Journal of Trauma & Orthopaedics - Vol 3 / Iss 3

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 03 / Issue 03 / September 2015 boa.ac.uk

Inside

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

In our Features section you will find articles that focus on hip fracture reviews, orthopaedic research in the UK and complications in orthopaedic literature

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

News & Updates ––– Pages 02-15

Features ––– Pages 16-48

Peer-Reviewed Articles ––– Pages 50-64

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JTO News and Updates

From the Editor

Contents

Ian Winson, BOA Vice President Elect As we approach the end of the year from a JTO point of view; it means it’s the Congress issue. I will leave it to others to talk about the serious issues, Colin’s final contribution at the end of his presidential year follows. However, I feel I should comment on the amazing energy of the BOA’s staff. There is a buzz in the office but this is only matched by the extraordinary amount of work I see being done by colleagues all over the country to provide a strong clinical structure (pages 16 and 18), trying to make education fit for purpose (page 42) and an ethos that is determined to take MSK research in the direction designed to push patients into treatment pathways that work (page 26).

I am grateful to Ian Stockley, our Guest Editor, for commissioning a set of peer-reviewed articles on the major problem of infection (page 50). It is thought-provoking and illustrates how important this subject is going to be in the era of growing resistance to antibiotics.

The importance of controlling and recognising complications to the cost of the service and to the patient and society is alluded to elsewhere (page 22) needless to say my Deputy Editor, Ananda Nanu, dealt with that article in isolation, but it makes its point!

There is a little theme of costs running through this issue. Peter Smitham’s article in the Trainee Section shows that the cost of being a trainee is not cheap (page 40).

I am delighted to see the enthusiasm for the thought process of planning care reflected in the article by the incoming OTS president, Bob Handley (page 64).

We constantly need to review professional issues that affect our practices. The “Duty of Candour”

article (page 46) is a must-read and, in an era where our practices and responsibilities maybe changing, Steve Hepple’s practical guide to insurance issues (page 34) is one that you should keep.

It is sad to see so many Myths and Legends of orthopaedics passing on; each with stories behind them that we can recall and smile about (pages 68 and 69).

How patients see us and how we should be aware of all of what we are dealing with on their and their families’ behalf is an important part of what we do (pages 28 and 42).

So, what is the JTO? I must admit I am one of those people who scans journals and reads the bits that I want and wonder why they bother with the rest. I pick up coffeetop magazines and look at the pretty pictures. JTO aspires to be something different, it is really by you for you. It wants, as the BOA does, to promote joined-up thinking, hence our front page illustration of trains coupling. Don’t forget that some articles are reproduced in full on the website. PS - this might be Ananda’s last issue. Rumour has it he’s been promoted, hope the new guy’s as much fun.

JTO News and Updates

02–15

JTO Features

16–48

The BOA Multidisciplinary Hip Fractures Reviews Hip Fracture Quality Improvement Programme Complications in Orthopaedic Literature; how well are they reported?

The value of what we do: a patient’s view Orthopaedic Research in the UK: current state of the art ATLS and the Orthopaedic Trainee On-Call: a continuing deficiency in training?

The Cadaveric Shoulder Arthroscopy Course Insurance for Surgeons Supporting a patient taken to a Major Trauma Centre The Financial Implications of Training within the UK System What makes a good training hospital?

The Duty of Candour

16 18

22 24 26 30 32 34 38 40 42 46

JTO Peer-Reviewed Articles 50–64

Prevention of Periprosthetic Joint Infection Biofilm and orthopaedic implant infection The future of diagnosis and treatment for Orthopaedic infections How I… Visualise a Fracture Fixation

In Memoriam General information and instructions for authors

50 54 58 64

68–69 70

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JTO News and Updates

Winding Up or Down?

Prof Colin Howie, BOA President

As ever the pre-election pollsters have proven woefully wrong. We have a majority government (albeit of a different hue in Scotland!).

Ironically this apparent medium term stability is unlikely to lead to an overall change in the structure of healthcare delivery, though we can be sure that there will be a significant change in emphasis. Simon Stevens has a five year plan which presents major challenges and opportunities and is likely to be the template for the future.

This is my final Presidential piece for the JTO. It seems appropriate, therefore, to reflect on the past year, and look towards the future. We started the year with the publication of GIRFT and the relative chaos in the commissioning landscape. I am pleased to report progress on both fronts.

Implementing GIRFT, our central objective has been to encourage local professionally-led ownership of the major points in the report, whilst avoiding prescription of ‘absolute numbers’. We hope that this will serve as an empowering framework for you, which can be extended to all areas of practice, not just those covered in GIRFT.

Prof Colin Howie

The BOA’s NICE accredited Commissioning Guidance Documents gave us the foundation to influence and engage locally.

Building on this, the BOA staff have developed a rigorous programme of engagement using the Guidance Documents and a detailed analysis of CCG data. Crucially, we managed to recruit significant numbers of Clinical Champions from amongst our members, which will allow us to continue with this rapid pace of engagement. Thanks to your collective support at a local level, the BOA has been able to broker high profile solutions in different areas involving local clinicians and the appropriate specialist society, creating win-win situations around the country.

Contact the BOA offices for support.

One such example can be seen in the case of Coastal West Sussex CCG, who earlier this year withdrew the elective orthopaedic contract from the local NHS hospital. This immediately destabilised the financial and clinical sustainability of the emergency unit (redolent of other cases elsewhere in the country). The BOA, alongside others, challenged this decision and we are pleased to report that this has now been reversed. However, the case highlights the ongoing and continuing requirement to provide a comprehensive, efficient, trauma and orthopaedic service at a local level.

One way forward for comprehensive T&O care will be to develop local clinical networks using a mixed economy of surgeons, doctors and extended role practitioners. This care model has been promulgated around the world in various guises, based on the recognition that stand-alone practitioners provide highly variable and often expensive fragmented care. Most systems are moving towards a hybrid model where senior clinicians from a variety of backgrounds form a team focused on a specific care pathway, with each working independently but meeting regularly with the same shared values and goals.

To this end we are involved with ARMA to engage with Allied Health Professionals, Rheumatologists and GPs to continue and develop the local engagement and empowerment themes.

Beyond commissioning, we remain under considerable pressure for many of our treatments which are seen as discretionary optional extras. Thankfully, there have been some excellent research publications this year from T&O. The NJR continues to provide data to show how cost effective we are for arthroplasty. There are a further eight orthopaedic registries with data run by enthusiasts with support from the specialist societies. Again, information from, for example, the spine registry has been hugely

helpful when approaching CCGs. This year we have been engaging with those specialist registries through our Quality Outcomes programme (see page 4 for more detail) which will remain key to proving our worth clinically and financially. I strongly encourage all of you to contribute to this work by submitting your procedures: this will allow us to demonstrate unequivocally to partners across the NHS that we have the privilege to work in a surgical specialty where almost everything we do makes people better and more economically active in society. For the individual participating surgeon you will be able to evidence your worth, a personal reward beyond remuneration.

To ensure the enduring strength of our own specialty, we must caution against over-specialisation early in future surgeons’ careers. There are a number of unemployed superspecialists here and many more abroad – a reflection of how often the flavour of the day becomes the under-employed of tomorrow. Given this, we must safeguard our excellent and dynamic training curriculum. It is essential that we continue producing comprehensively trained surgeons with a specialist interest, to ensure that both general T&O care and specialised surgery, like that delivered

by Major Trauma Centres, continue to be delivered to high standards.

Turning to this year’s Congress, I am pleased to note that the programme offers a unique combination of broader professional sessions and clinical revalidation and instructional sessions in the more common areas of practise for the general T&O surgeon. I would particularly recommend “Navigating the NHS and Health and Social Care Landscape”, “Regional Advisers and Clinical Champions; Influencing commissioning”, “T&O Surgery after the General Election” and “Top tips for improving quality in T&O”, key areas for your future.

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Throughout my 12 months I have been struck by the professionalism and dedication of our specialty which are now being recognised in the corridors of power. It has been an honour and absolute pleasure to serve as BOA President during this time of great change. To work with proactive willing volunteers who contribute so much to our various committees and Council, as well as the BOA staff team who have guided, cajoled and organised to huge effect has been a privilege.

I have every confidence that my successor, Tim Wilton will be equally well supported.

Tim Wilton: Incoming BOA President (2015-2016) I am deeply honoured to have been elected to be your President for 201516 and I sincerely hope that I can bring the necessary gravitas and energy to this prestigious and important role.

Colin Howie has steered us with wit and wisdom through many difficult

I am acutely aware as my own year as President begins, that there appears to be growing turmoil in the NHS, though I dare say previous incumbents may have felt much the same! Current circumstances do seem to offer a particularly toxic environment that could seriously affect our professional health.

Last but by no means least our membership has increased substantially across the board, we must be doing something right!

I am excited by the future and direction of the BOA as you continue to build on recent successes and accomplishments. Sally and I wish you all well. Thank you!

projects during the last year. He has developed the regional adviser network into something which has structure and definition. The Quality Outcomes work has taken shape and shows excellent promise. On behalf of all BOA members I thank him sincerely for his excellent work.

I hope on your behalf to be able to influence our professional environment in a number of ways:

Tim Wilton

1) I plan to ensure we listen even more carefully to the specialist societies and that we understand the

individual needs of those groups 2) I wish to reinforce Council’s full involvement in strategic decision-making, and to see Council members still more empowered to advise and shape the policies of the organisation 3) I see the implementation of the GIRFT project as being crucial and that means ensuring engagement with, and acceptance of, the entire process by the orthopaedic community 4) We will also seek out ways of reaching those many members who perform the great majority of orthopaedic work but who do not regard themselves as highly specialised.

I look forward to the challenge of getting in personal contact with as many of you as possible and ensuring that you too feel that the BOA is truly representative of your feelings and needs.

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JTO News and Updates

The BOA honours outstanding members

The BOA is pleased to announce the recipients of the 2015 Honorary Fellowship and Presidential Merit Awards, which will be presented at the Annual Congress in Liverpool.

Michael Benson – Honorary Fellowship

A last minute change of heart led Michael Benson to study medicine at St Mary’s Hospital rather than history. After specialist training at St Mary’s, The Middlesex, the RNOH and UCLA he was consultant at the Nuffield Orthopaedic Centre from 1977-2010. With a main interest in children’s orthopaedics, he co-edited several children’s orthopaedic textbooks. He is past-President of the BOA, the British and the European Children’s Societies and Chairman of the Journal of Bone & Joint Surgery. Happily married to Glyn; one son is a barrister and the other a plastic surgeon.

Malcolm Macnicol – Honorary Fellowship

Malcolm Macnicol graduated in 1969 in Edinburgh and, following surgical training in the USA,

Australia and Switzerland settled at the Royal Hospital for Sick Children (RHSC) in Edinburgh as a Consultant Orthopaedic Surgeon and a Senior Lecturer.

Malcolm became President of the BOA in 2001/2 and Lead Clinician in Surgery and Oncology at RHSC between 2005 and 2007.

He’s published 152 papers, six books (11 editions) and 26 chapters. Malcolm is also patron of the Scottish Post-Polio Network.

Prof Keith Willett – Honorary Fellowship

Guy’s and Westminster Hospitals. He returned to South Africa to complete his Orthopaedic training at the Groote Schuur Hospital. He was an ABC travelling fellow in 1982. He was appointed to the Pieter Moll and Nuffield Chair of Orthopaedic Surgery at the University of Cape Town in 1990 before being appointed as Professor and Head of the Department of Orthopaedic surgery at the University of Bristol in 1994. Amongst others he served on the Council of the Royal College of Surgeons of Edinburgh and of the BOA.

Professor Willett is the Director for Acute Episodes of Care to NHS England. He came from his role as the first National Clinical Director for Trauma Care to the Department of Health. He has extensive experience of trauma care, service redesign and healthcare management and is Professor of Orthopaedic Trauma Surgery at the University of Oxford.

J Keith Tucker – Honorary Fellowship

Keith Tucker is a consultant orthopaedic surgeon in Norwich. His contributions to British orthopaedics include, Chairman of ODEP and the Beyond Compliance Advisory Group, Honorary Secretary and President of the BHS, member of the steering committee NJR where he has also set up and chaired the implant Performance Committee. He has been a member of Council of the BOA and a BOTA Trainer of the year. He established the Gwen Fish Orthopaedic Trust to fund Orthopaedic research. Keith has a small farm where his wife, Jill, and he keep sheep. He has three grown up sons and two grandchildren.

In his current role, he has the national medical leadership roles for acute NHS commissioned services ranging from out-of-hours general practice, pre-hospital and ambulance services, emergency departments, acute and elective surgery, acute medicine, children’s and maternity services and is the lead for a transformation of the national urgent and emergency care services.

Geoffrey Walker – Presidential Merit Award

Geoffrey Walker began his orthopaedic career at the RNOH where Herbert Seddon encouraged him to spend time in Nigeria. He spent time in Kano, followed by a year as an Assistant Lecturer at Ibadan.

During his 23 years of NHS work, Geoffrey was able to continue his interest in the Orthopaedics of Low and Middle Income Countries (LMIC’s) firstly helping to establish a training scheme in Bangladesh shortly after their war of independence and then teaching in various other LMIC’s.

Prof Ian Learmonth – Presidential Merit Award

Prof Learmonth qualified MBChB at the University of Stellenbosch then did his general surgical training at

Since retirement, Geoffrey has worked for the British Council as Visiting Professor and Head of the Orthopaedic Department at the Black Lion University Hospital in Addis Ababa. He was also involved with establishing World Orthopaedic Concern UK.

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JTO News and Updates

BOA Latest News Consultant Outcome Publication 2015

This year, 30th November is the go-live date for the outcome publication initiative for orthopaedics, when existing consultant and hospital-level information will be refreshed with the latest data alongside additional information about surgeon case-mix. One further indicator (surgeon-level compliance, compared to HES data) is also being considered – the feasibility and timescale on this is currently being assessed.

Keep an eye out for emails from BOA/NJR and on our websites for further information as this becomes available, including in relation to checking data before publication and providing optional profile information.

CCG Outliers: Identifying potential under provision of Orthopaedic Surgery In order to identify the potential under provision of Orthopaedic Surgery by comparing CCG’s activity rates with the disease burden in their respective populations, the BOA has begun a scoping project to gather data. The project is expected to focus on Total Hip Replacement and Total Knee Replacement, and aims to help the BOA engage with CCGs that need most support with their Orthopaedic care pathways.

NJR Data Quality Strategy

The National Joint Registry (NJR) has published its data quality strategy (www.njrcentre.org.uk/ njrcentre/Dataquality/tabid/381/ Default.aspx) and begun the roll out of a national programme of local data submission and quality audits. The BOA supports this initiative and urges all orthopaedic team members to contribute.

BOA

Appointments It is our pleasure to announce the following appointments to key positions: • BOA President for 2017/18: Ananda Nanu • BOA Trustees for 2016-2018: Stephen Bendall, Karen Daly, Bob Handley, John Skinner • BOA Research Committee member: Professor Col. Jon Clasper CBE We would also like to congratulate Jon Clasper on receiving his CBE in the Queen’s birthday honours.

We are always grateful to those members who volunteer their time on behalf of the BOA. We also welcome members of the new BOTA committee appointed in June to their roles and look forward to continuing our successful relationship with them.

ASG Fellowship 2015 The four 2015 ASG Fellows, Dr C Zilkens, Dr M Egermann, Dr P Funovics and Dr H Miozzari started their week’s tour of the UK on 23rd May, visiting two Centres of Excellence. The London tour was hosted by Prof Tim Briggs and included a tour of the RNOH where they were able to join the Orthopaedic team in the Operating Theatre and Out-Patient Clinic. They were also given a tour of Biomedical Engineering Department and a tour of Stanmore Implants.

Next on the itinerary was a visit to Cambridge where the fellows were hosted by Mr Vikas Khanduja at Addenbrooke’s Hospital. They then attended an academic meeting where each of them gave a presentation. The Fellows were treated to a tour of the MSK Research Building and were invited to join the team in the Operating Theatre and Out-Patient Clinic.

The next visit to the UK by ASG Fellows will be in 2017.

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BOA Clinical Champions The BOA has a growing number of Clinical Champions, recruited to engage with Commissioners at a local level. BOA Clinical Champions represent individual trusts and hospitals, and work alongside BOA Regional Advisers. We are continuing to support the growth of the network, and we are pleased to report that BOA Clinical Champions have had a number of successes working with Clinical Commissioning Groups (CCGs). In one case, our local network has successfully encouraged a CCG to abandon BMI restrictions on Arthroplasty.

To support the capability of the network, the BOA are monitoring CCG activities and alerting local surgeons to issues in their area. In addition, this year’s Congress includes a session entitled ‘Regional Advisers and Clinical Champions: Influencing Commissioning’ to share success stories and plan next steps.

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

2016 Travelling Fellowships – Now open!

The BOA is pleased to offer a number of Travelling Fellowships to members of the BOA for 2016.

