THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 03 / Issue 01 / March 2015 boa.ac.uk
Inside
Read the News and Updates section for the latest from the BOA and beyond
Our Features section includes articles from the NCD for Trauma and on MCATS
For the latest updates on our clinical issues, see our Peer-Reviewed Articles; the focus in this issue is Foot and Ankle surgery
News & Updates ––– Pages 02-12
Features ––– Pages 14-42
Peer-Reviewed Articles ––– Pages 44-57
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JTO News and Updates
From the Editor
Contents
Ian Winson, BOA Vice President Elect So we enter 2015 in the knowledge that this is the year of an election a time of uncertainty which breeds an air of despondency. How will the political scene change? Will we be confronted with more change? Should we be pushing our political voice through the BMA? Should we embrace new ways of getting an even handed discussion about Trauma and Orthopaedics into the public arena? As we all know change for changes sake does not always achieve predictable consequences, so maybe the right thing is to use the structures and tools available to us and push our agenda hard for the sake of our patients. One of our tools is now the established JTO, so sit back, read, shout at the bits you don’t like and write us a letter or two! This issue is jam-packed full of great features including a Trauma update from Prof Christopher Moran, the National Clinical Director for Trauma (page 14). His article focuses on his commitment to two key areas: fragility fractures and major trauma.
You may be wondering about the front cover image. This piece of artwork is called “Ballet” by the artist Mojgan Safa. Mojgan was born with Cerebral Palsy but found that she had incredible dexterity with her toes. She painted this piece with her foot. This leads us onto the focus of our Peer-Review Section which is Foot and Ankle thanks to our Guest Editor, Fred “the foot” Robinson. You will find a general interest piece about the BOFAS Course and scientific piece on osteochondral lesions and a controversial piece being the pros and cons of minimally invasive forefoot surgery on page 44. Our regular “How I Do…” piece submitted by a member of the Orthopaedic Trauma Society (OTS) follows these and appropriately is about ankles (page 56). On a sad note we also pay tribute to an incredibly brave man – Stuart Calder – who will be deeply missed (page 60).
02–12
JTO Features
14–42
BOTA President, Peter Smitham, commissioned an article about a trainee led mentor programme for help passing the FRCS exams which you will find on page 34.
Reproduced by kind permission of the Association of the Mouth and Foot Painting Artists www.mfpa.uk.
Trauma When Two Become One Wilful neglect and ill-treatment – new criminal offence A Fellowship in Pre-Hospital Care: not a run-of-the-mill post Improvements in Musculoskeletal Triage and Assessment A survey of trainees’ opinion on the JCST’s index procedures in Trauma and Orthopaedics Paying it forward - a trainee led mentor programme Code of Practice for Orthopaedic Surgeons Preparing Reports in Personal Injury and other Cases
14 18 22 26 28 30 34 36
JTO Peer-Reviewed Articles 44–57
We see how reconfiguring orthopaedic services in a difficult changing environment has affected two merged hospitals in the Bristol and Maidstone areas (page 18).
The Medico-legal section in this issue is part one of the Code of Practice for orthopaedic surgeons preparing reports in personal injury and other cases, approved by the Professional Practice Committee (page 36). You will find part two in our next issue.
JTO News and Updates
Inspiring confidence, knowledge and safety in foot and ankle surgery Localisation of Osteochondral Lesions of the Talar Dome: MRI Compared With Clinical Findings - Can The Site Of The Pain Predict The Site Of The Lesion? Minimally Invasive Forefoot Surgery How I... Fix Ankle Fractures in Diabetic Patients
44 46 50 56
In Memoriam / Bookshelf
60
General information and instructions for authors
62
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JTO News and Updates
From the President Prof Colin Howie
The December edition of the JTO highlighted that a major challenge for the BOA and Trauma and Orthopaedic surgeons for 2015 was ensuring that we are not side-lined by the MSK commissioning process. In the last few months we have been actively engaged with a number of Clinical Commissioning Groups (CCGs) and NHS England. We have achieved a number of notable successes.
In North, East and West Devon with others, we are progressing work with the CCG to review its decisions to ration shoulder surgery based on smoking and Body Mass Index. In Coastal West Sussex we are now involved in constructive discussions with the CCG as part of the impact assessment of their recent MSK commissioning decisions following the PWC report in December, and we have started a dialogue with Ipswich and East Suffolk CCG to get to the bottom of their decision to introduce surgery avoidance targets. All of these initiatives require local knowledge and participation. We have recently held a workshop for our regional advisors who will represent us locally and be able to support those of you involved or concerned about local processes.
Prof Colin Howie
The key phrase here has been ‘constructive engagement’. In the best interests of patients we must work with CCGs to find solutions to the severe financial challenges they face when orthopaedic surgery appears a superficially attractive target. The BOA has had a presence at commissioning events across the South of England and in all cases we have been welcome, providing both clinical insight and wider knowledge of the MSK commissioning environment. We have often been the only clinical
professional representative body present at these events and the only representative for Trauma and Orthopaedic surgeons; put simply the BOA is leading the way in influencing CCGs by engagement at the earliest stage of the commissioning process. Why is this important? There are currently approaching 30 CCGs commissioning for MSK services in England, representing a commitment in excess of over £1 billion. Aside from the inappropriate rationing measures already mentioned there are also many far reaching issues to be challenged and reviewed before they become an immovable facet of MSK services. For example: commercial providers contracting solely for elective/planned services to the detriment of funding for trauma services; the exclusion of training and education from MSK commissioning; the move to the greater use of triage by Allied Health Professionals; and a shift away from surgery to patient self-management supported by conservative therapies. It is a fallacy to believe that the contracting landscape will change following the election; many of the commercial contracts now being let are for up to five years. There may be some change in emphasis however; the overall financial pressures will remain.
The registries project, which commenced on 1st September 2014, is now fully up and running with a new title of Quality Outcomes. We have eight registries and all are keen to be involved in the project. In the first phase of the project we focused on supporting the registries as they become established, with a particular emphasis on surgeon engagement, information governance and infrastructure (especially data input issues). Some surgeons are understandably apprehensive that the emerging registries will be used as a tool to force further individual outcome transparency: the BOA’s position on this is very clear. While we strongly support appropriate outcome transparency, our view is that patients’ interests are best served by a public overview of unit level performance for a variety of procedures rather than a concentration on individuals. We have asked for your views and a preliminary breakdown is available. In recent discussions with NHS England, the quality of the registries in trauma and orthopaedics has finally been recognised, well done to all those concerned and participating. If we can consistently prove the benefits of our various treatments it becomes difficult for purchasers of healthcare to do anything other than support our endeavours.
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“Quality Outcomes” - and our survey said… Prof Colin Howie
In December we invited all BOA members to complete an online survey as part of the BOA Quality Outcomes project about new and emerging national audits and registries. Many thanks to the specialist societies involved in the project who also circulated details to their members, which resulted in an excellent response rate. We received 393 responses, of which over 100 included written comments in addition to completing the main questions. The respondents included individuals across all the specialist societies, and from trainees, consultants and staff and associate specialist grade surgeons. A full analysis of this survey will be provided on the BOA website once this has been finalised; in the meantime, here are some of the headlines: • BOA and specialist society members are largely supportive of the principle of having national audits and registries covering a wider range of T&O procedures. Nearly half of those with a new audit or registry in their field of practice are actively contributing. This is shown in Figure 1. • Nevertheless, a range of concerns and reservations were reported, for example: o Almost half of respondents were concerned about having the time and resources needed in order to contribute to registries and audits relevant to them (49.0%) o Around a third of respondents raised concerns about how audits might handle individual performance issues (34.8%) and the robustness of information that would be produced (33.5%) o There were fewer people with concerns about appropriate consent, data security and governance being in place (11.3%), although we recognise that this is still an important
issue. Perhaps this is testament to the quality of the orthopaedic registries. • Although it was not the primary focus of this survey, the NJR was mentioned in a quarter of the comments received in the free-text section, and we will be following up on the issues raised with the NJR. We are pleased that our members are in favour of collecting data, but understand the challenges that this can present. As I have previously indicated, registry and audit data can have a range of valuable uses, such as: • providing surgeons with information for appraisal and revalidation; • helping surgeons to track the outcomes of their patients; • allowing surgeons/units to compare themselves to others/the ‘average’ and to identify areas for improvement; • providing evidence on trends in outcomes, and performance of different implants/procedures; • providing a platform for research. However, such data collection and analysis exercises must be undertaken carefully to avoid or minimise any pitfalls. We assure all our members that the work the BOA and specialist societies are doing in this area will indeed be undertaken carefully in line with national legal and guideline frameworks. We will keep you updated of our progress on this. Once again thank you to everyone who took part in this survey.
Figure 1: *NB - This analysis excludes responses where the respondent was retired, where no new registries were relevant to the respondent’s practice or the answer given was ‘does not apply’.
Quality Outcomes quick facts What are the new registries and audits? They are the British Spine Registry (BSR), the National Ligament Registry (NLR), the UK Knee Osteotomy Registry (UKKOR), the Non-Arthroplasty Hip Register (NAHR) and audits led by the British Society for Surgery of the Hand, British Orthopaedic Foot and Ankle Society, British Limb Reconstruction Society and British Society for Children’s Orthopaedic Surgery. Other groups (including trauma and the British Elbow and Shoulder Society) are considering similar initiatives. What stage are they at? • BSR, NLR, NAHR and the BSSH audit have been running for some time. So far they have collected records on over 27,000 cases between them. • UKKOR and the BOFAS registry have both opened for full data collection since the last JTO was published. • The BSCOS and BLRS audits are not yet open for data collection but both hope to be up and running this year. How can I find out more? Links for each of the registries and audits can be found at www.boa.ac.uk/ pro-practice/boa-quality-outcomes-project, along with more information about the Quality Outcomes project.
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JTO News and Updates
2015 BOA Instructional Course – Exciting new format! Revamped and re-energised based on feedback from previous years, this year’s BOA Instructional Course was outstandingly popular and delivered exceptional value to trainees.
Mike Reed and Colin Howie
BOFAS in Brighton The British Orthopaedic Foot and Ankle Society’s (BOFAS) annual scientific meeting was hosted by President Stephen Bendall in Brighton last year from 5th-7th November.
The BOFAS Meeting
We offered teaching in six critical conditions of the spine along with three in trauma, and each participant had the opportunity to gain up to four CBDs. Also on the schedule, was a plethora of informative and exciting lectures and discussions, which covered multiple topics ranging from “Preoperative Planning for Primary and Revision Hip and Knee Arthroplasty,” to “The Management of Skeletal Malignancy”. The programme also included a dedicated lecture on the FRCS (Tr & Orth) preparation and a broader horizon scanning lecture delivered by the BOA President, Colin Howie. Alongside the educational content, the BOA sponsored an evening reception for after the BOTA EGM to give trainees an opportunity to network.
Again, there was an excellent attendance with over 300 delegates. A worldwide faculty was present with speakers including Mark Glazebrook (Canada), Beat Hintermann (Switzerland), Peter Lam (Australia), and Carlos Maynou (France). The first day’s instructional courses covered total ankle arthroplasty, new surgical techniques in foot surgery and heart-sink cases. Beat Hintermann gave a key note speech illustrating the use of joint preserving osteotomies in ankle arthritis. The second day saw the introduction of the first GP programme arranged by Callum Clark. The Allied Health Professionals programme was led by Dr Anna van der Gaag, chair of the HCPC. In the afternoon, a joint session with the Orthopaedic Trauma Society looked at the current management of ankle fractures in the UK.
The reshaped course sold out well in advance of the closing date and many trainees joined the waiting list, hoping to be taught by our expert faculty. As a result of the dedication from everyone involved, the faculty and BOA staff team achieved truly fantastic results throughout the weekend course. The highest standards of teaching were on display and all 96 participants hopefully benefited from an innovative and engaging programme. We look forward to welcoming participants and faculty next year. For more information about the BOA Instructional Course, please contact policy@boa.ac.uk.
Friday’s discussion centred on outcome measures and was followed by well fought debates on the treatment of Haglund’s deformity, Lisfranc injuries and open versus minimally invasive hallux valgus surgery. A total of 34 free papers and 22 posters were presented throughout the meeting. The prize for best paper was awarded to Lyndon Mason for his work on “forefoot deformity in rheumatoid arthritis – a comparison of shod and nonshod populations”. The best poster was, “Is there a need for prophylactic antibiotics in lesser toe fusion surgery using K-wires?: A prospective randomised controlled trial” by Jitendra Mangwani. The meeting closed with the AGM and handover to the new BOFAS President Mr Anthony Sakellariou. The next meeting will be at the G Live centre in Guildford, 11th-13th November 2015.
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British Scoliosis Society Annual Scientific Meeting The BSS has met annually since 1976 and was last hosted in Bristol in 1994. The same meeting venue, The Marriott Royal Hotel, was chosen for its central location and excellent facilities.
Isabel Nelson and Michael McMaster
A pre-meeting instructional course for Allied Healthcare Professional took place on Thursday 9th October. The topic was the nonsurgical management of spine deformities. It is always a hard task keeping spine surgeons focussed on not talking about implants! There were notable contributions from Peter Heine on scoliosis specific exercises and Pauline Heaton on casting for early onset scoliosis, which has again become a popular treatment.
Society for Back Pain Research Annual Meeting: ‘Back Pain – the Big Picture’
Members of the Executive Committee and guest speakers at the Dublin meeting Front row: Suzanne McDonough, Frances Williams, Tamar Pincus, Susan Michie, Deirdre Hurley Back row: Steven Vogel, John O’Dowd, Lisa Roberts, Serena McCluskey
The scientific meeting was deliberately divided into paediatric and adult deformity sections with 39 podium, special poster and poster presentations. Adult spine deformity surgery has been more cautiously adopted in the UK than in France and the US. The adult section finally yielded some excellent UK based evidence on the outcomes and safety of these procedures. The contribution by the Stanmore unit to this section was substantial.
In November 2014, the annual SBPR meeting took place at the Radisson Blu Hotel, Dublin. It was a packed two days, with five keynote presentations, 19 oral papers and a special poster session, as delegates from orthopaedics, rheumatology, general practice, physiotherapy, chiropractic, osteopathy, basic science and bioengineering came together to discuss the challenges facing the back pain world. The opening keynote, from local Professor Susan Michie, considered behaviour change theory, including the behaviour change wheel (www. behaviourchangewheel.com) and its application to improving outcomes in back pain. Professor Tamar Pincus, University of London, challenged delegates about why interventions designed to change psychological obstacles to recovery, such as fear avoidance, catastrophizing and low mood, had only a small effect on outcomes such as disability. Professor Brian Caulfield, University College Dublin, outlined a connected health approach to managing
The prize winning presentations were given by Judith Meakin and Joseph Butler. Lee Breakwell led the annual BSS M+M with an analysis of the first cohort of deformity cases entered on the British Spine Registry. This will eventually serve as the basis for the reporting of surgeon level outcomes. Our invited lecturer was Dr David Scaggs MD from Los Angeles Children’s Hospital. David gave three excellent lectures and fared well in our own form of ‘Desert Island Discs’ during the Black-Tie Dinner. Bob Crawford, our new President, closed the meeting encouraging us to stay focussed on what we do best.
back pain that included technical advances for clinicians to use in ongoing measurement, feedback and rehabilitation. Professor Suzanne McDonough, University of Ulster, outlined a public health approach to musculoskeletal pain, focussing on solutions to encourage people to be more active, given that 19% of males and 26% of females are physically inactive. The final speaker, Dr Frances Williams from Kings College, London, addressed the genetic epidemiology of intervertebral disc degeneration and the reported 65% heritability of back pain. Alongside the excellent scientific programme, there was a memorable evening reception at the old Jameson’s Distillery in Dublin where members of the Society enjoyed the delights of Irish food, drink, music, while trying their hand at Irish dancing! The Society is indebted to local organiser, Professor Deirdre Hurley, and the support of the Irish Tourist Board. The next conference will take place in Bournemouth on 5th-6th November 2015.
