Journal of Trauma & Orthopaedics - Vol 2 / Iss 3 by British Orthopaedic Association

Volume 02 / Issue 03 / August 2014

ÂŠ Alison J Blake-Reed 2014

Inside Read the News and Updates section for the latest from the BOA and EFORT London l News & Updates -----Pages 02-18

Key papers on litigation and safety in T&O

-----Pages 32, 20, 22, 24, 25

Specialty Peer Reviewed Articles on common issues resulting in litigation l Peer Reviewed Articles -----Pages 40-56

*NICE conrms high rates of healing and cost savings with EXOGEN®

Approximately 10 Million adults smoke in the UK1 Smoking affects bone healing2 • Current smokers are 37% less likely to achieve union compared to non-smokers2 • Former smokers are 32% less likely to achieve union compared to non-smokers2 Count on EXOGEN • 86% non-union fracture heal rate4 • 38% faster healing of fresh fractures5,6 • 91% treatment compliance7 • 20-minute daily treatment • Unique ultrasound technology

Count on EXOGEN * The MTG12 guidance of the National Institute for Health and Care Excellence (NICE) – specic to EXOGEN – conrms high rates of healing and cost savings to NHS. The EXOGEN ultrasound bone healing system to treat long bone fractures with non-union is associated with an estimated cost saving of £1164 per patient compared with current management.

References: 1. Fact Sheets. (Oct 2013) ASH Action on smoking and health: http://www.ash.org.uk/information/facts-and-stats/fact-sheets 2. Castillo R, Bosse M, MacKenzie E, Patterson B, and the LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threating open tibia fractures. J. Orthopaedic Trauma. 2005; 19: 151-157 3. Ueng J. Trauma 1999 47(4) 752-759 4. Nolte PA, van der Krans A, Patka P, et al. Low-intensity pulsed ultrasound in the treatment of non-unions. J Trauma. 2001;51(4):693í703. 5. Heckman JD, Ryaby JP, McCabe J, et al. Acceleration of tibial fracture-healing by non-invasive, low intensity pulsed ultrasound. J Bone Joint Surg [Am]. 1994;76(1):26í34. 6. Kristiansen TK, Ryaby JP, McCabe J, et al. Accelerated healing of distal radial fractures with the useof specic, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebocontrolled study. J Bone Joint Surg [Am]. 1997;79(7):961í973. 7. As demonstrated in a non-union population of 101 patients. Schofer MD, Block JE, Aigner J, Schmelz A. Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskelet Disord. 2010;11(1):229 * The MTG12 guideline can be found at: http://guidance.nice.org.uk/mtg12 Issued January 2013. Summary of indications: EXOGEN is indicated for the non-invasive treatment of osseous defects (excluding vertebra and skull) that includes the treatment of delayed unions, non-unions†, stress fractures and joint fusion. EXOGEN is also indicated for the acceleration of fresh fracture heal time, repair following osteotomy, repair in bone transport procedures and repair in distraction osteogenesis procedures. † A non-union is considered to be established when the fracture site shows no visibly progressive signs of healing. There are no known contraindications for the EXOGEN device. Safety and effectiveness have not been established for individuals lacking skeletal maturity, pregnant or nursing women, patients with cardiac pacemakers, on fractures due to bone cancer, or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling at www.exogen.com. EXOGEN and the Bioventus logo are registered trademarks of Bioventus LLC. © 2014 Bioventus LLC

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 01

Welcome to the latest edition of the JTO

Contents

Colin Howie - BOA Vice President

The Trainee section this issue is written by its current Editor, Jeya Palan about the Shape of Training Report (SHoT) from a trainee’s viewpoint (page 22). More of this at our Brighton meeting.

In this issue we have focused on patient safety. At the recent London EFORT/BOA meeting, David Stanley presented “Today’s Challenges in Patient Safety” as his Sir Robert Jones Memorial Lecture, we enclose a summary of his excellent presentation on page 20. John Machin and Prof Tim Briggs present an extensive overview of litigation as it affects orthopaedics in the NHS on page 39. We have taken these two key articles as our theme and various Specialist Societies have added detail in the more specific areas of their practice. Generic issues relating to infection and consent are also covered. Nick Welch (Chair of the BOA Patient Liaison Group) gives us his view on patient safety, reminding us that care and safety is a culture not a tick box process (and the theme for the cover!).

We have introduced a “How I Do…” piece, which can be found on page 56. This is the first of a series of these articles submitted by members of the Orthopaedic Trauma Society (OTS). We also pay tribute to a really nice man and Past President of the BOA; Tony Ratliff who encompassed all the ideals we ascribe to (page 60). Alongside these articles you will find many news updates from the BOA and beyond.

We heard from our president, Prof Tim Briggs, on the “Getting it Right First Time” (GIRFT) initiative in the last edition. John Nolan from Norwich gives us his perspective of GIRFT following a recent visit from Prof Briggs (page 21).

Volume 02 / Issue 03 / August 2014

JTO News and Updates

02-18

JTO Features

20-38

The Sir Robert Jones Memorial Lecture 2014: ‘Today’s Challenge in Patient Safety – Caring Sharing and Innovating’_____________________________ 20 GIRFT: A Surgeon’s Perspective______________________ 21 Shape of Training and Patient Safety: A BOTA perspective_ _______________________________ 22 Training and tick boxes: a culture change is necessary________________________________ 24 Orthopaedic Practice and Consent___________________ 25 Litigation in trauma and orthopaedic surgery__________ 32

JTO Peer Reviewed Articles

Litigation claims following arthroscopic knee surgery_______________________________________ 39 Avoiding Litigation in the Treatment of Wrist Fractures___________________________________ 41 Shoulder Dislocations - Missed associated injuries_____ 44 Litigation in Paediatric Orthopaedic Management: _______ Common Errors and their Avoidance_ ________________ 46 Cauda Equina Syndrome – risk management__________ 49 TBGGGI (There but for the grace of God go I)__________ 51 Infected Arthroplasty________________________________ 52 Patient safety is more than delivering clinical standards, ticking boxes and following NICE Guidelines___________________________ 54 How I … Fix Medial Malleolar Fractures_______________ 56

Bookshelf

In Memoriam

General information and instructions for authors

Inside Read the News and Updates section for the latest from the BOA and EFORT London M News & Updates -----Pages 02-18

Key papers on litigation and safety in T&O

-----Pages 32, 20, 22, 24, 25

Specialty Peer Reviewed Articles on common issues resulting in litigation M Peer Reviewed Articles -----Pages 40-56

39-56

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 02

JTO News and Updates

My year as President Prof Tim Briggs Finally, I would like to encourage all members to consider standing for office in the BOA, whether as a Trustee, on a committee or as a Regional Advisor. The NHS faces unprecedented challenges and will need the backing and

It has been my privilege to act as the BOA President over the last year. As I look back, I am proud of what we have achieved as an organisation. The BOA is now truly engaged at the top table. I write this editorial having just returned from a very productive meeting with Lord Carter, the recently appointed ‘NHS procurement champion’. I also recently met with the Armed Forces Partnership Board, in relation to the Chavasse report that I published in July. In my final weeks as President I have a meeting with Simon Stevens, CEO of NHS England and Nick Seddon, the Number 10 Health Advisor. I hope all our members and

involvement of all our members through this; clinicians are the only group who can actually make a difference. Any non-BOA surgeons who read the JTO – I hope you can see the difference we are making and will consider supporting (or rejoining) the Association.

readers will be encouraged by this engagement at the highest level, and will be assured that the BOA provides a strong voice for T&O. I also remember the many trusts and health boards I have visited and people I have met. As part of the Getting it Right First Time project, I have visited 173 hospitals and travelled 15,000 miles meeting over 1,700 people. One of the strongest messages for me has been the engagement and enthusiasm from

Prof Tim Briggs

clinicians however there are striking variations in practice and some room for improvement in most areas which each and every one of us has a duty to achieve.

Last of all, may I thank everyone who has supported me during this past year and wish Colin Howie all the very best for his term as President.

See you in Brighton Join the BOA Annual Congress in Brighton 12-13 September 2014 Over 1,000 surgeons have now registered for BOA Annual Congress 2014. If you haven’t managed to register yet please secure your place at www.congress.boa.ac.uk. Please also view the latest programme on the Congress website. And if you are attending, remember to download the BOA App when you arrive for the Brighton Congress. Use the App to find your way around, preview the programme or check out exhibitors while you’re on the move and don’t forget to stop by the new BOA stand and meet the team.

Calling all SAS Doctors We will be running a session exclusively for SAS orthopaedic doctors on Saturday 13th September at 14:00. This session will be used specifically for SAS doctors to understand where we can help and engage, and to ensure that you feel valued and part of the MDT and orthopaedic family. We hope this will be an interactive session where we can discuss the way forward, listen to your concerns and stand shoulder to shoulder.

Prof Tim Briggs with Mike Kimmons and Julia Trusler at the new BOA Stand

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 03

JTO News and Updates

SAVE THE DATE BOA Annual Congress 2015 15-18 September Liverpool

Colin Howie: BOA President 2014-2015 Colin Howie is a Consultant Orthopaedic Surgeon in Edinburgh. Here he reflects on his task as BOA President 2014-2015. How do you follow Tim Briggs? Tim has been a powerhouse of enthusiasm travelling around the country driving the orthopaedic quality agenda. He has given us the information we need to move forward and the opportunities to make a difference. As incoming President I have plans in three broad themes: * Meaningful orthopaedic engagement and leadership at a local level

* Engaging and supporting the whole T&O workforce

The BOA 2015 Congress will take place at the award-winning ACC Liverpool. Located on the banks of the river Mersey, ACC Liverpool offers a world-class facility in a unique setting. Liverpool is a vibrant, modern city, proud of its rich heritage and renowned for its friendly people.

* Promoting quality and ensuring that the effectiveness of T&O is at the forefront. Focusing on these, alongside wider service changes, the forthcoming independence referendum (could I become the first “overseas” president?) and general election; proposed changes to training; consultant outcomes and new contracts; it will be a busy and important year.

Colin Howie

I look forward to the challenge and meeting many of you in Brighton.

We look forward to creating an exciting programme which will be based on the theme of Professionalism and Responsibility. Keep an eye on our Congress website for future updates – congress.boa.ac.uk.

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 04

JTO News and Updates

BOA honours remarkable members The BOA is pleased to announce the recipients of the 2014 Honorary Fellowship and Presidential Merit awards, which will be presented at the Brighton Congress.

Prof David Marsh Honorary Fellowship

David Marsh, now Emeritus Professor at University College London, advocated for the group of patients who were often overlooked and hence came off worst from the trauma services – those with fractured neck of femur. His idea and drive to establish the NHFD, in association with the British Geriatrics Society enabled the combined process, culminating in the introduction of a best practice tariff. This brought a fundamental change in the management and subsequently outcome of these cases, with decreased mortality and morbidity. In addition he is a successful ambassador for the Bone and Joint Decade and is President of the Fragility Fracture Network and the UK Arthritis and Musculoskeletal Alliance (ARMA).

John Callaghan Honorary Fellowship

John Callaghan was AAOS President in 2010. He is an orthopaedic surgeon specialising in joint arthroplasty and a Professor in the Department of Orthopaedics and Bioengineering, University of IOWA Carver College of Medicine. He has co-authored over 300 peer review articles and received many prestigious awards. He is particularly known for his work on the long term durability of various hip and knee implants and bearing surfaces.

In his time in Malawi his achievements included: · Establishing Beit CURE Hospital as a viable centre of excellence · Devising a local registrar training programme · Setting up Africa’s first national joint registry · Writing extensively on developing world orthopaedics and especially the impact of HIV on orthopaedics · Setting regional AO operating room staff courses He maintains a keen interest in developing world orthopaedics. He is the Africa Representative of the AO Socio Economic Committee, and more recently advisor and Task Force member in establishing the new AO Alliance Foundation (which will increase significantly development support for fracture care in Africa).

Prof Paul Gregg Honorary Fellowship

Professor Gregg is Emeritus Consultant Orthopaedic Surgeon at James Cook University Hospital Middlesbrough and Professor of Orthopaedic Surgical Science at the University of Durham, former President of the BOA and of the British Orthopaedic Research Society. He devoted years of commitment as Vice-Chairman of the NJR Steering Committee seeing it through some turbulent times. In addition, as a member of the Orthopaedic subgroup of NICE he has been very active on a number of issues for Orthopaedic patients. Under his presidency of the BOA in 2003, Council discussed and made the decision to have a patient liaison group which has been of such value to the BOA.

Mr Martyn J Parker Presidential Merit award

Prof Jim Harrison Presidential Merit award

Jim Harrison is a Consultant Orthopaedic Surgeon working currently in Chester. Previous to this he was Associate Professor in the Department of Surgery of the Malawi College of Medicine and senior consultant at the Beit CURE Hospital in Blantyre, Malawi. He was a founding member of this hospital, and along with Chris Lavy, oversaw the building of this institution. He stayed on as senior consultant and medical director for just over 10 years before returning to the UK.

Martyn Parker runs a nationally recognised hip fracture service in Peterborough. He was the second Hip Fracture Fellow at Peterborough and has since devoted his career to the care of patients with hip fractures. He personally treats many of all the hip fractures in Peterborough. He completed his doctorate, has published over 190 papers of which over 175 are on hip fracture, conducted the 24 Cochrane reviews on areas related to hip fractures and is the lead co-author in the standard textbook on the subject. He has been a member of the SIGN and NICE review teams for hip fractures, and continues to lead the world in evidence-based hip fracture management.

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 06

JTO News and Updates

14th EFORT Congress in association with the BOA London ExCeL 4th-6thJune, 2014 By Phil Mitchell, BOA Trustee

There are three reasons to attend major international conferences: 1. Academic 2. Social 3. Experience a new venue and culture The 14th EFORT ticked all three for me. From the 4th to 6th June 2014, thousands of people from all over the world including orthopaedic surgeons, trainees, medical students, allied health care professionals and members of Industry flocked to the London Docklands, Excel Centre for the annual 14th EFORT Congress in partnership with the British Orthopaedic Association. The conference theme this year was patient safety; highlighted in the opening session and integrated into many of the plenary and debating sessions. It was a scary thought that in 2002, a study estimated that 10% of patients were thought to have come to harm whilst receiving

Aerial view of the exhibition at EFORT

hospital care. The Wednesday afternoon symposium discussed wrong site surgery and antibiotic prophylaxis, and was a gentle reminder of how such errors and omissions can happen and how the WHO surgical checklist is now an integral part of surgeonsâ&#x20AC;&#x2122; practice. The BOA Presidential Guest Lecture was delivered by Lord Bernard Ribeiro CBE, who focussed on the challenge of reconfiguring health services in the 21st Century. The lecture was the precursor to the international healthcare session which included a panel of distinguished speakers, comprising leading experts in the international healthcare field as well as a high profile patient association leader. The session addressed the challenges facing healthcare

systems and orthopaedics around the world, with a specific focus on the impact of the ageing population and the imminent avalanche of demand for joint replacement surgery. Revalidation was a topic of much debate at EFORT this year. For the trainees, the BOA held a symposium on trauma revalidation, discussing among other things, intramedullary fixation of the humerus and the DRAFFT study for wrist fixation. The free paper sessions were of particular interest and discussed the importance of pain management in neck of femur patients and their optimal care pre and post operatively. The prestigious Robert Jones lecture was given on Friday by Mr David Stanley, and honoured the work and achievements of Sir Robert Jones. There were several courses being run during the congress including the advanced arthroplasty course which had excellent reviews and the Comprehensive Review Course, which was an all-day course on Thursday covering a wide range

Delegates at a bustling EFORT

of topics from abnormalities of the newborn foot to spine fractures. I particularly enjoyed the debate on cement vs. no cement in total hip arthroplasty. The BJJS held a session on the last day about what an editor seeks from a submission and research methodology, a must for all trainees. The annual poster and podium presentations represented high level quality research in all areas of orthopaedics and trauma. Nearly 1500 posters were presented during the congress. The trade show was a source of great interest. Revealing that our European colleagues use similar manufactured by different companies â&#x20AC;&#x201C; looking the same, but under different guises. I guess there are only so many ways that an uncemented hip can be manufactured. The whole experience was a tribute to the BOA and Steve Cannon especially, who was responsible for so much of the organisation. Looking forward to September in Brighton already!

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Literature: • Weber P, Jansson V. Teilwechsel an der Hüfte (Partial revision in THA), Orthopädische Nachrichten, 01/2014 • Woelfle JV, Fraitzl CR, Reichel H, Wernerus D.; Significantly Reduced Leg Length Discrepancy and Increased Femoral Offset by application of a Head-Neck adapter in Revision Total Hip Arthroplasty. J. Arthroplasty (2014) • Vaishya R, at al, Bioball universal modular neck adapter as asalvage for failed revision total hip arthroplasty. Indian J Orthop 2013; 47:519-22. • Helwig P, Konstantinidis L, Hirschmüller A, Bernstein A, Hauschild O, Südkamp P, Ochs BG. Modular sleeves with ceramic heads in isolated acetabular cup revision in younger patients- laboratory and experimental analysis of suitability and clinical outcomes. Inter Orthop (SICOT) (2013) 37:15-19 • Jack CM at al. The use of ceramic-on-ceramic bearings in isolated revision of the acetabulum component. Bone Joint J 2013,95-B:333-8

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 08

JTO News and Updates

BOA Latest News BOA Appointments It is our delight to announce the following appointments to key positions: 1. BOA President for 2016/17: Ian Winson 2. BOA Trustees for 2015-2017: David Clark, Simon Donell, Mike Reed, Fred Robinson 3. Medicolegal committee members: David Teanby, Don McBride, Peter Worlock 4. South Central North Regional Adviser/RSPA: Julian Flynn 5. Yorkshire and the Humber (East) Regional Adviser/RSPA: Sudhi Ankarath 6. BOA nomination to JCIE Intercollegiate Specialty Board for T&O: Raj Murali 7. SAS representative for Training Standards Committee and Education Committee: Mamdouh Morgan We are always grateful to those who take up these positions on behalf of the BOA. We also welcome members of the new BOTA committee appointed in June to their roles and look forward to working with them. The BOA would not work without your support.

Trials methodology support update We reported in the last issue of JTO that York Trials Unit has been awarded BOA funding for clinical trial methodology support, and this grant is now up and running. We encourage specialist societies with clinical trial ideas and anyone else with an interest in research to attend the Brighton session on research or visit their stand to find out more and get involved.

New BOA documents The BOA’s Patient Liaison Group with President Prof Tim Briggs and CEO Mike Kimmons

Milestone year for Patient Liaison Group The BOA’s Patient Liaison Group recently celebrated its 10th anniversary with a meeting attended by BOA President Tim Briggs. The BOA is pleased to see this group go from strength to strength, and encourages members and their patients to make use of the many expectations and information papers online at: www.boa.ac.uk/patient-information/plg The PLG has recently published and revised various papers including patient expectations and patient responsibilities about major trauma centres; the prevention of blood clots; patient understanding of hip and knee replacement; and information patients should know before orthopaedic intervention.

BOA response to bone cement media coverage JTO readers may have been aware of media coverage in June regarding use of bone cement in hip replacement surgery following a hip fracture. The British Orthopaedic Association, British Hip Society and Orthopaedic Trauma Society responded quickly with a joint position statement for surgeons and patients, available online at: www.boa.ac.uk/latestnews/boa-response-media-reports-regarding-usebone-cement. The summary of this position is that: 1. The evidence that the safe use of bone cement confers clinical advantage for the outcome of hip surgery after fracture of the hip is overwhelming 2. The National Institute for Health and Care Excellence (NICE) recommends the use of cement due to both improved clinical outcomes and reduced mortality at 30 days (guidance.nice.org. uk/cg124) 3. Over the past few years there has been a yearon-year reduction in mortality rates for patients treated for this condition.