Fellowships offer a unique opportunity to visit overseas centres of excellence to gain knowledge, experience and different cultural perspectives within Trauma and Orthopaedic surgery. Up to 20 Fellowships will be available and interviews will be taking place in January 2016. For more information, please visit www.boa.ac.uk/training-education/travelling-fellowships.

Undergraduate Syllabus Stakeholder Engagement: BOA Syllabus gains traction with GMC The GMC has committed to include a link to the BOA Undergraduate Syllabus T&O on their online Appendix to Tomorrow’s Doctors, the document which currently includes the outcomes that the GMC requires of medical school curricula. In addition, the GMC has also logged the Syllabus for consideration during their next review of those outcomes and has expressed an interest in hearing about the results of our engagement with stakeholders such as Medical Schools and the Medical Schools’ Council. www.gmc-uk.org/education/ undergraduate/undergrad_outcomes_ appendix2.asp

The British 10K London Run 2015 On Sunday 12th July, five runners took to the streets of London to run in the Vitality British 10K London Run, raising funds for Joint Action, the Orthopaedic Research Appeal of the BOA. We would like to thank consultants Koldo Azurza and Michael Beverly, trainee Donald Davidson and two members of staff from Smith & Nephew – Joanna Hare and Richard Sale for participating in the race. If you would like to run in next year’s race email Lauren Rich at l.rich@boa.ac.uk.

For further information about any of the news items here, please contact policy@boa.ac.uk.

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JTO News and Updates

Getting involved with the emerging T&O registries: what, where, how?

As Colin Howie has explained in his introduction to this issue, nine new registries are getting underway in orthopaedics. Here we provide a table giving a quick guide as to what they are, what they cover and some frequently asked questions.

Name

Website or contact

Remit

National Ligament Registry (NLR)

uknlr.co.uk

(Currently) Primary Anterior Cruciate Ligament injury, repair and reconstruction

British Society for Surgery of the Hand (BSSH) Audits

bssh.nuvola.co.uk

Basal thumb arthritis; dupuytrens; ulnar nerve decompression in elbow; wrist joint salvage for inflammatory arthritis; wrist joint salvage for non-inflammatory arthritis

Non-arthroplasty hip registry (NAHR)

britishhipsociety.com/ main?page=NAHR

Any type of hip condition and/or surgery other than arthroplasty and the treatment of acute fracture (including those who do not have surgery). Predominately arthroscopic treatment of femoroacetabular impingement and labral tears but also includes predominantly open surgery for the adult consequences of childhood hip disease such as hip dysplasia and Perthes’ disease.

British Spine Registry (BSR)

bsrcentre.org.uk

All spinal procedures

UK Knee Osteotomy Registry (UKKOR)

www.ukkor.co.uk

Knee osteotomies (High Tibial Osteotomies – HTO; Distal Femoral Osteotomies – DFO)

British Orthopaedic Foot and Ankle Society (BOFAS) registry

www.bofas.org.uk/ Outcomes

1- First MTPJ fusion; 2- ankle fusion

British Society for Children's Orthopaedic Surgery (BSCOS) audit

bscos.org.uk/registry

1- Slipped Capital Femoral Epiphysis, 2- Ponseti Management of Club feet, 3- Supracondylar fracture of humerus (Future release planned to cover: 4- Developmental dysplasia of the hip, 5- Perthes’ Disease and potentially one further area regarding treatment of cerebral palsy)

Not yet launched for data collection, but enquiries welcome British Limb Reconstruction Society (BLRS) audits

James Fernandes, President of BLRS, James.Fernandes@ sch.nhs.uk

1- Fibular hemimelia; 2- Tibial Pilon fractures; 3- Tibial non-unions; 4- Intramedullary limb lengthening nails

National Bone & Joint Information Registry

Mike Reed, mike.reed@nhs.net

1- Chronic community-acquired, post-trauma, or healthcareassociated ‘native’ joint or bone infections; 2- Chronic post-operative orthopaedic device related infections

“What would I get out of the registry?”

• Data and/or a report that can be used for revalidation/appraisal purposes.

• Collect patient reported outcome measures for all your patients, and review the data for each patient or your practice as a whole.

• Use data for identifying trends, undertaking audits and participating in local quality improvement initiatives.

“How do I get involved?”

• Use the website or contact details to find out more.

• For most* registries, users can sign up for free if they are a member of the relevant specialist society.

If you are not a member, contact the registry for advice.

• *Two registries (UKKOR and the NLR) are free for any surgeons undertaking the procedures.

“What wider benefits do these registries bring?”

• They allow T&O to evidence the difference it makes to patients’ lives.

• They contribute to a knowledge base that allows research and quality improvement at a local and national level.

The BOA is strongly supporting the registries through the Quality Outcomes Programme. For example, we have advised registries about meeting governance requirements and are currently working on resolving a number of service provider issues that we have identified. We believe a good surgeon is one who works to collect their outcome data and acts on it appropriately, and we urge all those whose practice is included in the areas outlined on the left to get involved. For further details about the Quality Outcomes Programme, contact Julia Trusler, Programme Director – j.trusler@boa.ac.uk.

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JTO News and Updates

ABC Travelling Fellowship 2015 Suken A. Shah, USA

During our five-week tour, we visited the United Kingdom, Australia, and New Zealand. We were greeted with the kindest of hospitality and friendship throughout. We were inspired to continue to improve how we train and educate residents, pursue important research questions and provide the best quality, valuebased care for our patients.

The UK Leg Upon our arrival in London, we were welcomed by the BOA as well as The Bone and Joint Journal. Our UK tour was meticulously organised thanks to David Limb and Hazel Choules.

In London, we enjoyed academic and social sessions, discussed issues of access, outcomes, quality, training, registries and costs of care and we were fortunate to visit a number of prominent academic and clinical centers: The Institute of Sport, Exercise and Health, hosted Prof Fares Haddad, current BJJ editor-in-chief; the Royal National Orthopaedic Hospital in Stanmore, hosted by Prof Tim Briggs, Robert Pollock, William Aston and Prof Alister Hart; the Royal London and St. Bartholomew’s Hospital, hosted by Pramod Achan.

The 2015 ABC Travelling Fellows: Alpesh Patel, Suken A. Shah, Kishore Mulpuri, Robert Brophy, Hue Luu, Sanj Kakar, and Rajiv Gandhi

Next, we went to visit Oxford and were warmly greeted by Prof Andy Carr and Duncan Whitwell.

During an academic session at the Kennedy Institute, we discussed health care disparities worldwide, quality improvement in trauma surgery, and RCTs. After Oxford, we traveled to Norwich and met Prof Simon Donell and colleagues at Norwich University Hospital. A short journey took us to Leicester, where we met Rob Ashford and Prof Angus Wallace.

Heading north to Glasgow, Scotland, we were greeted by Sanjiv Patil and Dominic Meek.

The evening festivities included a dinner reception at The Royal College of Physicians and Surgeons of Glasgow and we dressed in traditional Scottish kilts.

Upon arrival in Edinburgh, we were hosted by Prof Hamish Simpson, Leela Biant, and John Keating and the next day, donned our kilts again for a dinner at the Balmoral Hotel and met numerous past ABC fellows including Profs Colin Howie, Charles CourtBrown, Margaret McQueen, Michael McMaster and Miss Julie McBirnie.

In Northumbria, we met Mike Reed and colleagues at Hexham General Hospital and in Newcastle, we were privileged to attend the Combined Services Orthopaedic Society annual conference hosted by Prof Simpson and Lt Col David Cloke.

The 2015 ABC Travelling Fellows on the Sinclaw Bridge at the Old Course, St. Andrews, Scotland

Our last day in England was spent back in London. After attending a football match between Crystal Palace and Manchester United with Prof Haddad, we retired to

the Royal College of Surgeons of England before the long haul flight to Australia.

The journey home was exciting, as we knew we would see our family and friends after a fiveweek absence. We were treated royally by all the staff at the BOA, AOA, COA, AuOA, NZOA, trainees, consultants, local hosts and past ABC fellows. Through the alumni and experiences of the ABC fellowship we have learned the true meaning of the tour, namely leadership, inspiration and collaboration.

We truly have become friends for life as we embark upon the next part of our career journey together, as the 2015 ABC Travelling Fellows.

The full version of this article (including the Australia and New Zealand legs of the tour) can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

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BOA Membership Our membership has grown by 15% in the past twelve months and we are keen to sustain this healthy momentum, particularly in regard to SAS surgeons, acknowledging that we can only achieve this if we continue to demonstrate added value in everything we do on your behalf. We encourage you to share the BOA membership benefits with your colleagues, for more information on subscription categories please visit the BOA website - www.boa.ac.uk/membership/categoriesand-subscriptions.

BOA Instructional Course 2016 9th-10th January – Register now!

The BOA’s annual Instructional Course is a highlight of the BOA’s training and education calendar, bringing together trauma and orthopaedic trainees at all stages of their postgraduate training, to prepare for their FRCS examination.

The key focus of the 2016 course will be on paediatrics and trauma, and trainees will have the opportunity to gain up to 5 CBDs in the following areas: • Painful hip in the child • Painful spine in the child • Neurovascular injury • Necrotising fasciitis • Open fractures Guest Lectures include: • Professor Andy Carr “The Orthopaedic Surgeon of the future: Surgical Technician or Surgical Scientist, what can we learn from Astronauts” • Miss Deborah Eastwood on Paediatric Orthopaedics • Miss Leela Biant “Surgical management of articular cartilage defects” For more information about how to register, please visit www.boa.ac.uk/events/ instructional-course.

Save the date!

Clinical Leadership and Engagement

BOA Annual Congress 2016

13th-16th September, Belfast

We are delighted to host the BOA Congress 2016 at the Belfast Waterfront. Belfast is a dynamic and forward-thinking destination that has transformed dramatically in recent years. The new expansion plans opening in May 2016 will double the event space at the Waterfront to 7,000m2 offering a world-class facility. To get a taste of what’s to come watch the 3D flythrough - www.waterfront.co.uk/conferenceandmeetings/ newdevelopments.aspx. We will be building an exciting programme based on ‘Clinical Leadership and Engagement’, keep an eye on the Congress website for abstract submission details and programme updates – congress.boa.ac.uk.

BOA Annual Congress 2015 We wish you a very warm welcome to Liverpool.

Over 1,600 surgeons and trainees have registered for the Congress and we are delighted to bring you an excellent four day programme of debates, discussions and dialogue to ensure that we continue to raise standards, and encourage the highest levels of Professionalism and Responsibility. Remember to download the new BOA Congress App in advance and make the most of your experience before, during and after the Congress. The App will allow you to view the details of 100+ sessions, bookmark sessions in advance, post comments and photos, interact with other attendees, view podium and poster presentations, receive live notifications of the Congress programme and much more! We hope you enjoy this new facility.

Don’t forget to stop by the BOA stand (102) and meet the team. We look forward to meeting up with many of you and welcoming new faces to the BOA. The BOA merchandise will be available to purchase at the BOA stand so make sure to pick this up as you move around the Exhibition Hall.

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JTO News and Updates

BOTA Educational Weekend Review The 2015 weekend, at Carden Park for the final time, was well attended by over 150 trainees.

The opening Presidential address,

by Mike Kimmons, gave an overview of the BOA’s key areas of focus for the future, and was followed by Bill Allum, JCST Chair, discussing hot-topics around SHoT and surgical training.

Industry-sponsored workshops saw the popular Heraeus ‘VIVA preparation’ session (Jason Webb and Mike Whitehouse) return, as well as this year’s winner of Best Workshop, Stryker’s ‘External fixators in damage control’, delivered by Lt. Col. Tom Rowlands.

Consultant workshops covered clinical and non-technical skills, inaugural TPD of the Year, Mike Reed, speaking on running successful improvement projects, and Sebastian Dawson-Bowling and Iain McNamara on ‘How to get a Consultant job’. Although there is not enough space to thank all the speakers, feedback from trainees was excellent, and going ‘paperless’ has allowed us to ensure that talks are available

(L to R) TOTY nominees Mez Acharya (Greg Pickering accepting award) and Philippa Thorpe, with Mustafa Rashid and TOTY winner Niall Eames

online for future generations to enjoy (www.bota.org.uk/new).

The black-tie dinner was a lively occasion, seeing Niall Eames crowned Trainer of the Year for his contribution to training in

Northern Ireland. UKITE and the role of alternative core surgery programmes were discussed at Sunday’s TPD forum, and a new committee elected at the AGM. Mustafa Rashid succeeds Peter Smitham as President, and we

are already looking forward to the 2016 Weekend, to be held at Hinckley Island in June. Plans are afoot for a wider variety of workshops and opportunities for trainees to present their research watch this space!

BOOS Annual Meeting The 26th Annual Meeting of the British Orthopaedic Oncology Society in Oxford was a huge success. There was an interesting and varied programme looking at current topics of interest including trends in Endoprosthetic Replacement, neoadjuvant treatment for difficult conditions such as Giant Cell Tumour of Bone, advances in musculoskeletal imaging and a particularly interesting debate around recording outcomes for Endoprosthetic replacement.

The meeting discussed in some

detail the difficulties of recording implant data as part of the National Joint Registry dataset particularly given the specific nature of the tumour patients that have particularly challenging operations.

The meeting was well supported by industry and the guest lectures by Steve Cannon (“a life in sarcoma”) and Eric Henderson (“we took the route less travelled”) were particularly interesting and inspirational. It was fascinating to see the great pendulum of orthopaedics in

action where operations and techniques initially popular, become less so but then reinvent themselves again under a different guise. Many of the challenges that were present for tumour surgeons 40 years ago remain significant challenges today, for example in massive pelvic reconstruction or proximal humerus resection and reconstruction.

We enjoyed hosting delegates and faculties from over 28 countries to Oxford and the evening was rounded off with

a superb meal at the Cherwell Boat House. BOOS 2015 was a great success and we look forward to seeing friends and colleagues again in Dublin for the 27th meeting in 2016.

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BESS Meeting

BESS Garden Reception

BESS 2015 was held in Sheffield in what is referred to by some as Gods Own Country and thankfully the meeting lived up to all the Stainless and Stanley hype. The conference was composed of a balance of early morning excellent instructional courses followed by daytime thought provoking presentations from a combination of the well-known and perhaps soon to be well-known presenters with additional special sections throughout the three days. The scientific research symposium was based on the management of the unstable shoulder and elbow with invited speaker Dr Roger Van Riet, Belgium, providing a European angle with his talk on “Surgical and rehabilitation principles for the unstable elbow”.

Many, if not all, the leading companies attended what is now the largest subspecialty society of

orthopaedics in the UK enabling all attendees to see, feel and ‘use’ the latest innovations and products available in shoulder and elbow surgery. The delegates were treated to two thought provoking lectures from this year’s eminent guest speakers Dr Richard Kyle with a USA perspective “Orthopaedics, A great adventure: excellence through knowledge” and Dr Samuel Antuna from Spain detailing “Current controversies in the management of the stiff elbow”.

As ever, each day of the conference was topped off with formal and informal evening meetings amongst all the surgeons and AHP’s enabling old and new friends to meet and evaluate yet another year of shoulder and elbow surgery.

Our thanks to all the organisers of the Sheffield Conference for yet another BESS success and we all look forward to Dublin 2016.

WOC (UK) Annual Conference The second annual conference of World Orthopaedic Concern (WOC) (UK) took place at the Botnar Orthopaedic Research Centre in Oxford on 6th June 2015. The guest speaker was Dr Sailaj Ranjitkar, consultant orthopaedic surgeon at the Nepal Medical College in Kathmandu, who shared his experience of treating the injured from the recent earthquake. Steve Mannion, Chairman of WOC (UK) then gave an overview of the orthopaedic implications of natural disasters and profiled the work of the UK clinical team in Nepal. Also presented at the meeting were WOC (UK)’s flagship projects in Ethiopia and Malawi, both of which invite teaching visits from UK volunteer surgeons.

Mr Paul Offori-Atta described WOC (UK)’s projects in West Africa and also the link between WOC and the West African College of Surgeons (WACS), to which WOC provides examiners to each

diet of the specialist orthopaedic fellowship examinations and hosts an instructional workshop at the WACS Annual Scientific Conference. This year’s WACS conference was is Abidjan, Ivory Coast, where WOC hosted a hand surgery workshop given by WOC member and consultant hand surgeon Mr Bo Povlsen.

Free papers presented at the Oxford meeting included an audit of orthopaedic implant use in the southern African region, a project designed to produce low-cost antibiotic impregnated cement beads in Cambodia, an audit of tourniquet availability and use in Malawi and a presentation on the “Feet First” minimally invasive technique for the treatment of neglected clubfoot.

WOC (UK) has over 200 members, is a registered charity and a specialist society of the BOA. For more details, please see their website: www.wocuk.org.

Neglected clubfoot (subject of the “Feet First” free paper)

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JTO News and Updates

Indian Orthopaedic Society’s (IOS UK) Annual Conference The annual scientific conference was held at the BT Convention Centre in Liverpool on 3rd and 4th July 2015. It was organised by Vishal Sahni and Vijaya Bhalaik and attended by over 250 delegates.