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JTO News and Updates Section??????????????????
BOA Latest News NHS Five Year Forward View The NHS Five Year Forward View is a joint report produced by NHS England, Public Health England, the regulator Monitor, the NHS Trust Development Authority, Care Quality Commission and Health Education England and can be found online: www.england.nhs.uk/ourwork/forward-view. Key points include: • Far more care will be delivered locally but with some services in specialist centres, organised to support people with multiple health conditions • Multispecialty Community Providers – where groups of GPs combine with nurses, other community health services, and hospital specialists to create integrated out-of-hospital care • Primary and Acute Care Systems - combining general practice and hospital services, similar to the Accountable Care Organisations now developing in other countries • Plans include supporting viable smaller acute hospitals as well as concentrating specialist services, such as specialist surgery, in consolidated centres • Digital technologies and facilitating the spread of new innovations will help support these new models of care. The report says NICE will need to review a greater number of medical technologies than has previously been the case • The roles and responsibilities of non-medical NHS staff should be expanded, especially in primary care. The report is also critical that the number of hospital consultants have increased around three times faster than GPs • Increased funding will be required to fully back NHS England’s ambition. If the required level of funding is achieved, and the service makes efficiency gains of 2-3% per year, then the funding gap will be closed by 2020.
BOA Treasurer Elected We are pleased to confirm that Don McBride has been elected as the BOA’s Honorary Treasurer. Don has served as an elected member of the BOA Council since 2012, and steps into the position of Treasurer following Ian Winson, who had previously been elected onto the Presidential line as Vice President Elect. Don will serve as Treasurer from 2015 to 2017. We wish Don all the very best in the role and thank all those who were nominated for consideration in this role.
Ministry of Justice: Whiplash reform programme
Indian and Chinese Orthopaedic Associations
The Ministry of Justice is implementing changes to the process for commissioning initial medical reports for soft tissue injury claims brought under the Pre-Action Protocol for Low Value Personal Injury Claims in Road Traffic Accidents.
The BOA, at the invitation of the respective Presidents, has recently attended the Indian Orthopaedic Association (IOA) Congress and Chinese Orthopaedic Association (COA) Congress. The IOA Congress was attended by approximately 7,000 delegates with a strong focus on industry. A number of key themes emerged; significantly, it appeared that a growing number of UK trained Indian surgeons were returning to India, and as India’s health needs change, the UK surgical community must decide how to develop a strategic relationship with colleagues in this important economy.
With effect from the 6th April 2015, initial medical reports must be sourced via a new IT portal: ‘MedCo Registration Solutions’. Users will be able to search for individual experts or medical reporting organisations. The MedCo portal will return a choice of randomly generated results and the user can select which one to instruct. Medico-legal experts and medical reporting organisations will need to be registered with MedCo by the 6th April in order to provide the initial medico-legal reports for whiplash claims brought under the RTA Protocol. Registration for the portal is now open. Further information about the Government’s whiplash reform programme can be found online: www.justice.gov.uk/civil-justicereforms/personal-injury-claims.
Some 16,000 delegates attended the COA Congress 2014 which had a substantial industry exhibition (not far off the AAOS in scale) and extensive international representation, including the Past President and CEO of the AAOS. The BOA also used the opportunity to hold discussions with the Chinese government, as a consequence, and subject to the necessary approvals from Beijing, the BOA and COA intends to run a joint symposium at the COA Congress 2015 focused on the generic applicability of the Beyond Compliance and GIRFT methodologies to the challenged Chinese orthopaedic health economy.
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Section??????????????????
Consultant Outcomes Publication The Department of Health has published on the NHS Choices/MyNHS website the 2014 Consultant Outcomes Publication. While the BOA strongly supports appropriate outcome transparency, our view is that patients’ interests are best served by a public overview of unit level performance for a variety of procedures rather than a concentration on individuals. Appropriate outcome transparency is important: it reinforces public confidence in NHS hospitals and enhances patient safety by supporting surgeons to identify and address any issues.
Emerging Leaders The Emerging Leaders Programme is a new BOA initiative to identify and develop future strategic leaders of Trauma and Orthopaedics. Targeted at trainees at ST 5/6 level, the programme will prepare participants to take on senior leadership roles later in their careers. The programme will involve discussion, coaching and mentoring on key leadership issues. Participants will get to discuss important cases and problems with leaders through roundtable discussions, attendance at key meetings and self-directed learning. If you are a trainee at ST 5/6 level and would like to apply, details can be found at www.boa.ac.uk/trainingeducation/emerging-leadersprogramme.
BOA Simulation Award Each year, the BOA offers an award for excellence in Innovation in Simulation. For 2015 candidates are required to create a 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. An educational grant of £500 will be given to the winning team/individual. The winning simulator may be manufactured/ produced and used throughout the UK for training. Please submit your application by 15th May 2015. For more information please contact policy@boa.ac.uk and see www.boa.ac.uk/training-education/boa-simulation-award.
MSK Commissioning The BOA is attending clinical commissioning events across London and the South East so that we are able to fully understand Clinical Commissioning Group (CCG) plans for MSK services. The events are proving extremely valuable at engaging with CCGs and tender exercises at the earliest opportunity, thereby ensuring the best interests of patients and Trauma and Orthopaedics are considered in commissioning plans. The scale of MSK commissioning varies across the country but contracts are usually in excess of £50 million, and with approaching 30 CCGs commissioning for MSK services in England this representing a commitment in excess of over £1 billion. Key observations from current CCG tenders are: • Greater use of Allied Health Professionals in triage and treatment • Emphasis on greater patient self-management supported by conservative therapies • Reduction in surgical interventions, sometimes with explicit surgical avoidance targets • Efficiencies being encouraged through ‘gain share’ and other excess profit sharing schemes • Focus on elective services, i.e. trauma services are being left to existing NHS providers • Some service specifications not including provision of training and education.
BOASTs A further addition to the portfolio of BOASTs is Supracondylar Fractures of the Humerus in Children; this is the eleventh BOAST that can be found on the BOA website at www.boa.ac.uk/publications/ boa-standards-for-trauma-boasts. Other recent BOASTs are Fracture Liaison Services and Compartment Syndrome.
UKITE UKITE is a national, online examination providing immediate results to trainees and allows practice for the ‘real’ FRCS T&O examination with similar formatted questions based on the UK T&O curriculum. The continuation of UKITE and its future development depends on continuity of funding, as a consequence the BOA agreed to include UKITE as a benefit for BOA members. This year, the first year of UKITE within the BOA, over 500 trainees sat the UKITE exam across the UK. In 2015 we are anticipating more trainees will sit the UKITE exam and are developing BOA processes to ensure a smooth application and assessment process.
York Trials Unit The York Trials Unit is providing a two day training event (13th14th April) targeted at T&O surgeons who are early stage researchers, details can be found at www.boa.ac.uk/wp-content/ uploads/2014/01/BOSRC-Apriltraining-event-RCTs.pdf. The event has been designed so that delegates can attend individual days or both days; all costs are covered aside from £30 per day to cover catering and incidentals.
Orthopodcasts Orthopodcasts on: Complex Regional Pain Syndrome, Training in Major Trauma Centres, T&O curriculum changes, and the Distal Radius Acute Fracture Fixation Trial (DRAFFT) trial are available on the BOA website at www.boa. ac.uk/orthopodcast. Each podcast is a short conversation between experts (10-20 mins) intended for listening at your leisure: at home; in the car; or on a run.
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BOA Membership Membership at the BOA comes in many different categories to suit all stages of your career. In our last issue we highlighted the new three tier subscription structure for SAS surgeons which came into effect in January. If you have not yet moved into one of these tiers for specialty doctors, staff grades and associate specialists please let us know.
As part of our growing strategy focusing on excellence in Professional Practice, Training and Education and Research we are welcoming medical students and foundation year doctors and hope to see many of you at the BOA Congress in September.
Exclusive Offer from PG Mutual! First two months membership premiums now free for BOA Members with PG Mutual. PG Mutual can tailor income protection cover to meet your needs and is offering BOA members a 20% discount on your premiums for each of your first two years’ cover* – in addition to providing the first two months’ cover for free*. For more information visit www.pgmutual.co.uk/Quotation/?DC=BOA *Terms & Conditions apply, please visit www.pgmutual.co.uk. Offer ends 31st December 2015.
For more information on membership benefits please visit the BOA website – www.boa.ac.uk/membership/benefits.
BOA Annual Congress 2015 15th-18th September ACC Liverpool The BOA Congress 2015 will be back to the traditional four day programme. We are creating an exciting programme for delegates with Professionalism and Responsibility as the theme. The Congress will cover a wide range of sessions including commissioning; how to influence and work within the commissioning landscape, quality outcomes registry; dealing with medical data in 2015 and beyond, trauma/revalidation, NJR, medico-legal, political update, leadership; what does leadership mean in T&O and a dedicated session for medical students.
We hope you will join us to discuss, debate and shape ideas and best practice in order to ensure that we continue to raise standards, and encourage the highest levels of Professionalism and Responsibility. The BOA is committed to supporting and encouraging all surgeons to practice with the highest integrity, skill and professionalism. As the professional body, it is crucial that we take the lead in driving up standards; the beneficiaries will be our patients.
FREE* BOA Member Registration will open on 1st April and will be open for six weeks Non-BOA Member Registration will open on 18th May *Terms & Conditions apply, see website for details. Please visit www.congress.boa.ac.uk
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My Travelling Fellowship Mohamed Sukeik, ST6, The Royal London Rotation
Having undertaken an MD at University College London on management of periprosthetic joint infections (PJIs) after hip and knee replacements, I wanted to visit leading centres in the world to further enhance my knowledge of the subject and hence my choice of Hospital for Special Surgery (HSS) and The Rothmans Institute. Professor Javad Parvizi on the left in the operating room at The Rothmans Institute
I spent five weeks with Dr Amar Ranawat and Professor Javad Parvizi where I observed their strict protocols whilst performing primary and revision arthroplasty surgery being vigilant to the consequences of PJIs and optimising patient care peri-operatively to prevent such infections. On the other hand, for clinically suspected cases,
I observed their approach utilising evidence based medicine and novel diagnostic tools to diagnose infection. Treatment of established PJIs at those centres also follows clear protocols taking into account patient’s presentation and comorbidities and involving the patient with the decision making process throughout.
I have also observed the differences in the healthcare systems between the UK and the USA and the central role of physician assistants and operating room technicians in providing high turnover of patients and efficiency in theatres. Similar to university hospitals in the UK, there are also dedicated teams working on research and I had great
pleasure working on a number of research projects and publications during my visit to both centres. Overall, this has been a unique experience for me and I would like to thank the BOA, Zimmer, Dr Ranawat and Professor Parvizi for giving me the opportunity to visit HSS and The Rothmans Institute.
CONFERENCE LISTING:
Organisation
Conference/meeting
BASK (British Association for Surgery of the Knee) www.baskonline.com
Annual Conference 10-11 March 2015, Telford
BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk
Annual Meeting 12-13 March 2015, Liverpool
BASS (British Association of Spinal Surgeons) www.spinesurgeons.ac.uk
Annual Conference 18-20 March 2015, Bath
OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk
Annual Meeting 19-20 March 2015, Warwick
BLRS (British Limb Reconstruction Society) www.blrs.org.uk
Annual Meeting 19-20 March 2015, Birmingham
BSS (British Scoliosis Society) www.britscoliosissoc.org.uk
Annual Meeting 21-23 April 2015, Sheffield
BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk
Spring Meeting 30 April - 1 May 2015, Bath
WOC (World Orthopaedic Concern) www.wocuk.org
Annual Meeting 6 June 2015, Oxford
BOOS (British Orthopaedic Oncology Society) www.boos.org.uk
BOTA (British Orthopaedic Trainees Association) www.bota.org.uk
Educational Weekend 12-14 June 2015, Chester
BESS (British Elbow and Shoulder Society) www.bess.org.uk IOS UK (Indian Orthopaedic Society) www.iosukliverpool2015.com
Annual Meeting 12 June 2015, Oxford
Annual Meeting 24-26 June 2015, Sheffield Annual Meeting 3-4 July 2015, Liverpool
BOA (British Orthopaedic Association) www.boa.ac.uk
Annual Congress 15-18 September 2015, Liverpool
SBPR (Society for Back Pain Research) www.sbpr.info
Annual Meeting 5-6 November 2015, Bournemouth
BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk
Annual Meeting 11-13 November 2015, Guildford
BRITSPINE www.britspine.com
Meeting 6-8 April 2016, Nottingham
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JTO Features Section??????????????????
Trauma Chris Moran, National Clinical Director for Trauma, NHS-England
The role of National Clinical Director (NCD) is an interesting and challenging one, made easier by following Keith Willett’s footsteps. I have continued as a full-time clinician with on-call commitments for trauma so that I can remain in contact with the realities of working within the NHS. I am grateful to all in Nottingham for supporting me. During the last 18 months, I have focused on two key areas: fragility fractures and major trauma.
Fragility Fractures
Chris Moran
In the last six years, the best practice tariff (BPT) for hip fracture, together with the National Hip Fracture Database (NHFD) has been a potent combination leading to significant improvements in hip fracture care. We are now in the early stages of planning changes to both BPT and NHFD for 2016/17. NHS-England has also been working with multiple agencies, including Public Health England, the BOA and patient organisations such as the National Osteoporosis Society to promote secondary fracture prevention through Fracture Liaison Services. The aim is to ensure that all patients in England have access to these services, irrespective of the site of the fracture or where they present. Thus, the system must include patients with vertebral fractures as well as those usually treated in fracture clinic, such as wrist and proximal humerus. The enormous contribution of David Marsh to this project must be acknowledged. His group gives a step-by-step guide on how to commission and set up a FLS. This is currently in the final stages of approval by NHS-E before being
distributed to all 211 Clinical Commissioning Groups in the country. Local champions are needed to promote this important fracture prevention plan. Please support your local FLS!
Major Trauma Networks in England London led the way to improving the delivery of major trauma care by establishing three Major Trauma Centres (MTC) within the capital city. These went live in April 2010 and a fourth commenced in April 2011. The 22 regional major trauma networks started in April 2012. The ethos of good trauma care involves getting the patient to the “right place at the right time for the right care�. Each region took these specifications and adapted them for differing facilities, geography and populations served and this has led to the designation of three tiers of hospital providing trauma care: l Major Trauma Centres, which
provide definitive care for all injuries. l Trauma Units, which have the
capability to receive, resuscitate
and triage patients with major trauma, with rapid and safe transfer to the network MTC when required. l Local Emergency Hospitals,
which provide local A&E services but lack the facilities to receive and resuscitate major trauma patients and are always by-passed. The system has resulted in significant changes in patient flow. In the year 2011, 9,215 patients were taken directly to a MTC whilst a further 4,143 were transferred into the centres. Two years later, there was a 42% increase in patients taken directly to MTCs (n= 15,787) and, with transfers, a total of 21,461 patients received care in a MTC in 2013. In England, 4,000 severely injured patients with an ISS > 15 were received by a consultant-led trauma team on arrival in 2011, increasing to 11,300 in 2013. The number of patients receiving trauma CT scan within 30 minutes increased from 20% in 2011 to 45% in 2013. There has also been a rapid adoption of new practice, like massive transfusion protocols. In 2011, only 15% of trauma victims (blunt or penetrating) >>
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JTO Features IN 2011, ONLY 15% OF TRAUMA VICTIMS (BLUNT OR PENETRATING) WHO WERE HYPOTENSIVE RECEIVED TRANEXAMIC ACID WITHIN 3 HOURS OF INJURY, INCREASING TO OVER 90% IN 2013.