BOA response to RCS report – Is access to surgery a postcode lottery? The Royal College of Surgeons, England released a report in July, ‘Is access to surgery a postcode lottery’ which suggests that patients across England are facing a postcode lottery as to whether or not they get some types of treatment. The British Orthopaedic Association and the British Hip Society released a joint statement as we were concerned by the findings of the report on variations in commissioning policies for surgical procedures including total hip replacement. The report and response are available online at www.boa.ac.uk/latest-news/boabhs-response-rcsreport-access-surgery-postcode-lottery. Our view is that total hip replacement is a highly cost effective procedure. Broadly speaking, the cost effectiveness of THR is £10 per week if it survives 10 years (of which there is a 95% probability) and £7.50 per week if it survives 15 years (of which there is an 85% probability). Early and appropriate surgical intervention results in better operative scores and outcomes, and patients risk unintended harm if referral is delayed.

At the time that JTO was going to press, several BOA documents were close to completion and are due to be published in the near future. These are: 1. New commissioning guide on subacromial shoulder pain 2. Updated version of commissioning guide on low back pain 3. BOASTs (BOA Standards for Trauma) on The Management of Traumatic Spinal Cord Injury and Diagnosis and Management of Compartment Syndrome of the Limbs 4. Consultant Advisory Book updated by the Professional Practice Committee 5. Peripheral neurovascular observations for acute limb compartment syndrome – a consensus guideline: jointly badged by Royal College of Nursing and the BOA Members will be notified when published and our website will be updated with the publications. The Chavasse Report has now been published and this can be found at www.thechavassereport. com. The GIRFT Report is scheduled to be published in September. For more information go to www. gettingitrightfirsttime.com.

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 09

Wider News & Developments Latest reports and policies

Kumar Das

MBE for BOA Member We are delighted to report that BOA member Dr Kumarendra Das has been awarded an MBE for services to trauma and orthopaedic surgery. Dr Das is an Associate Specialist in Trauma and Orthopaedics at Friarage Hospital in North Yorkshire. Prof Tim Briggs commended Dr Das on this achievement, commenting “It is a pleasure to see a trauma and orthopaedic surgeon being recognised in this way. We are particularly delighted to see such awards go to a BOA member, as it enhances the reputation of orthopaedics and underscores the excellent service commitment of our members.” Congratulations to Dr Das from all at the BOA.

JTO readers may be interested in the following recently released documents relevant to our profession. • The Department of Health has published a review of the workings of the payment by results scheme (the “tariff”): www.gov.uk/government/ publications/payment-byresults-costing-in-the-nhs • The Academy of Medical Royal Colleges has issued guidance on the issue of named consultants, ‘Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients’: www.aomrc.org.uk/ doc_download/9765-takingresponsibility In other news: Sarah Wollaston, the Conservative MP for Totnes and a former GP, has been elected as the new chair of the House of Commons Health Committee, succeeding Stephen Dorrell.

Consultant outcomes publication – 2014 As mentioned in the previous issue, the consultant outcomes publication initiative will this year cover not only hip and knee replacements, but also ankle, shoulder and elbow replacements – all based on data from the National Joint Registry. For more information about what will be published this year, you can view the Consultant Outcome Publication pages on the NJR website: www.njrcentre.org.uk. By the time this issue of the JTO is published, the data validation period will have closed, and the final data will be in preparation for the launch, which has now been brought forward to the end of September. During September, there will be an opportunity for surgeons to provide additional information in certain fields to accompany the publication of their results. All surgeons in scope for the initiative this year should note that there will be a limited window for providing this additional information and the BOA will keep members updated on this.

Success for MTCs as a significant reduction in mortality rates announced Figures released by the Trauma Audit and Research Network (TARN) have shown that since the introduction of regional Major Trauma Centres (MTCs), patients in England have a 30% greater chance of surviving severe injuries. Survival rates have improved as a result of patients with the most serious injuries being taken straight to specialist teams who have the knowledge to treat such injuries. Since their inception in 2012 the 25 MTCs across England have saved an estimated 600 extra lives, as well as helping thousands of patients to walk away from severe injuries without major disability. NHS England Chief Executive Simon Stevens has praised the performance of MTCs saying, “this is a major success story - more people are surviving serious injuries because they are taken straight to specialist trauma teams who identify life-threatening problems quicker and perform life-saving operations earlier. That’s about 600 fewer lives cut short, 600 fewer bereaved families.”

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 10

JTO News and Updates

BritSpine 2014 at the Warwick Arts Centre The Eighth BritSpine 1st-4th April saw 485 delegates attending three days of scientific sessions and the AGMs of the British Association Spinal Surgeons (BASS) and the United Kingdom Spine Societies’ Board (UKSSB). Twenty-one senior spinal trainees spent the day prior to the conference practicing spinal approaches and instrumentation on fresh frozen cadavers. The scientific sessions included 64 free papers and 90 posters. Six keynote lectures were delivered by the international faculty: Dr Jo Perra gave a fascinating insight into the correction techniques of cervicothoracic deformities; Prof Tapio Videman spoke on the apparent paradox of an increase in vertebral height when intervertebral discs degenerate; Prof Wilco Peul gave an account of his economic analysis of spinal surgery for spondylolisthesis and spinal stenosis and Dr Hanne Albert gave a moving account of her struggle to have the theory of bacterial infection in the bone adjacent to degenerative discs causing chronic low back pain, accepted. Mr Max Reinhardt, President of Depuy Synthes Spine, spoke about the interaction between implant companies and spinal surgeons, before joining a panel of industry executives and spinal surgeons for the first Spinal Industry Question Time. The main meeting closed following a lively debate between the supporters of Dr Albert’s theory of bacterial causes for chronic low back pain and those who remain sceptical. The first Public Meeting about the Spine brought together 58 patients, researchers, and clinicians to

discuss the way forward for spinal research. The BritSpine flame was handed to Nas Qureshi who is hosting BritSpine 2016 in Nottingham. Everyone with an interest in the spine is invited!

Industry Exhibition at BritSpine

BASK in Norwich Standards Institute, the MHRA, Tim Wilton on ODEP, and Keith Tucker on Beyond Compliance.

The combined meeting of the British Association for Surgery of the Knee (BASK) and the Arthroplasty Care Practitioners Association was held in Norwich on the 8th and 9th April 2014 A total of 505 delegates attended including 40 from ACPA. BOA President Tim Briggs spoke on “The Emerging Themes from Getting It Right First Time (GIRFT)”. The Lorden Trickey lecture was delivered by Roland Biedert who is Head of the Sports Clinic Villa Linde AG on “Trochleoplasty – simple or tricky?”. The conclusion was that it is tricky! There were updates on the NJR,

BASK President Prof Simon Donell with the Lorden Trickey guest lecturer Dr Roland Biedert

by Sean O’Leary on the National Ligament Registry, and Adrian Wilson on the proposed Osteotomy Registry. There was a session on the Regulation of Orthopaedic Implants with contributions from the British

Free paper sessions covered Osteotomies, arthroplasty, ACL, arthroscopic surgery and knee scores. Fifty-eight podium presentations and 47 posters were presented along with 103 e-posters. The best paper by a trainee was awarded to Kiran Athwal, the poster prize to David Elson, and the consultant paper prize to David Beard. The President’s prize went to Zahr Jafry. The golf tournament held at Brancaster in high winds was won by Richard Nicholas, with Richard Parkinson as the runner-up. The prize for the best score by one of the sponsors went to Peter Verway. The dinner, held in St Andrews Hall, Norwich, was followed by a tour de force cabaret act. The next Annual Meeting will be held in Telford 10th-11th March 2015, hosted by Steve White from Oswestry.

l Volume 02 02/ / Issue 0301 / August 2014 l boa.ac.uk Volume Issue / January 2014 boa.ac.uk Page 11 22 l Page

JTO Features

I BELIEVE THAT THE NEW NHS ENGLAND STRUCTURE HAS SIGNIFICANT CAPACITY TO IMPROVE THE QUALITY OF THE PATIENT EXPERIENCE. I believe that the new NHS England structure has significant capacity to improve the quality of the patient experience, to improve the quality of services delivered and to improve the quality of outcomes. Input from clinical colleagues is essential to this process. The clinical voice must, however, be coherent and clear to be effective. Debate and discussion are important and will continue to be part of clinical practice in our Centres, in the Speciality Societies, in the BOA and in the CRGs and other structures of the Health Service. However, it is equally important that consensus

is achieved wherever possible so that I and other NCD’s can take into NHS England a powerful and undiluted message. Q

References 1. www.england.nhs.uk/ resources/spec-commresources/npc-crg/group-d/ d15 2. webarchive.nationalarchives. gov.uk/20130107105354/ http://www.dh.gov.uk/en/ Publicationsandstatistics/ Publications/

PublicationsPolicyAnd Guidance/DH_114528 3. www.nationalspinaltaskforce. co.uk 4. http://bit.ly/BOA-CG-lbp 5. UK health performance: findings of the Global Burden of Disease Study 2010. Murray CJL, Richards MA, Newton JN et al, Lancet 381:997-1020, 2013 6. www.SCIreferrals.org.uk

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As well as being National Clinical Director for Spinal Disorders, Professor Charles Greenough is a Consultant Orthopaedic Spinal Surgeon and Clinical Director of the Regional Spinal Cord Injury Centre at James Cook University Hospital, Middlesbrough. Research interests have been low back pain, spinal surgery and spinal cord injury. He Chairs the CRG in Spinal Cord Injury and was a member of the National Spinal Taskforce. Email: charles.greenough@stees. nhs.uk

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 12

JTO News and Updates

Training & Education Focus

New ‘Orthopodcast’ initiative On behalf of the BOA, Grey Giddins (BOA Trustee) has developed an exciting new BOA initiative: Orthopodcasts. Over the coming months, there will be series of podcasts on a variety of trauma & orthopaedic topics which serve to both educate and entertain. Each podcast is a short conversation between experts (10-20 mins), discussing current topics in T&O. They are not a repetition of book chapters or research papers, but a conversation that will be easy to listen to and digest whilst being educational. You will be able to download the podcast and listen at your leisure: at home; in the car; or on a run. The first two Orthopodcasts cover Complex Regional Pain Syndrome (CRPS) with Jeremy Field from Cheltenham and a discussion about training in Major Trauma Centres between Chris Moran from Nottingham, National Clinical Director for Trauma, and David Large, Chair of the T&O SAC. We hope you will enjoy these Orthopodcasts and will be generous with feedback and ideas for future topics. www.boa.ac.uk/orthopodcasts

Highlights of the BOA/SAC/TPD Day 7th May, 2014 Each year, the BOA Council, with the SAC and Training Programme Directors, hold a one day meeting to disseminate recent developments and share future plans. This is the one annual opportunity when those involved in oversight of educational strategy, maintenance of training standards and management of local delivery get together to take stock. These were just some of the day’s highlights: 1. We were delighted to welcome Clare Marx - the incoming RCS President - to the stage, making a smooth transition from an earlier discussion of undergraduate students to the postgraduate pathway, with her enlightening overview of the recent Shape of Training report (SHoT). This initiative, fronted by Professor Greenaway, is expected to have a far-reaching impact on the T&O career structure, and so the forum was extremely lucky to benefit from her unique SHoT insights as one of the report’s grassroots contributors. 2. David Large – the newly appointed SAC Chair – and Professor Tim Briggs spearheaded a discussion of national recruitment, prompted earlier on in the year by the Centre for Workforce Intelligence’s forecast regarding a prospective cut in training numbers. Since the meeting, the question mark hovering over trainee numbers has been resolved by local needs acting as the determining factor in final recruitment numbers. Furthermore, in order to maintain

training growth and stability, the BOA and SAC had submitted detailed T&O evidence derived from GIRFT to inform Health Education England (HEE)’s commissioning of Higher Surgical Training next year and beyond. This important topic continues to be discussed by the SAC and BOA Council. 3. A dialogue on the curriculum throughout the day saw Professor Phil Turner and David Large provide useful updates on training assessment tools, as well as featuring an excellently delivered evaluation of ISCP functionality from BOTA representative, Nick Ferran. 4. Dynamic presentations on Major Trauma Centres (MTCs) from trainers and trainees highlighted the full spectrum of perspectives on the NCD’s proposed change to trauma services. An exemplar MTC in the North was debated, with panelists offering their opinions on the challenges and benefits of a nationally-rolled out MTC network, specifically focusing on the knockon effect this would have on both trauma and elective orthopedic training. With such positive feedback, this event will remain a fixed date in the BOA calendar, serving as a vital forum for T&O educators to collaborate on a consensus that shapes the training of future generations for years to come – thank you to all those who took part in the forum this year!

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 13

JTO News and Updates

Peter Myers Sports Travelling Fellowship, Australia June 2013-June 2014 Francois Tudor The fellowship with Dr Peter Myers is a combination of public and private work and is specifically designed to allow the fellow increasing operative exposure and complexity as the year progresses. Training in surgical technique, research and education provides each fellow with an outstanding foundation for a future career in academic sports surgery. The fellowship encompasses management of all aspects of sports injuries but is particularly focused on knee surgery including complex arthroscopic work with meniscal repair and transplants, ligament reconstruction, osteotomies and patella stabilisations with primary and revision arthroplasty. The fellowship involves an operating list every day of the week and the sheer volume and breadth of cases is phenomenal. At the end of the year, my logbook contained more than 600 cases.

Dr Myers is recognised around the world as an expert in many aspects of knee surgery and hence is often invited to talk or publish on these subjects. He also has an established background and regular involvement in both clinical and non-clinical trials. These factors provide ample education from a scholarly aspect, allowing scope for co-authorship of presentations, papers and book chapters. During the fellowship, I experienced a massive improvement in my operative and decision making skills and learnt a vast amount about the intricacies of knee surgery. Dr Myers is incredibly kind and has a very special manner with all his patients and witnessing this aspect of practice has greatly affected the way that I treat my own patients. In all, this fellowship provides a fantastic learning experience and I would thoroughly recommend it to anyone with an interest in complex knee surgery. I had the most incredible experience this year and I am extremely grateful to Peter Myers for all the time, teaching and knowledge that he gave me. I would also like to thank Dr Peter McMeniman and Dr Tim McMeniman for their guidance, support and hospitality throughout the fellowship. Finally, I would like to thank the British Orthopaedic Association for providing funding towards the fellowship.

Francois and Peter McMeniman prior to a procedure

Francois is currently a Fellow of lower limb reconstruction & arthroplasty at Holland Orthopaedic & Arthritic Centre, Sunnybrook Health Sciences, Toronto, Canada.

BOA/SAC/TPD Day

Orthopaedic Clinical Leaders Develop Their Skills in Scotland On 22 June, trauma and orthopaedic clinical leads, from across Scotland gathered for a two day Training Orthopaedic Leaders course. Coursework used Scotland’s ‘Orthopaedic Quality Drive’ as the basis for the leadership challenges. The Scottish Quality Drive has five high impact workstrands: 1. AHP MSK Redesign – Getting patients on the right pathway, starting in the community 2. Fracture Pathway Redesign – Patients only attend fracture clinics if there is a clinical need 3. Enhanced Recovery Pathway – Optimising patient recovery after joint replacement 4. Hip Fracture Care Pathway – Optimising care of frail older people 5. Capacity and Demand Planning and Management – Supporting strategic and operational decisions

The Quality Drive is generating the pace and momentum for a year’s ‘national effort’ to sustainably spread each workstrand to all units. The clinical leads arrived with examples of how they had used their leadership skills and the challenges they had faced. One of the most powerful components of the programme was the action learning circles where groups of six worked on issues they wanted to address in the coming months. Colleagues questioned, shared and challenged until robust action plans were developed using the skills and opportunities presented by the course. Feedback has been extremely positive and they want to do it again, mixing clinical leads and management! Rather than registering as an individual for the TOLS programme, perhaps holding an event for your department, group or project might work for you! Phil Turner and Lisa Hadfield-Law could facilitate the programme in your area – contact the BOA for more details.

l Page 14

JTO News and Updates

Where are we with Consultant Contract Negotiations? Robert Harwood, CC Lead Negotiator

The BMA, NHS Employers (NHSE) and the Department of Health (DH) have been negotiating for nine months and the deadline set by the Government for the conclusion of the process, October 2014, is close. Looking back, the Doctors and Dentists Review Body’s (DDRB) report on consultant reward schemes was published in December 2012. Then, in early 2013, preliminary discussions between the BMA, NHSE and the DH began, leading to the development of ‘Heads of Terms’, setting out the parameters of negotiations. Following a mandate from the CC,

negotiations began in October. The negotiating environment is tough and any funding to pay for Government desired change has to come from within the current pay envelope, leaving little on the table in return. There is growing political pressure to deliver seven-day services, and NHSE see the removal of

Schedule 3 Paragraph 6 (S3P6) of the 2003 consultant contract, allowing consultants to decline non-emergency work outside core hours, as essential for this. The BMA is clear that removal or change of S3P6 would have to be replaced by appropriate, contractual safeguards, to protect the work-life balance and health of consultants. Consultants are already working across seven days of the week in various ways. These negotiations must ensure that all consultants are rewarded fairly for their work while protecting their right to a life outside of the workplace.

The Treasury has pledged to remove automatic pay progression across the public sector and NHSE wants to move away from time served systems. Pay progression is a complex area requiring detailed discussion and modelling; much remains to be done. Much is at stake in these negotiations. Consultants have emphasised the importance of a national contract so the BMA continues to work towards an agreement. Your views are important to us – please join the debate at http://communities.bma.org.uk. You can hear more at the BMA Session at the BOA Congress in Brighton on Friday 12th September.

Future BOA Course dates 9 -10 September 2014 – Casting Refresher Course (Stanmore) 15 September - 18 October 2014 – Casting Course (Stanmore) 15 -16 October 2014 – Training Orthopaedic Trainers (London) 10 -11 January 2015 – BOA Instructional Course (Manchester) 23 February - 27 March 2015 – Casting Course (Stanmore) Don’t forget that members can register at a discounted rate for all of these events. To register, or for more information, visit www.boa.ac.uk/events.

K O BO O W N

Postgraduate Orthopaedics FRCS (Tr & Orth) in collaboration with Northrumbria University are proud to announce the course to accompany the book series:

Postgraduate Orthopaedics FRCS (Tr&Orth) Revision Course 15–21st March 2015 Lecture & Viva section: Sutherland building Northumbria University, Newcastle upon Tyne Clinical section: Northeast Surgery Centre, Queen Elizabeth Hospital (QEH), Gateshead

A 6-day intensive course designed to cover all aspects of preparation for the FRCS (Tr& Orth) examination. The course material will closely mirror the material contained in the Postgraduate Orthopaedics book series. •

Day 1–4: Lecture presentations. Four full days of lectures covering all aspects of the key topics you need to know for the exam. The lectures will be delivered by relevant authors of the book and focus on important areas of the syllabus that regularly appear in the FRCS (Tr&Orth) exam. The course content has been signiﬁcantly revised to take into account candidate feedback from our ﬁrst course and also work in progress with our third edition book. The lecture programme promises to deliver exam related material that really will count for candidates about to sit the FRCS (Tr&Orth) exam.

