Journal of Trauma & Orthopaedics - Vol 2 / Iss 4

The journal OF the British Orthopaedic Association Volume 02 / Issue 04 / December 2014 boa.ac.uk

Inside

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

Our Features section includes articles about the importance of research and engaging juniors in T&O surgery

For the latest updates on our clinical issues, see our PeerReviewed Articles; the focus in this issue is the Spine

For some festive fun, gather your family around and head over to page 26!

News & Updates ––– Pages 02-14

Features ––– Pages 16-39

Peer-Reviewed Articles ––– Pages 40-50

Festive Quiz ––– Pages 26-27

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JTO News and Updates

From the new Editor – What’s the Agenda?

Contents

Ian Winson, BOA Vice President Elect Firstly I would like to thank Colin Howie for his time as Editor and for maintaining an extremely high standard. In the final issue of this year we look back at the BOA’s 2 day meeting in Brighton including reviews from various perspectives on pages 3 and 4. We welcome four new Trustees to the BOA who give you an insight into their lives on pages 8 and 9.

controversial article on adult spine deformity on pages 40-49.

Our second “How I Do…” piece submitted by a member of the Orthopaedic Trauma Society (OTS) follows these on page 50.

This issue has some excellent features including an article about the BOA’s plans for funding clinical research through the York Trials Unit by creating the BOA Orthopaedic Surgery Research Centre, on page 16. You will also read an article about how to engage juniors in T&O surgery on page 18.

Just for fun on pages 26-27 have a go at our quiz with your family over the festive period.

Benjamin Ellis from Arthritis Research UK has written an interesting piece about bridging the musculoskeletal measurement gap on page 24 and Phil Lewis from NHS Supply Chain updates us on procurement and performance data collection which you can read on page 20.

Our Medico-legal Editor, Mike Foy brings you two articles about knowing the limits of your competence and indemnity for treating NHS patients from page 36. Our trainee section this issue focuses on JCST guidelines which you can find on pages 34-35.

Our peer review section focuses on the spine, with thanks to our Guest Editor, Alistair Stirling. You will find a general interest piece on footdrop which is written as a debate between two orthopaedic surgeons, a scientific piece on chronic low back pain and a

We also pay tribute in this issue to two great men – John Fixsen and Louis Solomon who will be sorely missed (page 52).

The Agenda is that this is your BOA, your JTO. You want to tell your colleagues something, you want to challenge their thoughts and perceptions on issues that matter to us all in our professional lives - this is your voice, feel free to suggest things, gives us content, give us controversy ( jto@boa.ac.uk)!

Season’s Greetings.

JTO News and Updates

02–14

Letter to the Editor JTO Features

14 16–39

The BOA’s Research Plans Engaging Juniors in Trauma & Orthoaedic Surgery; Get ‘Em While They’re Young Informing the direction of orthopaedic procurement and performance data collection ABC Travelling Fellowship 2014 Bridging the Musculoskeletal Measurement Gap The JTO Festive Quiz Constructing Your Chambers Newer oral anticoagulants - their orthopaedic implications Meeting the JCST requirements for CCT in Trauma and Orthopaedics - the trainees’ perspective Providing Expert Reports: Knowing the Limits of your Competence Indemnity for treating NHS patients in the independent sector

Bookshelf

16 18 20 22 24 26 28 30 34 36 38

31

JTO Peer-Reviewed Articles 40–50

Debate Article: “Footdrop - Head and Heart” A potentially treatable cause of chronic low back pain Patient Safety in Adult Spinal Deformity Surgery How I ... Fix Tibial Plateau Fractures Percutaneously

40 44 48 50

In Memoriam

52

General information and instructions for authors

54

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JTO News and Updates

From the President Prof Colin Howie

Three months as BOA President and already the many issues around NHS reconfiguration and the financial impetus for change are impacting on our discipline. The necessity and obligation on all of us to ensure that we are actively engaged in shaping the decisions of colleagues, commissioners, and politicians as to the future direction of our care for patients is never more urgent.

Tim Briggs and my predecessors at the BOA have placed the organisation in a very strong position with respected views that are sought by clinicians and policy setters alike. Most recently, the Getting It Right First Time (GIRFT) report provided an objective, evidence based positive review of the quality and efficiency of orthopaedic services that can be used to inform and guide the future configuration and practice of elective surgery provision to complement the significant changes in our trauma network.

Prof Colin Howie

The major challenge for us in the year ahead is to ensure that we are not side-lined by the commissioning process. In excess of 20 major tenders for MSK services have been awarded, or are soon to be awarded, by CCGs totalling hundreds of millions of pounds. In some of these contracts the views and engagement of the profession has been sought, in others this has not been the case. The BOA has recently taken a far more active role in influencing the commissioning process through the development of clinical commissioning guidance documents, of which there are currently six, and are constantly reviewing active tenders, but there is a clear and present need for far

greater local clinical influence at the CCG coalface.

In January we will be holding a meeting of our Regional Advisers to support them to understand service planning and commissioning of MSK services. The BOA has worked hard to develop support strategies, however we need to engage our wider membership to ensure that we are involved in all MSK commissioning initiatives and that we are having a tangible impact on decisions. After the London meeting we hope to link up with more of you throughout the UK at subsequent regional meetings to focus on local issues and ensure that the BOA helps you influence local commissioning processes where possible. Where unfortunate bargains have already been struck we must ensure that our patients do not suffer unduly.

Our Quality Outcomes work (a.k.a. the registries work stream) will complement this in future. We also hope that by re-engaging locally through our Regional Advisers we will be increasingly involved in workforce planning, using the local evidence base to engage with LETBs. We became aware that many Staff and Associate Specialist (SAS) doctors were not members

of the BOA. This key group, who provide much valuable service, have been under represented for many years. Across membership categories, the BOA has had a year on year increase in membership for a number of years but, as with any membership organisation, a test of our success is to what extent our membership is a representative cross section of all our profession. Following a very successful session at the Brighton Congress we engaged in productive discussions with representatives of T&O SAS surgeons to develop the BOA and the support the BOA offers, such that (as their professional body) we meet the needs of this substantial group. SAS doctors will soon have a variety of incentives to join the BOA and I look forward to reporting on ever increasing numbers in our membership.

2015 will be a busy year, and then of course there is the General Election, the West Lothian Question, and the Rugby World Cup after the BOA meeting in Liverpool.

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Our Brighton Experience Dave Cloke, Orthopaedic Surgeon

I attended the Brighton BOA Congress this year with a degree of scepticism. I hadn’t been to the BOA for several years – then as a trainee in order to present a paper.

I recall the impressive trade exhibitions, but in honesty little else of substance.

However, the Congress appears to have undergone a sea change.

This time I attended primarily for the military session with Lord Dannatt as guest speaker, but overall the meeting gave me what I as a consultant want – discussion of important current issues – including commissioning, outcomes publication, changes in training, consultants contract, medico-legal issues, joint registries and more.

The Congress banner of “Managing Change” was true to its promise.

General Lord Richard Dannatt giving his Presidential Guest lecture

Lee Parker, Trainee

Sunshine, candyfloss, eminent guest speakers and military grandeur.

Where else but the Brighton BOA Annual Congress…?

efficient and patient-centred service as much as any other domain.

There was plenty for the trainee as well – specific sessions on changes to training, an exam session, instructional lectures, and an opportunity to hear regional trainee prize-winning presentations.

I particularly enjoyed the session on fracture clinic reform, hosted by the Orthopaedic Trauma Society.

This is an issue that I think tests our ability as professionals to deviate from tried and tested pathways in order to deliver a more streamlined,

Of course, the social and networking opportunities are never to be forgotten, but I felt that I came away from the BOA Congress better prepared to face the challenges facing our profession in the coming months and years. And all for free!

I shall book study leave early for Liverpool if the Congress has the same promise.

ideal opportunity to network with colleagues and visit some of the industry stands.

helping patients feel more informed about arthroplasty surgery. All of this and much more besides.

The second day began with a break-down of The Jackson Reforms into tackling the spiralling cost of clinical negligence litigation.

The NJR report was summarised and we heard how the NJR is

The BOA Congress remains a priority in my calendar and despite the success of our sub-specialist societies; it adds a little more “oomph” in a time when we as a specialty should be united.

morality of military conflict, on prehospital, field hospital and definitive trauma care with an emphasis on lessons learnt from the front-line.

There was something for everyone this year. Here are some of my top picks…

“The Consultant Contract” was a lively session - it was good to see the BMA’s negotiator fighting our corner and BOTA’s influence in galvanising the opinion of the delegates. “Managing Poor Performance” included presentations from the CQC, a case example of the transformation of a failing NHS Trust and The Royal College’s Invited Review Process. The symposium on training by IOS-UK was excellent and included sessions on how to pass the FRCS exam and choosing the right fellowship.

The first morning began with excellent talks on the law and

The end of the first day saw a live music drinks reception - an

>>

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JTO News and Updates

Judith Fitch, PLG Chair

Building on several years of work to further highlight the BOA Patient Liaison Group (PLG), this year’s BOA Congress included active participation by several members of the PLG. Four lay members were invited to present the patient perspective and were active in panels on: l Consultant Contract – Weng Ang l Surgeon Outcomes, Safety and

Good Practice – Judith Fitch l Spines Session Open Meeting – Judith Fitch l Managing Poor Performance – Bob Smith l Commissioning for Beginners – Josephine Fox As patient champions, we were delighted to be a part of these learned panels.

Along with our clinical colleagues Donald McBride and Phil Mitchell, the members also ran their own session on “What a patient should know before undergoing planned orthopaedic surgery”.

Phil Mitchell began this session presenting a surgeon’s perspective on a patient’s journey. After a summary of the Group’s updated guidance on “Expectations of Patients undergoing Planned Orthopaedic Surgery” (Weng Ang), members presented on “What was Missing” (Judith Fitch), “Tools and Support

Mamdouh Morgan, SAS Doctors’ Representative

Despite being the last session of the BOA Congress and on a Saturday, the SAS session was very well attended, and very well attended by SAS doctors. This is undoubtedly a reflection of a new era of trust in the BOA as our professional organisation.

Mamdouh Morgan speaks at the SAS session

A busy exhibition at the BOA Congress

for Orthopaedic Patients” (Josephine Fox) and the “Patient Journey and Experience” (Bob Smith). A very lively discussion on patient needs and expectations followed the presentations. We hope this is just the beginning of a continuing dialogue on patient needs.

with staff and our counterparts in other organisations that attended the Congress.

The PLG is honoured to participate at this level and we look forward to more opportunities to highlight and discuss the patient’s perspective at future events.

When members were not presenting, they took the opportunity to network

Professor Tim Briggs (BOA President) highlighted that only 200 SAS doctors are members of the BOA and the organisation aims to reach every SAS doctor in the country with an attractive membership package that supports career and educational needs.

Mr Mamdouh Morgan (Associate Postgraduate Dean for SAS doctors in West Midlands) explored the past, present and the future of the SAS doctors in the NHS with particular emphasis on the current barriers for career progression. He highlighted that every SAS doctor should be assessed and developed by a clear set of criteria guided by the BOA in order to avoid creation of a “lost tribe”. Furthermore, he suggested a “Career Progression Tier Model” as a career ladder for SAS doctors allowing for further enhancing career satisfaction and better patient care, therefore acting as a foundation for a future structure for SAS doctors.

Mr Hany Saleeb (Speciality Doctor) drew attention to what junior SAS doctors need from the BOA, including reasonable membership fees, SAS credential short term fellowships and an instructional course specifically for SAS doctors.

He also highlighted the fact that SAS doctors require the BOA to support clear guidance for session allocation and career progression.

The BOA committed to taking a leadership role in fostering the enhanced career progression for SAS doctors and ensuring SAS doctors are well represented in the organisation.

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JTO News and Updates

BOA Membership UKITE The BOA is pleased to announce the integration of UKITE into the BOA membership, thereby ensuring continued access to this assessment tool. UKITE is a national, online examination providing immediate results to trainees and allows practice for the ‘real’ FRCS T&O examination with similar formatted questions based on the UK T&O curriculum.

As well as UKITE, members receive the other benefits of their professional organisation including;

• Free attendance to the BOA Annual Congress • Inclusive reduced subscription to the Bone and Joint Journal • An annual membership handbook, including contact details of your peers • Reduced rates to the BOA training and educational events • Reduced rates for professional indemnity, personal insurance, air travel, and academic texts • Eligibility for Fellowships, Awards and Prizes • National leadership for excellence in Professional Practice, Training and Education, and Research.

UKITE is a powerful tool for selfassessment, if you are not currently a member of the BOA please complete the online application - www.boa.ac.uk/membership/ join-today.

New BOA Membership Following the BOA AGM in September we are pleased to announce that from January 2015 BOA membership will include medical students and foundation year doctors. The subscription rate for both will be £10 which will include online access to the

new Bone and Joint 360 but will exclude BOTA membership.

After a successful SAS session at the Brighton Congress, we now have a clearer idea on how the BOA can better meet the needs of SAS surgeons. In order to reflect the career structure of SAS surgeons we have devised a three tier subscription structure.

For more information on subscription rates and membership benefits please visit the BOA website www.boa.ac.uk/membership/ categories-and-subscriptions.

Inaugural BOA Simulation Award This year’s BOA Congress saw the inaugural “BOA Simulation Award” for excellence in innovation, simulation and technology. It aims to highlight the changing patterns of orthopaedic training and the importance of future technology to aid skill acquisition. Candidates shared their visions of a low cost simulator for T&O training.

The four finalists presented their simulators at the BOA Congress to high praise from the judging panel.

Kim Lammin receives award from Prof Tim Briggs

• Sam Heaton presented the “Royal London Hospital Non-Technical Skills Course”. A high fidelity simulator focusing on situational awareness, decision making, communication, teamwork and leadership. The first of its kind to cater specifically for orthopaedic surgeons.

• Maulik Gandhi exhibited the “Arthroscopic Skills Acquisition Tools” (ASATs). A low cost, reusable, accessible and easy-touse online arthroscopic simulator.

ASATs quantifies performance using objective measurements forming the basis of an assessment tool.

