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

Volume 02 / Issue 02 / May 2014

Inside

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

Our Features section includes an article from the new NJR Medical Director and a comprehensive update on GIRFT

For the latest updates on clinical issues, see our Peer-Reviewed Articles; the focus in this issue is Trauma

Our cover image this issue focuses on ‘A Good Pair of Hands’ – an extract from this year’s Robert Jones prize-winning essay

l News & Updates -----Pages 02-18

l Features -----Pages 19-58

l Peer-Reviewed Articles -----Pages 60-73

l Cover Image -----Pages 41-45

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

In the UK, there are approximately 23,688 tibial fractures every year.1, 2 The tibia is the most commonly fractured long bone in the body.1 The non-union rate may be as high as 10% ( § 2369 in the UK) 2, 3 which is compounded by smoking 4 and other non-union issues.5 EXOGEN has demonstrated a high heal rate of 91% (708/780) for non-union tibial fractures.6 Count on EXOGEN • 86% non-union fracture heal rate7 • 38% faster healing of fresh fractures8,9 • 91% treatment compliance10 • 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. Court-Brown C and Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37:691-697. (Estimation based on 43 tibial shaft fractures per 100,000 individuals and 2013 UK adult population of 55,475,220). 2. http://www.ons.gov.uk/ons/guide-method/census/2011/uk-census/index.html. Accessed on 08/13. 3. http://emedicine.medscape.com/article/1252306-overview#a0199. Accessed 01 March 2012. 4. Gaston M. and Simpson A. Inhibition of fracture healing. J Bone Joint Surg (Br). 2007;89-B:1553-60. 5. Wiss D and Stetson W. Tibial Nonunion: Treatment Alternatives. J Am Acad Orthop Surg. 1996;4:249-257. 6. DOF 12000.01 7. 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. 8. 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. 9. 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. 10. 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. 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. © 2013 Bioventus LLC

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

Contents

Welcome to the latest edition of the JTO Colin Howie - BOA Vice President

This issue has a Trauma focus; the next will be patient safety. We were grateful to have Nigel Rossiter from the Orthopaedic Trauma Society (OTS) as this issue’s Guest Editor. We plan to feature Guest Editors from Specialist Societies with a focus of general interest from their speciality in future. You will find the Trauma Peer-Reviewed articles on pages 60-73. You may be wondering about the significance of the front cover image. The illustration is Barbara Hepworth’s “Prelude II” (1948), and links with the Robert Jones essay prize-winning article “A Good Pair of Hands” (page 41). Barbara Hepworth was a British abstract artist and sculptor, who formed a close affinity with Sir Norman Capener an ex BOA President from Exeter. Capener invited her to watch him operate (and based the design for Capener’s gouges on her sculpting equipment). She became fascinated by the drama of the operating theatre and visited Stanmore for further artist in residence experiences. There has recently been a Tate touring exhibition of her work “The Hospital Drawings”. In an unpublished lecture she is quoted as saying that in the orthopaedic theatre “one can observe the highest intention and purpose; one can see the most perfectly attuned movements between a group of human beings”, perhaps evidence of “Human Factor’s” training in the past? You will find another of her illustrations within the Robert Jones article. The article amplifies and updates her other observation of “a close affinity between the work and approach both of physicians and surgeons, and painters and sculptors”.

We have a packed issue including an update from the Philippines (page 14), preparation for FRCS in our Trainee section (page 32) and an interesting piece on Cognitive Simulation, which fits in well with the Robert Jones article. There is some information on the Foot and Ankle syllabus for Europe from BOFAS and an update on where we are on harmonising standards of training from David Limb. In our Medico-legal section we have part two of the Jackson Reforms article following on from the last issue (page 48) and an article focusing on the medico-legal aspects of adult tibial shaft fracture (page 56). Your feedback about JTO has been really encouraging, even the critical comments have been positive. The JTO Team has been working very hard on this issue as it will be distributed at the 15th EFORT Congress in June to surgeons from across Europe. If you are attending the EFORT Congress, I look forward to meeting you and receiving more feedback!

Cover Image: Barbara Hepworth, Prelude No. 2, 1948 ©Bowness, Hepworth Estate / The Fitzwilliam Museum, Cambridge

JTO News and Updates

02-18

JTO Features

19-58

Themes emerging from ‘Getting It Right First Time’____ 19 Why I did an MBA_ _________________________________ 24 Shape of Training (Greenaway) Report________________ 26 Update on the National Joint Registry_________________ 28 Preparation for FRCS - a personal view_______________ 32 Cognitive Simulation: A novel method to enhance surgical skills____________________________ 34 A Good Pair of Hands_______________________________ 41 The Arthroplasty Care Practitioner’s Association_______ 46 The ‘Jackson Reforms’ in Civil Litigation and the Impact on the Expert Witness (Part 2)_____________ 48 Medico-legal aspects of adult tibial shaft fractures____________________________ 56

Measuring and changing practice – making a difference in hip fractures_________________ 60 AC Gray & TJS Chesser Managing trauma: The evolution from ‘early total care’/ ‘damagecontrol’ to ‘early appropriate care’______ 66 A Tasker & MB Kelly Common shoulder problems presenting to the fracture clinic_________________________________ 72 SE Aldridge & JR Williams

JTO Peer-Reviewed Features 60-73

Volume 02 / Issue 02 / May 2014

Inside

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

M News & Updates -----Pages 02-18

Our Features section includes an article from the new NJR Medical Director and a comprehensive update on GIRFT M Features -----Pages 19-58

For the latest updates on clinical issues, see our Peer-Reviewed Articles; the focus in this issue is Trauma M Peer-Reviewed Articles -----Pages 60-73

Our cover image this issue focuses on ‘A Good Pair of Hands’ – an extract from this year’s Robert Jones prize-winning essay M Cover Image -----Pages 41-45

In Memoriam and Bookshelf

General information and instructions for authors

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 02

JTO News and Updates

From the President:

Making an impact: The Chavasse Report and an International Healthcare Session Prof Tim Briggs

Approaching the half-way point in my Presidential year, it has been my pleasure to meet many members at the specialist society events I have attended and through the Getting it Right First Time meetings around the country. I’d like to take this opportunity to highlight two issues that I am particularly passionate about. Firstly, the Chavasse Report on the care we provide to armed forces and veterans with musculoskeletal injuries and infirmities; secondly, the anticipated avalanche of orthopaedics and the search for solutions. The Chavasse Report This independent report highlights the need to ensure better and greater continuity of care for those people severely wounded in action or suffering life-changing limb or back infirmities as a consequence of their military service. Inspired by Captain Noel Chavasse VC and Bar in 1917, this report highlights the importance of the provision of a comprehensive, fast-tracked, high quality orthopaedic service for all armed forces personnel, which can be achieved through a strengthened partnership between the Armed Forces and the NHS, Furthermore, this will lead to improved NHS standards for all those needing to access these services.

Bone, joint and muscular injuries account for 60% of medical discharges from the forces. Although the Defence Medical Service tracks personnel who undergo amputations and other operations whilst in service, some may require further surgery at a later date under the care of the NHS following discharge and nearly all will need effective rehabilitation support. The report sets out clear recommendations and proposes ways to deliver high quality, affordable care that helps to strengthen the partnership between the Armed Forces, The Nation and the NHS. I hope that I can count on BOA members and JTO readers to support the actions flowing from the report. The changes that are needed will require some re-configuration and should be guided by frontline clinicians working closely with management to ensure equitable on-going access to high quality services.

My Presidential Guest Lecturer: Lord Bernard Ribeiro will be speaking at 2.30pm and this will be followed by the international healthcare session at 3pm with a range of invited guests from the UK and overseas, including fellow surgeons, representatives from industry, private medical insurers, senior policy makers and the NHS, as well as from other healthcare bodies around the EU.

Prof Tim Briggs

Chavasse will be launched in the early summer and will be available on the BOA website.

EFORT/BOA session on the international “Avalanche of orthopaedics” In 2013, we published an article in the Parliamentarian called “The International Healthcare Timebomb: Time for Action”. The article highlighted the real pressure that we are soon going to be under from the ‘avalanche of orthopaedics’ resulting from an ageing population, higher rates of obesity and other contributory factors. Through the BOA Presidency I have been able to convene a major international healthcare session on this during the EFORT/BOA Joint meeting. For those of you reading this at the London meeting, I encourage you to attend this session which is taking place on Thursday 5 June in the ‘London’ room.

The session will address 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. The objective of the session is to establish a consensus on the way forward and the work streams required to prepare for a further high level international summit in 2015. I am looking forward to this important discussion and hope to see many of my British colleagues there. We make a cost effective difference to our patients’ lives and should act as their advocates.

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

BOA Congress registration now open

@BritOrthopaedic #BOAAC

Guest lecturers include:

This year’s BOA Congress 2014 will be held over two days in Brighton: 12th-13th September. The theme is ‘Managing Change’ with a stimulating programme of CPD focused on broader professional issues that will supplement clinical revalidation material from our combined meeting with EFORT and Specialist Societies. The Congress will provide significant opportunities for T&O surgeons to learn, debate and get up to date on the latest techniques and areas of orthopaedic research, as well as gain up to 10 CPD points. We promise an outstanding platform for hot topic discussion and an unparalleled networking opportunity. Congress Programme Highlights The new Consultant Contract l The employer’s perspective in the context of affordable high quality care and possible future career structures l What the profession views as realistic, achievable and properly representative l The trainee’s perspective and the patient’s view Surgeon outcomes: safety and good practice l Individual Surgeon Outcome Publication - the ‘why’ l Where we are now with outcomes publication - where next for individuals and units, and what about private practice SAS surgeon training and education

Managing poor performance l What does poor performance look like from the CQC’s perspective? Some cautionary tales l Case study: Transformation in action Commissioning for beginners l Specialised Commissioning what it is and how it works for T&O l How CCGs approach MSK l BOA Commissioning Guidance documents The Shape of Training Review - what the future holds l Greenaway and the case for change Medicolegal reforms and the rising cost of litigation l Lord Justice Sir Rupert Jackson lecture followed by panel discussion The NJR, other registries, data and evidence

Presidential Guest Lecture General Lord Richard Dannatt ‘The Changing Face of Military Conflict’ 100th Anniversary of the start of World War 1

Howard Steel Lecture Humphrey Walters For the past 30 years, Humphrey Walters has been inspiring and motivating individuals, teams and corporations in leadership and management and the concept of “The Business of Winning”.

View the congress website at congress. boa.ac.uk and download the proposed programme. Registration is free for BOA members until 31st May.* Non-BOA members can register from 1st May, and up until 31st May non-members who register can opt to become a BOA member for the rest of the year for no extra charge and receive a 10% discount off the 2015 subscription.* *Terms and conditions apply, see congress.boa.ac.uk for details.

Join us in Brighton Travelling to Brighton could not be easier! Trains from London Victoria or St Pancras Stations take approximately one hour and only half an hour from London Gatwick Airport. View the different travel options on the Congress travel page. Join the BOA team in Brighton and reunite with friends and colleagues in this vibrant seaside town for what promises to be an outstanding meeting.

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

JTO News and Updates

A European Curriculum for Trauma and Orthopaedic Surgery? David Limb, BOA Secretary

Trainees and specialty doctors have had the option of sitting the European Boards exam in Orthopaedics and Trauma (EBOT) for many years. In some specialties the European examination is treated as equivalent to the UK specialty exam. In Trauma and Orthopaedics this is not the case; the EBOT exam has no clinical component. Indeed, it is to date a test of academic clinical knowledge. In the UK we benefit from a detailed, evidence based and constantly reviewed curriculum written and maintained by the Education Committees of the BOA and accepted by the GMC. In many European states training programmes are much less formal, often linked to single institutions with no uniform standards or comparators to refer to. The EBOT exam would be a useful yardstick to ensure a certain level of academic knowledge is attained, but it does not mean that someone passing the exam will be able to perform surgery safely. The European Commission would like to see common standards across the output of all training programmes. EFORT are acutely aware of the need to bring some uniformity to training standards in member states. An honourable aim but no mean feat! Moving in that direction a European Education Platform is being developed, which will set out a syllabus, standards and a set of assessments. However, the expectations and workload of an orthopaedic surgeon vary around Europe. Trauma is not part of orthopaedics in some countries, in others it can be the entirety

of practise. In many countries training is very general yet others produce sub-specialists who have no experience in the generality of orthopaedics or trauma. In a

number of countries rheumatology, including the management of disease modifying drugs is regarded as part of the orthopaedic skillset. A comprehensive European Curriculum is a long way off! However EFORT hope to produce a syllabus for Trauma and Orthopaedics that is likely to be modular. Each country or institution can specify the areas to be included, competencies will be clear if there is migration. Some sub specialities already have Pan European exams (e.g. Hands, Foot and ankle) (see accompanying article for the foot and ankle perspective). Assessments are being worked on for in-post monitoring of trainees and the EBOT exam is being reviewed

for its suitability in testing against the syllabus. This work will not produce trainees of equivalence; however, it is hoped that it will help specify exactly what training programmes in individual countries or institutions produce. One day we may reach a stage where free movement across Europe can take place without risking patient safety. For the time being, however, this seems some way off. Current training programmes in the UK and Ireland, using the BOA Curriculum, can give assurances about their CCT holders that others cannot. Equally we have no plans to introduce rheumatology into the UK/ Irish Curriculum at present.

European Certification in Trauma and Orthopaedic Foot and Ankle Surgery Don McBride Chairman Certification Board European Foot and Ankle Society (EFAS), Honorary Treasurer EFAS, BOA Council Member The European Certification in Trauma and Orthopaedic Foot and Ankle Surgery is intended to ensure the highest standards of practice in our field of expertise to benefit patients. Entry to the exam will require a basic postgraduate trauma and orthopaedic qualification, evidence of at least five yearsâ&#x20AC;&#x2122; practice in the speciality, together with a ratified logbook, intended to evidence a knowledge base and practical skills commensurate with the syllabus. EFAS has developed

further additional criteria based on meeting attendance, publications and fellowships. The examination consists of a Multiple Choice Questionnaire (MCQ) and Viva. Should a pass be awarded, a recommendation will be submitted to the Union of European Medical Societies (UEMS) for ratification. This certificate will remain an additional and complimentary qualification to existing examinations in individual European Countries, for example, EBOT. There will be many benefits. The

standard is set at specialist level providing complete confidence in our art and science for the patients that we treat. Surgeons who complete this process will have a general understanding of the knowledge and surgical skills required. By investment in training young surgeons interested in pursuing a career in trauma and orthopaedic foot and ankle surgery shall be facilitated. In addition, it will promote educational and scientific research in the basic science, paediatric, adult and traumatic foot and ankle surgery. EFAS wishes to remain at the forefront of these exciting developments and pro-actively take our speciality in to the future setting the standard for many years to come. www.efas.co.uk

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16TH & 17TH OCTOBER 2014

COMBINING ORTHOPAEDIC REVISION AND ONCOLOGY EXPERTISE YOUR CHALLENGES - YOUR VIEWS - YOUR MEETING Specifically dedicated for surgeons specialising in these fields, encouraging them to come together and discuss the solution of extreme cases that both disciplines observe. CO-CHAIRS Mr Will Aston FRCS. The Royal National Orthopaedic Hospital, Stanmore Mr Lee Jeys FRCS. The Royal Orthopaedic NHS Trust, Birmingham Professor Tim Briggs FRCS. The Royal National Orthopaedic Hospital, Stanmore

Focused agenda items include:

t Management of Periprosthetic Fractures and Failed Trauma Fixation t Complex Problems around the Knee t Complex Problems of the Hip and Pelvis Meet the Experts â&#x20AC;&#x201C; an interactive session dedicated to case discussions And International Guest Lecturers speaking on cross-over surgery

EXTREME ORTHOPAEDICS ACADEMY Operative techniques in Extreme Orthopaedics

Courses held on the following dates: 10th June and 23rd September 2014 For further information or to register for an EOA course please go to www.extreme-ortho.com

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For further information or to register for the EOS 2014 please go to www.extreme-ortho.com

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

JTO News and Updates

The Establishment of the Orthopaedic Trauma Society Nigel Rossiter & Charlotte Lewis

The concept of the Orthopaedic Trauma Society has evolved over a number of years from discussions by British Orthopaedic Trauma surgeons who have attended the US Orthopaedic Trauma Association meetings and wished to emulate this organisation and that of the Canadian Orthopaedic Trauma Society. This was cemented from a lunchtime discussion held by this group in Minneapolis October 2012. Orthopaedic Trauma is now seen as a career choice in its own right rather than something tagged onto an elective interest. This has been fuelled by the rapid progress made by the National Trauma Network. The expansion of numbers of Orthopaedic Trauma surgeons coinciding with the advent of Major Trauma Centres has precipitated the need for our own Orthopaedic Trauma Society (OTS) that fully and formally represents the subspecialty of Orthopaedic Trauma within all hospitals in the British Isles and all those, surgeons or otherwise, involved in Orthopaedic Trauma. Nigel Rossiter has been nominated as the first President. He is supported by a committee of 15 trauma surgeons from around the

British Isles based at both Major Trauma Centres and Trauma Units. The OTS was launched in August 2013. At the Edinburgh Trauma Symposium, it held its first research meeting. Twenty-five papers were presented from both British and international hospitals. (The best paper was awarded to Reggie King from South Africa for his RCT comparing locked intramedullary fixation with anatomically contoured locked plates for clavicle fractures). The OTS held sessions at the British Orthopaedic Association meeting in Birmingham in October 2013. Both the instructional course and â&#x20AC;&#x2DC;boot campâ&#x20AC;&#x2122; sessions were well attended, well received and often over-subscribed. These were useful for both the Trauma surgeon and the

elective Orthopaedic surgeon on the on-call rota needing to update and revalidate in trauma. The first official meeting of the OTS was held at The Royal College of Surgeons of England on the 6th and 7th March 2014. You can read more about this on page 10. The society will again hold a research meeting for the presentation of original research in conjunction with the Edinburgh Trauma Symposium in August 2014. We have much to learn from the already established societies in North America. The Orthopaedic Trauma Association started in 1977 and recalled how their early meetings were useful and an important forum for the trauma surgeon. Many were able to share viewpoints on the cutting edge of trauma for the first time. We hope the OTS will grow into a similarly successful society not only organising meetings but also co-ordinating trauma research, education, fellowships and training. We endeavour to advance the practice of excellence in Orthopaedic Trauma in the British Isles. More information can be found on the website regarding membership and meeting details. www.orthopaedictrauma.org.uk

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

JTO News and Updates

BOA Latest News

BOA Regional Advisers/ RSPAs

BOA Simulation award This year, the BOA will be offering a new award for excellence in Innovation in Simulation. The prize will be awarded for “Innovation in Simulation and Technology Enhanced Learning”. Candidates are required to create a low cost simulator or form of simulation for T&O surgery for training purposes. The aim is to create some form of simulator which replicates for training purposes, one teachable component of trauma and orthopaedic surgery. It will preferably include as many different teachable components as possible, but certainly the essential steps. The deadline for applications is 1st June. For more information and how to apply, please contact Holly Weldin: h.weldin@boa.ac.uk

Commissioning Guidance and Data Tools A further Commissioning Guide on Subacromial Shoulder Pain has recently been finalised and will shortly join the other publications already available online. Data tools and dashboards for this guide have also been added to the National Surgical Commissioning Centre – www.rcseng.ac.uk/ healthcare-bodies/nscc. We are continuing to promote these guides and data tools in our communications and at events, and would encourage all JTO readers to raise awareness of them with commissioners in their areas.