•

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•

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 16

JTO News and Updates

BOA Membership

Prof Tim Briggs and Mike Kimmons with Arwani Choudhary, Mamdouh Morgan, Ara Nahabedian & Shenouda Shalaby

BOA support for SAS grade orthopaedic surgeons Prof Tim Briggs recently hosted a meeting with a group of SAS grade orthopaedic surgeons at the BOA. He has since written to Trusts around the UK to engage with this group of members, who are currently underrepresented in the BOA membership. He explained that the BOA needed to forge a new relationship and engage fully with our SAS doctors, and that more public recognition was needed of the essential contribution made by SAS doctors to the NHS environment.

Broader membership for BOA proposed

New publication for members also proposed

From January 2015, the BOA will welcome medical students and foundation year doctors to the membership for the first time, under planned changes to the BOA rules due for approval at the BOA AGM in September. The proposed changes will also make it easier for allied health professionals to join the BOA as Affiliate members.

In a further proposed change to the membership, all Fellows, Members and Associates of the BOA will receive the ‘Bone & Joint 360’ in addition to the Bone and Joint Journal from 2015. This is a new publication in the BJJ group, which members will have received

Announcing these moves, Prof Tim Briggs, President of the BOA, explained: “It is vital that the BOA is the body for students and professionals with an interest in trauma and orthopaedics, and I very much hope that the BOA members will support these changes at the AGM. During my many visits to hospitals and units in my time as President I have seen first-hand the team working and training environments that are in place across the country and I see the BOA as having a unique role to play in bringing together and supporting all those involved.”

New BOA Merchandise We will be launching a new range of BOA merchandise for our members at the Brighton Congress in September. Stop by the BOA stand and pick up your new BOA tie or scarf. We will also have a choice of cufflinks and brooches to choose from. If you are not attending the Congress, please contact the BOA office from 15 September onwards for more information and to buy your merchandise.

a sample copy of over the summer, and the BOA Council has endorsed this as a significant additional benefit for membership of the BOA. The BOA has negotiated an arrangement that allows us to provide it to members for a minimal uplift in the BOA subscription (£12 for Fellows and Members). A formal vote on this will be taken at the Brighton congress.

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 18

JTO News and Updates

BOA Instructional Course 2015 – exciting new format! Saturday 10 – Sunday 11 January, 2015 Manchester Conference Centre Registration NOW OPEN

www.boa.ac.uk/events/instructional-course 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.

Why you should attend our 2015 course The 2015 Course has been tailored specifically to trainees’ educational needs; the programme is revamped and reenergised to deliver the educational material you need. An exciting range of lectures and

expert-led clinical case based discussions (CBDs) will ensure you benefit from focussed discussions on core curriculum topics, as well as small breakout sessions on critical conditions that can have huge ramifications on patient safety. As well as tailored curriculum lectures and focused CBDs, there will be the traditional keynote lectures, delivered by inspiring orthopods sharing important insights and clinical experience. The Instructional Course will cover material that is useful to you beyond FRCS exam preparation, providing the chance

to proactively contemplate your T&O career pathway and engage with professionals to learn more and inform important decisions you will need to face – such as the understanding of fellowships – to make yourself stand out above the rest. Immerse yourself in the T&O community and engage over the weekend with fellow trainees, industry representatives, faculty, and of course, the BOA team. There will be limited spaces in 2015 so make sure you don’t miss out. Registration is now open – www.boa.ac.uk/ events/instructional-course. For more information please contact Holly Weldin at h.weldin@boa.ac.uk.

Conference listing: BOA (British Orthopaedic Association) www.boa.ac.uk

BOA Congress 12-13 September 2014, Brighton

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

Annual Meeting 8-10 October 2014, Bristol

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

Annual Meeting 16-17 October 2014, London

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

Annual Meeting 5-7 November 2014, Brighton

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

Annual Meeting 6-7 November 2014, Dublin

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

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 20

JTO Features

The Sir Robert Jones Memorial Lecture 2014: ‘Today’s Challenge in Patient Safety – Caring Sharing and Innovating’ David Stanley

In this article David Stanley summarises his Robert Jones Memorial Lecture of 6th June 2014 at the EFORT/BOA Congress in London. Robert Jones was born in Rhyl North Wales in 1857. His father was a freelance journalist and moved the family to London when Robert was five. Aged 17, he went to Liverpool to study medicine, living with his uncle Hugh Owen Thomas, who taught him much about the correction of deformity. He was appointed Honorary Assistant Surgeon at the Stanley Hospital in 1881 and Honorary Surgeon and Dean of The Royal Southern Hospital in 1889. He was medical officer in charge during the building of the Manchester Ship Canal and later, during the First World War, was appointed Inspector of Military Orthopaedics and promoted to Major-General. He was an inspirational leader that others wanted to emulate.

David Stanley

Figure 1: Relative Risk Curve Complexity of Case

Surgical Experience

Sir Robert Jones

During his life he received many Honours, but I suspect would have been most proud of the things that were said about him. William Mayo, who later with his brother founded the Mayo Clinic, said “So unassuming and modest is the man that he is I believe entirely unaware of his great ability” and Lord Moynihan stated “As an operator he is among the very greatest, his technique is flawless yet simple”. He was committed to providing his patients with the best possible care, and if we are going to follow in his footsteps, we must be mindful of the challenges we face in our clinical practice. It is essential that we know the patients we are treating. If, due to waiting list pressures we meet them for the first time immediately prior to surgery, there is, I believe,

a serious risk that we will not understand the clinical problem adequately and will certainly not fully appreciate their expectations. This potentially will result in increased litigation, a problem that has risen in orthopaedics by 60% in the last 3 years, unsatisfactory outcomes being the commonest reason for claims. It is also important that we know the accepted technique for a surgical procedure and are able to perform it safely. Associated with this is an understanding of our own ability. If we are faced with a difficult problem that we feel is beyond our competence, it is far better for the patient if the surgeon picks up the phone and “phones a friend rather than picks up the knife and wrecks a life”. We must also know our own outcomes rather than simply being aware of the literature, since our results may not match the published data. Finally it is important to know your own relative risk curve (Figure 1) and stay below it. If we adhere to these criteria we will provide a high quality professional service which will place at the centre of care the best interests of the patient.

David Stanley is the senior Shoulder and Elbow Surgeon at Sheffield Teaching Hospitals NHS Foundation Trust. He is a Past President of The British Elbow and Shoulder Society and Past Honorary Secretary of the BOA. He is currently Chairman of The Intercollegiate Examination Board for Trauma and Orthopaedic Surgery. For further information regarding the Robert Jones Lecture, please contact David Stanley by email at dave.stanley@sth.nhs.uk

David Stanley at the podium

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 21

GIRFT: A Surgeon’s Perspective John Nolan

Tanned and fit we have all returned from our summer break. Our scheduled and chartered flights were conducted within strict safety guidelines, by pilots who were both current and competent having undergone a recent assessment of their ability to deal with routine and emergency scenarios. The more complex flights require higher levels of training and expertise – pilots again demonstrably competent and current – we put our lives in their hands. The aircraft we flew in had proven track records over many years although from the pilots’ perspective Airbus and Boeing differ significantly – both work in the right hands. Right aircraft for the job though (not many 747’s on the Norwich to Cardiff route!). Pilots use check-lists and standard operating procedures whilst flying established routes. They will not

experiment with new aviation gizmos, non-standard routes or descend at inordinate rates. We expect them to do things right and trust them accordingly. Their real skill lies in their ability to deal with anything out of the ordinary, be it bad weather, a malfunction on the aircraft or some other unexpected situation. Airlines work to a strict budget – it is difficult to make money in commercial aviation – certainly there is no flexibility for the pilots to incur greater expense without good reason. Details of the airlines’ outcomes, punctuality/incidents etc. is available on the internet for all to see. Shouldn’t our patients expect the same? A competent and current surgeon using techniques and prostheses of proven value, cemented or un-cemented. Implants with track records for procedures that are common.

John Nolan

More highly trained/experienced and current surgeons for more complex and revision cases. No “just having a go” on the way to Rio. The real skill of an experienced consultant is in the decision making with nonstandard cases and dealing with the unexpected.

John Nolan in a Tiger Moth

Validated outcomes and transparency showing that in most cases we are: “Getting It Right First Time”. I was sceptical about our GIRFT visit. I had heard about GIRFT when Tim Briggs spoke at our BHS meeting but I remained unclear quite why our Association President was inspecting us. I had concerns about the data the team was using. As emails circulated about the “visitation”, it all sounded a bit Messianic! In the event Tim talked, listened and understood why some of the figures were awry. I am happier, not just because we seem to have ticked most of the boxes in Norwich but because I think I agree with the principle of GIRFT. The numbers of elderly folk is increasing (already 500,000 over 90 years old!) and NHS money is being cut in real terms.

There are choices to be made. We need to make the right ones. I like the idea of taking responsibility as departments, dual operating for complex cases and setting up surgical networks, as well as producing, publishing and acting on departmental level data. Generally, getting our own house in order. Airlines have a great incentive to get it right first time – we carry a similar responsibility. John Nolan has been a consultant in orthopaedics and trauma in Norwich for nearly 20 years and is currently President Elect of the British Hip Society. He enjoys all things to do with aviation!

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 22

JTO Features - Trainee Section

Shape of Training and Patient Safety: A BOTA perspective Jeya Palan

This year, a significant amount of my time as President of BOTA, has been spent reviewing the Shape of Training (SHoT) report. This is an independent review by Professor David Greenaway, ViceChancellor of the University of Nottingham and Professor of Economics. It sets out a number of recommendations regarding the provision and configuration of postgraduate medical and surgical training for the next three decades, with the aim of “securing the future of excellent patient care” 1. The review has had input from all the major stakeholders including the Royal College of Surgeons of England, the Academy of Royal Colleges and the Academy of Trainees Doctors Group (ATDG). The main focus of the review was to highlight the need for hospital doctors to provide more “generalist”

care and to avoid becoming overtly specialist. In specialities such as general medicine, and to a lesser extent, general surgery, the trend towards “super-specialisation” has led to concerns that acute medical and surgical cover was becoming increasingly difficult to cover and that trainees in certain specialities were unable to provide such emergency cover. The SHoT review stated that patients needed more general specialty care and that this needed to be delivered in both a hospital and also community setting. Doctors’ training needed to be broad based and general, enabling all doctors to look after acutely unwell patients as well as those with chronic conditions and to understand the need for prevention as well as cure. There is an emphasis on providing doctors with transferable skills enabling them to potentially move careers and specialities and also to help doctors’ work more effectively in multidisciplinary teams. On the face of it, there are many things to like and support with SHoT. There is a greater emphasis on

Jeya Palan

ensuring that training occurs only in centres which provide good training and that longer term placements, using some of the more positive aspects of an “apprenticeship” model, is a good idea. Clearly, there is a need to address the issues of doctors all becoming “superspecialists” and that there is an urgent need for all doctors to be able to provide acute general care within their specialty remit. In Trauma and Orthopaedics, trainees are trained in the “generality” of our specialty, with the ability to provide safe and competent acute trauma care as well as general elective care, irrespective of the chosen sub-specialty. In this respect, I believe T&O are ahead of the curve and we should showcase our training system as an example of how to provide general trauma care and still maintain a sub-specialty interest. Furthermore, working as part of a multi-disciplinary team approach is already well established in T&O with the development of ortho-geriatrics as its own specialty and working closely together with physiotherapists, occupational therapists, nursing staff and discharge coordinators. There are however, worrying elements of the SHoT report which, if implemented in its current state, would lead to detrimental effects on patient care and potentially safety; the law of unintended consequences. One of the key recommendations of SHoT, is the push to move the point of full registration from its current state (Foundation Year 2) to the point of qualifying from medical school. This could potentially have significant and worrying implications on patient safety and BOTA remains unconvinced that what students learn in medical

school is immediately transferable to the workplace. There is a clear difference between being a student and working in hospital as a doctor and Foundation Year 1 doctors need careful supervision and support during this critical year. Unfortunately, the remit of SHoT did not include a review of the undergraduate medical school training and certainly, it is this aspect of training that also needs a fundamental review. The erosion of traditional core subjects in undergraduate medical education such as anatomy and physiology, with a greater emphasis on communication skills, has led to the development of medical graduates who have better communication skills at the expense of having sufficient knowledge of clinical anatomy. This means that medical graduates planning on a career in surgery are less well prepared for the rigors of basic and higher surgical training. The recommendation to reduce the length of training at higher surgical training level by two years with an emphasis on “general” training, will inevitably lead to the creation of a “sub-consultant” group of T&O surgeons, only capable of delivering general care at a lower standard and dependent on their employer (local NHS trusts) offering “credentialing” as a way to gain sub-specialty expertise. How this would work in practice and who would fund this remains unclear. This is not in the best interest of patients and is likely to lead to a lowering of the standards required to be a “consultant”. The Shape of Training review has now entered its “implementation” phase and this is likely to take

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 23

As a profession, we should highlight the T&O model of delivering safe and effective emergency trauma care as well as maintaining sub-specialty interests.ll ll

some time. Whilst there are many recommendations in SHoT to support, there are also very real concerns over the implementation of other key recommendations. As a profession, we should highlight the T&O model of delivering safe and effective emergency trauma care as well as maintaining sub-specialty interests, which is consultant delivered, and part of a multidisciplinary team (such as working closely with Ortho-Geriatricians). This approach supports the career aspirations and expectations of future T&O surgeons whilst providing

References:

the public with highly skilled and dedicated professionals and a consultant delivered service. n Jeya Palan is Immediate PastPresident of BOTA. He is currently the NJR/RCS England Fellow and a ST6 trainee in T&O in the East Midlands Leicester rotation. He is an Associate Editor for the Bone and Joint Journal (BJJ) and is currently undertaking a three year Out of Programme for Research period of time for a PhD. His research interests include patient outcomes following hip and knee arthroplasty and the use of joint registry data.

1. ‘Securing the future of excellent patient care - the final report of the Shape of Training Review’ led by Professor David Greenaway is available on the Shape of Training website (www. shapeoftraining.co.uk)

Shape of Training Report

Total Orthopaedic Solutions for the NHS, by the NHS Surgeon-centred strategic purchasing Support the shift to surgeon-centred strategic purchasing by adopting the new Total Orthopaedic Solutions framework agreement. Bring sound business sense and contract compliance to your orthopaedics supply without compromising patient care: +LS DQG NQHH DUWKURSODVW\ ([WUHPLWLHV 7UDXPD HPHUJHQF\ DQG HOHFWLYH 6SLQH 0D[LOORIDFLDO $UWKURVFRS\ 3RZHU WRROV %RQH SUHSDUDWLRQ 5HJHQHUDWLYH WHFKQRORJ\ This truly collaborative approach by the four NHS procurement hubs working together as the NHS Collaborative Procurement Partnership enables trusts to apply a more strategic approach to the purchasing of orthopaedic products – sure in the knowledge that clinical engagement is at the heart of the decision making process. For more information contact Khalid Shihadah khalid.shihadah@noecpc.nhs.uk or call 07825 011 436 NHS Collaborative Procurement Partnership will be at the BOA Congress in September – come and see us on Stand 10

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 24

JTO Features - Trainee Section

Training and tick boxes: a culture change is necessary Jeya Palan The training programme for Trauma and Orthopaedics (T&O) in the UK is considered one of the most advanced and developed systems in the world with a newly developed curriculum and syllabus as well as an online electronic surgical portfolio system called the ISCP (Intercollegiate Surgical Curriculum Project) and the use of Elogbook for the recording of operative cases. The use of Work Based Assessments (WBA) with learning tools such as the Procedure Based Assessments (PBA) and Case Based Discussions (CBD), have been introduced as a way of providing formative assessments (analogous to driving lessons) of the trainee during their training period with a mechanism to provide feedback for the trainee. Such formative assessments are designed to demonstrate progress of the trainee over time rather than being used as a summative assessment (analogous to the driving test). The 2013 Trauma and Orthopaedic curriculum stipulated a number of key requirements for trainees

Jeya Palan

to have completed in order to be recommended for the award of the Certificate of Completion of Training (CCT) at the end of their higher surgical training (HST) period. These included the need to complete a minimum of 40 WBAs a year, undertake CBDs in 10 critical conditions (See Table 1) and to achieve a minimum of 1,800 operative cases in a 6-year training period from ST3 to ST8. Furthermore, the introduction of indicative numbers for key index operations (See Table 2) was introduced to ensure that all trainees had a broad based operative experience during their training. When trainees are shown a “target” they will do their utmost to ensure they reach that target but it is important to stress that the target is the minimum requirement needed for CCT. The principle of having indicative numbers and minimum WBAs is to ensure that there is a body of formative evidence to support the training being undertaken by the trainee. Such assessments are often implemented inappropriately, with trainees completing WBAs at the last minute or all at once, with minimal or no reflective feedback to improve a trainee’s knowledge or understanding. In other words, these assessment tools have become a tick box exercise with little educational value. In London, the requirement of needing 80 WBAs a year have proven contentious (with trainees in the rest of the UK needing 40 WBAs a year) and there is a concern that this has led to a tick box culture in completing these assessments. The value of such formative assessments is in the way they are completed, ideally with the trainer

and trainee spending time (for example, between cases in theatre) to review the procedure, operation or case and to provide constructive feedback for the trainee. This requires time, effort and planning, both on the trainee’s part and that of the trainer. Trainees and trainers need to engage with the system and to understand that WBAs are not “mini-exams”. Furthermore, the use of such WBAs should be built into the everyday work routine so it no longer becomes an extra thing to do but rather is fully integrated as part of a work schedule and everyday practice. Such a change in culture will take time but the roots for such change is now firmly embedded in the training system. What is needed now is to ensure that both trainees and trainers take ownership and value the training tools designed to facilitate learning and that instead of ticking the boxes, trainees use such tools to enhance their training.

This means supporting both trainers and trainees in the workplace to allow them to train and be trained appropriately. a. Compartment syndrome (any site) b. Neurovascular injuries (any site) c. Cauda equina syndrome d. Immediate assessment, care and referral of spinal trauma e. Spinal infections f. Complications of inflammatory spinal conditions g. Metastatic spinal compression h. The painful spine in the child i. Physiological response to trauma j. The painful hip Table 1: 10 Critical Case Based Discussions

Table 2: Indicative numbers for index procedures

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 25

JTO Medico-Legal Features

Orthopaedic Practice and Consent Gerard Panting

Negligence claims in orthopaedic surgery fall under four broad categories: 1. Delayed diagnosis or treatment 2. Failure to warn about potential complications of surgical or other treatment 3. Adverse events during surgery 4. Outcomes that fail to meet the patient’s reasonable or unreasonable expectations A robust consent process reduces the risk of facing a “failure to warn” claim and helps manage patient expectations over outcomes. A forensic assessment as to the adequacy of the consent process will depend on the physical evidence of what happened, not what actually happened. Unless clinicians are able to demonstrate by reference to notes, correspondence, fact sheets, consent forms and other documentation that appropriate advice was provided, the prospects of a successful defence decrease.

What do the courts expect of surgeons when it comes to consent? To be valid, a competent patient must have sufficient information to make an informed choice about their treatment options so that they can decide which to accept or reject, without being pressurised into a decision. For elective surgery the patient must have sufficient time to consider the options, including doing nothing. In practice the emphasis during the consent process is rightly on the information provided to the patient, because that’s where most of the problems occur. Occasionally, competence to consent and whether or not consent was given freely are the key areas of contention. Competence is nothing to do with age but all about understanding. The formal test of competence requires the patient to be able to understand the treatment information, to believe it, weigh it in the balance to arrive at a choice and then be able to convey their decision to the clinicians involved. Generally, it is assumed that adult patients are competent.

