE APPROPRIATE, AS THE KEY AIMS OF TREATMENT ARE FULL MOVEMENT AVOIDING ROTATIONAL MALUNION.

that “considerable displacement of torn ends can prevent the RCL from healing”35 (another unproven belief). Currently, there is no good evidence that operative treatment of these injuries is superior to nonoperative treatment.

Bony mallet injuries There are many papers reporting techniques for reducing and holding the dorsal avulsion fracture fragment in bony mallet injuries36-49. This is an operation with an acknowledged high risk of complications50,51, although less so more recently36-49.

Reasonably consistent good results are reported for various surgical treatments of bony mallet injuries with a dorsal fracture fragment of 1/3 or more. The recommendation to treat fractures of 1/3 or more has come from a number of authors52. The aim of surgery is to prevent subluxation of the main distal phalanx fracture fragment36, 38-49. What degree of subluxation (>2mm?) needs to be treated is unproven although some cases do progress to symptomatic dislocation.

In one of the most widely cited papers51 the authors reported that amongst patients with dorsal fracture fragments of over 1/3 followed-up for a mean of 3.25 years the 15 patients treated non-operatively

did as well as the six treated operatively. Webhe and Schneider51 noted no difference between operative and nonoperative treatment in rates of radiographic OA. Other authors have reported rates of DIP joint OA up to 50% yet some of only 0%. Almost certainly their criteria (which are rarely reported) differ, making comparison difficult. The risk of radiographic OA would be a potential concern except that long term symptomatic degenerative arthritis in the DIP joints is rarely seen in patients who have had

Figure 1: Gliding of the distal phalanx on the middle phalanx in response to extension stress testing

bony mallet injuries, i.e. as orthopaedic surgeons we rarely see patients requiring treatment for symptomatic DIP joint arthritis who had bony mallet injuries decades earlier.

A Cochrane review reported that there was a paucity of good studies and no evidence that surgery was better than non-operative (typically splint) treatment for all types of mallet injury53. They did, however, acknowledge that there may be a subgroup of these injuries that would benefit from surgery.

Figure 2: Pivoting with extension stress testing

The main area of concern is when there is a large fracture fragment ≥ 1/3 of the articular surface on the lateral radiograph with secondary volar subluxation of the main distal fracture fragment of the distal phalanx.

Recent work54 has shown that the risk of subluxation can be predicted reasonably reliably with a lateral hyperextension radiograph performed within 1-2 weeks of injury. If there is “gliding” of the distal phalanx (Figure 1) i.e. it remains congruent into extension then this is stable. The presumption

Figure 3: Tilting with extension stress testing

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Journal of Trauma and Orthopaedics: Volume 04, Issue 04, pages 48-51 Title: The non-operative management of hand fractures: a review Author: Grey Giddins

is that there has not been so much collateral ligament injury that subluxation will occur. If there is “pivoting” (Figure 2) then subluxation will usually occur, although this may only be mild.

There is a third intermediate type “tilting” which probably behaves like gliding (Figure 3). The data further narrow the indications for surgery. Again, most patients do not need surgery but there is a clear subgroup that should benefit.

Discussion There are many problems with the existing literature: a lack of RCTs; bias in many of the studies; and often incomplete data or outdated reporting of outcome. In addition, whereas operative treatments may be well described, there is often little detail about non-operative treatment. The quality of the follow-up almost certainly varies greatly. The outcome of and indications for non-operative treatment also depend upon other factors such as clinic availability, patient availability (some have to travel long distances making regular followup difficult) and therapy.

Nonetheless the available data suggest that for the above fractures surgery does not reliably confer benefit over “good” non-operative treatment.

As surgery typically costs

more both in patient risk and healthcare costs, non-operative treatment should be the default position for these fractures accepting the need for clinical judgement for individual cases.

In time, there may be newer techniques allowing much earlier return to function with lower risks that may supersede nonoperative treatment.