MTCs and Research
who were hypotensive received Tranexamic Acid within 3 hours of injury, increasing to over 90% in 2013. The focus on trauma has meant that many paramedic crews are now able to administer this drug pre-hospital together with other innovations, like pelvic binders. The odds of surviving major trauma in England are now 25% better than the year before the system commenced (Figure 1).
The next 2 years Many challenges remain. Variation in performance and outcomes between Major Trauma Centres will diminish as good practice is shared between clinical teams. This has been facilitated by regular meetings of lead surgeons from each of the MTCs, so that clinical developments, such as rib fracture fixation for severe chest trauma rapidly become routine clinical practice. In some Networks, consultants working in TUs who have a major interest in trauma, now have work plans that allow them to work for short periods within the MTCs. This has a double benefit – the MTCs gain from additional clinical expertise whilst these clinicians are able to take recent advances in trauma care back to their base hospital. The biggest unmet need is in rehabilitation and psychosocial care. There is a great deal we can learn from the military rehabilitation program, which aims to turn patients from “victims” into “survivors” and focuses on exercise and vocational training. We hope to change the focus from mortality as the main outcome to patient reported outcomes that measure quality of life, impairment and return of function.
Figure 1
Changes are also afoot in Scotland and Wales. Scotland now has ministerial support for the development of a regional trauma system based around four major trauma centres, whilst Wales has commissioned a pre-hospital medical emergency system that will inevitably change the flow of patients and is likely to lead to a change in the major trauma system.
MTCs and Education The rapid shift of services and patients due to the development of regional major trauma networks has implications for training. The vast majority of trauma will continue to be treated at local hospitals and major trauma represents less than 2% of the trauma workload in most hospitals. Exposure to major trauma remains essential
if trainees are to be capable of managing these patients, particularly if they are appointed consultant to a Trauma Unit. The MTCs provide the opportunity for intensive training focusing on decisionmaking, team membership and leadership skills. NHS-England has been working with BOTA and the T&O SAC to look at this issue and it is likely that each regional program will develop bespoke solutions to ensure the quality of training in musculoskeletal trauma is maintained. Other specialties, such as General Surgery and Anaesthesia, are also addressing this issue. A recent survey by BOTA has shown that the vast majority of trainees recognise that some exposure to cases in a major trauma centre is essential and hopefully this will become available on all training rotations.
Reconfiguration of services for trauma presents a unique opportunity for research led by Amar Rangan and Matt Costa. The aim is to form a research collaborative within the MTCs, using the National Trauma Audit and Research Network (TARN) as the platform for data collection. Large, multicentre randomised controlled studies should become a routine part of clinical practice. In the past six months alone, TARN has collected prospective data on nearly 600 cases of open tibia fractures. In the next 5-10 years England, and hopefully the whole of Britain if Scotland and Wales develop similar systems, has the potential to lead the world in not just major trauma care but also research. We have come a long way. Chris Moran is National Clinical Director for Trauma to NHS England and Professor of Orthopaedic Trauma Surgery at Nottingham University Hospital. He is a full-time trauma surgeon with a special interest in polytrauma, complex articular fractures and the treatment of non-union. His research portfolio includes 150 published scientific papers and abstracts with over 3,500 citations, mainly in the field of trauma. He continues in active research in this field. He is editor of the AO “Principles of Fracture Surgery” and co-authored the BOA/BAPRAS “Standards for the Management of Open Fractures of the Lower Limb”.
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When Two Become One Reconfiguration of Trauma and Orthopaedic Services in Maidstone and Tunbridge Wells Paul Gibb Contributing authors: Will Cobb & Oliver Chan
Trauma remains the most common cause of death and disability in patients under the age of 401. Direct costs of trauma to the NHS are estimated at ÂŁ300-400 million, with indirect costs to the economy of ÂŁ3.3-3.7 billion2. The bulk of trauma is still treated in acute general hospitals but the inception of Trauma Networks has provided the gold standard of structure and systems for the rapid assessment of the individual trauma patient3,4,5,6. In the South East of England; the South East London, Kent and Medway Trauma Network has defined three Trauma Units which support the Major Trauma Centre at Kings College Hospital, one situated at the Tunbridge Wells Hospital at Pembury.
Here we use the example of the reconfiguration of the two preexisting Trauma and Orthopaedic departments in Maidstone and Tunbridge Wells, to illustrate the challenges and outcomes of implementing centralisation.
Reconfiguration
Paul Gibb
James Murray
Maidstone and Tunbridge Wells NHS Trust previously consisted of two district general hospitals (DGHs) serving the counties of Kent and East Sussex, each serving approximately 250,000 patients a year. In late September 2011 the Kent and Sussex Hospital in
Tunbridge Wells, which had served the area since the 1930s closed, and services were transferred to the newly built Tunbridge Wells Hospital at Pembury three miles away. The move provided the opportunity to centralise Trauma and Orthopaedic services previously provided on both sites. The new Trauma and Orthopaedic department serves a total catchment population of 450,000 patients. There are 120,000 new presentations to Accident and Emergency (A&E) a year 4,800 trauma admissions, including 480 hip fractures. The trauma committee was able to influence planning of the new >>
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build. At the new site, there are a total of 30 trauma beds in addition to 25 beds for Orthogeriatric medicine/rehabilitation. Day Case and Paediatric beds are available, and in addition there are a total of 40 beds for elective Orthopaedics, nominally ‘ring fenced’. All trauma activity is now Consultant led/delivered at the Tunbridge Wells site. Initial running hours of the trauma theatre were 09:00-18:00 on weekdays and 09:00-17:00 at weekends, however this proved inadequate and as a result the weekday trauma lists were extended to finish at 19:30, 7 days a week, giving a total of 10 hours of trauma operating/day. In spite of this an additional 10 hours per week of elective theatre time on average is still utilised for trauma. The weekday trauma operating list begins with a specialist trauma list in the morning, rostered between the Orthopaedic consultants to allow time for the consultant on call to perform trauma rounds and ensure their presence/supervision in theatre for the afternoon list. Anaesthetists are rostered to cover the trauma theatre daily and supervised by a consultant, reviewing patients from 08:00. The night on-call anaesthetist reviews the ‘golden’ first patient, which is nearly always an inpatient. The consultant on-call takes patients from 8am Monday to 6pm Friday, (or 6pm Friday to 8am Monday), to facilitate as normal a working week as possible. At the point of reconfiguration, there
were 15 (14 WTE) consultants participating in the rota. The trauma commitment was rewarded as completely as possible in job plans: each 7 day trauma week (broken into 08:00 Monday – 19:00 Friday, and 18:00 Friday to 09:00 Monday) is worth 56 hours of predictable standard rate, and 36 hours of predictable premium rate time, with an additional 5 hours of unpredictable premium rate time allocated (having auditing out-ofhours calls and attendances etc.). This amounted to almost 2PA in total from which was deducted the consultants normal elective PA activity during the trauma week. A consultant led handover takes place each morning and evening in a trauma meeting room with state of the art projectors. Formal email referrals between consultants have been agreed, and all consultant ward rounds are dictated (initially presenting problems as secretaries would on occasion be required to come in at weekends). The new hospital has been designed with open plan office suites into which it has been very easy to accommodate new colleagues, preventing any pre-existing issues of limited office space/room sharing. The date of the move saw services feeling the strain over the first few weeks - the volume of work dramatically increasing (the new hospital attracting health tourists), and initially insufficient levels of equipment (e.g. hip fracture and trauma fixation instrument sets). Difficulty in getting the first trauma patient
of the day into theatre in a timely fashion prompted the identification of a priority patient that would be agreed in advance with anaesthetics and theatres.
trauma board using Microsoft Access has been reasonably successful. Trauma theatre requirements had been underestimated.
The reconfigured workforce consists of 15 Consultants, 2 Staff Grades, 10 Registrars, 4 senior clinical fellows, 2 CTs, 10 F2s and 2 F1s - a net reduction with loss of several non-training junior and middle grade posts. Two new specialist nurse Trauma Coordinator positions have been required as a result of the new volume of trauma taken on; they are present at morning handover and on trauma ward rounds and oversee all trauma admissions and complex discharge planning. A third is desired. Monitoring and maintaining standards of care at monthly clinical governance meetings has been enhanced by the employment of a TARN (Trauma Audit and Research Network) and NHFD (National Hip Fracture Database) Coordinator, the trust also going from being one of the poorest at TARN data submission to being the best in the region.
Funds are available for the appointment of Trauma Coordinators, and this was made use of. Although similar arrangements exist for osteoporosis nurses this is something that the trust has not taken on at present. It is important to recognise that any further additional funds for the development of the department have been generated by achieving CQuins targets, and that the reconfiguration of the department has not required extra funds beyond this.
Discussion It has been apparent that no enterprise can anticipate every challenge: Lack of Information Technology has been problematic. For example, operative trauma was previously written on a whiteboard at the Kent and Sussex; an outdated system that left no audit trail and lacked detail. An electronic
High satisfaction rates in trainees have been observed, perhaps as a direct result of the level of supervision and balance of trauma/elective work. Training has been improved considerably, and log books demonstrate much higher levels of consultant supervision post reconfiguration.
Conclusion The principal foundations for the success of the Orthopaedic Department in this endeavour were the early consensus achieved between the Orthopaedic consultants, the early involvement of other specialties.
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HIGH SATISFACTION RATES IN TRAINEES HAVE BEEN OBSERVED, PERHAPS AS A DIRECT RESULT OF THE LEVEL OF SUPERVISION AND BALANCE OF TRAUMA/ELECTIVE WORK.
Lessons from the Frenchay Southmead merger James Murray
The ideal hospital move would be built on meticulous planning, acceptance of subspecialty advice by the design team, maintenance of the strengths of the ‘old’ hospital and duplication of staff around ‘time zero’ to allow a staggered transition. So how does this Utopian ideal match up to the reality of moving into the Brunel Building? In April 2014 we had two acute trusts, University Hospitals Bristol (UHB) and North Bristol NHS Trust (NBT). UHB encompasses the Bristol Royal Infirmary and Bristol Children’s Hospital and NBT included Frenchay Hospital, housing the Major Trauma Centre (MTC) and Southmead Hospital where the Avon Orthopaedic Centre (AOC) was situated. In May of 2014, after many years of planning and an enormous amount of work Frenchay and the ‘old’ Southmead (and the AOC) were closed with all services being centralised in the ‘New Southmead Hospital’.
The architecturally spectacular new superhospital, built on the Southmead site, was opened under the banner of ‘The Brunel’ building. There was a two week staggering across the trust for the move, but all Orthopaedic services were moved within one week. Then comes staggering of admissions, with a maximum of two patients being admitted at 07:00 for an 08:30 start in theatre, with the ensuing patients at 09:00 and 11:00. This is definitely the correct concept for patient care, to avoid unnecessary patient delays, but there have been some rather undesired consequences, which have had the diametrically opposed result – same day patient cancellations!
So what is the advice from Bristol for Trusts planning moves: • Plan carefully – the trust needs to listen to the advice from the specialty directorates – failure to do this means increased future expense and reduced income if cases are lost. For example if theatres need lead lining, this needs to be agreed very early and checked! • Do not lose ring-fenced elective beds – there is a significant impact with cancellation of elective orthopaedic cases. • Do not forget storage – lack of sets has had a huge impact on our cancellation rate. • Stagger the move carefully – do you have to move trauma and elective together? Perhaps keeping elective services running in the old facility may have had a significant effect on preventing increases in our waiting lists?
James Murray is a Consultant Knee and Trauma surgeon at the Avon Orthopaedic Centre, now situated in the new Brunel Building at Southmead Hospital, Bristol. He was trauma lead for four years during the establishment of the Major Trauma Centre in Bristol and his elective practice is in knee surgery from ligaments to revision arthroplasty. He has a keen training interest from undergraduate students to consultant cadaveric training courses.
References: References can be found online at www.boa.ac.uk/publications/ JTO or by scanning the QR Code.
Good luck to future movers! Paul Gibb began working as a Consultant Orthopaedic Surgeon in Tunbridge Wells in 1995. As Clinical Director of Trauma and Orthopaedics for the Maidstone and Tunbridge Wells NHS Trust he oversaw the reconfiguration of Trauma and Orthopaedic services from the old Kent and Sussex and Maidstone General Hospitals in 2011. He has published and presented on various topics related to Knee Surgery and remains actively involved in the teaching of Knee Surgery. He set up and chairs the South East Knee Study Group and is a member of the British Association for Surgery of the Knee.
The full article can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Code.
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Wilful neglect and ill-treatment – new criminal offence Dr Michael Devlin, Head of Professional Standards and Liaison, Medical Defence Union
A new offence of wilful neglect or ill treatment of patients was introduced in the Criminal Justice and Courts Bill 2014 (clauses 19 and 20)1. The legislation, which is currently (January 2015) at the consideration of amendments stage in Parliament, will apply to both healthcare organisations and individual practitioners.
Michael Devlin
The change follows a Department of Health consultation in March 20142. The DH perceived a gap in the law that meant healthcare workers could only be prosecuted for wilful neglect or ill-treatment of a limited group of patients specifically, children, and adults who lack capacity or have mental illnesses. The government responded to the consultation in June, indicating that it intended to legislate to bring in the new offence.
patient. It is not hard to see that it will be easier to pursue the individual doctor where allegations are made, even if the root of the problem lies in systems failures within the organisation.
The legislation sets different thresholds at which an offence might apply. For an individual doctor, prosecutors merely need to show that a doctor has ill-treated or wilfully neglected a patient. The legislation does not define these terms, and this lack of clarity will doubtless be a concern to those accused of the offence.
Doctors practising in England may be aware that a contractual duty of candour has existed since 1st April 2013. This applies to organisations that provide NHS services under a standard contract, such as hospital trusts. The contractual duty obliges the trust to tell a patient when something goes wrong that causes moderate or severe harm, or tell relatives if the patient dies. The trust must provide full information promptly to the patient or their representative.
For organisations, the same offence would apply only where there had been a gross breach of a relevant duty owed to a
Lady Finlay’s speech3 in the Committee stage in the House of Lords sets out these concerns in greater detail.