The team from York Trials Unit: L-R Dr Catherine Hewitt, senior statistician; Dr Catriona McDaid, Senior Research Fellow; Professor David Torgerson, Director York Trials Unit, Ms Belen Corbacho, Health Economist and Dr Stephen Brealey, Research Fellow and Trial Manager

Grant awarded for trial methodology support As mentioned in the last JTO, the BOA has shifted the direction of its research funding as we seek a step-change in T&O research in the UK. Following our call for applications in the autumn for funding to support development of clinical trials, we are pleased to announce that we have awarded funding to York Trials Unit after a highly competitive selection process. York has considerable experience of planning and running

clinical trials in T&O and had strong ideas for how they could seek wider clinician engagement and develop new studies through this initiative, and we are looking forward to working with them on this. More information will follow in the next JTO and the team from York will be involved in the research session at the Brighton Congress where you can find out more about what will be happening as part of this initiative.

BOA support for research priority setting As part of the BOA research strategy, we plan to increase our support for T&O research-priority-setting partnerships in the coming years in collaboration with the James Lind Alliance. There is already a priority setting partnership for hip and knee joint replacement, which is due to be completed in the coming months; and a further initiative is just starting for shoulder surgery, to which we are contributing. We are pleased to be working with organisations such as Arthritis Research UK (ARUK) and NIHR Oxford Biomedical Research Unit on these important projects. Other similar initiatives have led to research being funded in many of the priorities identified, and we are hoping that this trend will be seen in our sector also.

We are pleased to announce four new appointees to these roles: l London (North East) – Barry Ferris l London (South) – Joydeep Sinha l East Midlands (North) – David Clark l West Midlands – James Arbuthnot Recruitment is currently underway for further vacancies in the following regions l South Central North l Yorkshire and the Humber (East) If you are a BOA member in one of these regions and would like to apply, please supply a CV and supporting statement to Natasha Wainwright (n.wainwright@boa. ac.uk) by 6th June and note that interviews will be held on 7th July.

Virgin Money London Marathon 2014 We would like to thank BOA Members, Callum McBryde and Vikram Desai, and Orthopaedic Registrar, Mike Barrett, for running in this year’s London Marathon. At the time of writing, these three runners along with the remaining two runners in the Golden Bond have raised over £3,500 with much more expected. We would also like to thank Noel Fisher for recommending someone to replace him following an injury. If you’re interested in running the London Marathon for Joint Action next year, please contact Lauren Rich: l.rich@boa.ac.uk.

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

Wider News & Developments

Consultant outcomes publication – gearing up for 2014

Latest reports and policies JTO readers may be interested in the following recently released documents relevant to our profession. l NICE has published new reports on:

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.

If you have any queries on how to access the data and validate it, contact the NJR for assistance. The BOA is working with specialist societies, NJR and HQIP on this initiative, and will keep members updated as the initiative progresses this year.

CG177 Osteoarthritis: Care and management in adults http://guidance.nice.org.uk/ CG177

The BOA has also been advised that this year consent by surgeons for publication will not be required. The information is due to be published in the autumn, ahead of that time the BOA and NJR are strongly encouraging all surgeons in England who have undertaken these procedures to validate NJR data relating to their practice.

Clare Marx as President-Elect with Prof Norman Williams, current RCS President

Orthopaedic surgeon to lead RCS England Past President (and first female President) of the British Orthopaedic Association, Clare Marx, has been elected as the first female President of the Royal College of Surgeons of England (RCS) and will take up her appointment in July 2014. The RCS presidency lasts for three years, subject to annual re-election by the College Council. Miss Marx works as Associate Medical Director at Ipswich Hospital NHS Trust. During her time as an RCS Council member she has championed patient safety and quality measures, including her role as vice-chair of the NHS’s Surgical Never Events taskforce. She has worked on initiatives to encourage more women to enter surgery, as well as training and workforce issues.

STOP PRESS New BOA website goes live The BOA website has had a facelift and you can view it now by going to www.boa.ac.uk or scanning the QR Code

TA 304 Arthritis of the hip (end stage) hip replacement (total) and resurfacing arthroplasty http://guidance. nice.org.uk/TA304. l QS56 Metastatic spinal cord compression http:// guidance.nice.org.uk/QS56.

NHS England’s Surgical Never Events Taskforce has made a series of recommendations for new standards and systems to further improve the safety of surgery in English hospitals. A full summary of the report is available online: www.england.nhs.uk/ wp-content/uploads/2014/02/ sur-nev-ev-tf-sum-rep.pdf ‘Building a Culture of Candour’ - A report produced by Professor Norman Williams, RCS (England President), and Sir David Dalton Chief Executive of Salford Royal Hospital at the request of the Secretary of State for Health following the Government’s response to the Mid Staffordshire Public Inquiry. www.rcseng.ac.uk/policy/duty-of -candour-review

l National Hip Fracture Database report ‘Anaesthesia Sprint Audit of Practice (ASAP)’ www.nhfd.co.uk

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

JTO News and Updates

The First OTS AGM fascinating talk entitled “Reception and resuscitation in trauma: A fast changing world”. He showed how as a nation we had changed so much to benefit the care of trauma victims.

The Orthopaedic Trauma Society (OTS) held its first official meeting at RCS England on 6th March 2014. The morning session provided updates from the BOA trauma group, the MTC 22 group, the Scottish, Northern Irish, Eire and Welsh trauma representatives. Keith Synott shared experiences from Haiti and Nigel Rossiter talked about setting up trauma training in Uganda. Jon Clasper and Anthony Bull gave a great start to the day looking at military trauma and the effect of blast injury. Matt Costa headed speakers

The first annual meeting for OTS

looking at successes in multicentred randomised controlled trials in trauma.

The keynote speaker was Professor Chris Moran - National Clinical Director for Trauma – who gave a

A “Dragon’s den session” was held for research proposals to be presented to choose the next multicentred study/ies. Proposals were of a high standard and included hip fracture studies, a new design of shoulder hemiarthroplasty, fibular nail fixation for ankle fractures, thromboprophylaxis in plaster casts, distal femoral fracture management, minimal supplementary screw fixation for nonunions and compartment syndrome monitoring. Pictures can be seen at the OTS website www.orthopaedictrauma. org.uk. For more information about the OTS see page 6.

The British Hip Society Meeting The British Hip Society meeting for 2014 was hosted in early March by the President, John Timperley, in Exeter Cathedral - a magnificent building dating back to the 12th Century. Topics this year included a combined session with paediatric surgeons examining the prognosis and treatment of paediatric and adolescent hip disorders. The changing nature of our employment contracts was addressed by the BMA representatives involved in negotiations, an update on Getting it Right First Time (GIRFT) from Tim Briggs and Peter Kay

explained the present and future of commissioning of MSK services and Payment By Results. NJR data was discussed paying particular attention to the accuracy and the way data is accessed, interpreted and disseminated. The Presidential Guest lecturer was Stephen Graves, the Director of the Australian Joint Register who gave an insightful presentation on “Arthroplasty Registries: What they can and cannot do. What they should and should not do. What makes a quality registry?” John Timperley spoke on the transparency agenda, the role of orthopaedic registries, commissioning guidelines and NICE guidelines. We learned that data in the public domain is increasing exponentially but there remain profound problems with the completeness and accuracy of data. The Profession is engaging

Magnificent venue for British Hip Society meeting

in efforts to help validate NJR data and must lead and formalise the mechanisms by which only relevant, validated metrics are published that will lead to improved patient care. Surgeons will be less exposed to risk themselves if they engage to ensure accurate data is collected in their name.

The Presidency was handed over to John Skinner from RNOH and the 2015 meeting will be in London in March 2015. For more information, or you have an interest in hip surgery and would like to join, please visit www.britishhipsociety.com.

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

JTO News and Updates

Travelling Fellowships BOA Zimmer travelling fellow 2012-2013 Hussain Kazi My fellowship was at the Holland Orthopaedic and Arthritic Centre, part of Sunnybrook Health Sciences Centre. Sunnybrook is Canada’s biggest trauma centre and the Holland Centre is Canada’s biggest arthroplasty unit performing 2,500 joint replacements per year. My supervisors were Dr JC Cameron, Dr J Gollish, Dr JJ Murnaghan, Dr CS Wright, and Dr VMR Wadey. Work started at 0600, with pre op clerking followed by a ward round, with a theatre start time – knife to skin of 0745. Instead of anaesthetic rooms a “block area” was utilised. Theatres were very uncluttered and had fewer nurses than at home – usually two up until 10am. The nurses were usually dual trained and could assist the anaesthetist as required. Advanced practice physiotherapists ran outpatient assessment and follow up. The Canadian healthcare system is very similar to the NHS but there is no private practice. The patient pays for all outpatient drugs. Surgically I performed 220 TKRs and 100 total hip replacements as well as revision hip and knee replacements. I gained experience

in osteotomies for unicompartmental arthritis, rotational problems and patella dislocations, as well as meniscal allograft transplantation. At weekends, I participated in the trauma rota at Sunnybrook, the province’s major trauma centre.

Research My year afforded me a whole spectrum of research opportunities including: l Meniscal allograft with and without osteotomy: a 15-year follow up study l Single stage single component revision in infected hip arthroplasty l The presence of a learning curve in preoperative arthroplasty templating l Lower Extremity Arthroplasty Fellowship Education in Canada: A Needs Assessment of Competencies

Awards I was nominated for the University of Toronto, Department of Surgery, Zane Cohen Fellow of the Year Award before leaving Toronto. http://orthopaedics.utoronto.ca/ education/fellowship/fellowship_ arthroplasty/arthroplasty_shsc.htm

Mr Rick Brown, Dr Nohakhelha Nyamulani, Dr Kumbukani Manda and Mr Simon Henderson, BOFAS President 2013

BOFAS Malawian Travelling Fellows attend Annual Conference Rick Brown

Members of both the BOA and BOFAS will be familiar with the achievements in Malawi of a series of British Orthopaedic Surgeons, who have over the last fifteen years, led the provision of orthopaedic services. Now there is a growing need to train the next generation of Orthopaedic Surgeons in Southern and Central Africa. The Council of BOFAS decided in 2012 that it should take a lead in supporting the Malawian Orthopaedic Services. It recommended that a link be established between Orthopaedic Surgical Trainees in both countries, and each year, two trainees should complete a mini-fellowship in the other country. Dr Nohakhelha Nyamulani and Dr Kumbukani Manda were sponsored by the BOFAS Educational Committee to visit hospitals in the Severn area, and during two weeks, travelled between the Avon

Fellows and Staff Surgeons (author is back right)

Orthopaedic Centre, Bristol to Cheltenham General Hospital before continuing to the Royal Gwent Hospital, Wales. The final stage was a flight to Belfast to spend three days at the BOFAS Annual Meeting and enjoy warm Irish Hospitality. The Malawian registrars were welcomed at each stop during their travelling fellowship and are seen here with Mr Simon Henderson, BOFAS President 2013. Later this year two UK trainees will be flying out to Malawi, on the reciprocal leg of this fellowship. Any reader wishing to be considered for this BOFAS mini-Fellowship to Malawi in 2015 should apply through the BOFAS website. BOFAS is hoping to support a week long teaching module on Foot and Ankle Surgery in Malawi in the autumn for Orthopaedic Registrars from Central and Southern Africa, as part of the Regional Training programme with COSECSA (College of Surgeons of East, Central and Southern Africa).

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

Bone & Joint Journal/EFORT Travelling Fellowship in Scandinavia Abbas Rashid, Amit Atrey & Owen Diamond – BOA Associates/Members This was the inaugural fellowship initiated and funded by the British Editorial Society of the Bone & Joint Journal and supported by EFORT and the BOA. Every year three orthopaedic surgeons are selected to spend two weeks visiting orthopaedic centres of excellence in either the UK or mainland Europe, culminating in attendance at either the EFORT or BOA Congresses. We enjoyed visits to: Odense University Hospital, Odense, Denmark; Hvidore University Hospital, Copenhagen Denmark; Skane University Hospital, Lund Sweden and The Orton Clinic, Helsinki Finland. Our tour concluded with a trip to the 14th EFORT conference in Istanbul where we enjoyed a drinks reception with Professor Philipe Neyret (Lyon, France) who selected the units and the late Mr Mark Paterson (London, UK) who was our linkman from the BJJ. In addition to getting an excellent insight into how Scandinavian hospital systems are structured to tackle healthcare provision in a changing economic environment, we were able to broaden our clinical experience, make important professional contacts and gain experience in presenting our own work in an international setting. We hope our visit provided a welcome stimulus for the centres involved, as well as giving them an opportunity to strengthen their ties with the UK. We would like to express our gratitude to all the organisations involved for their generosity.

Our full report can be found at: www.efort.org/wp-content/ uploads/2013/06/bjj_boa_efort_ tf_2013.pdf This Fellowship has now been renamed the Mark Paterson Travelling Fellowship and the next opportunity for BOA members to take part will be in 2015. Find more information at: www.efort.org/fellowship-awards/ fellowships/bone-and-jointefort-tf

Biplanar c-arms being used to fix an intertrochanteric neck of femur fracture at Malmö University Hospital in Malmö, Sweden

BOA Awards 18 Travelling Fellowships – Could it be you next year? The BOA was delighted to award eighteen fellowships in this year’s round of BOA Travelling Fellowships. Generous funding from legacies, generous donors and internal funds (with values between £1,500 to £10,000) enables the BOA to offer members career-enhancing opportunities to develop their surgical skills under expert clinical guidance, whilst forging close working relationships with prestigious medical institutions around the world. Congratulations to the following outstanding individuals, who each demonstrated a commitment to broadening and furthering

Jacobs, Asim Rajpura, Parag Jaiswal, Tony Bateman, Dennis Kosuge, Narayana Prasad, Wiqqas Jamil, Mohamed Sukeik, Louise McCullough, Darryl Ramoutar, Jaykar Panchmatia, Joseph Baker and Shin-Jae Rhee.

their T&O careers, in a variety of subspecialties: Alex Trompeter, Jonathan Stevenson, Jeya Palan, Arpit Jarawala, Alex Aarvold, Neal

To find out if you are eligible to apply for the 2015 BOA Travelling Fellowships, please visit the Training & Education section of the BOA website where you can read about each of the fellowship opportunities in more detail. Applications for 2015 will open in October 2014, and in the meantime please do not hesitate to contact Holly Weldin: h.weldin@boa.ac.uk if you have any queries, and keep an eye on the BOA website.

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 14

JTO News and Updates

Trauma in Tacloban following Typhoon Haiyan Steve Mannion, Chairman, World Orthopaedic Concern

At 0800 local time on the 7 of November 2014 Typhoon Haiyan, a category 5 tropical storm, made landfall in Tacloban on the eastern side of Leyte Island in the Philippines. Winds up to 270km/hr and a massive storm surge wave devastated much of the city of 220,000 people, with estimates of 4,000 dead and 12,000 injured. th

As part of the UK response, the Secretary of State for International Development, Justine Greening, activated the United Kingdom International Emergency Trauma Register (UKIETR) to mobilise personnel to assist in a humanitarian medical response project administered by Save the Children / Merlin. The UK team of 13 was divided into two groups, a more primary care / emergency medicine focused team were deployed on HMS Daring,

Steve Mannion operating in Tacloban

which was tasked to undertake an assessment of the damage to outlying islands which could not otherwise be accessed, and a surgically focused team, whose remit was to assist at the tented AUSMAT (Australian Medical Assistance Team) field hospital in Tacloban. The Tacloban team included two orthopaedic surgeons, Steve Mannion and Richard Villar. The majority of the cases encountered

were limb wounds, typically caused by the impact of corrugated iron roof sheeting which had been ripped away by the wind. Presenting days or weeks after the injury, 50% of the cases were deeply infected, the commonest operation being wound debridement. Particularly challenging cases included salvage of field “guillotine” transtibial amputations which had been conducted in the immediate aftermath of the storm (striving to preserve the knee) and reconstruction of late presenting “spaghetti” wrist lacerations. The UK surgical team contributed to over 100 emergency operations whilst in Tacloban. By 23/24 November, over two weeks following the impact of the storm, the number of trauma presentations had declined and the focus of the international medical relief effort shifted to primary health care and restoration of local healthcare infrastructure. The seafront Tacloban government hospital, devastated by the storm surge wave had also been

Paediatric guillotine amputation in Tacloban

restored to function, including its surgical capacity, thereby permitting the UK team to withdraw. The UKIETR is a database of clinicians prepared to assist in the wake of natural disasters anywhere in the world. Volunteers undergo training in disaster relief at the National Fire Service College in Moreton-in-the-Marsh and surgeons go on to attend the Surgical Training in the Austere Environment (STAE), cadaveric based course at the RCS. It is hoped that prospective arrangements with employing NHS Trusts will allow timely release of volunteers for future disasters, with back-filling funding to cover the cost of absence. More details can be found on the website www.uk-med. org.

IMPROVES PERIPROSTHETIC FRACTURE OUTCOMES REVISE RATHER THAN PLATE

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References 1. Bhattacharyya T et al, Mortality after periprosthetic fracture of the femur, published in Journal of Bone and Joint Surgery Am.2007;89:2658-2662 2. Risk factors for failure after treatment of a periprosthetic fracture of the femur H. Lindahl,; H. Malchau, A. OdĂŠn, G. Garellick, J Bone Joint Surg Br January 2006 vol. 88-B no. 1 26-30 3. N Rahmatullah N et al, Abstract number L148, BOA and IOA Annual Congress Meeting, Dublin: The Uncemented Cannulated Cannulok Revision Prosthesis: Do we know enough about it? 4. Jimenez, ML et al OTA 20th meeting Florida, Morbidity and Mortality Associated with Periprosthetic Fractures of the Femur

www.orthodynamics.co.uk

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

JTO News and Updates

BOA Membership: Get involved

Are you a BOA member? Are you making the most of your membership? Are you thinking of becoming a member? There’s never been a better time to join. As a BOA member you will be part of our growing strategy focusing on excellence in Professional Practice, Training and Education, and Research.