The dichotomies of different authors recommending such radically different treatments may have occurred for a number of reasons: surgeon preference/ bias; misunderstanding of the pathophysiology of the injury; over-reliance on biomechanical or cadaver studies which may not apply in clinical practice; an over-emphasis on bone union which may not affect outcome; and the variability of the injuries such that a sub-group of each pattern of injury does poorly with non-operative treatment skewing the perceptions of the outcome of treatment.

As reported for paediatric fractures in BJJ 360, nonoperative treatment risks being forgotten. In light of the Montgomery ruling by the Supreme Court, surgeons need to be aware of how well many fractures do with non-operative treatment and that offering surgery requires very detailed consent. In addition, we should focus our future research efforts on areas where we might make

a significant difference ahead of tackling those with marginal gains.

Different patterns of displaced phalangeal fractures and proximal inter-phalangeal joint fracture subluxations or pilon fractures are two topics where the optimal treatments are very unclear and where research could make a considerable difference. n Prof Grey Giddins is an Orthopaedic and Hand Surgeon in Bath. He works as a team of three hand surgeons within the Orthopaedic department in Bath. He has a particular interest in the natural history of common conditions especially hand fractures in an effort define more clearly the problems that benefit from surgery and vice versa. He is also researching in distal radio-ulnar joint stability and arthritis, mechanisms of falling and avoidance of wrist injury, and hand and wrist biomechanics. As well as a Council member of the BOA he is currently the Editor-in-Chief of the Journal of Hand Surgery (European) and will next year be the President of the BSSH.

Correspondence: Email: greygiddins@thehandclinic.co.uk

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

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The role of implant arthroplasty in the management of the painful distal radio-ulnar joint Lisa Leonard

A dysfunctional distal radioulnar joint (DRUJ) can significantly impair the ability of the wrist and hand to bear load and function effectively. The DRUJ is anatomically and kinematically a complex area of the body; pathology is rarely confined to one area.

Problems with the DRUJ present frequently to orthopaedic clinics but are often poorly understood and difficult to treat effectively.

This brief review considers the current place of arthroplasty in the treatment of DRUJ pathology.

Lisa Leonard

Hip and knee arthroplasty has transformed the lives of countless patients around the world. Replacements are available now for almost every joint in the body and the DRUJ is no exception. Historically, simple resection of all, or part, of the ulnar head was favoured, for instance the Darrach procedure. Sometimes this was combined with fusion of a distal portion of the ulnar head to the adjacent radius to longitudinally support the carpus - the SauveKapandji procedure. None of these procedures restored the normal transverse load bearing characteristics of the wrist. Patients, who loaded their wrists to any extent, after these procedures, were at risk of painful impingement of the ulnar stump against the distal radius, which significantly impairs wrist function (Figure 1a & b).

Over time our understanding of the anatomy and pathology of the ulnar side of the wrist has also developed. A recent review4 highlighted four key areas to consider when a patient presents with pain around the ulnar head:

a

1. Bony deformity – for instance following a previous distal radius fracture 2. Cartilage defects – arthrosis 3. Triangular-fibro-cartilagecomplex (TFCC) injuries – the primary static stabiliser of the DRUJ 4. Extensor carpi ulnaris tendon instability – the primary dynamic stabiliser of the DRUJ. In each patient, the contributions from these four areas should be considered, and addressed, in order to optimise the outcome.

Only 20% of DRUJ stability is bony, the other 80% derives from the surrounding soft tissues. With ulnar head arthroplasty the 80% soft tissue stability is provided by preservation, repair, reconstruction or replacement depending on the type of implant employed. >> b

Figure 1a & b: (a) Darrach’s distal ulnar resection with no load on wrist4 / (b) with a 5lb load on wrist

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AROUND THE WORLD MANY, IF NOT MOST, HAND UNITS INCLUDE SOME FORM OF ULNAR HEAD REPLACEMENT IN THEIR ARMAMENTARIUM.