Professor Simon Frostick and a team from the GMC conducted a pre-conference workshop on Certificate of Eligibility for Specialist Registration (CESR) applications.

The highlight of the first day was an Instructional Course in Trauma, featuring ‘top tips by experts’.

The Trauma session concluded with a brilliant keynote lecture by Professor Christian Krettek from Hannover titled “Philosophy of treating complex fractures around the Knee”.

The MChOrth degree from Liverpool has the distinction of being the oldest orthopaedic training program in the world, commencing in 1926, when orthopaedics was not even a separate speciality. The MChIOSUK Dinner was attended by alumni from the UK as well as those who flew in from India and Nepal.

It was an emotional reunion for many alumni who met with previous Professors Leslie Klenerman, George Bentley and Simon Frostick.

The second day of the conference comprised free paper sessions, instructional course lectures and a medico-legal symposium. The highlight was the excellent guest lecture delivered by Mr Ananda Nanu on “Minimally Invasive Osteosynthesis”.

IOS office bearers Mr Bijayendra Singh, Mr Vikas Khanduja, Mr Anand Arya and Mr Venu Kavarthapu presenting honorary life membership certificate to Mr Colin Howie, President of the BOA.

At the AGM, the outgoing President Mr Venu Kavarthapu relinquished charge to Mr Anand Arya. Other office bearers installed included Honorary Secretary Mr Bijayendra Singh, Education Secretary Mr Nikhil

Shah and Honorary Treasurer Mr Amit Tolat.

The conference ended with a gala dinner in the iconic St George’s hall with Indian dancers, Bollywood music and Indian food.

CONFERENCE LISTING:

Organisation

Conference/meeting

BTS (British Trauma Society) www.bts-org.co.uk

Annual Meeting 4 November 2015, Stoke-on-Trent

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

Annual Meeting 5-6 November 2015, Bournemouth

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

Annual Meeting 11-13 November 2015, Guildford

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

Annual Meeting 20-21 January 2016, Coventry

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

Annual Meeting 10-11 March 2016, Aylesbury

BHS (British Hip Society) www.britishhipsociety.com

Annual Conference 16-18 March 2016, Norwich

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

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

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

Annual Conference 30-31 March 2016, Liverpool

BRITSPINE www.britspine.com

Meeting 6-8 April 2016, Nottingham

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

Annual Meeting 13 May 2016, Plymouth

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

Annual Meeting 20 May 2016, Dublin

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

Annual Conference 8-11 June 2016, Japan

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

Educational Weekend 16-19 June 2016, Hinckley

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

Annual Meeting 22-24 June 2016, Dublin

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

Autumn Meeting 15-16 October 2015, London

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JTO Features

The BOA Multidisciplinary Hip Fractures Reviews Tim Chesser, Chair BOA Trauma Group Co-authors: Paul Dixon, Helen Wilson, Karen Hertz, Iain Moppett

The National Hip Fracture Database (NHFD) was started in 2007 as a collaboration between the British Orthopaedic Association and the British Geriatric Society. It has become the largest hip fracture database in the world with over 380,000 records, capturing over 96% of the hip fractures in England and Wales, and is used to instigate Best Practice Tariff payment. The NHFD produces a publically available annual report, with trust-level data. These data give an indication of attainment of standards and benchmarking at both regional and national levels.

Collecting large datasets in healthcare is beneficial if the data can be used to measure performance and improve patient care. In addition to quality standards, the report also includes the 30-day mortality.

Tim Chesser

The NHFD has defined criteria for identifying ‘outlier’ Trusts for mortality. By definition, approximately half of reporting Trusts will fall below the average, and by using a similar approach to analysis of other standardised mortality ratios, those Trusts identified to be between two and three standard deviations below the mean are felt to reflect a serious cause for concern.

The analysis is now reported on three-year data, to improve the statistical robustness. In liaison with HQIP it was agreed that the profession had to do more than publish data, and has

a responsibility to review and support underperforming units.

In response to this a peer review process was established, led by the BOA, but with support from the Royal College of Anaesthetists, British Geriatric Society and Society of Orthopaedic Trauma Nurses. The purpose of the review is to provide an overview of the standards of hip fracture care in a particular Trust. The aim is to support and give practical advice in a realistic way so that the service and care quality can be improved.

Aims The aim is to assess standards of care, as set down by current NICE guidance (Quality Standard 16 and Clinical Guideline 124), BOA Standards for Trauma (BOAST 1), Association of Anaesthetists

guidelines for hip fracture anaesthesia, and Best Practice Tariff, together with other metrics collected by the NHFD.

Method The process involves a pre-visit questionnaire, a peer review visit and an agreed final report. The process involves understanding the whole patient pathway revealing problems with systems rather than individuals.

The Trust is asked to provide information about the process of care for patients with hip fracture including protocols and policies, staffing (nursing, ward doctors, consultants), governance structures, alongside other relevant information such as service changes that have occurred since the NHFD data were collated. A pre-visit questionnaire detailing the current infrastructure and service provision provides baseline information along with data from the NHFD. The visiting team consists of at least one orthopaedic surgeon, an anaesthetist, an orthogeriatrician and a specialist nurse. The team also includes a lay member, usually a non-executive director from the Trust to ensure the review is balanced and to maintain ownership. A senior manager has also been included in a recent visit, recognising the importance of management processes to safe delivery of hip fracture care.

It is the responsibility of the Trust

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to provide indemnity to the reviewers and this is organised by the BOA.

undergone the review process.

It is assumed that others have relied on internal review.

The team meets all key individuals from the Trust to discuss current data, patient pathways and resources. The key individuals include senior staff from the emergency department, the orthopaedic lead for hip fracture, the clinical director, the orthogeriatrician, the lead anaesthetist for hip fractures, the trauma manager, the trauma nurse co-ordinator, the hip fracture specialist nurse, lead physiotherapist and occupational therapist, the lead nurse for Trauma and whoever is responsible for data entry into the NHFD. The visiting team walk the patient pathway, visiting the emergency department, the trauma meeting, theatres and the wards.

Themes from Trust Reviewed

A definitive written report and action plan is delivered to the Trust within 28 days from the initial visit. The aim is to provide specific recommendations, which are achievable, cost effective and will lead to improved patient care. It is anticipated that this will result in a reduction in hip-fracture related mortality and morbidity.

Since 2012, 11 Trusts have been reported to be greater than two standard deviations below the adjusted mean mortality rate.

These Trusts are informed of their outlier status by the NHFD team and offered BOA review.

To date, six have requested and

Whilst it is recognised in the system we work in, with its finite financial resources, it can be difficult to provide the best care possible 24 hours a day and 7 days a week, there were many common themes which run through every review. These include: pre-existing internal recognition of a problem; failure of previous change; insufficient leadership and joined-up working; problems with orthogeriatric cover in all grades; lack of standardisation; and insufficient senior involvement in clinical management. The whole pathway can be disjointed and lack both leadership and continuity.

A strong theme from Trusts where reviews have taken place was a long-standing recognition that the hip fracture pathway had been sub-optimal and that previous internal attempts at change and improvement had had insufficient impact.

Feedback from the Trusts suggests that the process of having a review itself helps to catalyse change, even before the review team arrives.

Continuity of orthogeriatric cover appears to be a common problem with an inability to recruit to both consultant and junior grade staff. The culture

of leaving the anaesthetic and surgical treatment of patients with a hip fracture to junior staff is still prevalent. Frequently, there is no standardisation of prostheses.

Every review has demonstrated areas of excellent practice - there has been no Trust without aspects of care of which they can be proud. The common theme here is the role and the enthusiasm of the hip fracture nurse, who often goes well beyond what might reasonably be expected of them. Engagement from the senior orthopaedic surgeons, orthogeriatricians and anaesthetist is crucial, especially in eliminating unnecessary variations in care.

The efficiency and multidisciplinary workings of the units can often be quickly assessed at the trauma meeting. The attendance, interaction of staff and approach to the complete care of each individual patient can give a clear indication of any lack of cohesion or communication between members of the hip fracture team. Having a lay member on the visiting team is invaluable, both during the process and once the review has been reported. They have seen at first hand the whole pathway and get a clear understanding of areas requiring change. Their local knowledge is of further benefit. In Trusts reviewed we have seen mortality drop in

each Trust, by up to 5% in two years, and the attainment of best practice tariff going up over 60% in some hospitals. Feedback from the Trusts reviewed has been overwhelmingly positive.

One Trust following a review dropped its thirty day mortality by 6%.

Conclusion The reviews put hip fracture care on the Trust agenda, giving them a clear process for service improvement. We believe the strength is due to its multidisciplinary nature; its sole purpose of supporting the unit and practical help it can give.

Tim Chesser is a Consultant Trauma and Orthopaedic Surgeon at North Bristol, Chair of BOA Trauma Group and lead for Hip Fractures and Hip Fracture Reviews for the BOA. He is a board member of the Falls and Fragility Fracture Audit Project (which includes the National Hip Fracture Database) and sits on the Clinical Guideline Group for NICE Hip Fracture Guidelines and Quality Standards.

References www.nhfd.co.uk www.nice.org.uk/guidance/cg124 www.nice.org.uk/guidance/qs16 www.boa.ac.uk/wp-content/ uploads/2014/12/BOAST-1.pdf

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JTO Features

Hip Fracture Quality Improvement Programme Dominic Inman & Annie Laverty

We recently had the honour of accepting the award for ‘BMJ patient safety team of the year’ at the prestigious BMJ awards 2015 on behalf of Northumbria Healthcare NHS Trust’s hip fracture quality improvement programme (HIPQIP).

176 hospitals admitted 70,000 patients with hip fracture last year. Ensuring safe, effective and equitable care for this large and often vulnerable group of patients remains a major public health issue and a real challenge to individual NHS Trusts.

‘HIPQIP’ was instigated by the Trust Board in 2010 due to concerns over mortality in our hip fracture patients. This followed renewed focus on these patients

Dominic Inman

with the launch of the National Hip Fracture Database. Our vision was to provide integrated care of the highest quality within a culture of continuous learning, innovation and development.

A large launch event in 2010 with 140 participants ensured effective engagement from all stakeholders.

We established a multidisciplinary audit framework (Quality Account) which outlined 12 deliberately ambitious standards.

Annie Laverty

We committed to measuring the right things, measuring well, measuring relentlessly and acting quickly. Our steering group met monthly to review progress against service goals. Multidisciplinary teams received weekly reports of their performance.

Evidence suggested that prioritising additional nutrition for patients with hip fracture could lead to a reduction in our death rate1. Other interventions introduced over the last 5 years include: • The use of a surgical care bundle to standardise peri-operative care across the Trust • The routine use of fascia iliaca nerve blocks in A&E • Prioritising hip fractures patients early on trauma lists (the ‘Golden patient’) • The ‘twenty minute rule’ (if the guide wire is not correctly positioned (extra-capsular fracture) or the femoral head has not been successfully extracted (intra-capsular fracture) by 20 minutes from knife-to-skin then the consultant surgeon must (if not already) scrub in to ensure the operation proceeds at a safe pace to minimising lengthy operation times) • Intra-operative fluid optimisation using non-invasive cardiac output monitoring • Extra interventions have been introduced for high risk patients identified using the Nottingham hip fracture2 score – with a patient scoring 6 or more 1) the consultant surgeon must scrub in from the start of the operation 2) the consultant anaesthetist prescribes the post-operative

The BMJ Patient Safety Team of the Year 2015 Award

fluids and suggested fluid boluses if hypotensive on the ward 3) routine ICU outreach review on days 0 and 1 post-op • Routine pre-operative templating for intra-capsular hip fractures requiring hemiarthroplasty or total hip arthroplasty using templated x-rays obtained during the first x-ray visit of all patients suspected of having a hip fracture • Adoption of enhanced recovery techniques used in elective practice: 1) pre-operative administration of tranexamic acid 2) intra-operative high volume/ low concentration local anaesthetic infiltration (LIA) 3) indwelling wound catheters for post-operative LA infusion 4) day 0/day 1 mobilisation post-operatively • Change of cement used for hemiarthroplasties from single antibiotic cement (Palacos) to >>

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JTO Features

high dose dual antibiotic cement (Copal) based on RCT data from our Trust showing a decrease in post-operative infection rates when compared. (848 patients, 5% vs 1.5%, p=0.02) • 7 day working physiotherapists on trauma wards • root cause analysis of every death discussed at quarterly meetings Training and support was provided to improve nutrition, pain management, information provision, early mobilisation and compassion at the point of care.

Real time patient feedback was built into the local improvement strategy. Outcomes are reported to teams within 24 hours of capture and also shared with patients, families and the public.

• Trust wide 30 day mortality has improved from a high 14.3% to 8.4% - a 40% reduction • Both our hospitals named as best in NHS for timely surgery in 2011 NHFD report - top 5% position maintained since then • 100% of medically fit patients are now mobilised by day 1 and 25%

on the day 0 (previously 4%) • 90% now receive a fascia iliaca nerve block on admission Previously 0% • 97% of patients (n = 384) believed we did everything we could to effectively control pain • 90% of patients now receive additional feeding each day from dedicated nutritional assistants.

patients are now more likely to survive, have faster access to information, imaging, surgery, better pain management and early physiotherapy 7 days a week.

We believe HIPQIP has transformed the quality of our care and brought issues of safety and clinical effectiveness into the work of improving patients’ experience.

We believe these results are entirely replicable. Effective leadership has been crucial in creating a service culture that supports the delivery of the highest quality care.

The Department of Health Best practice tariff (BPT) defines quality measures around timely surgery and orthogeriatric care. We moved from a baseline of 2% in April 2010 to 90% by December. This has been maintained over the last five years.

Through the adoption of local CQUIN HIPQIP targets, real time measurement and reporting have continued to drive improvements year on year.

An improved quality of care has therefore prevented significant loss of income through missed best practice tariff payments.

Five years on, we have significant improvements to share: our

2015 has seen consistently excellent Patient Experience scores of above 95% across the domains of care that matter most to patients.

Our mechanism for measuring, improving and acting, led by the Steering Group has continued as part of an on-going process of pathway development.

Our challenge for the future is transferring and continuing these improvements to the new Northumbria Specialist Emergency

Care Hospital opened in June 2015 where all our hip fracture patients will now be treated.

We have tried to spread the word on quality improvement in hip fracture and have run a session on hip fracture care during our yearly QIST conferences (Quality improvement for surgical teams).

These are provided at cost to multidisciplinary teams from UK NHS Trusts. The next Northumbria QIST conference is on 20th October 2015 in Newcastle-uponTyne (visit www.qist.co.uk for details and booking).

Dominic Inman is a consultant orthopaedic surgeon at Northumbria Healthcare NHS Trust and is chairman of the Trust’s HIPQIP hip fracture quality improvement steering group.

Annie Laverty is the Director of Patient Experience at Northumbria healthcare NHS Trust. She qualified as a speech and language therapist in 1990.

She has worked as part of the Trust’s stroke team for the past 20 years and has recognised expertise in engaging patients and carers in service redesign and improvement. She has been heavily involved with and instrumental in the success of, HIPQIP since its launch in 2010.

References 1. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. D G DUNCAN, S J BECK, K HOOD, A JOHANSEN Age and Ageing 2006; 35: 148–153

The team at the new Northumbria Specialist Emergency Care Hospital

2. Maxwell MJ, Moran CG, Moppett IK. Development and validation of a preoperative scoring system to predict 30 day mortality in patients undergoing hip fracture surgery. Br J Anaesth 2008;101:511-7

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JTO Features

Complications in Orthopaedic Literature; how well are they reported?

Daniel Winson Contributing authors - Juliet M Clutton, Narendra K Rath, Ibrahim Malek

The quality and detail of the reporting of Orthopaedic complications in the literature is very varied. The cost of claims damages in Orthopaedics cost the NHS over ÂŁ50 million in 2013-14.

Understandably therefore, there is an increased pressure on clinicians to minimise their complications.

In the interests of the advancement of Orthopaedics, researchers are required to accurately report any complications encountered within their literature. This study aims to establish the quality of complication reporting within Orthopaedic literature.

Daniel Winson

Methods

Original criteria

Modified criteria

1

Method of accruing data Prospective or retrospective accrual of defined data is indicated

2

Duration of follow up indicated

Report clarifies the time period of postop accrual of complications (e.g. 30 days)

3

Outpatient information included

Study indicated that complications first identified following discharge are included in the analysis

4

Definitions of complications provided

Article defines at least one complication with specific inclusion criteria

5

Mortality rate and causes of death listed

The number of patients who died in post-operative period are recorded together with cause of death

6

Morbidity rate and total complications indicated

The number of patients with any complication and the total number of complications are recorded

7

Procedure-specific complications included

Dependent on the procedure being reported

8

Severity grade utilised

Any grading system designed to clarify severity of complications including ‘major and minor’ is reported

9

Length of stay data

Median or mean length of stay indicated in the study

10

Risk factors included in analysis

Evidence of risk stratification and method used indicated by study

The authors selected five international journals and reviewed all the articles published during 2014. These journals were the Journal of Shoulder and Elbow Surgery, Spine, Journal of Arthroplasty, Bone and Joint Journal and Foot and Ankle International.