Gerard Panting

Unless they make a decision which appears to be irrational, it is unlikely that anyone will question their ability to decide for themselves. Making a bad choice may make you question the patients’ competence but is not proof in itself. A proper assessment, which may involve psychologists, interpreters or other, is required before the patient is condemned as incompetent. Even then the law requires the patient to be involved in decision making in so far as that is possible. Competence is not an all or nothing phenomenon and may vary: it depends on the specifics of the situation and the proposed treatments. The classic case is Re C where a patient detained under the Mental Health Act developed a gangrenous foot. The surgeons called to see him wanted to amputate the foot but he refused consent and having been found to be competent by the court was granted an injunction preventing the proposed surgery. The idea of a claim being based on consent not being given freely may seem far-fetched, but if patients feel pressurised into a decision which they later regret, it can occur. In one case a patient underwent a discectomy, and subsequently suffered cauda equina syndrome. The patient claimed he had not been warned of the risk, the surgeon said he had been warned on the day of surgery. The judge found that even if CES had been discussed on the day of surgery, this did not represent valid consent as the patient would not have had sufficient time to digest and reflect on the new and material risk. Except in exceptional emergency situations consent on the day of surgery may be deemed to be under duress.

The most frequent consent claims are “failure to warn” cases. Unfortunately, the leading legal cases are following spinal surgery. Since 1999, the General Medical Council has published guidance on taking consent. It has been updated over the years, but has always emphasised the degree of information that should be provided to patients. This includes: 1. Details of the diagnosis and prognosis, and any uncertainties 2. Options for treatment or management of the condition, including no treatment 3. The purpose of a proposed investigation or treatment 4. Details of the procedures 5. How to prepare for the procedure 6. Common and serious side effects and serious or frequently occurring risks 7. The probability of success 8. A range of other issues, including the patient’s contribution to their own care before and after surgery. In the case of Chester v Afshar1, decided by the House of Lords in 2004, a patient suffering from a long history of low back problems, was advised to have surgery but was not warned about an unavoidable risk, of between 1 and 2%, of cauda equina syndrome, which unfortunately did occur. The law lords held that ‘as a result of the surgeon’s failure to warn the patient, she cannot be said to have given informed consent to the surgery in the full legal sense’ and as a result she was awarded damages. >>

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 26

JTO Medico-Legal Features

When patients come to sign a consent form, they have questions which have to be answered fully and honestly.ll ll

Cases like this give rise to the myth that there is no need to warn about complications with a frequency below 1%. This is completely untrue: the requirement is to inform the patient about all information material to their decision, which should include the low risk of a serious complication such as paralysis. Signing the consent form might seem to be the moment that the patient consents to treatment, but this is far too simplistic a view. The consent form itself is at best just one piece of evidence that the patient consented. When deciding whether or not valid consent to treatment was obtained, it is important to review all the discussions that took place about the diagnosis likely progression, options for management and potential problems that will have taken place during perhaps several consultations. Numerous studies have shown how little some patients retain of the information they are given in outpatient appointments, so it’s not surprising that there is often a conflict of evidence with the surgeon saying that various issues were discussed and the patient honestly replying that they have no recollection of any such issue being raised. So if there are clinical records which set out these details, letters to the GP copied to the patient providing this information, and

information leaflets that are routinely given to the patient about the condition or procedure in question, it is no longer one man’s word against another but a clear evidential trail setting out the thorough nature of the consent process. Against this background the consent form itself becomes less important, so whilst it is required in most hospitals and adds some weight, it is not the one document on which claims are won or lost. Nevertheless when patients come to sign a consent form, they may have questions which have to be answered fully and honestly. In the case of Hatcher v Black2, which came to trial in 1954, a patient suffering from thyrotoxicosis was advised to have surgery. The patient occasionally broadcast for the BBC was concerned about potential risks to her voice and specifically asked about this. She was assured that there was no risk to her voice even though the surgeon knew that this was not true. Her recurrent laryngeal nerve was damaged during surgery and her voice was affected and she never broadcast again.

At trial the truth emerged, but it was accepted that the surgeon had lied ‘for her own good.’ The Judge said ‘…as far as the law is concerned, it does not condemn the doctor when he only does what many a wise man and good doctor so placed would do.’ Consequently, Mrs Hatcher lost her claim. 60 years on the same would not be true – the case would never get to trial because it would be indefensible and if there was a complaint to the GMC the surgeon would be at serious risk of a warning or worse. The GMC advise that ‘You must answer patients’ questions honestly and, as far as practical, answer as fully as they wish.’ Ideally, the surgeon undertaking the procedure should oversee the entire consent process. If this is not practical all or part of the process can be delegated to others. However, if delegated, the person taking consent must be in a position to provide all the necessary information about the procedure and potential complications and answer any questions. A common question is when patients should be asked for consent. The issue here is that patients need to know the pros and cons of the proposed surgery well in advance so that they can go home and decide whether or not to go ahead. In practical terms at the clinic, prior to listing for surgery, is the optimal opportunity to take (and record) full and informed consent. Provided they have been given all the relevant information in the clinic,

there is no problem with completing the consent form on the day of surgery. However, providing new and important information at the last moment is wrong as illustrated by the cauda equina case discussed earlier in this article. In elective cases patients should have time to consider their options, but in emergencies there may be little or no time to spare and patients may be unconscious or in a severely compromised state. Consent cannot be glossed over in an emergency but the approach will be dictated by circumstance. If the patient is unconscious, necessary treatment can and should be provided unless there is a clear advance refusal of a specific therapy, such as a Jehovah’s Witness not wanting to have a blood transfusion. Some adult patients will have granted lasting powers of attorney to trusted relatives and friends which can include consenting to treatment on the patient’s behalf, but in an emergency, time cannot be wasted trying to find anyone in that position, so proceeding on the basis of necessity is the default policy. Any person with parental responsibility can give consent on behalf of a child, but otherwise you should do whatever is required to serve the child’s best interests. Even in elective procedures not everything goes to plan: there may be unexpected findings or complications requiring additional treatment. If additional treatment is required to ensure that the patient’s >>

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 28

JTO Medico-Legal Features

Even in elective procedures not everything goes to plan: there may be unexpected findings or complications requiring additional treatment.ll ll

condition is not jeopardised, it should be provided but where no urgent intervention is required for an unexpected condition, where the treatment options are different, the patient should be allowed to make their own decision once they have recovered from the anaesthetic. The requirements for obtaining valid consent are onerous if viewed in isolation, but in practice providing all the necessary information is interwoven with the clinical care of the patient. Provided that in the event of a claim the care and

attention taken in explaining all the relevant issues can be demonstrated by reference to the notes, letters and leaflets, allegations of “failure to warn” can be robustly defended. n

References: 1. Chester v Afshar [2004] UKHL 41 2. Hatcher v Black (1954) Times, 2 July (QBD)

Dr Gerard Panting is medico-legal advisor to the Orthopaedic and Trauma Specialists Indemnity Scheme (OTSIS), the not-for-profit professional indemnity exclusively for orthopaedic surgeons. www.otsis. co.uk info@otsis.co.uk

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Sponsored Content Advertiser’s Content

After a turbulent few years, surgeons are adept at ‘managing change’. How has the responsibility for your career switched from employer to employee? Dr Mark Martin, former anaesthetist and now specialist financial planner for medical professionals, writes:

collect a large, up-front tax bill thanks to the newly reduced annual and lifetime pension allowance rates.

In the halcyon days of becoming a hospital consultant, you completed your training, secured a clinical post and settled down to many years of loyal, hard work. After a long and successful career, you retired early, drew your pension and, quite possibly, went back to work.

For many doctors, the NHS pension was a source of light at the end of a very long tunnel. Unfortunately 40-year-old doctors will have to join the 2015 NHS pension, a career average earnings scheme with a much later normal retirement age. This means more needs to be added to the retirement pot now if you want to be financially independent in the future. The tax-free lump sum will only be available by giving up valuable index-linked pension income at retirement.

As we know, surgeons today are facing a very different landscape. More limited training opportunities, frozen pay levels and watered-down pensions ensuring your consultancy post now feels very much like an employed position. Fifteen years ago I doubt the average consultant knew they had a line manager. Now it is quite possible that your ‘boss’ is 15 years younger than you and has recently graduated from a town you didn’t even know had a university. You may have less authority than even before and yet you are probably being encouraged to contribute more to management. You may have entered medicine with the expectation of being a clinician but your role has developed into that of a clinician manager. Researchers have shown that training opportunities are being lost in orthopaedics as a result of the implementation of working time directives. So as the junior doctors are unable to step up to the mark due to a lack of experience, you could well be completing low level tasks as well as managing more duties at the top. Last year’s widely-criticised Public Accounts Committee (PAC) report on the consultant contract is still causing reverberations. It declared the consultant contract ‘poor value for money to the taxpayer’ and stated that NHS management has to get tougher with doctors. Now we steel ourselves as negotiations continue on changing the consultant contract focussing on seven-day services, pay progression and CEAs. CEAs have already been effectively devalued. In the run up to retirement, high-achieving consultants could work towards CEAs to achieve recognition for their efforts and boost their final salary. If you receive an award now, however, you may enjoy a congratulatory slap on the back but could also

None of this will encourage the brightest students to consider a consultancy career. Even before pay becomes performance instead of time-related (in order to reward a ‘well-motivated, stable workforce’ of course) figures show that consultants’ pay has been outstripped by inflation while that of NHS managers has increased by 13 per cent since 2009. While it is still possible to ‘retire and return’ to your position, there is less guarantee of how long you might be employed. More than ever before consultants must take stock of their financial situation and consider how these relentless changes can impact their longterm plans. Decide now what your ideal retirement might look like in terms of the amount of income you might need and how that standard of living can be maintained. Your finances – however complex – should be working just as hard as you. The good news is that with expert help many senior consultants now have strategies in place to accomplish their own financial objectives. In the new NHS world of profit and revenue, your career path is no longer in the safe hands of your employer. Time to take control of your retirement too – and by this achieve a greater sense of being in control of your destiny.

Cavendish Medical is a specialist financial practice helping senior medical practitioners in private practice and the NHS. To discuss your financial plans in confidence, call Cavendish on 020 7636 7006. www.cavendishmedical.com

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▼This medicinal product is subject to additional monitoring Xarelto® 10 mg film-coated tablets (rivaroxaban) Prescribing Information (Refer to full Summary of Product Characteristics (SmPC) before prescribing) Presentation: 10 mg rivaroxaban tablet. Indication(s): Prevention of venous thromboembolism (VTE) in adult patients undergoing elective hip or knee replacement surgery. Posology and method of administration: Dosage 10 mg rivaroxaban orally once daily; initial dose should be taken 6 to 10 hours after surgery provided haemostasis established. For patients who are unable to swallow whole tablets, refer to SmPC for alternative methods of oral administration. Recommended treatment duration: Dependent on individual risk of patient for VTE determined by type of orthopaedic surgery: for major hip surgery 5 weeks; for major knee surgery 2 weeks. Refer to SmPC for full information on duration of therapy & converting to/ from Vitamin K antagonists (VKA) or parenteral anticoagulants. Renal impairment: Mild & moderate (creatinine clearance 5080ml/min & 30-49 ml/min respectively) – no dose adjustment; severe (creatinine clearance 15-29ml/min) - limited data indicate rivaroxaban concentrations are significantly increased, use with caution. Creatinine clearance < 15ml/min –not recommended. Hepatic impairment: Do not use in patients with coagulopathy & clinically relevant bleeding risk including cirrhotic patients with Child Pugh B & C patients. Paediatrics:

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Not recommended. Contra-indications: Hypersensitivity to active substance or any excipient; active clinically significant bleeding; lesion or condition considered to confer a significant risk for major bleeding (refer to SmPC); concomitant treatment with any other anticoagulants except when switching therapy to or from rivaroxaban or when unfractionated heparin is given at doses necessary to maintain an open central venous or arterial catheter; hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B & C; pregnancy & breast feeding. Warnings and precautions: Not recommended in patients: undergoing hip fracture surgery; receiving concomitant systemic treatment with strong CYP3A4 and P-gp inhibitors, i.e. azole-antimycotics or HIV protease inhibitors; with creatinine clearance <15 ml/min. Please note - Increased risk of bleeding, therefore careful monitoring for signs/symptoms of bleeding complications & anaemia required after treatment initiation in patients: with severe renal impairment; with moderate renal impairment concomitantly receiving other medicinal products which increase rivaroxaban plasma concentrations; treated concomitantly with medicinal products affecting haemostasis; with congenital or acquired bleeding disorders, uncontrolled severe arterial hypertension,

active ulcerative gastrointestinal disease (consider appropriate prophylactic treatment for at risk patients), vascular retinopathy, bronchiectasis or history of pulmonary bleeding. There is no need for monitoring of coagulation parameters during treatment with rivaroxaban in clinical routine. If clinically indicated rivaroxaban levels can be measured by calibrated quantitative anti-Factor Xa tests. Take special care when neuraxial anaesthesia or spinal/epidural puncture is employed due to risk of epidural or spinal haematoma with potential neurologic complications. Elderly population – Increasing age may increase haemorrhagic risk. Xarelto contains lactose. Interactions: cf. Warning and precautions Avoid co-administration with dronedarone. Use with caution in patients concomitantly receiving NSAIDs, acetylsalicylic acid (ASA) or platelet aggregation inhibitors due to the increased bleeding risk. Concomitant use of strong CYP3A4 inducers should be avoided unless patient is closely observed for signs and symptoms of thrombosis. Pregnancy and breast feeding: Contra-indicated. Effects on ability to drive and use machines: syncope (uncommon) & dizziness (common) were reported. Patients experiencing these effects should not drive or use machines. Undesirable effects: Common: anaemia, dizziness, headache, eye haemorrhage,

hypotension, haematoma, epistaxis, haemoptysis, gingival bleeding, GI tract haemorrhage, GI & abdominal pains, dyspepsia, nausea, constipation, diarrhoea, vomiting, pruritus, rash, ecchymosis, cutaneous & subcutaneous haemorrhage, pain in extremity, urogenital tract haemorrhage, renal impairment, fever, peripheral oedema, decreased general strength & energy, increase in transaminases, post-procedural haemorrhage, contusion, wound secretion. Serious: cf. CI/Warnings and Precautions – in addition: thrombocythemia, angioedema and allergic oedema, occult bleeding/haemorrhage from any tissue (e.g. cerebral & intracranial, haemarthrosis, muscle) which may lead to complications (incl. compartment syndrome, renal failure, fatal outcome), syncope, tachycardia, abnormal hepatic function, renal impairment; hyperbilirubinaemia, jaundice, vascular pseudoaneurysm following percutaneous vascular intervention. Prescribers should consult SmPC in relation to full side effect information. Overdose: No specific antidote is available. Legal Category: POM. Package Quantities and Basic NHS Costs: 10 tablets: £21.00, 30 tablets: £63.00 and 100 tablets: £210.00. MA Number(s): EU/1/08/472/001-10 Further information available from: Bayer plc, Bayer House, Strawberry Hill, Newbury,

Berkshire RG14 1JA, U.K. Telephone: 01635 563000. Date of preparation: January 2014. Xarelto® is a trademark of the Bayer Group.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Bayer plc. Tel.: 01635 563500, Fax: 01635 563703, Email: phdsguk@bayer.co.uk References: 1. Xarelto 10 mg Summary of Product Characteristics. United Kingdom: Bayer Healthcare AG. 2. Lassen M, et al. N Engl J Med. 2008;358:2776–86. 3. Patient data are based on internal calculations of IMS sales data (Source: IMS MIDAS Database: Monthly Sales, January 2014).

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 32

JTO Features

Litigation in trauma and orthopaedic surgery John T Machin, Timothy WR Briggs Contributors: Harry Krishnan, Shahrier F Saker, Jagmeet S Bhamra, Elizabeth Gillott

Litigation in health has dramatically increased since it became mandatory for the National Health Service Litigation Authority (NHSLA) to be informed of all claims against NHS trusts in England. Before 2002 there was no complete record of litigation as trusts did not routinely inform the NHSLA regarding smaller claims. This rise in litigation is not surprising; there has been a change in society as a whole reflected in a less trusting public and a more active promotion of legal services. These changes have been matched by key rulings from the House of Lords. Chester vs Afshar (2004) raised the standard of acceptable care and confirmed the responsibilities of the surgeon to provide informed consent1. The rate of litigation and its cost continue to rise at an uncontrollable rate.

John Machin

Tim Briggs

The NHSLA has reported a year on year increase in claims. Between 2007/2008 and 2011/2012 there was a mean number of claims per year of 7202 with a total of 9143 new clinical claims in 2011/20122. NHSLA estimates there are £18.9 billion of potential clinical negligence claims against the NHS2. Surgical specialities are associated with higher rates of litigation3. In the NHSLA report and accounts 2012/13 orthopaedics was found to have the largest expenditure with the exception of obstetrics and gynaecology. Trauma and orthopaedic surgery has always been considered a highly litigious specialty due to the quantity of work undertaken and the subsequent problems if mistakes or complications occur. Medical indemnity insurance companies classify orthopaedics as the third highest risk specialty behind obstetrics and neurosurgery. The Medical Defence Union (MDU) expects a claim against orthopaedic surgeons practicing independently every eight years compared to every 35 years in specialities such as anaesthetics4. The total cost of orthopaedic claims has risen by 60% over the last three years compared to a 12% rise in overall NHS litigation claims during the same time period5. The MDU, Britain’s largest defence union’s review of claims in orthopaedic surgery found that the average settlement was in excess of £60,000.6 Especially concerning is the rise in proportion of total legal costs accounted for by the claimants’ lawyer which has risen to nearly 80%. The NHSLA has found that the growing use of Conditional Fee Agreements in NHS litigation cases has resulted in the legal costs outstripping the value of damages paid to the patient2.

Previously published work relates to claims before the NHSLA received all claims and as a result do not reflect the total litigation in orthopaedics3,7,8,9. The majority of studies have focused on closed or successful litigation against the NHS. However the mean claim in 2012/13 took over a year to close and in previous years this was an even longer process resulting in a delay in publication of current trends2. The importance of reviewing both closed and open claims is well summarised by the Rt Hon Lord Justice Jackson. He said ‘Litigation is, however, a matter of last resort. There is a huge need to prevent claims arising in the first place. That is by far the most effective way to reduce legal costs and to promote patient satisfaction.’3 The aim of this study therefore was to provide current trends in ligation against trauma and orthopaedic surgery from the NHSLA database from the first year of full notification. To determine whether there was a rise in litigation in orthopaedic surgery consistent with the rise seen across the NHS and to elicit the main causes in order to aid awareness and to allow the development of strategies to improve practice, improve patient satisfaction and reduce legal costs.