Indications for DRUJ arthroplasty The indications for DRUJ arthroplasty are primary and secondary. Primary indications are primary and post-traumatic osteoarthritis (OA) and rheumatoid arthritis (RA) with its associated destruction of the distal ulna and DRUJ, in the higher demand patient.

Secondary indications include marked symptoms following ablative distal ulnar surgery, such as after a Darrach’s or SauveKapandji procedure.

Types of arthroplasty Ulnar head replacement began with Swanson’s silicone prosthesis. This was abandoned in the 1990s as a result of poor results, with loosening and bone resorption. The first solid hemiarthroplasties of the ulnar head were implanted in 1995.

Partial ulnar head replacements have been developed more recently. These aim to retain the ulnar styloid and its soft tissue attachments. The latest design has been a total joint replacement that replaces the sigmoid notch of the distal ulna as well as the ulnar head.

head resection. A prospective, international, multi-centre study group was set up at the start of this process. This group consisted of workers in Germany, Switzerland, the USA and Australia. Von Schoonhaven6,7 has reported the early and later results of this cohort of 23 patients who had a mean age of 45 years at the time of implantation. Sixteen patients remained for review at a mean of 11 years postimplantation. The good early results had been maintained with a mean pain score of 1.7/10, mean patient satisfaction of 8.9/10, grip strength of 81% of the contralateral hand and no radiographic signs of progressive loosening. These results are attractive, but only relate to a very small cohort of patients.

Solid ulnar head arthroplasty Solid ulnar head arthroplasties (Figure 2) were initially implanted solely following failed ulnar

Figure 2: The Herbert Ulnar head replacement

The indications for ulnar head hemiarthroplasty quickly expanded to include patients with arthritis of all types, including abutment of a long ulnar against the ulnar side of the carpus. A recent unpublished systematic review looked at all published results on ulnar head hemiarthroplasties (Moulton LS and Giddins GEB). The study used PRISMA guidelines to review the literature. Only 14 studies with 355 implants were identified. Not all implants were of the original design reported by von Schoonhaven’s group and a more varied set of indications for surgery were included. The overall survival for the whole group, at a mean of 45 months, was 92.5%.

A careful soft tissue repair is necessary following ulnar head arthroplasty. Partial ulnar head replacements have also been developed (Figure 3) with the aim of preserving the ulnar styloid and TFCC intact, thus limiting the surgical soft tissue reconstruction. Published results for partial arthroplasty are very limited. The 11 months results for three patients were published in 2007 for the Eclypse pyrocarbon model3. A further five cases in patients with RA were reported with a mean follow up of 64 months in 20161; only four cases were reviewed. The mean pain score was 1.5 with a mean grip strength of 148% of the other side. Two cases were presented using the Integra partial resurfacing design with only one year of follow up5.

Figure 3: The Integra Partial Resurfacing implant

Complications described for ulnar head arthroplasty include residual instability of the distal ulna, infection, implant loosening, bone resorption, tendon rupture and implant failure.

Total DRUJ replacement In 2005 Luis Schecker, of the Kleinert Institute in Louisville, began implanting the Aptis total DRUJ prosthesis (Figures 4 and 5). This replaced the ulnar head and the adjacent sigmoid notch of the radius and has a constrained construct. This prosthesis is indicated if the sigmoid notch has been significantly damaged, or worn, along with the ulnar head and/or if the surrounding soft tissues are poor. Schecker published his preliminary results in 20142. This study consisted of

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17 patients all with rheumatoid arthritis and a mean age of 57 at the time of implantation.

The mean follow-up was 39 months. Pain scores and forearm rotation were improved; all the patients were satisfied with their procedure and no progressive signs of loosening were identified.

Further reports of this prosthesis were reviewed in the systematic review mentioned earlier. They identified a total of 15 studies with 319 implants. All prostheses reported were the Aptis design, or a prototype thereof. A range of indications for surgery were described. The overall survival for the whole group, at a mean of 44 months of follow up, was 97%.

Complications for the total DRUJ replacement include infection, heterotopic bone formation, tendonitis, bone resorption, implant fracture, screw irritation and loosening.