Excellence in Professional Practice Take advantage of our close collaborations with: l Our sister Surgical Specialty Associations and the Royal Colleges on all issues l The MHRA, ODEP and Beyond Compliance on devices l The NJR, NHFD, TARN and other national clinical audits l The Healthcare Industry on innovation

l NICE – on Quality Standards and Outcomes l The BMA to influence our members’ terms and conditions of service l The Federation of Independent Practitioner Organisations for private practice matters l NHS England on commissioning and service reconfiguration l Health Education England for workforce planning and the EWTR l The NHS in the devolved nations l BODS, our Regional Advisers and TPDs across the UK We have produced various Blue Book publications and BOAST sheets, as well as the BOA’s Consultant Advisory Book. These are circulated to all members throughout the year, with downloadable versions available on the BOA website.

Training and Education In 1925, Sir Robert Jones said that training needs to be ‘sufficiently comprehensive to enable one to appreciate the scientific basis of any new advance and to maintain a technical facility to traverse any fresh operative avenue’. Today, we develop and revise the T&O Curriculum for the GMC and set standards for its delivery, as well as supporting training and education opportunities for T&O surgeons throughout their careers. As a member you can continue your Professional Development through: l FREE attendance at our 2014 Annual Congress in Brighton (congress.boa.ac.uk) l Discounted rates for our Training Orthopaedic Trainers and Instructional courses l Your subscription to The Bone and Joint Journal (BJJ) (included in your membership fee)

Trauma & Orthopaedic Research We have moved away from direct funding of small research grants (previously known as Joint Action funding) and are concentrating our resources on infrastructure and facilitating future research, where we believe we can create a bigger and longer-lasting impact. We are working closely with Arthritis

Research UK, the James Lind Alliance and NIHR to further our work in this area. As a Member you can receive information about opportunities to get involved in this, and updates on the latest developments that could affect you.

Member benefits Your BOA membership entitles you to special promotions or rates on the following: l Medical malpractice cover from CJ Coleman l Private medical insurance from General & Medical l Income protection insurance from PG Mutual l Frequent flyer programme with Virgin Atlantic l Private healthcare insurance from Western Provident Association l Medical titles from Wisepress online medical bookshop Did you know our UK members also receive an exclusive hard copy handbook of peers that includes a comprehensive list of all members of the association, and highly informative monthly Presidential and news e-mails keeping you abreast of all the latest trends, political landscape and best-practice policies? All UK members also receive the Journal of Trauma and Orthopaedics (JTO), on a quarterly basis.

Call for International Members

Are you an overseas orthopaedic surgeon wanting to form closer links with your peers? Now is the time to take advantage of our networking opportunities. With almost 4,000 members the BOA enables you to exchange, collaborate and share information. Advance your learning and career development and join the BOA today.

Visit boa.ac.uk for further details

BOA Congress, Birmingham 2013

For further information on all aspects of BOA membership, please visit www.boa.ac.uk.

Supporting healthcare professionals for over 150 years

www.smith-nephew.com/education

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

JTO News and Updates

BOA’s First ‘Training Orthopaedic Leaders’ Course Hailed a Success “Most helpful aspect was the learning circle. Both mine, and everyone else’s. Seeing other styles and the discussion / constructive criticism raised far more points than lectures ever could”

Now, more than ever, T&O requires leaders with great leadership skills, who are able to work at every level within our organisations. Following an initial idea from Martyn Porter during his Presidency, Professor Phil Turner and Lisa Hadfield-Law (BOA Education Advisor) ran the first 2-day Training Orthopaedic Leaders programme (TOLs) in January, at the BOA in London. The programme was: l aimed at established T&O consultants seeking development in the leadership aspects of their consultant role and have potential to assume a wider leadership role within the T&O community e.g. training programme directors, clinical directors and committee chairman. l designed to support and challenge T&O leaders at trust level and beyond, and covered:

“Following the course I shall try to be more forceful, less worried about upsetting feelings……building networks / contacts - tend to have neglected this in past.” “Group size was good. Smaller the better, certainly limit to 8-10 max.”

Two-day TOL course proves a success

different leadership styles and self-awareness of strengths and weaknesses; managing conflict; negotiation; influencing without authority; and teamwork.

Feedback was extremely positive: “..fitted the brief and I found it extremely stimulating, as well as good fun!”

“..great to take time out, in well facilitated discussion and think hard about what I do as a leader”

“Better insight into leadership difficulties with interesting cases to discuss”

“Discussing different department problems with experienced and insightful colleagues”

We are looking to build on the success of this course. The TOL course being held in Scotland in June is full but registration will be opening soon for a course in London on 18th-19th September, and we will be keeping the group small to allow maximum discussion. If you are interested in joining, find out more on the BOA website www.boa.ac.uk.

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

Spring Meeting 1-2 May 2014, Gateshead

EFORT/BOA www.efort.org/index.php/events-calendar/efort-event-directory

15th EFORT/BOA Combined Congress 4-6 June 2014, London

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

BOTA Educational Weekend 20-22 June 2014, Chester

•

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

BOA 2-Day Meeting 12-13 September 2014, Brighton

•

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

Research Meeting 19 October 2014, Edinburgh

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

Annual Meeting 5-7 November 2014, Brighton

BHS (British Hip Society) www.britishhipsociety.com BASK (British Association for Surgery of the Knee) www.baskonline.com

Annual Meeting 4-6 March 2015*, London (*subject to change)

Annual Conference 10-11 March 2015, Telford

Future BOA Course dates

•

28-29 August 2014 - Training Orthopaedic Trainers (London) 18-19 September 2014 Training Orthopaedic Leaders (London) 10-11 January 2015 BOA Instructional Course (Manchester)

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.

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 19

JTO Features

Themes emerging from ‘Getting It Right First Time’ Professor Tim Briggs, BOA President

More than 1 in 5 (22 per cent) of hospitals will be in deficit by the end of this financial year (King’s Fund’s quarterly monitoring report1). This situation will worsen next year as budgets tighten relative to inflation and in light of rising demand. Depending on where they reside, some patients are unable to access THR and TKR (Doctor Foster 2013). This evidence of post code lottery style rationing is prevalent in areas served by the most financially challenged CCGs. This makes some of the early findings from ‘Getting It Right First Time’ (GIRFT) national professional pilot particularly pertinent. ‘GIRFT’ is now well under way. 144 acute trusts have been contacted and, so far, 502 trusts (over 91 hospitals) have been visited: a review of 216,902 episodes of care. A further 63 visits are booked between now and the end of July. There have been no refusals to date. Ultimately

reports will be produced for each of the 27 NHS England (NHSE) Local Area Teams, the 12 Senates, and the four NHSE regions and for the Secretary of State and Sir Bruce Keogh in the summer. Each of the CCGs in England will also be offered a report reviewing the providers they commission elective orthopaedics from. What themes are emerging?

Clear evidence of ‘having a go’ Too many surgeons are ‘having a go’ and undertaking low numbers of certain procedures, especially complex procedures, and this applies in all sizes of hospitals. For example within the first 50 trusts we have reviewed, out of the total 27,768 primary hip replacements that were undertaken by 523 surgeons in 2011/12 there was an average of 51 cases per surgeon – however, nearly 20% of surgeons were undertaking less than six cases a year. This is happening even in large units. 49% of surgeons undertaking knee replacement were undertaking less than six cases a year. The situation is worse with knee and hip revision surgery with 56% of surgeons undertaking

Prof Tim Briggs

less than six knee revisions a year and 44% undertaking less than six hip revisions. Moreover, 59% of surgeons using unicondylar replacement undertook less than six that year. Surely we should consider concentrating revision surgery to a smaller group of more experienced surgeons either in larger hospitals or within local networks where the expertise already exists amongst colleagues. Many hospitals performing revision surgery hire in equipment regularly and then pay full market price for the implant. As a consequence the NHS is losing many millions of pounds.

Little evidence of evidence-based implant selection Most arthroplasty takes place in those over 65. In this group the proportion of uncemented arthroplasty has been rising sharply over recent years and we have found significant inexplicable regional variation in implant usage. According to the NJR cemented THR reduced from 54% of THR in 2005 to 36% in 2010 and cementless THR increased from 22% in 2005 to 43% in 2010. In the 10th annual report published in 2013 data this trend has continued. Can this be justified in terms of evidence, outcome or cost given recent NICE guidance? The recent register study of combined Nordic >>

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

JTO Features

Removal or denial of ring-fenced beds is perceived by orthopaedic teams as clear evidence of a lack of commitment to the service by management.ll ll

databases of four nations concluded that the survival of cemented implants for total hip replacement was higher than that of uncemented implants in patients aged 70 years or older and that the increased use of uncemented implants in this age group is not supported by these data3. Perhaps the time has come for clinical orthopaedic directors to ensure they work with their colleagues to review the whole cost (human and financial) of a procedure and the patient’s likely need for revision – theatre productivity should not be allowed to become a driver for what should be clinical decisions based on evidence from the NJR and other countries’ registries. Indeed our visits have demonstrated that overall productivity is falling despite the greater use of uncemented devices. I hasten to add that the appropriateness of uncemented procedures for those under 65 is a question that still needs answering.

Benefits of ring fenced beds While the clinical advantages of having ring fenced orthopaedic beds are well known (reduced infection, shorter length of stay4, fewer cancellations5 etc.) a number of less obvious patterns have come to light. It is apparent from a significant number of visits that the removal or denial of ring-fenced orthopaedic beds is perceived by orthopaedic teams as clear evidence of a lack

of commitment to the service by management. Increased infection rates, last minute cancellations and increased length of stay are perceived as driven by that lack of management commitment, understanding or concern. This is unsurprisingly very bad for morale.

NJR Early sight of the data suggests that there is a widespread issue with the accuracy of revision data – partly because many of the primaries were not originally recorded or date from before the NJR began – and partly because a significant proportion apparently arise from poor administration of the NJR submission process. It is clear that the advent of the new best practice tariff for primary arthroplasty (that requires NJR compliance) has encouraged rates to improve dramatically in most places in the past year; perhaps best practice tariff should be extended to revision surgery? The actual revision rate at trusts is significantly more than those recorded. This is a particular concern when the data feeds into the process of long term capacity planning and affects the number of trainees that we need to recruit to serve this unrecorded torrent. While all surgeons see their own NJR reports the trust wide one is not often circulated to the orthopaedic team; quite a few clinical directors report having difficulty excavating the report from their Chief Executive’s administrative support system. Given the current push for transparency this is amazing. We will be recommending to the NJR that they copy the report to Orthopaedic Clinical Directors.

PROMs are failing some areas of orthopaedics Because of the outsourcing of post-operative PROMs gathering by purchasers the compliance is very poor and as a result any health gain cannot be measured. Perhaps this should be a key performance indicator for purchasers? Case mix adjustments remain a major issue for the most specialist providers. We have also found a major disjoint between management and clinicians with clinicians at one unit unaware that they were amongst the worst in the country for health gain. When shown the data not only were they disappointed but immediately wanted to work to improve this. Empowerment of key members of staff is essential for service improvement.

Closer working with clinical coders A number of the trusts we have visited are not submitting data to HES. Surgeons feel that the data does not accurately represent the activity being undertaken. Many trusts will not be receiving appropriate recompense for their activity; also, the national data set is not an accurate reflection of some activity. This makes it very difficult for commissioners to plan services and undermines the financial position of the orthopaedic departments concerned. Investing resource and effort into specialist

orthopaedic training for coders as happens in Avon Orthopaedic Centre, whereby their surgeons and coders work together to undertake ‘live coding’ in the theatre department, pays dividends. Accuracy and income have improved dramatically as a result of this project.

Procurement Many orthopaedic teams are unaware of the total profile of their prosthetic purchasing – evidence base or relative cost. Understanding the cost implications of key decisions around implant selection and the amounts spent on loan kit, should be shared amongst the surgical team. NICE Guidance and DH Orthopaedic Procurement QIPP activity will bring this into focus. We will be working with the DH to review what lessons we may learn from the GIRFT project. The NJR will be collecting pricing information from this year onwards.

Relationship with local ‘Any Qualified Providers’ (AQP) is critical A good relationship with the local AQPs can add value and help manage waiting times. However, it has been apparent how damaging competitive relationships can be. We have seen more than one trust where the same surgeons are in effect fatally undermining local NHS provision. The key difference at these sites is the quality of the relationship between management of different sites. Transparent dealings and a mutually supportive approach are critical. Commissioners can help to support and encourage provider collaboration if so minded. Moving forwards the importance >>

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JTO Features

An increasing proportion of complex work will require two senior surgeons present. This maintains quality in complex procedures, but is tough on capacity/throughput.ll ll

of a ‘level playing field’ in terms of governance and benchmarking has never been greater. ‘Cherry picking’ must be either managed or acknowledged as a reality. Otherwise some providers will be penalised by the expense of treating a higher proportion of more complex patients and the consequences of a more complex case mix.

Networks We have been working with a number of nascent area networks to review their shared output and help them understand the variations in quality and practice across their region. This has highlighted some astonishing variations in small demographically cohesive geographies – something that has provided significant food for thought for those considering reconfiguration or rationalisation of services.

The Capacity Gap Many trusts are either failing to achieve 18 weeks or having a severe struggle doing so - often using outsourced waiting list initiatives – indeed in our data set over half of trusts failed this target in orthopaedics. This represents a large volume of unmet need sourced at great expense. Furthermore, the surgical burden is growing; we must question whether there will be sufficient surgical posts, trained surgeons to fill them, theatres and beds to meet this increase and unmet need for more complex surgery?

Moreover, an increasing proportion of complex work will require two senior surgeons present. This maintains quality in complex procedures, but is tough on capacity/throughput. New surgeons will have less experience of complex surgery as a result of changes to training and will need to work alongside a mentor for a long period – again a stress on productivity.

The project was intended to have a long term positive impact. Delivering a clinically led provider focused catalyst for improvements in quality; reductions in costs; setting up and/ or enhancing of robust clinical networks; and supporting the direction of travel being developed by the Clinical Reference Groups guiding specialised commissioning within NHS England.

How will we know if GIRFT has been successful?

Added value

GIRFT National Professional Pilot will be measured by the following metrics:

Short Term Reductions in: l Prostheses costs l Loan kit costs l Readmission rates l Length of stay l Surgical site infection

Medium Term Reductions in: l National variation for procedures l Outliers in national registries l Infection/complication rates

Long Term Reductions in: l Revision surgery l Readmissions l Litigation numbers and rates

The many visits by the GIRFT Team have provided added value to the BOA, Trusts and surgeons, by providing a robust evidence base for informing guidance regarding tariff, coding, PROMs, NJR issues, developments in specialised commissioning, and relationships with AQPs. Already the data on unmet need has changed central thinking on training numbers towards a significant increase. The Chavasse report (which I refer to in my editorial on page 2) has been informed and shaped, an indicative pricing strategy is being piloted and a session at EFORT has been arranged to debate the benefits and problems facing orthopaedics in the medium future. Many thanks for your help and co-operation. n

References 1. The King’s Fund (22 January 2014) NHS coping well with winter pressures so far but more hospitals heading into deficit www.kingsfund.org.uk/press/ press-releases/nhs-coping-wellwinter-pressures-so-far-morehospitals-heading-deficit 2. As at mid-March 2014 3. Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations BMJ 2014;348:f7592 - www.bmj. com/content/348/bmj.f7592 4. Barlow D, Masud S, Rhee SJ, Ganapathi M, Andrews G. (2013) The effect of a ‘ring fenced’ orthopaedic arthroplasty ward on length of stay for elective arthroplasty patients Surgeon 11: 82-86 www.ncbi.nlm.nih. gov/pubmed/22717284 5. M.R. Whitehouse, N.S. Atwal, J.A. Livingstone (2008) Does Ring-Fencing Improve Efficiency in an Orthopaedic Day Case Unit? Ambulatory Surgery www.iaas-med.com/files/ Journal/14/14.4/WHITEHOUSE. pdf

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

JTO Features

Why I did an MBA Scarlett McNally BSc MB BChir FRCS(Tr&Orth) MA MBA

Last summer, after being Consultant Orthopaedic Surgeon for 11 years, I graduated (with distinction!) with an MBA from Keele University. Before starting, like many Orthopaedic Surgeons, I thought I had a fair idea of management. The major change in my thinking following my MBA is how different leadership and management are. As doctors, we sometimes consider the two together but I now feel they are almost opposites. A leader has vision; ambition and is inspirational; a manager makes sure that everything is in order. To take on a leadership role needs some managerial skills, and a good manager needs to have a leader’s support. Yin needs yang. I started the MBA course when I had just taken on the additional role of Director of Medical Education for my Trust. At the interview for the post, I was told that I lacked management experience, so I decided to go on a course. My view then was that an MBA was the Gold standard, so for a little extra effort, I might have a recognisable qualification with an academic focus.

Why Keele University? I chose Keele University as their MBA programme is specifically health focussed. At the time it was 50% doctors and 50% health service managers, so great conversations occurred during breaks and after dinner. I also knew

Scarlett McNally

that for me a residential course (one week per module) would suit my learning style. I had previously done the Keele short course in “Medical Management for surgical Senior Registrars” in 1999 and remember changing my perception of NHS processes over just a few days last century.

Other options There are day release MBA courses and on-line courses. I had previously done an MA in Clinical Education (Brighton University 2008), which was day release, with five different days each term comprising one module. On the day release course, returning to emails, re-scheduled patients and children after just one day away was difficult. Those with specific gaps might prefer short courses on being an effective Medical Manager, Financial Management, business planning or project management.

The practicalities (time, money and distance) My course was a series of seven residential modules, arriving Sunday evening and leaving on Friday afternoon. For that week, I could immerse myself in academia. Each module was followed by a 4,000 word essay. It costs around £10,000 for the whole programme. I received £1,000 from KSS Deanery and £2,500 from my Trust. Although I negotiated exceeding my study leave time, I never took this up as I realised I had forgotten to take my full Annual leave allowance.

I would aim to do one or two evenings’ work during the week, but discussions at the bar were often more appealing and more educational. The accommodation costs could often be claimed from Trust study leave expenses and trains booked in advance were cheapest. I travelled by train each time, aiming to get the bones of the assignment sorted on the journey home each Friday night (four hours of travel from Stoke-on-Trent to Eastbourne). I tended to put my bike on the train and cycle the seven miles to Keele University from Stokeon-Trent station, to make up for missing normal Karate sessions.

Modules The MBA is billed as a four year program, with seven taught modules over seven terms, followed by a 15,000-word dissertation. The cohort was mostly the same, although a few people joined for modules they had missed, and some did all the taught modules and the dissertation in one year as a full time MBA.