• Georgios Arealis showcased his below £50 arthroscopic stimulator

using a web camera and items from a hardware shop. The purpose is to improve triangulation skills and allow training in arthroscopy.

The final project is on YouTube as arthrostimulator.

• Kim Lammin and Ronnie Davis presented their “Orthopaedic Surgical Simulation App”. The app provides details of how to assemble and use easily available constituents to simulate operations.

The key steps of the procedure with prompts regarding anatomy, consent, and post-op instructions are included. The aim is for trainees to be able to download the App, construct the simulators, practice the operations and then undergo assessment.

Kim Lammin’s “Orthopaedic Surgical Simulation App” received the first prize from BOA President Professor Tim Briggs which included £500 towards further developing the project.

For further details of the simulators please contact the authors directly: samheaton@hotmail.com maulikjgandhi@gmail.com garealis@yahoo.gr klammin@hotmail.com

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JTO News and Updates

The New BOA Trustees (2015-2017) David Clark

Simon Donell the Nottingham rotation. During this period, I spent time out on fellowships in Auckland, New Zealand and also as an upper limb fellow in Wrightington.

My clinical interests has centred on the patellofemoral joint; following my fellowship with Henri Dejour in Lyon. I was Editor of The Knee journal, currently as Emeritus Editor, and thus on the Executive Committee of BASK becoming President from 2012 to 2014.

My family are originally from Derbyshire and I was delighted to be appointed as a Consultant Upper Limb Surgeon at the Derbyshire Royal Infirmary in October 2000. My interest in upper limb surgery was inspired after working for Angus Wallace and Lars Neumann in Nottingham and Peter Lunn in Derby.

David Clark

I would like to thank the BOA membership for supporting my application to serve on the BOA Council as an elected Trustee, where I hope to represent both the interests of the profession and our patients.

I trained in Sheffield and during that time took a year out to do a BMedSci in orthopaedics and bioengineering under the direction of Professor Tom Duckworth and Mr Mike Saleh, who cemented my interest and enthusiasm for orthopaedics. I undertook my SHO rotation in Leicester and Nottingham, before starting my higher surgical training in Trauma and Orthopaedics on

I have an interest in the organisation and management of orthopaedic services. As Clinical Director in Derby, I oversaw the planning and enlargement of the orthopaedic department when moving from the Derbyshire Royal Infirmary to the present Royal Derby Hospital site.

I went on to serve as Chairman of the British Orthopaedic Directors’ Society in 2012-2014 during which I sat on the BOA Council as an ex-officio member.

My other area of interest is in protecting and developing the apprenticeship training model we have in orthopaedics, and the importance of the continuity of care given by all levels of doctors, including SHO’s.

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

My research interests have been in drug and device clinical trials.

I was the Lead for the Injuries and Emergencies Local Specialty Group in the Norfolk and Suffolk Comprehensive Local Research Network.

Simon Donell

I went to University College London. I did my middle-grade training at Oxford, and senior registrar training on the Barts (now Percivall Pott) rotation.

I became Clinical Senior Lecturer at the Royal National Orthopaedic Hospital, and am now a Consultant at the Norfolk & Norwich Hospital.

I was on the European Committee of the BOA, following which we joined EFORT, and the Hyponatraemia Committee to counter a disparaging editorial in the BMJ. I was an ABC travelling fellow, a European Travelling Fellow, and Editorial Secretary for the BOA from 2000-2001.

I developed the Locomotion Module (which includes orthopaedics) for the Norwich Medical School. I was an Examiner for the Intercollegiate Speciality Examination and sat on the written paper committee.

I am currently on the Education Committee of ESSKA with an interest in certification of fellowships. I am currently involved in the BOA’s Basic Science updates at the Annual meeting.

My wife is a GP and I have four grown-up children. We live near Norwich and have a smallholding with alpacas and chickens; the former are field pets. We also have four cats; our house pets.

I look forward enormously to working as a BOA Trustee.

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Mike Reed

Mike Reed

As is customary I’ll introduce myself.

I’m a full time NHS surgeon working with trauma, hip and knee replacement and revision.

I trained in the Northern deanery, with fellowships in Auckland, and studied for my MD in Sheffield. I work in the beautiful North East of England, with my area catchment bordering Scotland, and am part of a great team in Northumbria.

I have a strong interest in training and education and, with others, have developed projects like the elogbook and the UKITE the annual trainee exam. I’m a

Fred Robinson programme director and Chair the Education Committee for the BOA.

surgeon covering everything from trauma through diabetes to ankle arthroplasty.

My research focuses on clinical outcomes and is based around infection, the NHS dataset, and the National Joint Registry. This has given me experience in the benefits of data, but perhaps more significantly its perils. As knowledge of our outcomes becomes more personal and widespread, I plan to help the Association in promoting meaningful statistics that describe our practice and outcomes.

To help that, I’ll be joining the National Musculoskeletal Health Data Group.

I was President of BOFAS in 2010/11, having been the chairman of the scientific committee for three years before this. I am still closely involved with BOFAS as a Trustee and helping to address the issues around surgical podiatry. I have recently been involved in drawing up guidelines on the treatment of the diabetic foot.

At a hospital level I’ve run improvement programmes in hip fracture care, infection prevention and enhanced recovery. I abandoned private practice in 2011 to instead consult on quality for several NHS trusts. That transition, although initially financially punishing, has allowed me to work with some great departments around the country, and pick up some sound ideas.

Fred Robinson

I’m married to Alex and have two children, Ben 9 and Anna 8. Like many of us, I struggle to get the time to spend with them.

I was born and brought up in Bristol. I started my medical training at the Middlesex Hospital.

I completed my training at the combined medical schools of University College and Middlesex in 1988. After finishing the Bart’s SHO rotation, I was a registrar and senior registrar in East Anglia.

Following a knee fellowship in Lyon, France and a foot and ankle fellowship in Dallas, Texas, I took up my consultant post at Addenbrooke’s Hospital in Cambridge in 1998.

I’m honoured to have been elected as a Trustee. I hope to serve the membership well and help progress the profession.

My clinical work has always focused on foot and ankle surgery, although I would consider myself a “general” foot and ankle

I have enjoyed being on the editorial board of the JBJS serving three years between 2005 and 2008. I have just started a second term with the BJJ. I have also enjoyed recommending papers for BJ360.

I live with my partner Jane, who works as a consultant anaesthetist in London. We have a 15 year-old son, Alex.

In my spare time I like to travel, watch opera and make a vague effort to keep fit. I am a keen skier, with varying degrees of success. Jane and I alternate winter meetings between the North Thames Anaesthetic Meeting in Tignes and the British Orthopaedic Study Group in Zurs.

I am proud and honoured to have been appointed as a BOA Trustee and look forward to serving you, the orthopaedic community, as best I am able.

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JTO News and Updates

Conference listing:

Organisation Conference/meeting BHS (British Hip Society) www.britishhipsociety.com

Annual Meeting 4-6 March 2015, London

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

Annual Conference 10-11 March 2015, Telford

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

Annual Meeting 12-13 March 2015, Liverpool

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

Annual Conference 18-20 March 2015, Bath

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

Annual Meeting 19-20 March 2015, Warwick

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

Annual Meeting 19-20 March 2015, Birmingham

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

Annual Meeting 21-23 April 2015, Sheffield

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

Spring Meeting 30 April - 1 May 2015, Bath

IOS (UK) (Indian Orthopaedic Society) www.indianorthopaedicsociety.org.uk

Annual Conference 3-4 July 2015, Liverpool

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

Annual Congress 15-18 September 2015, Liverpool

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

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JTO News and Updates

BOA Latest News T&O Undergraduate Syllabus The BOA Education Committee has developed a new syllabus for undergraduate Trauma & Orthopaedic education. It has been designed to reflect the needs of the current medical student who is likely to become a GP and less likely to become an orthopaedic trainee. It also reflects the reality of the time available and the exposure obtained. The syllabus is not intended to be prescriptive, but instead, used as a guide for the provision of teaching.

For more information please contact policy@boa.ac.uk and see www.boa.ac.uk/trainingeducation/undergraduate-project.

BOA Instructional Course 10-11 January 2015 Register Now! The BOA’s Annual Instructional Course is a highlight of our training and education calendar, bringing together trauma and orthopaedic trainees at all stages of their postgraduate training to prepare for their FRCS examination. There will be an exciting new format for the 2015 course with limited spaces, so make sure you don’t miss out on the chance to register! More details about the course and how to register can be found on our website – www.boa.ac.uk/events/instructional-course.

The BOA T&O Curriculum App is now available to download for all Android devices. The App is designed for trainees and trainers. It serves as an interactive quick-reference tool to the complete curriculum, featuring an easy-to-navigate copy of the syllabus. It contains useful tips and advice to make the most of the curriculum, along with many other topics.

The link for the application is: boa.ac.uk/to-app.

The Consultant Advisory Book has now been revised and is available for download on the BOA website.

The work has been led by Prof Joe Dias and the BOA Professional Practice Committee. It offers consultants a comprehensive guide to contemporary clinical issues and is aimed at helping all involved in developing, specifying, commissioning and delivering high quality trauma and orthopaedic surgery in the United Kingdom.

BOASTs

Commissioning Guidance Documents Further to our recently published guides on Subacromial Shoulder Pain and Low Back Pain, we have now published two new guides on Pain Arising from the Hip in Adults and Painful Osteoarthritis of the Knee. There are also two other guidance documents previously published that remain extant - Painful Tingling Fingers and Painful Deformed Great Toe in Adults. All of the documents are available for download from the BOA website - www.boa. ac.uk/pro-practice/commissioning-guidance-documents.

Trauma and Orthopaedics Curriculum App

Consultant Advisory Book

The Commissioning Guidance Documents aim to provide information to support commissioning rather than detailed guidelines on clinical matters. Members are encouraged to bring these guidance documents to the attention of colleagues so that they are used to inform local commissioning decisions.

Wikipaedics Wikipaedics will be an online revision aid for postgraduate orthopaedic surgical trainees, who are preparing for their FRCS (Trauma & Orthopaedics) examinations. Beyond serving as an online revision aid for trainees, we hope to develop the platform into an eLearning tool for the entire Trauma and Orthopaedic community, providing vital revalidation tools for consultants.

The majority of content for Wikipaedics is now being uploaded onto a staging site prior to launch of the full site in 2015.

Further to our recently published BOASTs on the Management of Traumatic Spinal Cord Injury and Fracture Liaison Services, we have now published a new BOAST on Compartment Syndrome, all of which can be found on the BOA website - www.boa.ac.uk/ publications/boa-standardsfor-trauma-boasts/. As well as copies being posted to members, laminated versions have been placed in operating theatres around the country. Several extant BOASTs are currently under review and will be re-issued in the near future.

Regional Advisers event BOA Regional Advisers will be meeting in London on 12th January 2015 to look at the current challenges in MSK commissioning and how the profession can best influence local CCG decisions through our regional structure supported by the BOA staff. There will also be a series of local events across the country focusing on commissioning of MSK services and how best to work with Clinical Commissioning Groups to ensure the best long-term outcomes for patients.

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BOA’s Quality Outcomes programme launched Earlier this year the BOA approached NHS England to gain support for an initiative promoting new national audits and registries in trauma and orthopaedics, following the establishment of several such projects over the last few years. We were delighted to receive funding for two years to support this ‘Quality Outcomes’ workstream.

The work programme began with the scoping of current projects and identifying how best the BOA could support them. The specific projects we are working with are the British Spine Registry, National Ligament Registry, NonArthroplasty Hip Register, UK Knee Osteotomy Registry, and audits by the BSSH, BOFAS, BSCOS and BLRS. However, if you are involved in a new audit that isn’t mentioned here please let us know via Julia Trusler ( j.trusler@boa.ac.uk). We look forward to engaging with all members in the near future about the further plans on this initiative.

We would also like to thank John Timperley who oversaw the early stages of this work.

Hip Fracture Reviews Led by the BOA Trauma Group we have recently undertaken several invited hip fracture reviews, offering multi-disciplinary support to Trusts who have been identified as mortality outliers in the National Hip Fracture Database, with the aim of helping them improve their delivery of care. Should you or your Trust wish to learn more about a hip fracture review please contact policy@boa.ac.uk.

British 10K London Run There are still a limited number of places available for the British 10K London Run on Sunday 12th July 2015, for anyone interested in participating please contact Lauren Rich (l.rich@boa.ac.uk) for details.

For all of us seeking motivation to run, congratulations to Jane Leslie (BOA President 2005/06 Ian Leslie’s wife) who has recently become World Champion in her age group for the Olympic Distance Triathlon, won the European Triathlon Championships in Kitzbuhl in June, and won silver in the World Aquathon Championships in Edmonton.

Consultant Outcome Publication

Surgical Podiatry

Consultant Outcome Publication 2014 is now online at www.hqip.org.uk/ consultant-outcomes-publication.

As in 2013, activity and mortality data is provided with an indicator as to whether outcomes are in the expected range. Discussions with HQIP through the NJR Medical Advisory Committee have emphasised the case for the future publication of unit level outcomes constructed using individual surgeon data.

The BOA is actively involved in developing a coherent way forward for surgical podiatry training, this has included participation in the Health and Care Professions Council consultation into Standards for Podiatric Surgery, and (alongside BOFAS) engagement with Foot and Ankle Scotland, CMO Scotland, and NHS Education Scotland to get a forefoot training curriculum in place for Scotland from April 2015.

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JTO News and Updates & Letter to the Editor Section??????????????????

Emerging Leaders programme The BOA is preparing an Emerging Leaders Programme.

The programme will identify and support future leaders in Trauma and Orthopaedics through high calibre mentorship, training and support at ST5/6 level. If you are an ST5/6 trainee who would like to apply, or you are a senior clinician and would like to nominate an ST5/6 trainee for the programme, details can be found at http://boa. ac.uk/elp.

Professional Practice Committee Membership Recruitment The BOA’s Professional Practice Committee (PPC) is looking to recruit a member to take up position from February 2015 until February 2018. The PPC: • Develops a framework of standards with other members of the broader musculoskeletal clinical and allied health professional multi-disciplinary team.

• Reviews existing guidance, including Blue Books, and highlight gaps in coverage that need to be filled.