Conclusions

Figure 4: The Scheker Total DRUJ7

Figure 5: An Exploded View of the Scheker Prosthesis

Around the world many, if not most, hand units include some form of ulnar head replacement in their armamentarium. When faced with a summary of the actual evidence on which we are using these implants, however, it is difficult not to feel uncomfortable. The published data describes a very small number of patients, with only short-term follow up in most cases. Most of the published reports are from the implant designers themselves or established experts in this field. One is left feeling, not for the first time, that routine, prospective collection of data regarding ‘new’ implants should be common place in this age when connectivity is so easy. In this country we are lucky enough to have a National Health Service

and we should be able to collect this data relatively easily. In the future this will surely be the way all implant development and implementation will take place. n Lisa Leonard is a Consultant Orthopaedic Hand Surgeon based at the Brighton and Sussex University Hospitals NHS Trust.

She has been the lead for MSK services in her Trust for the last three years, has served on the BSSH Committee for Education and Training and is currently on the committee developing distal radius fracture management guidelines. Her research work includes the kinematics of arthroplasty design in the wrist.

Correspondence Email: lisa.leonard@bsuh.nhs.uk

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

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Measurement and assessment in modern hand surgery research Alexia Karantana, Jeremy Rodrigues, Tim Davis

The outcome of hand surgery has traditionally been objectively assessed with measures such as sensory thresholds, grip strength and range of thumb, finger or wrist movement. Cut-off thresholds for each of these measures are often broadly categorised as “excellent”, “good”, “fair” or “poor”; or “good” or “bad”. In Dupuytren’s disease it is stated that surgery is indicated if there is a 30o or more flexion deformity of a joint, regardless of whether the contracture is causing inconvenience or loss of function.

Alexia Karantana

Jeremy Rodrigues

Tim Davis

Additionally, a 20-30o increase in the flexion deformity following surgery is categorised as “recurrence” and thus a “poor” outcome. This again is regardless of whether there is loss of function or disability, or whether it requires revision surgery. However, angular deformity does not correlate well with loss of function in Dupuytren’s disease, and does not reflect the impact of surgical complications such as digital artery and nerve damage, or loss of finger flexion.

Hand surgery outcomes may also be assessed radiographically.

This may be acceptable if the x-ray measurement is a reasonably good surrogate for the clinical outcome, as, for example, is the case for union/non-union of a scaphoid fracture. However, the assessment of outcome according to x-ray features which do not correlate well, or at all, with the clinical outcome are unsatisfactory. Similarly, dorsal tilt, radial angle and shortening of a united distal radius fracture have not been shown to reliably correlate with function, despite a plethora of studies. They may predict the cosmetic outcome but this is more readily assessed by actually looking at the wrist or, best of all, by asking the patient what they think of the appearance of their wrist – a PROM (patient reported outcome).

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PROMs assess variables that cannot be measured directly, such as “hand function”, “health status” or “health-related quality of life”. Improving these is the aim of treatment in non-terminal conditions that are usually encountered in hand surgery.

Such PROMs are more pragmatic than many objective outcomes.

For example, it is probably more important to establish whether or not patients’ function improves as a result of treatment, rather than whether they achieve an arbitrary improvement in grip strength yet still require social care for activities of daily living. PROMs typically involve questionnaires completed by the patient and, if well-designed and validated, can provide a patient-centred perspective on treatment effect.

Increasingly, robust science underpins the design and validation of high-quality PROMs1, and their use in research and clinical practice2.

PROMs can be used to assess the outcome of both hand trauma and elective surgery. There are many PROMs available for use in hand surgery. They range from those that assess general health status or health-related quality of life, through domain-specific PROMs to assess the hand or upper limb as a functional entity, to diseasespecific measures that assess a particular condition3. Often,

the most popular PROMs are domain-specific to the hand, wrist or upper arm4. These include the Disabilities of the Arm, Shoulder and Hand (DASH), the Patient Evaluation Measure (PEM), the Michigan Hand Questionnaire (MHQ) and the Patient Rated Wrist Evaluation (PRWE). At present no specific upper limb PROMs are superior in terms of their reliability, validity and responsiveness.