Articles were excluded if they did not describe a procedure on live patients, if they reported no complications or if they failed to comment on complications at all.

All included articles were reviewed and scored according to ten criteria (Table 1). Where possible, the reported classifications were scored according to the Modified Dindo criteria.

reporting orthopaedic procedures failed to comment at all on complications either positively or negatively. The mean score was 5 out of 10 and no study scored a maximum 10 out of 10.

Results

Conclusion

250 articles reporting 3,727,373 procedures in 3,619,281 patients were included in the study. Of the 636 articles originally reviewed, 123 were excluded due to the authors not commenting on complications in their article. In 2014, across five major journals, 23.7% of articles

The cost of complications is becoming an increasing burden on the NHS. The emphasis is on clinicians to ensure that complications are reported appropriately in the Orthopaedic literature. This study shows that complications are consistently

Table 1: Criteria used to review and score articles

underreported in the literature and as such we suggest the use of set criteria for presenting complications such as the ones presented.

Dan Winson is currently an ST3 in Trauma and Orthopaedics in Wrexham.

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

“Please visit us on stand number 29 at the BOA Congress.”

Andy Foley & Nancy Layton-Cook

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JTO Features

The value of what we do: a patient’s view Matthew Barker

Matthew Barker sits in the Policy and Programmes team at the BOA and has had orthopaedic surgery on his foot to help manage his left hemiplegia.

I have a left hemiplegia. My disability has been a lifelong, occasionally excruciating, nuisance that I have largely overcome.

I have achieved this through hard work and determination, aided by physiotherapy, orthopaedic boots and splints, and orthopaedic surgery. Surgery was a small, but very important part of my treatment.

Matthew Barker

as an exercise in short term pain (and there was a lot of it) for long term gain. That’s a world of difference from the long slog of physiotherapy which was, albeit beneficial, incredibly frustrating and regularly left me in tears in the early days.

I had a Peroneus Longus transfer and an Achilles’ tendon lengthening at age eight. The surgery shifted my foot from pointing out sideways to facing the way I’m going. I dread to think how much worse my condition would have affected me but for the surgery.

In my adult life, I have had issues with my left foot rolling outwards. It has been a problem that has gone up and down. I once started physiotherapy to deal with the issue, but couldn’t stomach seeing it through. As an adult I felt that I really wasn’t prepared to put myself through the frustration of trying to get my foot to do things it didn’t want to do.

My memory of my orthopaedic care is generally a good one.

I had fun trips to London and saw a Consultant at Guy’s Hospital, whose expertise gave my family and me confidence, even though there was never really any rapport. Most importantly, I remember surgery

I recently decided enough was enough and saw my GP. I was fed up with my foot rolling out, feeling immobile, and wearing down shoes in five minutes flat. I was also worried that my walk would get worse if I didn’t act fast. I, therefore, suspect going back to wearing a splint

and orthopaedic boots is the way forward. Ultimately though, I would sooner go to theatre than the physiotherapist’s office.

Learning from my story Since joining the BOA, I’ve seen first-hand how difficult it is to mobilise patients to put pressure on the Government to improve access to orthopaedic surgery.

There are plenty of reasons why this is the case, but first and foremost, I suspect, is how patients identify themselves. If I was to label myself as ‘a patient’ it would be as a ‘Cerebral Palsy patient’ not an ‘orthopaedic patient’.

This tells me the speciality needs to be speaking to the conditionbased patient groups as a matter of course. That’s not just arthritis and similar, but those representing disabled people with conditions such as CP. As a patient, I hope engaging with patient groups will be just one part of the speciality standing

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up to raise awareness of the value of orthopaedic surgery and demonstrating to politicians, Government and commissioners that T&O transforms mobility and improves lives - with a better frustration/gain ratio than physiotherapy.

BOA PLG Response from Judith Fitch: Matthew’s story highlights the benefits of early access to surgery

– both for patients and the NHS. Not only did his surgery offer him increased and improved mobility, it also offered far more efficient treatment by reducing Matthew’s need for long-term care. Should Matthew and his GP decide that more surgery is the way forward, we hope that this decision will be supported by swift access to a specialist surgeon who is best placed to assess his medical needs.

The BOA PLG continues to see a disturbing trend in the classification

of “elective” orthopaedic surgery. Like Matthew, many orthopaedic patients are referred for conservative treatment or told to “wait until you can’t stand the pain anymore”. Sending a patient who obviously needs a joint replacement to endless rounds of physiotherapy and injections versus surgery wastes NHS resources (clinical and financial) and directly impacts quality of life for the patient. In many cases delaying the surgery may result in a longer and

more complicated post-surgery recovery and yet more drain on clinical resources.

The BOA PLG will continue to champion orthopaedic patients’ right of access to surgery. And unless there is clear clinical evidence that a delay benefits the patient, we urge our clinical colleagues to continue to address any barriers to secondary care referrals or surgery.

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JTO Features

Orthopaedic Research in the UK: current state of the art Belen Corbacho, Health Economist, York Trials Unit

In orthopaedics, new interventions related to musculoskeletal health are developing rapidly thus decision makers must judge the effectiveness of new interventions compared to usual care.

Given limited funding, it is imperative to determine whether costly orthopaedic procedures - including surgeries, joint replacements or biologicals - can be considered cost-effective to ensure that services provided actually add value to the NHS, patients and to society.

Belen Corbacho

In contrast to other areas of care, in orthopaedics, it is common to encounter opposing clinical opinions for treating the same condition. This increases variation and uncertainty in practice.

Decision makers, clinicians and indeed patients, are progressively more interested in well-designed and conducted research evaluating the costs and benefits relevant to orthopaedic care. Randomised controlled trials (RCTs) are considered the gold standard approach to draw causal inferences to support clinical and policy decisions. However, RCTs have been less frequently conducted in orthopaedics because of several potential barriers. This has primarily

concerned major challenges to patient recruitment, particularly from treatment preferences (or lack of equipoise) both of the surgeons and patients. There may also have doubt that trial follow-up is long enough to measure outcomes appropriately.

Despite these challenges, orthopaedic research in the UK seems to be evolving from small observational studies to multicentre pragmatic RCTs. The portfolio of orthopaedic trials funded by the National Institute for Health and Clinical Research (NIHR) has visibly expanded during the past years. The NIHR journals library website was

searched from 2004 to 2015 for orthopaedic procedures (Table 1).

During this period the NIHR funded a total of 33 musculoskeletal studies that comprised evidence synthesis (58%) and primary research (42%). Research is also considering the ‘big picture’ as both systematic reviews (83%) and RCTs (86%) are regularly incorporating cost-effectiveness within the analysis.

Initiatives to increase RCTs in orthopaedics appear successful in achieving this objective. Within a ten year period (2004-2014) there were only 11 trials conducted.

Yet, in 2015, there have been three published trials, four trials are >>

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JTO Features

awaiting publication and eight are currently in progress. In general, the research is well balanced in terms of areas of the body: upper limb (38%), low limb (31%) and spine (31%). Similarly both trauma (45%) and elective (55%) studies are well represented, with joint replacement being an intervention generating the most uncertainty and hence a higher demand for research. It is also noteworthy that the majority of trials had a pragmatic design which reflects actual clinical practice.

The most recently published trial in orthopaedics clearly emphasises the value of RCTs. The results of the ProFHER trial showed that despite an increased usage of surgical intervention for patients with displaced proximal humeral fractures, surgery is actually not cost-effective for the NHS compared with non-surgical treatments. Reducing the number of surgical procedures by half would save the NHS around ÂŁ2.5 million annually. As funding the

ProFHER trial cost ÂŁ1.3 million, this investment could be recovered in less than a year of altered practice.

This highlights a real example of the potential economic value of orthopaedic trials to patients, the NHS and to the UK economy.

Next issue: The Value of Orthopaedics in the UK

Belen Corbacho is a health economist with special interest in the assessment and appraisal of health technologies. Her research interests include methods to deal with missing data and sources of data (HES, PROMs) to conduct economic evaluation alongside clinical trials. She has worked in diverse disease areas, with a recent focus on orthopaedics and trauma (ProFHER, REFORM and UKFROST trials).

Table 1: Research on orthopaedics funded by the National Institute for Health and Clinical Research (NIHR) between 2004 and 2015

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JTO Features

ATLS and the Orthopaedic Trainee On-Call: a continuing deficiency in training?

Kalpesh Vaghela Co-authors: Gajendiran Thiruchandran, Debashis Basu, Syed Aftab

The Advanced Trauma Life Support (ATLS) course has been shown to improve outcomes in trauma and is a prerequisite for admission into higher surgical training in the United Kingdom1-3.

Those who respond to trauma calls in hospitals should have ATLS certification or be supported from trained staff.

The introduction of the European Working Time Directive (EWTD) has changed the provision of 24hour support for management of trauma. A previous survey in 2008 of levels of ATLS training amongst on call trainees in 26 London hospitals found that only 22% had completed the course and 12% of hospitals had 24-hour on site registrar cover4. We have repeated this exercise five years later.

Method

Kalpesh Vaghela

We conducted a telephone survey of 24 London Deanery Hospitals.

The on call orthopaedic bleep holder was contacted after 5pm.

All registrars, non-training grade and GP vocational training doctors were excluded. We asked the following questions: 1. What is your current level of training?

2. Are you ATLS certified?

3. Do you have an on-site out of hours senior Orthopaedic surgeon?

4. Have you had to lead a trauma call without senior support?

Results We surveyed 131 trainees (F Year 1/2 and Core Surgical Trainees 1/2) at 24 London hospitals.

The results are summarised in Table 1 and Figures 1 and 2.

40 trainees (30.5%) were ATLS trained. This figure was 22% in 20084. Six (25%) hospitals surveyed had 24-hour Trauma and Orthopaedic registrars on site. This was 12% in 20084. All four major level 1 trauma centres had 24-hour registrar cover. Trainees at seven hospitals (29%) had led trauma calls without senior support but they were ATLS certified. No trainees surveyed were required to lead a trauma call without having prior ATLS certification. One hospital had compulsory ATLS training for all FY2 trainees.

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Trainee Level

N

ATLS Trained

%

FY1

33

0

0%

FY2

47

5

10.60%

CT1

26

15

57.70%

CT2

25

20

80%

Total

131

40

30.50%

Table 1: Number of trainees in survey ATLS certified

Discussion Our survey showed that 40.8% of surgical FY2, CT1 and CT2 trainees forming the trauma team have been ATLS trained which has improved from 22% in our previous study. Moreover, 25% of hospitals surveyed now had 24-hour Trauma and Orthopaedic registrars on site, out of hours in comparison to 12% in our previous study. All level 1 trauma centres have 24-hour senior support, which is where the majority of multiply injured trauma patients would be treated.

Despite this improvement in training and senior support, 29% of trainees continued to feel that senior support was not readily available out of hours; although no-one was required to lead a trauma call without previously completed ATLS certification.

There appears to a disparity in training and senior support with major centres having better levels of ATLS completion.

The surgical trainees were asked what the major barriers to completion of ATLS training were. Responses were lack of study leave, high course fees and lack of study budget. The Royal College of Surgeons recommends trainees to be within specialist (CT1–CT2) training posts when holding the trauma call. We showed that FY2 trainees

constitute a large proportion of the workforce dealing with trauma. Compulsory ATLS training as part of foundation training was only found in one hospital.

It has to be recognised that other specialities contribute to the trauma team. The majority of foundation year doctors will complete a surgical placement during their 2-year programme. We feel that successful completion of the foundation programme should include ATLS in addition to the current Advanced Life Support (ALS) course. The level of ATLS completion amongst Orthopaedic trainees in London hospitals has improved since our previous survey however continues to be deficient and requires improvement. The rising costs and access to postgraduate training remains a problem. A potential solution is introduction of ATLS training into medical school and foundation training curricula to improve management of the critically ill trauma patient in the future.

Kalpesh Vaghela is an ST3 Trauma and Orthopaedic registrar on the North East Thames Percival Pott rotation.

He is currently at the Royal London Hospital.

Figure 1: Proportion of out of hours orthopaedic registrars on site with juniors

Figure 2: Proportion of ATLS trained juniors in survey (excluding FY1s)

References 1. ATLS subcommittee, American College of Surgeons committee on trauma. Advanced Trauma Life Support (ATLS): ninth edition.

J Trauma Acute Care Surg 2013 May; 74(5): 1363-6.

2. van Olden GD, Meeuwis JD, Bolhuis HW et al. Clinical impact of advanced trauma life support.

Am J Emerg Med 2004; (7): 522-5.

3. Hogan MP, Boone DC. Trauma education and assessment.

Injury 2008 Jun; 39(6): 681-5.

4. Aftab S, Amirthanayagam T, Sinha I. MMC and ATLS: a deficiency in training? Ann R Coll Surg Engl (Suppl) 2008: 90: 168-169.

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JTO Features

The Cadaveric Shoulder Arthroscopy Course Njalalle Baraza Location: Keele University Medical School, Stoke-on-Trent Sponsors: DePuy Synthes Course Convenor: Matt Ravenscroft Cost: £250

On 17th-18th September 2014, Keele University Medical School hosted the Cadaveric Shoulder Arthroscopy Course. The faculty, all of whom were experienced and approachable (Muthu Jeyam, Damien McClelland, David Miller, Barnes Morgan, Mark Webb, Matt Ravenscroft, Raj Sandher, Philip Wykes) spent the first hour taking the 22 delegates through peri-operative particulars of shoulder arthroscopy - running a successful shoulder service by getting peers and management on board, clinical acumen to enable judicious patient selection and consistently working with the same, well trained theatre team, including an anaesthetist interested in shoulder surgery.

The next talk was dedicated to the anaesthetic concerns of shoulder surgery and patient positioning beach chair vs. lateral, permissive

Njalalle Baraza

hypotension, regional blocks, cerebral perfusion and shoulder swelling. Brief clinical lectures on shoulder intra-articular pathology followed - instability, SLAP lesions and biceps tendon pathologies.

After a short tea break we commenced the hands-on part of the course. The mysteries of the arthroscopic stack and wiring - light cable, camera, fluid management system, shaver and radiofrequency - were unravelled.

Common hiccups with the set up were touched on and solutions suggested. We practiced arthroscopic knots on dry saw bones, got a feel of the various kinds of anchors, and model scapulas were made available to practise stabilisation. After lunch we moved on to the state of the art surgical training centre wet labs with two delegates per cadaver. Diagnostic scope sequence, repair of Bankart and SLAP lesions and biceps tenotomy was undertaken on the cadavers under the watchful guidance of the faculty. At the end of day one we found ourselves walking up the steps of the elegant stately mansion house - Keele Hall - where the course dinner was served. The hospitality of the caterers was superb, as was the meal, and festivities carried on into the night.

Day two comprised extra articular shoulder pathology. Brief presentations on subacromial decompression and rotator cuff pathology were followed

The DePuy Course

first by saw bone sessions to demonstrate the cuff repairs and familiarise the delegates with the anchors then by arthroscopic models where the skills were practiced. In the afternoon, it was back to the wet labs (and somehow they did manage to recreate the sometimes tense theatre atmosphere one senses, especially when one is not completely familiar with a procedure) where subacromial decompression and rotator cuff repair was performed on the cadavers. It was difficult, but most delegates did manage to complete a decent double row repair. We were glad and somewhat relieved when one member of the faculty confessed: “It is difficult operating on the cadaveric models. If you can do it here, you can definitely do it on a real patient”. That rounded up proceedings, and after a question and answer session, certificates were issued and the course formally ended.

The enthusiasm of the faculty to share their knowledge

and expertise was reflected in overwhelmingly positive feedback with most delegates having learned more than they had expected. It was pitched at just the right level (registrars in central to latter period of training) though more junior trainees still found it easy to build up their knowledge and skills by joining the informal break away sessions. This was facilitated by the first class infrastructure of Keele University Medical School and the wet lab staff who worked tirelessly on both days to ensure procedures ran smoothly.

Special thanks go to DePuy for subsidising the cost, and to the amiable consultants whose patience and attitude made the course a resounding success. We are looking forward to the next one!

Njalalle Baraza (Jal) is an orthopaedic trainee. He lives in Birmingham and in addition to orthopaedics enjoys creative writing; violin; motorcycling; and, in tropical destinations, open water diving. He has a keen interest in arthroscopic surgery as a sub-specialty.

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JTO Features

Insurance for Surgeons Stephen Hepple

Insurance would not be top of the list of favourite reading material for most orthopaedic surgeons but with more and more of us taking the decision to incorporate in private practice it is important that the individual understands the legal requirements and options available for insuring a small business set up. There are also some opportunities for cost savings.

This brief overview of the more common insurance policies to be considered is not intended to offer specialist advice but rather to encourage individuals to evaluate their own circumstances to establish what cover may be required.

Professional indemnity insurance

Stephen Hepple

All surgeons are aware of the importance of reliable medical mal-practice insurance. Many will have a long relationship with one of the traditional medical defence organisations such that their policy is renewed each year without question. There is a degree of awareness that litigation costs are rising steadily year on year and that has led to an acceptance that premiums for these policies have inexorably increased. These organisations

often claim that they offer a superior product compared with a simple insurance policy.

