THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 04 / Issue 03 / September 2016 boa.ac.uk
Inside
Read the News and Updates section for the latest from the BOA and beyond
In our Features section you will find articles that focus on research, training, regional spinal networks and responses from our Specialist Societies about innovations in their subspecialty
For the latest update on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is innovation, plus our regular “How I…” piece
News & Updates ––– Pages 02-23
Features ––– Pages 24-55
Peer-Reviewed Articles ––– Pages 56-68
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JTO News and Updates
From the Editor
Contents
Ian Winson, BOA Vice President
So, two years as JTO Editor have flown by, as I step into my presidential role, Phil Turner will take over and continue, I am sure, to move things ever onwards and upwards. I have to say a huge thank you to Lauren, Emma and the two deputies I have had – Ananda, and now Fred. It is true they do all the hard editorial work, but really it is the contributors who put in the hours and give us the opportunity to discuss very publicly so many professional issues that need to get into black and white. We have a great relationship with our publishers and we are exploring the potential for a JTO app. This will give us an opportunity to reach a wider audience and make the JTO more accessible for our current membership.
You only have to look at the range of subjects discussed in this issue and in particular look at the sections on innovation (pages 34-35 and pages 56-67) to see that we as a profession are fully engaged with driving our professional lives and patient care forward. Focusing on the future does challenge us to consider what innovations are going to be made that will change our clinical care over future years. A major issue is how innovation and change can be controlled but not inhibited; it will be the biggest question over the next few years, this will take leadership. Trying to develop leaders for the future is clearly something the BOA has taken on board. It is so much better to develop leaders taking into account their natural talents than to let Napoleonic diminutive rotund megalomaniacs take over... Finally, we have letters (page 20)! The caption competition winner (page 17) was for me a special moment as I have been mistaken for Des Lynam on many occasions which just helps to reinforce my belief that despite all the evidence to the contrary I am 6ft. 4in tall (see above).
JTO News and Updates JTO Features
Why Opt In? Inspiring the best to be better: The BOA Clinical Leadership Programme Regional Spinal Networks
02–23
24–55
From CT scan of a bone to 3D printed model, using Open Source software and a desktop printer
24
26 27 26
Hip Fracture Research: The WHiTE study and beyond 32 What’s your innovation?: From our Specialist Societies 34 New Guidelines for Diabetic Feet 36 Care Quality Commission (CQC) Inspections 38
Self-Perception in Orthopaedic Trainees: Is there a Gender Difference? Variability in Trauma and Orthopaedic Training Programmes: Two perspectives Incorporating leadership and professional skills training into a T&O regional teaching programme The Importance of Recognising the Different Kinds of Expert Surgical Evidence
40 42 50 52
JTO Peer-Reviewed Articles 56–68 Innovations in Trauma and Orthopaedic Surgery: 3D Printing
56
Advances in osteoarthritis imaging: What will make it into clinical practice?
60
The use of stem cells in articular cartilage defects: Where are we now?
64
How I… fix a Monteggia variant injury with a radial head fracture
68
In Memoriam
69
General information and instructions for authors
72
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JTO News and Updates
My year at the BOA helm Tim Wilton, BOA President
It has been a busy and rather surprising year at the BOA helm! First of all I would like to thank you all for the wonderful opportunity I have had to lead the organisation over the past year. I have enjoyed it immensely despite the undoubted rigours involved from time to time. I am looking forward to the chance to meet up with and speak to as many of you as possible at the Congress in Belfast. I have greatly enjoyed the chance to have direct contact with so many of you at the Specialist Society meetings I have managed to attend. Our relationships with the various Specialist Societies have, I think, never been better and it is certainly a major priority for the BOA that they should remain so. There have been many challenges during the year, and some unfortunately remain unresolved. The junior doctors dispute with government has been a huge issue and I hope you agree the BOA has supported our trainees steadfastly throughout. The imposition of a new contract which causes any of the juniors to earn less seems to me a huge error of judgement when seen against a backdrop of the enormous debts they all now carry into their working lives. Our own solution to the problem of morale amongst trainees must surely be to work hard to ensure their time spent training is never wasted.