The modules: Health Policy and Strategy Policy formulation, implementation and review. Future planning. International comparisons. Explanations of failures and successes. Management of Human Resources Recruitment, workforce planning, staff retention, appraisal and review, Employment law. Performance management. >>

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Economics and Management Key concepts and methodologies of health economics. How to plan using economic models.

problem! My Trust management has been undergoing a very acrimonious merger and my suggestions on skillmix and documentation have been quoted only to be dismissed. Even our carefully-constructed patient information leaflet that formed part of my dissertation was heavily criticised by a Geriatrician and an A&E consultant from the â&#x20AC;&#x153;otherâ&#x20AC;? site.

Management science How complex systems function. Business planning. Carrying risk. Institutional memory, receptiveness to change. Accounting and Financial Management Budgets, depreciation, costs, use of resources and financial information systems.

On a national level, I have developed ideas from a module on change management, empowerment and education into a national report for the Academy of Medical Royal Colleges. This is aimed at encouraging behaviour change to increase physical activity. I gained insight into the structure of Mastersâ&#x20AC;&#x2122; programmes, which has been invaluable in my other roles, accrediting some courses and developing others with Brighton & Sussex Medical School and the Royal College of Surgeons of England.

Operations Management How to manage details, especially around processes, avoiding waste: six sigma, theory of constraints, LEAN, queuing theory. Research for Managers, Clinicians and Policy-Makers How to conduct management research, analysis, evaluation, methods for dissertation.

Dissertation There is close email supervision from your supervisor. I was helped by a change in research ethics guidelines that meant questionnaire surveys of NHS staff no longer needed detailed ethics approval.

My Dissertation I chose streamlining the care of patients with wrist fractures as my dissertation. This addressed process management, theory of constraints, organisational theory and change management. The project was around converting events that occur fairly randomly over 168 hours per week (wrist fractures) into an urgent quasielective process (fracture clinics over

Scarlett at her graduation supported by her children

15 hours per week and day case trauma list operating). I focussed on empowerment of staff and patient education. I held focus groups and we wrote information leaflets together which became a tool for staff education.

What I got out of it I learned how to support and develop staff, services and institutional culture. People treat

you differently if you have an MBA. Maybe choosing an MBA, and sticking with it, was just stubbornness? Or that a decade of long hours, followed by another of working and child-rearing meant that I needed to have more challenges than just the day job? I have had a chance to work out why things are done, how to value staff and get things to work better. At a local level, my MBA has been a

A surgeon with an MBA and a bit of management experience and good managerial help would be fantastic at running a Trust or any other organisation. My MBA taught me to understand where to start, especially around valuing staff and understanding money. With so many changes in the NHS now and in the future, we need more surgeons with awareness of how things get done. n

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JTO Features

Shape of Training (Greenaway) Report Colin Howie, BOA Vice President

At the last BOA Council meeting, Clare Marx (Past President of the BOA, President Elect RCS Eng and member of the report team) led a discussion on this landmark report into postgraduate training. In this article, Colin Howie feeds back to members on what this means for T&O. The specific aim of this report was to review the structure of postgraduate training. Much effort was expended by the enquiry group who consulted widely on the needs of patients and the service to identify what mix of specialist and generalist services were required. This consultation was to define the depth and scope of training required, recognising and balancing the need for specialism and lifetime career flexibility.

The key messages were: 1. 2. 3. 4.

Patients and the public need “generalists” working in different settings Postgraduate training needs to adapt to deliver safe and effective general care Specialists will still be needed to meet local need Medicine has to be a sustainable career with opportunity to change over time

The broad conclusions of the report are: 1. 2. 3. 4. 5.

Colin Howie

Local service and patient needs should drive opportunities to train or credential in specific areas Doctors in Academic training need flexibility to move in and out of training, yet achieve the same standards and competencies of clinical training Full registration should be brought forward to graduation from medical school; however patients’ interests must be considered first and foremost Implementation should be phased and UK wide A UK wide delivery group should be formed

Several models of postgraduate training are presented with a variety of implications. Arguments around detail in the models will distract us

from the focus of the report, which is to improve training to reflect the needs of our patients while adjusting our current frenetic working patterns.

What might all this mean for Orthopaedics and our specialist groups? Orthopaedics will most likely be regarded as a “generalism” and our excellent curriculum is geared towards this. One caveat may be that “trauma general surgeons” are proving difficult to create and the consequence may be an attempt to move to the continental model of the trauma general surgeon, who treats fractures and covers the accident part of emergency departments. The SAC will take the report forward and review our training. Perhaps the biggest challenges will be at core training level, where the curriculum and training would become generic such that trainees can move between specialities, at least at the beginning of their careers. This will be difficult to manage, and will have implications for the practical surgical skills of those entering what is currently badged as higher surgical training. No doubt more on this later! The report has Cassandra like sections. The implications for undergraduate training and our lifelong careers, though not directly

part of the remit, are implied and perhaps more contentious for orthopaedics. Undergraduate training will have to become more clinically based and competence driven, and there are implied criticisms of the existing undergraduate curriculae in the report. We must wait to see if musculoskeletal problems become a greater part of the curriculum. At consultant level the implications are that we will be appointing generalists, perhaps with a speciality interest to departments that are big enough to support specialism yet organised to provide a comprehensive general service. Are the days of appointing a specialist direct from training numbered? How will we develop our careers over time? How and what support will local departments give to enhance our skills, improve services and allow career progression? We must avoid steering our ship towards the iceberg of lifetime rotas that have made Emergency Medicine an unattractive career! The BOA will engage with the speciality associations on all of these topics. We must inform and adapt to these new drivers. On-going education and conferences will have to reflect the new environment. Above all, we should avoid fixing on irritating detail and influence the big picture to ensure that orthopaedics remains an exciting and dynamic speciality throughout our careers.

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JTO Features

Update on the National Joint Registry Martyn Porter, BOA Past President & NJR Medical Director

There have been important changes to the NJR structure and I am delighted to have been appointed to the new position of Medical Director of the NJR and be given this opportunity to highlight some of the progress. The NJR was set up in 2003 very differently from other international orthopaedic registers. In all other countries the Registries have been set up by the orthopaedic profession however, in England and Wales it was the failure of the 3M Capital hip and the ensuing publicity that led to the recommendation by Lord Hunt to set up a National Registry. In other words this was a political rather than a professional mandate. Instead of the NJR being an integral part of the BOA it was

Martyn Porter

set up by the then Department of Health and the Steering Committee appointees were appointed by the Appointments Commission which led to representatives from multiple “stakeholders”. The three surgical representatives – Paul Gregg, Tim Wilton and myself - were appointed as orthopaedic surgeons, not as representatives of the BOA or specialist societies (BASK, BHS). Moving forward ten years we have established a number of sub committees namely the NJR Editorial Board chaired by myself, the NJR Research Subcommittee chaired until recently by Alex MacGregor, Rheumatologist, the Surgeon Outlier Subcommittee chaired by Paul Gregg, the Implant Performance Subcommittee chaired by Keith Tucker, the NJR Data Quality Group chaired by Paul Gregg and the Regional Clinical Co-ordinators Network chaired by Peter Howard. This led to a significant amount of work and outputs from the NJR.

It became apparent that despite the success of the NJR, sometimes progress was not always optimal and therefore a new committee, the Medical Executive Committee will be set up in the coming weeks. This will support the present National Lead, Elaine Young, and allow some of the strategy to develop more quickly and the NJR to be more proactive.

Alex MacGregor has now demitted as Chair of the Research Committee and following competitive interview he has been replaced by Mark Wilkinson from Sheffield. Mark will be working to develop the research strategy and I know he wants to develop the research ready data set working with the University of Bristol and Ashley Blom’s team.

Another potential area of concern of the NJR was perceived lack of buy-in from the profession including the BOA and specialist societies and therefore the other new committee will be the Medical Advisory Committee which will be representatives from the Executive of the BOA, BHS, BASK, BOFAS and BESS. This will be the forum where professional issues are discussed in depth. I expect these to include issues relating to professional practice, service development and publication of surgeon outcomes. One of the most important and exciting opportunities is to ensure that the NJR is seen as a valuable component of all the specialist societies, something that specialist societies feel that they have access to and they will help develop strategy.

We have two new industry members with Mick Borroff (DePuy International Ltd) and Dean Sleigh (Biomet) demitting. They have been replaced by Michael Green (Implants Stryker UK) and Nick Wishart (Wright Medical). We have just completed interviewing for the replacements for Paul Gregg and myself, and these will be announced very shortly.

The NJR is also refreshing the Steering Committee membership and after ten years Paul Gregg is now demitting office. On behalf of the whole of the NJR we would very much like to thank Paul for his outstanding contribution to the Register, Paul of course acting as Vice Chair.

There will be significant changes this year with improvements to Clinician Feedback; the facility to significantly support revalidation; and hopefully an opportunity to provide more granular data to units and surgeons for audit purposes and even data validation. Speaking of which, data quality and data validation will be our No 1 priority over the next 12 months having held a Data Quality Workshop on the 3rd March 2014. We will be discussing this in some detail and hopefully improving data quality significantly as we move forward. We realise that data validation is critical if we start reporting publically more data on individual surgeons. There is much work to do on case mix adjustment; Ashley Blom tells me that he has received funding from the MRC for a statistician to support this process. >>

K O BO O W N

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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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Day 5: Viva Course for the FRCS (Tr&Orth). The Viva Course for the FRCS (Tr&Orth) exam is based on the book Postgraduate Orthopaedics. Viva guide to the FRCS (Tr&Orth) exam. The format closely mimics the real viva examination and has had excellent feedback from previous candidates.

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For more information, including price options, application and accommodation, visit our website, email joanne.mcstea@gmail.com or call 0191 445 2989.

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 30

JTO Features

There will be significant changes this year, with improvements to Clinician Feedback; the facility to significantly support revalidation; and hopefully an opportunity to provide more granular data to units and surgeons for audit purposes.ll

There will be significant changes to the format of the Annual Report this year. We will be producing much less in terms of the published content but an exciting development will be a digital platform to support an online version which will allow the user to interrogate the data in more detail. This year will apply to mainly Part 2 descriptive data but as we move forward it will also apply to more of the analytical data in Part 3.

I am also pleased to report that the NJR is working in the international field with Keith Tucker leading the International Consortium of Orthopaedic Registers on behalf of the NJR and in New Orleans at the AAOS I started my tenure as President of the International Society of Arthroplasty Registers. ISAR have also developed an exciting new strategy which dovetails very well with the NJR strategy and for those interested I would like to bring your

CY CMY

attention to our forthcoming ISAR meeting in Boston from 31st May to 2nd June 2014. We have received over 107 abstracts and there will be plenary sessions to support this. The meeting should be very exciting indeed. These are exciting new times for the Register. I am very proud to be supporting this in my new role. n

Martyn Porter is a Consultant Orthopaedic Surgeon at the Centre for Hip Surgery at Wrightington Hospital in Wigan.Â Martyn is Immediate Past President of the BOA, has previously been President of the British Hip Society and has recently been appointed as Medical Director of the National Joint Registry. He is the current President of the International Society of Arthroplasty Registers (ISAR).

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

JTO Features - Trainee Section

Preparation for FRCS – a personal view Mr Andrew Hughes, Publicity Officer, BOTA

Few post FRCS surgeons are without some words of wisdom for prospective exam candidates. Having recently passed the FRCS (Tr & Orth) I am now in a fairly useful position to offer my insights into the exam process. Despite the fact that many of us believe orthopaedic surgeons share similar characteristics, we are all individuals with our own learning styles, and should stick to revision techniques that have worked for us in the past. The exam format can be found on the website (www.jcie.org.uk) along with the exam fees! The thought of paying twice provides ample motivation to make a start on the revision programme. In the early years of training, the exam

Andrew Hughes

may seem like a distant shadow; however, keep on top of knowledge acquisition as you progress through your rotations and get to grips with basic science from the outset. Most people dedicate a year to progressing through both exams, with a short break between part 1 and 2 to reacquaint themselves with family and friends. Part 1 requires a good library or study and two key books, which for me were indispensable in the run up: Miller’s ‘Review of Orthopaedics’ and Ramachandran’s ‘Basic Orthopaedic Sciences’. It is important to practice MCQs and EMQs. I would recommend identifying someone in your region with a copy of previous UKITE exams. The questions are comparable to the FRCS and some even came up in the exam! Practicing questions can be a productive break from reading when you are feeling saturated. Part 2 is a different affair. Working and practicing Viva technique in groups is important. Groups of no more than four work really well. By virtue of passing the first part you have proved you have the knowledge. You now have to demonstrate your ability to apply that knowledge and concentrate on producing answers in a viva format. Identify seniors locally who have a track record in exam preparation, who will organise viva practice.

Courses on Paeds and Hands are particularly useful near to the exam as these subjects always seem to cause most angst. General exam courses are normally available locally and they have the advantage of being less costly. Prepare really well for the clinical. Treat every patient you see as an exam case and an opportunity to practice your clinical stations, even if only internally. Most bosses if you ask them will organise clinical exam sessions where they bring their ‘interesting’ cases up for you to see. The orthopaedic admissions ward provides ample clinical opportunities and if well practiced, there are chances to pick up easy marks in this section. Do not lose faith; there is light at the end of the tunnel!

BOTA Annual Educational Weekend 2014 A new programme with an exceptional faculty 20th-22nd June 2014 Carden Park, Cheshire Registration is still open BOOK NOW www.bota.org.uk/bota2014

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 34

JTO Features

Cognitive Simulation: A novel method to enhance surgical skills Dr Uttam Shiralkar FRCS(Ed) MRCPsych, Consultant Psycho-oncologist and Psychiatrist Prof Phil Turner FRCS FRCS(Ed) FFSEM(UK), Head of the School of Surgery, HENW; Chairman TSC, British Orthopaedic Association Lisa Hadfield-Law, BOA Education Advisor

Expansion of surgical techniques and changing patterns of healthcare delivery have made it difficult to continue the “see one, do one, teach one” system of surgical craft skill transfer. The effect of the EWTD in reducing working hours has diminished skill learning opportunities even further. Several alternatives have been developed to compensate for the loss of ‘hands-on’ experience: from cadaveric dissection via synthetic material to the most expensive virtual reality simulators. However, all have limitations: availability of facilities, cost and fidelity. In contrast, the novel method of cognitive simulation is a unique approach for acquiring surgical experience that is free and accessible 24 hours a day.

Mental techniques have been used to enhance psycho-motor skills in sport. In many ways, surgical performance is similar to competitive sports performance. Given the similarities, surgeons would benefit from adopting techniques that have been shown to improve psychomotor performance in sports. In view of the current curriculum requirement for surgical trainees and trainers to engage with simulation, it is useful to develop an understanding of this novel method and its role in surgical learning.

Cognition is a process by which sensory information is mentally assimilated and applied by the individual. Cognitive simulation is the creation of an experience of a surgical procedure in your mind. This is not the same as just ‘thinking’ about the procedure, since cognitive simulation requires the surgeon to use multiple senses to get the ‘feel’ the procedure and the mentally created experience vividly resembles the real experience of an operative procedure. Unlike a conventional simulator that reproduces a specific procedure, cognitive simulation can be applied to any procedure and it creates a quality experience that no conventional simulator can match. An example should make the process clear. Before performing a total knee replacement that will be a part of formative assessment, a trainee and trainer will discuss the steps. Rather than simply reading and remembering them, the trainee should vividly recreate every aspect of the procedure in their mind using the key points in the assessment as a “script”. The trainee must recreate the sight, sound and feel of every movement as if they were performing it for real. This is exactly

what an athlete will do before competing. It does not have to be done in real-time; it is a matter of mentally rehearsing the vital manoeuvres. Similarly, an experienced surgeon about to tackle a novel and complex case will often write down the steps. By employing cognitive simulation and mentally running through the procedure simulating the sights, sounds and movements of each step then a more efficient and effective operation should follow. One of the differentiating points is the inclusion of kinaesthetic or movement sensation. The other senses that are incorporated are tactile, auditory, olfactory and verbal. When you are able to practice a procedure incorporating all these senses, the effect will be the same as actually performing the procedure. Some people are able to generate these sensations easily but others require deliberate effort and practice. The first step is to become aware of those senses while performing a procedure. After all, cognitive simulation is a skill and like any other skill it requires updated information and practice.

How does it work? It is now recognised that our mind cannot differentiate between a real and an imagined experience, provided the experience is imagined in a specific manner1. If conducted appropriately, the same building of neural pathways occurs, through imagined practice, as it does through >>

Dr Uttam Shiralkar

Prof Phil Turner

Lisa Hadfield-Law

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 35

Fibula Rod System EFORT Booth #H12-14

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

JTO Features

Imagined muscle movement is observed on electromyography, imagined visual sensation affects the cerebral blood flow in the occipital cortex and imagination of auditory stimulus is recorded on the Positron Emission Tomogram (PET) of the temporal cortex.ll ll

actual practice. Thus, we have the potential to make mental practice almost, if not as effective as physical practice. Studies have shown that if carried out correctly, imagined muscle movement is observed on electromyography, imagined visual sensation affects the cerebral blood flow in the occipital cortex and imagination of auditory stimulus is recorded on the Positron Emission Tomogram (PET) of the temporal cortex2,3.

What is the evidence? As it is impossible to observe cognitive simulation directly, indirect methods must be used to assess the effect. This creates difficulties in the surgical context, as results are likely to be affected by a number of variables. It is therefore necessary first to extrapolate evidence from other disciplines. A review of literature reveals the paradigm of mental practice studies as 1. Physical practice, when subjects practice the task a fixed number of times 2. Imagery, when subjects mentally rehearse the task the same number of times 3. The control, when subjects do not practice In general, outcomes have been consistent across a number of studies. Physical practice has a greater effect on performance than imagery practice, which in turn is

mental practice. All participants practiced one procedure every day on a simulator for five days. Prior to each session, participants in the intervention group conducted mental practice for half an hour. Each participant from the control group spent the same amount of time with a faculty member, during which time they were asked to conduct an academic activity. Since all participants were engaged in some kind of activity, they were oblivious to the fact that they were either in the intervention or control group,

more effective than no practice at all4. Examining the effect of combining imagery and physical practice (initial physical practice followed by mental practice) is where results are particularly interesting when compared to physical or imagery practice alone. Those studies have shown that a combination achieves far better results than mental practice or physical practice alone5. Researchers suggest replacing some physical practice with cognitive simulation, which will save time and resources, without affecting performance enhancement6. Studies in surgical literature have shown that cognitive simulation can be used to demonstrate and optimise the perceptual motor learning and skill decay in surgical skill training7. Results of the first randomised controlled trial of mental practice in surgery were published in 2007 in the Annals of Surgery8. In this study the effect of cognitive training on performance of a simulated surgical procedure was evaluated. A statistical analysis of the results showed that there was a significant improvement in performance in the mental training group, but not in the practical training group. Mental training accomplished superior results, compared to other groups, in the task specific checklist. Authors of this study recommended that mental and physical teaching should be blended, as in sport, and considered a critical part of training. A recent randomised controlled study determined whether mental practice really does improve surgical skills9. Participants were assigned randomly to an intervention arm or a control arm. Subjects from the intervention group were trained in >>

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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:

April 2014 L.GB.04.2014.6164

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).