• Co-ordinates responses to public consultations where they relate to professional practice issues.

The full terms of reference of the PPC and further information can be found on the BOA website at www.boa.ac.uk/committee/ppc.

Letter to the Editor Dear Sir,

Re: The article by Grey Giddins and Ilana Langdon – JTO Vol 2 / Iss 3

I am very concerned at the failure to mention in primary treatment that the majority of Casualty Departments fail to control the primary reduction with a cast that prevents forearm rotation.

The commonest cause of wrist fractures is rotation and unless rotation is controlled post reduction, particularly with relation to the distal radio-ulnar joint, displacement is so common as to be almost inevitable.

Most operative stabilisation is undertaken because primary reduction and stabilisation was ineffective.

For decades we were able to adequately reduce distal radial fractures using finger trap suspension and haematoma block. Excellent anatomical alignment can be imaged while in finger trap suspension and an above elbow cast applied with

the wrist in supination to reduce the distal radio-ulnar joint.

Since Accident and Emergency Departments have been staffed by those who have not had extensive orthopaedic training this basic principle of reduction and stabilisation with plaster has been overlooked and as a result vast numbers of operative fixations are now undertaken which were not necessary 25 years ago.

It is time that trainees both in A&E and orthopaedics are taught the merits of finger trap suspension, haematoma block and above elbow cast at 90 degrees in supination. This simple alteration to clinical practice would greatly reduce the burden on trauma theatre time, the cost of vast numbers of implants, the cost of litigation for peripheral nerve injury (particularly the superficial branch of the radial nerve) and the incidence of chronic regional pain syndrome. It also has the advantage of stabilising the proximal row of the carpus.

I have been unable to find any reason why this simple tried and tested method of primary reduction and stabilisation of distal radius fractures (both Smith’s and Colles’) has fallen out of use. However, this article is very compelling in indicating the frequency with which complications arise in surgery and therefore the avoidance of surgery by excellent primary treatment should clearly be seen as a matter of great clinical and medico-legal urgency.

Gordon MacLellan FRCS

Response from the authors Dear Sir, We thank Mr MacLellan for his letter.

We completely agree that a good primary reduction and a well moulded backslab can hold many fractures avoiding the need for surgery. The pressures of the 4

hour wait often seem to lead to suboptimal reductions and plaster support. Improvement in this care can only be a positive step.

We are not aware of data that has shown than an above elbow backslab/plaster has been proven to be better than a well moulded below elbow plaster. The keys to success probably lie more in the attention to detail of the treating team rather than exactly what they do.

Grey Giddins, Ilana Langdon

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JTO Features

The BOA’s Research Plans Amar Rangan, BOA Research Committee Chair

It has been an exciting time for orthopaedic and trauma research, with a growing number of multi-centre clinical trials under way to generate high quality evidence to guide our practice.

The NHS Constitution 2013 states: “The NHS in England has a statutory responsibility to promote health and social care research funded by both commercial and non-commercial organisations”.

Research is therefore set to become core activity in the NHS. We have a number of initiatives in place to support this change and to drive wider engagement in research. Some key developments are summarised in this feature.

BOA Orthopaedic Surgery Research Centre (BOSRC)

In order to gain further momentum and harness the growing enthusiasm in clinical research, the BOA research funds have been re-allocated in a ‘pump priming’ fashion to establish the BOA Orthopaedic Surgery Research Centre (BOSRC) at the York Trials Unit, University of York.

This initiative should help attract substantial funding into T&O research and allow BOA members to access methodological support for research.

The BOSRC came into being on 1st July 2014, and has launched the following two initiatives that all BOA members can access: 1) CI course on 13th and 14th March 2015: A two-day course that is specific for T&O research, ideal for colleagues interested in becoming Chief Investigators / research leaders. Details of the course can be found at http://tinyurl.com/tandoevent.

Amar Rangan

2) Application for research support: BOSRC will help BOA members develop their research

ideas into grant applications and help run commissioned projects.

In order to be successful in research funding, the research question needs to convince the relevant funding body of its importance and relevance to the NHS. Not all ideas may come to fruition, but if you do have an idea you wish to explore, the form available at the following link needs to be completed and emailed to the BOSRC: www.york.ac.uk/healthsciences/ research/trials/bosrc.

The James Lind Alliance (JLA) Priority Setting Partnership (PSP)

The JLA-PSP is an effective method of identifying our research priorities. The process identifies and ranks top ten priorities for research in a given field. Funding bodies are more likely to be convinced of the need for research addressing these ranked topics.

There are currently two JLAPSPs being conducted. First is

by BASK in collaboration with BOA Research Committee, on early hip and knee OA. The second is by BESS in collaboration with BOA Research Committee, on surgery for shoulder pain. It is anticipated that both these processes will be completed in 2015, with clearly identified and ranked research priorities, which will help us construct a programme of research to address these questions.

Society of Academic and Research Surgery (SARS) Annual Meeting, 7-8 January 2015, Durham

The SARS annual meeting hosts surgical specialties involved in high quality research, with abstracts of papers presented at the meeting being published in the British Journal of Surgery. It also provides a forum for academic trainees and surgeons to interact with other surgical specialties.

For the first time, the BOA has been invited to participate in the SARS meeting. The BOA research committee has finalised the programme in conjunction with BORS and OTS. Surgeons and trainees with an interest in research and academia should find this forum particularly useful.

The final programme will be available on the SARS website www.surgicalresearch.org.uk/sarsannual-meeting/sars-2015.

Professor Amar Rangan is a Consultant Shoulder Surgeon and Clinical Professor at the James Cook University Hospital, Middlesbrough. He has considerable experience with clinical effectiveness and translational research and is committed to help enhance the UK T&O profile internationally by promoting high quality research.

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JTO Features

Engaging Juniors in Trauma & Orthopaedic Surgery; Get ‘Em While They’re Young Simon Fleming, Training Standards Committee Member, BOTA Education Representative

Nobody seems to want to be a surgeon anymore and it’s a cause for concern. There are many who will espouse the “we only want the best” and “surgery is a vocation” party line, but it is worse than that.

Surgical and T&O posts remain unfilled and even those who apply are of two minds about whether or not they really want to be a surgeon (Figure 1). Perhaps the wrong people are looking at this – those of us who are surgeons have already made that choice and thus can’t empathise with those who choose otherwise. We did the onerous ward years and the exams and came out the other side still wanting a T&O national training number. This isn’t concerned with the Centre for Workforce Intelligence1 suggesting a cap on NTNs. This is concerned with people not wanting one in the first place.

Simon Fleming

The trend is the slow decline in number of applicants and number of posts, with 512 applicants and 441 interviewed in 2014. There were 145 specialty training level 3 (ST3) T&O posts available in 2010-11, which fell to 121 in 2012-13, a 17 per cent decline and all the numbers are on a similar trend (Figure 2)1.

I think we should try to influence this before it is too late.

So why do passionate and interested medical students become disinterested and broken foundation and core trainees and what can be done about it?

Cleland et al from the University of Aberdeen, found that “medical school itself seems to influence career progression,” with each medical school having “a different profile of students’ career preferences on exit”2. But there’s more to it than simply recognising that young minds start to make adult life decisions early on. The work also identified that many students and junior doctors believe that being a surgeon is nothing but a life of sacrifice, misery, bullying, misogyny and worse. Cleland et al went on to say “It may be that today’s students are basing their perceptions of surgery on the messages from role models

from another generation, one raised with different expectations of medical school and practising medicine, and who are likely to be male [compared with the majority of medical students]”. I think the idea that work-life balance is impossible in surgery is based on old-fashioned values and it is the responsibility of all surgeons, of all levels, genders, ethnicities and sub-specialties to readdress the balance and reinforce that T&O surgery is hard work, but worth it!

How can we change things then?

The BMA’s career choices survey shows that quality of life appears to have been, and will increasingly be, the biggest factor in doctors’ career decisions. While interest in a particular specialty can initially influence career decisions, work/ life balance and limited variety/ pace within a specialty are the factors that most influenced cohort doctors’ reassessing their desired specialty, post graduation3. The prospect of improved quality of life is a fundamental factor to doctors choosing to relocate overseas4.

This is where we need to change the culture. We must engage with young, enthusiastic, idealistic students and show them that, apart from the getting older bit, nothing need change. We cannot recline in our rose tinted glasses and talk

about the good old days; it is not our junior’s fault they have come up through the ranks in an EWTR world.

Consultants and registrars that do engage with juniors must realise that they need to be inspirational; now, more than ever. We have medical students and foundation doctors who face the threat of a seven day working week, for the same or lower pay, more debt, a sub-consultant grade at the end of their training and certainly a perception that other specialties, especially general practice, are a quicker route to good pay and work:life balance.

Certainly the first step is to inspire, but not to romanticise. Yes, the work is hard, the life requires commitment and sometimes sacrifice, but it’s also hugely rewarding and the people you work with are some of the best, brightest and most enthusiastic people on the planet; a well organised and passionate surgeon can have their T&O cake and eat it.

These behaviours are epitomised

by BOTA Trainers of the Year and are what we should all aspire to – finding a learning opportunity in every situation, involving every member of their team, from the medical students up to the most senior of trainees and being open and approachable. Reviewing the nominations and characteristics of the winning trainer, Pete Bates of The Royal London, there are common themes:

Figure 1: Core Surgical Training Application behaviours. 25% of CST applicants apply to GP

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round, the odd workplace based assessment, a cup of coffee now and then, writing your own notes so the FY1 can get to theatres.

This shift in culture and perception, will be won inch by inch and it could start today.

Why should you influence your trainees now?

Because, in the future, they may not be there.

Figure 2: Vacancies, applicants and appointments to T&O ST3 positions in England from 2011-2013

• Make every opportunity a training opportunity; “In comparison to other trainers, he does not view teaching as a “sometime thing” when it suits them or in a specific clinic or session but an “all time thing”.

• Make time to train; “If I’m struggling, he does not take over from me. Instead, he stops me and explains why I am struggling, and then lets me correct it and overcome the struggle” • There’s more to training than technical skill; “He teaches all the facets of becoming a great surgeon…knowledge, technical skill, enthusiasm, compassion, approachability, teamwork, communication, patience and effective leadership” This is more than the “why are we losing our trainees”. This is the “what we can do about it”.

Each surgeon can make small changes and have a huge impact; the behaviors above work just as well with juniors as they do with registrars. Trainers must make time for their juniors, whether this is setting time aside during a busy ward round, list or clinic or outside of the usual office hours. Identify those who are struggling and support them, feedback to them, listen to them and then let them

show you what they’ve learnt.

A trauma meeting need not be a “grilling”, but a great learning tool for even the most junior trainee.

Convincing a core trainee that T&O is the way forward is akin to closing the stable door after the horse has bolted. The trick will be to engage with the real juniors: the medical students and the foundation doctors; arranging an SSC (Selected Study Component) is easily done with a little support. The British Orthopaedic Trainees Association is developing a toolkit, to help enthusiastic trainers engage in a meaningful, educational way, with medical students. This toolkit will be available online and on request and will be a road map for any enthusiastic trainer, student or institution to take a T&O SSC forward. It will contain guidance on learning outcomes, based on the new BOA T&O Undergraduate Syllabus, to assist the enthusiastic student “Outline the aetiology, pathophysiology and clinical presentations of common T&O conditions. Make a differential diagnosis and select the most appropriate initial investigations. Set priorities and

plan management of the critically injured patient”. More importantly, it will contain suggestions on particular learning and teaching strategies to enthuse and inspire those that have taken the first step, by opting for a SSC within our specialty. Equally, the passionate and pro-active BOTA Linkman network will be supported in engaging at a local level, offering career guidance and talks on whatever the local institution feels would best suit their students and trainees.

In addition, BOTA hopes to get their Linkmen to engage at a local level and are soon to produce a collection of truthful stories of how the committee got to where they are, warts and all. Students and junior trainees are less likely to be disillusioned and disheartened if they have realistic expectations of training and work but also the rewards it can offer.

My final thoughts: arguably, we have the most influence on the attitude of our juniors. We, as trainers, as the BOA and BOTA recognise, must engage and support our juniors from the get go. A little teaching, a daily ward

Simon Fleming is an Orthopaedic trainee on the Pott rotation and a keen educator. He is the educational representative for BOTA and has just begun his PhD in Medical Education. When not training or being trained he enjoys good food and better company.

References: 1. www.cfwi.org.uk/publications/ securing-the-future-workforcesupply-trauma-and-orthopaedicsurgery-stocktake/attachment.pdf 2. Cleland J, Johnston P, Anthony M, Khan N, Scott N. A survey of factors influencing career preference in new-entrant and exiting medical students from four UK medical schools. 23 July 2014. www.biomedcentral.com/14726920/14/151/abstract 3. Career choices: findings from BMA cohort studies, BMA, August 2012 (http://bma.org.uk/-/media/ files/pdfs/working%20for%20 change/negotiating%20for%20 the%20profession/workforce/ careerchoicescohortstudyreport.pdf) 4. Survey report on the future UK medical workforce: Career intentions, BMA, June 2012 (http://bma.org.uk/workingforchange/negotiating-for-theprofession/workforce/careerintentions-survey-2012)

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JTO Features

Informing the direction of orthopaedic procurement and performance data collection Phil Lewis, Clinical Trading Manager, NHS Supply Chain

Driving efficiencies that enable cost savings whilst maintaining high standards of care is one of the biggest levers for improvement within the NHS today. Individual departments within trusts are finding themselves in new territory that will now inevitably require a change in gear which will see clinicians utilising their product expertise to procure in more innovative ways that doesn’t compromise on quality or care.

One of the focus areas highlighted within the Procurement Strategy was the potential to leverage savings in orthopaedics. The complexity of the product area results in a clear requirement for clinicians to become involved in the procurement process; in addition, equally the complexity of the market and procurement law requires guidance from specialist procurement teams. Procurement partners, such as NHS Supply Chain are able to work closely with clinicians and trust procurement departments to facilitate effective decision making tailored to specific

Phil Lewis

requirements which has the potential to generate significant savings.

part of cost saving initiative or for improving patient safety.