Tim Wilton
Clearly one good way to avoid being caught out by events is to expect the unexpected…or at any rate the unlikely. This is easy to say and not always simple to do but those of you who were able to read my first Presidential article last year may recall that
I predicted a fairly torrid and eventful year. Nonetheless, I wonder just how many of us would have predicted that we would be the first to EXIT with all the talk there had been of GREXIT the year before. Closer to home but in parallel we in trauma and orthopaedics have unfortunately been faced with not one, but two separate ‘annual’ attacks on Tariff within just four months. In March the threat was made very forcefully that we would be subject to substantial reductions in Tariff for orthopaedics from April 2016, only to have the threat lifted at the last minute and the ‘old Tariff’ continued despite its acknowledged short-comings. This was not because NHS England wished to go on paying the same price for our work, but simply because they thought at that time it would be “too disruptive to make such major changes across the board” by the introduction of the new HRG4+ system. We did, therefore, anticipate that this change was waiting in the wings to be introduced next year. What we did NOT anticipate was that NHSI (Ex Monitor) would see fit to stack all the potential weapons in a row and fire them at orthopaedics; as a volley! The dust had barely settled when in July this year we were informed that a new Tariff based on HRG4+ would indeed be introduced from April 2017, but would be accompanied by swingeing cuts in Tariff which would amount to 19% reductions for trauma and orthopaedics.
This announcement, planned to be made just days before the summer recess, was made up of a 10% ‘efficiency saving’ across all specialities, another 2% adjustment which they cannot really explain but relates to overuse of ‘specialist commissioning’ and then a 7% additional cut because trauma and orthopaedics has allegedly been ‘overfunded’ for about seven years since the waiting list push was supposed to end. You will be pleased to hear that our immediate and energetic interventions lead to an urgent review and step-back from the edge by the NHSI team. You may be slightly less reassured to hear that they then agreed to reduce the planned reduction in Tariff from 19% to 11.5%, which is still hugely worse than most Trusts think they can possibly manage. We will persevere with negotiations! Waiting lists have come down dramatically and have largely stayed down in much, but not all, of the country. However, that is due in no small part to the large number of elective cases being done on extra lists at weekends and/or being transferred to the Independent Sector, both of which have the potential to disappear overnight if the finances do not stack up for the hospitals. The waiting-times for “elective” surgery have always been volatile which is due largely to the erroneous view that this sort of surgery is a luxury. Our patients awaiting surgery for painful hips and other disabling conditions are unlikely to agree
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with that view, but they remain the target whenever a government wishes to reduce expenditure in the NHS because they are less politically emotive than other groups such as paediatrics, cancer patients, heart disease etc.
cheaper devices in our work where they produce equivalent or better outcomes for the patients, our priority has to be to ensure and improve quality of care rather than to reduce costs if these two aims are not coincident.
As a profession we must continue to lead the charge in pressing for proper access to appropriate treatment for our patients.
To my mind this principle applies across the whole spectrum of orthopaedics and is perhaps the one guiding principle that we can and must retain if we want to maintain a first class trauma and orthopaedic service for ourselves as well as our patients.
Currently in much of Canada financial constraints have led to waiting times very similar to those in England 10-15 years ago and there are still, or already, pockets of similarly poor access in the UK. BREXIT and the ensuing financial strictures are likely to be used by politicians as an excuse to tighten the financial screws on the NHS still further. It will have to be made clear to ministers that if the funding is cut severely, as they suggest; a return to waiting lists of over a year is highly likely and will be directly attributable to these actions by them. While we will continue to support making savings where they are clinically appropriate and using
There is some light along the tunnel. Our first and very urgent response to NHSI about Tariff in July resulted in a re-think and a delay in publishing their plans. Regarding BREXIT, the EFORT hierarchy with whom I met in July feel there is no reason why BREXIT should have any adverse impact on our dealings with them and they are keen to press ahead with various plans we have jointly concerning implant safety, training standards, and such matters as mutuallyagreed European guidelines for some orthopaedic conditions.