Simple, proven, predictable anticoagulation

For more information, please visit www.xarelto‐info.co.uk

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

JTO Features

Cognitive simulation has immense potential and scope to add value to surgical learning, but its value is dependent on the quality of the application.ll ll

ensuring blind control. Every subject from the intervention group was trained in MP using a mental practice script. The script depicted steps of the procedure, and also highlighted the related clues intended to improve the mental representation of the skill. The main outcome of the study concerned quality of performance during five surgical procedures. All the procedures were recorded and sent to experienced surgeons for assessment, adhering to blind protocols. When results were evaluated, it showed that the intervention group performed considerably better than the control group during all sessions.

Application in T&O surgery Cognitive simulation, in a broad sense, is like computer software designed for the human mind. It is a technique that programmes the mind to respond in a certain manner. No physical props or outside stimulus are necessary to engage in the activity in any position or situation. During intense and vivid imagery, the brain perceives and interprets images as being real.

Cognitive simulation has immense potential and scope to add value to surgical learning, but its value is dependent on the quality of application. Cognitive simulation has a wide range of applications in surgical practice including a. Acquisition of new surgical skills b. Shortening the surgical learning curve c. Maintenance of surgical performance d. A range of operative experience e. Transfer of surgical skills from an established technique f. Assessment of operative performance problems g. Management of unfamiliar operating theatre conditions h. Development of stress coping strategies Peter Campbell an assigned educational supervisor from York has expressed the view: “when this is truly integrated into surgical training & from there, into surgical culture, it will result in a paradigm shift in terms of consolidation of learning surgical skills & ultimately patient outcome”10. Learning cognitive simulation is like learning a foreign language. Both require practice before attaining fluency. Proficient surgeons are often good at what they do because of their attention to detail, which is vital to those wanting the best results from cognitive simulation. There is nothing to stop a motivated surgeon from taking the plunge into the emerging and splendid domain of cognitive simulation! n

References 1. Uttam Shiralkar. It’s not all in the mind - the evidence in Cognitive Simulation - techniques to enhance surgical skills; Surgical Psychology Publishing. 2013. p 109-122 2. Suinn R. Body Thinking: Psychology for Olympic Champions. In: Suinn R Psychology in Sports: Methods and Applications. Minneapolis: Burgess; 1980. p 306–315 3. Decety J. The neurological basis of motor imagery. Behavioural Brain Research. 1996;77: (1-2): 45-52. 4. Richardson A. Mental Practice: a review and discussion, part one. Research Quarterly. 1967;38, 95–107. 5. Weinberg R. The relationship between mental preparation strategies and motor performance: a review and critique. Quest. 1982;33 (2): 195–213. 6. Durand M, Hall C, Haslam IR. The effects of combining mental and physical practice on motor skill acquisition. The Hong Kong Journal of Sports Medicine and Sports Science. 1997;4, 36-41. 7. Shi-Hyun PARK, Irene H. SUH , Jaehyon PAIK, Frank E. RITTER, Ka-Chun SIU et al. Modelling Surgical Skill Learning with Cognitive Simulation. Medicine Meets Virtual Reality 18 J.D. Westwood et al. (Eds.) IOS Press, 2011: 428-432

8. Immenroth M, Buerger T, Brenner J, Nagelschmidt M, Eberspaecher H, Troidl H. Mental training in surgical education - randomized control trial. Annals of Surgery. 2007;245 (3): 385-395. 9. Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N, Darzi A. Mental practice enhances surgical technical skills, a randomized controlled study. Annals of Surgery. 2011;253 (2):265–270. 10. Personal communication Dr Uttam Shiralkar practices in surgery and psychological medicine. He is actively involved in various aspects of human factors training in surgery. Prof Phil Turner is senior consultant in the knee unit at Stepping Hill Hospital, Stockport. He is also the Head of the School of Surgery, Health Education North West and a clinical domain lead, Manchester Academic Health Science Centre. Beyond knee surgery, his interests are in surgical education, patient safety and non-technical skills. Lisa Hadfield-Law is the BOA Education Advisor and has been a surgical educator since 1992. She has helped over 5,000 surgeons from 57 countries to improve their teaching and learning skills. Previously, she had 20 years of trauma nursing experience in the UK and abroad.

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A Good Pair of Hands Andrew Wainwright

What does having a ‘good pair of hands’ mean to Trauma and Orthopaedic surgeons? Can you tell if a surgeon has a ‘good pair of hands’? Can this be taught? As part of a Masters in Surgical Education I explored these questions using Grounded Theory to study the qualitative nature of the meaning of a ‘good pair of hands’ to Trauma and Orthopaedic surgeons. The findings call into question the notion of ‘natural talent’, and suggest instead that sustained deliberate practice can be used to develop a ‘good pair of hands’. Surgical ability is a quality that can be recognised and described more easily than measured. Social learning theory revealed that methods used in apprenticeship training may still be better assessments to evaluate surgical ability than the current dependence upon assessing competencies.

Andrew Wainwright

Background Sir Robert Jones, the founder of modern Orthopaedic surgery was renowned as being an excellent surgeon1-4. Mayo and others described his surgical expertise; “He is expeditious, yet neglects not the smallest detail, and his wonderful experience enables him to do wizard-like operations with a precision which is startling”.3 His hands ‘seemed to become almost plastic and almost to blend with the material on which they were working’.4 To be judged by peers as having ‘a good pair of hands’ is the ultimate accolade for surgeons. This familiar term refers to a quality at the heart of being a surgeon and often is used to describe an excellent, gifted colleague or trainee. A ‘good pair of hands’ may mean different things to different people; a musician’s dexterity, artist’s creativity, rugby player’s safe pair of hands, craftsman’s use of tools, or magician’s sleight-of-hand.

Figure 1 - Barbara Hepworth, Prevision, 1948 ©Bowness, Hepworth Estate

Beyond surgery, the concept of Craftsmanship ‘has become fashionable again’5, re-emphasising the worth of manual and technicalskills6. There is a movement away from a romanticised, idealistic view of craftsmen, to a modern view of a community of practice; of craftsmen who comprehend and work with the in-built character of material. This ‘desire to do a job well for its own sake’ is proposed as a template for living7 and is reflected in Mayo’s description of seeing Robert Jones work3 and captured in Hepworth’s drawings of Norman Capener’s operations (Figure 1). –

‘Every tool has two ends; one working on the material, the other on the man’ Halsham, 19078 In surgery and craftsmanship, there is great value of a Master, with years of experience, working with an Apprentice, assessing knowledge, skills and attitudes. According to constructivist learning-theory, Apprenticeships are viewed as gaining legitimate peripheral participation in a community of practice9. Masters soon understand if a pupil has potential; are they trainable? This potential cannot >>

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JTO Features

effectively be assessed by objective measures of competence. These holistic characterisations of Craftsmanship contrast with current atomistic competency-based approach to training. Objective standardised assessments have been developed to assess a wide range of competencies10 by supervisors, and review panels. ‘Competence’ has become a ‘god term’, and never questioned14. However, the notion of ‘competence’ is being more critically examined recently11-12, particularly within surgical education13. Recent events reported in UK media highlight the hazard of having signed-off competencies, without a holistic overview15. Stripping skills into component parts 13,16,17 risks losing the complexity of human unpredictability. Preoccupation with competence is bought at the expense of professionalism11; the’ tick-box’ evaluation of different competencies is not necessarily appropriate for assessment of professionals18. Instead we could consider what does having ‘good pair of hands’ really mean to surgeons?

Methodology Establishing in-depth understanding of potentially complex concepts requires a qualitative studymethod to answer an ontological question. I used Grounded Theory, ‘a systematic, inductive and comparative approach for conducting enquiry for the purpose of constructing theory’19 about social patterns. It emerged as a method of generating theory from research, ‘grounded’ in the data20, to reflect the real world, rather than test abstract concepts in an idealised world model.

Table 1 - Participants Subspeciality

Hospital

Practice

Gender

Tumour Spinal Spine, hip & Trauma Reconstructive Upper limb Paediatric Knee surgeon Trauma Child and young adult

University teaching University teaching District General University teaching District General University teaching District General University teaching University teaching

Pure elective Mixed elective/trauma Mixed elective/trauma Pure Elective Mixed elective/trauma Pure elective Mixed elective Trauma Pure Trauma Pure elective

Male Male Male Male Male Female Male Male Male

There are few Grounded Theory studies published in Trauma and Orthopaedics21. A small number of interviews representing authentic views of participants are required until saturation is achieved22. From interview transcripts, codes, categories and concepts are derived to create a conceptual framework to illuminate the meaning of a ‘good pair of hands’.

Difficult definitions

Results

Nature or Nurture

Interviews exploring what ‘a good pair of hands’ meant to orthopaedic surgeons produced 984 lines of coding; these clustered into 198 codes. As the interviews and memos were analysed, various categories emerged:

Making difficult things look easy

Most surgeons agreed that being born with ‘gifted hands’ was not an important factor in being a good surgeon. There was much more to doing an operation well. Instead the able surgeon learned through experience, and acquired the skills, knowledge, and attitudes of a surgeon; ‘having the demeanour of a surgeon’. Surgical ability is derived, not from genes, but from life experiences, even hobbies and crafts from childhood, well before starting surgery. ‘Design technology’, ‘fixing bicycles’, ‘working in a father’s workshop’ gave potential surgeons familiarity and understanding of how to use tools effectively.

Watching surgeons operate with ‘a good pair of hands’ was described as ‘smooth’ or ‘comfortable’. This concept of being effortless, smooth and flowing was a recurrent theme; performing tasks ‘efficiently’, or ‘slickly’, ‘with economy of movement’. This was achieved by the surgeon staying in their ‘comfort zone’, rather than operating at the limits of their ability. ‘If you make things easy, they are easy, but it’s hard work making things easy’. A comparison was made of driving a fast car and not slowing down for corners. >>

Table 2 - Categories ‘A good pair of hands’ – categories Difficult definition Nature or nurture Making difficult things look easy The effect The Set-up The Method The Secret

All surgeons recognised the term, ‘a good pair of hands’, a feature that surgeons were able to identify when present in other surgeons and which was obvious when it was absent. ‘It’s very difficult to define, and almost immediately you work with a doctor you know if [they have a] good pair of hands or not’.

Most trainees could learn to develop these surgical attributes through sustained deliberate practice, within a surgical community. Expertise development through deliberate practice is well described in musicians and amongst many elite sportsmen, who may have been otherwise attributed with innate talent23. Surgeons agreed that this applied to surgical skills too.

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For more information or to arrange a visit from your local representative please email contactus@aquilantorthopaedics.com or visit our website www.aquilantorthopaedics.com Acta Orthopaedica 2009 80 (3): 298-302; 2 The Journal of Arthroplasty Vol. 17 No. 4 Suppl. 1 2002; 3Clinical Orthopaedics and Related Research No 429, pp 227-231; 4Clinical Orthopaedics and Related Research No 417, pp.224-231; 5Hip International Vol 17 no 3 2007 pp 143-149; 6The Journal of Arthroplasty Vol. 28 No. 1 2013; 7The Journal of Arthroplasty Vol. 18 No. 3 Suppl. 1 2003; 8 The Journal of Arthroplasty Vol. 26 No. 3 2011 1

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JTO Features

An able surgeon has a clear idea of the steps within an operation whilst performing them. Able surgeons know exactly what needs to be done in each step before moving onto the next.ll ll

Table 3 - Familiarity Comparison was made with magicians creating an illusion, using three ingredients to look smooth, comfortable and confident:24-26 l ‘The Effect’; clear idea of how the illusion will look l ‘The Set-up’; detailed preparation; time invested beforehand for the illusion to run smoothly and purposefully in real-time. l ‘The Method’; distinct series of steps; always aware of which step they have reached, and which step arrives next.

The Effect Good surgeons have a clear notion of their final goal, having ‘worked out what they need to do to make that look good’. Whereas inexperienced surgeons plan an operation from beginning to end, ‘a better way to plan an operation is the reverse’: from final goal to first step.

The Set-up Preparation is the vital component to a surgeon with ‘a good pair of hands’. It appears that things are happening smoothly and with ease in real- time. Unseen time and effort must be put in place beforehand setting up a particular mechanism or manoeuvre. Specialist tools are used, techniques refined, manoeuvres, or sequences of steps are rehearsed repeatedly until they become familiar. Familiarity breeds good results:

Familiar Anatomy Familiar patient Familiar operation Familiar theatre-list Familiar tools Familiar environment

The Method An able surgeon has a clear idea of the steps within an operation whilst performing them; ’a series of rather seamless events’ or ‘waypoints’. At the start of the operation a good surgeon completes what may seem like trivial steps such as positioning, skin preparation and setting up drapes. Paying attention to these essential first steps makes the operation easy. ‘There are some steps which are exciting and some which are necessary and boring’. Able surgeons know exactly what needs to be done in each step, and what the next step will be. They will make purposeful progress, operating efficiently and completing each step before moving onto the next. They follow an ordered logical sequence; have an accurate three-dimensional awareness of where they are and where dangers lie.

Surgical secrets In an idealised world every operation would be done perfectly; all operations would proceed according to predictable rules. In the real world no surgeons operate perfectly the whole time. Perfection is an ideal to strive for, but in reality is a rare occurrence. ‘A hole in one is a

nice way to play golf but that’s not the way you do it’. It was agreed that operations do have tolerances and surgery is not as hard as it is perceived to be; if an operation was technically too difficult for most surgeons then it would not be done. Many interviewees acknowledged that ‘consultants plan more than their trainees are aware’; it may not be obvious how much they ‘set-up’ through reading, drawing-out plans, or through mental visualisation. One surgeon referred to a colleague as never needing to plan before cases. ‘He’s an absolute natural…so he’s not a great planner; he will go in... get on and the operation will unfold in- front of him’. So, I asked the colleague if this was true; he was surprised; ‘of course I plan – I often spend a long time thinking through, and playing with different ways of doing an operation and read up a lot’.

Summary and implications From this study and social learning theory, it appears that trainers could help surgeons develop a good pair of hands by: l Encouraging the learning of craft-skills. l Selecting trainee surgeons on the basis of their potential rather than their experience.

l Using targeted deliberate practice, with simulation and modern coaching techniques. l Being explicit about the amount of preparation that experts use. l For an operative session: l Ensuring that trainees have a clear goal and image of what is to be achieved. l Planning steps in reverse from the final goal to understand all essential steps. l Discussing and rehearsing the intended operative plan beforehand. l Assessing against pre-agreed individualised set of steps, using narrative feedback. Consultants should be encouraged to take time for higher level study: this encourages critical thinking and reassessment of assumptions. In the modern competence-based training environment, there is a danger of discarding all of the advantages of the Apprenticeshipbased training that Sir Robert Jones promoted. By attending to the social aspect of learning frees us from the ‘Henry Ford’ quantitative world of competency and measurable efficiency:

‘Why is it every time I ask for a pair of hands, they come with a brain attached?’ Henry Ford (1863-1947) >>

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Instead it will allow us to develop the deeper values of Sir Robert Jones who recognised the attributes of an able Orthopaedic surgeon who had â&#x20AC;&#x2DC;a good pair of handsâ&#x20AC;&#x2122;:

â&#x20AC;&#x2DC;In addition to operative skill, it demands special qualities of mind; a mechanical aptitude and untiring perseverance and patienceâ&#x20AC;&#x2122; Sir Robert Jones, 192127 n

Acknowledgments The study was approved by Imperial Medical Education Ethics Committee. Informed consent was given by the participants and Confidentiality assured. This study has been submitted for a Masterâ&#x20AC;&#x2122;s degree at Imperial College. I would like to thank the Surgical Education team at Imperial College, my colleagues and my family for providing the opportunity to learn about Surgical Education.

Andrew Wainwright is a Paediatric Orthopaedic Surgeon working at Oxford University Hospitals. He is Training Programme Director in Oxford and was inspired by his colleagues to learn more about Surgical Education by taking a parttime Masters at Imperial.

This article is an abbreviated version of the 2014 BOA Robert Jones essay-prize winning essay. The full essay along with the reference list for this article is available online at www.boa.ac.uk/JTO or by scanning the QR Code

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

JTOFeatures Peer-reviewed Articles JTO

The Arthroplasty Care Practitioner’s Association Lindsay K. Smith PhD, MSc, MCSP

The Arthroplasty Care Practitioner’s Association (ACPA) represents a multidisciplinary group of advanced health professionals involved in the care of patients with a joint replacement. They can provide care at one or more points in the pathway, from referral for surgery, through pre-, periand post-operative care. History In 2005 the British Hip society (BHS) invited any non-medical health professional involved in arthroplasty to attend their meeting at Wrightington. This led to the formation of the fledgling Arthroplasty Care Practitioner’s Association, which was formally launched at the 2006 BHS meeting in Edinburgh. It provides an umbrella network of health professionals working together with orthopaedic surgeons to improve the process of arthroplasty care.

The founding constitution of ACPA included the following aims: l To provide a forum for discussion of the development of a national standardised programme of joint replacement follow-up l To support joint registries including the National Joint Register (NJR) and the Scottish Arthroplasty Project (SAP) l To work with the British Orthopaedic Association (BOA) and associated Specialist Societies to achieve common goals l To support training of Arthroplasty Care Practitioners through education including training at the national meeting l To promote research into joint replacement We are now formally affiliated to the British Orthopaedic Association (BOA, which with the BHS and BASK (British Association for Surgery of the Knee)), have been very supportive, sharing their annual conference facilities with ACPA. This has facilitated interaction and discussion between surgeons and ACPA members that has been mutually beneficial.

Lindsay K Smith

The ACPA has developed courses and defined competencies in

Figure 1: AP view of silent osteolysis 2010

conjunction with established universities and the BOA. Our annual meeting provides members with the opportunity to hear key speakers present on current topics and to network with other members across the UK in order to share practice.

Current Our membership includes physiotherapists, orthopaedic nurses, surgical care practitioners, radiographers and occupational therapists. All of these health professionals are working at an advanced level, many having completed a master’s degree. They work as part of the orthopaedic team linked directly with the surgeons and very often trained by them, thus crossing professional boundaries through local accreditation to our national standards. The advantages of membership of ACPA include access to courses on image interpretation and biomechanics of arthroplasty, and access to a network of colleagues

in similar situations. We have had practitioners from Canada and Australia attend our courses and visit units where arthroplasty practitioners are in place. This had led to some international exchange that has potential for future networking.