Statutory duty of candour
From 27th November 2014, a new statutory duty of candour has been added to the contractual duty, under the Care Act 2014. The Act will lead to changes in the regulations that govern CQC registration. Like the contractual duty, it will apply to organisations, rather than individuals. But the threshold is again a complex one involving moderate and severe harm or death – but also including “prolonged psychological harm”. Both the contractual and statutory duty of candour exist in addition to doctors’ ethical duty of candour4. An MDU survey5 found that doctors are well aware of their ethical duty to tell patients when things go wrong (and not just when harm reaches an arbitrary threshold) so it does raise a question as to why the new duties were necessary. But with complex new legal requirements and their equally complex (and different) thresholds, there may be confusion as to an individual >>
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A REFERRING CLINICIAN IS PROHIBITED FROM REQUESTING, AGREEING TO RECEIVE OR ACCEPTING ANY DIRECT INCENTIVE FROM, OR ANY OBLIGATION FROM, A PRIVATE HOSPITAL OPERATOR TO GIVE PREFERENCE TO THE FACILITIES OF THAT PRIVATE HOSPITAL OPERATOR WHEN TREATING PATIENTS OR REFERRING PATIENTS FOR TREATMENT OR TESTS.
doctor’s responsibilities in working with their employer to ensure they comply with the duties. Your responsibilities are likely to be met by following local procedures for notifying patient safety incidents and by cooperating fully with clinical governance procedures generally. It may be wise to find out if your trust has published any specific guidance (in which case, be sure to follow it and ensure your team does so too).
Competition and Markets Authority report on private practice The Competition and Markets Authority (formerly the Competition Commission) has now published its report6 on measures to increase competition in the private healthcare market. The BOA provided comments7 to the CMA’s investigations. The report’s proposals were, following consultation, worked up into a Statutory Order8. Some of the report’s findings have subsequently been quashed by the Competition Appeal Tribunal9, but several of the Order’s proposed articles may have direct implications for surgeons undertaking private practice. Articles 14.1 and 15.2 describe prohibited practices, some of which are as follows:
“Any scheme or arrangement, whether legally enforceable or not, or incentive, which is intended to induce or may reasonably be regarded as inducing a referring clinician to refer private patients to, or treat private patients at, the facilities of a particular private hospital operator, is prohibited.” “A referring clinician is prohibited from requesting, agreeing to receive or accepting any direct incentive from, or any obligation from, a private hospital operator to give preference to the facilities of that private hospital operator when treating patients or referring patients for treatment or tests.” One of the pitfalls may be arrangements some private clinicians have secured to use rooms or administrative services that are not paid for at full market rates (article 16), which are classified as “higher value services” in the Order. Lower value services, such as tea/coffee, stationery, parking, etc. do not generally fall into the ambit of proposed prohibitions. Article 21 contains quite detailed requirements for publishing performance statistics, which will be at both hospital and consultant level, and will be published by an “information organisation”, to be established by the CMA. Article 22.3 contains prescriptive requirements about what a
consultant must tell the patient about planned treatment and costs. You may wish to keep abreast of the developments to ensure future compliance with them. Michael Devlin is Head of Professional Standards and Liaison at the MDU, having previously been Head of Advisory Services. He joined the MDU in 1997 and since then has written and lectured extensively on medical law.
Correspondence Email: michael.devlin@themdu.com References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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A Fellowship in Pre-Hospital Care: not a run-of-the-mill post Aswin Vasireddy
London’s Air Ambulance (LAA) is a charitable organisation that was established following a report in 1989 from the Royal College of Surgeons of England highlighting deficiencies in the management of trauma patients. Now in its 25th year, the service has attended more than 31,500 critically injured patients and undertakes approximately 2,000 missions a year (Figure 1).
The service provides an Advanced Trauma Team (call sign – ‘Medic One’), which consists of a Doctor and Paramedic, to the scene of an incident via the helicopter during the day or fast response cars at night. Doctors are usually at ‘Senior’ Registrar or Consultantlevel and their base specialty is usually either Emergency Medicine or Anaesthetics. The aim of the service is to deliver advanced medical interventions, e.g. rapid sequence induction of anaesthesia, to injured patients in order to better improve their outcome.
Aswin Vasireddy
The post offers the unique opportunity to treat patients in time-critical, life-threatening situations, often in hostile environments, for example under trains, lorries and in the middle of roads and building sites (Figure 2). The minimum criteria to work for the service include recognised training in Emergency Medicine, Anaesthesia and Intensive Care. Fortunately, I had completed posts in Intensive Care and Emergency Medicine prior to my entry onto the London South East Thames Orthopaedic Registrar rotation. However, I still had to complete a post in Anaesthesia. After applying for and being offered a post with LAA, I then passed the FRCS (Tr & Orth) before completing
Figure 1: Team photo of past and present LAA staff taken on the 25th Anniversary (Jan 2014) on the helipad
an 8-month stand-alone post in Anaesthesia at King’s College Hospital (a Major Trauma Centre). To do all this, I was fortunate in being well supported by my own Orthopaedic Training Programme Director and the Regional Anaesthetics Programme Director. When I first visited The Royal London Hospital Helipad (‘the Pad’) located on the 17th floor of the hospital, I felt very privileged to be the only Orthopaedic Surgeon to join the service in recent years. The Pad is a small set of offices where the Pilots, Firecrew, Doctors, Paramedics and Office Managers work closely together, and above which is located the helipad and helicopter. Outside the offices, there is an open space
full of training equipment and mannequins that are used for daily moulage practice. All new Doctors and Paramedics have to go through an intense six-week sign-off period culminating in a 12-hour
Figure 2: An example of a hostile scene with numerous scene safety issues but where timely extrication and clinical management of the patient is imperative
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ALL SHIFTS ARE 12 HOURS LONG AND ARE FROM 7AM TO 7PM (DAY) OR 7PM TO 7AM (NIGHT). THE GENERAL ROUTINE (FOR WHICH THERE IS AN SOP!) INVOLVES THE DOCTOR AND PARAMEDIC PREPARING AND CHECKING EQUIPMENT PRIOR TO TAKING A HANDOVER FROM THE PREVIOUS TEAM – ALL WITH THE AID OF A CHECKLIST.
assessment during a clinical shift. Some aspects of the sign-off period are very stressful, even more so than studying for the FRCS (Figure 3).
Figure 3: Some of the reading material that needs to be learnt during the sign-off process
During this time, all shifts are supervised by senior colleagues. All missions are debriefed in a very open and blunt fashion and one is forced to accept inevitable limitations and deficiencies – this was a real eye-opener as most people tend to be very defensive when criticised. Many seminal journal articles need to be committed to memory; this includes the results of the studies as well as their limitations, so that all clinicians understand the evidence that underpins the interventions provided by the service. There are also over 50 Standard Operating Procedures (SOPs) that need to be learnt. Other associated documents need to be read, e.g. the London Emergency Services Liaison Panel (LESLP) Major Incident Procedure Manual. It is important to note that LAA has been involved in the majority of the capital’s major incidents including the 7/7 bombings and numerous railway crashes.
All shifts are 12 hours long and are from 7am to 7pm (day) or 7pm to 7am (night). The general routine (for which there is an SOP!) involves the Doctor and Paramedic preparing and checking equipment prior to taking a handover from the previous team – all with the aid of a checklist. Duplicate equipment is present in both the car and aircraft so that both transport options are available depending on the incident location. Once at an incident, we carry two Thomas packs that contain all the necessary drugs and medical equipment. Once all medical interventions are completed, the patient is then escorted to hospital via land or air. Clinical governance is a crucial part of the service with twiceweekly Death and Disability meetings in which clinical cases are discussed. There is also a monthly Clinical Governance Day, open to all outside the organisation, in which clinical cases are audited. A fair-blame culture is key in order to highlight areas of improvement. Guest speakers also lecture in their particular areas of interest, which include clinical and non-clinical topics. The evolution of the Clinical Governance framework is due in large part to the efforts of the four Pre-Hospital Care Consultants (Drs Gareth Davies, Anne Weaver, Gareth Grier and Prof David Lockey). Apart from clinical duties, the registrars have numerous other responsibilities. I was the registrar-lead for major incidents and was responsible for ensuring the service was in a constant state of readiness for any major
incident. In addition, I had to develop and test the system in a major incident exercise as well as work alongside the other emergency services in full-scale live exercises. I was also co-lead for medical students, which involved mentoring students in developing, completing and presenting their audit projects. I, as part of the wider team, was also responsible for the day-today running of the service by ensuring the pad was always tidy, which included washing the dishes at 3am on night shifts if there was no mission. I also worked with the Charity Fundraising team and undertook corporate talks and presentations at local schools. I also had the opportunity to present at numerous medical meetings and conferences as an invited speaker. I had an incredible experience in this unique post. It was intense
and, in addition to the medicine, I was able to develop other non-clinical skills, which included leadership, communication and managerial skills. I would like to thank the Pilots, Firecrew, Doctors and Paramedics for their support during my time with LAA (Figure 4). In particular, the four Pre-hospital Care Consultants need to be recognised for their tireless efforts in managing and developing the service, often in their own free time. Aswin is a ST7 trainee on the South East Thames Rotation. He has had a long-standing interest in trauma management that extends from pre-hospital care through to in-hospital resuscitation, surgery, intensive care and rehabilitation. After completing his training, his long-term aim is to work as a fulltime Orthopaedic Trauma Surgeon at a Major Trauma Centre with commensurate roles in the regional pre-hospital care service and in the ED as a trauma team leader.
Figure 4: The Medic 1 team (from L-R: Fireman Mick Horton, Chief Pilot Neil Jeffers, Prof David Lockey, the author, Paramedic Steve Read, Captain Dave Rolfe and Chief Fire Officer John Power)
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Improvements in Musculoskeletal Triage and Assessment Oliver Pearce & James Pegrum
The Department of Health (DoH) has budgeted for over £5 billion for musculoskeletal services, the fourth highest areas of NHS spending, doubling in the last decade1. Sixty per cent on long term sick leave cite musculoskeletal conditions as the cause and the most common reason for general practice (GP) repeat visits1. With the population aging, and doubling of the over 65 year olds by the year 2020, there is going to be further pressure on these resources2. A Musculoskeletal Clinical Assessment and Triage Service (MCATS), devised by the DoH in 2006, has the ability to be cost effective and rationalise the referral process between primary and secondary care3. Conversion to surgery in secondary care has been suggested as an outcome measure which improves patient satisfaction4, 5. This article evaluates and describes the potential pitfalls and successes of a musculoskeletal triaging service.
The DoH Framework Tables 1 and 2 taken directly from the DoH article3, highlights the DoH musculoskeletal framework algorithm. The triaging service sits between primary care (GP referrals) and secondary care (Trauma and Orthopaedic Services, Pain services and Rheumatology services).
Oliver Pearce
James Pegrum
Any new system of triage must have robust protocols to distinguish red flag conditions reliably and provide timely onward referral. Needless to say,
influencing change involves sharing the knowledge and skills within the triaging team, alongside close collaboration with secondary care clinicians for auditing and advice.
MCATS Design Rationale There is concern that patients could be ‘directly listed’ for surgery from such a triaging service (Table 2). This process bypasses the elective outpatient consultation, and with its accompanying expense of £156 for the first appointment and subsequent appointments averaging £766. The ability to directly list onto a consultants operating list must be carefully analysed to avoid disagreement with the indications for, or the type of surgery proposed, resulting in ‘on the day cancellations’. In the case of a well-functioning system, referrals that clearly require forwarding directly to the orthopaedic outpatients for surgery (e.g. total knee replacement for significant arthritis) will be picked up at MCATS triage level. And, one would hope, not be delayed by a trial of physiotherapy or joint injection, by an extended scope physiotherapist.
Opportunities for the Clinician to Influence the MCATS Design • Forging good links with the triaging and treatment staff to clarify what constitutes appropriate cases for immediate onward referral to secondary care • Ensuring ease of communication of the triage system and the T&O department in cases of triage difficulty
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Table 1: The musculoskeletal services framework taken from the DoH article3
• Also some real time involvement in the MCATS clinics themselves both for patient assessment and educational purposes for the MCATS staff
MCATS Setup There needs to be good leadership between the primary and secondary care services, the following information is required to successfully launch a triaging service. 1. Ascertain the number of patients attending secondary care and waiting times 2. Establish conversion rate for orthopaedic surgery from outpatient consultations 3. Organise meetings of key stakeholders: consultants in orthopaedics, rheumatology, pain services; GPs; physiotherapists and other allied health professionals 4. Develop referral pathways 5. Identify available evidencebased guidance 6. Agree clinical guidelines and protocols
7. Put in place agreed training schedules and programmes of continual professional development 8. Agree outcome measures, referring to agreed protocols and standards of care. These should include patient satisfaction measures 9. Agree clinical audit framework and schedules
Benefits Since the introduction of a local triaging service there has been a 6.8% reduction in orthopaedic referrals during 2014 compared with the year before. This is in comparison with a 17.7% increase in all hospital referrals during the same time period. The collaboration of local services, which act as a triaging system can conduct clinical assessments, organise investigations and provide advice and treatment that otherwise would have occurred at a secondary level. With exhaustion of appropriate non-surgical treatments outside of secondary care the hope is to provide
Region
Outcomes summarised
Cambridgeshire
• Reduction to Trauma & Orthopaedic outpatient visits by 50% • Reduction in rheumatology outpatient visits 42%
North Staffordshire
• Surgical outpatient conversion rate increased from 18% to 60%
Somerset
• 63% of GP patient referrals seen by MCATS • Only 20% referred for a surgical opinion • 75-80% of these patients listed for surgery
Pennine
• MCATS deal with 95% of GP referrals • In 2007/8 90% were treated within the service
Surrey
• >70% managed within MCATS • <30% sent to secondary care • 70% surgical conversion rate when they are referred
Table 3: Early outcomes from established MCAT services
Table 2: A framework for the management of hip and knee pain taken from the DoH article3
a higher conversion rate to surgery. Since the introduction of our local triaging service the conversion rate to surgery has increased from 65% (2013) to 75% (2014). Similar findings have been found in other regions around the country (Table 3). The benefit of triaging will allow greater number of patients to be treated in primary care, thus maximising the secondary care resources for patients requiring surgery7. This is further supported by a systematic review suggesting 72-97% of patients can be managed within primary care reducing secondary orthopaedic consultations by 20-60%8. Although these figures were not achieved in our institution.
What does the Future Hold? With a well-run and organised triaging service a greater proportion of patients seen in secondary care will be listed for surgery. The delay in referral, to exhaust conservative measures, needs to be balanced against an inappropriate delay in those who clearly need early surgery. Creating high standards of clinical care can be maintained by regular review of the clinical evidence, together with auditing the appropriateness of secondary care referrals. For this type of service to work effectively relies on a close relationship and work with hospital consultants. Involvement of hospital consultants will enable elimination of services that might disadvantage the patient, such as direct patient listing. The literature is currently devoid of high quality, prospective and
comprehensive evaluation of referral and surgical waiting times and the cost effectiveness of a musculoskeletal triaging system. The ultimate question will be to determine the impact of musculoskeletal triaging on patient sick days and ability to return back to work.
Conclusion At the heart of the development of a successful MCATS is the need for close collaboration between clinicians in both primary and secondary care and a robust clinical governance system with strong leadership and clear accountability. Oliver Pearce is a consultant Hip and Knee Surgeon in Milton Keynes Foundation University NHS Trust. He is Director of Trauma Surgery, and lead clinician for Orthopaedic Research. He runs the department of Musculoskeletal Sciences at the newly formed University of Buckingham Medical School. And he is visiting Professor at the University of Bedfordshire (ISPAR). James Pegrum Oxford Orthopaedic Registrar and honorary clinical lecturer sports and exercise medicine at Queen Mary University of London. References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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JTO Features
A survey of trainees’ opinion on the JCST’s index procedures in Trauma and Orthopaedics Benjamin Dean
Changes to surgical exposure time secondary to EWTD reforms have, for many years, concerned both trainees and trainers. In response to both these concerns, and an increasing demand for demonstrable competency amongst those preparing for CCT, key index procedures have been introduced to attempt to standardise the training experience. The selection of each procedure as index and the number of procedures required of each can appear arbitrary to trainees. In this context we designed a survey to assess the opinion of trainees on the JCST’s current index procedures in Trauma and Orthopaedics.