In contrast, disease-specific PROMs, such as the Unité Rhumatologique des Affections de la Main (URAM) scale for Dupuytren’s disease, may be more sensitive when working within a condition, for example, comparing two operations for Dupuytren’s disease. However, they do not compare different hand conditions. While most of the PROMs currently used in hand surgery have good points, they have limitations. Most have not been developed using contemporary methods and do not perform ideally when subjected to rigorous modern psychometric assessments of validity, reliability, responsiveness and interpretability. In the future, it is likely that existing PROMs will be refined, and new PROMs will be introduced. PROMs should be seriously considered for use as the primary outcome in most hand surgery studies, whilst acknowledging their limitations.

Unfortunately, there is little consensus on which PROM is best for any clinical setting.

carpal tunnel surgery or newer technologies such as collagenase in Dupuytren’s?

Outcome assessment with a PROM may show that treatment ‘A’ produces good results in 85% of cases while treatment ‘B’ only produces good results in 70% of patients. In this case, should all patients receive treatment ‘A’?

This could be the case if treatment ‘A’ costs no more than treatment ‘B’. However, if treatment ‘A’ is more expensive, is it not reasonable that those paying for the treatment should be involved in the decision? Cost and, more specifically, the concept of “value for money” is an increasingly important factor in decision making for the modern NHS.

The National Institute for Clinical Excellence (NICE) was established in 1999 to address geographic variations in prescribing (‘postcode lottery’) by providing national-level guidance on the clinical and cost-effectiveness of health technologies in the NHS5. As part of its process of technology appraisal, NICE has adopted a ‘reference-case’ approach, specifying methods and outcomes used to assess the cost-effectiveness of treatments6.

In general, a new treatment is considered clinically effective if, in day-to-day clinical practice, it results in an overall benefit to health. It is considered costeffective if these health benefits are greater than the costs required to fund it, in the context of limited NHS resources. In other words, the general consequences for the wider group of patients in the NHS are considered alongside the effects for those patients who directly benefit from the new treatment. For example, is the benefit of a renal transplant greater than that of using the same resources for

Cost-effectiveness analysis (CEA) from the perspective of the NHS does not take into account personal or societal costs. Costs borne by patients, such as loss of income or personal expenses, are included only when reimbursed by the NHS or Personal Social Services. Wider costs to society do not feature in this setting. The health system does not benefit from returning someone to work earlier, as the purchaser pays the provider the same, whether the person is off work for one day or one year.

Health benefits are measured in terms of Quality of Life (QoL) using generic outcome instruments, such as the EQ-5D7 or SF-368. These are designed to >>

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cover the more common, core dimensions of health and, unlike clinical PROMs, allow direct comparisons across different conditions and treatments in healthcare. On the other hand, they can be less sensitive to change than clinically focused patient-reported outcome measures for a particular treatment. They also require a potentially larger sample size.

The EQ-5D is the required measure of QoL in the NICE reference case (Guide to the methods of technology appraisal, 2013). NICE also use Quality Adjusted Life Years (QALYs) as a measure of cost-effectiveness.

It considers that a QALY cost of £20,000-£30,000 represents good value for money in terms of cost-effectiveness.

Alongside clinical appraisal, CEA is now a requirement for NIHR comparative studies,

Remember them fondly It is with great sadness that we report the passing of Neil Bradley. Our thoughts are with his family and friends at this time.

such as multicentre randomised controlled trials of interventions.

The NICE reference case has been set to specify the methods and outcomes “considered by the institute (NICE) to be appropriate for the Appraisal Committee’s purpose and consistent with the NHS objective of maximising health gain from limited resources”6.