Discretionary cover and run off cover are issues often cited as unique to the MDOs, but over the last five years other providers have shaken up the market with straight forward insurance policies that offer equivalent cover at substantial discount.

My own personal experience five years ago was an immediate 40% reduction and minimal increase since, such that the gap has widened. The MDOs have tried to discredit these policies for not offering the same level of cover or service and whilst this may initially have been true it is in my opinion no longer the case. The type of cover is subtly different and each policy varies but the savings are potentially huge and so please take the initiative and time to review your policy as soon as possible. At

the very least a phone call to your existing provider to chat about your circumstances and requirements can lead to a reduction in premium. It is important to ensure that a new policy includes the necessary protection levels (check with your private hospital what is required) and all of the necessary protection for events not yet declared or occurring after retirement.

Although written from a pro-insurance/anti MDO perspective the blog at www.m-i-c.co.uk/blog/?cat=7 gives one of the clearest explanations of the differences I have seen.

Employers Liability There is an absolute legal requirement for anyone employing staff to maintain a suitable employers liability policy of at least ÂŁ5 million (although many advise ÂŁ10 million). There is a fine of up to ÂŁ2,500 per day for failure to comply. If you are a sole trader i.e. not a limited company, then employing members of your family will be exempt, but once operating as an incorporated entity there are no exemptions. Legally, the certificate of insurance needs to be displayed by the employer, although this can now be done electronically.

For further information on this important topic read www.hse. gov.uk/pubns/hse40.pdf.

>>

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JTO Features

THERE IS A DEGREE OF AWARENESS THAT LITIGATION COSTS ARE RISING STEADILY YEAR ON YEAR AND THAT HAS LED TO AN ACCEPTANCE THAT PREMIUMS FOR THESE POLICIES HAVE INEXORABLY INCREASED.

The law is less clear cut regarding the status of volunteers, certainly there is no legal requirement but there are cases of volunteers working for charities taking legal action as if employees. Most employers liability policies will include volunteers. This may be most relevant to directors of charitable organisations such as the specialist societies.

Public Liability This is not a legal requirement, but in my experience most quotes for employers liability come with public liability as a non-optional extra. It is also often included in medical mal-practice insurance provided by insurance agencies rather than the medical defence bodies so it is prudent to check you are not insuring yourself twice unnecessarily.

If working solely from a hospital then it is unlikely that this particular insurance is required, but if utilising your own premises or using instruments or machinery that may injure a third party then it is essential that such a policy is in place.

Property/Contents Insurance Typically buildings insurance would be an obvious necessity for individuals owning their own premises but remember to consider the contents carefully.

Those renting office space whether in a hospital or not need

to establish clear responsibility for the buildings and contents insurance. Landlords should be insured against damage to their property but would not usually arrange cover for your personal property or office equipment. Ensure that you value the contents accurately as under insurance is one of the commonest causes of failure to fully reimburse by underwriters.

Directors and Officers Liability insurance Directors or Officers of a company can be held personally liable for their actions as officers of that company. This form of liability may have more relevance to surgeons acting as officers in national bodies or societies. Often the articles of association of such bodies stipulate that this cover be provided by the company, but Directors and Officers should be aware of the need and ensure that the policy is in place. Though rare, claims can come from a variety of sources and can relate to decisions or actions made in your role as a Director or Officer of the company. The company should establish an appropriate insurance policy to cover the costs of legal action and compensation.

Home Insurance If using your home as an office, especially if patients are

being seen, it is imperative that your home insurance policy is appropriately set up. Seeing patients at home is likely to invalidate a standard home insurance policy.

read this helpful document from the Association of British Insurers website - http://bit.ly/10dNQse.

Practice/Staff/Income protection policies

With the growing trend for the nature of practice to change, more of us are ending up providing part or all of our services through an independent company. This is unfamiliar territory as to what we need to do to protect our interests in a litigious world. Steve Hepple’s thoughtful and thorough approach to these issues, are important to check through and to recognise where the risks are and how to avoid them. Steve said after producing this “It’s a bit of a dry subject”. That may be, but I am willing to bet most of you read his advice and follow the links!

A variety of policies exist to cover lost income to a practice.

A surgeon’s inability to practice due to sickness is not usually amenable to simple locum cover due to the specifics of practice and in such a situation a suitable income protection policy should be in place.

Sickness, jury duty, emergency leave and other unpredictable absence of key staff in a small practice may result in significant financial pressure that can be offset by staff absence insurance.

Undoubtedly insurance is the proverbial minefield. If like me you are sceptical of insurance, baulk at the premiums for policies that you fear will not pay out anyway then it pays to be aware of what is available and research the best deal. Orthopaedic surgeons incorporating themselves for tax purposes necessitates an understanding of the legal requirements and options available. Make the time to do this, especially with respect to professional indemnity where the biggest savings are to be made.

For more information you can

Editor’s Comment

Stephen Hepple is Clinical Director and Consultant Orthopaedic Surgeon at North Bristol NHS Trust. He is Treasurer and Director of the British Orthopaedic Foot & Ankle Society and Financial Director of the Sports and Orthopaedic Clinic, Bristol.

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JTO Features

Supporting a patient taken to a Major Trauma Centre Nick Welch, PLG Corresponding Member

Major trauma (defined as limb- or life-threatening injury) is a sudden and life changing injury that can have a devastating effect on patients, their families and friends. The development of major trauma networks has significantly improved care for these patients but has required patients and relatives to travel relatively long distances, sometimes to unfamiliar towns or cities, to receive care in a Major Trauma Centre.

Major trauma has an impact on patients’ lives, not just their physical well-being but also major psychological, social and financial impacts. It has become increasingly clear that recovery from severe injury requires coordinated care: early rehabilitation and good communication that addresses all of these facets is a key factor.

Recently, I have been able to see at first hand the steps taken by the major trauma centres to facilitate good patient/family and inter-hospital communication.

However, there seemed to be no basic minimum standards.

Therefore with the help of Professor Christopher Moran and my colleagues at the NHS-E Clinical Reference Group, I have written a set of measurable standards aimed at unifying the excellent initiatives from all the major trauma centres.

These standards include:

Nick Welch

• The identification of a key contact (normally the next of kin) and providing them and

the patient with a named nurse (or Allied Health Professional) contact and a dedicated telephone number, within 24 hours. This phone should be available seven days a week during normal working hours, with a message service at other times • The provision of information about visiting hours, parking, where to eat, in-house and local hotel services and details about expenses • The provision of at least one face-to-face meeting with a Major Trauma Coordinator • The provision of information about the patient’s treatment and care pathway (including any planned changes) in a medium that they can understand and assimilate • Planned discharge or repatriation must be discussed and agreed with the patient and their next of kin • Patients and carers should be provided with written information about medication, rehabilitation, community care services and any other relevant information, in preparation for discharge

• At the time of discharge or repatriation the patient, general practitioner and any receiving hospital or rehabilitation unit should be provided with a written summary of their injuries, operations, proposed rehabilitation and any outpatient follow-up appointments • All discussions must be recorded in the nursing or medical records.

NHS-E is looking to include these standards in the Service Specification. A full copy of the Standards is available from the author.

Furthermore, the BOA Trauma Group has adapted the standards to make them relevant across all trauma units and hopes to publish them as an Audit Standard in Trauma (BOAST).

In conclusion, there is no doubt that including the patient and their family in every aspect of their treatment pathway improves outcomes and patient satisfaction.

I recommend the full Standards to your attention.

Nick Welch is a Past Chair of the BOA’s Patient Liaison Group, and a past lay representative on NICE’s Major Trauma Guidelines Development Group. He is a lay member of NHS-England’s Major Trauma Clinical Reference Group.

Nick Chairs his GP’s Patient Participation Group and the Local CCG Patient Network. Nick can be contacted by email at nickwelch@hotmail.co.uk.

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JTO Features - Trainee Section

The Financial Implications of Training within the UK System Peter Smitham, BOTA Past President Co-authors: M Rashid, S Kahane, J Shelton, J Davidson, S Shelton, D Ryan, P Tarassoli, S Fleming, M Sangster, M Reidy, V Paringe, W Nabulyato, J Palan Contributing author: Will Manning (on behalf of the linkmen)

Last year the Daily Mail published an article entitled “The doctors’ exodus: They cost us £610,000 to train - but 3,000 a year are leaving us for a life in the sun in Australia and New Zealand” (8/10/14).

This headline, often debated, ignores the amount that the trainees themselves contribute towards their own training. The British Orthopaedic Association asked BOTA to estimate the cost to the trainee to reach consultant level. With this in mind the BOTA committee and linkmen attempted to estimate the costs from Core Training (CT) onwards. Costs were broken down into exam and membership fees, courses, books, equipment and meetings.

Commuting costs, parking, laptops and mobile phone for on-calls were ignored, as these were considered standard for some professions.

Commuting and relocation costs are covered within the expense allowance however others such as a laptop for writing papers or a mobile when non-resident on-call could be considered mandatory and would be provided within some professions.

Peter Smitham

Exam fees (MRCS & FRCS) totalled £2,250 if passed on the first attempt. Membership of organisations including BMA, BOA, ISCP, GMC, RCS AoME, specialist

societies and medical negligence insurance cost approximately £1,700 per year. There are a number of mandatory, desired and personal development courses available including exam courses that trainees attend each year. Similar to meetings this is hard to estimate as costs will vary considerably each year and trainees gave a range from £500£2,000 per year for courses and £500-£1,000 for meetings. Books and equipment including loupes (total approx. £500 over eight years). This gives an approximate amount between £27,000 and £45,000 for a nine year programme from CT 1 to consultant.

Finally, the cost of a higher degree and fellowship costs were considered. Although neither is mandatory, a high proportion of trainees complete a minimum of a Masters degree (full or part-time) and spend a year on fellowship.

MSc courses currently cost £9,000 and trainees’ salaries are often reduced by at least a third during the fellowship year and maybe lower during a full-time

higher degree programme. These costs could double the previous estimate (or not be a factor at all) and the training period may be longer than nine years.

Some of these costs can be claimed as tax deductible; books can be handed down from senior trainees and trainees are provided with a training allowance per year, although from our linkmen roadshow discussions we have found the amount offered to trainees varies considerably around the country.

A trainee’s salary ranges from £30,002 to £47,175 excluding overtime per year. Crudely, therefore, one could consider that their first year’s salary as a core trainee will be entirely spent on the cost of their training for the next eight years. In the past ten years, salaries have reduced for trainees in real terms particularly given that very few, if any, trainee are on a band 3. If the cost of courses and membership fees continue to increase and more become mandatory it is understandable why trainees may be considering alternative options.

Peter Smitham is the Immediate Past President of BOTA and currently on a year’s fellowship in Adelaide, Australia.

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JTO Features - Trainee Section

What makes a good training hospital?

John Stammers, ST6 North East Thames: Royal London Rotation Matthew Barry, Training Programme Director: Royal London Rotation

There is an increasing culture of defining metrics in healthcare.

Historically word of mouth and the after teaching pub chat provided sufficient understanding of which hospitals are the best for training.

Trainee success is increasingly influenced and defined by meeting targets such as minimum numbers, indicative procedures and WBA’s. As a result of these targets, trainees are increasingly aware which hospitals and trainers provide the opportunity to achieve them.

With this in mind we aimed to create a scoring system to rank hospitals within the region and generate healthy competition amongst consultants in hospitals to be part of the best training hospital and improve training around the region.

Method Following consultation with colleagues around the rotation on which factors are important to providing training, ten factors were identified, three from logbook data and seven via a trainee survey.

Three E-logbook factors: 1. Overall numbers 2. Ratio of supervised trainee scrubbed (STS) / supervised trainee unscrubbed (STU) / Performed (P) / Training junior trainee (T) to assisted 3. Number of indicative procedures

Towards the end of their six month rotation a Survey Monkey questionnaire link is sent out to each of the trainees on the rotation containing the questions outlined in Table 1.

Calculations The overall numbers and number of indicative procedures are calculated as a ratio of the highest scorer.

For example, if hospital X has the highest with 250 cases they get ten points. Hospital Y with 200 would get eight. Assisting in high volume indicative procedures has limited training value and therefore only indicative procedures STS/ STU/P/T are included. The ratio of STS/STU/P/T to assisted is directly converted to a score out of 10. For example the mean ratio of trainees at the hospital is 69% it scores 6.9. >>

1

Which Hospital are you working at? What is your Name? Level?

Consultant? Subspecialty?

2

What is your rota, working pattern and banding?

3

Average Number Clinics/week? Do you internally cover other registrar's or consultant's clinics when people are away?

4

Average Number Operating sessions/week?

5

Are your training opportunities limited by a strictly compliant EWTD rota?

6

How do you rate the educational value of the trauma meeting?

7

Are you given fair opportunity to get to teaching?

8

Are clinics used to provide any educational value?

9

Are your training needs considered in planning theatre case-mix volume or type?

10 Would you recommend this job/Hospital to your colleagues/Would you pick this job/Hospital again if you could turn back time?

John Stammers

Matthew Barry

Table 1: Questions asked of trainees via Survey Monkey.

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JTO Features - Trainee Section

The score for the number of clinics is based on JCST guidelines and scored as Table 2. Trainees cross covering extra clinics on a week by week rota basis instead of cancelling these clinics score an additional penalty as this was deemed of limited training potential particularly if there is no consultant supervision.

If a maximum number of clinics are enforced in the rota this number is used. Theatre sessions were scored as per Table 3. The remainder of the survey monkey results are converted into numbers corresponding to one of the five answers. For example, strongly agree, agree, indifferent, disagree, strongly disagree corresponds to 10, 7.5, 5, 2.5, 0 points. Each factor is worth 10 points and the mean calculated based on each trainee per six month period. A maximum of 100 points is available.

Clinic sessions

Points

<3

10

3-3.5

7.5

3.5-4

5

4-4.5

2.5

>4.5

0

Table 2: Scoring for number of clinics

Theatre sessions

Points

<2.5

0

2.5-3.0

2.5

3-4

5

4.0-4.5

7.5

>4.5

10

Table 3: Scoring for number of theatre sessions

Discussion In the two years we have run the award, the outcomes of each training element are presented and the overall winner of the award is announced at our Annual Academic Meeting. In addition to the award of winning in front of representatives from all the hospitals, an email to the chief executive and medical

The 2015 winning team at Newham Hospital

director provides a good news story for the department and hospital.

Consultants of winning departments have used the award as evidence of training in revalidation and justification for an increase in deanery funded trainees during deanery visits.

A concern was whether trainees would participate given our inboxes are regularly filled with surveys to complete. The GMC survey and JCST survey focuses on safety and wellbeing rather than training although there is some cross over.

Trainee engagement was reassuring with 96% of eligible trainees completing surveys for the first six months and 100% in the second.

A number of trainees have had direct benefit using the data to improve rotas if their hospital is an outlier for too many clinics, a lack of theatre sessions or inflexibility attending the teaching programme.

A comment is that the award is biased by a hospital having a gifted, ‘glass half full’ or more senior trainee. The last two years data has not shown this to be an influence. It is anticipated that senior trainees are more likely to perform an increased ratio of STS/ STU/P/T than junior trainees but junior trainees are often less picky with training opportunities, even if assisting and have higher overall numbers. Like many rotations the TPD endeavours to match trainees to hospitals suited to junior trainees and hospitals that suit senior trainees. The annual award is based on two 6 month blocks,

April-October and October-April.

Even if a trainee stays at a hospital for a year, October is the usual changeover and therefore outcomes are based on two trainees per post.

The majority of hospitals have more than two trainees. Half the marks are from objective scores and half from subjective balancing the effect of a ‘glass half full’ trainee.

Another comment is that the results for a particular hospital are going to be affected by which trainer you work for. Absolutely, but trainer allocation in our rotation is determined by the department’s educational lead and therefore a trainee should not be matched with a poor trainer or one that does not suit their training needs. Hospitals rarely have one good trainer. Good hospitals have a culture of training and attract and employ consultants with an interest in training. Good trainers turn service provision into training and defend trainees from infrastructure changes such as poor rotas.

The survey has evolved based on feedback. Banding is easy to record and our data suggested there was a correlation with a non EWTD 2b banding and increased overall numbers compared to a band 1 EWTD compliant rota but the impact on training of specific rota patterns, such as nights, oncalls and compliance with rotas is multifactorial and difficult to compare between hospitals.

In future years we are changing the questions to include education

in MDT or trauma meetings and a question on opportunities in research/publishing/audit, removing the question regarding compliance with the EWTD. This should enable tertiary hospitals to reasonably compete for this award and potentially raise standards in all the hospitals within the region.

A brief survey of BOTA linkmen representing all rotations suggested that this is a unique concept and there is an appetite to expand this survey to other rotations and agree on standard methodology to compare training nationally.

See www.rlhots.org/training_hosp.html for the presentation of our results.

Acknowledgements North East Thames: Royal London Rotation Trainees for completing and continuing to complete the six-monthly surveys and the Royal London Rotation Trauma and Orthopaedic Society (RLHOTS) Committee for their support.