Methods
Benjamin Dean
A web based survey was distributed by email to the complete trainee email lists in 10 training regions from June until August 2014. We received 138 responses from a total of 338 trainees email yielding a response rate of 41%. We asked two simple questions relating to each of the JCST’s index procedures. The first question was “What is your opinion on the following procedures being ‘index’ procedures for CCT?” with the following Likert responses available: strongly disagree, disagree, neutral, agree, and strongly agree. The second was “What is your opinion
on the JCST’s recommended numbers for the following index procedures?” with the following Likert responses available: far too few, too few, about right, too many, far too many. The third and final question asked openly if any other procedures should be included as index procedures.
Results There was a relatively even spread of training grades from ST3 to ST8. The results for this question are depicted in Figure 1. The ‘1st ray’ was by far the least popular with 49% of trainees
feeling this should not be an index procedure. No other procedure had more than 20% of trainees in disagreement with its status as an index procedure. The results for this question are depicted in Figure 2. Trainees felt the number of ‘1st ray’ procedures was too many (66% responded too many or far too many). Other procedures with a >20% responding too many or far too many were tendon repair (54%), TKR (41%), THR (37%), CTD (32%), IM Nail (31%) and tension band fixation (24%). In terms of trainees’ opinion in which other procedures should be ‘index’, the response ‘distal radius fixation’ was by far the most common answer (37%).
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Discussion
Figure 1: Trainee responses to ‘What is your opinion on the following procedures being ‘index’ procedures for CCT?’
In the context of our findings and the work of Jayatilaka et al1, it appears that trainees feel that the 1st Ray should not be an index procedure and that the numbers of other index procedures should be modified to better reflect the modern training environment. It is concerning that less than a third of trainees feel the current number of primary index procedures is attainable1. We suggest that the JCST publish the evidence for the inclusion of each procedure as ‘index’ and the method by which they determined the number of each required. In addition, future changes to the work based assessment process should consider the potential harms of competency based methods, which include minimum standards and demotivating trainees2, and the adequate validation of methods of procedure selection. The involvement of trainees in this process will help assuage anxieties and thus minimise any potential future harm.
Response from Mike Reed, Education Committee Chair:
Figure 2: Trainee responses to ‘What is your opinion on the JCST’s recommended numbers for the following index procedures’
The rationale for ‘index’ procedures is laid out in the Trauma and Orthopaedic curriculum. ‘Index’ procedures are descriptive of T&O activity in general and are not designed to accredit particular procedures, but rather to indicate an educational trajectory in the discipline as a whole. The senior trainers who devised this list felt that forefoot surgery was common and
had skills not readily tested in other areas of the specialty. Numbers for ‘index’ procedures came much more recently. I’d agree attainability of specific targets in the current training environment is a separate issue, and one we don’t yet have a true handle on. The authors would no doubt agree we shouldn’t drop the standards bar, but perhaps explore whether those skills can be tested in another way. This will be revisited by the curriculum committee in due course as the results from ARCPs filter through. Benjamin Dean is an Orthopaedic registrar in the Oxford region. Ben is currently finishing a PhD investigating the role of glutamate in rotator cuff tendinopathy under the supervision of Professor Andy Carr. Away from medicine Ben enjoys expending energy outdoors and spending time with his family.
References 1. Jayatilaka L and Cope M. Meeting the JCST requirements in Trauma and Orthopaedics - the trainees’ perspective. Journal of Trauma and Orthopaedics. Volume 2; Issue 4; December 2014. 2. Pereira EA, Dean BJ. British surgeons’ experiences of mandatory online workplacebased assessment. Journal of the Royal Society of Medicine 2009;102(7):287-93.
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JTO Features - Trainee Section
Paying it forward - a trainee led mentor programme Staton Phillips
A wise man once said â&#x20AC;&#x153;Our greatest strengths are our greatest weaknessesâ&#x20AC;?. As orthopaedic trainees we are absolute masters of time management. Six years of timetabled commitments from early morning to evening, on calls and weekends all with the knowledge that, the things that will be used to differentiate us are the very things that are not timetabled, but are fitted in between our regular commitments. We are experts at prioritising our time, in fact we rather enjoy fitting in a meeting here, some revision there or submitting a paper via iPhone while travelling from one clinic to another.
Our near obsession about constantly working on our most immediate priority is however a weakness when it comes to long term projects, especially those that require a considerable investment of time before there are any dividends, or heaven forbid, projects which require our time but have no direct benefits to ourselves or our curriculum vitae.
Staton Phillips
Consider the FRCS part 2 examination in which trainees are expected to display higher level thinking. We are tested on our ability to verbalise our thoughts, explain our plans and then justify them when challenged. These are skills that need to be acquired
through practice and more than any other part of our training it is here that trainees require the help of a senior colleague. By senior colleague in this context I mean anyone who is FRCS positive! Sometimes it can, however, be unaccountably difficult for trainees to identify people willing to invest the required time to produce realistic questions and then take them through some viva practice. Unfortunately, this may mean many candidates feel unprepared going into the part 2 viva stations. Most candidates will have spent years perfecting operative techniques or clinical consultations, identifying surgical
mentors or courses to attend in order to take responsibility for their own training however, they may have spent little time preparing for an oral examination. Often a senior consultant may be found to provide valuable pearls of wisdom for the exam; however, it may be challenging to find regular available time slots within the increasingly packed consultant timetable. A more accessible resource close at hand may actually be registrars who have recently passed the exam. An FRCS Mentoring group was set up with a simple aim, to give candidates on our rotation two hours of high quality viva practice per week for the period of their part two revision. What was required from these registrar/mentors was something surprisingly difficult, the willingness to spend a couple of hours a week providing viva practice with an additional few hours preparation time. These registrars themselves had not received any form of organised viva practice within their rotation and were going to give up their time over the summer for no direct benefit, other than pure altruism, or rather enlightened altruism in the form of the possible gratitude of successful colleagues and the previously mentioned TPD. All this with the additional pressure of numerous more pressing tasks such as finalising fellowships that had received fairly limited attention during a year of revision. It was therefore a struggle to recruit post exam registrars to the group. Almost everyone who was approached was willing to help in theory, but as the specific
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teaching date approached, other commitments tended to become a priority. The group quickly coalesced around one or two registrars who were keen to teach and willing to give their time. As a trainee who entered medicine following a career in teaching and subsequently in the manufacturing industry it was apparent that a much longer term view of the project was required for the creation of a self-sustaining tradition of mentoring to be instilled within the rotation, where those who have just passed the exam are obliged to help the next tranche of candidates as they had been helped themselves and seen it work.
The detailed workings of the mentoring group do not involve any revolutionary teaching concepts. The sessions themselves follow a very standardised format. The most valuable use of time for both the mentor and the candidate is felt to be realistic viva practice. Each candidate is asked a typical five minute viva question, or if time permits a succession of three questions in fifteen minutes. The natural temptation is to enter into discursive feedback after every question but as the examination nears it becomes increasingly important to keep to time in order to build up a kind of â&#x20AC;&#x153;viva staminaâ&#x20AC;?.
We have found that registrars who have most recently passed the FRCS often make very good mentors because the exam is such a recent memory, though help from past examiners in the immediate run up is invaluable. Prepared questions are essential; a simple radiograph taken from the internet and presented on an iPad creates a realistic atmosphere, although in practice it is difficult to reduce the resolution sufficiently to make them truly resemble the images used in FRCS (Orth). Iâ&#x20AC;&#x2122;m sure that the FRCS mentoring group, or similar older traditions are familiar concepts to many orthopaedic surgeons from
around the country, certainly there are regions where candidates consistently seem well prepared when they are encountered on revision courses. This project aimed at taking the first steps towards establishing, or perhaps re-establishing a mentoring tradition within our training programme and it is now a formal part of our teaching program, well into preparing a second group of candidates for the exam with 100% pass rate within the first group. In retrospect it seems to have been an obvious project to set up. Everyone gains from the group as a candidate then contributes their time in the few months after passing. All our registrars want to be involved. The question is therefore, why did it take us so long to get the thing started? Clearly it required the first group of mentors within the system to contribute their time without first having received the benefits, however a pay it forward philosophy can be used at various levels of training particularly given the unfortunate continued demise of the firm structure.
An FRCS Mentoring Group
Staton Phillips is a Registrar on the Stanmore (North East Thames) Rotation. After obtaining a first degree in Natural Science, focusing on materials, he worked in manufacturing industry for seven years in positions including sales, marketing, production and process management before realising the exceptional market opportunities offered by the medical profession.
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JTO Medico-Legal Features
Code of Practice for Orthopaedic Surgeons Preparing Reports in Personal Injury and other Cases Approved by the BOA’s Professional Practice Committee
The British Orthopaedic Association Blue Book guidelines on this subject were last updated in August of 2006. The Woolf reforms came into force in England and Wales in 1999 following the Access to Justice Report published in 1996. They introduced the concept of the single joint expert. They gave clear guidelines on the nature of questions that could be put to experts.
They aimed to ensure that: 1. All parties in litigation were on an equal footing 2. Expense was reduced 3. Proportionality 4. Cases were dealt with more quickly A new protocol was drafted by the Civil Justice Council in 2005 to supplement part 35 of the Civil Procedure Rules (CPR). This was updated in October 2009 and is a useful reference point. It can be accessed through the Ministry of Justice (MoJ) website. It emphasises the importance, role and responsibilities of experts in civil litigation.
The ground rules have changed again with the introduction of the Jackson reforms on 1st April 2013. At the time of redrafting these guidelines in January of 2014 it is too early to assess the impact of these reforms. There are a number of procedural issues relating to solicitors and insurance companies. As far as the expert is concerned the major changes are: 1. The requirement for compliance with Court timetables, with “sanctions” for experts who fail to do so 2. Compliance with budget requirements and the need to provide a clear estimate of
costs to the Court at the time of receipt of initial instructions 3. “Hot tubbing”, a technique developed in Australia to permit (but not require) experts of the same discipline to give evidence concurrently at the direction of the Judge i.e. without the necessity of the legal representatives agreeing to this. Barristers are permitted to put questions to the experts and the experts may question each other. 4. It is important to note that, although this rule change came into effect on 1st April 2013, the provisions apply to all cases after that date and NOT just cases commenced
after that date. This means that although initial reports may have been prepared pre April 2013, any subsequent work undertaken will be subject to the new rules and potential budgeting provisions and sanctions. Since the publication of the previous guidelines there has also been a significant change to the position of the expert witness following Jones v Kaney (2011). The expert is no longer immune from prosecution or retribution if their report or opinion is flawed or deficient. >>
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JTO Medico-Legal Features
Dealing with Instructions The process is usually initiated with receipt of a letter from a solicitor, insurer or agency requesting provision of a report. If the letter is from an agency then it should be accompanied by a letter from the instructing solicitor. On occasions there will be a more preliminary, general enquiry prior to receipt of formal instructions querying whether the matter falls within the experts remit and requesting terms and conditions, CV, fee structure, waiting times, turnaround times etc. Given the issues surrounding an expert’s ability to comply with timetables and with budgeting restraints, initial enquiry as to competence and capacity are likely to be more common except where the instruction comes through an agency where the agency will usually deal with those issues. The formal letter of instruction should include: 1. Name, address, date of birth and contact details concerning the person that the report is to be provided on 2. A brief description of the matter to be dealt with i.e. date, nature of injury (single/ repetitive) 3. Whether it is necessary to interview and examine the claimant. Reports on liability and causation may, on occasions, be prepared from clinical records and radiology only 4. An outline of the main issues to be dealt with and whether the opinion is required on
liability, causation or condition and prognosis 5. An indication of the claimants level of mobility i.e. whether they can manage stairs, whether they require wheelchair access 6. An indication of the requirement for a translator/interpreter if appropriate 7. An assurance that there is no claim against the expert or his employer 8. An assurance that all relevant medical records and other documentation together with X-Rays will be provided before the appointment 9. A copy of the claimants witness statement if available and any particulars of claim or defence available at that time 10. Copies of other expert reports relevant to the case 11. The instructing parties’ timeframe for preparation of the report. Any important Court dates relevant to the claim. The new rules indicate that if a timetable has already been ordered by the Court, the instructing solicitor should provide a copy of the Court order with the instructions. It is then incumbent upon the expert to ensure that they are able to manage diaries to comply with any deadlines given the drastic repercussions for non-compliance (cases being struck out or parties not allowed to rely on reports that do not comply with timetables). If there is any doubt about the expert’s ability to comply with the timetables set either instruction should not be accepted by the expert or enquiries should be made as to whether timetables can be
varied to ensure compliance. 12. An agreement to the payment of the expert’s reasonable fees within an agreed timeframe. This may now contain a provision that expert fees may be subject to a budget set by the Court and agreement may be sought as to whether instructions will be accepted on that basis. In Orthopaedics rules of supply and demand may apply, such that except for some very specialist areas, experts may be forced to accept restriction of fees. 13. An indication that the report is being provided within the CPR 35 protocols. It is recommended that the expert should have terms and conditions giving clear details of their fee structure, settlement terms, travel expenses for attendance at Court, conferences etc. and Court attendance fees. It is recommended that the expert has these terms and conditions signed by the instructing solicitor before accepting instructions (see section on Fees).
Medical Records/ Radiology It is the duty of the instructing party to obtain, at their expense, all relevant medical records including X-Rays and scans and to provide them to the expert in viewable format. Ideally, particularly in more complex cases, the clinical records should be filed and paginated in date order. Notes should be checked for relevance and legibility before posting.
Accessing CDs containing radiology can often be difficult because of the large number of different formats that they are stored and presented in and because of the increasing use of security layers to protect the information contained therein. Storage of documentation can pose problems for the expert. When the report has been compiled the documents can be returned to the instructing party. However, this can be cumbersome, particularly if supplementary questions are raised subsequently and the records have to be sent back. Medical records on CD is one solution, but in complex cases these can be difficult to navigate and bookmark. Therefore, some storage space is usually required for active cases. All documents should be returned to the instructing party or destroyed at the conclusion of the case. All experts who carry out this work should be registered under the Data Protection Act. Long term storage of reports and correspondence is a matter for the individual expert. This can be done in paper format, CD or hard disc.