Andrea Ramsey, Purchasing Manager at Mid Yorkshire Hospitals NHS Trust said, “NHS Supply Chain fully engaged with our orthopaedic consultants, theatre teams and procurement. The amount of support and assistance we received from NHS Supply Chain was excellent and was key to delivering the required clinical outcome resulting in overall cost reduction.”

In the next stage of development, NHS Supply Chain would like to invite orthopaedic clinicians to participate in a new orthopaedic group to share and develop best practice in orthopaedic procurement, product performance and the introduction of innovative products and services. The initial aims of the group will be to understand how national initiatives such as the NJR/QIPP pricing benchmark, the British Orthopaedic Association’s “Getting it Right First Time” (GIRFT) and new ODEP guidelines can be effectively implemented within EU

NHS Supply Chain’s orthopaedic team recognise that whilst savings are increasingly important, clinicians require assurance that products purchased perform to the high standards that they and their patients require. As such NHS Supply Chain has continued to invest in the collection of product performance evidence as shown by continuing to host the Orthopaedic Data Evaluation Panel (ODEP), which will soon expand to include knee procedure benchmarks. As well as being instrumental in creating the Beyond Compliance programme, ODEP promotes the introduction of innovation safely into the NHS thus supporting surgeons with introduction of new implants either as

procurement regulations. NHS Supply Chain also hope to work with clinicians to understand and share what evidence is available in addition to these initiatives, to allow informed decisions on clinical performance to be made.

To have your say in the purchasing of the right products at the right time, ensuring you have the opportunity to share your clinical expertise and have access to NHS Supply Chain’s Specialist Orthopaedic Procurement skills and expertise: simply email your name, role and trust details to consultationgroups@ supplychain.nhs.uk.

Phil Lewis has worked in the orthopaedic team since 2007 and is responsible for running the Orthopaedic Data Evaluation Panel and the Advisory Group for Beyond Compliance as well as the trading team at NHS Supply Chain.

Prior to a short consultancy spell at PaSA he spent nine years in manufacturing, predominantly within the fine chemical and microbiology industries, managing procurement of raw materials, finished goods and research technologies.

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NHS Supply Chain’s orthopaedic team recognise that whilst savings are increasingly important, clinicians require assurance that products purchased perform to the high standards that they and their patients require.

Note from the editor: It is fairly obvious that, following on from the recent Academy of Royal Colleges statement about need for clinical involvement in the delivery of efficient care and the evidence from the GIRFT exercise about the variations in costs to the health service of prostheses, we need to have a sense of how we obtain our equipment and implants. The problem is that any process of procurement should be aimed at reducing costs while maintaining an ability to exercise a degree of clinical freedom and avoid a “one size fits all� concept. It is slightly crazy that the same prosthesis should be sold for entirely different

amounts to different parts of the same organisation. On the other hand there are risks to mass purchasing and mass supply not least the danger of becoming overly bureaucratic and simply costing the service more in costs of a different variety. It seems fairly obvious that clinicians should be aware of the differing costs across the service and ask the question why is my unit and effectively therefore my patient being charged more than the unit up the road.

As such, if there is a process in place to look at these questions, it is up to clinicians to engage, get involved and make sure that decisions made are on the basis of efficiency and quality of care.

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JTO Features

ABC Travelling

Fellowship 2014 William Aston

For five weeks, seven Orthopaedic Surgeons, four from the UK, one from South Africa, Australia and New Zealand travelled the East Coast of America and Canada representing our National Orthopaedic Associations.

We visited 12 Premier Orthopaedic Centres, clocked up 122 hours 12 minutes travelling on planes, trains and automobiles, 5 am starts, lost one set of luggage, delivered 79 talks and listened to 30. Took in four baseball games, played 27 holes of golf, saw New York from the air, learnt to line dance, got wet under Niagara, gained a significant amount of weight, had one fellow’s birthday and missed several birthdays of partners and children.

But most importantly made relationships in North America that will stand the test of time as well as six life-long friendships.

We met in London on the 23rd May and had dinner at the Royal Society of Medicine hosted by the BJJ and the BOA. Although some of the UK fellows had met

William Aston

each other before, this was our first meeting with what were to become our travelling companions for the next five weeks.

At each destination an educational meeting took place, at which we were the guest speakers and spoke on a varied range of topics form pure research to education and training. We had submitted five talks each prior to departure, from which the hosts chose. We had the opportunity to spend time both in theatre and clinic, with colleagues in our own sub specialties and meet with the residents to get their views on training and education.

First stop Emory University School of Medicine, Atlanta hosted by Scott Boden president of the AOA. This was our first experience of what was expected of us and what was to come. Exceptional hospitality and incredible generosity not only in being treated as guests, but also in the amount of time both professional and personal that was devoted to social and academic exchanges.

We then travelled to Miami where we learnt about tissue harvesting and the Miami Stem Cell from Dr Eismont and Tom Temple. Then, onto Nashville with Ginger Holt; Memphis with Dr Terry Canale and Dr Jim Beatty. During which a special presentation was made to Dr Canale

by Mr Patil of a signed photograph.

Our next destination was Duke University with Dr Alman and played golf with Dr Jim Urbaniak before getting swept off our feet by Dr

Freddie Fu in Pittsburgh who seemed to be able to make anything happen!

Dr Scott Levin hosted us at the University of Pennsylvania, and Dr Jay Parvezi from the Rothman Institute looked after us in Philadelphia. Then, onto New York, at the Langone Hospital for Joint Diseases with Dr Joe Zuckerman and a whistle stop tour from Mr Achan of his fellowship stomping ground.

Boston saw us give our talks in the Ether Dome at the University of Harvard with Dr Harry Rubash and Dr David Ring, visit the home of the JBJS and tour the city on a Segway.

Then we crossed the border into Canada – first stop McMaster University with Dr Mohit Bhandari and Michelle Ghert where we were exposed to the power of Niagara

and evidence based medicine.

Montreal was our next stop for the AOA meeting where we were honoured guests and presented with our Fellowship certificates. Final stop Toronto, with Dr Albert Yee who taught us how to throw an axe.

Mr William Aston is a Consultant Joint Reconstruction and Sarcoma Surgeon at the Royal National Orthopaedic Hospital, Stanmore.

He undertook a fellowship in arthroplasty and sarcoma surgery with Dr Paul Stalley at the Royal Prince Alfred Hospital in Sydney, Australia. He has a particular interest in complex primary and revision hip and knee surgery and end stage limb salvage. Research interests include biological fixation of implants to bone and innovative ways to improve functional outcomes in limb salvage.

The ABC Fellows L-R: William Aston, Greg Firth, Brendan Coleman, Pramod Achan, Robert Ashford, Phong Tran, Sanjiv Patil

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JTO Features

Bridging the Musculoskeletal Measurement Gap Benjamin M Ellis, MB BS MSc MPH MRCP, Senior Clinical Policy Adviser, Arthritis Research UK Contributors: Ray Fitzpatrick, Dr Jonathan C Hill, Andrew Price

Painful musculoskeletal conditions are a leading cause of lost quality of life, work absence, and health and social care costs.

Each year, the NHS in England spends over ÂŁ5bn supporting and treating people living with these conditions. An ageing population, combined with rising levels of obesity and physical inactivity, is likely to dramatically increase the number of people whose lives are affected. As health services globally strive to achieve more with less, the relentless quest for better value demands that outcomes are measured, reported and improved at every opportunity.

Benjamin Ellis

The health burden for people with painful musculoskeletal conditions, such as arthritis and back pain, cannot be summarised with biomarkers or imaging. Patient reported outcome measures (PROMs), however, are well suited to this purpose. In many ways, musculoskeletal health care has led the way in measuring patient reported outcomes. In England, for example, Oxford Hip and Knee scores are routinely collected before and after joint replacement surgery and the data made available for academic, clinical and business analysis.

outpatient departments. Here too, measurement is needed to monitor health outcomes and thereby support quality improvement. In this context, it may not be practical to use a separate patient-reported outcome measure for each different condition that is seen.

Moreover, whereas PROMs for surgery have been before-after tools, people with long-term musculoskeletal conditions, which typically fluctuate in their impact over the short as well as the long term, need ways to monitor their health longitudinally over extended time periods.

However the majority of people receiving care for musculoskeletal conditions are not treated in secondary care and do not undergo surgery. Large numbers of people with a wide range of musculoskeletal problems attend their GP surgery, community physiotherapy or rheumatology

In July 2012, Arthritis Research UK hosted a musculoskeletal health community workshop, including representation from the British Orthopaedic Association, the British Society for Rheumatology, the Chartered Society of Physiotherapy and Royal College of General

Practitioners as well as people with arthritis from the Birmingham Arthritis Resource Centre and patient representative charities such as Arthritis Care and the National Rheumatoid Arthritis Society.

The decision by Arthritis Research UK to develop the Arthritis Research UK MusculoSkeletal Health Questionnaire (MSK-HQ) prompted this discussion within the musculoskeletal community.

Representatives were asked to consider how many different measures might be required to capture the musculoskeletal health of the diverse range of conditions seen in a typical clinic.

A consensus emerged that despite disease activity measures being by nature disease specific, many of the symptoms that patients with musculoskeletal conditions share are common between diseases.

Symptoms such as pain, stiffness and fatigue, along with health domains such as pain interference with work/daily routine, are arguably of prime concern and common to those affected by musculoskeletal conditions.

A combination of these could therefore best capture the impact of a musculoskeletal condition on an individual’s health. Another important point that emerged from the discussions was the notion that rather than being seen as yet another uni-dimensional outcome measure, evaluating the effect of a single intervention, the MSK-HQ should aim to be a broad multi-dimensional health status measure that captures and summarises the extent of symptoms and impact on common health domains over time.

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Symptoms such as pain, stiffness and fatigue, along with health domains such as pain interference with work/daily routine, are arguably of prime concern and common to those affected by musculoskeletal conditions.

The initial work to develop the candidate MSK-HQ instrument was led by Dr Jonathan Hill working with a team at the Arthritis Research UK Primary Care Unit at Keele University, and Professor Ray Fitzpatrick and Professor Andy Price at the University of Oxford. The aim was to identify the health domains that matter to patients with musculoskeletal conditions and design a valid, reliable and relatively brief tool that could be used by people with a wide range of musculoskeletal conditions to report their own health at various steps along diverse treatment pathways. Although the MSKHQ may be used alongside other scores, it was designed to produce meaningful data if used independently. Following an extensive literature review to derive a list of musculoskeletal health constructs, the list was refined and prioritised through successive qualitative interviews, patient focus groups and patient and stakeholder workshops.

The candidate MSK-HQ that emerged included fourteen questions alongside a further item quantifying physical activity (Figure 1).

The second phase of the work began in the spring of 2014.

Led by Professor Andy Price and Professor Ray Fitzpatrick at the University of Oxford and supported by joint funding from NHS England and Arthritis Research UK, this phase will examine how the MSK-HQ can be used in practice while at the same time further understanding its psychometric properties.

Three clinical settings will be investigated at a number of sites across England: people referred for orthopaedic surgery, individuals receiving treatment from community physiotherapy, and those attending rheumatology outpatient clinics with early inflammatory arthritis, including rheumatoid arthritis. A fourth arm of the pilot will employ qualitative methods to understand how managerial and commissioning decisions are affected by the availability of outcomes data from collection of the MSK-HQ. The results from phase two are due towards the end of 2015.

measure health gain attributable to the intervention. The MSKHQ will have a role in this, with achievement in particular domains helping to guide quality improvement. In many long-term conditions, such as diabetes or asthma, measurement is also used to guide treatment. This too is part of the vision for the MSKHQ. By capturing an overall rating of a person’s musculoskeletal health at any given time, the MSK-HQ enables patients and their clinicians to monitor progress over time and response to treatment. Considering individual components of the score, such as sleep quality or mood can allow particular aspects of musculoskeletal health to be addressed, ensuring a holistic approach to patient needs. As more people with long-term musculoskeletal conditions engage in an annual care planning process, the MSK-HQ may play an important role in supporting people to report their symptoms to their clinical team.

To date, PROMs have largely been used as summative measures, collected before and after a specific procedure to

Measurement of health status matters, because clinical data change behaviour for patients, clinicians, managers and policymakers. The routine and systematic use of outcome measures such as the MSK-HQ throughout musculoskeletal health services has the potential to empower patients, support clinical decision making, drive forward quality improvement and ensure that the best services are rewarded for their achievements. Accountability in the English NHS is through the

FIGURE 1 - Examples of health domains and symptoms included in the Arthritis Research UK MusculoSkeletal Health Questionnaire (MSK-HQ).

• Pain/stiffness • Walking ability • Washing/dressing • Physical activity • Interference with work or daily routine

• Interference with social activities and hobbies • Independence • Sleep • Fatigue

various outcomes frameworks, through the Outcomes Indicator Set for clinical commissioning groups and the NHS Outcomes Framework nationally. Currently, though outcomes of hip and knee surgery are included, there are substantial gaps which could be filled. The current phase of work on the MSK-HQ aims to see whether the MSK-HQ can address this measurement gap to provide data that the musculoskeletal community so desperately needs. Increasingly, services will be rewarded on the health benefits they deliver, as well as the activity they do. As with all measurement, there is always a risk of unintended consequences.

But the potential reward is great.

Benjamin Ellis is a consultant rheumatologist at Imperial College Healthcare, working part time as senior clinical policy adviser at Arthritis Research UK. In 2008, he undertook a two-year secondment to work as clinical advisor to the Chief Medical Officer, and subsequently completed his master of public health degree at John’s Hopkins. His interests include promoting a public health approach to musculoskeletal health, improving the extent and quality of musculoskeletal health data and developing systems to support self-management for people with long-term conditions.

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Festive Fun

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

Q1. What was the most lethal infectious disease of 1990?

Q7. What was the Mystery of Edwin Drood?

Q2. La Manege Enchante was the original French title of which children’s programme?

Q8. What piece of sports equipment is made from compressed biscuits of African sisal?

Q3. Take the year of 9/11 and multiply it by the number of symphonies Beethoven wrote and subtract the number of countries in South America.

Q9. What was former BOA President, Sir Henry Osmond-Clarke’s nickname?

Q4. Who is this former BOA President?

Q5. How are William Munny, Harry Callahan and Robert Kincaid linked?