NICE have decided to take a completely fresh look at VTE prophylaxis, and came to see us this week to consult us about our issues with their current advice… perhaps a breakthrough! Our trauma community goes from strength to strength, with BOA hip fracture service reviews in demand. Please rest assured that the income stream from this activity is used to fund BOAST production and dissemination, as well as the annual training day (featured on page 14). The OTS meeting in Warwick earlier in the year was a particular success, reflecting a strength in depth in orthopaedic, as well as orthoplastic, trauma. Orthopaedics has some of the most effective, and costeffective, treatments available in medicine and in the UK we have increasingly good information about what works, how we are doing and when and how to intervene to get the best results. The outcomes data from the Registries give an excellent tool to help us to do our jobs better. ODEP ratings now
extend to knees, and we have the potential with the Beyond Compliance scheme to get far better information about implants in the early phase of their use. We can get first class costeffectiveness data for much more of our interventions if we take the emerging registries seriously and raise compliance with them as quickly as possible. Then we will really have data which can effectively counter the pressures to limit what we offer patients. I do have concerns that I have not managed to ‘sort’ all of these issues to my satisfaction before Ian Winson takes over as BOA President. On the other hand, there is no doubt that he is more than up to the job: he has been an outstanding and hugely supportive Vice-President to me over the last year and he will be a great success as President in the coming year. I would like you all to welcome him to the Presidency with the enthusiasm he deserves and to offer him any and all assistance in the coming year so that he may carry out his duties with the energy and wisdom of which I know he is capable.
You just keep going! Ian Winson, Incoming President 2016-2018
Ian Winson
Well this should be interesting. Two years ago when I joined the Presidential line we had a debate as to where the curse “may you live in interesting times” came from. Often known as the Chinese curse, the nearest actual translation of the Chinese saying is “better to be a dog in a peaceful time than a human in a chaotic period”. I guess, looking around at medical, national and international politics, it doesn’t get much more chaotic than this. Then again, 100 years ago the
world was in the grip of the First World War so maybe we should not overstate the case. But it does illustrate how important it is to check your data! The BOA as an organisation has developed, not only to be reactive, but to be proactive, and during my period as President we will continue to look to the future. We have really established the principle that for MSK patients it is actually important to have a dialogue with orthopaedic
surgeons along with those other professionals involved in their care. As clinicians we are encouraged to reflect on our practices, as President I think it is important I operate to the other definition of reflection and reflect your views on how we move forward. I do have my own views of what has made this happen in the past; Quality and Innovation, hence my theme for the year and for the Congress in a year’s time. Wish us all luck!
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JTO News and Updates
The BOA honours outstanding members The BOA is pleased to announce the recipients of the 2016 Honorary Fellowships, which will be presented at the Annual Congress in Belfast.
Frank Burke
Frank Burke trained and graduated in Newcastle and completed orthopaedic training in Oswestry with six-month hand surgery fellowships in Derby, Louisville and Iowa City. He was appointed a hand surgeon in Derby in 1978 and Professor of Hand Surgery in July 1996. Frank developed a Diploma of Hand Therapy and, with others, the Hand Society Manchester Instructional Courses and was the external assessor for the Hand Society’s Diploma in Hand Surgery. He is currently archivist of the International Federation and was awarded the title of Pioneer in Hand Surgery. The Derby Hand Surgery Service is currently staffed by nine full-time hand surgeons drawn from plastic surgery and orthopaedics.
Stephen Cannon MBE
A native of Sheffield, Stephen Cannon studied medicine at Trinity College Cambridge and Middlesex Hospital qualifying in 1974. He commenced a surgical career, initially in obstetrics, and after junior posts in other surgical specialties gained FRCS in 1978. He returned to the surgical rotation at Middlesex Hospital which incorporated exposure to orthopaedics with Rodney Sweetnam and Michael Edgar. He was appointed Senior Registrar on the Middlesex/Royal National Orthopaedic Hospital rotation in 1981 and soon developed an interest in musculoskeletal oncology and knee surgery. Stephen was fortunate to be exposed to some of the world leaders in orthopaedics at that time particularly by working with George Bentley, Tony Catterall and the late Lorden Trickey. He went to the US as a Johnson and Johnson Fellow and was appointed to the RNOH as consultant in 1988. He has developed, with his colleagues, both the Bone and Soft Tissue Tumour Unit and the Joint Reconstruction Unit at Stanmore which work closely to the Biomechanical Engineering Dept. of University College London. Stephen was awarded MBE in 2016.
Charles Court-Brown
Charles Court-Brown graduated with a BSc in Zoology from Aberdeen and an MBChB from Edinburgh. His surgical training was in Edinburgh with a Spinal fellowship in Toronto in 1984/85 in a Level I Trauma Centre. He was very impressed by the non-British approach to trauma and returned to Edinburgh as Senior Lecturer with a major interest in trauma. He contributed to much of the early work on tibial intramedullary nailing and then worked with Margaret McQueen studying the treatment and outcomes of the common fractures. Charles also developed a major interest in open fractures and helped Edinburgh become one of the first orthoplastic units in the UK. In the mid-1990s, Charles realised that fracture epidemiology was easily studied in Edinburgh as there was only one hospital treating trauma. Since then he has concentrated mainly on epidemiology, social deprivation and fractures in the elderly.