Responsibilities of the Expert On receipt of a request to provide a medico-legal report the expert should: 1. Acknowledge the request and establish whether they are being asked to report as a witness to fact, an expert
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A NEW PROTOCOL WAS DRAFTED BY THE CIVIL JUSTICE COUNCIL IN 2005 TO SUPPLEMENT PART 35 OF THE CIVIL PROCEDURE RULES (CPR). THIS WAS UPDATED IN OCTOBER 2009 AND IS A USEFUL REFERENCE POINT. IT EMPHASISES THE IMPORTANCE, ROLE AND RESPONSIBILITIES OF EXPERTS IN CIVIL LITIGATION.
witness or to provide advice to the Court on a particular matter. This should usually be clear from the letter of instruction. If in doubt the expert should immediately seek clarification from the instructing party. 2. Clarify whether or not there are any time constraints for provision of the report. This should be clear from the letter of instruction, but if in doubt, this should be clarified
with the instructing party. If it becomes clear that the Court has already timetabled the case then the expert should request a copy of the Court Order and ensure that he/she can comply with all the terms of that order. This means that the expert can comply not only with the date for the disclosure of the report and any supplementary reports, but also the dates for expert meetings, preparation of joint
statements and attendance at trial. 3. The expert should provide a detailed breakdown of fees to include: a. The estimate of the fee or range of fees for the report (including an hourly rate and an estimate of the number of hours to be taken) together with any cancellation fees which may be incurred if the claimant fails to attend for assessment. The expert may
have to justify the fee level by reference to the volume of records/scans or the complexity of the case b. The estimated cost of any supplementary report/s c. The cost of any attendance at conference with counsel d. The cost of joint expert meetings and preparation of joint statements e. Fees for attendance at Court, including late cancellation charges
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JTO Medico-Legal Features
THERE SHOULD BE A CLEAR UNDERSTANDING BETWEEN THE EXPERT AND THE INSTRUCTING PARTY REGARDING THE RANGE OF FEES APPLICABLE TO THE CASE IN QUESTION.
f. Details of travelling expenses 4. Keep a comprehensive time sheet, recording all work done in order to justify the fees incurred. 5. Arrange to interview and examine the claimant in a suitable clinical environment allowing sufficient time to carry out a full assessment. 6. Ensure that at the time of the assessment, if appropriate, a chaperone is available. 7. Following the assessment the completed report should be sent to the instructing party within six weeks of the appointment at the latest unless there has been prior agreement that it will be provided at an earlier date or the date specified by the Court Order. 8. Return any original documents to the instructing party with the report. 9. Ensure that he/she has suitable professional indemnity insurance in case of later litigation following Jones v Kaney (2011). 10. The expert should ensure that they have appropriate clinical experience and knowledge to provide the report. For common conditions/injuries it would be expected that the expert would have regular exposure to such conditions in their clinical practice. For example it would be inappropriate for a specialist hand surgeon to give an opinion on a low back problem and vice versa. In such situations the expert may have to be prepared to defend his position when challenged by the other sides’ barrister or by the Judge at “hot tubbing” session.
11. However, the expert should be aware that after the Legal Aid, Sentencing and Punishment of Offenders Act (LASPO, 2013), there will be increasing pressure from Judges at directions stage or from instructing solicitors due to budget restraints to restrict the amount of expert evidence that is permitted. This may mean that an orthopaedic expert is asked to provide an opinion on all orthopaedic aspects of a case and not those within his/her areas of competence. In such circumstances, the expert should seek clarification, and if concerned about their ability to provide opinions on all matters contained within their instructions should write to their instructing party setting out their concerns and/or their inability to cover certain areas. This is likely to give the instructing party the ability to go back before the Judge for variation of the Order. If the Judge refuses to vary and the expert proceeds with the instruction, the expert should express any concerns or reservations in the report itself. 12. In general terms it is felt that experts should not give opinions on their own patients except on matters of fact. The consultant’s primary responsibility is to his/her patient. The expert’s primary responsibility is to the Court. These differing responsibilities can cause significant conflicts of interest which are best avoided. In some cases however, instructing solicitors may require a report from the treating consultant either because the Judge orders it
or because an initial needs assessment is required. In such cases, the expert should clarify and ensure that the claimant/patient consents to the treating consultant acting as an expert in the case. 13. Under no circumstances should an expert accept instructions that are conditional on the success of the case. This would provide a significant conflict of interest and compromise the expert’s independence. It is also formally prohibited under the Rules. This is in contrast to the fact that experts will increasingly be required to accept instructions on a fixed fee basis. In the latter case this is permitted by the Rules.
Fees There should be a clear understanding between the expert and the instructing party regarding the range of fees applicable to the case in question. This should become more relevant following the Jackson reforms. This will be facilitated by: 1. Clear instructions outlining the nature of the claim, any unusual issues and a clear idea of the volume of documentation (including scans and X-Rays) that need to be reviewed. 2. Detailed terms & conditions provided by the expert as discussed earlier including expected time for settlement of fee note. The terms & conditions should include: a. Basis of the charges (daily or
hourly rate). Likely fee range. Preferably the expert should try to accurately assess fees to aid the legal team in cost budgeting. b. Fees for travelling, subsistence and accommodation if required. It should be borne in mind that the Court will be scrutinising these. c. Cancellation charges for claimant non-attendance for assessment. Charges for late cancellation of Court appearance. Details of timeframe (21 days/7 days/48 hours) need to be outlined together with relevant penalty. If the expert attends Court the full fee should be payable whether or not he is asked to give evidence. This matter is discussed further later in this section. d. Fees for attending meetings with Counsel, telephone conferences, answering supplementary questions should be listed. Usually charged at basic hourly rate. Consideration should be given whether physical attendance is required at the conference or attendance is possible by telephone or video link. e. If the expert works in the NHS it should be made clear that his employing Trust requires 6/8 weeks’ notice for cancellation of clinical commitments and therefore ample warning is required for scheduling of Court appearances etc. during the normal working day. The instructing party should pay the agreed fee within the agreed time.
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Advertiserâ&#x20AC;&#x2122;s Content Section??????????????????
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JTO Medico-Legal Features
UNDER NO CIRCUMSTANCES SHOULD AN EXPERT ACCEPT INSTRUCTIONS THAT ARE CONDITIONAL ON THE SUCCESS OF THE CASE.
It is a matter for individual experts whether they enter into deferred fee arrangements. Experts should be aware that there have been agencies (and more recently a large midlands firm of solicitors) that have gone out of business owing money to experts. They should also be aware that in such circumstances they will be at the foot of the queue when it comes to recovering their fees. The likelihood of recovery is virtually zero. Therefore it is not sensible business practice to run a large deferred debt book with one or two agencies or solicitors. Experts should also be aware that agencies, insurers and solicitors are in the business of making money. Experts should also set themselves up in a business-like fashion so that they too are similarly minded. They need to adopt a different mind-set from routine clinical practice where their primary responsibility is to the patient. In medicolegal practice the primary responsibility is to the Court and the aim of the practice is to provide first rate expert opinions. However, it is important to be aware that in Orthopaedics, with the exception of a very few specialist areas, there is a potential over supply of experts. Therefore, when setting up in medico-legal practice some compromises may have to be made until the practice and the reputation of the expert is established. Experts should be aware that since 1st April 2007 (following a European Court of Justice
decision), the provision of expert medal reports is no longer VAT exempt. The VAT threshold in the United Kingdom from 1st April 2013 is £79,000. Therefore, once medico-legal income reaches this level the expert will have to register for VAT and charge VAT at the prevailing rate (currently 20%). Any VAT threshold changes are usually announced in the budget. Under no circumstances should an expert accept instructions that are conditional on the success of the case. This would provide a significant conflict of interest and compromise the expert’s independence. It is also contrary to CPR part 35. The issue of cancellation fees is, and will, remain controversial. Solicitors/ insurers are reluctant to pay them. The recent changes to the expert witness rates for legally aided claimants (1st April 2013) indicates that cancellation fees will not be paid “where the notice of cancellation was given to the expert more than 72 hours before the relevant hearing or appointment”. There is an assumption that experts can always find something else to do if there is late cancellation of Court cases in particular. There seems a lack of awareness on behalf of the Ministry of Justice that clinics and operating lists cannot be reinstated at very short notice and that busy clinicians involved in NHS practice usually have to take annual leave to attend Court/ Meetings in these cases. Generally the situation is best
managed with clear terms and conditions agreed when instructions are accepted and close liaison with the instructing party in the weeks leading up to a potential Court appearance. The legal profession warn us that with the advent of cost budgeting, it is likely that experts will be forced to accept instructions on the basis of fixed fees set by the Courts. Terms which seek to require instructing solicitors to pay above the fixed/budgeted fees are likely to receive short shrift in a climate where instructing solicitors own costs are restricted and the claimant may not have the means to meet any shortfall. They also believe that market forces are likely to mean that orthopaedic experts (with rare exceptions) will not be able to dictate fees. Part 2 to feature in the next issue of the JTO.
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JTO Peer-Reviewed Articles Section??????????????????
Inspiring confidence, knowledge and safety in foot and ankle surgery Hiro Tanaka & Paul Halliwell
The British Orthopaedic Foot and Ankle Society (BOFAS) Principles of Foot and Ankle surgery course started in 2011. It was written and implemented by the BOFAS Education Committee. The aim is to teach core foot and ankle content for safe consultant practice in an informal and interactive environment. One of the key components is the hands on examination of patients. The course is financially sponsored by members of the society and runs three times a year across the UK. To date, over 240 trainees have benefited from the experience. Feedback has been consistently high.
Figure 1: Informal, interactive and individual teaching
The courses provide a vital supplement to the educational needs of trainees, both as a foundation in the early years and as a refresher before the FRCS (Tr & Orth) examination. The course has been carefully designed and refined to allow trainees to feel more confident and better equipped to apply their knowledge in daily practice.
prepared. This includes a summary of the key preparatory steps and templates for the necessary documentation (Figure 2), such as brochures and feedback forms. The most demanding aspect of the job is the arrangement of suitable patients for the clinical sections.
Environment Students learn best when they feel safe and supported. The course is deliberately informal for both students and faculty. We have found that this allows for more open interaction allowing them to learn in their own way. Jeans and T-shirts are encouraged (Figure 1)!
Course direction and administrative support
Hiro Tanaka
Paul Halliwell
An organised course director is essential. The director must have previous experience as faculty, to maintain the standards and ethos of the course. A course directorâ&#x20AC;&#x2122;s pack providing all of the relevant paperwork has been pre-
Figure 2: Flier for a course â&#x20AC;&#x201C; BOA 2013
Faculty We believe that a high faculty to delegate ratio is important to give candidates individual attention, encouraging them to ask questions
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Section??????????????????
© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 01, pages 44-45 Title: Inspiring confidence, knowledge and safety in foot and ankle surgery Authors: Hiro Tanaka & Paul Halliwell
support in the form of a Principles course, available to all trainees and consisting of the features which characterise the BOFAS course.
freely and request support when they need it. All of our courses are run with a minimum ratio of two delegates to one faculty. This also helps the faculty to teach in groups, so that they can give each other feedback and learn from one another’s teaching styles. Fifty consultants have now taught on the course. We usually run a pre-course faculty dinner to welcome new members.
Reproducibility The course produces consistent learning outcomes each time it is delivered. We ensure the standardisation of content and format by providing all the previous course material and lectures to the faculty. The files are made available on a cloud server. We actively encourage our faculty to engage in development of the lectures to keep the content up-to-date.
Self-directed learning We believe that a group of 20 candidates is the optimal number to allow social and intellectual interaction and for venue costs to be kept to a minimum. In advance of the course, the 20 students are split into four groups of five according to their experience level.
Active involvement in learning The course content is split, with 40% lectures and 60% small group learning in the form of clinical examination cases and X-ray based discussions. On every course we have run the candidates have rated the small group learning the most highly, as it allows them to apply
Hiro Tanaka is a Consultant Foot and Ankle Surgeon at Aneurin Bevan University Health Board. He has led the development of the BOFAS course and has been a member of the BOFAS Education Committee since 2009. He is a Health Foundation Fellow and is passionate about Clinical Leadership.
Figure 3: Small group learning for clinical examination
their knowledge to practice and to receive individual teaching (Figure 3).
Teaching style We do not believe in “grilling”. This is not an FRCS (Tr & Orth) preparation course but the “exam candidate” group are given simulation of exam conditions if they request it. All of our faculty have an accredited background in surgical training and we encourage a facilitative teaching style so that the students are free to learn the way that suits them the best.
Responding to feedback and quality improvement This has been vitally important in order for us to improve the quality of the programme. Since the first course in 2011, feedback has allowed us to improve the course in line with the expectation of the candidates. The format, content and timings of the course have been modified and the effect of change closely monitored. We aim to deliver education which caters to the needs of our trainees.
Feedback is shared with all faculty members and discussed openly. Our feedback ratings and positive comments have improved year on year as a result (Figure 4).
Pre-course learning material A course book will be available from 2015, which will encourage the candidates to read in advance of the course and hopefully improve their learning experience. We will not be introducing any form of summative assessment into the Principles course. One of our students stated that the BOFAS course is a “model for future training”. We believe, and our feedback suggests, that the quality of orthopaedic training and patient safety can be enhanced by providing educational
Paul Halliwell is consultant orthopaedic surgeon in Guildford, Surrey, specialising in trauma and problems of the foot & ankle. He is Director of the BOFAS Principles Course, a member of the BOFAS Education and Outcomes Committees and is an FRCS (Tr & Orth) examiner.
Correspondence: Email: hiro.tanaka@virgin.net Email: paul-halliwell@hotmail.co.uk
Figure 4: Using feedback for continual improvement
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JTO Peer-Reviewed Articles
Localisation of Osteochondral Lesions of the Talar Dome: MRI Compared With Clinical Findings - Can The Site Of The Pain Predict The Site Of The Lesion? Mark Davies
Osteochondral lesions (OCL) of the talar dome are defects of the cartilaginous surface and underlying bone1. The lesions range from a small defect in the talar articular surface, to lesions associated with a subchondral cyst, or a large detached osteochondral fragment2. Berndt and Harty3 proposed that such lesions are resultant on an intra-articular fracture, although others have suggested a possible genetic predisposition1,4.
of poor scientific quality with anecdotal reporting of the sites of tenderness. Other pathologies frequently coexist with OCL, and this can lead to confusion in diagnosis. The purpose of this study was to investigate the relationship between the site of perceived pain, physical findings on examination and the location of the OCL on MRI scanning.
Materials and Methods
Recently Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) have led to more accurate imaging of these lesions, which in turn has led to new classifications. The new classifications record subchondral cysts9 and acute bone marrow oedema.10 Berndt and Harty described lesions as being antero-lateral or posteromedial, whilst MRI scanning localised 43% to the lateral and 57% to the medial sides of the talus. Lesions in the middle of the talus are rare, but have been reported1,12. Mark Davies
Acutely OCL’s occur in 6.5% of all ankle sprains5,13. Chronically
they are found in 20.5% of ankle sprains and 57% of cases of ankle disability14. OCL’s are one of the most important causes of residual pain after ankle sprain15. The clinical diagnosis is regarded as difficult10, and delay in establishing the diagnosis is common3. The pain associated with OCL’s has been noted to be generalised and non-specific8, similar to the symptoms of osteoarthritis. Localised tenderness is frequently lacking3,5,15, although localised tenderness has been described, usually postero-medially or antero-laterally in accordance with the site of the lesions3,5,8. Nevertheless, these studies are
Patients identified as having chronic talar dome OCL’s on MRI were asked to indicate the point of maximal pain in their ankle and a removable skin marker was positioned at this site. Chronic OCL was defined as the presence of pain for more than three months. The position was independently measured and the skin marker was then removed. The patient was then examined to elicit the point of maximal tenderness in the ankle joint. The position was again marked and measured. The examiner was blinded to the first location and the measurements were taken blindly, the instrument readout was not visible whilst measurements were being made. The measurer and the examiner were both blind to the MRI findings, to eliminate bias. An adapted technique of anthropometrics was used to obtain orthogonal dimensions of >>
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Figure 1: Digital callipers positioned to take the measurements
the locations16,17,18. A frame with a moveable 90o angle bracket was constructed to use as a reference point for the measures. This base was level and marked with parallel lines for reference. Digital callipers were then positioned to take the measurements (Figure 1). For the best comparison of the measurements with MRI, a standard position was used. The subject placed their foot in the frame in the same position as their foot was in for the MRI (Figure 1).