John Stammers is an ST6 at North East Thames: The Royal London Rotation. John is also a BOTA linkman and the RLHOTS webmaster.

Matthew Barry is a Consultant Trauma and Orthopaedic Surgeon with a special interest in children’s orthopaedics and limb reconstruction. He is the Training Programme Director at North East Thames: The Royal London Rotation.

Young Adult Hip/Joint Preservation Cadaver Course

November 30th and December 1st 2015

School of Medicine, David Weatherall Building, Keele University, ST5 5BG, U.K. 12 CME/CPD Credits

Contact: hipjointpreservation@gmail.com Phone: +44 1302323489 www.hipjointpreservation.com Course Chairman: Sanjeev Madan Invited Faculty: Frederic Laude (France); John O’Hara (UK); Etienne Belzile (Canada); Aresh Hashemi Nejad (UK); Olof Risto (Sweden); James Fernandes (UK); Fabian Kalberer (Switzerland); Mark Flowers (UK), Srino Bharam (USA); Nigel Kiely (UK); Mark Wilkinson (UK); Jörg Schröder (Germany); Jon Conroy (UK); Oliver Marin Pena (Spain); Giles Stafford(UK); Michel Brax (France); Olufemi Ayeni (Canada) Course Content • Hip Arthroscopy • Minimally Invasive Peri-Acetabular Osteotomy • Other Triple Pelvic and Paediatric Osteotomies • Intertrochanteric/Pertrochanteric Femoral Osteotomies • Surgical Dislocation of the Hip • Intracapsular Femoral Osteotomies • Articulated Hip Distraction for Avascular Necrosis • Non Arthroplasty Option for Osteoarthritis • Arthroplasty options in the young adult.

Course Guidance • Course is suitable for Consultants and Senior trainees who are interested in hip joint preservation surgery.

• Course will discuss Adult and Paediatric Hip conditions, and therefore is suitable for Hip Surgeons and Paediatric Orthopaedic Surgeons.

• Course will not cover Revision Hip Arthroplasty.

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JTO Medico-Legal Features

The Duty of Candour Clare Chapman, Solicitor

April 2015 saw significant pieces of legislation come into force which will impact greatly upon healthcare professionals. From 1st April 2015, the duty of candour now applies universally to all CQC registered providers and on 13th April the criminal offences of ill-treatment or wilful neglect came into force.

Duty of Candour The Duty of Candour was introduced by regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The duty requires all CQC registered providers to act in an open and transparent way in relation to care and treatment provided to service users. The duty will apply whenever providers become aware of a “notifiable safety incident”.

What is a “notifiable safety incident”?

Clare Chapman

The definitions of a “notifiable safety incident” vary slightly for health service bodies and other registered providers.

For health service bodies it is: “any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in: a) The death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition; or b) Severe harm, moderate harm or prolonged psychological harm to the service user” (Regulation 20(8)) For other providers it is: “any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional –

a) Appears to have resulted in – i. The death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition, ii. An impairment of the sensory, motor or intellectual functions of the service user which has lasted, or is likely to last, for a continuous period of at least 28 days, iii. Changes to the structure of the service user’s body, iv. The service user experiencing prolonged pain or prolonged psychological harm, or v. The shortening of the life expectancy of the service user; or b) Requires treatment by a health care professional in order to prevent – i. The death of the service user, or ii. Any injury to the service user which, if left untreated, would

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WHILST THE STATUTORY OFFENCE APPLIES ONLY TO HEALTH CARE PROVIDERS AND NOT TO INDIVIDUAL HEALTH CARE PROFESSIONALS, INDIVIDUALS HAVE A PROFESSIONAL DUTY OF CANDOUR, WHICH IS OVERSEEN BY THE PROFESSIONAL REGULATORS.

lead to one or more of the outcomes mentioned in subparagraph (a).” (Regulation 20(9)) “Moderate harm” is defined as a) harm that requires a moderate increase in treatment, and b) significant, but not permanent, harm.

Although the definitions are similar, it appears that a health service body’s duty to be candid about near misses is broader than that of other registered providers.

What exactly is required?

The registered provider must: • Notify the relevant person that a notifiable safety incident has occurred; • Provide reasonable support; • Provide an account, which is true to the best of the body’s knowledge, of all the facts known about the incident at the time of notification; • Advise about other relevant enquiries; • Include an apology (defined as an expression of sorrow or regret); and • Record the account in writing and keep it securely.

What happens if there is non-compliance?

The CQC can issue fixed penalty notices and prosecute providers for a breach. Non-compliance could also affect a provider’s continued registration with the CQC.

What do I need to do to ensure compliance?

the section 21 offence applies to health care organisations.

Whilst the statutory offence applies only to health care providers and not to individual health care professionals, individuals have a professional duty of candour, which is overseen by the professional regulators.

When is an offence committed?

You should: • Know what your employing Trust’s policy is on duty of candour: • Be familiar with any guidance documents on the Trust’s definition/interpretation of what constitutes a “notifiable safety incident” and the steps to be taken when such an incident occurs; • Identify the staff members to whom any notifiable safety incident should be reported and the mechanism by which the report should take place; and • Ensure detailed records are kept of all patient care and any investigations when things go wrong.

A care provider commits an offence if: a) An individual providing care as part of the care provider’s arrangements ill-treats or wilfully neglects another individual under their care; b) The management or organisation of the care provider’s activities amounts to a gross breach of a relevant duty of care owed by the care provider to the individual who is ill-treated or neglected; and c) In the absence of the breach, the ill-treatment or neglect would not have occurred, or would have been less likely to occur.

Ill-treatment or wilful neglect

A “gross breach” is one which falls far below what can reasonably be expected of the provider in the circumstances. The focus is on conduct, not the resultant harm, so an offence can be committed without any harm being suffered.

However, the level of harm is likely to have an impact at the sentencing stage. There will need to be proof of intent or knowledge that the care or treatment being provided was inadequate or of a “couldn’t care less” attitude in order to establish the offence.

The criminal offences of illtreatment or wilful neglect are contained in sections 20 and 21 of the Criminal Justice and Courts Act 2015. They were introduced to address a gap in existing law which meant that a patient who received poor treatment, but had capacity and did not die, had no protection.

The section 20 offence applies to individual care workers, whilst

A care worker commits an offence if they ill-treat or wilfully neglect an individual under their care.

To whom does the offence apply?

The offences only apply to those individuals who provide care as paid work, as part of a contractual or employment arrangement. Individuals who provide informal care on a voluntary basis, e.g. family and friends, are not subject to the offence.

The offence applies to: • Paid managers and supervisors of the provision of care (and directors of organisations performing this function); • Services where children receive health care, including young offenders institutions; • Pharmacists; and • The private sector as well as the NHS. However, the offence will not apply to: • Schools; • Children’s homes; • Residential family centres; • Child care services; or • Children’s social care.

• It will apply though to situations where adults are receiving formal domiciliary care.

What are the sanctions?

Individual care workers found guilty of the offence could be liable to up to five years’ imprisonment and/or an unlimited fine. Care providers >>

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DESPITE ASSURANCES THAT GENUINE HUMAN ERROR WILL NOT LEAD TO CRIMINAL LIABILITY, CONCERNS HAVE BEEN RAISED THAT THE NEW OFFENCE WILL LEAD TO A CLIMATE OF FEAR.

could face an unlimited fine, a remedial order (requiring the provider to address the failing which led to the offence), and/ or a “naming and shaming” publicity order.

What impact will the new offence have?

Whilst the offence is not intended to penalise genuine accidents or errors or to hinder the free exercise of clinical judgment, and it is expected that the offence will only be used in extreme cases, the Department of Health has said that the offence is intended to “send a strong message that poor care will not be tolerated and ensure that wherever ill-treatment or wilful neglect occurs, those responsible will be held to account”. The government estimates that there could be in the region of 240 prosecutions per year.

Detailed guidance about when prosecutions should take place is awaited and an element of uncertainty is expected, particularly given the lack of definitions of “ill-treat” and “wilful neglect”. There may also be uncertainty following a prosecution as to whether a jury would be satisfied “beyond reasonable doubt”.

Despite assurances that genuine human error will not lead to criminal liability, concerns have been raised that the new offence will lead to a climate of fear.

However, it should be possible for an individual to defend themselves on the basis that they were acting in what they thought were the patient’s best interests and that they were exercising clinical judgment. In any event, there are practical steps that can be taken which would assist in the unlikely event of criminal proceedings being commenced.

What should I do to avoid criminal liability?

Good note keeping will be very important, as evidence of the care and treatment provided and as a tool to ensure continuity of care.

You should ensure that a patient’s records contain sufficient detail to explain all clinical decisions made. As set out above, the ability to justify clinical decisions, and to demonstrate that clinical judgment was being exercised, when faced with allegations of wilful neglect can have a significant impact on investigations, assist in defending any criminal proceedings brought and could prevent a prosecution being made at all.

Equally, good communication skills and a caring, compassionate attitude shown towards patients can help to deflect a “couldn’t care less” finding, and could in some circumstances avoid a matter being reported to the police in the first instance.

Concerns have been expressed that the new criminal offence could

inadvertently undermine the duty of candour if individuals fear criminal sanctions where things have gone wrong. The circumstances in which the criminal offence will arise are rare and it is essential that there is a culture change, with openness and honesty being embraced.

It is worth remembering that, in addition to the statutory offence for health care providers, individuals have a professional duty of candour, policed by the healthcare regulators, so any failure to be open and honest could result in regulatory action. Patient safety must be the priority and any fear of prosecution must be overcome.

Clare Chapman is a partner in the healthcare team at law firm BLM. She is a professional discipline and regulatory specialist.

Correspondence Email: clare.chapman@blmlaw.com

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Prevention of Periprosthetic Joint Infection Ramsay Refaie, Simon Jameson and Mike Reed

Periprosthetic joint infection (PJI) can be a catastrophic complication following joint replacement surgery. The financial costs and morbidity associated with PJI are well established1-3 with evidence now emerging that PJI is an independent risk factor for mortality4. Prevention is better than cure and whilst an exhaustive list is beyond the scope of this article we will discuss some offbeat tactics to consider in practice.

Ramsay Refaie

Simon Jameson

Mike Reed

The Basis of the Problem When Charnley wrote about prosthetic joint infection in 1969 he stated there was “still uncertainty as to how often a wound is infected in the operating room and how often at a later date during the healing of the wound”5. This same uncertainty still persists to this day. Contaminants may arise from the patient’s skin, from the surgical personnel or from the surgical instrumentation itself 6, 7.

It is likely that almost all surgical wounds are contaminated because skin preparation at the time of surgery will only decontaminate the skin surface and bacteria will remain in deeper layers of the skin8.

Whilst it is also possible for infection to seed to the implant in haematogenous spread or so called “metastatic infection”9 this occurs less frequently.

Gram-positive organisms are the most commonly reported with Staphylococcus aureus accounting for over a third of reported PJIs in England and Wales10.

Broadly speaking prevention strategies target modifiable patient factors and peri-operative factors; these are summarised in Table 1. Many of these tactics are presented at open events with The Quality Improvement in Surgical Teams initiative11.

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Risk Factor

Management Patient factors

Inflammatory arthritis

• Disease-modifying anti-rheumatic drugs (DMARDs) including methotrexate should be discussed with the prescriber • Peri-operative steroids are generally not required • Balance the risks and benefits of stopping antiTNF – stop at 3-5 half-lives pre-operatively, restart after wound healing and no evidence of infection

Obesity

• Dietician input to encourage weight loss • Adjust peri-operative antibiotic doses appropriately • In super-obese consider bariatric surgery prior to joint replacement surgery

Smoking

• Consider a smoking cessation programme

Methicillin Resistant and Methicillin Sensitive Staphylococcus aureus carriage (MRSA and MSSA)

• Screening based on local guidelines, and decolonise prior to surgery

Peri-operative factors Patient preparation

• Shower on day of surgery • If hair removal required, use electric clippers on day of surgery • Avoid oil-based skin moisturisers

Antibiotics

• Prophylactic antibiotics should be given as early as possible in the anaesthetic room • If cementation is required, antibiotic-impregnated cement should be used • There is little consensus or evidence for which antibiotic prophylaxis

Theatre

• Use laminar flow where possible • Keep theatre door opening to a minimum

Personnel

• Hand wash with antiseptic surgical solution, using a single-use brush or pick for the nails • Before subsequent operations hands should be washed with either an alcoholic hand rub or an antiseptic surgical solution • Use scrub staff assisted glove donning • Double glove and change gloves regularly

Skin preparation

• Use an alcohol pre-wash followed by a 2% chlorhexidine-alcohol scrub solution, or alcoholic betadine. Beware of fires

Anaesthetic

• Maintain normothermia • Maintain normovolaemia • A higher inspired oxygen concentration perioperatively and for 6 hours post-operative may be of benefit

Table 1: Summary table of common prevention tactics

Proven strategies and some food for thought MSSA screening and decontamination

5% (p<0.001) in patients undergoing hip and knee arthroplasty17.

Smoking cessation should be considered for all patients.

Patient warming

Methicillin Resistant Staphylococcus aureus (MRSA) is the emotive “superbug” that every patient seems to fear.

Indeed MRSA infections have been shown to have significantly higher treatment costs than other causal organisms of PJI12. MRSA screening is now well established across the NHS with positive results prompting decolonisation prior to surgery. However, nasal carriage of Methicillin sensitive organisms (MSSA) also confers an increased risk of PJI. Carriage is common (~20%)13 and decolonisation presents us with an easy “high yield” strategy in the fight against PJI. A large, randomised, placebo controlled multi-centre trial published in the New England Journal of Medicine in 2010 showed that decolonisation of MSSA carriers with mupirocin nasal ointment and chlorhexidine soap prior to orthopaedic and cardiothoracic surgery reduced their risk of MSSA SSI by almost 60% from 7.7% to 3.4%13. This strategy has also been shown to be cost effective14. Despite this, many centres still do not routinely screen for MSSA. After MSSA screening and decolonisation was introduced in one NHS joint replacement unit, MSSA infections reduced from 0.84% to 0.26% - the caveat being there were other infection prevention methods implemented during the time period15.

Pre warming of patients before theatre is a proven strategy for preventing hypothermia intraoperatively and in recovery18, 19.

A large RCT from the UK published in the Lancet showed that pre warming reduced the risk of infection by around 65% in clean surgery20.

Despite this pre warming is still not widely adopted in UK centres.

Smoking cessation

Given the fragile nature of laminar air flow, we wanted to investigate the impact of popular suspended theatre lights. In a series of experiments using neutrally buoyant helium bubbles we evaluated the efficacy of laminar flow at clearing particles from the operative field looking specifically at the impact of lights. These experiments

Smokers are at increased risk of wound complications and infections16. A randomised controlled trial from Denmark, published in the Lancet, has shown that cessation or at least 50% reduction in smoking decreased wound complications from 31% to

Intra-operative warming is widely performed but the method of intra-operative patient warming may also alter the risk of infection during clean air surgery21.

Randomised studies have demonstrated that the popular forced air warming devices interact with laminar air flow currents in such a way that non-filtered air can be drawn from outside the clean air canopy into the wound area22, 23.

Our own switch to the alternative conductive fabric warming led to a significant decrease in deep infection rates22. These concepts are best demonstrated in high definition video (www.youtube. com/user/orthopodresearch).

Laminar flow and lights Historical evidence has shown that laminar flow in combination with antibiotic prophylaxis reduces infection rates in joint arthroplasty24. Recently however, the benefit of laminar flow has come into question10, 25, 26.

>>

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are best viewed in high definition video (www.youtube.com/user/ orthopodresearch). Perhaps unsurprisingly we found that placing lights directly above the operative field impairs the ability of the system to clear airborne particles. Figure 1 shows the rate at which particles were cleared from the operative field after one minute of filling with bubbles. No lights, a single light and two lights over a mannequin knee (Figure 2) were evaluated.

This provides further evidence for the intuitive interactions between laminar air flow currents and objects within it. Based on this the lead author has joined several others who operate without suspended theatre lights for knee replacement. Hugh Howorth and Sir John Charnley worked closely to develop the optimal operating environment.

The original greenhouse used by Charnley contained two banks of lights to illuminate the operative field27. Subsequent Howorth/ Charnley theatre designs contained banks of lights outside the laminar flow canopy. The theatre picture of Wrightington Hospital (Figure 3) clearly shows a bank of lights outside the laminar flow enclosure.

Whilst this approach is not for everyone, an awareness of the potential interactions with laminar flow and attempts to minimise these should be encouraged.

Summary PJI is catastrophic and every feasible step should be taken to prevent this. Whilst this article is not exhaustive it may encourage achievable strategies to reduce the incidence of PJI. Ramsay Refaie is a Specialty Trainee in the Northern Deanery.

He is currently on an out of program experience for research at Newcastle University and is looking at novel diagnostic biomarkers in Prosthetic joint infection.