Nevertheless, the methodology of economic evaluation in healthcare, and in particular CEA, is fraught with areas of uncertainty and controversy. In addition, the concept of costeffectiveness has yet to be fully grasped by surgeons and users of the NHS alike. n Alexia Karantana is Clinical Associate Professor in Hand Surgery at the University of Nottingham and Honorary Consultant Hand Surgeon at Nottingham University Hospitals

NHS Trust. She is Deputy Director of the Centre for Evidence-Based Hand Surgery, which aims to facilitate high quality patientcentred studies on common hand conditions, addressing clinically important areas of uncertainty relevant to patients and the NHS.

Hospitals and an Honorary Professor at Nottingham University.

He is interested in clinical research on common hand conditions and injuries.

Jeremy Rodrigues is an NIHR Academic Clinical Fellow registrar in plastic surgery at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) of the University of Oxford, an Honorary Research Fellow at Warwick Evidence, and a Fellow at the National Institute for Health and Care Excellence (NICE). His MSc dissertation, PhD thesis and ongoing research focus on outcome measurement in hand surgery.

Email: Alexia.Karantana@nottingham.ac.uk Email: j.n.rodrigues@doctors.org.uk Email: Tim.Davis@nuh.nhs.uk

We have shifted our focus from funding multiple pump-priming 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.

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

Tim Davis is a Consultant Hand Surgeon at Nottingham University

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.

Correspondence

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.

Festive Fun Answers Solve the Puzzle answer: Thank you to all of our members for a successful year Festive Quiz answers: 1. Holiday Inn; 2. Ladies dancing; 3. Christmas cracker; 4. Mexico; 5. The Nightmare before Christmas; 6. Dr Seuss; 7. Canada; 8. George V (in 1932); 9. Clarence (Odbody); 10. Robert Burns

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Acute Traumatic Spinal Cord Injury Symposium

A Symposium on the diagnosis, management and outcomes 16 March 2017

11th Trauma & Orthopaedics Update

Val d’Isere 30 January – 2 February 2017 www.doctorsupdates.com info@doctorsupdates.com +44 (0) 208 7151924 Doctorsupdates 2017, in their 28th year will feature 11th Trauma and Orthopaedics Update. This meeting is unique as it provides

Wrightington Hospital

WRIGHTINGTON HAND DIPLOMA REVISION COURSE 17 & 18 January 2017

Course Venue: Hospital Conference Centre

BASIC SCIENCE VIVA COURSE 24 & 25 January 2017

BBiOrth® course is held at The Royal Society of Medicine, London.

It is delivered over one day with a mixture of lectures and small group break out sessions. The material is covered by a range of speakers, who are keen to relate the theory to surgical examples.

Venue: The Royal Society of Medicine 1 Wimpole Street, London W1G 0AE

info@bbiorth.co.uk @bbiorth Basic Biomechanics in Orthopaedics Course Next course Saturday 20 May 2017 Saturday 16 December 2017

Venue: Robert Jones and Agnes Hunt Orthopaedic Hospital

interaction between a number of different specialities: orthopaedics, anaesthetics, critical care, pain, radiology, plastic surgery, dermatology and general practice.

Each day concludes with a lecture of general interest by an eminent guest speaker.

The programme is suitable for consultants and senior trainees.

The format is informal and sessions include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees.

DUPYTRENS DISEASE IN THE WORKPLACE 26 May 2017 SHOULDER ULTRASOUND 9 June 2017

26 & 27 January 2017

For further information: www.orthopaedic-institute.org or contact alison.whitelaw@rjah.nhs.uk

We have an excellent orthopaedic faculty lined up and the programme will be available at www.doctorsupdates.com when confirmed.