Figure 2: Measurements taken in the 3 axes
Measurements were made using digital callipers held at 90 degrees to the axis measured, using the bracket to ensure that the calliper was in the correct position. Trial measures were taken to test for reliability and repeatability. Measures were then taken in three axes, moving the 90 degree angle bracket into the correct position to measure from the landmarks below (Figure 2).
X (medial to lateral) - from the medial malleolus in a lateral direction Y (caudal to cranial) - from the plantar surface in a superior direction Z (posterior to anterior) - from the Achilles tendon insertion in an anterior direction The MRI scan and reports were then reviewed for each patient. Digital measures were replicated from the same landmarks above, to the centre of the lesion. Reference lines were added between each view and between the slices of each view (Figure 3). Measures were taken from these reference lines on separate occasions to test reliability and repeatability. The orientation of the foot in each view was set with reference lines through each slice, using equivalent landmarks used in the direct measurements. Coronal View – a line parallel to the orientation of the leg (Figure 3) Axial View – a line parallel to the anatomical axis of the foot, through the second ray (Figure 4)
of the ankle joint, was taken as the equivalent (Figure 4). Axial views were disregarded if the plane of the image did not correspond to the plane of the foot, such as occurs in a very plantar flexed foot position at the time of MRI (Figure 4). The “Z” (posterior to anterior) measure taken in this view thus represented the hypotenuse not the direct measure.
Figure 3: MRI of ankle in the coronal plane showing reference line; a line parallel to the orientation of the leg and measurements taken from this line
Sagittal View – a line parallel to the plantar surface of the foot If the image did not show the landmark sufficiently well due to the size of area shown or the number of slices taken, we used equivalent points that were found to be representative. This occurred mostly in the axial view, if there were insufficient slices for the second ray to be visualised. A line through the centre of the Achilles tendon to the lateral border of the tibialis anterior tendon, at the level
Analysis of the data was carried out to test for correlations between measures made of the lesion as identified by the subject, the examiner and the measures from the MRI in all three axes. The Euclidean distance between the measures was calculated and descriptive statistics produced for each measure group. In addition, the 95% confidence interval was calculated to show the range of measures to be expected in any population, to show the degree of association between them.
Results A total of 19 patients with OCL were recruited. The methods and equipment used, proved to be repeatable and reproducible (unpublished data). Using the frame and callipers was repeatable and reproducible to within 2.7mm. The tools on the computer system for the MRI were repeatable to within 3.4mm. In terms of whether the lesion was medial or lateral; the subject and examiner agreed in 84% of cases, the subject’s location of pain agreed with the MRI in 58% of cases and the examiner’s location of tenderness agreed with the MRI in 63% of cases.
Figure 4: MRI of ankle in the axial plane showing reference line; a line parallel to the anatomical axis of the foot, through the second ray and measurements taken from this line
Agreement with respect to the localisation between quadrants in two planes, i.e. antero-lateral, postero-medial etc., the subject
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© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 01, pages 46-49 Title: Localisation of Osteochondral Lesions of the Talar Dome: MRI Compared With Clinical Findings - Can The Site Of The Pain Predict The Site Of The Lesion? Authors: Mark Davies
and examiner agreed in 63% of cases, the subject’s location of pain agreed with the MRI in 42% of cases and the examiner’s location of tenderness agreed with the MRI in 37% of cases. Figures 5, 6 and 7 show these location points as scatter plots with Pearson correlation coefficients. These plots in each plane demonstrate the degree of spread. Scatter plots of the locations between the subject and examiner show the best correlation with the highest correlation in the coronal plane (X axis, 0.87), whilst the lowest correlation was in the sagittal plane (Z axis, 0.38). The subjects’ localisation of pain and the location of the OCL on MRI were generally more poorly correlated with the lowest correlation also in the coronal plane (X axis, 0.49). Correlation between the maximum tenderness as assessed by the examiner and the location of the OCL on MRI was higher in all three planes compared to that localised by the subject correlated with the MRI.
It was highest in the axial plane (Y axis, 0.82) and again lowest in the coronal plane (X axis, 0.62). The range of Euclidean distances, between the locations was high, ranging from 6mm to 59mm.
The location as assessed by the subject was, on average, 30mm away from the location found by the examiner. The subject generally localised pain further from the lesion on MRI than did the examiner on palpation.
Discussion
Figure 6: Location points as scatter plots with Pearson correlation coefficients between Subject Locations vs. MRI Locations in all 3 planes
Different authors suggest symptoms differ between lesion sites and that pinpoint tenderness can be elicited1,19,20. References to physical findings include tenderness in the antero-lateral corner of the tibio-talar joint for lateral lesions and in the antero medial corner for medial lesions8. Fransom21 and Berlet22 found that with the addition of plantar flexion and dorsiflexion respectively, antero-lateral lesions can be palpated antero-laterally, and postero-medial lesions may be palpated posterior to the medial malleolus; however neither group provided supporting evidence for these claims. Verhagen, in their prospective study on diagnostic strategies, did not evaluate the findings on physical examination in isolation15. Although they specified the locations of lesions and endeavoured to determine the diagnostic value of clinical findings, they did not relate them to routine radiological examination.
Figure 5: Location points as scatter plots with Pearson correlation coefficients between Subject Locations vs. Examiner Locations in all 3 planes
Figure 7: Location points as scatter plots with Pearson correlation coefficients between Examiner Locations vs. MRI Locations in all 3 planes
The scale of the measures has to be taken into account when considering any relationship. The dimension of an average sized talus is approximately 50mm in both the sagittal and coronal planes, thus a separation between the subject’s localisation of pain and the examiner’s assessment of maximal tenderness of 50mm represents the whole width or depth of the articular surface of the talus. Thus, a medial lesion may present with lateral pain and tenderness and vice versa.
The source of pain when there is damage to articular cartilage and subchondral bone is unclear. Articular cartilage is not innervated and is therefore not the direct source of the pain23,24,25. Associations between subarticular bone marrow changes and pain are strong and these are analogous to the changes seen in OCL, but whether this is a direct source of pain is unclear23,24,26. In this study, the pain experienced by the patient and the area of tenderness found, were as variable to each other as to the actual site of the lesion. We suggest that OCL of the talar dome result in pain that is poorly localised, with respect to the site of the lesion, and the area of maximum tenderness. As a result, vaguely located ankle pain with poor clinical localisation would warrant MRI to exclude an OCL. Care must be taken when attributing an OCL on an MRI to the subject’s pain. Mark Davies is a Consultant Orthopaedic Surgeon at Northern General Hospital, Sheffield specialising in elective and trauma of the adult foot and ankle. He co-ordinates the research activity for the Sheffield Foot and Ankle Unit.
Correspondence: Email: mark.davies@sth.nhs.uk References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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Minimally Invasive Forefoot Surgery Editorial comment from Fred Robinson
For – Anthony Perera
As in all spheres of surgery, there is always a tension between our desire to reduce the size of the skin incision, minimising the soft tissue dissection and the need to ensure that the bony and soft tissue elements of the surgery are completed with accuracy. Foot surgery is no different and over the last few years foot and ankle surgeons have been debating the pros and cons of minimally invasive forefoot surgery. In the next two articles the pros and cons of minimally invasive surgery are debated. Of course there is no right answer but at least it helps to be better versed in the arguments!
Anthony Perera
Dishan Singh
Adam Lomax
Co-authors Andy Molloy & David Redfern
The debate as to whether minimally invasive forefoot surgery is justified needs a frame of reference. Pitting everything done with a small incision against a few successful things done with a large incision, without consideration of the deep dissection, osteotomy, fixation, biomechanics and rehabilitation is illogical. All of these factors have much a greater bearing on the outcome than the superficial wound. For example, somewhat bizarrely the Hohmann osteotomy, rebranded as the Bosch or the SERI, now finds itself switching sides. It no longer counts as ‘open’ surgery, despite being an open approach done with a standard saw, just because it has a smaller cut and is skewered with a K wire. For a scientific debate clarity is essential. This article is not a defense of the Bosch, SERI or Reverdin osteotomies, they did not work through a large hole and are no more useful through a small hole. Neither are they in anyway related to the percutaneous, fixed chevron osteotomy (MICA – minimally invasive chevron Akin) any more than the scarf is related to the Wilson, Mitchell or indeed Hohmann. Such diverse procedures would not be treated as a single entity just because they are all done with a saw. NICE guidance fails to recognise such distinctions. >>
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THE COMMONEST COMPLAINTS ARE SOFT-TISSUE RELATED SUCH AS STIFFNESS AND SWELLING.
Nor is this a case for MICA supremacy. Whilst this is our preferred technique, bunion patients vary in numerous factors and it is therefore just one part of our armamentarium, which also includes the scarf osteotomies, amongst others.
Why can’t we just be satisfied with what we know? To put it simply we have just not found an ideal surgical solution yet, far from it in fact. The variety of procedures and the lack of any universally agreed ‘gold-standard’ clearly demonstrates this. The 2014 ‘A Systematic Review’1 found that there was insufficient evidence to comment on the effectiveness of both the Scarf and percutaneous osteotomy - including the MICA for which there were no randomised control trials (RCT). Only the open distal chevron osteotomy was found to be “likely to be beneficial and more effective than no treatment or orthoses”. All techniques have complications. Up to 38% of Chevron patients had complications in one RCT. In another 10% were dissatisfied with the appearance, 10% had metatarsalgia and whilst there was better function and pain relief at one year there was no difference in the ability to work compared with no treatment! The Scarf fares no better and Coetzee in demonstrated in his paper ‘Scarf Osteotomy…the dark side”2. Nevertheless, we know that generally problems related to the bone surgery are uncommon for
any technique that follows the principles of bunion surgery as laid out by Barouk and others. On the contrary the commonest complaints are soft-tissue related such as stiffness and swelling. Unfortunately, these are largely under-reported as they are harder to measure. The reliance on x-ray parameters and the AOFAS score to determine the ‘success’ of surgery is a major failing of the literature.
What is the case for the Percutaneous, Fixed Chevron osteotomy (Or MICA)? There has been very little change in the soft tissue element of bunion surgery for some time, if anything it has become more aggressive even though, the lateral release and the medial capsulorraphy all contribute to the overall insult. Yet soft tissue preservation is very important in foot surgery as it is in trauma surgery and the importance of this central tenet of the AO philosophy becomes more apparent if a first ray osteotomy is likened to a fracture. Thus a scarf osteotomy is more like a grade II or even III injury and the MICA more like a grade I. We know that whatever osteotomy is used the bony part of the surgery is reliable. The question is whether the same basic principles of bunion surgery can be applied through a smaller surgical approach. This is not about cosmesis. It is about deep soft tissue complications (swelling, stiffness) and the superficial soft tissue complications (in one UK study3 of the scarf there was a 4% infection rate and a further 31% scar complication rate).
As MICA is in its infancy there is very little in print available for comparison, much like the scarf in its early stages. Perera’s series of two consecutive cohorts of open and percutaneous bunion corrections (primarily Chevron) based on ‘intention to treat’ was presented at BOFAS 20134. This showed equivalent bony correction but improved soft-tissue outcomes including infection, stiffness and functional outcome scores for MICA. There was a learning curve and this was primarily related to the fixation. Lam presented his results of a randomised trial on scarf versus MICA at BOFAS 20145, again demonstrating equivalent radiological results but improved soft tissue outcomes for MICA.
So what of the future? Orthopaedics must constantly strive to improve and one should not write-off exploration of percutaneous surgery as the latest gimmick, or worse as just a marketing ploy, as this would fail to recognise the need to improve what we have. However, patient safety is paramount and trumps innovation, thus it is essential that patients are aware that MICA is a new procedure and that they understand the NICE guidance on the subject. There is a learning curve and it is not for everybody. This applies to both surgeon and patient. Thus it should only be performed by an appropriately trained expert and then only as part of audit and research, acknowledging the possibility that MIS may not be the answer. This will only be possible if we collect data and monitor outcomes in scientific study.
It will not come from both sides brandishing individual examples of poor outcomes. Of course, no other innovation (e.g. scarf, basal opening wedge and Tightrope procedures) has been subjected to this level of scrutiny and therefore it is clear that the evidence base of bunion surgery as a whole and not just minimally invasive surgery needs work.
Against – Dishan Singh & Adam Lomax Minimally invasive surgery (MIS) for correction of hallux valgus (HV) is not justifiable. There is insufficient evidence to support its use and its historical failures should not be repeated. Since the introduction of MIS for HV correction in the United Kingdom (UK) in the 1980’s, three main procedures have been used. Bosch described a linear osteotomy at the metatarsal neck, performed with a saw through a small vertical skin incision. An intramedullary k-wire was then used to displace and hold the metatarsal head laterally6. Using his own modification of this technique Giannini published good results, but these results were not matched elsewhere7. Myerson abandoned the procedure after observing dorsal mal-alignment in 69% of cases and a recurrence rate of 38%8. Magnan reported a malalignment rate of 25.5%, Huang showed a poor radiographic result in up to 63.9% of cases and Ianno observed an overall complication rate of 29.4%9-11. This technique has now largely been abandoned in the UK.