Figure 1: Rate of bubble clearance

Simon Jameson is currently Robin Ling Hip Fellow at the Princess Elizabeth Orthopaedic Centre in Exeter. He trained on the Northern and Glasgow Orthopaedic rotations. He is a past NJR research fellow with an MD thesis focused on outcomes after primary hip replacement.

Figure 2: Knee mannequin with bubbles being introduced

Correspondence Email: ramsay2000@gmail.com Email: simonjameson@doctors.org.uk Email: mike.reed@nhs.net

Targeted antibiotic prophylaxis The benefits of prophylactic antibiotics are widely accepted across most surgical specialties28, 29.

Prophylaxis is however not without risks and the potential reduction in SSIs must be balanced against the adverse effects of antibiotics.

Cephalosporins, once a panacea in our prophylactic armamentarium, have fallen out of favour in the UK largely due to their association with Clostridium difficile associated diarrhoea (CDAD), despite this representing a relatively minor complication

Mike Reed is an orthopaedic surgeon for Northumbria Healthcare and a Senior Lecturer with Newcastle University. He Chairs the Trustâ&#x20AC;&#x2122;s Surgical Site Infection Prevention Programme.

References Figure 3: Old Theatre 1 at Wrightington Hospital

in elective orthopaedic surgery (1.7 per 1000)30. A systematic review reported that there is insufficient evidence of a significant difference between cephalosporins, teicoplanin or penicillin derivatives31. In practice, most prophylactic regimens are now based on dual therapy yet these are frequently associated

with higher incidence of acute kidney injury and no change in rates of PJI32-35. Elsewhere, gentamicin alone has also been shown to offer no benefit in terms of reducing CDAD36. With all this confusion a large randomised trial is required to best protect our patients undergoing primary joint replacement.

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

Š 2015 British Orthopaedic Association

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Biofilm and orthopaedic implant infection Heledd Havard & Jonathan Miles

Biofilm is a colony of microorganisms suspended within a selfproduced matrix, the extracellular polymeric substance (EPS).

Estimates report that 99% of bacteria can exist within a biofilm state. The likely organisms responsible in approximately 75% of biofilm-associated infection include S.epidermidis, S.aureus and Pseudomonas aeruginosa1.

Biofilm formation

Heledd Havard

Jonathan Miles

A surgical skin incision exposes otherwise harmless bacteria to a change in environment leading to an opportunistic change in behaviour. The adhesion of a planktonic bacterium to an inert surface leads to the formation of a biofilm in phases: adhesion - aggregation - mutation dispersal. The process is dependent upon local conditions such as the hydrophobicity and acidity, oxygen concentration, presence of inert material (and its surface area) and the ability of the bacterium to initiate contact via pili/flagella2,3,4. Secretion of positively charged homopolymers

such as polysaccharide intercellular adhesin (PIA) leads to the creation of a protective extracellular matrix that acts as a physical and electrostatic barrier1.

Recruitment, proliferation and maturation follow, resulting in the adhesion and incorporation of other microbes. In its early phase of formation, the structure of the biofilm is susceptible to the host immune system and antibiotic penetration but, within one hour, DNA transcription changes alter gene expression5. Proliferation and phenotypic modulation within the biofilm culminates in maturation and dissociation/ disaggregation with dispersal of bacterial cells.

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of bacterial and fungal prostaglandins by targeting the cyclooxygenase dependant pathways thereby inhibiting biofilm formation4.

Antibiotics

Figure 1: The dispersal of bacterial cells

Biofilm function

Biofilm prevention

The ultimate function is to create a protective environment within which bacteria can sustain a state of existence without overwhelming the host. Secretion of virulence factors conveys a unique environment for the bacteria to continue to evolve and mature allowing evasion of innate and adaptive immune responses and development of tolerance to antimicrobial agents.

Anti-adhesins

The structure of biofilm is designed such that the high cell density allows cell-to-cell communication through quorum sensing (QS). Bacteria can modify gene transcription based on cell density and population, resulting in areas of differentiated metabolic activity that create subpopulations of phenotypically distinct bacteria3, 4, 6. Surface bacteria are more metabolically active and demonstrate some susceptibility to antibiotic penetration yet the sub-lethal exposure encountered by centrally located dormant cells often leads to expression of virulence factors with up to a x1000 fold increase in resistance to systemic therapy7,8.

Treatment of Biofilm There are opportunities to target specific cells at different stages of development. Agents have been classified as ‘biofilm preventing’, ‘biofilm disrupting’, ‘biofilm bypassing’ and ‘antibiofilm vaccines’4.

The attachment of a planktonic bacterium is a key phase in formation. Surface proteins known as adhesins expressed from the planktonic cell initiate cell attachment. Within each microbial species there are hundreds of different adhesins, such as the sortase family in gram positive bacteria.

Many of these membrane enzymes have proven to be universal virulence factors for gram positives and offer a potential drug target for anti-adhesin activity. In vitro studies demonstrate promising results leading to the blockage of bacterial adherence to fibronectin coated surfaces4.

Quorum-sensing inhibitors Cells within a biofilm behave as communities rather than individuals, using the communication pathway referred to as ‘quorum sensing’.

Cell density and population influence gene expression within the biofilm resulting in adaptive behaviour. This reduces metabolic activity in the central cells of the biofilm which modulate and mutate enhancing the biofilm’s ability to evade the host immune system.

Numerous quorum sensing pathways exist in gram positive and negative species with two major classes - furanones and

RNAIII-inhibiting peptides (RIP)3,4,6.

RIP has proven to be most effective against staphylococcal species including MRSA and S.epidermidis.

Further work has suggested that the use of QSIs in combination with conventional antimicrobial agents enhanced the susceptibility of the biofilm to standard antibiotics but further research into the product stability and toxicity is needed.

Biosurfactants/Antimicrobial peptides/NSAIDs Biosurfactant and macromolecule (heparin/albumin) coating of prosthetic surfaces reduces the adhesion of microbes1,3. However, once attachment is successful, the microbes can modify the coated surface to break down the protective layer and create further adhesions/aggregates. Further research is ongoing to produce more stable inhibition.

Antimicrobial peptides (AMPs) such as melamine and citropin are effective against biofilm formation due to their ability to bind to negatively charged structural molecules on the microbial membrane4. AMPs combine with certain antibiotics to enhance their effects. However, these peptides are susceptible to protease digestion so research is now focused on developing synthetic and selectively targeted second and third generation AMPs4.

In vitro studies have proven that non-steroidal anti-inflammatory drugs can influence the synthesis

Systemic antimicrobials continue to be effective against bacteria in their planktonic state yet cannot target biofilm bacteria.

Factors reducing the efficacy of antibiotics Biofilm evasion Biofilm evasion Poor penetration Dormant / persister cells Sublethal antibiotic dose Changes in local environment Figure 2: Factors reducing the efficacy of antibiotics

The susceptibility of bacteria to systemic antibiotic therapy can be influenced by the concomitant use of biofilm disrupting/ disaggregating agents which release the bacteria to their planktonic state. This may explain the synergistic effects seen when combining antibiofilm agents with standard systemic antibiotics.

Vaccines Attempts to produce an antibiofilm vaccine have thus far proved futile. Whilst much of the work has focused on creating an anti-staphylococcal vaccine e.g. StaphVAX - its protective properties at one year post vaccination was less than 30%.

Development of a quadrivalent vaccine used in conjunction with antibiotic therapy proved more efficacious suggests that further advances in the field of vaccination may offer future benefits7. >>

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Biofilm Disruption Disrupting an established biofilm is challenging, as a combination of cellular communication and a protective physical barrier provides the biofilm with the ability to evade host immune detection and inhibits the penetration of systemic antibiotics. Agents suitable to target biofilm disruption include proteolytic enzymes, such as deoxyribonuclease I (DNAse I) and dispersing B (DspB), and mucolytic agents such as N-acetylcysteine (NAC)1,4. NAC has been extensively studied in cystic fibrosis and its mechanism of action as an antioxidant reduces the production of the EPS as well as promoting disaggregation of the mature biofilm. It has a synergistic effect when used in combination with antibiotics, reducing biofilm in S.aureus, S.epidermidis and gram-negative bacilli4. Positive results are being seen with NAC in the setting of implant coating of orthopaedic implants9.

Alternatives proven to disrupt biofilm formation include the use of larval secretions that appear to disrupt biofilm in the digestion of necrotic tissue. Recent studies have also demonstrated that maggot excretions inhibit biofilm formation on biomaterials including polyethylene, titanium and stainless steel4.

Nanomolar nitric oxide is effective at dispersing motile strains of bacteria and is thought to be useful against gram-negative pathogens, yet its mode of delivery and potential toxicity remains a concern1,4,7. An alternative option is to target the â&#x20AC;&#x2DC;persisterâ&#x20AC;&#x2122; cells whilst they remain in a dormant state whereby activation of cytoplasmic protease by the antibiotic acyldepsipeptide (ADEP4) can initiate autolysis of the cells1.

Development of nanoparticles as drug carriers enable local antibiotic elution, improved drug delivery and avoidance of the burst effect (near complete elution occurring within hours or days, with subsequent sub-inhibitory exposure which theoretically can lead to antibiotic resistance).

It utilises the natural properties of metals such as silver with its antimicrobial capacity against both gram positive and gram negative organisms1,4. Promising results are seen with core/shell nanoparticles consisting of a bioceramic core and polymeric shell providing controlled drug elution over a period of 30 days4.

Attempts have also been made to directly tether antibiotics to the surface of prosthetic implants demonstrating potency for up to 48 hours. Alternatively, both biodegradable and nonbiodegradable cements can function as local drug delivery systems achieving high local concentrations without the effects of systemic toxicity4,6,8.

This method is however susceptible to the burst effect.

Implant materials Research has established the properties of an inert material which influence the formation of biofilm. Advances in orthopaedics have seen modification of implants to improve bearing wear or osseointegration. For example, hydroxyapatite coating creates a rougher surface.

This topographical change creates a structurally favourable environment for bacterial adherence2. Equally, microporous coating is more likely to lead to planktonic attachment than an implant with a smooth polished surface2. Metallic compounds

possess a negative charge thereby attracting positively charged bacterial molecules with high energy surfaces demonstrating increased biofilm2,6. The hydrophobicity of a material appears to have a parabolic type relationship in terms of biofilm formation with highly hydrophilic properties and superhydrophobic surfaces both associated with a reduction in biofilm adherence2.

Different alloys display different biofilm properties even when they have similar chemical and mechanical characteristics.

It has been demonstrated that titanium materials tend to keep bacteria dispersed on the surface thereby reducing the adherence of bacteria as compared with stainless steel or polymethylmethacrylate7.

Researchers have also found that vanadium free titanium alloys display decreased bacterial adherence as compared to those containing vanadium7. These titanium alloys are also less biofilm resistant than titanium dioxide, titanite (a mixed titanium and calcium silicate) and medical tantalum.

Properties influencing biofilm adherence Material Topography and roughness Hydrophobicity Porosity Electrical charge Surface area Phenotypic variations Figure 3: Properties influencing biofilm adherence

Silver has long been known to have bactericidal properties by disrupting their folding of proteins and producing toxic reactive oxygen species, harming the DNA and cell membrane.

Again, this increases the susceptibility of a bacterium to antibiotics: the combined effect of silver and antibiotics leads to a synergistic response killing between 10 and 1000 times as many bacteria. Silver has already been utilised both as a coating and as nanoparticles which, when combined with titanium dioxide, display further bactericidal properties2,4,7.

SILVER CONTAINING RESERVOIRS MODIFIED SURFACE

Ti ALLOY SUBSTRATE Figure 4: Bactericidal properties of silver

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Journal of Trauma and Orthopaedics: Volume 03, Issue 03, pages 54-57 Title: Biofilm and orthopaedic implant infection Authors: Heledd Havard & Jonathan Miles

Modification of implant surfaces offers a novel approach to targeting biofilm infection with potential to introduce bactericidal surfaces, bacteriostatic surfaces, anti-adhesive coatings and smart coatings.

Conclusion The use of prosthetic implants in orthopaedics provides an ideal environment for biofilm formation. Inert material within a hypovascular and hypocellular area of scar tissue creates an

environment that is no longer exposed to the routine host immune surveillance and creates additional challenges to the treating clinician. An improved understanding of biofilm within the orthopaedic community will lead to a more streamlined approach in the pre-operative, peri-operative and post-operative periods to optimise treatment and improve patient outcome.

Heledd Havard is an ST6 trainee on the London RNOH Stanmore rotation. She is currently working within the Joint Reconstruction

Unit and has a special interest in sarcoma, endoprosthetics and pelvic reconstruction surgery.

Jonathan Miles is a consultant joint reconstruction surgeon at The Royal National Orthopaedic Hospital, Stanmore. He is the orthopaedic lead for bone and joint infection and a founder member of the joint infection multidisciplinary team meeting.

He has research interests in the diagnosis and management of recurrent joint infection and associated bone loss.

Correspondence Email: stanmoremiles@gmail.com Email: heleddhavard@doctors.org.uk

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

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The future of diagnosis and treatment for Orthopaedic infections Gemma Wheldon & Rob Townsend

Bone and joint infections are deep infections, often associated with prosthetic material. This makes treatment particularly difficult due to the poor vascular supply and the formation of Biofilms on the prosthetic material by the bacteria. Long courses of antibiotics are frequently used in conjunction with surgery for prosthesis removal or debridement, antibiotics and implant retention (DAIR) for early/acute prosthetic joint infections.

Gemma Wheldon

Rob Townsend

Infection occurs by two main routes; direct spread and haematogenous seeding. Direct spread is most commonly related to intra-operative acquired or post-operative wound infections adjacent to the prosthetic material. Infection associated with these routes can be mono or poly-microbial compared to haematogenous seeding which can occur if the patient is bacteraemic and tends to be mono-microbial.

A Staphylococcus aureus bacteraemia is associated with a 30-40% risk of infection1.

Haematogenous seeding accounts for 20-40% of

prosthetic joint infections with the remainder being due to local spread2. The prevalence of infection for elective Orthopaedic surgery is 1%3.

Healthcare associated infections are a serious cause of morbidity and mortality for affected patients and they are a major source of cost to the NHS4. In Orthopaedics, there is a mandatory requirement for surveillance during each financial year5. With increasing worldwide development of resistance, these infections are becoming increasingly difficult to treat. We describe the Microbiology of bone

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and joint infections including the importance of making an accurate diagnosis, the problems with antibiotic treatment and the future of antibiotics for bone and joint infections.

Microbiology of bone and joint infections Bone and joint infections become particularly problematic when prosthetic material is involved as this reduces the size of the inoculum needed to produce an infection.

Adherence of bacteria to the avascular prosthetic material and the formation of biofilms by the bacteria allows them to be overlooked by the bodyâ&#x20AC;&#x2122;s defense system. Biofilms are communities of bacteria that form on prosthetic material including heart valves, pacemakers, central venous and urinary catheters.

These biofilms result in the bacteria becoming much more resistant to antibiotics, it is estimated that the MIC of an organism in a biofilm is up to 1,000 higher than the planktonic form. The organisms in biofilms are less metabolically active and grow at a slower rate. This reduces uptake of the antibiotics1 while at the same time down regulating the expression of antibiotic targets making the organism more resistant to treatment. They are therefore often associated with treatment failure and recurrent infection when antibiotic treatment is stopped. They may also cause a delay in the

presentation of infection and surgery maybe the only way to remove them. Certain antibiotics such as Rifampicin have the ability to penetrate some biofilms.

The microbes involved in bone and joint infections are numerous. The most common being Gram positive organisms.

These include Staphylococci and Streptococci. Staphylococcus aureus (S.aureus) and Coagulase negative Staphylococci (CONS) account for the majority of prosthetic joint infections (PJIâ&#x20AC;&#x2122;s). Staphylococcus aureus is a highly virulent pathogen which often causes acute early onset infections. Coagulase negative Staphylococci are skin commensals and are therefore much more indolent. Infections with this organism may not become apparent until weeks or months later.

Other Gram positive organisms which commonly cause infections include Streptococci and Enterococci which account for 10% of infections2. Gram negative organisms such as Escherichia coli are also capable of causing infections and more commonly cause early onset infection due to their virulent nature. Propionibacterium acnes is a Gram positive bacillus that is part of the normal human flora and has low virulence. It likes to live on the skin on the upper back and shoulders and therefore has a higher association with upper limb replacements compared to lower limb replacements.

It causes indolent infections similar to CONS.

Figure 1: Gram positive cocci: Staphylococci

Figure 2: Gram negative bacilli: coliforms

Diagnosis Culture remains the gold standard for Microbiological diagnosis.