Q6. What was Elvis Presley’s rank and serial number while serving in the military?

Q10. Who said ‘Experience is the teacher of all things’?

Q11. What is the most abundant metal on earth?

Q12. Which member of the BOA Executive is this Father Christmas?

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Q13. Which came first - the invention of the alcohol thermometer or the mercury thermometer?

Q21. What is the name of the Icelandic volcano which brought Europe’s air travel to a halt in 2010?

Q14. What honour did Sir Robert Jones receive in 1919?

Q22. How many stages are there in complete metamorphosis of insects, and name them?

Q15. Where did Sherlock Holmes keep his tobacco?

Q16. If you flew directly east from Bermuda what is the first land mass you reach?

Q17. What was former BOA President, Sydney Higgs’, middle name?

Q23. What year was “A History of the British Orthopaedic Association: The first seventy-five years” first published?

Q24. Who is this member of the BOA Executive?

Q18. George Lazenby is to 1 as Roger Moore is to…?

Q19. How many Shakespeare plays does the character Falstaff actually appear?

Q20. Who is this “wee” child who is on the BOA Executive?

Q25. What date was the British Orthopaedic Society formed?

(Answers on page 53)

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JTO Features

Constructing Your Chambers Ian Winson, BOA Vice President Elect & JTO Editor

In an era of extensive and rapid change in our practices trying to keep control of the environment in which we work is becoming an increasing problem. The change in the nature of independent practice adds to that complexity. It is clear that sole trader status leaves us open to being pressured in a variety of ways and can make that sector more complex.

One solution to this is to generate a collaborative structure which gives the opportunity for mutual support without being entirely dependent on a separate provider.

The following represents a personal view of our experience of setting up the equivalent of a set of chambers and maintaining them for now over fifteen years.

Setting out the rules

Ian Winson

There are obviously a variety of ways of establishing the core business. A set of chambers, or a clinic, best functions if a core group of consultants, with similar ideas, set out the structure at the start. There are a variety of legal entities which can be the basic structure; the two most commonly used being a Limited Liability Partnership or a Limited Company.

In truth there is not a great deal to choose between the two of them.

We chose to go down the company route as our impression at the time was that it gave us great flexibility in how we developed future activities. It is clear though that the key issues remain the same.

You must have both financial and legal advice right from the start as to how to structure the business. You have to have an agreement in principal as to how funds of the chambers are going to be divided. Options include all activities being equally divided by the partners through to everything (both earnings and expenses) being divided up on the basis of activity. The option we have found works best for us was to produce a company that charged us for the services it provided in proportion to our activities. Capital investment in the structure is outside these terms and is equally divided between the partners.

Obviously, this might not suit everybody, but the point is you have to have a set of rules that are agreed and put down in black and white. That should include how you agree to the inclusion of new partners, how the business runs on a day to day basis, who has responsibility for what, and how someone leaves the organisation.

If this is done thoroughly at the start then the default position if there is any sort of dispute is to go back to the rules and stick to them. It allows you to operate on the principal that any disputes go on behind closed doors. Regular scheduled meetings improve communication.

The Clinic These days the option of having to own a building labelled as “the clinic” is not the only option. The internet means that a chambers can exist and be based on one site or several sites. If there is an obvious opportunity to invest in a property so be it but

leasing has the appeal of the underlying infrastructure being the responsibility of the ‘landlord’, any rental agreement becomes a formal contract between two businesses and not involving individuals. This may address some of the issues brought up by the recent requirements of the competition commission. Clinical governance and audit activity can be included in company activities.

There does need to be a clear understanding of employment law but actually there are a variety companies who will contract to give advice. Getting one of them signed on at early stage is helpful. Most sets of chambers no matter what their structure will be covered by the rules that apply to small businesses.

Finally, looking for opportunities which generate income without any one of the partners having to work directly for it is possible and should be sought. All the partners gaining some form of financial benefit without individual effort always makes for a relaxed atmosphere!

Apart from being Vice President Elect of the BOA, current Editor of the JTO, and past President of EFAS and BOFAS Ian Winson has been Chairman of the Sports and Orthopaedic Clinic Bristol for the last 15 years. It is set up as a limited company and provides support services for 11 surgeons.

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JTO Features

Newer oral anticoagulants their orthopaedic implications Ian Sinha

The use of dabigatran, a thrombin inhibitor, and rivaroxaban, a factor Xa inhibitor has increased for the management of stroke prophylaxis in conditions such as atrial fibrillation and venous thromboembolism (see Figure for inhibition in the clotting cascade)1.

Common Clotting Cascade and Sites of Action of Modern Oral Anticoagulants

In contrast to warfarin, these anticoagulants do not require routine clinic monitoring, making them ideal for use in the community.

However, these drugs have distinct disadvantages in emergency/ urgent surgery. Firstly no reversal agent is available for these anticoagulants1.

Prothrombin complex concentrate has been demonstrated to reduce the anticoagulant effect of factor Xa inhibitors, but acts on the basis of replacement, as opposed to reversal; it has no such effect on dabigatran2.

Secondly the effect of these anticoagulants cannot be reliably quantified using routine coagulation

Ian Sinha

assays such as prothrombin time, activated partial thromboplastin time and thrombin time (which although may be abnormal in patients taking dabigatran or rivaroxaban, do not reliably assess drug concentration or bleeding risk), a problem in patients where no medication history can be taken, e.g. reduced Glasgow Coma Score (GCS) or abbreviated mental test score1. There have been reports of the use of plasma assays of dabigatran and rivaroxaban, to quantify their circulating plasma concentration (with levels equal to or less than 30ng/ml considered safe to proceed with urgent surgery with a high bleeding risk), but these are not yet widely available3.

In the UK, best practice guidelines recommend a 36 hour time limit from diagnosis of hip fractures to surgery4.

This proves particularly troublesome with dabigatran; current practice dictates that it, with a half-life of 1417h, must be stopped 48 hours prior to major surgical procedures; as dabigatran is predominantly renallyexcreted, this necessary time interval increases in patients with decreased renal function5. Haemodialysis has been demonstrated to be effective in removing circulating dabigatran in patients requiring emergency surgery, but emergency access to haemodialysis will be limited in many hospitals6.

As the use of these novel anticoagulants increases in prevalence, more orthopaedic units will be faced with fractured neck of femur patients regularly prescribed such drugs. In the absence of established reversal agents, the ability of hospitals to safely operate within the 36 hour time to surgery target is challenging.

For elective surgery patients, it is recommended that dabigatran must be discontinued at least 24-36 hours prior to surgery with a standard risk of bleeding; this increases to 48-72 hours for procedures with a high risk of bleeding or where haemostasis is vital7. As described earlier, in patients with renal impairment dabigatran excretion will be reduced and discontinuation will need to be commenced earlier pre-operatively.

Post-operatively, dabigatran should be restarted carefully as its anticoagulation effect is reestablished quickly. In patients with high risk of thromboembolic disease, alternative anticoagulation, such as low molecular weight heparin, should be considered for the first 72 hours after surgery before restarting dabigatran at the standard dose7.

We would highly recommend close liaison with haematologists, orthogeriatricians, and in relevant

cases, renal physicians and intensive care physicians when faced with elective and trauma patients on these new generation of oral anticoagulants to optimise their management and ensure patient safety.

Recommended reading: Breik O, Tadros R, Devitt P. Thrombin inhibitors: surgical considerations and pharmacology.

ANZ J Surg. 2013 Apr;83(4):215-21.

(Available via Royal College of Surgeons website: Members area, online journals)

Correspondence: Email: iansinha77@me.com References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

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JTO Bookshelf Section??????????????????

Wisepress Book Review Book of the Quarter Practical Shoulder Arthroscopy Author/s: Alexander, S; Neumann, L; Wallace, A ISBN: 9781903378601 Publication Date: 1st October 2014 Price: £65.00 A novel textbook describing current state-of-the-art shoulder arthroscopy. All authors are involved in a successful and established course on practical arthroscopy skills held twice yearly in the UK and this book is an extension of the course.

There are two sections within the book, the first of which covers instrumentation and the second covers applications.

NOW AVAILABLE

Essentials of Hand Surgery

Spinal Deformities: The Essentials

The Adult Hip

Author/s: Chung, K C ISBN: 9781907816321 Publication Date: 17th October 2014 Price: £90.00

Author/s: Heary, R F; Albert, T J ISBN: 9781604064117 Publication Date: 31st August 2014 Price: £82.00

Author/s: Clohisy, J C; Beaule, P E; Dellavalle, C ISBN: 9781451183931 Publication Date: 1st August 2014 Price: £172.00

A Manual of Orthopaedic Terminology Author/s: Nelson, F R T; Taliaferro Blauvelt, C ISBN: 9780323221580 Publication Date: 26th September 2014 Price: £43.99 + VAT

Master Techniques in Orthopaedic Surgery: The Elbow Author/s: Morrey, B F ISBN: 9781451173093 Publication Date: 1st September 2014 Price: £167.00

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Features

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JTO Features - Trainee Section

Meeting the JCST requirements for CCT in Trauma and Orthopaedics – the trainees’ perspective Lara Jayatilaka & Marcus Cope Contributors: Steven Kahane, Daniel Perry

The Speciality Advisory Committee (SAC) produced new training guidelines for the Joint Committee on Surgical Training (JCST), which were introduced towards the end of 2012 and covered areas such as clinical and operative experience, operative competency, research and quality improvement together with management and leadership1.

A minimum number of 1,800 operations (including assisting) over the period of training were set, as a requirement for the award of a CCT. Certain index procedures were identified and a minimum number (indicative numbers) were set that had to be achieved throughout the training programme (Figure 1).

These specific operations can only be recorded as ST-S (Supervised Trainer Scrubbed), ST-U (Supervisor

Trainer Unscrubbed but in theatre) or P (Performed) and must be supported by evidence from Work Based Assessments (WBAs) over a range of trainers and time periods.

We undertook an online survey of the British Orthopaedic Trainees Association (BOTA) membership to discover trainees’ opinions related to these additional requirements.

Carpal Tunnel Decompression

30

Knee (and simple) arthroscopic procedures

40

Total Knee Replacement

40

First Ray Surgery (Foot)

20

Total Hip Replacement

40

Compression Hip Screw for Intertrochanteric Fracture Neck of Femur

40

Hemiarthroplasty for Intracapsular Fracture Neck of Femur

40

Application of External Fixator

5

Operative Fixation of Weber A, B or C Fracture of Ankle

40

Tension Band Wiring (Patella or Olecranon)

10

Intramedullary Nailing for femoral or tibial shaft fractures

30

Tendon Repair (all types)

20

Figure 1: The primary procedures and their requisite number

Results 446 trainees responded (27.3%) which has previously been shown to be an expected response rate for electronic questionnaires.2 The majority of trainees were towards the end of their training programmes (38.1% ST7 or ST8) and from the London deanery closely followed by the Scottish deanery.

Three quarters (74.4%) of trainees either agreed or strongly agreed that achieving 1,800 cases is achievable during the training programme (Figure 2) and the majority felt that a combination of operative numbers and WBAs was the best way forward (Figure 3).

Lara Jayatilaka

Marcus Cope

Number Required (ST-S, ST-U or P)

Procedure

Less than a third (32.8%) of trainees thought that the new primary procedure numbers were achievable. First ray surgery numbers concerned trainees the most (60.5%) because of

the potential difficulties in being exposed to these cases. Nearly a third of trainees (29.8%) were not attending three operating lists a week affecting exposure to number of index procedures (the majority (96.6%) of trainees have been attending at least two clinics per week).

Over two thirds of trainees thought that training a junior is a skill required for consultant practice. As training a junior does not count towards the numbers for the primary procedures, 53% of trainees would no longer train a more junior colleague until they had met their targets.

A third of all trainees surveyed had index procedures that they had performed that were not counted because they were not performed during their training programme.

Nearly all (94.8%) trainees disagree that completing double the number of WBAs to 80 was beneficial.

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Discussion There will be differences in training according to placement location, the complexity of cases being undertaken and departmental preference for method of fixation.

Trainees do not always have the opportunity to pick their rotations, making it potentially unfair to set numbers and to tell trainees they must be responsible for their own training when they might not be able to influence it directly.

Working at a tertiary referral unit also influences exposure to cases that can be logged as ST-S, ST-U or P because there are often many complex revision cases. Whilst it is good for gaining experience of a revision practice, there is less scope for trainees to perform these operations.

In Wales, first ray surgeries have been classed as a procedure of limited clinical benefit and therefore are no longer available on the NHS hence opportunities to undertake such cases would be reduced. Carpal tunnel surgery is

occasionally performed in primary care, by plastic surgeons or even by nurse specialists.

Early specialisation, particularly in upper limb, makes some of the target numbers difficult to achieve in the generality of orthopaedics without compromising training in their chosen subspecialty. The structure of training can be a problem when the last two years of training concentrates on a particular sub-specialty. This has left many senior trainees lacking the required numbers in areas they do not intend to practice.

Training a more junior surgeon does not count towards the indicative numbers for primary procedures. Many trainees felt that it required more skill to deal with someone else’s complications.

They also felt that the ability to train is a standard skill for a consultant and so should be included.

Many trainees felt that it would be more beneficial to do a smaller number of WBAs and take time

Figure 3: Factors important to surgical competence

getting appropriate feedback rather than a larger number (80) with a disengaged trainer.

Whilst we applaud the further development and improvement of the standards for training, we believe they have been implemented too widely. Higher orthopaedic training takes six years and to introduce new hurdles for trainees at the end of their training is unfair, as trainees do not have the time left to be able to achieve the new number goals for the index operations. We suggest that the Primary WBAs should be implemented much more flexibly for senior trainees.

The majority of trainees will go on to practice trauma in their job plans hence achieving numbers for these primary procedures is relevant. It could be argued that elective index procedures should be themed for the trainee’s intended subspecialty; however, how many and what would be appropriate?

Conclusion

Figure 2: Results of a survey on achievable cases within a 72-month period

A more rounded approach is needed with a smaller number of well-executed WBAs from multiple trainers demonstrating progression, as well as key numbers achieved on relevant operations.