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Š 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 01, pages 50-54 Title: Minimally Invasive Forefoot Surgery Authors: Anthony Perera, Dishan Singh & Adam Lomax
A second technique, the Reverdin-Isham osteotomy involves an intracapsular osteotomy performed with a burr through a percutaneous incision12. The correction was achieved through a medial closing wedge osteotomy of the head, decreasing the distal metatarsal articular angle. No internal fixation was used. The result was shortening of up to 9mm along with non-congruence of the 1st MTPJ in up to 47%
of cases13. This technique has also largely been abandoned throughout Europe. A third MIS technique then emerged; the Minimally-Invasive Chevron-Akin (MICA)14. This is advocated by approximately 15 surgeons in the UK today. Again however, it has a track record of problems. The fixation, performed initially with one screw was inadequate. Subsequent attempts, next with two dorsal
screws and then with two short medial screws also proved insufficient. Now in its 4th generation, fixation using two long screws from the medial side is currently favoured. There have been articles promoting MICA in the national press, generating public interest with claims of good long-term results, reduced swelling and pain and earlier return to function15. This may be headline grabbing and attractive
to patients, but medicine must remain evidence based. These publicised results and early postoperative benefits have not been substantiated with robust clinical evidence. Importantly, the good published results for HV correction with open chevron osteotomy should not be transferred to the MICA technique because the surgery is very different. The chevron is used to correct mild or moderate HV deformity
>>
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A LATERAL SOFT-TISSUE RELEASE, WHEN REQUIRED IS ALWAYS PERFORMED BEFORE THE OSTEOTOMY...
at most, since the head translation should be no more than 50% of its width to maintain stability16. A lateral soft tissue release, when required is always performed before the osteotomy to allow relocation of the sesamoids as the head is translated laterally. Finally, a medial capsular plication is performed to address the attenuated medial soft tissues. For the MICA technique, bony cuts are made percutaneously with a burr using x-ray guidance. The cuts that are made are inaccurate having been shown to be out-with the surgeons intended orientation in 100% of cases17. The burr is thicker than the saw, meaning that bone loss is more pronounced and metatarsal shortening occurs18. Furthermore, the burr causes severe damage to the bone such that bone healing is not faster simply because the skin incision is small. Subsequent displacement of the head is frequently beyond 50%, even 100% in cases of more severe deformity. The lateral release is always performed at the end of the procedure, after the head translation and not before19. The medial soft tissue attenuation is not addressed. It is clear that the MICA procedure is not the same as the open operation, but for the fact that the bone cuts are performed percutaneously and with a burr. This is a completely different surgical procedure, which must be evaluated for outcomes in its own right. The only evidence available for the good outcomes of MICA comes from short-term follow up (mean
3-7.5 months) of small cohort groups, without comparison or control. All of these studies come from technique-originator data, in abstracts submitted to scientific meetings. It remains unpublished in peerreviewed literature20-22. In fact, similar unpublished evidence presented recently from a non-originator surgeon who has now abandoned the technique showed a complication rate of 27%23. There are no comparative trials to prove that MICA delivers any of the suggested benefits over open techniques. It is unsurprising therefore, that two systematic reviews have failed to recommend the use of MIS surgery over open techniques for the correction of HV24,25. In summary, assuming equivalence in long-term outcomes for MIS surgery and open techniques is flawed. The suggested additional advantage of improved early postoperative recovery is not evidence based. The published evidence in MIS for HV correction shows an increase in complications and a record of failure. Until well-conducted comparative trials show proven outcomes and beneficial results from this technique, we must not recommend it to our patients. Anthony Perera is an Orthopaedic Foot and Ankle surgeon in Cardiff. He trained on the Warwick Rotation followed by fellowship training in Dublin and Baltimore. He has been performing minimally invasive foot surgery for the last 5 years and teaches on the UK and GRECMIP courses as well as conducting audit and research on the techniques.
Dishan Singh is a consultant orthopaedic surgeon at the Royal National Orthopaedic Hospital in Stanmore and director of the foot and ankle unit. He is a Past President of the British Orthopaedic Foot and Ankle Society and is a member of the scientific committee of the European Foot and Ankle Society. His research interests include bunion surgery, hindfoot deformity and inferior heel pain. Adam Lomax is an orthopaedic trainee who completed his speciality registrar training on the West of Scotland rotation. He has undertaken fellowship training in foot and ankle surgery with Dishan Singh at the Royal National Orthopaedic Hospital, and is currently with James Calder at the Fortius Clinic in London.
Correspondence: Email: anthony@footandankleuk.com Email: Dishansingh@aol.com Email: 1adamlomax@gmail.com References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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Case of the Interesting Ankle by Alison Blake-Reed
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JTO Peer-Reviewed Articles
How I... Fix Ankle Fractures in Diabetic Patients Tim White & Kate Bugler
Unstable ankle fractures in elderly, obese or diabetic patients with vulnerable soft tissues are challenging injuries to treat. Concerns regarding wound dehiscence and infection following lateral plating can tempt the surgeon to consider conservative management, with acceptance of malreduction, or to potentially restrictive interventions such as spanning fixators or calcaneotibial nails. The use of a fibular nail allows for stable fixation with only a small lateral wound, significantly lower rates of infection1,2 and good clinical outcomes3.
The patient is positioned supine on the operating table with a sandbag under their buttock and the fracture then reduced using ligamentotaxis. A small 1cm wound is then made just distal to the distal fibula and a 1.6mm guidewire inserted into the very distal tip of the fibula heading towards the centre of the metaphysis. Image intensification is used to confirm the guidewire position as a poorly chosen entry point can lead to malreduction.
Tim White
Kate Bugler
The canal is then prepared in a style common to any long bone nailing; in this case first with a cannulated drill and then with a
hand reamer. The nail is then implanted using the jig, with around 20 degrees of external rotation of the nail necessary to ensure that a screw through the nail is able to cross the syndesmosis. Locking screws are then inserted starting with a distal locking screw. This screw should abut but not penetrate the posterior cortex of the fibula to prevent damage to the peroneal tendons. Using the jig the final reduction of the fracture can then be undertaken with a little backslapping and rotation of the nail if necessary.
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Where there is a syndesmotic diastasis, careful reduction is assisted by fluoroscopic views of the contralateral side and a periarticular reduction clamp. A final screw is then inserted from lateral-to-medial into the tibia to provide the strong lateral buttress required to prevent talar shift. This can be supplemented with a second screw, if required, to confer additional strength. The three small wounds are then closed to complete the procedure.
Tim White is a Consultant Orthopaedic Trauma Surgeon at the Royal Infirmary of Edinburgh. He and Kate Bugler are the authors of the chapter on ankle fractures in the new edition of Rockwood and Green. Kate Bugler is a specialty registrar in Trauma and Orthopaedics in the South East Scotland deanery.
Š 2015 British Orthopaedic Association
Correspondence: Email: timwhite@doctors.org.uk
References: 1. Asloum Y, Bedin B, Roger T, Charissoux JL, Arnaud JP, Mabit C. Internal fixation of the fibula in ankle fractures. A prospective, randomized and comparative study: plating versus nailing. Orthopaedics & traumatology, surgery & research: OTSR 2014; 100(4Suppl): S255-9.
Figure 3: Insertion of screw across the syndesmosis
Figure 1: Displaced pronation external rotation type ankle fracture in an obese patient with diabetes
Figure 2a & 2b: Identification of the starting point for the nail
2. White TO, K.E. B, Appleton P, McQueen M, Court Brown C. Randomised controlled trial of fibular nail fixation in elderly patients. OTA; 2012; Minneapolis; 2012. 3. Bugler KE, Watson CD, Hardie AR, et al. The treatment of unstable fractures of the ankle using the Acumed fibular nail: development of a technique. J Bone Joint Surg Br 2012; 94(8): 1107-12.
Figure 4: Final construct
Figure 5 & 6: Post-operative wounds (medial and lateral)
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24 & 25 September 2015 Wrightington FRCS (Orth) Upper Limb
Further information: please contact Mavis Luya, Upper Limb Research on +44 (0) 1257 256248 or Jackie Richardson FRCS/Basic Science & Ultrasound only on +44 (0) 1257 256248/6413
4 September 2015 Shoulder Ultrasound
1 & 2 October 2015 Hand & Wrist Cadaveric (Elective) Course
Email:
Orthopaedic surgery courses suitable for all stages of your career and covering sub-specialty interests and exam revision including
Orthopaedic Surgery in courses l Basic Techniques Arthroscopic Surgery Over 30 courses available to l Hip, you Ankle and Distalyour Radial support throughout career * Fractures Orthopaedic Surgery * Orthopaedic Trauma l FRCS (Tr and Orth) Viva Course * Orthopaedic Sports for Orthopaedic Surgeons Trauma Surgery l Surgical Approaches to the Upper and Lower Limb
On selected we offer Find out morecourses, www.rcseng.ac.uk/ a 10% discount to Members courses/course-search/specialty/ and Fellows of The Royal College orthocourses.html of Surgeons of England The Royal College of Surgeons ofFor England, Lincoln’s a full list35-43 of courses and Inn dates Fields, London WC2A 3PE Charity www.rcseng.ac.uk/courses no: 212808 | T: 020 7869 6300 | E: education@rcseng.ac.uk
l Advanced Arthroscopic Knee l Anatomy revision for FRCS (Tr & Ortho)
The Cuschieri Skills Centre in Dundee has developed a comprehensive new orthopaedic course portfolio to include courses suitable from FY2 to ST6 level. The following Sawbone and Thiel Cadaveric courses are available in 2015: l Cadaveric Shoulder Arthroscopy 2 March l Cadaveric Knee Arthroscopy 3 March
Quality Improvement for Surgical Teams (QIST) is an opportunity for Orthopaedic Surgeons, Anaesthetists, Nurses, Managers, Commissioners, Pharmacists and Allied Health Professionals to share best practice at a 2 day conference hosted by Northumbria Healthcare NHS Foundation Trust held at The Marriott Hotel Gosforth Newcastle.
12th ICRS World Congress
22 & 23 September 2015 Wrightington Basic Science
upperlimb @wrightington.org.uk Websites: www.wrightington.com www.wiganleigh.nhs.uk
l Cadaveric ACL Reconstruction 21 April l Cadaveric Surgical Approaches to the Spine 1 May l Principles of Hip Arthroplasty 16 June l Principles of Knee Arthroplasty 17 June l Cadaveric Lower Limb Amputations 31 August l Surgical Approaches to the Upper Limb 10-11 September l Cadaveric Forefoot Surgery 6-7 October
Please visit our website for full details and to register.
Day 1 Tuesday 20th October 2015 - Elective Hip and Knee replacement surgery • New ERAS guidelines • Pre-op preparation • Key surgical factors • Improving PROMS • Measuring results
Day 2 Wednesday 21st October 2015 - Surgical Site Infection • Understanding the effects of infection: A patients experience • NICE Quality standard 49 – SSI • What’s new in infection prevention • Revision surgery planning following infection • Patient safety – sepsis update • Novel tests – update Convenor Mr Mike Reed Consultant Orthopaedic Surgeon Go to www.qist.co.uk for more details and to register
Delegate rate £40 per day
- Hip Fracture • Enhanced recovery programmes • Reducing mortality
The 12th ICRS World Congress will be held in Chicago on May 8-11, 2015. ICRS has earned its niche among professional orthopaedic societies with a unique focus on cartilage repair and biotechnology. Our mission is to bring innovative research and education to our attendees. This meeting will deliver this mission at an incredible venue filled with a
robust scientific programme, technology updates, clinical innovations, satellite symposiums, debates on controversial issues, and opportunities for career development. Clinicians, researchers, bioengineers, and industry partners will have the opportunity to discuss the latest developments in bio printing, joint resurfacing, rehabilitation, nanofabrication, imaging and more.
Cuschieri Skills Centre, University of Dundee, Level 5, Ninewells Hospital and Medical School, DUNDEE DD1 9SY Scotland, UK Tel: + 44 (0)1382 383400 Fax: + 44 (0)1382 646042 Web: www.cuschieri.dundee.ac.uk
Email: office@cartilage.org Website: www.cartilage.org Phone: +41 44 503 73 70
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 60
In Memoriam
Stuart James Calder 3rd August 1962 – 26th October 2014 Stuart Calder grew up in a military family stationed overseas travelling to and from school at Windlesham before
Stuart James Calder
Winchester and finally in Ilkley, North Yorkshire. He studied medicine at Bristol where he met Clare, whom he married in 1990, and surgical training in Bristol, London and Yorkshire followed qualification in 1986. He spent two years in research in Leicester with Professor Paul Gregg, resulting in the award of an MD in 1994, after which he returned to Yorkshire to complete his orthopaedic training. In 1997 he spent a year with his family in Brisbane and completed a fellowship in knee surgery with Peter Myers. He was appointed consultant at the Leeds General Infirmary in 1998 as a hip and knee surgeon. His practice rapidly developed into a specialist knee service
accepting complex cases from the Yorkshire region and beyond. With his straightforward approach to clinical practice he earned genuine respect and affection from his patients. He established numerous training courses in arthroscopic surgery and ligament reconstruction and taught around the country. He supported a trainee and senior knee fellow many of whom continued to seek his help long after completing the fellowship. He maintained his research interests with colleagues at Leeds University studying alternative clinical and basic science approaches to knee arthritis and continued to publish throughout his career. Stuart placed enormous importance on teaching and training. He organised the local trainees for many years and always strongly defended their cause through the challenges of the last 15 years.
Stuart had an uncomplicated approach to life and work and never took himself too seriously. This belied a deeply caring person for whom Clare and their family were foremost. He had an ease about him that allowed him to give and seek help without judgment. He accepted challenges, often absurd, such as the London Marathon or cycling across the Pyrenees, with humour and determination, if not great glee, and would always find time to encourage others, often with the phrase “Pain is just weakness leaving the body”! This, whilst seriously questioning the sanity of his own involvement. Above all, Stuart enjoyed his life. He was an entertainer yet took his responsibilities to his family, friends and patients very seriously. Selflessly going to the aid of others was how he lived and it is why he is no longer here today. He will be greatly missed.
Wisepress Book Review BOOK OF THE QUARTER
NOW AVAILABLE
Dynamic Reconstruction of the Spine
Skeletal Trauma: Basic Science, Management and Reconstruction
Author/s: Kim, D H ISBN: 9781604068733 Publication Date: 31st January 2015 Price: £151.50 The most up-to-date resource on the instrumentation, technologies, and fundamental science integral to achieving spine motion preservation and stabilization. It is a completely revised text that includes not only the latest technologies and surgical approaches, including MIS techniques, but also significantly more detail on the clinical biomechanics of the spine than the previous edition. 15% discount to BOA members, just enter promo code BOA at the checkout.
Author/s: Browner, B D; Jupiter, J B; Krettek, C; Anderson, P A ISBN: 978145576283 Publication Date: 26th January 2015 Price: £329.70
Imaging Skeletal Trauma Author/s: Rogers, L F; West, O C ISBN: 9781437727791 Publication Date: 12th January 2015 Price: £80.84
MRI of the Knee Author/s: Bolog, N V; Andreisek, G; Ulbrich, E J ISBN: 9783319081649 Publication Date: 14th February 2015 Price: 108.00
Crash Course Rheumatology and Orthopaedics Author/s: Elias-Jones, C; Perry, M; Horton-Szar, D ISBN: 9780723438670 Publication Date: 5th January 2015 Price: £27.99
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 62
Imprint
JTO:
Instructions for authors Authors wishing to submit a news item, feature article or peer-review article for the JTO should, in the first instance, submit a synopsis of 120 words explaining what the article is and its relevance within the JTO. This should be emailed to JTO@boa.ac.uk. This will then be passed on to the Editorial Team for confirmation that the subject matter will be appropriate for publication. You will receive an email from the JTO team indicating their decision. The JTO does not publish audits or case reports.
Information for readers, advertisers & potential authors
JTO Editorial Team l l l l l
Ian Winson (Editor) Ananda Nanu (Deputy Editor) Michael Foy (Medico-legal Editor) Peter Smitham (Trainee Section Editor) Fred Robinson (Guest Editor)
BOA Executive Colin Howie (President) Tim Briggs (Immediate Past President) Tim Wilton (Vice President) Ian Winson (Vice President Elect) Don McBride (Honorary Treasurer) David Limb (Honorary Secretary) l Mike Kimmons (Chief Executive) l l l l l l
BOA Elected Trustees l l l l l l l l l l l l l l l l l
Colin Howie (President) Tim Briggs (Immediate Past President) Tim Wilton (Vice President) Ian Winson (Vice President Elect) Don McBride (Honorary Treasurer) David Limb (Honorary Secretary) Gordon Matthews Ananda Nanu Alistair Stirling R. Adam Brooks Grey Giddins Ian McNab Philip Mitchell David Clark Simon Donell Mike Reed Fred Robinson
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Special thanks We are grateful to the following for their contributions to this issue of the Journal: Caroline Lever, Ian Nelson, Dr Lisa Roberts & Mark Emerton.
Copyright Copyright© 2015 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820
BOA contact details The British Orthopaedic Association 35-43 Lincoln’s Inn Fields London WC2A 3PE Telephone: 020 7405 6507 Fax: 020 7831 2676