Initially, a diagnostic preoperative arthrocentesis can be performed to enable appropriate antibiotic choice. Multiple, deep peri-prosthetic intra-operative samples (5-6)6 are required to enable true interpretation of the culture results. The bacterial load in these tissues is often low so sending more samples is more likely to yield a positive culture result7. Receiving multiple samples brings the false positive

rate down to <5% compared to 30% when a single sample is sent8. Atkins et al, has shown that the isolation of identical organisms from three or more of the 5/6 specimens sent is highly predictive of infection (Sensitivity 65%, Specificity 99.6%). When five specimens are sent, the chance of all samples being negative is only 1% compared to 3% when four samples are sent. A single positive result in isolation is of no diagnostic value7. Sonication of the implant >>

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HEALTHCARE ASSOCIATED INFECTIONS ARE A SERIOUS CAUSE OF MORBIDITY AND MORTALITY FOR AFFECTED PATIENTS AND THEY ARE A MAJOR SOURCE OF COST TO THE NHS.

itself helps to breakdown the biofilm and increase the culture rate (Sensitivity 78.5%)9.

Each specimen should be taken with a separate set of instruments and placed into a separate sterile universal. All specimens are cultured directly and placed into an enrichment broth8. Upper limb samples routinely receive 14 days at our institution compared to 7 days for lower limb due to the dominance of Propionibacterium in this area. To ensure that there is a chance of growing the causative pathogen the patient would ideally have had no antibiotics for the two weeks preceding the operation6, 8.

however varies from 50-86%13.

Using specific PCRâ&#x20AC;&#x2122;s can increase the sensitivity when used on sonicated fluid, in some cases up to 97%13. This technique does not provide information on antibiotic sensitivities12.

Treatment considerations The mainstay of treatment continues to be surgical intervention in combination with

antibiotics6. Extensive courses of antibiotics are required for periods of weeks to months.

The need for these long courses of antibiotics creates several concerns; the most significant of these is the development of anti-microbial resistance.

Exposing patients to prolonged courses of broad spectrum antibiotics selects out multiresistant organisms. This is not restricted to the UK alone but is a worldwide concern. The Department of Health set out

a UK five year Antimicrobial Resistance strategy 20132018 to tackle this threat14.

This highlights the importance of ensuring that appropriate samples are sent from patients at an early stage of their illness so that targeted narrow spectrum antibiotics are used. It is recommended that if patients are systemically well, treatment should be withheld until the culture results are available12.

This negates the need for broad spectrum empirical antibiotics. >>

MALDI-TOF (Matrix assisted Laser desorption ionization time of flight) is a new diagnostic technique that uses mass spectrometry in the identification of Micro-organisms.

Over 90% of isolates are identified to species level, 98% to genus level and <1% fail to identify10. It provides accurate and rapid identification of micro-organisms10, 11.

For some patients, who may have received antibiotics prior to samples being taken, the causative organism may fail to grow on both the direct plates and enrichment broth. In these culture negative cases, new molecular techniques may enable us to identify the responsible organism. This is a broad range Polymerase chain reaction based test targeting the 16s rRNA of the bacterial genome12 and is not reliant on the bacteria being alive. This is an option in patients who have clinical signs and symptoms of infection but are culture negative. Its sensitivity

Table 3: Occurrence of carbapenemase-producing Enterobacteriaceae in 38 European countries based on self-assessment by the national experts, March 2013. ECDC Technical report: Carbapenemase-producing bacteria in Europe: interim results from the EuSCAPE project

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THE DEVELOPMENT OF ANTIBIOTIC RESISTANCE WILL CONTINUE TO BE A CONCERN IN THE FUTURE AS BACTERIA CONTINUE TO MUTATE.

Of these emerging multi-drug resistant organisms, the most concerning are the carbapenemase producing enterobacteriaceae (CPE).

Enterobacteriaceae constitute part of the normal flora of the human gut and can be responsible for healthcare associated infections. Over the last decade, worldwide increasing resistance has been observed in Gram negative bacteria15, 16, initially with the development of extended spectrum beta lactamases (ESBL’s). Treatment options for these infections are limited and Carbapenems such as Meropenem are used to combat these more resistant infections. Carbapenems are a class of Beta lactam antibiotics that are very broad spectrum. Carbapenemases are enzymes produced by these resistant organisms that are capable of hydrolysing the Beta lactam side chain, rendering the antibiotic ineffective. Due to the increasing prevalence of these infections in countries such as Greece, Italy and India, more and more of these infections are being imported into the UK each year16. Care must be taken to identify these patients early with active surveillance, to slow the spread of these organisms and to ensure that they do not become endemic flora in our hospitals and operating theatres. Screening of high risk patients should be undertaken to help identify carriers of these organisms15, 16, 17.

The Future of antibiotics Between 1940 and 1970, there was a consistent increase in the development of new antibiotics. Subsequently, only three new systemic antibiotics have been discovered18. These include quinupristin-dalfopristin, linezolid and daptomycin.

Linezolid and daptomycin are from two new classes of antibiotics, the oxazolidinone and lipopeptides. These target Gram positive infections only and there are few new antibiotics targeting increasing Gram negative resistance.

Unfortunately, there is little incentive for the pharmaceutical industry to invest in the development of antibiotics as they generate little income. This is due to antibiotics being given for relatively short periods of time compared to drugs that are required daily for chronic illnesses19. We are at risk of reaching a stage where antibiotics are ineffective and simple infections such as urinary tract infections are untreatable. This highlights the importance of prudent antimicrobial prescribing to preserve our current antibiotics.

The Infectious Diseases Society of America has set up the 10 x ’20 initiative to develop 10 new antibiotics by the year 202020, as the rate at which bacteria are developing resistance far outweighs the development of new antimicrobials to combat this. New antibiotics that are being developed include Tedizolid and Ceftobiprole.

Summary The development of antibiotic resistance will continue to be a concern in the future as bacteria continue to mutate. Prudent anti-microbial prescribing will ensure that the antibiotics that we currently have will last longer, but this is dependent upon making an early accurate diagnosis so that the need for broad spectrum empirical antibiotics is eliminated. This relies on the appropriate samples being sent to Microbiology. Antimicrobial stewardship should be a top priority for all prescribers.

The need for development of new antibiotics cannot be emphasised strongly enough and there appears to be increasing worldwide recognition of this.

Gemma is an ST4 Trainee in Medical Microbiology currently based in Sheffield teaching hospitals NHS Foundation Trust.

She graduated from Medical school in 2008 and subsequently went on to get a Microbiology registrar post in 2010. Gemma has an interest in orthopaedic infections, having taken part in Orthopaedic ward rounds and attended Orthopaedic Infection conferences in both Oxford and Sheffield.

Rob is currently a Consultant Medical Microbiologist at Sheffield Teaching Hospitals NHS Foundation Trust. He is also an honorary clinical lecturer for both Sheffield Hallam University and the University of Sheffield. Rob’s main clinical interest area is orthopaedic infections. He is one of the main organisers of the annual

Orthopaedic Infections meetings held in Sheffield and is currently on the national working party, responsible for the production of national guidelines for the management of orthopaedic infections.

Correspondence Email: gemma.wheldon@sth.nhs.uk Email: rob.townsend@sth.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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Š 2015 British Orthopaedic Association

How Iâ&#x20AC;Ś Visualise a Fracture Fixation Bob Handley

Jack Nicklaus told me (via his book) to form a mental picture of a golf shot before playing it. When operating, I do the equivalent with a fracture fixation; visualise then do.

The initial image of the bone and the fracture is based on anatomy and the preoperative investigations. It is then refined as the reduction and fixation proceeds with direct inspection, palpation and fluoroscopy. The basic picture is in black and white, as the fracture fixation construct is built the picture is embellished with colour to represent what is happening mechanically.

The first AO course I attended included a presentation by Stefan Perren. What stayed in my mind was a physical demonstration of the function of screws and plates (Figure 1). Using an overhead projector and cross polarisers he showed in real time the stresses within a Perspex bone model. As plate and screws were applied there was a colourful illumination of the stress patterns within the material. This gave me a format to imagine what was happening in the operating theatre.

I visualise two types of loading of my construct. The static loading applied in theatre at the time of fixation and the dynamic loading which may occur planned or unplanned in the post-operative period.

Bob Handley

The work that is put into a screwdriver or hammer must go somewhere. Useful energy is

The construct can also be visualised as it may appear under post-operative conditions; likely points of failure imagined and addressed.

Figure 1: The function of screws and plates

often stored as potential energy or pre-load within the construct.

As components are tightened energy is stored within the implant or bone distorted within its elastic limits. The location of this stored energy can be imagined and visualised on an illuminated mental image (Figure 2).

Diagrammatic

Visualised

Compression Tension Figure 2: Fracture fixation construct

I find the imagined colour helps to identify the key areas in a construct where the greatest care needs to be taken. For instance one particular screw may be critical; therefore only insert this key screw once to protect its interface with the bone. A vulnerable area of bone may be identified and protected with a washer or plate.

A plate that needs to store energy should be contoured appropriately and mechanically be up to task.

Some may believe there are better things to imagine in an operating theatre but saving some of your RAM to visualise the mechanics of the task in hand is both constructive and educational.

Bob Handley is a Consultant Trauma and Orthopaedic Surgeon at John Radcliffe Hospital Oxford. He is incoming President of the Orthopaedic Trauma Society. He has worked in a seven day a week consultant delivered orthopaedic trauma service for 21 years.

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Wisepress Book Review BOOK OF THE QUARTER

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Individual chapters are devoted to topics such as acute pain management, the role of technological aids, prosthetic kinematics, alignment targets, unicompartmental arthroplasty, patellar resurfacing, outcome measures, and cost-effectiveness.

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In Memoriam

Frank Howard Beddow 8th May 1927 - 21st February 2015

Howard’s forebears hailed from Pembrokeshire; but he was born in Sheffield and as a young boy the family moved to Merseyside where he spent the rest of his life.

His early education was at Kingsmead and Birkenhead schools. He decided on medicine as a career qualifying at Liverpool University in 1950.

Having served in the army for National Service, he was attracted to orthopaedic surgery being fascinated by the anatomy of the human arm. He gained his MChOrth Degree with the Examiner’s Prize; and shortly after his Fellowship of the Edinburgh College in 1955.

Frank Howard Beddow

His first consultant post at age 34 was at Whiston Hospital and after

Robert Robins

7th August 1923 - 23rd February 2015 Robert Robins was educated at Gayhurst and Aldenham in Hertfordshire and studied medicine at Queen’s College Cambridge with his clinical years at St Bartholomew’s Hospital, qualifying in 1947.

After early training at Bart’s and Bath he spent his National Service as a Ship’s Surgeon in the merchant navy.

He returned to Bath in 1949 before being awarded the Luccock Research Fellowship in Newcastle where he began his life-long interest in Hand Surgery.

Robert Robins

He continued his training in Exeter until he was appointed as Consultant Orthopaedics and Trauma at the Royal Cornwall Hospital in 1961.

some years moved to the Royal Liverpool Infirmary as a surgeon and part-time lecturer at the University.

Howard had courage and perseverance in abundance.

When he was a young surgeon, his left femur developed an osteosarcoma necessitating in disarticulation at hip level. Some years later a large secondary tumour appeared in his chest which was removed. He returned to full duties in a few weeks. This was the measure of the man.

He continued with teaching and surgery until retirement at 65.

He developed an early interest in Rheumatology and continued his interest in all aspects of rheumatic diseases at the Royal Infirmary. He was a pioneer in the development of the Liverpool shoulder prosthesis and a founder member of the British Elbow and Shoulder Society. Nationally, he served

Robert contributed to many local and national committees serving on the executive committees of the British Orthopaedic Association between 1966 and 1967. He was an examiner for the FRCS(Orth) and represented hand surgery on the Presidential Board of Surgical Specialities RCS. Robert played an important part in the development of hand surgery in this country. He and a few other young surgeons formed a club which was brilliantly named “The Second Hand Club” as they were too young to join the “Hand Club”.

This was the real progenitor of the British Society for Surgery of the Hand (BSSH), which was formed by the merger of these two clubs in 1969 and which was open to any surgeon who was interested.

In 1979 he became President of BSSH. Robert also became Chairman of the Committee of Management for “The Hand” journal. In 1989 the journal became the Journal of Hand Surgery (British volume).

on the Council of the BOA. At home he was Vice President of the Liverpool Medical Institution and also contributed substantially to Health Board affairs.

Latterly he and his wife Ann were avid gardeners but most of all they enjoyed cruising in their narrow boat “Badger”. He was a religious man involved in local church activities. There are few of us that can emulate his achievements in the face of adversity.

He is survived by Ann and sister, Jean.

The full length obituary can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

Robbie was a very knowledgeable gardener creating an extensive garden at Perranarworthal that was often opened to the public for charitable events. He was keen follower of sport particularly cricket, being a member of the MCC. He supported many local arts and crafts institutions and was responsible for setting up three Morris Rings in Cambridge, Exeter and Cornwall.

He is survived by Shirley, his four children, nine grandchildren and one great grandchild.

The full length obituary can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

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In Memoriam

Anthony John Blakely Fogg 21st June 1950 - 19th March 2015

Tony was born and brought up in Wales and was proud of his Welsh heritage. He went to medical school at the Royal London qualifying in 1975, training in orthopaedics on the Royal National Orthopaedic rotation in London. He worked for some of the doyens of the orthopaedic world including George Bentley, Rolfe Birch, Lorden Trickey and Ernie Kirwan.

Anthony John Blakely Fogg

During his senior registrar training he sparred regularly with George Bentley about orthopaedics in general and his lack of publications in particular. Apparently it became something of a challenge to see if Tony could be appointed to a consultant post sans publications!

However, he did have a paper on shoulder instability (with another of his mentors Ian Bayley) accepted

by the (then) JBJS prior to his consultant appointment.

He arrived at Princess Margaret Hospital (now Great Western) in Swindon on the 1st April 1989.

Influenced by Ernie Kirwan and Michael Sullivan, he had developed a sub-speciality interest in spinal surgery. He quickly became clinical director of the orthopaedic department and was instrumental in its expansion. Despite being recognised as an outstanding spinal surgeon himself, he continued with general orthopaedic practice in the field of hip and knee surgery in particular, a rapidly disappearing breed in these days of super specialisation. He was an inspirational and supportive mentor. He was appointed as an examiner at the Royal College of Surgeons in London.

He took a somewhat greater interest in research, writing and publication as a consultant, writing book chapters and a number of papers on spine related subjects.

Tony was a passionate follower of all sports, and enjoyed nothing better than a day at the Arms Park roaring on the Welsh rugby team. He was a keen and proficient golfer playing regularly at Marlborough GC. He was interested in wine and had a fine collection of top vintages. He loved the theatre and travelling.

Despite all his achievements in orthopaedics and spinal surgery Tony was above all a family man. He was devoted to his wife Jane and children Ben, Jack and Anna.

Stephen Andrew Copeland 7th May 1946 - 10th April 2015

Stephen Copeland was a leader in Shoulder Surgery in the UK, Europe and the World for 30 years. He died at the age of 68 from a recurrence of malignancy after a non-Hodgkin’s Lymphoma first diagnosed in 1998.

In 1965 he went to Medical School at St Bartholomew’s (Bart’s) in London. He obtained his FRCS from the Royal College of Surgeons of England in 1974. His first shoulder paper on Scapulo-thoracic fusion for Facio-Scapulo-Humeral Dystrophy was published in the JBJS(Br) in 1978 and this remains a landmark paper.

Stephen Andrew Copeland

In 1979 Steve was appointed a Consultant Orthopaedic Surgeon with an interest in Paediatric Orthopaedics at the Royal

Berkshire Hospital at the age of 33. From 1994 Steve focused totally on Shoulder Surgery.

His Reading Shoulder Courses, started in 1984 became legendary. He was awarded the ABC travelling Fellowship 1982 and a Johnson & Johnson Travelling Fellowship in 1985.

He developed his own shoulder replacement – the Copeland Surface Replacement Shoulder Arthroplasty, published 58 referenced research papers; wrote four textbooks; 10 chapters in textbooks and a number of teaching videotapes and a CD-Rom. He was appointed President of the British Shoulder and Elbow Society (1995-7); President of the European Society for Shoulder and Elbow Surgery

from (1998-2000); and Chairman of the International Board of Shoulder and Elbow Surgery (2005-10). He was awarded the Sir Robert Jones Lecture in 2005 and retired from clinical practice in 2010.

He was a masterful teacher, an excellent but humble surgeon, a good friend and a true gentleman.

The full length obituary can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.

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Imprint

JTO: Information for readers, advertisers & potential authors

JTO Editorial Team l l l l l

Ian Winson (Editor) Ananda Nanu (Deputy Editor) Michael Foy (Medico-Legal Editor) Peter Smitham (Trainee Section Editor) Ian Stockley (Guest Editor)

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

l

l

l

l

l

BOA Elected Trustees l

l

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l

l

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

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

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 Assistant ............................Matthew Barker Policy & Programmes Assistant ..............................Kenni Akinloye Policy & Programmes Assistant .............................. Phoebe Jones

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

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

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Instructions for authors

Future publications

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

JTO is published quarterly.

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

We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 200 words and should include a photo. Feature articles and Peer-Review articles should be no longer than 1,500 words. Please be aware that the Editorial Team reserves the right to reduce the content where appropriate.

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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: Simon Fleming, Danny Ryan, Tom Cosker, Steve Mannion, Martin Holt, Anand Arya, Angus Wallace, Mike Foy, Bob Owen, Thomas Scott & Nicholas Barton

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

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