Materials and Methods We made a formal request to obtain all data regarding claims against ‘Orthopaedic Surgery’ from the NHSLA database of NHS trusts in England since the registration of all claims became mandatory. This category included all trauma and elective work and all open and closed cases without exclusion between April 2003 and April 2012. The information supplied included: claim status (whether open or >>

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 33

closed), incident date, claim details, the costs incurred of closed claims (damages paid, defence costs paid, claimant costs paid and total paid) and the Strategic Health Authority (SHA) to which the provider receiving the claim had previously been associated. Global trends were reviewed for all financial years from 2003/2004 to 2011/12. A claim by claim analysis was made during the last five years of data from 2007/2008 to 2011/12,

during which period there has been the greatest rise in claims. A team of researchers using a set protocol divided claims according to trauma and elective work, sub-specialty, operation performed and cause of claim. Causes of claims were determined by the definitions in Table 1. Due to the multifactorial nature of the claims often more than one cause was attributed to each claim. This has therefore resulted in more causes identified than claims listed. Of the closed cases those that had no costs were defined as those

that were successfully defended. An estimated cost is calculated by the NHSLA based on the current costs from closed cases and the predicted cost of open cases. The percentage of cases in each former SHA per head of population was calculated. This was displayed on a funnel plot using the variance between SHAs to determine those that are greater than 3 standard deviations from the mean which were regarded as outliers.

Results From 2003/2004 to 2011/12 there were 9009 claims registered with the NHSLA against ‘Orthopaedic Surgery’. Of these 6989 claims (77.58%) were closed with a combined cost of £384 million. However the NHSLA estimates that closing the remaining claims could result in an overall total cost of £897 million (calculated from NHSLA July 2012 estimates). Over the nine year period a total of 36 of the closed claims cost over £1 million to settle. >>

Cause

Description

Accidental Injury

Injury that occurred whilst patient was under orthopaedic care either in theatre, ward or outpatients including burns, lacerations and falls.

Amputation

Any presentation which resulted in amputation as a result of negligent care or treatment

Cauda Equina

Claims relating to cauda equina syndrome

Compartment Syndrome

Claims relating to compartment syndrome

Consent

Any claim relating to dissatisfaction with consent

Death

Death for any cause

Dislocation

Any claim involving joint dislocation

Equipment/Implant

Claims relating to incorrect equipment or implant use including wrong alignment, size or incorrect implant

Infection

Infection both deep and wound as well as systemic infection such as pneumonia and hospital acquired infections (MRSA etc.)

Interpretation of Results/ Clinical Picture

Any claim relating to clinical assessment, interpretation of results or clinical signs

Judgement/ Timing

Any claim relating to alleged incorrect decision-making following the correct interpretation of results and clinical picture. Includes inappropriate delays once the correct decision had been made.

Limb Length Discrepancy

Claims relating to limb length discrepancy

Mobility

Any claim relating to mobility of the patient or decreased range of movement at a joint.

Nerve Damage

Any claim involving nerve damage

Pressure Sores

Any claim involving pressure sores

Retained Instrument Post-operation One or more instruments or swabs unintentionally retained following an operative procedure – Never Event Tissue Damage

Claims relating to damage of any tissue including neurological or vascular injury

Tumour / Cancer

Any claims relating to neoplastic disease

Unsatisfactory Outcome to Surgery

Any claim relating to dissatisfaction with the result of a surgical procedure

Venous Thromboembolic Events

Any claim with reference to Deep Vein Thrombosis or Pulmonary Embolism

Wrong Operation

Claim alleging the incorrect procedure was performed

Wrong Site Surgery

Claim relating to a surgical intervention performed on the wrong site, the patient requires further surgery, on the correct site, and/or may have complications following the wrong surgery – Never Event

Table 1: Causes which claims were reviewed against

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JTO Features

The highest single claim was £2.3 million paid in 2006/2007 for allegation of a failure to act to reduce dislocation and relieve pressure on spinal cord resulting in the claimant becoming quadriplegic following a sporting injury.ll ll

Figure 2: Variation in percentage of population making clinical negligence claims against orthopaedic surgery between 2007/2008 and 2011/2012 across Strategic Health Authorities. SHA population based on the ONS National Population Census 2001. (1= North East, 2= South Central, 3=South East Coast, 4=East Midlands, 5=South West, 6=Yorkshire and the Humber, 7=West Midlands, 8=East of England, 9=North West, 10=London).

Figure 1: Litigation claims against surgical specialities

Year

2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

2010-2011

2011-2012

Total Claims Received

846

810

822

835

935

956

1061

1271

1474

Total Claims Closed

845 (99.88%)

807 (99.63%)

818 (99.51%)

821 (98.32%)

905 (96.79%)

852 (89.12%)

855 (80.58%)

778 (61.21%)

308 (20.90%)

Total Claims Open

1 (0.12%)

3 (0.37%)

4 (0.49%)

14 (1.68%)

30 (3.21%)

104 (10.88%)

206 (19.42%)

493 (38.79%)

1166 (79.10%)

Total Claims Successfully Defended

310

289

290

279

259

245

203

156

104

Percentage of Closed Claims Successfully Defended 36.69%

35.81%

35.45%

33.98%

28.62%

28.76%

23.74%

20.05%

33.77%

Total Cost of Closed Claims (£million)

Total Predicted Cost of Claims (£million)

110

124

159

187

Table 2: Claim volume against orthopaedic surgery from 2003/2004 to 2011/2012 Of these claims 13 were related to spinal surgery with claims resulting from delayed/failed treatment of cauda equina syndrome, negligent spinal decompression and failure to remove haematoma from the spine resulting in neurological deficit. A further five of the most expensive claims related to negligent total knee replacements resulting in amputation. The remainder of claims costing over £1 million were related to delayed or inappropriate surgical treatment of long bone trauma,

failure to diagnose bone tumour, failure to diagnosis compartment syndrome, acetabular fracture during hip surgery, vascular injury during total hip replacement and knee arthroscopy. The highest single claim was £2.3 million paid in 2006/2007 for allegation of a failure to act to reduce dislocation and relieve pressure on the spinal cord resulting in the claimant becoming quadriplegic following a sporting injury.

Comparison with other surgical specialities When comparing against other surgical specialities, claims against orthopaedics are increasing (Figure1). Over 25% of all surgical interventions in the NHS are musculoskeletal5. In 2003/2004 orthopaedics represented 45.46% of all surgical claims, which rose to 49.93% by 2011/12. Throughout

orthopaedics has remained the specialty against which most litigation claims have been made in surgery, with the exclusion of obstetrics and gynaecology.

Trends Total Claims against orthopaedics have increased yearly since 2004/2005. Peaking at 2011/2012 with 1474 claims (Table 2). When 2003/2004 is compared

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 36

JTO Features

to 2011/2012 we find a 74.23% increase in yearly claim volume. During the same period the estimated cost of yearly claims rose 356% from ÂŁ41million to ÂŁ187million (as calculated by the NHSLA, July 2012). There is a geographical variation in the percentage of a population making clinical negligence claims when the country is divided up into the former SHAs. Rates of litigation are highest in the Yorkshire and the Humber and North West (Figure 2 - page 34). >>

Figure 3: Causes of litigation claims against orthopaedic surgery 2007/08 to 2011/12 Cause of Litigation

Foot & Ankle

Hand

Hip

Knee

Shoulder & Elbow Spine

Accidental Injury Amputation

15 (7.28%) 10 (4.85%)

17 (9.44%) 7 (3.88%)

44 (18.41%) 2 (0.84%)

18 (8.37%) 6 (2.79%)

15 (11.62%) 0 (0%)

13 (12.75%) 0 (0%)

Cauda Equina

0 (0%)

12 (11.76%)

Compartment Syndrome

1 (0.49%)

1 (0.56%)

0 (0%)

Consent

4 (1.94%)

5 (2.78%)

3 (1.26%)

12 (5.58%)

8 (3.72%)

6 (5.88%)

Death

3 (1.46%)

1 (0.56%)

11 (4.6%)

3 (1.40%)

0 (0%)

Equipment/Implant

8 (3.88%)

6 (3.33%)

32 (13.39%)

21 (9.77%)

8 (3.72%)

3 (2.94%)

Infection

22 (10.68%)

5 (2.78%)

23 (9.62%)

25 (11.63%)

11 (5.12%)

11 (10.78%)

Interpretation of results/ clinical picture

72 (34.95%)

77 (42.78%)

49 (20.50%)

44 (20.47%)

33 (15.34%)

50 (49.02%)

Judgement/ Timing

100 (48.54%)

93 (51.67%)

106 (44.35%)

82 (38.14%)

64 (29.77%)

53 (51.96%)

Mobility

80 (38.83%)

42 (23.33%)

122 (51.05%)

83 (38.60%)

32 (14.88%)

28 (27.45%)

Nerve Damage

15 (7.28%)

18 (10.00%)

25 (10.46%)

9 (4.19%)

16 (7.44%)

44 (43.14%)

Retained items

5 (2.42%)

4 (2.22%)

4 (1.67%)

6 (2.79%)

3 (1.40%)

3 (2.94%)

Tissue Damage

97 (47.09%)

76 (42.22%)

104 (43.51%)

83 (38.60%)

55 (25.58%)

59 (57.84%)

Unsatisfactory Outcome to Surgery

121 (58.74%)

76 (42.22%)

177 (74.06%)

149 (69.30%)

70 (32.56%)

74 (72.55%)

Venous Thromboembolic Events

8 (3.88%)

0 (0%)

1 (0.42%)

5 (2.33%)

0 (0%)

Wrong Operation

5 (2.42%)

3 (1.67%)

6 (2.51%)

7 (3.26%)

5 (4.65%)

0 (0%)

Wrong Site Surgery

2 (0.97%)

4 (2.22%)

1 (0.41%)

2 (0.93%)

1 (0.78%)

5 (4.90%)

Table 3: Causes of litigation claims for sub-specialities of orthopaedic surgery in 2011/2012

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It has been suggested that orthopaedics and more specifically spinal surgery as well as total hip and knee arthroplasty are not suffering from the same clinical negligence problem as the rest of the NHS..ll ll

Analysis of 2007/2008 to 2011/2012 Over this five year period there were 5697 claims of which 2369 (41.58%) were against trauma work, 2264 (39.74%) were against elective work, and 1064 (18.68%) could not be classified from the description. Claims according to sub-specialty: 924 (16.02%) Knee, 909 (16.00%) Hip, 741 (13.01%) Foot & Ankle, 650 (11.41%) Hand (including forearm), 480 (8.43%) Spine, 360 (6.32%) Shoulder & Elbow, 9 (0.16%) Pelvis & Acetabulum. The remaining claims could not be classified into subspecialty.

Causes of claim The most common causes contributing to claims from 2007/2008 to 2011/2012 were ‘unsatisfactory outcome to surgery’ (3030 claims, 53.19%), ‘judgement/ timing’ (2904 claims, 50.97%), ‘interpretation of results/clinical picture’ (2369 claims, 41.58%), ‘tissue damage’ (1801 claims, 31.61%) and ‘mobility’ (1545 claims, 27.12%) (Figure 3). The same claims are seen to be most common in each year when reviewed separately. Furthermore, when reviewing the claims by sub-specialty from 2011/2012 these five causes are the most common in foot & ankle, hand, hip, knee and shoulder & elbow. Even in spinal surgery the common causes are the same with the addition of nerve injury instead of mobility in the top five causes (Table 3).

Discussion The rate of litigation in orthopaedic surgery is increasing on a year on year basis in the NHS with a 16% increase between 2010/2011 and 2011/2012 compared to only 6% increase in claim volume for the NHS as a whole. It has been suggested that orthopaedics and more specifically spinal surgery as well as total hip and knee arthroplasty are not suffering from the same clinical negligence problem as the rest of the NHS8, 10. One of the key limitations of studies using the NHSLA records is NHSLA principally collects data for legal purposes. As a result there is an issue concerning the clinical information that is available for analysis. Despite full access to the database some claims are unable to be fully categorised including by sub-specialty and procedure due to insufficient clinical detail. Unfortunately, studies carrying out such specific analysis are at risk of under reporting litigation rates. It has been proposed that although there is a rise in litigation in total hip and knee arthroplasty this increase has been out-stripped by the rise in activity8. However looking at trauma and orthopaedics as a whole between 2010/2011 and 2011/2012 there was a 1.6% rise in activity as indicated by Finished Consultant Episodes (FCE) recorded by the Hospital Episode Statistics, far less than the increase in claims11. Even considering that patients have three years from an event to commence their legal claim, the rise in FCE from 2008/2009 to 2011/12 was only 8%11. When comparing orthopaedics to other surgical specialities its growing size and dominance (49.93% of surgical claims) over other surgical specialities illustrates that litigation in orthopaedic surgery is a problem

increasing at a greater rate than litigation as a whole in the NHS. The rise in costs related to this trend cannot be ignored with a potential estimated cost of £897 million over a nine year period in a specialty attempting to reduce costs to contribute to £15-20billion of efficiency savings by 201512. This is a not insignificant number when it is considered this equates to the cost of between 163,000 and 176,000 primary joint replacements13,14. It is clear that the financial problem must be addressed if the specialty is to avoid rationing of even its most effective treatments. The financial costs for certain orthopaedic sub-specialities are higher than others with over a third of cases costing greater than £1million being related to spinal surgery. This is a pattern that is borne out in other studies both in the United States and in private practice in the UK and therefore surgeons working in this area especially must adapt their practice to reduce suspicion of negligent care4,15. It is possible that not all claims have been included in the complete dataset and this may be due to some cases where negligence has not been proven but a settlement has been made to avoid the creation of a case. Certain claims may be under reported in the dataset due to co-liability. These claims may have not reached the NHSLA even though they could have been brought against the NHS as they have been instead brought against another

party. An example of this is a patient making claims against an implant manufacturer rather than the NHS trust that carried out their operation. This issue of co-liability may in part explain why there were only two claims in 2011/12 related to metal on metal hip replacements. Unfortunately, ‘never events’ still occur on a yearly basis. Between 2007/2008 and 2011/2012 128 claims were made regarding ‘retained instruments’ and 62 claims relating to ‘incorrect site of surgery.’ These events represent system failure and are patient safety issues that can be eradicated by more diligent organisation and closer adherence to tools including the World Health Organisation checklist. It is encouraging that claims relating to consent are fairly infrequent, 62 claims (4.21%) in 2011/12. However, it is important to recognise that the benefit of informed consent with a discussion including the possible risks would not only reduce claims directly linked by the patient to consent but would also decrease patient’s dissatisfaction with surgery which is the major cause of claims. These submitted claims are based on the patient’s perception of negligence. Although there is not an agreed method of claim analysis >>

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JTO Features

Lessons can be learned from all claims brought whether or not they are successfully defended.ll ll

between studies there is common themes amongst the causes of litigation. ‘Failure to protect structures in the surgical field’, ‘technical errors’ and ‘other surgical errors’ are frequently reported as common causes and would include the claims identified in our study as ‘unsatisfactory outcome to surgery’ and ‘tissue damage6,15. Strategies to prevent these claims could include an increased number of procedures in surgical training and the improvement in education provided to surgeons once trained. Other common causes

such as ‘judgement/ timing’ and ‘interpretation of results/clinical picture’ could also be overcome by increased experience while training as well as the creation of structured approaches to patient management. Regrettably the NHSLA does not record the seniority of the surgeon against which claims have been made so we cannot provide evidence of the expected benefit of experience and training. There is concern that the rise in litigation has promoted the

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practice of defensive medicine which although in the main can lead to an improvement in care has also led to surgeons ordering unnecessary investigations and restricting their practice to avoid patients or procedures that are thought to be high risk.16 However, surgeons should be advised when considering high risk procedures, which are not part of their regular practice, to consider referral to a high volume specialist centre which has the critical mass of expertise to maximise patient safety and satisfaction in such procedures. Indeed analysis of claims by division of providers into the former SHA’s demonstrates that litigation rates are not uniform throughout the country however, it is beyond the scope of this study to explain these differences as a more detailed analysis of each individual healthcare provider within the SHAs would be required.

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Litigation is a growing problem for orthopaedic surgery. The current trend and resulting costs are unsustainable. Most orthopaedic surgeons will face a negligence claim during their career17, 18. Lessons can be learned from all claims brought whether or not they are successfully defended and these need to be disseminated to the profession. We believe the common causes for claims are preventable. Specialists being given sufficient time to analyse and discuss the patient’s problems, proposed treatment and manage expectations could reduce claim volume. n

John Machin is a Specialist Registrar at Queen Medical Centre in Nottingham. He is a contributor to the ‘Chavasse Report’ and the national pilot of ‘Getting It Right First Time’. He is a member of the BOA Medical Negligence working party set up in response to the pilot. Professor Briggs is Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital Trust and also Medical Director until May 2012. He is the President of the British Orthopaedic Association and is also the Chairman of the Federation of Specialist Hospitals and Chairman of the National Clinical Reference Group for Specialist Orthopaedics. His special interests are reconstruction of the lower limb, as well as sports injuries of the knee and orthopaedic oncology. 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

Litigation claims following arthroscopic knee surgery Will Harrison Contributors: Graeme Wilson, K. Henry Rourke, Joanne Banks

Litigation claims within orthopaedic surgery are the fifth most frequent of all medical specialties1 and are becoming more common in England and Wales2. Orthopaedics accounts for over 40% of litigation across all surgical specialties3. Compensation for proven negligence is awarded on the basis of pain, suffering and loss of amenity as well as the financial losses to the claimant. Surgery of the knee is widely practiced and has a high commercial value. A recent five centre doubleblinded RCT of partial arthroscopic meniscectomy versus sham surgery showed no statistical improvement within the first 12 months4. Despite this, arthroscopic knee surgery is becoming more frequent annually5. There are an estimated 700,000 knee arthroscopies performed each year in the United States of America, with a combined cost $4 billion6. In addition, litigation in the USA has become a major cost and burden to healthcare providers7.

The National Health Service has an established Litigation Authority (NHSLA), founded in 1995, which acts as a mediator for all malpractice claims in England and Wales. All hospital trusts are mandated to provide the NHSLA with details on litigation proceedings. The NHSLA estimated potential liabilities of £16.6 billion across all areas of healthcare8. Previous literature from McWilliams et al on litigation claims following hip and knee arthroplasty surgery have demonstrated significant costs. Over a 15 year period there were 523 claims for knee replacement which cost £21 million9. The current paper analyses the same NHSLA database over the same 15 year period. The British Orthopaedic Association has commented that rising litigation costs are no longer sustainable for the modern NHS10. Our aim was to identify patterns of litigation within arthroscopic knee surgery and provide learning points to protect clinicians from malpractice claims.

Methods Will Harrison

Data was obtained through the NHSLA using the Freedom of

Information Act and was extracted in July 2013. There were 9,865 orthopaedic litigation claims between 1995-2010 within England and Wales available for analysis. The NHSLA database contains a case narrative with a synopsis of the claimants’ complaint. It also details the date of alleged negligence, the date of claim creation, the compensation award and defence costs. Litigation specifically relating to arthroscopic knee surgery was identified within the case narratives using search terms relating to arthroscopy and cruciate ligament reconstruction. Unsettled cases were excluded. Patterns of litigation, subsequent compensation and defence costs were analysed.

Results There were 342 claims relating to arthroscopic knee surgery of which 217 have been settled and are therefore eligible for inclusion in this series. Of these, 125 (58%) were deemed negligent resulting in compensation. Anterior cruciate ligament reconstruction was implicated in 71 cases (33%). A classification of the claim profiles is detailed in Table 1, ranked according to the cumulative cost to the NHS. The sum total of compensation and defence costs was £10 million. The mean compensation per claimant was £47,440 (median £20,000, range £500–£1,270,666). Total defence costs were £4.1 million with a mean cost per case of £18,783, (range £0-180,540).