Concern remains that we are at risk of producing a new breed of consultant surgeon, complete with all the required paperwork but potentially incapable of doing the job, having spent the last few months gaining exposure for primary WBAs because of an imbalance in training in their programme early on; and less able to train the future generations of surgeons that will follow them.

Dr Lara Jayatilaka Core surgical trainee East Midlands North Orthopaedic SHO Royal Derby Hospital.

Mr Cope is a lower limb revision arthroplasty surgeon and Clinical Director at Southport and Ormskirk trust. Since 2013 he has been the Assigned Educational Supervisor at his Trust. He is passionate about training and was Mersey Orthopaedic Trainer of the Year in 2012.

References: 1. JCST website - www.jcst.org/ quality_assurance/cct_guidelines 2. The adequacy of response rates to online and paper surveys: what can be done? D D Nulty, Assessment & Evaluation in Higher Education, Vol. 33, No. 3, June 2008, 301–314

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JTO Medico-Legal Features

Providing Expert Reports: Knowing the Limits of your Competence Michael A Foy

A recent brief article in the BMJ provides food for thought for Orthopaedic surgeons who carry out expert witness work (Dyer, 2014)1. It concerns the case of a Consultant Psychiatrist who was felt, by the Medical Practitioners Tribunal, to have acted beyond his competence in preparing an expert report on a paramedics’ fitness to work.

Briefly, the Psychiatrist in question was instructed by solicitors in October 2011 to provide a report for the Health Professions Council on the fitness of a person to work as a paramedic. The paramedic had a personality disorder and PTSD. The doctor worked as a psychiatrist in a prison and specialised in learning disability.

His standing as an expert was challenged by the expert for the paramedic. It transpired that the only time he had worked in the field of general adult psychiatry was as an SHO. The tribunal concluded that he did not have

Michael A Foy

sufficient experience to act as an expert in this case and had misled those instructing him.

It was agreed that he was more than competent in his day to day practice at the prison. However, the Medical Practitioners Tribunal suspended his licence to practice for three months. They concluded that his behaviour amounted to,“misconduct which required a message to be sent to you and to the public that undertaking the duties of an expert witness is not a matter to be taken lightly”.

A number of references were made to the GMC guidelines on the duties of an expert witness (2013)2 and in particular paragraph 12 “You must only give expert testimony and opinions that are within your professional competence or about which you have relevant knowledge. If a particular question or issue falls outside your area of expertise you should either refuse to answer or answer to the best of your ability but make it clear that you consider the matter to be outside your competence”.

I recently attended Court in a “whiplash” claim where there were significant ongoing neck/shoulder girdle symptoms and more general pain issues. I was acting as an

expert witness for the defence and there was a Pain expert on each side. The “Orthopaedic/ Spinal” expert for the claimant was a Spinal Injuries Consultant.

It became clear during the trial that the Spinal Injuries Consultant didn’t have a great deal of day to day experience of managing patients with neck and shoulder girdle problems and was not a sensible choice of expert to act for the claimant. The Judge dismissed his evidence. As far as I am aware the matter was not taken any further. However it appears to me with the precedent set by the case discussed above it is only a matter of time before experts from other specialist areas find themselves before the Medical Practitioners Tribunal if they stray outside their areas of expertise.

The message to take from these cases is that it behoves all of us to ensure that we really are experts in the area that we are providing opinions on. If seriously challenged in Court it may not be sufficient to put forward an argument that we treated patients with back pain, shoulder problems, foot/ankle problems or whatever as an SHO but have not been actively involved in their management for a number of years.

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

References: 1. Dyer C (2014) Tribunal suspends doctor for acting as expert witness beyond his competence BMJ ; 348 : g4126 2. www.gmc-uk.org/static/ documents/content/Acting_as_ an_expert_witness.pdf

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Advertiser’s Content Section??????????????????

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JTO Medico-Legal Features

Indemnity for treating NHS patients in the independent sector Dan Howcroft

In years gone by, before Foundation trusts ISTC’s and “Any Qualified Provider”, the opportunity to undertake NHS waiting list initiative work was seen by many as an opportunity to supplement their NHS income without incurring the further costs of indemnity required in private practice. Patient choice has been seen as vitally important by successive governments for a number of years. There have been many reforms over the years to facilitate this, the latest being that of AQP.

Since April 2012 any provider can now provide NHS services if they meet the required standards and they will be paid a fixed fee (tariff).

This was started in a few specific initial priority areas, but the areas included are growing year on year.

In theory providers supplying excellent quality care will be more popular and therefore lower quality providers will improve in order for them to be able to compete. Of course whether this desired effect will be realised is yet to be determined1.

Historically it was straightforward to identify the “NHS patient” bringing with them the benefit of NHS indemnity provided by the Clinical Negligence Scheme for Trusts (CNST) on behalf of the NHS Litigation Authority (NHS LA).

Dan Howcroft

The purpose of this article is to highlight how these new ways in which NHS patients can receive care both in NHS hospitals and the private sector can impact on this previously seemingly straightforward arrangement.

The BMA have provided some helpful “clarification” on this issue2. Although the NHS LA has confirmed that nationally procured NHS contracts attract the benefit of CNST indemnity, locally arranged initiatives are not specifically covered. It is imperative to check the individual contract for each agreement prior to commencing any clinical work. Most indemnifiers base their subscription rates on the amount of money that is earned on “non-indemnified” patients. This means that if you are operating on “NHS patients” outside of your formal NHS employment contract which do not bring with them CNST indemnity and this represents a significant proportion of your additional income, then you may be operating without appropriate cover.

This may leave you personally liable for any potential litigation should it follow. The risk is not merely financial. The GMC imposes an obligation on all registered medical practitioners to have appropriate indemnity cover as highlighted in “Good Medical Practice” 3, paragraph 63:

“You must make sure you have adequate insurance or indemnity cover so that your patients will not be disadvantaged if they make a claim about the clinical care you have provided in the UK.” Given that Medical Defence Organisation’s base subscriptions on earnings (as a proxy for the number of patient interactions and therefore risk), surgeons need to ensure that they make accurate declarations of their earnings in respect of procedures and consultations that are not covered by the CNST. This can cut both ways – some surgeons may have declared income that was, in fact, derived from NHSindemnified procedures, and may be able to claim a refund of subscriptions. Others might have assumed that all consultations and procedures were covered

by NHS indemnity when in fact some were not, in which case additional subscriptions may be payable. For this reason, we would encourage all surgeons to double check their contracts and

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“You must make sure you have adequate insurance or indemnity cover so that your patients will not be disadvantaged if they make a claim about the clinical care you have provided in the UK.” ensure that they are clear about the indemnity arrangements for each patient seen.

What should you do?

the outset what the indemnity arrangements are for any NHS patient for whom you are providing care. The suggestion would be:

It is clear that the ways in which patients are able to receive NHS funded care are changing. It is much more difficult for surgeons to know where they stand regarding indemnity for these patients. The GMC, however, are less changeable. It is therefore important to be very clear at

• Ask for a contract before starting any work; • Make sure you understand the contract. This is often more difficult than it sounds.

If in doubt clarify indemnity arrangements with the contracting body or with your own indemnifier;

• Make sure your own MDO is kept up to speed on your working pattern.

Dan Howcroft is a member of the BOA Medicolegal Committee. He is also employed as a Medicolegal Adviser at the Medical Protection Society (MPS). Previously he was awarded a CCT in Trauma & Orthopaedics following completion of training on the Stoke/Oswestry training program.

References: 1. Understanding the reforms…

Choice and any qualified provider.

BMA (April 2013) 2. Private Practice – Medical indemnity for NHS-funded treatment in the independent sector. BMA http://bma.org.uk/ practical-support-at-work/privatepractice/medical-indemnity-in-theindependent-sector 3. Good Medical Practice (2013). GMC

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JTO Peer Reviewed Articles Section??????????????????

Debate Article: “Footdrop – Head and Heart” Editorial comment from Alistair Stirling

The developing tensions present between evidence based medicine (EBM) and expert consensus based medicine (ECBM) are encapsulated in the August BJJ editorials and specialty update. In the course of developing the care pathways for the National Pathfinder project on back and radicular pain significant debate occurred resulting in drop foot (and other significant motor radiculopathy) being included as a “red flag” requiring emergency referral. This pair of articles from two eminent spinal surgeons illustrates the conundrum. What would you choose for yourself and by inference for your patients?

Ashley Cole

Ashley Cole

Richard Nelson

Spinal surgical training is a combination of an appreciation of the scientific literature and an apprenticeship and therefore our management decisions are based partly on science and partly on what we have been taught, some of which is anecdotal – hence a debate of the scientific literature versus what some feel is the right thing to do. I hope the new generation of spinal surgeons will favour science over anecdote and look towards answering the questions that we still have no scientific answer for.

The only evaluation of the evidence for lumbar radicular weakness was by Lee et al.

(2012)1 and I was one of the authors. It concludes that we do not have enough information to determine whether surgery is beneficial for patients with lumbar radicular weakness and if so, what the optimal timing for surgery is. We have no accurate incidence of radicular weakness even in patients with radicular pain as mild, non-disabling weakness is common. Relatively mild weakness (MRC 4) may not be tolerated by some due to high physical demand and more severe weakness (MRC 2 or 3)

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© 2014 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 02, Issue 04, pages 40-42 Title: Debate Article: “Footdrop - Head and Heart” Authors: Ashley Cole & Richard Nelson

may be tolerated well in less active patients and of course, the muscles involved are also of different functional importance (L3 weakness is less well tolerated than L5 weakness).

Weakness may also be only apparent on activity rather than on clinical testing such as the patient who develops a dropfoot as they walk but have good power on clinical testing (‘stenotic drop-foot’). When studying this condition, different nerve roots are involved with different initial MRC grades and different mechanisms of compression with multiple potential confounding variables (age, pain, smoking, diabetes) all of which may influence conservative or surgical success rates. This may partly explain why our knowledge on this problem is less than ideal.

What do we know about lumbar radicular weakness?

• There is no conservative treatment that has shown any benefit for radicular weakness over simple observation.

• The evidence suggests that MRC grade <3 is associated with poor functional outcome.

Surgical decompression improves MRC grade to ≥3 in between 5080% with no benefit from surgical treatment over conservative treatment. Of course surgeons will tend to remember the patients who did well from their surgical treatment.

• Patients with milder weakness probably do better from both operative and non-operative management than those with

more severe weakness although the evidence is not conclusive.

• There is weak evidence that a longer duration of radicular weakness may reduce the chance of surgical benefit although this is probably after 2-3 months for more severe weakness and 6 months for milder weakness.

There is no evidence that early surgery is of any additional benefit.

• Older age may be a negative predictive factor but this is controversial.

• Patients with lumbar stenosis may be less likely to recover from surgery but this may be just a reflection of age.

• No studies have demonstrated smoking or diabetes to affect outcome although this needs further evaluation.

• Extruded and sequestrated disc protrusions are more likely to be associated with radicular weakness as is double crush of the same nerve root but these factors are not known to be related to the likelihood of recovery.

• Surgery for motor weakness from L2-4 is more likely to recover than for L5 or S1.

• There is conflicting evidence regarding the likelihood of recovery if the radicular weakness is accompanied by pain or not.

Intolerable pain at 2-3 months is likely to be the main indication for surgery.

• Most of the recovery after surgery occurs early and certainly within the first 6 months. There are a few reports of late recovery up to 2 years. Studies should probably report results at 6 months which will improve loss to follow-up rates.

• One report suggests improved motor recovery with the use of anti-adhesion gel (Oxiplex) and this needs further evaluation.

In summary, I don’t think anyone would suggest emergency surgery in patients with radicular weakness unless there is obvious progression. Similarly, there is no evidence to support surgery on the next available operating list (24-48 hours). However, patients should be carefully assessed by the GP or Emergency Doctor to ensure more widespread neurology or upper motor neurone signs are not present requiring emergency referral.

Given the anxiety that radicular weakness produces and that it may be the initial presentation of tumour or infection, the patient should be assessed by a spinal surgeon within 2 weeks ideally with an MRI scan already performed (and if not, it should be performed within 1-2 weeks following the assessment depending on the view of the spinal surgeon). It may be possible to provide this service in the local hospital otherwise referral should be made to the regional Spinal On-Call hospital.

Our primary duty is to the patient and we should only perform surgery where we are convinced that it will do more good than harm and even a nerve root decompression in a patient with radicular weakness has risks especially if the patient has no pain. In my opinion, the literature would support a conservative approach for 2-3 months in the majority of patients with radicular weakness. This would involve

engagement with the patient such that they understood that early surgery is of no additional benefit compared with observation.

Indications for early surgery would include progressive weakness and severe, noncontrollable pain. At 2 months a re-assessment should occur and the decision whether to proceed to surgery should depend on the severity of the pain and the disability caused by weakness.

Of course, any improvement in the symptoms may result in a further re-assessment at an agreed time in the future. If surgery is agreed then it should be given priority and performed within 4 weeks, ideally within 3 months of onset of the radicular weakness.

This is the best balance of the available evidence but that this debate still exists and the complexities involved suggests we should collect prospective data on these patients to finally resolve this continuing controversy, the associated legal battles and considerable continuing costs.

Richard Nelson “Mr X you’re an experienced spinal surgeon. What would you do if you were me?” …..

Two Sundays ago you woke with an unusual deep seated aching in your left buttock. Your natural reaction was to blame a game of tennis the previous day. Driving to work on Monday you found it strangely difficult to use the clutch pedal; stalling the car on a couple >>

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JTO Peer Reviewed Articles Journal of Trauma and Orthopaedics: Volume 02, Issue 04, pages 40-42 Title: Debate Article: “Footdrop - Head and Heart” Authors: Ashley Cole & Richard Nelson

of occasions. On Tuesday you noticed some altered sensation over the dorsum of your foot as you were putting on your socks.

By Wednesday it was clear that you had a profound left footdrop.

A discreet word with your radiology colleague led to a lumbar MRI scan early on Friday morning. At the end of your morning clinic you looked up your colleague’s report: “There is isolated L4/5 disc degeneration with loss of T2 signal and disc height. A large, left-sided, extruded disc fragment is extending into the lateral recess compressing the exiting L5 root”.