Clinical models There are a number of different models of arthroplasty surveillance in place across the UK, each having arisen in response to the local need. In some centres, practitioners may be involved in pre-surgery screening, while others use them at surgery. Another model employs practitioners as physicians’ assistants, on the wards involved in post-operative monitoring and preparation for discharge. Many centres provide an after care service, including the use of a telephone helpline for patients and GPs. The traditional model of long-term follow up has been a clinical review, although some hospitals are now moving to a mix of virtual surveillance and clinics. This can provide a better use of scarce resources but as yet, we have no

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk 73 l Page 47

clear evidence to suggest which patients should be seen and which can undergo a virtual review. Thereâ&#x20AC;&#x2122;s a need for good quality research to determine a gold standard for arthroplasty surveillance.

Competency The skills needed by an arthroplasty practitioner will be determined by their role within the arthroplasty pathway. As with many other advanced practitioner roles, the skills have traditionally been taught by committed local medical staff that have recognised a need and identified a health professional with the ability to meet that need. These professionals retain all their profession specific skills, but add to them in order to expand their role. The problem with this approach is that the advanced practitioner has difficulty in demonstrating the development of their skills if transferring to a job elsewhere. In 2010/11, ACPA worked with Peter Kay (then President of the BOA), the Department of Health, Skills for Health, major professional bodies and a higher education institute to define the competencies required for a practitioner in each part of the arthroplasty pathway. The documents produced were based on those used in medical training to show evidence of procedural skills, which was a major step towards making the arthroplasty practitioner role a transferable skill within the UK. The documents are available from the ACPA website (www.acpa-uk. net) and provide a useful checklist for any surgeon wanting to employ or train a practitioner locally. There is one for each of four areas of the pathway: pre-operative, perioperative, early post-operative and long term follow up (see example in Figure 2).

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+ A.)#%"*+;(F./C+ ,4#+&(#.0/#+(#+0()0+-%<<4/.-(#0)+-'0("'*+ + 24''+$.)#%"*+%@+&"0K.%4)+)4"C0"*+ + V0'0K(/#+&"0K.%4)+<05.-('E)4"C.-('+$.)#%"*+ + :&0-.@.-+T40)#.%/./C+"0'0K(/#+#%+$.&EF/00+2L+ + V0-%C/.#.%/+%@+)*<&#%<)+#*&.-('+%@+@(.'4"0+ + !))0))<0/#)+%@+%#$0"+W%./#)+./+'%30"+'.<?+ + :&0-.@.-+T40)#.%/./C+#%+50#0-#+"05+@'(C)+ + V0'0K(/#+-%/-4""0/#+<05.-('+&"%?'0<)+ + Figure 2: Work Based Assessment tool L/50")#(/5+:%-.('+@(<.'*+$%<0+0/K."%/<0/#+ + !))0))+&(#.0/#)+0U&0-#(#.%/)+ + L)0+%@+(&&"%&".(#0+)-%"./C+)*)#0<)+.@+"0T4."05+ + For a new practitioner !?.'.#*+#%+50)-".?0+S+5%-4<0/#+@./5./C)+ + developing role, + the+ surgeon should decide =U(<./(#.%/+ which of the four areas of the

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+ + :4&0"K.).%/+'0K0'+/005++++M++P++Q++R+ + + + + + + + + + + + + + + + + + + + + + + + + + + :4&0"K.).%/+'0K0'+/005++++M++P++Q++R+

Future ACPA will continue to work with the surgeons and other bodies to develop the processes of review and to support new practitioners and those that are in role. Arthroplasty practitioners provide a stable element to the team with a good working knowledge of their surgeonsâ&#x20AC;&#x2122; practise and extensive problem solving skills as a result. They have the flexibility to be able to deliver the service in a variety of locations but to retain the crucial link to the surgeon. As such, they provide the surgeon with feedback and confidence in his/her arthroplasty practice.

Enquiries ACPA welcomes any enquires about arthroplasty practitioners and their work via the website: www.acpa-uk.net or info@acpa-uk.net

Financial crises

Although there is no doubt about + =/)4"0+)(@0#*+(/5+-%<@%"#+%@+&(#.0/#+ + + arthroplasty pathway are to be the benefit of + X?)0"K0+&(#.0/#+3('F./C+(/5+-%<<0/#+ + + surveillance within + !))0))+3('F./C+(.5)+(/5+&"%)#$0#.-)+ + + included and then use the relevant the orthopaedic community, the + :&0-.@.-+0U(<./(#.%/+%@+$.&+E+F/00+ + + competency document to assess current economic situation is widely + =U(<./(#.%/+%@+%#$0"+W%./#)+E+?(-F+ + + any health professional for + potential Y()-4'("+0U(<./(#.%/+ + + affecting these services. Some + role.>04"%'%C.-('+0U(<./(#.%/+ + + the This provides guidance Trusts themselves + !55.#.%/('+0U(<./(#.%/+./5.-(#05+@"%<+$.)#%"*+ + are finding + for+ the level of expertise needed !?'0+#%+50)-".?0+S+5%-4<0/#+@./5./C)+ + forbidden to+ offer follow up beyond in a given situation and highlights a 6-week post-operative check. any area for which further training In such times, it is imperative that is required. ACPA would also we collect the evidence to show recommend a visit to a unit with an the benefit to patients and to the arthroplasty practitioner in situ, and NHS of periodic review. This will all members are willing to assist new involve examining different models practitioners in this way. Further of delivery and the essential time supportive information is available periods for review, as well as the to ACPA members via the website, effect of surveillance on the costs of such as the minimum requirements revision surgery. The financial crisis for a health professional conducting may well be the catalyst for research early post-operative follow up. to support an evidence-based practice approach to arthroplasty surveillance.

Lindsay K Smith trained as a physiotherapist and developed an interest in musculoskeletal work that led to higher degrees and orthopaedic research. Her involvement with ACPA was integral to her doctoral thesis and has developed into a recent National Institute of Health Research award during which she will be investigating the need for hip arthroplasty surveillance.

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 48

JTO Medico-Legal Features

The ‘Jackson Reforms’ in Civil Litigation and the Impact on the Expert Witness (Part 2) Giles Eyre

Continued from JTO Volume 2 / Issue 1

The so-called ‘Jackson reforms’ – the changes in the civil procedure process introduced with effect from 1st April and 31st July 2013 – have recently been described as creating ‘the most chaotic period in legal costs and funding since the concept of legal costs was codified in the Statute of Westminster 1275’. The lives and business practices of lawyers, and particularly those dealing with injury claims (personal injury, disease and clinical negligence), have been and will be fundamentally changed by the reforms, and the access of an injured person to professional support in bringing a claim will in some areas be substantially restricted. The impact of the reforms on the medical expert providing reports in civil litigation is both direct and indirect. Some reforms directly

refer to the use of medical experts in litigation, while others will affect the approach to the use of medical expert evidence in litigation.

Costs estimates and identification of issues Part 35 of the Civil Procedure Rules 1998 is concerned with the use of expert evidence. Rule 35.4 has always required the court’s permission to rely on expert evidence. However an amendment to Rule 35.4(2) now requires (from 1st April 2013) that an application for such permission be accompanied by an estimate of the cost of the proposed expert evidence as well as identification of the issues which the expert evidence will address. The order granting permission may specify the issues which the expert evidence should address. Therefore in future the expert must provide the solicitor with sufficient information for the solicitor to provide the court with an estimate of costs, that is the potential fees of all the stages of the litigation

Giles Eyre

down to trial, and the solicitor may require assistance in identifying the issues which the expert will address. The estimate will, in many cases, therefore be provided prior to formal instructions being received and without knowledge of the potential dispute on expert evidence to which the claim might give rise. Unless permission is granted the cost of the expert will not be recoverable by the successful party at the end of the case, even if a report has already been provided. This is of course only an ‘estimate’ of costs but, as will be seen below, estimates may well get turned into, or reduced to, straightjackets within which the litigation will thereafter be conducted. As the court is effectively required to have consideration of the potential cost of employing an expert in a claim, it is likely that there will be greater pressure to restrict the number of experts permitted and to increase the use of single joint experts.

Concurrent evidence The Practice Direction to Part 35 has been amended with effect from 1st April 2013 to add a new paragraph 11 to provide for the giving of concurrent evidence (or ‘hot-tubbing’ as it is sometimes referred to). 11.1 At any stage in the proceedings the court may direct that some or all of the experts from like disciplines shall give their evidence concurrently. The following procedure shall then apply. 11.2 The court may direct that the parties agree an agenda

for the taking of concurrent evidence, based upon the areas of disagreement identified in the experts’ joint statements made pursuant to rule 35.12. 11.3 At the appropriate time the relevant experts will each take the oath or affirm. Unless the court orders otherwise, the experts will then address the items on the agenda in the manner set out in paragraph 11.4. 11.4 In relation to each issue on the agenda, and subject to the judge’s discretion to modify the procedure – (1) the judge may initiate the discussion by asking the experts, in turn, for their views. Once an expert has expressed a view the judge may ask questions about it. At one or more appropriate stages when questioning a particular expert, the judge may invite the other expert to comment or to ask that expert’s own questions of the first expert; (2) after the process set out in (1) has been completed for all the experts, the parties’ representatives may ask questions of them. While such questioning may be designed to test the correctness of an expert’s view, or seek clarification of it, it should not cover ground which has been fully explored already. In general a full cross-examination or reexamination is neither necessary nor appropriate; and (3) after the process set out in (2) has been completed, the judge may summarise the experts’ different positions on the issue and ask them to confirm or correct that summary. >>

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l Volume 02 02/ / Issue 0201 / May 2014 l boa.ac.uk Volume Issue / January 2014 boa.ac.uk Page 50 22 l Page

JTO Features JTOMedico-Legal Features

The process is intended to enable the judge personally to investigate area or areas of dispute I BELIEVEthe THAT THE NEW NHS between experts and toENGLAND try to clarify the STRUCTURE HAS SIGNIFICANT CAPACITY nature, extent and reasons for the dispute.ll TO IMPROVE THE QUALITY OF THE PATIENT EXPERIENCE. ll

I believe that the new NHS England hasan significant capacity It isstructure unlikely that expert will turn the quality of the up to at improve court expecting traditional patient experience, improve cross-examination, andto instead be the quality of services delivered and to subjected to concurrent evidence. improve the quality of outcomes. The direction for an agenda will Input from clinical colleagues is normally mean that the concurrent essential to this process. The evidence needs to be directed in clinical voice must, however, advance of the hearing. However be coherent and clear to be the judge has the power to decide effective. Debate and discussion at the to conduct of are trial important and the will giving continue evidence by experts in this manner. to be part of clinical practice in Particularly if theinjoint our Centres, thestatement Specialityhas effectively provided agenda Societies, in the an BOA and inforthe 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 then can take such concurrent evidence there into NHS why England a powerful is no reason the judge shouldand message. notundiluted so direct on the day.QGiven that the judge hearing the trial may only be identified very shortly before trial, References and that some judges will be far more comfortable and pro-active 1. www.england.nhs.uk/ than others in their approach to resources/spec-commconcurrent evidence, a direction resources/npc-crg/group-d/ could be made at trial. d15 The2.process is intended to enable webarchive.nationalarchives. gov.uk/20130107105354/ the judge personally to investigate the areahttp://www.dh.gov.uk/en/ or areas of dispute between Publicationsandstatistics/ Publications/

PublicationsPolicyAnd the experts and to try to clarify the Guidance/DH_114528 nature, extent and reasons for the dispute. The process is therefore 3. www.nationalspinaltaskforce. dependant on the judge having a co.uk good understanding of the issues. 4. willhttp://bit.ly/BOA-CG-lbp That have been obtained, not (as with counsel) by meeting with UK health performance: and5.having a discussion with one of the prior Global Burden or morefindings of the experts to the Disease 2010. hearing,ofbut largely Study (if not entirely) Murray Richards from the writtenCJL, evidence of theMA, JNinettheir al, Lancet expertsNewton submitted reports 381:997-1020, and their joint statement.2013 Given 6. www.SCIreferrals.org.uk

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As well as being National Clinical for Spinal Disorders, theDirector non-specialist judiciary usually Professor Charles Greenough assigned to cases, it cannot be is a Consultant Orthopaedic Spinal assumed that the judge will have Surgeon and Clinical Director of the any background or experience prior Regional Spinal Cord Injury Centre to the case relevant to the issues at James Cook University Hospital, involved. Therefore the importance Middlesbrough. Research interests of the expert addressing the salient have been low back pain, spinal issues clearly in spinal a medical surgery and cordreport injury. He in language which be readily Chairs the CRGcan in Spinal Cord understood a professional with Injury andbywas a member of the no National medical knowledge is again Spinal Taskforce. emphasised. Email: charles.greenough@stees. Thenhs.uk experts do not have to be of the same or identical disciplines, >>

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 52

JTO Medico-Legal Features

Although the adversarial approach of crossexamination may be foreign to the expert’s normal practice in discussing differences of opinion with colleagues, the approach of the judge in discussing the issues with the experts may be equally, although differently, foreign, in particular if the judge’s understanding of the issues... is limited.ll

and that can, as it does in joint discussions, lead to some difficulty for the experts who may have a different approach from one another to the issues in the case. It is also likely that the experts will be of different personalities and therefore there may well be an imbalance in the way they present their evidence in the course of this process. The court is likely to direct that an agenda for concurrent evidence be prepared, and this will be based on the areas of disagreement in the joint

statement. The agenda is concerned only with the areas of disagreement. In an effective joint statement following a joint discussion, the agenda should already be apparent, listing the areas of disagreement and the reasons for such disagreement. Although the ‘parties’ are ordered to prepare the agenda, the lawyers will most probably provide the final agenda based on the input of the experts, which should have been largely provided in the joint discussion. The agenda will be

crucial in guiding the process of the concurrent evidence and in assisting the judge to investigate the disagreement with the experts. The Judge is in charge of the process of concurrent evidence and has discretion as to how this is done, but the Practice Direction above suggests a format in paragraph 11.4. Although the adversarial approach of cross-examination may be foreign to the expert’s normal practice in

discussing differences of opinion with colleagues, the approach of the judge in discussing the issues with the experts may be equally, although differently, foreign, in particular if the judge’s understanding of the issues, in the absence of any medical training, is limited. The process of the judge summarising the experts’ positions at the end of the evidence will be extremely important and is likely subsequently to form an important aspect of the judge’s judgment. It >>

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The President’s prize papers Thursday 19 June 2014

Early intervention in hip surgery Friday 10 October 2014

Orthopaedics section Christmas dinner

Thursday 4 December 2014

Future orthopaedic surgeons conference

Saturday 8 – Sunday 9 November 2014

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Wednesday 21 – Thursday 22 January 2015

Trauma symposium

Tuesday 24 – Thursday 26 February 2015 Getting it right first time – improving outcomes and reducing complications Friday 8 April 2015 For information on our other conferences or to book please: Visit: www.rsm.ac.uk/orthopaedics Mail: orthopaedics@rsm.ac.uk Tel: +44 (0) 207 290 3918

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

JTO Medico-Legal Features

will therefore be a very important task for the expert to ensure that the summary, while for example trying to simplify the area of dispute into nonexpert language, is also accurate and does justice to the areas of disagreement and the matters which have to be resolved by the judge. How extensively ‘hot-tubbing’ will be used is difficult to predict, and will depend to some extent on judicial training, the confidence of the judge to deal with the issues in the case in this manner and the nature of the

dispute. Judges with more specialist knowledge are likely to find an advantage in this procedure and to see a way in which to shorten trials, while some interventionist-minded judges will believe that ought to be an advantage. n

Giles Eyre 9 Gough Square London EC4A 3DG



                            

       

Giles Eyre is co-author of a manual for medico-legal experts and those instructing them, ‘Writing Medico-Legal Reports in Civil Claims - an essential guide’ (2011) and co-presenter of the e-learning programme ‘Medico-Legal Report Writing (Core Skills)’ (www.prosols. uk.com). He frequently gives seminars and workshops for medical experts in medico-legal report writing, giving evidence and other medico-legal issues.

Giles is a barrister specialising in personal injury, disease and clinical negligence claims. He is mediator and a member of the CEDR Solve Lead Mediators Panel. He was appointed a Recorder in 2004. Giles is a contributing editor to ‘Clinical Negligence Claims - A Practical Guide’ (2011) and ‘Asbestos Claims: Law, Practice and Procedure’ (2011), both published by 9 Gough Square.

Book now to attend

HIPToulouse 2014 The congress on hip surgery on

17th-19th September 2014 The congress will be translated from French to English

There will be many round-table discussions with international speakers on topics such as: M intra articular cervical fractures M periprosthetic fratures M metal back problems M diameter of the femoral head M leg length inequality M the prosthetic surgery on obese people and children M avascular necrosis of the femoral head M how many times should revision of septic arthroplasties take place. There will be an interactive quiz on tumours Yves Coppen, a famous palaeontologist, will give a lecture on “Walking the Last Ten Million Years” We will spend an unforgettable evening in the city. Toulouse, France: The city is old, the food is good and the weather is sunny (most of the time)!

Organised by the surgeons of: Institut Locomoteur, Du centre Pierre Paul Riquet, CHU de Toulouse it takes place at Le Théâtre National de Toulouse For details visit: http://www.hipnews.org/hiptoulouse/page4.html

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 55

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JTO Medico-Legal Features

Medico-legal aspects of adult tibial shaft fractures Leela C Biant

Fracture Union

Fracture of the tibial shaft is a common injury. There is a bimodal distribution of incidence1. The mechanism of injury is usually high-energy trauma or sports injury in the young, and fall from a standing height in the elderly2. The long term outcome from such injuries is of great importance when preparing medico-legal reports. Recently results after 12-22 (mean 17) years, including functional outcomes, have been reported. Fractures are graded by multiple different systems in the literature. Gaston et al3 reviewed AO fracture classification, Winquist-Hansen grade, open and closed injuries, fracture displacement, Tscherne Score, location of fracture and associated fibula fracture in an attempt to find a prognostic correlation with outcome. These factors may be significant in predicting closed plaster or bracing treatment outcomes, but fragmentation and initial displacement of fractures are not reliable indicators of outcome when fractures are treated with intramedullary nailing3. Open fractures are usually graded after Gustilo and Anderson. Approximately 20% of open fractures are Grade 1; 25% are grade 2 and 55% are grade 3. Of the grade 3 open fractures, approximately 45% are grade IIIA, 50% are grade IIIB and 5% are grade IIIC2,4. The majority of open fractures unite. The literature reports a range of non-union from 0-17%, the majority reporting around 4%.5 There is no clear breakdown of nonunion rates between Gustilo grades. Leela C Biant

Time to fracture union can be influenced by the severity of the injury and the treatment method. In a meta-analysis of 2372 trials6, the time to union varied slightly with fixation device, but there was no difference in the number of fractures united at 20 weeks, or the incidence of non-union between treatment devices. However, caution should be exercised when interpreting such data as the more severe injuries may have been nailed. Primary union occurs without further intervention in over 90% of tibial shaft fractures2. Some require further interventions such as bone grafting, exchange nailing, removal of locking screws and alternative fixation methods.