Conclusions The cumulative cost of over £10 million demonstrates that arthroscopic knee surgery carries a significant litigation burden. McWilliams et al demonstrated that knee arthroplasty resulted in more than twice the number of litigation claims (n=538) than in this series of knee arthroscopy claims (n=217)9. Both papers analyse the same NHSLA database over the same 15 year period. The majority of negligence claims result from events in the intraoperative period. A single case of popliteal artery injury during arthroscopy resulting in amputation had cumulative cost of £1.45 million. Vascular injuries were also the most costly per case in the McWilliams et al arthroplasty litigation paper9. There were five incidences of wrong site surgery. One episode related to an anaesthetist placing the tourniquet and shaving the leg on the incorrect side whilst the surgeon scrubbed. Focused team engagement in the WHO checklist is paramount in preventing “Never Events”. Surgeons are also urged to review the National Patient Safety Guidelines for limb marking preoperatively (www.npsa.nhs.uk). Consenting issues (n=7) related to further procedures being performed without informed consent, for example unplanned microfracture for osteochondral

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 40

JTO Peer Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 39&40 Title: Litigation claims following arthroscopic knee surgery Author: Will Harrison

Number

Cumulative cost (£)

Mean (£)

Median (£)

ACL failure (non-specific)

1,469,000

75,400

67,000

Vascular injury

1,450,000

ACL graft failure

1,413,000

109,000

44,000

Infection

1,400,000

108,000

85,000

Nerve injury

920,000

84,000

64,000

Graft harvest injury

676,000

225,000

244,000

Unknown

445,000

64,000

25,000

Failure to follow-up

444,000

111,000

7,000

Retained metal

279,000

25,000

13,000

Burns

242,000

35,000

12,000

Consent

200,000

24,500

15,000

Delayed diagnosis

182,000

36,000

19,000

Missed diagnosis intra-op

127,000

43,000

14,000

Pain (non-specific)

120,000

24,000

14,000

Wrong site surgery

98,000

20,000

13,000

Carbon fibre graft

98,000

Deep vein thrombosis

50,000

25,000

n/a

Tourniquet damage

35,000

12,000

5,000

Compartment syndrome

31,000

Scarring

2,000

Unsterile equipment

500

Table 1: Litigation claims following arthroscopic knee surgery defects. Obtaining consent on the ward and in preoperative waiting areas has been shown to increase the risk of litigation compared to clinic (p<0.004)11. Documenting the discussion of surgery with the patient is also advised, for example, a dictated record in the clinic letter. The NHSLA database is one of the largest data records of medico legal negligence claims in the world. However, the limitations in our database analysis are inherent in the quality of the content. The case narrative used to classify claims is created by legal administrators, not clinicians. As such, the necessary detail to identify specific learning

points for each case is lacking. This is reflected by the seven cases with unknown reasons for litigation (Table 1). Litigation relating to post-operative management often featured in the case narrative. For example, patients with infection (n=13) are not awarded compensation for this recognised complication, but rather for a lack of early recognition or protocol driven follow-up. Surgeons should be aware of the relevant causes of litigation and have strategies to optimise patient communication, patient safety and follow-up protocols. Consenting surgeons should consider the results

above when discussing potential complications of arthroscopic knee surgery with patients. n

Correspondence:

Will Harrison is an Orthopaedic Registrar in Liverpool with an interest in trauma and medico-legal research. He has published work on litigation following scaphoid fractures and has presented internationally on litigation following non-technical errors and long bone fractures.

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

Email: will.d.harrison@gmail.com

Avoiding Litigation in the Treatment of Wrist Fractures Grey Giddins Ilana Langdon

Wrist fractures are common. Some are complicated, such as highly comminuted distal radial fractures or trans-scaphoid peri-lunate dislocations. However, even straightforward cases cause litigation claims, most of which appear avoidable3. The aim of this article is to identify the common pitfalls and how to avoid them.

Radiographs It is the responsibility of the requesting clinician to ensure adequate radiographic views. Remember to check for carpal injuries, including scapho-lunate dissociation on the postero-anterior (PA) radiograph and check distal radio-ulnar joint (DRUJ) alignment on the lateral radiograph, not merely focus on alignment.

Decision to Operate

extra-articular fractures5,7 (Table 1). Well beyond these parameters the decision making is usually easy. However, treatment may be recommended below these parameters for patients with high functional demands. Decision making is difficult at or around these parameters or if there are concerns regarding co-morbidities or compliance. It is important to hold a detailed, informed, consent process with the patient; ultimately it is their decision. This must be recorded clearly in the notes. In doubt, take the opinion of more than one clinician and again record in the notes.

Mainly seen on the PA radiograph: Shortening of <2mm, loss of ≤10o of radial inclination intra-articular step of ≤2mm Mainly seen on the lateral radiograph: ≤10o dorsal tilt (i.e. dorsal tilt of ≤ 21o from the normal volar tilt of 11o)

Re-manipulation Re-manipulation does not improve outcome6. If a fracture displaces following a satisfactory manipulation in the Emergency department, re-manipulation is very unlikely to help. When a patient is reluctant to have open surgery remanipulation can be of value. The patient needs to be counselled carefully. As always, the key is the consultation with the patient, which should not be rushed, and maintain detailed records.

Follow up in the Fracture Clinic

Well established parameters guide decision-making, particularly for

Grey Giddins

Table 1 - Acceptable parameters for distal radius fractures

Ilana Langdon

It is well recognised that distal radial fractures may displace for “up to 2 weeks” following the injury. If a fracture has not displaced significantly either from the original radiographs or from the original post-manipulation radiographs, then at two weeks from injury it is very unlikely to displace further and it is reasonable to continue to immobilise in plaster. “Two weeks” means at least 12 days. Ten and even 11 days are not enough. It is easy to bring the patient back the following week for another radiograph. This is simple, relatively low cost to the patient and NHS, and avoids litigation.

There is a mistaken belief that beyond two weeks there will “never” be further displacement. If at two weeks the fracture has displaced in the preceding week it must be assumed to be mobile unless proven otherwise, by repeating the radiographs in another week. The most important lesson of this article is that if a fracture is displacing, i.e. the position is worse than a week before, then just because a patient has reached the two week mark, it does not mean that the fracture will not continue to displace. They should continue to be reviewed, unless surgery is indicated. Some patients may need review up to four weeks.

Choice of Operation There is a recent trend towards the use of volar locking plates. Recent research, particularly the provisional findings from the DRAFFT trial suggests that K-wiring of fractures gives equivalent outcome to volar plating, providing there is an adequate position on closed manipulation. The choice is not critical. Both options appear acceptable.

Performance of K-wiring Biomechanically a better reduction is more stable. Dorsal comminution adversely affects stability. Typically 3-4 1.6mm K-wires should be used with more wires in less stable reductions. The optimal configuration is unproven; most combinations, including intra-focal wiring, appear reasonable.

Performance of Volar Locking Plating This is technically a difficult operation. Many complications have >>

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 42

JTO Peer Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 41&42 Title: Avoiding Litigation in the Treatment of Wrist Fractures Authors: Mr Grey Giddins & Miss Ilana Langdon

been described1,2. The key steps include: • Ensuring the distal row of screws is reasonably parallel with the articular surface of the distal radius so that as the plate is applied proximally, there is correct alignment. • It is easy with locking plates for the plate to sit off the bone. Using a non-locking screw as the first screw in the distal plate pulls the plate onto the bone; subsequent screws/pegs can be locking; • The distal screws/pegs should not be too long. On the lateral radiograph the screws or pegs should end around 3-6 mm short of the dorsal cortex not least as the base of the 3rd dorsal compartment is usually up to 3mm volar to the radiographic shadow of the dorsal cortex. Rarely should a distal screw/peg be >22mm long. • It is easy to place the tip of the screws in the radial carpal joint or the DRUJ. That is not a breach of duty of care, but leaving the screws misplaced is. Take and scrutinise perioperative radiographs carefully.

Figure 1: At 10 days postoperatively the distal ulna has started to sublux dorsally following volar plating. The patient had < 100 supination. Over the four weeks following surgery the distal ulna dislocated dorsally

• Avoid missing DRUJ abnormality (Figure 1); assess forearm rotation at closure.

Follow Up Care Soft Tissue: Too often the focus is on the radiographs. Soft tissue problems such as carpal tunnel syndrome, EPL rupture or complex regional pain syndrome (CRPS) are overlooked. Patients should achieve virtually full finger and thumb movement within 10-14 days of injury or surgery. If not, initiate investigation and appropriate treatment. Bone Alignment: In non-operative treatment, bone alignment should be checked as above. Repeat radiographs: While it is tempting to accept peri-operative radiographs, a post–operative radiograph is recommended at the first clinic visit. Many times an abnormality is shown on postoperative radiographs, which was not clear before. In particular, take specific radiographs demonstrating screw placement. There is rarely a good reason for leaving a screw in the radio-carpal joint or DRUJ. Failed K-wiring of distal radial fractures: The management of an unacceptable distal radial fracture position one week after K-wiring is complex. It is difficult to know whether to re-operate; there needs to be a discussion with the patient and probably a documented discussion with colleagues to decide how best to address this problem. If there is marked re-displacement repeat K-wiring may be appropriate. Volar plating is probably preferable. Because of concerns over infection following K-wiring many surgeons recommend removing the K-wires and waiting 3-5 days before ORIF. Overlooked scapho-lunate instability: Scapho-lunate instability

Dinnerfork deformity seen in Colles’ fracture

may present which was not evident initially. This may represent a progression of the instability or a settling out of the bones once the fracture position has been corrected. It is easy to overlook the scapholunate gap; it is essential to review the entire radiograph, not just the obvious fracture. Management decisions are complex8. At present there is insufficient evidence that one means of treatment is superior to another. Delay in treatment of up to three months probably makes little difference, although ideally repair should be earlier if considered appropriate. Discussion with a hand or wrist surgeon is essential. Late DRUJ instability: Late DRUJ instability can occur4. Typically the ulna subluxes dorsally (technically the radius goes volar with the ulna a fixed structure) and is easy to overlook radiologically (Figure 1). Blocked supination should alert the clinician to this possibility on clinical evaluation. Supination is the most important movement to restore early around the wrist. Wrist flexion and extension may return late, even beyond a year, and are less important functionally, but forearm rotation needs to be re-established quickly, preferably within six weeks. Patients should achieve 20-30o of supination and pronation within two weeks. A block in one direction indicates a DRUJ problem. In a busy clinic all of these points are easily overlooked. Attention to detail is critical: it takes much less time

than responding to complaints or litigation. n Grey Giddins is an Orthopaedic and Hand surgeon in Bath. He has an interest in wrist injuries and in medical error. He has published a number of articles on both topics. He is also the Editor-in-Chief of the Journal of Hand Surgery (European). Miss Ilana Langdon trained in trauma and orthopaedics in Bristol and with an interface hand fellowship in Manchester, followed by a AO trauma fellowship in Harborview Hospital, Seattle. She has been a consultant hand and T&O consultant in Bath since 2002. Her other interest is medical education, and is Training Programme Director for Core Surgical Training in T&O for Severn Deanery, and Associate Director of Medical Education for the Royal United Hospital, Bath.

Correspondence: Email: greygiddins@thehandclinic.co.uk Email: ilana.langdon@nhs.net References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 44

JTO Peer Reviewed Articles

Shoulder Dislocations Missed associated injuries Magnus Arnander Duncan Tennent

The shoulder is the most commonly dislocated joint, with an overall incidence of 24 per 100,000 person years, of which less than 3% are posterior1, 2.The incidence is bimodal, with peaks in young men aged 20-29 and women over 602-4. Most dislocations are uncomplicated but a small proportion will have additional injuries which may be missed â&#x20AC;&#x201C; these are commoner in older patients, with up to 75% of them reporting persistent symptoms5. A recent analysis of NHS litigation cases showed failure to diagnose glenohumeral dislocations as the largest group within orthopaedic upper limb cases6. Missed diagnosis Posterior dislocations pose a special threat. Diagnosis is tricky as manifest by case series of chronically undiagnosed posteriorly dislocated shoulders7-9. Delay to diagnosis leads to an increase in the size of

the humeral head defect and the necessity of open procedures1. A modified axillary radiograph helps diagnosis, as anteroposterior views are difficult to interpret10, 11. 65% have associated lesions such as fracture and cuff tears, and in the absence of fracture the risk of cuff tear increases 4.6 times12.

Associated fractures

Rotator Cuff

These are common and easily missed, with an overall fracture rate of 29% if including Hill Sachs lesions, with up to 59% of fractures not diagnosed initially13, 14. Despite this, propagation of an unnoticed neck fracture or Hill Sachs lesion by manipulation has only rarely been reported â&#x20AC;&#x201C; all of these cases also had a tuberosity fracture. We suspect this scenario is commoner than reported. The use of general anaesthetic, muscle relaxation and image intensification didnâ&#x20AC;&#x2122;t prevent displacement with manipulation, but in one report prophylactically stabilising the humeral head prior to manipulation helped15-19.

With anterior dislocation the posterior and superior rotator cuff are stretched. With advancing age the cuff becomes less pliable and cuff tear rates of 54% - 61% are reported in the over 40s and rising in severity and frequency with age - even though it is not possible to know if these tears were present before the dislocation22-24. The supraspinatus is always involved, and a significant correlation was found between full thickness tears, night pain and the inability to raise the arm to 90 degrees in the scapular plane at two weeks following dislocation22. This inability to abduct the arm also mimics an axillary nerve lesion. Almost half of these patients report symptoms persisting for years25.

The anterior rim of the glenoid may be fractured during the dislocation creating a bony Bankart lesion. Most commonly this is a small flake of bone that may or may not be visible on plain x-ray. The larger the lesion, the more likely that the shoulder may develop instability. As with all fractures, early surgical intervention has shown better results than late reconstruction20. If a glenoid fragment is seen on plain radiograph, a CT to quantify it is helpful in decision-making. Independent risk factors for fracture have been shown to be first dislocation, age over 40 and mechanism of injury21.

Magnus Arnander

Duncan Tennent

In the early post reduction phase it is not possible to interrogate adequately the rotator cuff by clinical examination, and therefore it is the responsibility of the clinician in the fracture clinic to ensure follow up until an injury can be excluded, especially as there is evidence that the outcome of repair of acute rotator cuff tears is better if performed earlier26. >>

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 44&45 Title: Shoulder Dislocations - Missed associated injuries Authors: Magnus Arnander & Duncan Tennent

Neurological Injuries Owing to its route and position, the axillary nerve is the most commonly injured. This is followed by the suprascapular nerve, which tends to recover spontaneously27, 28. In one series, 48% of all patients had documented nerve injuries when using EMG to aid diagnosis. Prognosis was too variable to help predict outcome. Although axillary nerve injury accounted for almost half of the injuries, combinations were also seen with an average of 1.8 nerves involved. Risk of nerve injury increased with age, fracture and the presence of haematoma. Examination of sensation in the distribution of the axillary nerve did not reliably indicate the presence of a lesion, whereas abnormal forearm sensation did indicate a more severe injury. Even with good EMG recovery, shoulder function often did not return to normal, but physiotherapy did improve outcomes. The recommendation was EMGs at three weeks if function had not resolved28. A few patients are reported as having a terrible triad of dislocation, cuff tear and nerve injury, which leads to a poor prognosis23, 25, 29.

Vascular Injuries These are quite rare and may be missed due to an extensive collateral circulation around the shoulder. Case reports of axillary artery transection, circumflex artery avulsion and delayed presentation of pseudoaneurysm and upper limb deep vein thrombosis have all been published. Older patients with less compliant and atheromatous arteries are at greater risk, and there is an association with neurological

injury, which along with bruising and axillary swelling should alert the physician to this emergency and prompt further investigation30-33.

Correspondence:

Conclusions

Email: Magnus.Arnander@stgeorges.nhs.uk Email: Duncan.Tennent@stgeorges.nhs.uk

We make a number of recommendations based on the published evidence:

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

1. Beware the older patients, especially first time dislocators, as they are a high risk group 2. Formal assessment of the nerves should be performed both before and after manipulation 3. Radiographs should be undertaken both before and after manipulation, including a modified axillary view if in doubt 4. Immediate referral to orthopaedics if the shoulder hasn’t reduced first time 5. If a glenoid or complex humeral fracture is identified a CT scan is helpful 6. All patients are reviewed in outpatients within three weeks to reassess the nerves, cuff and arrange physiotherapy as required. n

Call for papers now open!

Magnus Arnander is a Locum Consultant Upper Limb Surgeon at St. George’s Hospital London and an Honorary Lecturer at St. George’s University of London. Duncan Tennent is a Consultant Shoulder & Elbow Surgeon at St. George’s Hospital London and an Honorary Reader in Orthopaedic Education at St. George’s University of London.

Conference dates announced! The 2014 BTS Annual Meeting The Oxford Belfry Hotel 5th – 7th November 2014

CALL FOR PAPERS NOW OPEN! The President and Treasurer of the BTS, AD Patel, and Stuart Matthews have announced dates for the 2014 British Trauma Society Annual Meeting. This year the multidisciplinary conference will be taking place at the Oxford Belfry Hotel. Situated just off the M40. Please contact the conference office on +44 (0) 1608 659900 or bts@archer-yates.co.uk

Renew your membership now to benefit from the best conference rates available! To download the BTS Abstract Guidelines, Submission form and to renew your membership, please visit the re-launched BTS website at www.bts-org.co.uk

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk 72 l Page 46

JTO Peer-reviewed Peer ReviewedArticles Articles

Litigation in Paediatric Orthopaedic Management: Common Errors and their Avoidance Nick Nicolaou Fabian Norman-Taylor

Management of children with both traumatic and non-traumatic Orthopaedic pathology differs from region to region within the UK. Some populations will have a dedicated Paediatric Orthopaedic service, but at present for the vast majority, and particularly for trauma, most patients continue to be managed by general Orthopaedic surgeons1. The true generalist who would be able to manage a host of pathologies is now a dying breed, and sub-specialisation amongst those treating mainly adults may be leaving a void for local care of children. One of the possible reasons for this change is the fear of litigation for those not regularly treating such pathology and the improvement in care and expertise that is expected with subspecialisation. This combined with a similar problem in anaesthetic provision may be driving these changes.

Perusal of the number and types of claims is often a good guide to where errors continue to be made by those treating children. The NHS Litigation Authority (NHSLA) is a specialist health authority established in 1995 to deal with all claims excluding those arising in primary care and private practice. The incidence of claims managed by the NHSLA continues to increase, and within Orthopaedics we account for almost half of all surgical claims arising. Of course, the increase in claims is not directly proportionate to an increase in negligence, but rather reflects a number of issues such as cultural changes and changes in the way claims are funded. The cost to the health service is huge, with payments for the period 2008-2013 for Orthopaedic Surgery totalling ÂŁ490 million2. By far the most frequently encountered cause of litigation is the management of Paediatric Fractures, and specifically delayed diagnosis and inappropriate treatment.

Missed injuries are the commonest encountered3. The most significant area is management of trauma around the elbow 4, 5 and treatment of Slipped Capital Femoral Epiphysis (SCFE)6. The strong association with elbow trauma is independent of the healthcare system, and is a problem reproduced around the world7.

Injuries around the elbow Supracondylar fractures of the Humerus represent over 10% of all cases of paediatric orthopaedic litigation6. Common reasons are malunion, delayed or missed diagnosis and poor intra-operative fixation. Iatrogenic nerve injuries do account for some cases. Additional issues exist with other fracture types such as the Lateral Condyle fracture, an injury often difficult to diagnose and with poor outcomes following inadequate treatment (Figures 1a-d). A number of cases will also result from simple factors that must not be underestimated as causes of harm, >> d

Nick Nicolaou

Fabian Norman-Taylor

Figure 1a-d: Lateral condyle fracture treated in fracture clinic as an undisplaced supracondylar fracture (a, b). When seen at 4 weeks post injury, the fragment is displaced (c, d). Treatment requires fixing in situ to avoid osteonecrosis and leads to a poorer outcome that could have been prevented by recognition and correct treatment of the injury.