Over the weekend you come to appreciate how disabling a foot drop is. Walking on the flat takes twice the normal effort. Walking the dog over rough ground was quickly abandoned. Driving is very difficult; to be frank not safe. That master’s tennis tournament in three months’ time looks rather unlikely.

The next week you see Mr Ashley Cole, a proper academic spinal surgeon, accustomed to debating from the head. He explains that the principal indication for lumbar disc surgery (in the absence of cauda equina compression) is the persistence of intractable pain unresponsive to best conservative management. He points out that there is no compelling evidence in the medical literature that surgery for painless footdrop will improve the long-term outcome.

You decide to seek a second opinion from Mr Richard Nelson, a jobbing neurosurgeon, who paradoxically speaks from the heart rather than the head. He prefers

to approach the issue from a basic pathophysiological standpoint. He agrees that there are situations when a major motor radiculopathy is the result of axonal infarction and de-myelination, such that early decompression is unlikely to have any impact and the long term prognosis is poor. On the other hand his, personal experience is that many patients, even those with a complete footdrop, have a reversible axonal neurapraxia or an axonal conduction block which occurs at an ion channel level2.

For these patients, a lumbar microdiscectomy will accelerate both the rate of recovery of the neurological deficit and the ultimate extent of the recovery.

He cites the example of elite sportsmen recovering volitional muscle activation within 24 hours and thus avoiding secondary muscle atrophy.

Not content with bamboozling you with neurophysiological concepts, he mentions that analogy much beloved of spinal surgeons – ‘I’m squeezing your L5 root tightly between my thumb and forefinger. Would you like me to stop in the next few days, or carry on for several weeks until the peri-neural inflammatory response starts to settle and the autolysis of the disc fragment is beginning to occur?”

You discuss the situation with your wife that evening. The following afternoon you undergo an L4/5 microdiscectomy. Next morning you wake to discover that you can actively dorsiflex to grade 3+/5. Walking out to the car you cannot help but muse to yourself – ‘So much for evidencebased medicine; sometimes the

heart should rule the head!’ That master’s tennis tournament now seems within your reach.

Acknowledgements: RJN acknowledges the support and advice of Dr Nick Kane, Consultant Neurophysiologist, North Bristol NHS Trust, in managing patients with spinal and peripheral nerve entrapment.

Ashley Cole is a Consultant Orthopaedic Spinal Surgeon at Sheffield Children’s Hospital. He has been interested in radicular weakness since organising the BOA session on this subject at the 2010 meeting in Glasgow. This prompted the review article published in 2012 in the JBJS. Now as Chair of the Complex Spinal Surgery CRG and Vice Chair of the Trauma Programme of Care, he understands the importance of evidence based surgery and how this will become increasingly important to all spinal surgeons.

Richard Nelson joined the Neurosurgical Department at Frenchay Hospital, Bristol, in 1990 after training at the Wessex Neurological Centre in Southampton. As Chairman of the SAC and Vice President of the Society of British Neurological Surgeons (SBNS), he led the development of the neurosurgical curriculum, neurosurgical training programme and Neurosurgical National Selection centre. He is the current President of the SBNS. He specialises in vascular, skull base and spinal surgery.

Correspondence: Email: ashley.cole@sch.nhs.uk Email: richard.nelson@nbt.nhs.uk

References: 1. Lee SW, Sharma H, Cole AA. (2012). The management of weakness caused by lumbar and lumbosacral nerve root compression. [Review] Journal of Bone & Joint Surgery (Br); 94(11):1442-7.

2. Kaji, R. (2003), Physiology of conduction block in multifocal motor neuropathy and other demyelinating neuropathies.

Muscle Nerve, 27: 285–296.

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JTO Peer Reviewed Articles

A potentially treatable cause of chronic low back pain Editorial comment from Alistair Stirling

At this yearâ&#x20AC;&#x2122;s BritSpine Hanne Albertâ&#x20AC;&#x2122;s presentation on an infective potentially treatable cause for some back pain and the subsequent debate achieved the highest delegate evaluation.

If independently confirmed this would represent a very significant advance in the management of a major cause of disability.

She has kindly prĂŠcised her work on this in the following paper.

Similarly Phil Sell has crystallised the balancing points made in subsequent debate defining the current position.

Hanne Albert Chronic non-specific low back pain was the leading cause of disability in the Global Burden of Disease reports in 1990 and 2010 and is rarely reliably attributable to specific patho-anatomical causes.

Hanne Albert

Phil Sell

MRI scans in some patients with low back pain have identified characteristic changes in the vertebral bodies adjacent to the disc spaces. These were classified by Modic, an American radiologist. Type 1 changes are bone oedema and are commonly observed in, and closely correlate

with back pain. A recent systemic review showed a 46% prevalence for any type of Modic change in patients with non-specific low back pain as opposed to 6% in the general population. A positive association has also been found between Modic changes and non-specific low back pain with a mean odds ratio of 4.5.

Given the previously documented findings of positive bacterial culture in patients undergoing discectomy it was hypothesised that these changes might be due to bacterial infection.

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© 2014 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 02, Issue 04, pages 44-46 Title: A potentially treatable cause of chronic low back pain Authors: Hanne Albert & Phil Sell

An RCT was therefore designed to test the efficacy of antibiotics in patients with chronic low back pain (greater than six months duration) subsequent to a previous disc herniation and Modic type 1 changes (bone oedema). After randomisation patients received either 100 days of Augmentin in single or double dose or placebo and were assessed at baseline, the end of treatment and one year follow-up. 144 out of 162 patients were available for follow up at one year. There was a highly significant improvement in the antibiotic group in all recorded outcome measures: • disease-specific disability • lumbar pain • leg pain • constancy of pain • number of hours with pain last four weeks • global perceived health • EQ-5D thermometer • days with sick-leave • Magnetic Resonance Image (MRI) appearances Improvement continued from 100 days follow-up until 1-year follow-up.

There was also a trend towards a dose-response relationship with double dose antibiotics being more effective.

There have been a number of criticisms both of the study itself and the implications.

It has been suggested that the observed effect might be due to antibiotics inhibiting an inflammatory response rather than an antibacterial effect.

This seems unlikely given that

patient improvement did not occur until 6 to 8 weeks after commencing antibiotics. If the effect had been due to inhibition of inflammation this improvement should have occurred at a much earlier stage. In addition Amoxicillin only has a very minor anti-inflammatory effect.

It has also been suggested that this form of treatment unnecessarily exposes patients to risks of gastrointestinal complications. Firstly these were rare in this study, generally short-lived and not serious.

Secondly is anticipated that most of these patients will have had an adequate trial of the usual conservative methods of treatment including a functional restoration programme and the remaining available form of treatment would be surgical.

From this study it would seem antibiotics in this highly selected patient group are in the short term at least, as (if not more) effective and considerably less expensive than surgery.

To date the endurance of the treatment response has been maintained with few exceptions.

Complications are much less serious and less frequent than with surgery.

It has been implied that antibiotic prescription for this condition would encourage multiply resistant bacteria. In Denmark if the 50% of the 10,000 patients per annum who have a disc prolapse and develop Modic type 1 change received a double dose of antibiotics this would increase the national consumption by 1.5 tons per annum. This has to

be contrasted with the 98 tons per annum of penicillin used as prophylaxis for the 27 million pigs (each receiving 3.6g. over their lives) to “save the bacon”.

This paper has made many ask “should antibiotics be given for Low Back Pain?” which is similar to asking “Should surgery be done for Low Back Pain?”. The answer to both questions is “yes” in defined subgroups, who are likely to respond well. In the case of antibiotics, I propose that the defined subgroup is patients with chronic low back pain (> 6 months), a previous disc herniation, and Modic changes in the adjacent vertebrae to the previous herniated disc.

As yet however the surgical and scientific communities should maintain a tempered and objective response to these initial results recognising that much remains to be done. The clinical trial needs to be replicated in different settings and we are aware of several groups in Europe planning additional trials. The follow up study where MIC was explored, also suggested other antibiotics or combinations should be used instead of Amoxicillin.

In conclusion the efficacy of this possible method of treatment for a specific sub-group with back pain is still being defined. If confirmed would it be ethical not to offer antibiotics before offering surgery given that antibiotics are easier, less risky, with fewer sideeffects, possibly as effective, and substantially cheaper.

Which would you choose?

A note of caution Phil Sell

There are two studies, one on culture of organisms from material removed at surgery, the other a clinical trial of antibiotics for a specific sub-group of patients with back pain after sciatica.

They read well together and are complimentary side by side. They resonate with clinicians frustrated by the absence of identifiable pathology and effective treatments for many patients that they see in clinics.

The hypothesis flow like this 1) Modic One changes are caused by an infecting organism 2) A specific cause of back pain is Modic one changes after previous sciatica 3) Evidential ‘proof’ is provided by treatment of that specific group of patients with 100 days of antibiotics.

The work of the Leiden–Hague Spine Intervention Prognostic Study Group presented on the EUROSPINE podium 2013 an analysis of 263 patients from an RCT of sciatica. In contrast to their intuitive feeling, those with and those without vertebral end plate signal change reported disabling back pain in nearly the same proportion and so concluded that the signal change did not seem to be responsible for disabling back pain in patients with sciatica.

It is rare and potentially hazardous to change practice on a single trial regardless of the quality of that trial. Examples abound of harm >>

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JTO Peer Reviewed Articles Journal of Trauma and Orthopaedics: Volume 02, Issue 04, pages 44-46 Title: A potentially treatable cause of chronic low back pain Authors: Hanne Albert & Phil Sell

occurring particularly when media interest is high. One extreme example of this would be deaths and disability as a result of nonvaccination of children as a result of MMR ‘scare’. A consequence of this is a healthy sense of doubt with regard to any publication regardless of provenance.

This study is high quality and high integrity. I have no doubt

about the good intentions of all involved. There are some unusual features. The control group showed no improvement at all.

That is very unusual for a study of back pain.

There was rapid recruitment as a result of an invite to attend to patients previously treated at a single centre. The period of trial entry was short. This raises

questions about external validity that can only be established after further studies from other researchers.

study groups repeating the antibiotic trial and a change of practice should await that further evidence.

There seems to be a large treatment effect with regard to the statistical change in Roland Morris, it appears to be clinically significant too, but the minimal important change is poorly understood. The study does not report the standard deviation, so again, caution. Kovacs et al (2007) reported different MCIC according to baseline disability and in patients with more severe disability such as this study, with 15 or more, an MCIC ranging from 5.5-13.8 was considered clinically significant. It is only at one year that an average change of 8 is given.

Hanne Albert has worked as a full time researcher since 2000, first as an associate professor at Back Research Center at University of Southern Denmark. Clinical Research was her main focus area. Since 2013, she has been working as senior researcher at The Modic Clinic combining clinical work with patients with Modic changes.

It is an unusual study for chronic back pain as both groups were advised not to exercise.

In testing specimens obtained during surgery it is usual to have cross contamination controls.

This study did not have them, which is unusual. Whenever cross contamination controls are used they reveal high levels of Propionibacterium acnes in skin, drapes and air. It is surprising that this methodological error of the original Stirling 2002 Lancet article is repeated.

There are two main themes to this study and many other questions are raised for enquiring minds.

The study is high quality and must not be rejected because it challenges beliefs and for some is counter –intuitive. There are

Philip Sell was President of Eurospine 2014 and will finish the Presidential line as past president in October 2015.

Philip has a ‘Two Trust’ job with clinical sessions divided between University Hospitals of Leicester and Nottingham University Hospitals NHS Trusts. Philip has been President and Secretary of the British Association of Spine Surgeons, and has had active roles on the executive of the Society for Back Pain Research and the British Scoliosis Society.

He has over 40 peer reviewed publications on diverse topics related to spine and surgery of the spine. Philip is passionate about education and spreading the word of good practice regarding the latest developments and concepts within the fast developing speciality of spinal disorders.

Correspondence: Email: hanne.albert@galnet.dk Email: psell2.spine@tiscali.co.uk

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JTO Peer Reviewed Articles Section??????????????????

Patient Safety in Adult Spinal Deformity Surgery Editorial comment from Alistair Stirling

Current demographic changes mean there are now a higher number of patients with symptomatic adult deformity with increased expectations and a possibly unrealistic anticipation of what safely can be achieved. This article provides insight into the problems which may arise and what is currently being done to minimise these. Hopefully this may facilitate discussion between patients with a serendipitous finding of adult deformity and general orthopaedic surgeons about possible referral for a spinal deformity surgical opinion.

Ian Harding Spinal surgery to correct deformity in adults is a significant surgical challenge with frequent complications, many of which have significant patient and financial consequences.

Historically there has been a reluctance to embark upon surgery in the older population with spinal deformity, but modern medical and surgical techniques have improved patient safety and outcomes1,2. Surgical rates vary considerably depending on resource availability as well as patient/cultural demands. Patient safety is an absolute priority in all aspects of spinal deformity surgery, both adult and paediatric, and has recently been the subject of two educational seminars by the Scoliosis Research Society (SRS)3 â&#x20AC;&#x201C; an international organisation dedicated to the education, research and treatment of spinal deformity.

Ian Harding

Patient safety is especially pertinent in adult spinal deformity surgery as the complication rate is approximately 40%.4 The SRS collects data on the three

serious adverse outcomes of peri-operative death, blindness and neurological deficit. These are fortunately rare with most complications/re-operations occurring due to mechanical failure or infection.

The majority of deaths are of cardiac and respiratory origin, rising with age from 0.1% age 50-60 to 2.8% age 60-70 and 3.7% age 70-80.5 The prevalence of blindness in all spinal surgery is 0.094%6 and although not clearly defined does appear to be increased in adult deformity surgery. This is possibly due to prolonged surgery, blood loss and the need for low head positioning which should be avoided or limited as much as possible. The prognosis is dependent upon an early recognition, diagnosis and on whether there is a reversible cause.