Compartment syndrome

Tibial Shaft Fracture

Treatment Treatment of tibial shaft fractures may be through plaster immobilisation, functional bracing, intramedullary nailing, plating, or primary amputation in the unsalvageable limb. Undisplaced transverse fractures may be treated non-operatively, however, the majority of displaced fractures in the UK are treated operatively in 2014.

Compartment syndrome is a potentially devastating complication of tibial shaft fracture. The intracompartment pressures are related to the extent of the associated soft tissue injury7. Even in open fractures the associated soft tissue injury can cause a compartment syndrome. The incidence of compartment syndrome is reported from 1.6 - 9%8,9. However, true comparisons between case series are difficult due to lack of criteria for diagnosis and severity. There is a huge clinical difference between early decompression of oedematous muscle that responds and recovers fully, and excision of necrosed dead muscle as a lifesaving measure or the later formation of ischaemic >>

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JTO Medico-Legal Features

Knee and ankle discomfort are common long term complaints. At a mean of 17 years, 47% patients were free of discomfort.ll ll

contractures. However, all can be labelled compartment syndrome. We found an 11.5% fasciotomy rate, but no functional difference between those who underwent fasciotomies and those who did not at mean 17 years follow-up. The majority of the patients in this series had compartment pressure monitoring, so it was likely that timely intervention was undertaken before irreversible muscle necrosis occurred.

Knee and Ankle Symptoms Stiffness of the knee or ankle may occur after tibial shaft fracture. This was a more prominent immediate feature when the knee, ankle and subtalar joint were immobilised for protracted periods by plasters and splints10. Joint stiffness may occur in the long term, but this has not been specifically studied in patients treated by modern operative techniques. It is possible that articular cartilage injury within the knee or ankle can occur at the time of tibial shaft fracture that may contribute to degenerative joint pathology and late stiffness. Knee and ankle discomfort are common long term complaints11. At a mean of 17 years; 47% patients were free of discomfort, 17% had both knee and ankle discomfort, 26% had knee discomfort alone and 10% had only ankle discomfort2. The level of discomfort in the

majority did not affect their ability to work. The presence of long-term discomfort in the ankle was related to the severity of the initial injury, suggesting a degenerative process. Women were more likely to have ankle pain in this series, and this may be due to the women being much older than the men at the time of fracture, with the higher likelihood of pre-existing degenerative change in the joint. Vallier et al12 found that joint pain did not affect function in the majority of patients with a tibial shaft fracture. Tibial nails inserted through the patella tendon are associated with higher rates of anterior knee pain than nails inserted without disruption to the tendon11. Removal of metalwork does not always resolve knee discomfort11.

Post-phlebitic syndrome Post-phlebitic syndrome of the lower limb and venous ulceration can occur, particularly in older patients, after tibial shaft fracture. This phenomenon may not present clinically for up to 10 years following injury and therefore Aitken et al13 highlighted the potential medicolegal implications of early settlement of cases with regard to the onset of these symptoms.

Return to work In a series of 1502 patients, of the patients alive for review; 74.6% were able to return to their pre-injury employment. Of the remaining 25.4%; 17.3% were unemployed at the time of injury, 2.3% changed to a less physically demanding job, 0.5% took early retirement and

7% reported they were unable to return to work due to continuing disability. Younger patients had a higher likelihood of return to work, and earlier return to work. Increased age and presence of a grade II open fracture was associated with a reduced likelihood of returning to work at all.

Mortality Crude mortality at 17 years following a tibial shaft fracture is 37.5%. Mortality in the 12 months following fracture is high in the elderly. The one-year mortality in patients aged 65-69 is 6.5%, this rises to 21.6% in those aged 70-74 and 31.6% in those aged over 85 years at the

time of injury2. This mortality rate is similar to patients who sustain a hip fracture. n Leela is Consultant Trauma & Orthopaedic Surgeon at The Royal Infirmary of Edinburgh, Honorary Senior Lecturer at The University of Edinburgh, NRS Career Clinician Scientist Fellow. Her clinical practice, translational and clinical research interests are in the area of degenerative joint disease of the knee from cartilage repair to joint replacement, and optimising outcome for injured patients.Â References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

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

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

JTO Peer-reviewed Articles

Measuring and changing practice – making a difference in hip fractures AC Gray BSc MD FRCS(Tr&Orth), Consultant Orthopaedic & Trauma Surgeon, Newcastle Hospitals TJS Chesser FRCS(Tr&Orth), Consultant Orthopaedic & Trauma Surgeon, North Bristol NHS Trust

Hip fractures are a leading cause of hospital admissions in an increasingly elderly population. The annual incidence of hip fractures in the UK is around 65,000. These are associated with high morbidity and mortality rates. In-patient and 30-day mortality rates range from between 3-10% with a 1-year mortality rates that varies between 20-40%. There is also a frequent loss of independence and mobility after injury and subsequent surgery. A poor prognosis is associated with advanced age. Cognitive impairment, male gender, institutionalised living and patients with more associated co-morbidities.

Andy Gray

Tim Chesser

A hip fracture

For a number of years there has been recognition of the disjointed approach to their care. Whilst numerous publications have highlighted the issues of multidisciplinary and co-ordinated care, the results in terms of length of stay and mortality were little altered. For many it was considered a medical problem, and the majority of the surgery required was deputed to junior orthopaedic staff, often on unsupported emergency lists, with junior anaesthetists. Subsequent complications were attributed to the patient group, who present with significant medical comorbidities. In the last 8 years there has been a paradigm shift in how these patients are cared for, managed and measured. They are now a benchmark of how hospitals treat emergency admissions This change was initiated by the recognition and acceptance that

unless standards are created, care cannot be measured and subsequently audited against an accepted norm. From this the National Hip Fracture Database (NHFD) was started, initially supported by enthusiastic hospitals, and now by every hospital in England. Over 310,000 cases have been added since 2007, making it the largest hip fracture database in the world. The database is centrally funded via HQIP (Healthcare Quality Improvement Partnership) as part of the Falls and Fragility Fracture Audit Programme. The British Orthopaedic Association and the British Geriatric Society jointly published the standards of care in a “Blue Book” titled “The Care of Patients with a Fragility Fracture”. Professor Keith Willett, a clinician, was appointed National Clinical Director of Trauma with a remit to improve the management of hip fractures and major trauma.

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JTO Peer-reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 02, pages 60-64 Title: Measuring and changing practice – making a difference in hip fractures Author/s: AC Gray & TJS Chesser

NICE published standards of care for hip fractures in 2011. There was sparse data on outcomes and the Best Practice Tariff was based on processes which were felt to be most likely to lead to optimum outcomes. The original criteria included the requirement for a multidisciplinary pathway, orthogeriatric review within 72 hours, bone health and falls assessment, surgery within 36 hours and submission of data to the NHFD. The initial incentive was £440 for each individual patient achieving the criteria. Interestingly, the funding for this was achieved by dropping the National Tariff. The BPT has increased to £1335, with additional criteria of pre-and post-operative cognitive assessment added. In the first year, just over 20% of patients achieved the criteria to obtain the tariff – less than four years later this has risen to 60%. NICE guidance was challenged to provide standardisation in areas where there remained a huge variation in practice and reported

on all aspects of the pathway from initial assessment, timing of surgery, standardisation of surgical procedure, mobilisation and rehabilitation. This has led to the NICE quality standards, the majority of which can be monitored by the NHFD. The quality standards have now become statutory for Commissioning Groups. The 2013 NHFD report considers 61,508 patients and provides data from previous years for comparison. 86% of patients in 2013 had surgery within 48 hours of admission, an improvement from the 75% in 2009. Similarly, the proportion of patients receiving a falls assessment prior to hospital discharge has improved from 44% in 2009 to 94% in 2013, with a higher number also being discharged on bone protection medication. Pre-operative orthogeriatric review has also improved from 24% (2009) to 49% (2013). The overall ‘return to home after injury’ figures have improved modestly from 43% in 2011 to 46% in 2013. Challenges and areas to improve include: admission to an orthopaedic ward within four hours of admission, which remains

relatively low at around 50% (55% in 2009) and accurate documentation of the abbreviated mini-mental test score (this now seems to have improved but was initially a main reason for failing to achieve BPT). Recent changes introduced have given the lead clinicians the responsibility for checking data entry, as retrospective changes are no longer allowed. Have these standards influenced key outcome measurements used to assess hip fracture care? The NHFD uses case mix adjustment to help correct for age and complexity of patients when comparing mortality rates between individual units. Those falling outside the 2 standard deviations are offered support with external reviews. All units have full access to their data for audit and the national reports include success stories of changing practice and culture. Obtaining accurate and complete data in the first year after injury has proved challenging. Only 45% of patients in the 2013 NHFD report had complete 30-day data, with figures declining further on the 120-day review. Continued independence and rehabilitation success are key markers used to assess the quality of multidisciplinary care received. There is a programme

to try to introduce patient reported outcome tools at the 30 and 120day reviews to get a measure of the quality of care given. So where are we now? All hospitals have changed their practice. Hip fractures are both on local and national agendas. The patients now receive urgent care (often prioritised on Consultant led Trauma lists) with both early orthogeriatric input and multidisciplinary rehabilitation. Good hospitals are rewarded with more income to invest in services. The information of performance (through the NHFD), including mortality, has been published on the Internet long before the recent surgeon specific mortality figures. Those who struggle are offered multidisciplinary reviews to try to address local issues, and the standards continue to rise. In just a few years the mortality associated with hip fractures has dropped by between 10 and 20%, the length of stay in the NHS has dropped by between three to six days, and the cost of treating these patients has reduced rather than increased. Better care is not always more expensive care. >>

THERE’S A REASON SOME ORIGINALS ENDURE. Proven – Backed by 40 years of proven clinical performance.1,2 Progressive – Backed by an active medical education and design panel.3 One – Streamlined system for Primary, Revision and Hip Fracture procedures.4 To find out more about how one stem can fit all your needs, contact your Stryker Representative. 1. “The long-term results of the original Exeter polished cemented femoral component” Ling R, Charity J, Lee A, Whitehouse S, Timperley A, Gie G Journal of Arthroplasty, (2009); 24(4):511-1 2. National Joint Registry for England and Wales. 9th Annual Report 2012 3. The Exeter Hip 40 years of Innovation in Total Hip Arthroplasty. Issue 1. Ling et al. Exeter Hip Publishing 2010 4. The Exeter Hip 40 years of Innovation in Total Hip Arthroplasty. Issue 1. Chapter 3.1 “Exeter Hip Instrumentation” J Howell. Exeter Hip Publishing 2010

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 64

JTO Peer-reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 02, pages 60-64 Title: Measuring and changing practice – making a difference in hip fractures Author/s: AC Gray & TJS Chesser

In 2013 the NHFD also used HES (Health Episode Statistics) to look at ‘super-spell’, which is the total length of hospital stay to the admitting hospital but also to any subsequent hospital or trust (e.g. for rehabilitation). This reduces potential bias in comparing units who have rehabilitation facilities on site and therefore would appear to have an elevated mean length of hospital stay. Approximately 50% of elderly patients are still unable to mobilise independently after a hip fracture. Increasing elderly patients, institutionalised living and cognitive impairment are factors linked to poor outcome and are difficult to influence. However, there are factors that we believe do make a difference and can improve the functional outcome and overall quality of life in this vulnerable patient group. Quality surgery and a better knowledge base for implant choice are factors that we can influence. NICE guidelines based on a reasonable body of clinical evidence would now indicate replacement rather than fixation for intra-capsular neck of femur fractures in elderly patients to facilitate weight bearing, improve

function and avoid the need for reoperation due to avascular necrosis and non-union. Furthermore, total hip replacement rather than hemi or bi-polar arthroplasty is now recommended for all independently mobile (one stick or better), cognitively intact patients who can tolerate the surgery. There is good evidence that well selected patients have a reduced length of hospital stay, enjoy a better level of function and are more likely to remain independent after a total hip rather than a hemiarthroplasty. The use of the traditional cemented Thompson’s implant remains controversial. This cheap, trusted and well-used implant has enjoyed low revision rates, which are certainly comparable to more modern, expensive and better ODEP rated stem designs. However, NICE guidelines have now recommended that it be discontinued and placed in the same category as the uncemented Austin-Moore implant which has a well-documented higher rate of implant failure and intra-operative fracture. Adequate nutrition and fluid intake are prerequisites to optimise outcome. Nutritional supplements and staff/ volunteers present on the ward to assist with feeding can make a

significant impact on morbidity and mortality. Better monitoring and follow up in the community may also help as there is very often a lack of coordinated rehabilitation once the patient has been discharged from hospital. The care of hip fracture patients has improved following closer working between the BOA, the British Geriatric Society, the Association of Anaesthetists of Great Britain and Ireland, and other allied health professional bodies. There has been a tangible improvement in care which can be attributed to Professor Keith Willett’s drive with the BPT & NHFD incentivising and improving compliance and standardising care. The next step is prevention, led by the developing fracture liaison services and further development of evidence-based rehabilitation. Hopefully this will benefit, not just those who suffer hip fractures, but our whole orthogeriatric population. n

References: British Orthopaedic Association. The Care of patients with fragility fracture. British Orthopaedic Association 2007. www.boa.ac.uk British Orthopaedic Association Standards for Trauma (BOAST).Hip fracture in the older person. BOAST 1, version 2. www.boa.ac.uk Best Practice Tariff www.dh.gov.uk/ health/2012/02/confirmation-pbrarrangements/ The National Hip Fracture Database. National Report, 2013 www. nhfd.co.uk/003/hipfracturer.nsf/ NHFDNationalReport2013_Final. pdf (BPT) National Institute for Health and Clinical Excellence. Hip fracture; the management of hip fracture in adults. CG124. London: NICE, 2011 www.nice.org.uk/nicemedia/ live/13489/54918/54918.pdf

Correspondence: andrew.gray@nuth.nhs.uk tim.chesser@nbt.nhs.uk

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 66

JTO Peer-reviewed Articles

Managing trauma: The evolution from ‘early total care’/ ‘damage control’ to ‘early appropriate care’ A Tasker MB BS, MRCS MB Kelly MBBS, MD, MRCS Eng, FRCS(Tr&Orth)

There are over 48,000 serious trauma victims per year in England. 20,000 risk death or severe disability and the annual mortality is 5,400, many more are left with a permanent disability(1). In April 2012 trauma care delivery in England underwent a major change to respond to these challenges. The country was divided into 18 major trauma networks, four having been established in London in the year before. These networks of trauma units are supported by major trauma centres. Service reconfiguration brought a new focus on how trauma care is delivered using a specialist multi-disciplinary approach to the individual patient.

90% of multiply-injured patients will have a bony injury, orthopaedics accounts for 50% of the operations undertaken(2), orthopaedic services are very much in the forefront of delivery. The aim of the multidisciplinary approach is to identify the seriously injured patient and navigate them through their surgical needs without delay while adding as little as possible to their injury burden in terms of complications, particularly pulmonary problems. The term ‘early appropriate care’ was coined by Vallier et al (3) and is the practical voice of reason that supersedes the decade long debate over the place of ‘early total care’ and ‘damage control’ orthopaedics and is the method by which the MDT achieve their goal. This article outlines the chronology of the terms ‘early total care’ and ‘damage control orthopaedics’ and reinterprets the debate in the face of the latest studies.

Background

Andrew Tasker

Michael Kelly

The 70s and 80s saw the popularisation and success of fracture fixation. Early fixation of femoral fractures appeared to lead to better outcomes and decreased pulmonary complications(4). Throughout the 80s multiple studies described better outcomes from early operative stabilisation of femoral fractures, resulting in the adoption of what became known as ‘early total care’ (4-8). It was apparent that unstable long-bone fractures contributed to secondary lung injury. Early stabilisation offered the benefit of minimising on-going tissue damage, inflammatory activation and haemorrhage (‘stabilising the haematoma’) with the benefit of early mobilisation and reduction of the secondary lung problems. Most

of the studies were retrospective until the publication of Bone’s landmark prospective randomised study of 178 patients(9). Bone reported markedly reduced rates of fat embolism, respiratory distress and sepsis related mortality in patients who underwent definitive fracture stabilisation within 24 hours of admission. Delay in stabilisation after that time resulted in a five times greater risk of adult respiratory distress syndrome (ARDS). The argument became “patients are too sick not to have an operation to stabilise their long bone fractures”(10). However during the following decade it became apparent that early stabilisation might be deleterious in a subgroup of patients, those that were haemodynamically unstable, or had concomitant chest or head injury (11, 12). In 2000, Scalea et al (12) coined the term ‘damage control orthopaedics’ (DCO), borrowing from the general surgeons’ transduction of the military term (13). The aim was to prevent exsanguination and death, rather than to definitively treat the broken bone. Stabilisation rather than fixation became the operative aim of the orthopaedic surgeon when faced with a severely injured patient in extremis. Pape et al (in his 2002 tribute to the lifetime achievements of Professor Tscherne(14)) then tried to better define groups of patients. The paper outlined an observed change of practice from 1981 to 2000 and identified a group that lay between the stable patient and the patient in extremis, named the ‘borderline’ patient in whom prolonged orthopaedic attempts at definitive care, particularly of the femur may lead to a ‘second hit’. This is where the inflammatory cascade is further activated by the surgical ‘insult’ resulting in >>

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 68

JTO Peer-reviewed Articles

Journal of Trauma and Orthopaedics: Volume 02, Issue 02, pages 66-70 Title: Managing trauma: The evolution from ‘early total care’/ ‘damage control’ to ‘early appropriate care’ Author/s: A Tasker & MB Kelly

pulmonary complications, systemic inflammatory response syndrome (SIRS) and even multi-organ dysfunction syndrome (MODS). Pape sought to extend the utility of the damage control principles. While damage control orthopaedics has a definite place, Meek in his John Border memorial lecture, cautioned against the sudden surge in it use(10). He reinterpreted the Pape figures and reached very different conclusions. On closer examination, the benefits of damage control orthopaedics in the stable and borderline populations are not superior to those of definitive fixation. Meek’s conclusion was that either approach was appropriate and a matter of surgeon and institutional philosophy. Subsequent papers sought to show advantages of one relative to the other. This debate has now been superseded by the later publications of Scalea and Vallier(3, 15).