Further information: Mavis Luya - Cadaveric courses and Dupytrens Conference Telephone: +44 (0) 1257 256248 Email: upperlimb@wrightington.org.uk Jackie Richardson - Hand Diploma/ FRCS/Basic Science/Ultrasound Telephone: +44 (0) 1257 256413 Email: jackie.richardson@wwl.nhs.uk Websites: www.wwl.nhs.uk (Our hospitals, Wrightington, Forthcoming Courses), www.wrightington.com (Courses)

HAND & WRIST CADAVERIC ELECTIVE WORKSHOP 23 & 24 February 2017

Orthopaedic Surgery courses suitable for all stages of your career pathway and covering sub-specialty interests and exam revision including:

www.bbiorth.co.uk

Target Audience: Consultants and Trainees in orthopaedics, neurosurgery, intensive care, trauma centres, accident and emergency and spinal injury related healthcare professionals and ambulance personnel.

UPPER LIMB FRCS (Orth) COURSE

RCS Orthopaedic Course Portfolio

For further information:

l Anatomy revision for FRCS (Tr & Ortho) l Basic Techniques in Arthroscopic Surgery l FRCS (Tr and Orth) Viva Course for Orthopaedic Surgeons l Hip, Ankle and Distal Radial Fractures

On selected courses, we offer a 10% discount to Members and Fellows of the Royal College of Surgeons of England Further details: www.rcseng.ac.uk/courses

Volume 04 / Issue 04 / December 2016

Page 60

boa.ac.uk

Imprint

JTO:

Instructions for authors

Information for readers, advertisers & potential authors

JTO Editorial Team l l l l l

Phil Turner (Editor) Fred Robinson (Deputy Editor) Michael Foy (Medico-Legal Editor) Simon Fleming (Trainee Section Editor) Grey Giddins (Guest Editor)

BOA Executive l Ian Winson (President) l Tim Wilton

(Immediate Past President) l Ananda Nanu

(Vice President) l Phil Turner

(Vice President Elect) l Don McBride

(Honorary Treasurer) l David Limb (Honorary Secretary) l Mike Kimmons (Chief Executive)

BOA Elected Trustees l Ian Winson (President) l Tim Wilton

(Immediate Past President) l Ananda Nanu

(Vice President) l Phil Turner

(Vice President Elect) l Don McBride

(Honorary Treasurer) l David Limb (Honorary Secretary) l R. Adam Brooks l Grey Giddins l Ian McNab l Philip Mitchell l David Clark l Simon Donell l Mike Reed l Fred Robinson l Stephen Bendall l Karen Daly l Bob Handley l John Skinner

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 eLearning Officer .................. Silvia Bianco

Communications & Operations Director of Communications & Operations ........................ Emma Storey JTO & Joint Action Officer ..... Lauren Rich Membership & Marketing Officer ....... Jenna Redelinghuys Office Co-ordinator ...... Natasha Wainwright Information Systems Officer ... Hardik Bhatt

Quality Outcomes Programme Director ............... Julia Trusler (maternity leave) Interim Programme Director ..... Minoo Esat

Finance Director of Finance ���������������������������Liz Fry Deputy Finance Manager.................. Sherrine Wilson-Smith Finance Assistant ������������������Hayley Oliver

Events & Specialist Societies Director of Events Management ....................... Hazel Choules Exhibition Manager �������������������Janet Mills UKSSB Executive Assistant ...... Jo Wilson

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. In some cases the Editorial Team will request to see the full article based on the synopsis.

This, however, does not guarantee publication. The JTO does not publish audits or case reports. To have an article printed in the journal, you must be a BOA member.

Word Limit

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 250 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.

References are not included in the word count but will be included separately on the BOA website in the JTO section and will not be included in the print version of the journal. References should be supplied in the Oxford Referencing format.

Images

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.

An indication within the article should identify where the image should be inserted. The article should state a short title/caption for each image.

Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.

Peer-Review

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.

Important items to note Registered Charity No.1066994 Company limited by guarantee Company Registration No.3482958

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.

Future publications JTO is published quarterly.

How to subscribe If you’d like to subscribe to future issues either for yourself or your organisation, we’d be happy to add you to our mailing list; please contact us at JTO@boa.ac.uk Please note all issues are free of charge.

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: Ines Reichert, Alexander Durst, Royal College of Surgeons of England.

Copyright Copyright© 2016 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