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk boa.ac.uk Page 47 02 / Issue 01 / January 2014 l Volume Page 17

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JTO Peer Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 46&48 Title: Litigation in Paediatric Orthopaedic Management: Common Errors and their Avoidance Authors: Nick Nicolaou & Fabian Norman-Taylor

such as problems resulting from poor plaster application and use of plaster saws for cast removal. Some NHS innovations, such as virtual clinics in which all cases receive senior Orthopaedic input may help with radiological diagnosis and reduce litigation8. Injuries thought to be radiologically benign, without the benefit of subsequent clinical review may lead to delay in both diagnosis and treatment. Surgical treatment by sub-specialists may decrease the incidence of poor intra-operative treatment, but with the current healthcare structure it is not feasible for all paediatric Trauma to be managed in this way, and will therefore result in treatment being carried out, particularly out of hours, by those who have less experience. Changes to Orthopaedic training other than Sub-specialisation is also likely to have an impact that is, as of yet, not quantified.

management the gold standard treatment for many remains pinning in situ with ‘gentle’ limited reduction for severe unstable slips, with the aim of reducing the risk of Osteonecrosis associated with open reduction12. Historical studies have shown good functional outcomes for the majority of hips treated in this manner. The increasing understanding of Femoro-acetabular impingement however does raise concerns that pinning in situ may result in symptoms and poor functional outcomes13 that surgeons may then be held responsible for later in life (Figure 2a-b). This needs to be balanced with the 20% risk of osteonecrosis quoted for open reduction techniques. The role of pinning hips with devices that allow ongoing capital physeal growth (such as de-threaded screws) also has had a renewed surge of interest. This in itself raises concerns for harm, particularly if further slips

develop as a result of their use. Even contralateral pinning can be associated with harm. Further prospective randomised studies are needed for this condition to help guide the best form of treatment. Meanwhile, for those without the facility to treat by open reduction, pinning in situ for both acute and chronic slips with careful attention to a safe technique is recommended, but this must be combined with careful follow up, and early referral to a centre with necessary expertise for severe deformities and those that develop symptoms of pain and impingement. With regard to choice of open reduction technique, familiarity with a method and the frequency of its performance are more important factor than the

Slipped Capital Femoral Epiphysis With an incidence of 10 per 100,0009 litigation should be rare in comparison to treatment of other Children’s Orthopaedic pathology, but we see high pay outs and rates of claims resulting from this condition in NHSLA data, as well as with other non-traumatic hip conditions such as sepsis and Developmental Dysplasia of the hip. Management of SCFE has seen some changes over the last decade, particularly with treatment of severe deformities and increasing popularity of the Modified Dunn Procedure10, 11. In terms of general

Figure 2a,b: Post op radiographs of a moderate slip, pinned in situ with mal-positioning of screw(a) and joint penetration on CT scan (b). Poor fixation led to a worsening of the initial slip. At skeletal maturity this patient is left with significant pain and stiffness requiring major hip preservation surgery.

actual technique. Consent is always important, and the high risk of osteonecrosis needs to be at the forefront of any discussion with patients and their carers. n Nick Nicolaou is a Consultant Paediatric Orthopaedic and Limb Reconstruction Surgeon at Maidstone & Tunbridge Wells NHS Trust. Fabian Norman-Taylor is a Consultant Paediatric Orthopaedic Surgeon at Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust.

Correspondence: Email: nick.nicolaou@nhs.net Email: fabian.norman-taylor@gstt.nhs.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

Cauda Equina Syndrome – risk management Jeremy Fairbank

Cauda Equina Syndrome (CES) is the number one ‘spinal’ patient safety issue for orthopaedic surgeons providing on call and emergency care1. A major source of litigation against GP’s, emergency care doctors and orthopaedic surgeons, the average compensation following missed or delayed diagnosis of CES is £336,000 per case in the United Kingdom and $549,427 per case in the United States. HES data were used by the Spine Task Force to show that in England alone ~1000 operations are done each year for CES, so it is not a rare condition (www.nationalspinaltaskforce.co.uk). The number of cases coming to litigation each year in the UK is uncertain. Gardner et al estimated between 30-40 cases per year in UK2. Well-known features of Cauda Equina Syndrome Bilateral sciatica, perineal and perianal sensory loss, incontinence or retention of urine, incontinence or retention of faeces, and disturbance of sexual function are well recognised features of CES. Clearly it would be a breach of duty to ignore these.

Jeremy Fairbank

McFarlane and Gleave, in a much quoted paper, distinguished between Cauda Equina Syndrome Incomplete (CESI) and CES Retention (CESR) 3. What is less well recognised are the symptoms leading up to the status of CES. A recent analysis from China of the current literature on CES cases

has been helpful in specifying the main patterns of progression of this condition. It is at this initial stage of symptom onset that ‘Early CES’ should ideally be recognised and treated before established urinary incontinence or retention. The Chinese authors, whilst not the first to suggest a further category of CES E (E for Early) to designate this group, have done a much more exhaustive systematic review than anyone else, with ranking of the frequency of presentation of each feature4. They state: ‘The result of sequential pattern mining demonstrated that the progression process of CES could be divided into three stages: early stage of CES (CESE), with bilateral peripheral nerve dysfunction characterised by progressive sensory-motor defects from unilateral to bilateral in lower extremities; incomplete CES, with reduction of sphincter functions; and CES in retention, with sphincter dysfunction’. They go on to say ‘Our analysis revealed that the most common initial CES symptoms were perineal paresthesia and bilateral lower extremity pain, paresthesia, and motor power abnormality. These CESE symptoms usually developed from unilateral symptoms of primary diseases. Sphincter dysfunction, on the contrary, was only the initial symptom in patients with acute onset or ankylosing spondylitis. To achieve timely diagnosis, clinicians should consider the possibility of CES when these characteristic symptoms are present, especially when they progress from unilateral to bilateral. Claimants’ experts are now suggesting that Breach of Duty may occur when patients’ symptoms are ignored in this spectrum. Emergency MR is indicated in this group of patients, even though it recognised that many will have

no evidence of cauda equina compression, and the symptoms are associated with severe pain. Clinicians should also consider lesions higher up the neuraxis, and whole spine MR scans may be indicated when no lesion is found in the lumbar spine. The cause and level of the spinal pathology in Cauda Equina Syndrome can only be established with an MRI scan. This is one of the main reasons for hospitals providing emergency care to have access to out of hours MRI scan available 24/7. There is good evidence that expedient surgery in CESI will improve the outcome. If surgery is delayed more than 24 hours from onset, the results are significantly worse (and even worse if delayed for >48-hours). There is a strong indication for out of hours surgery in this group. It seems logical, but unproven, to say that surgery in the CESE group should be offered as an emergency too. For patients with CESR, surgery is much less likely to reverse the neurological deficit and in these circumstances operating the next day is reasonable. The problem for doctors is to try to diagnose CES when it presents in the early stages. I believe we need to rethink our training in this area to take into account CESE. In the Chinese analysis of the initial symptoms in non-acute cases, they ranked the early symptoms in order of frequency (Table 1). Reduction of sexual function and sexual dysfunction were not common presenting complaints in this population. Unfortunately, these symptoms are also frequent in people who do not subsequently develop Cauda Equina Syndrome. >>

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JTO Peer Reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 49&50 Title: Cauda Equina Syndrome – risk management Author: Jeremy Fairbank

We are exploring the sensitivity and specificity of these symptoms in our Oxford Triage Database at present. Table 1: Symptoms of CES suggesting immediate MRI 1. 2. 3. 4. 5. 6. 7.

Bilateral sciatica Bilateral parasthesiae Bilateral motor deficit Perineal pain Perineal parasthesia Altered bladder / anal function Bladder dysfunction

It is the misinterpretation of these early presenting features, especially when viewed in retrospect, which often loses the legal case in Cauda Equina Syndrome. Misdiagnosis and procedural delay are also expensive causes of problems. Trainees and their consultants need to pay particular attention to these cases and be assertive in obtaining out of hours MRI. The raw data do suggest that about 40% of out of hours MRI scans requested will be ‘normal’ but this seems to me (and to CES patients) to be a reasonable price to pay to prevent what is a deeply unpleasant condition. The clinical message is that if you think someone might have CES, even without signs, you should consider getting a scan and you MUST warn of the symptoms of deterioration and advise immediate re-attendance. Finally, it is essential that this is put in the notes – the old adage is right – “if it wasn’t recorded, it didn’t happen”. The Society of British Neurological surgeons’ guidance concludes: ‘Decompressive surgery should be

Sagittal and Axial MRI scan of a patient with a massive L4/5 central disc herniation with CES

undertaken immediately whenever the clinical and radiological assessment indicates that long-term neurological morbidity might be reduced. Nothing is to be gained by delaying surgery and potentially much to be lost.’ The Cauda Equina Policy is available on their website www.sbns.org.uk/ index.php/policies-and-publications n

References: 1. Lavy C, James A, WilsonMacDonald J, Fairbank J. Cauda equina syndrome. BMJ. 2009 31 March 2009;338:936. 2. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011 May;20(5):690-7. 3. Gleave J, Macfarlane R. Prognosis for recovery of bladder function following lumbar central disc prolapse. Br J Neurosurg. 1990;4:205-9. 4. Sun J-C, Xu T, Chen K-F, Qian W, Liu K, Shi J-G, et al. Assessment of Cauda Equina Syndrome Progression Pattern to Improve Diagnosis. Spine. 2014 April 01, 2014;39(7):596-602.

Jeremy Fairbank is Professor of Spinal Surgery at the Nuffield Orthopaedic Centre, Oxford University Hospitals. He has been Clinical Director of the Thames Valley Comprehensive Local Research Network since 2006. He was President of British Scoliosis Society and has just been President of the International Society for the Study of the Lumbar Spine. He is Chair of the United Kingdom Spine Societies Board (UKSSB), which represents UK based specialist spine societies.

Correspondence: Jeremy Fairbank Nuffield Orthopaedic Centre Windmill Road Oxford OX3 7LD Email: jeremy.fairbank@ndorms.ox.ac.uk

TBGGGI (There but for the grace of God go I) Barry Ferris

CORESS (Confidential reporting system in surgery) was set up in 2005 to allow surgeons to report critical incidents in confidence. As BOA representative for three years there were repeated and uncomfortably resonant underlying themes.

Inexperience or lack of supervision Individual surgeon error due to inexperience or lack or supervision occurred many times, in particular, general surgeons exteriorising the wrong bit of bowel.

Cutting corners Difficult procedures being done in a difficult patient and corners being cut resulted in unusual and disastrous problems. Vascular surgeons using tunnelling devices for aorto-bifemoral grafting transfixed the colon or rectum on several occasions.

Ignoring guidelines A patient had his fingers debrided after a sledgehammer injury under local anaesthetic using a rolled up disposable glove as a tourniquet. The glove tourniquet was forgotten and despite several A&E attendances, it was several days before this was recognised.

Perfect Planning Prevents P*** Poor Performance A surgeon set off to remove a plate from a finger. The correct screwdriver was not in the set. Strike one. The wound was closed and the patient readmitted when the screwdriver was available. After the wound was re-opened it was realised that the foot and ankle version had been sent. Strike two.

Reason’s Swiss Cheese effect (Process issues) There are usually a series of safeguards set up to prevent patient harm throughout the process of care. If they are all bypassed then harm may occur.

Barry Ferris

An ENT trainee was performing a list of sinus surgery as his boss was away. The patient had presented with a post nasal drip. A CT scan was said to show extensive sinus disease; this was a transcribing error (Error 1). CT scan was not indicated as the original history did

not support chronic sinusitis (Error 2). The CT was not seen in the clinic (Error 3) when they were listed by another registrar on the basis of the written report (Error 4). The operating surgeon had seen the scan but still proceeded with surgery (Error 5). During surgery the surgeon created a CSF fistula (Error 6) and called the consultant for help. The fistula was dealt with, the patient spent three days in hospital. Finally, review of the CT scan showed the patient did not have the condition they were treated for.

Orthopaedic “Cheese” A patient underwent a total knee replacement in a surgicentre without resident medical cover located in the grounds of a district general hospital. The operation was undertaken on a Friday afternoon by a locum consultant without junior support. The patient bled into the drain and the dressings required repeated changing. There was no medical review over the weekend. The patient developed chest pain and a myocardial infarct secondary to profound anaemia and was admitted

to coronary care. She recovered but was not seen by a physiotherapist or an orthopaedic surgeon for six weeks resulting in a stiff knee. The themes that emerge from this committee are often not solely individual technical failure per se, but more commonly not adhering to the principles of good practice (human factors) resulting in harm to patients. When problems occur they often multiply. Take Care! Barry Ferris qualified from the late Westminster hospital in 1977 and was appointed consultant to Barnet Hospital in 1990. He was a Wellcome training research fellow at The Kennedy Institute and Northwick Park where he did research for his MS. As a consultant he has been an examiner for the MRCS, President of the orthopaedic section of the RSM, member of council of the BOA and is currently co training program director at the RNOH.

Correspondence: Email: barry.ferris1@btopenworld.com

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JTO Peer Reviewed Articles

Infected Arthroplasty Ian Stockley

Prosthetic joint infection is probably the most devastating complication following arthroplasty surgery both in terms of cost and patient outcome. Over 16,000 revision hip and knee procedures were recorded in the 10th annual report of the National Joint Registry (NJR) in 2013, 12% of the hip surgery was infection related whilst for the knee, this was 23%. This observation is not limited to NJR data alone; data from the Australian and Scandinavian registries show similar dramatic figures for infection related surgery. With the exponential increase in the number of primary arthroplasties performed worldwide, the burden of infected revision surgery is likely to increase significantly over the coming years. Never has there been a better time to “getting it right first time”. So, why is the infected arthroplasty becoming an increasing problem for the NHS? There is a changing pattern of bacteria with an increasing number of gram negative bacteria seen, but the gram positives still remain the most common form identified. Increasing bacterial resistance as a consequence of inappropriate antibiotic prescription may well be a major problem for infection control in the future but it is certainly not responsible for the current increase in arthroplasty related infections today. The majority of our hospitals today are generally overcrowded with patients often ‘hot bedding’ in non-dedicated

Ian Stockley

arthroplasty wards as our managers try, at all costs, to achieve their elective admission targets. Whilst the hospital environment may not be perfect, a degree of complacency within the medical and nursing fraternity may well be a contributory factor with the acquisition and chronicity of the infection problem. Hospital acquired infections in general are among the top four contributors to avoidable adverse events, along with perioperative errors, medication errors and lack of awareness of the deteriorating patient. The interventions needed to avoid adverse events are often well described, evidence-based, generally simple and non-technical. For elective arthroplasty surgery, this is nothing new. Sir John Charnley, soon after introducing hip arthroplasty surgery in the 1960’s, became acutely aware of the devastating effects of deep infection. So much so that he considered stopping such surgery. However, he decided to continue, but put into place measures to lessen the risk e.g. prophylactic antibiotics, ultra clean air, respect for the soft tissues, amongst many others.

It is customary when assessing risks associated with a surgical procedure to separate into patient factors, surgical factors and the environment of theatre and ward. By focusing on each of these in turn, you are able to identify any risks and their potential solutions. Although the clinical outcomes associated with infection are devastating, it is relatively rare in a general orthopaedic practice. Infection rates following primary arthroplasty surgery vary tremendously (0.2% to 4%) and if you are not regularly undertaking such surgery in high volumes you will probably see little, if any infection complications. When a complication is not commonly seen, it can be assumed by some not to exist and complacency with prevention of that complication can set in. The use of prophylactic antibiotics is a good example. It is accepted by all that the use of prophylactic antibiotics plays a significant role in the prevention of infection. However, if not administered at the correct time, they have little, if any, effect on the prevention of infection. The effect of this error will probably be delayed in time as most infections tend to be of a chronic insidious nature and so the relevance of the error is often not seen. >>

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 53 ÂŠ 2014 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 49&50 Title: Infected Arthroplasty Author: Ian Stockley

The introduction of a safe surgery check list including a surgical site infection bundle has led to a decrease in mortality and a dramatic decrease in the incidence of surgical site infections by up to 50% in a global population (Haynes et al 1999). It is simple to use, takes little time to implement and should be used as a routine to maintain the awareness of infection and by doing so, helps to prevent its occurrence. Unfortunately, there is often no strong scientific evidence in peer review publications to support our different attitudes and behaviour towards infection. However, there was strong consensus amongst orthopaedic surgeons and microbiologists to support our approach, which was recently highlighted at the International Consensus Meeting on Periprosthetic Joint Infection, held in Philadelphia in 2013. With infection being relatively rare in everyday clinical practice, there is often a significant delay in considering infection as a potential reason for failure of that surgical procedure. Infection following arthroplasty surgery presents in many different ways. The majority, do not present acutely with the cardinal symptoms and signs of sepsis, instead the symptoms tend to be rather vague with minimal or no abnormal signs on clinical examination. Suspicion is the key when considering a diagnosis of infection. You need to ask yourself why this patientâ&#x20AC;&#x2122;s clinical outcome is different despite undertaking the same surgical procedure many

times. If in doubt, ask a colleague for their opinion. They may have had similar experiences in the past. Simply delaying helps nobody, least of all your patient.

way to cure the patient would be to perform exchange surgery. This as we all know is far more invasive and costly to both the patient and the healthcare system.

Acute presentation of infection is much less common than that of chronic infection. Prompt diagnosis and appropriate aggressive management of the early infection can lead to a successful outcome with preservation of the original prosthesis. Unfortunately, time is not on your side, with Biofilm formation starting within hours of exposure to the infecting organism. If a wound is oozing, erythematous or swollen, donâ&#x20AC;&#x2122;t just prescribe antibiotics blindly and sit on the fence. Either seek advice from a colleague or take the patient back to theatre and explore down to the joint capsule. Take multiple samples, debride, change whatever is exchangeable, prescribe broad spectrum intra venous antibiotics and await culture results. If positive cultures return, you can change antibiotics to be more specific for that particular organism and sit back knowing you have done the right thing for your patient. If they return negative, you can reassure your patient and yourself that there is no infection present and that it was a worthwhile investigatory procedure. Leaving the patient for another week or two and then exploring would be regarded as inappropriate as the infection is now chronic and the only

The development of deep periprosthetic infection can occur in the best of hands and one should not feel guilty or inadequate if this complication occurs, assuming all preventative measures have been taken. Colleagues acting as medicolegal experts for the plaintiff in a case of alleged medical negligence will find it extremely difficult to win the case if your patient has been appropriately pre-assessed, prophylactic antibiotics prescribed and detailed operative and postoperative clinical records made. Take home message: if in doubt act promptly, talk to colleagues, work as a team. n

Ian Stockley has been a consultant orthopaedic surgeon in Sheffield for 22 years. His main interest throughout this time has been the management of infection and bone loss.