Measuring Injury Throughout the early total care and damage control era of orthopaedic management of the multiply-injured patient, quantifying the severity of the injury in terms of decision making remained problematic. Injury Severity Scores help to quantify the trauma ‘dose’, facilitate research and could correlate with morbidity and mortality. The injury Severity Score (ISS) is now the most commonly used and defines the criteria for transfer within the trauma networks in England. However, it is not specific enough to guide the orthopaedic decision making. Other more specific markers have been sought. Inflammatory cytokines,

These images demonstrate bilateral retrograde femoral nails inserted as part of early appropriate care in a polytraumatised patient

in particular Interleukin 6 (IL-6), appear to be robust in interpreting the trauma ‘dose’ in terms of the pathophysiological response (16). The European poly-trauma study on the management of femur fractures (EPOFF) group have shown that levels differ with different severities of injury and in response to the surgery undertaken to treat those injuries (17). However, measurement of cytokine levels is not readily available in the vast majority of trauma centres. Therefore other more readily available markers have been sought.

The ‘new’ focus resuscitation In 1999 Blow et al reviewed their trauma patients with ISS>20 and introduced the concept of endorgan occult hypoperfusion (18). They noted a higher infection and mortality in those with occult hypoperfusion (19). They applied these observations to their femoral fractures and reported a two-fold higher incidence of post-operative complications (50% versus 20%) in patients with normalised haemodynamic parameters whose serum lactate

remained greater than 2.5 mmol/L at time of primary intramedullary nailing (20). They concluded that adequate resuscitation reflected by a normalised lactate could act as a guide to the timing of surgical intervention. Focus therefore changed from seeking quantitative markers of tissue injury, which were proving difficult to implement at a practical clinical level, to markers of resuscitation. The orthopaedic literature had become too focused on fracture management techniques and overlooked the contributions from intensive care and anaesthetic resuscitative techniques applied to trauma which had also evolved hugely (2, 10). In addition, experience >>

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 70

JTO Peer-reviewed Articles

reported by the British Military Medical Services from various conflicts in the 90’s and 2000’s regarding the use of blood products much earlier and more aggressively in the trauma patient rather than fluid resuscitation leading to quicker and more complete normalisation. The early group in Pape’s 2002 paper were operated on in less than eight hours, probably leaving insufficient time for adequate resuscitation (14). Baltimore applied the principles of adequate resuscitation using standard physiological markers and a lactate of under 2.5 and reported reduced morbidity and mortality (15). Their mean time to theatre was 14 hours. DCO was implemented in only 12% of their patients.

Early appropriate care Vallier et al. reported on a retrospective study of 1442 patients with pelvic, spinal and / or femoral shaft fractures in 2013 (3). The aim was to define the injury or clinical parameters that warranted delaying definitive fracture fixation in relation to resuscitation and to determine the optimal timing of surgery. Statistical modelling was performed to develop cut-off values beyond which the probability of a complication diminished to an

acceptable level (below 20%). In a patient responding to resuscitation measures, a lactate < 4.0mmol/L, pH≥7.25 or a base excess (BE) ≥ -5.5mmol/L was indicative that they could proceed with definitive fracture care. They also found that the greatest predictor of pulmonary complications was chest injury. Failure to respond to resuscitation and normalise acidosis resulted in increased morbidity and mortality with lactate the most specific predictive measure. Presenting pH was lower, base excess worse and lactate levels higher in those that subsequently developed pulmonary and non-pulmonary complications. In their centre, DCO is reserved for those who fail respond to resuscitative measures within the first eight hours and definitive management timed for when these parameters normalise. Vallier et al. concluded that the focus should be on ‘Early Appropriate Care’ (EAC) with definitive management of mechanically unstable fractures of the axial skeleton and long-bones within 36 hours of injury as long as the patient has demonstrated response to resuscitation as based on improvement of acidosis with lactate< 4.0 mmol/L, pH ≥7.25, or BE above 5.5 mmol/L.

Resuscitation and economics On the basis of their findings, Vallier et al. instituted a standardised protocol to expedite definitive fracture fixation once patients are physiologically optimised. They compared the performance of multiple surgeries in one sitting to a staged approach over several days (21). Although the complication profiles were no different; so long as they had been adequately resuscitated; those undergoing multiple sessions stayed an average of 1.4 days longer in the trauma centre. In an allied study, they undertook a prospective cost analysis study. In adequately resuscitated patients, those undergoing single session surgery were more efficiently treated and generated better incomes for the institution (22). The implementation standardised protocol to expedite definitive fracture fixation reduced costs and enhanced the profitability.

Conclusion It is no longer a question of ‘camps’. The duality of the traditional discussion has been superseded by ‘early appropriate care’: a more consistent focus on the physiological state of the patient and in particular the success of the resuscitative effort. No single physiological parameter or blood marker can as yet be used to guide intervention, but the accepted level of 2.5mmol/L for lactate is likely too conservative and is being superseded by a more comprehensive and patient centred approach, focusing on physiological improvement and reversal of acidosis reflected by a lactate< 4.0 mmol/L, pH ≥7.25, or BE above 5.5 mmol/L. By monitoring and maintaining the resuscitative effort, multiple injuries can be dealt with in one session in most of these patients. This results in an improved complication profile, shorter hospital stay, improved hospital income and much better use of hospital and operating theatre resources. At its core is a multidisciplinary approach that evaluates when definitive care is most appropriate. n

Correspondence: andrewtasker@doctors.org.uk Michael.Kelly2@nbt.nhs.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 71

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 72

JTO Peer-reviewed Articles

Common shoulder problems presenting to the fracture clinic SE Aldridge MA MD FRCS(Orth) JR Williams MA DM FRCS(Orth)

We present our approach to some common shoulder problems, which frequently present to general fracture clinic after referral from the Emergency Department for acute treatment. Clavicle Fractures Clavicle fractures comprise about 5% of the fractures presenting to hospital, with an incidence of 30/100,000. Midshaft and lateral end fractures tend to behave differently and may require different methods of operative intervention. Until recently, the majority of midshaft fractures were treated non-operatively, but a multicentre randomised controlled trial from the Canadian Orthopaedic Trauma Society, suggested that patients with displaced fractures would benefit from fixation to avoid the risk of non-union and functionally inferior results with symptomatic malunion1. Subsequently, systematic reviews and meta-analyses have been performed2,3,4. These suggest that the long-term outcome is unaffected

Stephen Aldridge

by surgical or non-operative treatment. There is a higher rate of non-union in the non-operative groups, but this is amenable to operative correction. The time to union is also longer and there is a later return to function in the nonoperative group. These advantages of surgery must be weighed against the risks of wound dehiscence, infection, and the need for secondary surgery due to prominent hardware. These studies lead us to take a view that midshaft clavicle fractures should be treated on a case by case basis, in discussion with the patient. We treat undisplaced fractures non-operatively in a broad arm sling for 4 weeks, unless there is a pressing reason to get early function. Displaced fractures are discussed with the patient. Indications for

John Williams

intervention are: open fractures, skin compromise, shortening greater than 2cm1, and wide displacement with high chance of tissue interposition. The best method of fixation has been investigated, and the alternatives include intramedullary fixation and plate fixation. There are no clinical differences in outcome between the two, but intramedullary fixation is technically demanding, and there is a greater risk of shortening in comminuted fractures when compared to plate fixation5. We fix these fractures with a plate, with intrafragmentary compression in simple fractures and in bridging mode for multifragmentary fracture configurations. Lateral clavicle fractures are thought to have a higher risk of non-union, and there has therefore been more inclination to fix these injuries. The fracture has been classified with respect to the integrity of the coracoclavicular ligaments and whether the medial fragment maintains an attachment to these, to reduce the deforming force of gravity pulling the arm (and lateral fragment) away from the medial fragment. Fractures with an intact coracoclavicular ligament attachment to the medial fragment can be treated nonoperatively, with good results, and simple surgical options in the event of failed conservative treatment. The fractures with medial fragment displacement (coraco-clavicular ligament disruption) have a 30% non-union rate6,7. However, surgery for these fractures has a 22% complication rate6. Functionally there is little difference between the groups8, and there may be an argument for treating these fractures non-operatively, after discussion with the patients, accepting they may have symptomatic non-union,

which could be treated later, although personal experience is that these non-unions can be difficult to treat late due to the size of the distal fragment, and new bone formation blocking reduction. The complication rate varies between surgical modalities. Hook plate and tension band wiring have the highest complication rates of up to 40% and the majority of these patients will require further surgery to remove the implants. Coraco clavicular stabilisation (to reduce the fracture without fixation between the medial and lateral fragments to allow healing with callus) and interfragmentary fixation have the lowest rates of complication (4-6%)6. On this basis, we avoid fixing these fractures with devices that cross the ACJ, and aim to apply a lateral plate crossing the fracture with multiple fixed angle locking screws, and if necessary augment this with sutures through the CC ligament, or around the coracoid, depending on the quality of the tissue.

Acromioclavicular Joint Injury There had been a paucity of evidence to lead decision-making in the treatment of AC Joint injuries9. The classification of these injuries relates to the integrity of the coracoclavicular ligaments. Rockwood types I and II have intact coracoclavicular ligaments with sprains of the capsule and acromioclavicular ligaments. These are generally treated non-operatively, although the injury to the joint can lead to some long-term problems with pain that may require treatment with AC Joint resection. It is the Type III or greater, that have previously provided controversy in their treatment. One meta>>

Journal of Trauma and Orthopaedics: Volume 02, Issue 02, pages 72&73 Title: Common shoulder problems presenting to the fracture clinic Author/s: SE Aldridge & JR Williams

analysis of studies treating these injuries (based on 6 retrospective case series) concluded that there is not enough evidence to guide treatment10. The surgically treated group had improved cosmesis, but the non-operative group returned to function earlier with less sick-leave. There was no difference in pain, strength or throwing ability. The Canadian Orthopaedic Trauma Society have recently performed a study randomising type III injuries to operative or non-operative management. At all points the nonoperative group attained better and quicker function (Data presented at OTA meeting 2012). On this basis we treat the majority of ACJ dislocations non-operatively with early mobilisation, and review symptoms at three months, although some injuries require earlier reconstruction. Ignoring cosmesis, indications for intervention at three months is pain on activity, particularly above shoulder height, and a feeling of the arm being “not attached to the body”. There are various ways to reconstruct the AC Joint, and the number of devices being developed for this injury is increasing. There is little evidence for one over the other, although reconstruction using the coraco-acromial ligament has a 12-20% failure rate for late reconstruction11. We choose to excise the lateral clavicle and reconstruct the coraco-clavicular ligament with a loop of synthetic ligament around the coracoid attached to the clavicle with a screw, giving a strong fixation with a good clinical result.

Anterior dislocation of the shoulder Traumatic shoulder dislocation

is a very common injury, which is treated with acute reduction in the emergency department under sedation, and often presents in the fracture clinic to non-shoulder traumatologists. The rationale for treatment of these injuries depends on a number of factors, relating to the risk of recurrence, and associated injuries/complications. The patients can be divided into first time dislocators and those with previous dislocations. For first time dislocators, the risk of recurrence is related to their age (younger patients having a higher risk), and to their functional requirements (those playing contact sports, or loading their arm in abduction and external rotation having a higher risk). The risk for people who play contact sport is in the region of 80-90% - highest in the under 20’s, the risk decreasing exponentially with age, and so a discussion with these patients about primary reconstruction should be made, but non-operative treatment with a rehabilitation programme can be pursued in the knowledge that further dislocations would be an indication to undertake the reconstruction at that stage12, and studies have not shown worse outcomes for stabilisation after recurrent dislocations. If after a full programme of rehabilitation aimed at glenohumeral control and cuff strengthening they continue to have symptoms of instability, then discussion about surgical stabilisation is undertaken. There was a vogue for treating patients with anterior dislocations with external rotation braces, but studies have not found this to have any improvement over traditional sling, and patients were not compliant with the external rotation brace13.

For older patients with a first time traumatic dislocation, the risk of redislocation is low in the absence of complicating factors, and the main risks are of stiffness and associated injury. They can be treated with early mobilisation, but need physiotherapy input, to maintain their range of movement, as stiffness can often be more of a problem than instability. It is important to exclude associated complications, such as fracture (of both glenoid and greater tuberosity) as this may change management, and to assess the function of the rotator cuff, which can tear as a result of the dislocation. Any suspicion of a cuff tear should be investigated with either ultrasound or MRI depending on availability, and if torn, surgical repair undertaken on an urgent basis, before retraction of the tendon becomes fixed14 – dependent on age and other patient factors. Our practice is for all patients suffering simple dislocations to be seen in our weekly specialist shoulder injury clinic for assessment. Adequate radiographs (AP, Scapula Y-view, axillary) are taken to allow assessment of tuberosity fractures, and any subtle glenoid fracture can be identified. An axial, or modified axial – “Velpeau”, view is required post reduction to confirm reduction. If they are comfortable enough to allow assessment of cuff function and this is normal, they are treated appropriately by specialist physiotherapists. If the cuff cannot be fully assessed, they are seen by physiotherapists and brought back for reassessment after 2-3 weeks, and an urgent ultrasound requested if there is ongoing suspicion at this point. Recurrent dislocators are counselled about their continued risk of instability. If they decide that they

would like surgical intervention they are assessed and undergo an MR arthrogram to identify the soft tissue defect that needs to be addressed, and to assess any damage to the glenoid15, especially if the initial history of the first dislocation is unclear. There is little evidence to support arthroscopic against open stabilisation in the literature16, and the choice of technique relies on the individual surgeon’s preference, though the trend is towards arthroscopic stabilisation. In our practice, one surgeon prefers open stabilisation and the other arthroscopic stabilisation, although De Beer’s criteria for not performing arthroscopic (anterior) stabilisation are respected (engaging Hill-Sachs deformity, inverted tear drop glenoid, total lack of labral tissue, large bony Bankhart lesion, HAGL lesion, and, previously failed arthroscopic procedure in contact sportsman). n

Correspondence: Stephen Aldridge/John Williams Upper Limb Trauma Unit Royal Victoria Infirmary Queen Victoria Road Newcastle upon Tyne NE1 4LP Email: stephen.aldridge@nuth.nhs.uk Email: john.williams@nuth.nhs.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code

l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 74

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 75

Training and Recruitment – Sponsored Content

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 76

In Memoriam

Hugh Lister McMullen: 13 February 1917 - 21 January 2014 By Wendy McMullen

Named after Joseph Lister who mentored his father, Hugh was educated at Oundle School, Kings College Cambridge and The Middlesex Hospital London, being awarded the Senior Broderip Scholarship. He worked as surgical and trauma registrar at the Middlesex through the Blitz, marrying Middlesex nurse, Joy, in 1945.

Hugh served with the Royal Army Medical Corps on the North West Frontier where he developed an immense respect for the people of that region. Returning to the UK after partition he completed his orthopedic training in Mansfield. Appointed consultant orthopedic surgeon to the Bassetlaw hospitals in 1951, he was an active and early member of the ‘Holdsworth Club’ and the BOA. Having delivered

a split-site service, effectively singlehandedly, during the time of polio epidemics, tuberculous joints and mining accidents, through to the advent of joint replacements, he remained sceptical of the need for universal sub-specialisation. After retirement he continued to work part time and enthusiastically attended BOA and other postgraduate meetings until well into his 80s. Pre-deceased by his wife, he devoted his final years to enjoying travel, music and the company of his three children, grandchildren and great-grandchildren.

Hugh Lister McMullen

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l Volume 02 / Issue 02 / May 2014 l boa.ac.uk l Page 78

Imprint

JTO: Information for readers, advertisers & potential authors

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ERRATUM The T&O App review in the last issue of the JTO should have stated that the first author was Tom Lewis, alongside co-author Jeya Palan.

The AO Foundation is a non-profit organisation based in Switzerland, dedicated to the advancement of the care of those suffering from musculoskeletal injury and disease. AOUKI is a national section of the parent foundation and is a registered UK charity. In collaboration with an industrial partner DePuy Synthes, who provide technical support and the instruments and implants for the practical workshops, AOUKI conducts educational activities in the form of combinations of lectures, skills workshops and discussion groups, which have established AOUKI as a world leader in surgical education. Sound educational principles are deployed in the planning and delivery of AOUKI’s courses and this initiative has been influential throughout the world.

Courses 2014/15 UK & Ireland AOTrauma Courses for Surgeons AOTrauma Course – Basic Principles of Fracture Management AOTrauma Course – Periprosthetic for Surgeons AOTrauma Course – Paediatric for Surgeons AOTrauma Course – Basic Principles of Fracture Management AOTrauma Course – Shoulder & Elbow AOTrauma Course – Current Concepts AOTrauma Course – Foot & Ankle AOTrauma Course – Wrist (includes cadaveric) AOTrauma Course – Basic Principles of Fracture Management AOTrauma Course – Advanced Principles of Fracture Management AOTrauma Course – Hand Fixation AOTrauma Course – Basic Principles of Fracture Management

Dublin Midlands Nottingham Edinburgh Newcastle Coventry Bristol Coventry Leeds Leeds Leeds Basingstoke

26 – 29 January 2015 4 – 6 February 2015 11 -12 February 2015 9 – 12 March 2015 18 – 20 March 2015 22 – 24 April 2015 27 – 29 April 2015 9 – 10 June 2014 23 – 26 June 2014 24 – 27 June 2014 6 – 8 October 2014 17 – 20 November 2014

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

Dublin Leeds Basingstoke

27 – 29 January 2015 25- 27 June 2014 18 -20 November 2014

AOSpine Course for Surgeons AOSpine Course – Advances Forum

Newcastle

23 – 24 October 2014

AOCMF Courses for Surgeons AOCMF Course – Ballistic Injuries Symposium AOCMF Course – Basic Principles in Maxillofacial Fixation Techniques AOCMF Course – Distraction

Birmingham Leeds Birmingham

26-27 February 2015 30 April – 1 May 2014 20 – 21 October 2014

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

Leeds Plymouth

1 – 2 May 2014 14 July 2014

PO Box 328, Welwyn Garden City, Herts. AL7 1YR Tel: +44 1707 823 300 Email: info.gb@ao-courses.com Web: www.aouk.org

A Patient Education Initiative from DePuy Synthes

“I GOT TO THE STAGE WHERE I COULDN’T TAKE MY GRANDSON OUT”

As soon as she experienced the relief from pain following her first hip operation, Jean Deakin knew she didn’t want to let the other side get as bad before seeking help. So, when her mobility started to suffer again Jean didn’t delay, and once more enjoys life to the full. This is just one of the positive stories for you and your patients to access at RealLifeTested.co.uk – an educational initiative that aims to improve understanding about knee and hip arthroplasty.

In collaboration with Arthritis Care

Visit www.RealLifeTested.co.uk Where information aids preparation and rehabilitation

Jean Deakin #FOKPKUVTCVKXG QHƂ EGT Grandmother Bilateral hip replacement