Spinal cord injury has become much less common even in high risk groups with severe deformity because of the evolution of better neuro-monitoring techniques, such as evoked motor potentials, that provide sensitive real-time analysis of cord function. In a recent large

series the use of intraoperative monitoring and protocols reduced a potential (based on historical expectation) 3.1% incidence of neurological deficit to 0.13%.7 Patient safety algorithms continue to be developed to aid the surgeon intra-operatively in the event of monitoring abnormalities. A key requirement for monitoring is to maintain an adequate mean arterial pressure for that specific patient (which needs careful anaesthetic consideration) that is as low as possible to limit blood loss and transfusion requirement. Limiting blood loss is improved by better patient positioning, reduced operative time, minimally invasive surgery, local haemostatic agents (gelatin-thrombin matrix), systemic pharmacological agents (e.g. tranexamic acid) and cell saver8 and is in itself a key patient safety factor.

Thrombosis (and embolism) is much less common (1.09% deep vein thrombosis, 0.06% pulmonary embolism)9 than in hip surgery and appropriate prophylaxis requires individual and iterative consideration given the potential for continuing postoperative loss from raw fusion sites and the risk of compressive haematoma in the canal.

In contrast, deep infection is much more frequent (3-5%) than in primary hip surgery.10 Treatment can be difficult and it is usually preferable to keep metalwork in situ until fusion has occurred. Bacteriological culture is imperative. It is usually preferable to delay commencing antibiotics until positive cultures and sensitivities are available.

Given this background, an overriding consideration is whether any specific patient will see overall benefit from the intended surgical procedure.

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© 2014 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 02, Issue 04, pages 48-49 Title: Patient Safety in Adult Spinal Deformity Surgery Authors: Ian Harding

This is decided upon by careful history with particular attention to: • the location type and severity of pain and neurological symptoms and potential for improvement • the consequent disability, whether interfering with activities the patient needs to do, rather than would like to be able to do • whether there has been a trial of appropriate conservative modalities of treatment and the response to these Examination: • including assessment of usual coronal and sagittal spinal balance and spinal mobility • neurological assessment Imaging to include: • full length standing x-rays with stress views • MRI and CT with 3D reconstruction • DEXA scans (Severe osteoporosis may preclude any or many surgical options) • selective nerve root blocks to identify symptomatic areas of neural compromise The case should be presented to a multi-disciplinary team meeting with appropriate expertise taking into account the current presentation

Pre-operative images

and potential for future deterioration if left untreated, with second opinions being sought if necessary, the most important decision being whether or not to offer surgery at all.

If the patient has intimated that they might wish to consider surgery and it is concluded he/she might benefit, the patient safety algorithm starts with a clear explanation of the goals and risks involved to facilitate true informed consent. A systems based approach has been proposed to reduce peri-operative complications to patients in a true multidisciplinary environment11, an approach mimicked in many other centres when treating high risk patients12.

Specific surgical factors include careful pre-operative planning with particular attention to: • level selection • sagittal profile • whether or not an osteotomy should be performed • operative approach (anterior, posterior or combined – simultaneous or staged) • type of instrumentation • whether or not pelvic fixation technique is needed An increasingly common practice is to have a second senior

Post-operative images

surgeon performing surgery when the case is very complex, such as an osteotomy, potentially to reduce the risk of complications, although this has yet to be formally evaluated.

Better surgical techniques have led to improved deformity correction and fusion rates with reduced complications from sagittal or coronal imbalance, incomplete correction, failure of fusion (pseudarthrosis) and implant failure (breakage, loosening, migration).

Pseudarthrosis is more common in smokers and when there is marked residual sagittal imbalance/ malalignment. Careful surgical planning with attention to the sagittal plane and the specific techniques to be employed are therefore mandatory. Software is available to facilitate this and obtaining good sagittal alignment has subsequently been shown to improve patient outcomes13. However, the potentially better outcomes from osteotomies14, which have recently become more popular, expose the patient to an increased risk of pseudarthrosis, blood loss, and neurological deficit.

Solid implant fixation is a particular challenge in the elderly patient but becomes even more pertinent when the spine is destabilised by osteotomy and excellent fixation is required proximally and distally.

Modern pedicle screw systems, interbody cages, robotic positioning of screws, image guidance and specialised pelvic fixation15,16,17 facilitate this but it remains a challenge in thin patients with poor bone stock who may suffer with prominent metalwork and/or implant loosening. In patients with a low bone density, surgery may be inadvisable and although cement augmentation techniques and HA coated screws are now available; their potential improved efficacy is as yet unproven.

The biggest challenge in improving patient safety in adult deformity surgery is ensuring the comprehensive and accurate collection of data, including patient related outcomes and complication rates. The British Spine Registry18 is a growing resource which has been developed to improve patient safety and monitor the results of spinal surgery, which will hopefully define the most effective and safest interventions.

Currently data entry is voluntary and although surgical risk can never be eliminated hopefully complications will continue to be reduced by patient safety initiatives facilitated by integrated and improving multi-disciplinary working and the combined efforts of the spinal societies and spinal deformity surgeons.

Ian Harding is a Consultant Orthopaedic Surgeon in Bristol with a specialist interest in spinal deformity surgery. He completed his fellowship at the Institut Calot in France. Research interests include spinal sagittal alignment and disc degeneration.

Correspondence: Email: ian.harding@nbt.nhs.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Peer Reviewed Articles

How I … Fix Tibial Plateau Fractures Percutaneously Alex Trompeter

Certain fracture patterns of the tibial plateau lend themselves to being fixed using the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique, however careful case selection and planning is required in order to achieve optimum results.

Figure 1: (A-B) - Pre-operative planning

In a typical lateral plateau fracture (Figure 1A), the CT scan identifies the principal fracture lines and degree of joint comminution and depression and lets you plan exactly where to place your percutaneous incisions. I look for the anterior split (highlighted by the white arrow on the axial CT slice - Figure 1B) over which I make a stab incision well distal to the level of the articular fragment. The sagittal CT lets you know if the fragment is anterior, central or posterior and thus where to aim your instrument. The instrument needs to be small enough to ‘wiggle’ through the anterior split.

A traditional punch is too big.

I prefer a periosteal elevator or even a pair of scissors (Figure 2A – white arrow = depressed joint) – these are then used to lever the fragment up

and elevate the joint (Figure 2B) rather than punching it up.

It is not always possible to reduce significantly rotated fragments or highly comminuted fractures this way so be careful in selecting the right case.

Once the joint is reduced, the lateral split needs reducing using a lateral buttress plate. To do this percutaneously, a short oblique incision (3-4cm) is centred just above Gerdy’s tubercle, and a tunnel is made deep to the fascia of tibialis anterior to allow the plate to be slid in. The positioning of this skin incision is critical if the procedure is to be performed minimally invasively. Too distal or proximal and it will need extending, too vertical and it will not allow you to access the anterior and posterior screw holes of the plate without extending the wound.

Figure 2: (A-B) - Intra-operative percutaneous plateau reduction

The post-operative radiograph (Figure 3A) and photographs (Figures 3B, C) highlight the incision placement and the return to a normal range of movements at just 3 weeks post operatively.

Alex Trompeter is a specialist complex trauma and limb reconstruction consultant working at St George’s hospital in London. This is a level 1 major trauma centre and tertiary referral centre for complex orthopaedic conditions.

Correspondence: Alex Trompeter

Email: alex.trompeter@stgeorges.nhs.uk

Figure 3: (A-C) - Post operative enhanced recovery

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In Memoriam

John Andrew Fixsen

22nd November 1934 - 14th August 2014

John Fixsen was brought up in Altrincham and excelled at Manchester Grammar School but before progressing to Magdelene

College, Cambridge to read Zoology, undertook National Service in The Royal Navy, where he learned Russian and worked as an interpreter.

At Cambridge he switched to Medicine and completed his clinical studies at The Middlesex Hospital where he was influenced

by Philip Newman and Rodney Sweetnam. He progressed to FRCS, MCh and senior registrar on the RNOH circuit.

John Andrew Fixen

In 1969 he was appointed consultant to St. Bartholomew’s Hospital and Queen Elizabeth Hospital, Hackney, which was later incorporated into Great Ormond Street Hospital. Other appointments included Civilian Consultant to the Royal Air

Louis Solomon

31st May 1928 - 19th August 2014 Prof Louis Solomon grew up in Keimoes, a tiny village in the remote North Western Province of South Africa. His parents were both of Jewish Russian descent, his father from Ireland and his mother a Glaswegian lady who instilled in him a lifelong love of art and literature.

He excelled academically and won a scholarship to study Medicine in Cape Town. While still a medical student, he met and married Joan, who was his constant companion for the next 66 years.

Louis Solomon

He elected to train as an Orthopaedic surgeon first at the Royal National Orthopaedic Hospital, Stanmore and

In memoriam

Force and Visiting Consultant to Gibraltar, Chailey and Tadworth.

At Barts his diverse practice included trauma, renal transplantation and bone tumours. However, it was through tireless work at Great Ormond Street and its associated hospitals that he gained his national and international reputation in children’s orthopaedics. Not only did he cover a general practice but accepted the most complex tertiary and quartenary cases.

He had a straightforward approach to orthopaedics, was always inclusive with his surgical team and supportive of colleagues requesting advice or ongoing care of difficult cases.

He was much in demand nationally and internationally as a teacher and speaker and a particular honour was The Robert Jones Lectureship (1994). He also served the British and European Children’s Orthopaedic Societies with distinction.

then the Massachusetts General Hospital, Boston working with Otto Au Franc. In 1962 he joined the newly formed Department of Orthopaedic Surgery at the University of the Witwatersrand. In 1968, at 40 years of age, he was appointed as the third professor and head of department at Wits University.

He was Chairman of the Bone Tumor Registry of South Africa, and was President of the Rheumatism and Arthritis Association. He was awarded the Robert Jones Medal by the BOA, and in 1982 he gave the Robert Jones lecture at the combined meeting of the English Speaking Orthopaedic Associations in Cape Town entitled “Peeling the Onion”.

He had an encyclopaedic knowledge of the literature and published widely in books and journals. He served the BOA as Editorial Secretary and the JBJS as a reviewer, Board Member 1982-85 and Associate Editor 1997-2011.

In 2002 he became medical adviser to Sandy Gall’s Afghanistan Appeal and, in visits over the next ten years, made a marked difference to the lives of many disabled Afghan children, not only through his excellent clinical skills but also by identifying local orthopaedic surgeons interested in paediatric cases. In 2010 he was made an Honorary Fellow of the BOA. Outside orthopaedics he was a voracious reader and rarely at a loss to discuss any subject. He was an active walker, a keen sailor and a stalwart of the British Orthopaedic Ski Club.

He will be sorely missed by his family, colleagues and countless patients.

the words of one of his distinguished protégés - Dr Anthony Hedley - who noted: “My mentor had an amazingly fertile mind, and not only was he intellectually superior, but he was also able to embrace all of the ideas emanating from the young minds around him, and to capitalise on them and to nurture them. Some of the happiest years of my life were spent under his tutelage”. High praise indeed, but richly deserved!

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

Louis had an encyclopaedic knowledge of Orthopaedic Surgery and was an inspirational teacher. His influence is perhaps best captured in

It is with great sadness that we report the death of Stuart Calder shortly before the JTO went to press.

A brave man who risked his life to save others, Stuart was a popular surgeon who will sorely missed by everyone who knew him.

Our thoughts are with his wife, Clare; his four children; his parents and his wider family and friends. A full obituary will appear in our next edition.

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Festive Quiz Answers 1.

2.

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6.

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8.

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10.

Pneumonia The Magic Roundabout 17,994 Sir Frank Holdsworth Movie characters played by Clint Eastwood Sergeant – 53310761 Final (unfinished) novel by Charles Dickens Dartboard Nobby Julius Caesar

11.

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16.

17.

18.

19.

Aluminium Ian Winson Alcohol KBE In the toe of a Persian slipper Morocco Limbrey 7 3 (Henry IV Pt 1, Henry IV Pt 2, Merry Wives of Windsor) 20. Colin Howie 21. Eyjafjallajökull

22.

23.

24.

25.

4 = Egg, Larva, Pupa, Adult 1993 David Limb 3 November 1894

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Imprint

JTO: Information for readers, advertisers & potential authors

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Ian Winson (Editor) Ananda Nanu (Deputy Editor) Michael Foy (Medico-legal Editor) Peter Smitham (Trainee Section Editor) Alistair Stirling (Guest Editor)

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

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Colin Howie (President) Tim Briggs (Immediate Past President) Tim Wilton (Vice President) Ian Winson (Vice President Elect) Ian Winson (Honorary Treasurer) David Limb (Honorary Secretary) Tony Hui​ Don McBride Ratakondla Ravikumar​ Martin Gargan Gordon Matthews Ananda Nanu Alistair Stirling R. Adam Brooks Grey Giddins Ian McNab Philip Mitchell

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

BOA Staff Executive Office Chief Executive.............Mike Kimmons CB Deputy CEO .............................. Kevin Hunt Personal Assistant to the Executive........................ Celia Jones Office Co-ordinator.....Natasha Wainwright Education Advisor ........ Lisa Hadfield-Law Programme Director - Quality Outcomes Workstream .......... Julia Trusler

Policy & Programmes Policy and Programmes Officer.................................Rayshum Notay JTO & Joint Action Officer........................................Lauren Rich Policy & Programmes Assistant ............................Matthew Barker

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

Marketing, Communications & Membership Marketing & Communications Officer ....................................Emma Storey Membership Administrator . ......................Leslie O’Leary

Events & Specialist Societies Head of Events ................... Hazel Choules Exhibition Manager ....................Janet Mills

Information Systems Information Systems Manager ..............................Melanie Knight Information Systems Assistant.................................Claire Wilson

Word Limit

How to subscribe

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.

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

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

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

These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title. An indication within the article should identify where the image should be inserted. The article should state a short title/caption for each image.

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

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

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

Instructions for authors 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.

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

Future publications JTO is published quarterly.

Please note all issues are free of charge.

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

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

Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations.

Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Sam Heaton, David Jones, Ian Learmonth, Ashley Blom and Shelley Scothorne.

Copyright Copyright© 2014 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820

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

Erratum The EFORT Congress review by Phil Mitchell in the last issue should have stated it was the 15th Congress not 14th.

Volume 02 / Issue 04 / December 2014

boa.ac.uk

Page 55

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Volume 02 / Issue 04 / December 2014

boa.ac.uk

Page 56

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