Correspondence: Email: ianstockley56@gmail.com

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 54

JTO Peer Reviewed Articles

Patient safety is more than delivering clinical standards, ticking boxes and following NICE Guidelines Nick Welch

We were led to believe that the “New NHS” in England would place the provision of healthcare into the hands of those who really know patients - our GPs. We lay representatives who have been recruited onto local and national bodies might challenge this: too many people commission services without fully understanding the needs of and risks to orthopaedic patients whose care is often seen as discretionary. The NHS in Scotland and Wales, whilst organised differently, would seem to be struggling with similar issues albeit by a different route. Is the safety of orthopaedic patients too expensive for 21st century commissioners? Is patient safety compromised by a reluctance to build into the structure of healthcare delivery measures necessary to maximise good patient outcomes? Fully integrated and enhanced recovery patient pathways are not currently adequately understood,

supported, protected, planned or discussed by the gatekeepers of our healthcare either with health and social care workers or with patients. For example, the ongoing debate about follow-up x-rays and the ability of various disciplines (e.g. Orthotists) to cross-refer patients without sending them back to their GP. Enhanced recovery programmes have been high-jacked for the purpose of cost containment at the expense of quality. It does not have to be like this: better outcomes for patients in the long run achieves NHS goals and is likely to enable the services to run more effectively and efficiently.

Nick Welch

As well as an adherence to best clinical practice patient safety requires: • A commitment to manage me as a patient from the first appointment to the final discharge in an agreed care programme tailored to my particular needs

• Treatment by an appropriately trained multi-disciplinary team under the aegis of a named consultant who is responsible because he is authorised to effect change • A joined up health and social care service, which can manage patients across CCG borders • Wards adequately staffed by nurses qualified in orthopaedic or orthogeriatric care. Enhanced recovery is high turnover high intensity nursing, it requires adequate staffing levels. • An understanding that short term planning is not necessarily the most cost effective strategy • A willingness to undertake the necessary research where there is inadequate evidence. Above all, steps taken to ensure patient safety should be a partnership between those commissioning the service, health and social care providers and, on equal terms, the recipients of the service: the patients and their next of kin. Recently, the British Orthopaedic Association’s Patient Liaison Group wrote a paper highlighting the information a patient should have before the day of their operation1. We strongly believe that a well-informed patient is better empowered to help those responsible for their healthcare to manage their recovery and minimise the risks that currently beset many Trusts. There are no easy fixes. The NHS piggy bank contains limited funds; those who control our Health Services locally need to learn to plan the service more wisely. Cutting the numbers of healthcare professionals, fragmenting care pathways and discouraging or financially penalising

best clinical practice will not solve the issues. However, simply doing the opposite has patently not worked either. Unless clinicians and patient groups engage with commissioning leads in their respective Clinical Commissioning Groups those who are responsible will not know what is fundamentally necessary to ensure patients are treated in a safe and wholesome environment. It is the duty of commissioning General Practitioners to ensure we are getting the most cost effective treatment – in other words treatment that maximises our chance of the best possible recovery and reduces the long term impact on their limited resources. It is an orthopaedic surgeon’s duty to evidence and supply cost effective quality. Commissioners must listen to the GPs, the Acute Trusts, the Specialists as well as patients. These are the people who can best advise on adequate staff levels, appropriate patient management and patient expectations – all of which, if properly addressed, will enhance the patient experience and reduce risk to the patient, both in hospital and in the community. This may mean that the commissioners will need to fund pathways in a more empathetic way – encouraging and protecting more intense acute and rehabilitation phases in the knowledge that the better outcomes reduce long term costs, by giving patients the best chance of a complete recovery. None of this need be complicated: indeed keeping the process simple, taking it step by step, and ensuring each part of a given orthopaedic patient pathway is in line with best >>

Journal of Trauma and Orthopaedics: Volume 02, Issue 03, pages 54&55 Title: Patient safety is more than delivering clinical standards, ticking boxes and following NICE Guidelines Author: Nick Welch

practice and directly connected with the following steps helps reduce putting the patient at risk. Building in agreed time lines identifying when the various hospital and community health and social care disciplines should become involved reduces delays to the treatment pathway and improves the patient experience.

is incumbent on the clinicians to undertake the necessary work.

There are guidelines about staffing levels and staff competencies which should be enshrined in service commissioning – shortfalls put patients at risk.

Patient safety is the responsibility of all the participants in the process: the Commissioners, the Acute Trusts, primary and secondary health and social care providers and patients. Providing fully financed, appropriately tailored patient pathways with integrated health and social care, which have been agreed

Best clinical practice should be backed up by appropriate studies, and where these do not exist it

The supply of walking aids, prostheses, and orthoses should be managed with patient needs in mind, and patient safety should not be compromised by short term budget pruning.

by those responsible for delivering the service, to well-informed patients will help improve patient safety and compliment the clinical efforts of the healthcare providers. n

References 1. “Information you should know before your orthopaedic intervention” BOA PLG Web page.

Nick Welch spent 35 years in the Pharmaceutical Industry and since retiring has been a member of the BOA’s PLG for the past eight years. At the end of 2014 he will have completed his three-year stretch as the PLG’s Chair. He will then continue to represent patients on NICE, NHS-E and his local CCG committees as well as contributing to the PLG from the ranks of Corresponding Members.

Correspondence: Email: nick-welch@hotmail.co.uk

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Minimally Invasive Spine Surgery: Surgical Techniques and Disease Management Author/s: Phillips, F M; Lieberman, I; Polly, D ISBN: 9781461456735 Publication Date: 31st May 2014 Price: £126.00

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 56

JTO Peer Reviewed Articles

ÂŠ 2014 British Orthopaedic Association

How I â&#x20AC;Ś Fix Medial Malleolar Fractures Peter Hull FRCS (Tr&Orth) Adam Starr, MD

Ankle fractures are among the most common lower extremity injuries encountered by the general orthopaedic surgeon. Treatment options include both operative and non-operative modalities. This article will outline the authors preferred method of operative treatment of medial malleolus fractures. Under tourniquet, hockey stick incision is made over the centre of the fracture, curving from anterior to posterior, to ensure adequate visualisation of the joint surface and access to the distal most extent of the medial malleolus. The soft tissues are dissected sharply to the level of the fracture. Periosteum is cleared from the edges of the proximal and distal fragments, and a curette and irrigation are used to

remove debris. A 2.0mm k-wire is used to make a uni-cortical hole approximately 1 cm proximal to the fracture; this acts as the proximal anchor point for a pointed reduction clamp. The clamp is then placed and the fracture is reduced. This provides compression of the fracture and obviates the need to lag by technique or design. The joint surface is inspected to ensure anatomic reduction. Two 2.0mm

retrograde k-wires (the correct drill size for 2.7mm screws) are then placed to secure the medial malleolus. The wires should be parallel, well-spaced, as distal as possible, and perpendicular to the fracture. Fluoroscopy is used at this time to ensure maintenance of reduction and appropriate wire placement. The wires are then sequentially replaced (to prevent rotation) with 45mm fully threaded 2.7mm screws1. Importantly, no drilling is needed prior to replacing the 2.0mm wires with 2.7mm screws. The wound is thoroughly irrigated and closed in a step-wise fashion.

References Parker L1, Garlick N, McCarthy I, Grechenig S, Grechenig W, Smitham P - Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy. Bone Joint J - www. ncbi.nlm.nih.gov/pubmed/24293597 2013 Dec;95-B(12):1662-6. doi: 10.1302/0301-620X.95B12.30498.

Correspondence: Email: hullpd@gmail.com

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 57

Training and Recruitment – Sponsored Content Dear Colleagues You are welcome to

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For Inquiries: Dr C Liu Tel: 020 89549427 E-mail: Chaozong.Liu@ucl.ac.uk http://www.ucl.ac.uk/ surgicalscience/prospective_ students

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Training and Recruitment – Sponsored Content WRIGHTINGTON HOSPITAL Course Venue: Hospital Conference Centre

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 59

Training and Recruitment – Sponsored Content THE TRAUMA DEBATE 2014 NON-UNIONS AND BONE DEFECTS

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l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 60

In Memoriam

Anthony Hugh Cyril Ratliff 18th August 1921-21st June 2014 Tony, or “Ratty”, as he was known affectionately by friends and colleagues, had a long and productive life dying two months before his 93rd birthday. He was born in Manchester on 18th August 1921 and died in Bristol on 21st June 2014. He was a great innovator, a tireless and enthusiastic worker and his talents were widespread. He was a major influence in helping the orthopaedic department in Bristol to develop from what he described as a “glorified district hospital” to one of the leading orthopaedic centres in the country with a formidable academic reputation. Tony’s passion was teaching and research and his over-riding priority was the importance of educating the next generation of orthopaedic surgeons. He took huge interest in his registrars’ research looking up and providing relevant papers and encouraging their endeavours. He was quick to congratulate a good presentation, offer constructive advice and took transparent pride in high quality work. He and Jean were generous hosts to the registrars who they invited regularly to social, College and Medico-legal Society dinners. Tony was born of relatively humble origins in Manchester and his early years were blighted by the sadness of the death of his mother Elsie when he was only 10 years old. Tony had a brother Brian, four years his junior. His father, who was a master

mariner and served at Gallipoli in World War I was a businessman and retailer and ran a handbag repair shop in Manchester. In the uncertain years between the World Wars his business thrived and Tony was sent to private school and received a broad classical education. At the start of World War II Tony was in the sixth form at William Hulme Grammar School Manchester and had decided to study medicine. This was a protected profession for the purposes of conscription and he was admitted to Manchester University, which was a short walk from his home. Tony threw himself into medical studies, won various prizes and qualified with a distinction in surgery in June 1945. The early years after qualification were spent obtaining a broad experience in general and orthopaedic surgery at the Manchester Royal Infirmary.

Tony Ratliff

In 1943, Tony met his future wife Jean at the Christian Endeavour holiday home in Plas-y-Nant in North Wales. She was a student at Homerton College, Cambridge and was to become a Physical Education teacher. They married in Leeds in the summer of 1947 and Tony then spent two years in National Service as a captain in the RAMC. By 1951 he had passed the final FRCS and gained further experience in Manchester hospitals. Like many young surgeons Tony fell under the profound influence of a tough, brilliant and charismatic boss, Sir Harry Platt at the Manchester Royal Infirmary. He recalls Sir Harry carrying out a tendon transplant with John Charnley as first assistant and

himself as second assistant. Sir Harry stimulated Tony to carry out the first of many clinical reviews for which he has become well known. He did not think that the treatment of mallet finger was satisfactory and Sir Harry replied “Better review the results of 100 cases”. Although he did not achieve 100 cases, he did publish a review of 45 cases in the Manchester Medical School Gazette of 1947. Tony spent a year at the Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry in 1953 to enhance his experience of poliomyelitis where he was influenced by the magnetic Sir >>

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Reginald Watson-Jones. He then gained senior registrar experience in Edinburgh for two-and-a-half years under the influence of Sir Walter Mercer and I R Stirling. He realised that he and Jean would not be happy in Scotland and in 1956 applied successfully for the post of Lecturer in his alma mater, the Manchester Royal Infirmary. Consultant posts at that time were scarce and in 1959 he was appointed consultant orthopaedic surgeon at Southend, a busy district general hospital in Essex. Tony had been greatly influenced by his academic background in Manchester and when a post became available in Bristol the opportunity to make a contribution to academic orthopaedics and clinical research in a large pleasant city was overwhelming. Tony was appointed Consultant Orthopaedic and Trauma Surgeon at the Bristol Royal Infirmary in 1963 and, shortly afterwards, by a stroke of luck, Arthur Eyre-Brook, the Senior Surgeon announced that the BOA annual meeting would be held in Bristol. As the new boy on the block and the youngest consultant, Tony was made Scientific Secretary and so began a long association with the British Orthopaedic Association (BOA), post-graduate activity and clinical research. Tony was a prolific writer and organiser. He had over 37 orthopaedic publications on a wide variety of clinical subjects especially paediatrics, hand surgery and rheumatoid disease. His classic papers on Perthes’ disease and

fractures of the femoral neck in children were regarded as important reviews and in 1960 he was elected Hunterian Professor for his work. In the same year he was awarded the ABC Fellowship to North America. He also published on bone tumours, the vascular and neurological complications of total hip replacement, which was the subject of his Robert Jones Lecture in 1981. He authored several books, particularly selected references on orthopaedic trauma and elective orthopaedics. Tony made significant contributions to Bristol orthopaedics and in the late 1960s was largely responsible for planning the new Accident and Emergency department which opened in 1972. The Bristol Bone Tumour Registry had been started in 1946 and Tony played an active part in its development especially as Chairman between 1982 and 1991. Education of the next generation was one of his passions and he started a three day postgraduate course in orthopaedics in 1965. This gained a popular national reputation as “The Winford Course” which he continued to organise for another 15 years. Academic orthopaedics was developing in the United Kingdom but Bristol did not have a Professor of Orthopaedics. In 1980 a fund raising committee was formed to inaugurate a Professorial Chair in

Orthopaedics and Tony was closely involved with this development. He maintained a close relationship with the BOA and became the Editorial Secretary in 1978 to 1979, a Member of Council and then President in 1984. In 1983 Tony was elected to the Council of the Royal College of Surgeons of England having been Orthopaedic and Surgical Advisor for the South West Region from 1974. He served on several College committees and with his usual energy and enthusiasm made many contributions to the work of the College. Through his extensive travel representing the College and the BOA he was able to secure a steady flow of Australian registrars who came to Bristol for further training. In later years, though he retired from the Bristol Royal Infirmary in 1986 aged 65, he continued to represent the Royal College of Surgeons and the BOA for nearly 20 more years. He also continued his medico-legal practice and advisory work until 2008. Although devoted to medicine and orthopaedics all his life, after retirement he joined the local Rotary and gained great joy and satisfaction from a wide range of new friends. He was a great walker, enjoyed long country walks and was also known to take the medical secretaries on cinema trips.

Tony was a passionate family man and has two sons, David who is a vascular surgeon in Northampton and John, a barrister in Brussels. He was devoted to his five grandchildren; Isabelle, Matthew, Alison, Scott and Guillaume. Sadly, Jean died in 2003 and Tony coped with this loss with his typical stoicism and resilience. Tony was always a tower of strength and energy and an example to all who knew him. He was a charming and open-hearted man with a huge sense of fun and a penchant for “shaggy dog stories”. He got on well with all his fellow men and will be sadly missed by his many friends and family. His last few years were spent in the St Monica Trust Retirement Home and he died in the Bristol Royal Infirmary of pneumonia on 21st June 2014. n The full length obituary can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code

l Volume 02 / Issue 03 / August 2014 l boa.ac.uk l Page 62

Imprint

JTO: Information for readers, advertisers & potential authors

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

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Colin Howie (Editor) Ananda Nanu (Deputy Editor) Michael Foy (Medico-legal Editor) Jeya Palan (Trainee Section Editor)

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

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Tim Briggs (President) Martyn Porter (Immediate Past President) Colin Howie (Vice President) Tim Wilton (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

Head of Policy & Programmes ......................... Julia Trusler Policy and Programmes Officer.................................Rayshum Notay JTO & Joint Action Officer........................................Lauren Rich Policy & Programmes Assistant .................................. Holly Weldin Policy & Programmes Assistant ...........................Declan Mullaney

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 Graham Membership Administrator . ......................Leslie O’Leary

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

Information Systems Information Systems Manager ..................................Daniel Maby Information Systems Assistant.................................Claire Wilson

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.

Word Limit News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 and must include an image. We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 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. 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 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). You will be sent a Copyright Form following your article submission and this should be returned by email (signed, dated and scanned) to JTO@boa.ac.uk or posted to JTO Team, BOA, 35-43 Lincoln’s Inn Fields, London WC2A 3PE.

Future publications JTO is published quarterly.

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

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

Disclaimer The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication. Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations. Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Simon Donell, Nicholas Birch, Christopher Ackroyd, Ian Leslie, EFORT

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

AO UK Training & Education for Orthopaedic Surgeons & ORP Courses 2014/15 - UK & Ireland

WHAT'S NEW

AOTrauma Courses for Surgeons

AOUK LAUNCHES THE NEW AND IMPROVED LOCAL WEBSITE: WWW.AOUK.ORG

AOTrauma Course – Hand Fixation

Leeds

6 – 8 October 2014

AOTrauma Course – Advanced Principles of Fracture Management Basingstoke

11– 14 November 2014

AOTrauma Course – Basic Principles of Fracture Management

Basingstoke

17– 20 November 2014

AOTrauma Course – Basic Principles of Fracture Management

Dublin

26 – 29 January 2015

AOTrauma Course – Periprosthetic for Surgeons

Midlands

4 – 6 February 2015

AOTrauma Course – Paediatric for Surgeons

Nottingham

11 –12 February 2015

AOTrauma Course – Basic Principles of Fracture Management

Edinburgh

9 – 12 March 2015

AOTrauma Course – Shoulder & Elbow (includes cadaveric)

Newcastle

18 – 20 March 2015

AOTrauma Course – Current Concepts (includes cadaveric)

Coventry

22 – 24 April 2015

AOTrauma Course – Foot & Ankle (includes cadaveric)

Bristol

27 – 29 April 2015

AOTrauma Course – Wrist (includes cadaveric)

Coventry

8 – 9 June 2015

AOTrauma Course – Basic Principles of Fracture Management

Leeds

22 – 25 June 2015

AOTrauma Course – Advanced Principles of Fracture Management Leeds

23 – 26 June 2015

AOTrauma Course – Pelvic

London

7 – 9 September 2015

Basingstoke

18 – 20 November 2014

AOTrauma Courses for Operating Room Personnel AOTrauma Course – Basic Principles of Fracture Management

AOTrauma Course – Advanced Principles of Fracture Management Dublin

27 – 29 January 2015

AOTrauma Course – Advanced Principles of Fracture Management Leeds

24- 26 June 2015

VISIT WEBSITE FOR NEW VIDEO OVERVIEWS FROM RECENT COURSES - FEATURING PARTICIPANT FEEDBACK AND FACULTY RECOMMENDATIONS NEW REGISTER YOUR INTEREST - VISIT WEBSITE AND ENTER YOUR DETAILS TO BE ALLERTED TO UPCOMING REGISTRATION OPENINGS BIENNIAL COURSES IN 2015:

AOSpine Courses for Surgeons AOSpine Course – Advances Forum

Newcastle

23 – 24 October 2014

AOCMF Course – Advances in Distraction Osteogenesis

Birmingham

20 – 21 October 2014

AOCMF Course – Ballistic Injuries Symposium

Birmingham

26 – 27 February 2015

AOCMF Course – Basic Principles in Cranio-maxillofacial Fixation

Leeds

6 – 7 May 2015

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AOCMF Courses for Surgeons

techniques for Surgeons

AOCMF Courses for Operating Room Personnel AOCMF Course – Basic Principles in Cranio-maxillofacial

Leeds

7 – 8 May 2015

Registration

Contact

If you have any enquiries do not hesitate to contact

TO UPCOMING COURSE REGISTRATION OPENINGS:

us or register your interest online for upcoming

Full course listings and online registration for UK and

courses:

international courses can be found by visiting the relevant AO specialty website: www.aotrauma.org www.aospine.org www.aocmf.org For an overview of UK based courses, please visit: www.aouk.org

AOTRAUMA PAEDIATRIC COURSE, 11 & 12 FEBRUARY

•

AOTRAUMA PELVIC COURSE WITH CADAVERIC SPECIMENS, 7 - 9 SEPTEMBER

AOUK & Ireland PO Box 328, Welwyn Garden City, Herts. AL7 1YR Tel: +44 1707 823300 Email: info.gb@ao-courses.com Web: www.aouk.org

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A Patient Education Initiative from DePuy Synthes

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