Ian Ritchie
Ian Ritchie was a DGH Trauma and Orthopaedic surgeon in Forth Valley, Central Scotland for 24 years. During that time his practice was in the generality of T&O with an interest in the upper limb. Other interests included surgical training and education. He was on the AO Faculty for the Principles Course for a number of years. He convened Training the Trainer courses for RCSEd both in the UK and internationally. In 2000, he was elected to the Council of the College. Ian was Director of Surgical Training at the College from 2005 to 2009 when he was elected Vice President. He was elected President of the College from 2012-2015. He now leads the development of the RCSEd International Surgical Fellowship Programme to support International surgeons who wish to come to the UK for up to two years to enhance their skills and understanding in a surgical discipline.
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JTO News and Updates
BOA Latest News BOA Screencast: Assessing casting techniques for surgical trainees The latest BOA screencast is available on our website and is on the topic of ‘Assessing casting techniques for surgical trainees’. Casts applied by surgeons could be better; the traditional approach to training in the art of casting has been inadequate and British Casting Certificate holders are encouraged to engage with surgical training and assessment. The BOA has created a 10 minute screencast for holders of the BCC and T&O trainees, aimed at collaboration between the two groups to drive up standards of casting in the UK. Viewers are briefed about how best to use the T&O curriculum and one of the ISCP workplace based assessments to structure learning and assessment. Please visit www.boa.ac.uk/training-education/orthopodcasts to view the screencast.
Orthopodcast: Episode 8 If a peer or a more senior colleague is doing surgery for which there is no evidence, what would or should you do? The drive for professional recognition puts tremendous pressure on surgeons to engage in questionable practices… who and how should we illuminate these? In ‘Surgery: the ultimate placebo’, Professor Ian Harris, an Australian orthopaedic surgeon and academic, provides us with a view that some surgery may be ineffective, or as effective as placebo. Much has been written recently about ineffectiveness and overtreatment in modern medicine; Professor Harris links this with the topic of placebos, and applies it to surgery. This 15-minute orthopodcast interview with the author explores how to stop the surgical malaise of ignoring good science and how to handle the situation when faced with such ignorance www.boa.ac.uk/orthopodcast/ episode-8-surgery-ultimate-placebo.
BOA NICE-accredited Commissioning Guides At the beginning of August, the BOA opened a one-month public consultation as part of a review process for four of its NICE-accredited commissioning guides. Consultation responses are now being reviewed and the guides will be reissued before the end of the year. We would like to take this opportunity to thank all who responded to any or all of the consultations.
BOA Instructional Course 2017 We are pleased to announce that the 2017 BOA Instructional Course, being held on 7th-8th January, will focus on spine and trauma. Delegates will have an opportunity to gain a number of clinical case-based discussions (CBDs) in the physiology of trauma, complications of inflammatory spine conditions and immediate assessment, care and referral of spine trauma. The Instructional Course is a highlight of the BOA’s training and education calendar, bringing together T&O trainees at all stages of their postgraduate training to prepare for their FRCS examination. Registration is now open, but please note that places are limited so we would encourage you to apply as soon as possible - visit the BOA website for further details: www.boa.ac.uk/events/instructional-course.
Queen’s Birthday Honours The BOA is delighted to announce that Past President, Stephen Cannon, was appointed a Member of the British Empire in the Queen’s Birthday Honours. Mr Cannon has made such a strong contribution to trauma and orthopaedics - both nationally and in Europe and we are proud that his work with the Skeletal Cancer Action Trust is getting the profile it so very much deserves. Congratulations, Steve – a much-deserved honour!
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BOA Appointments It is our pleasure to announce the following appointments to key positions: l BOA President for 2018/19: Phil Turner l BOA Honorary Secretary for 2017-2019: Deborah Eastwood l BOA Trustees for 2017-2019: Mark Bowditch, Lee Breakwell, Simon Hodkinson, Richard Parkinson
BOA Clinical Leadership Programme The BOA Clinical Leadership Programme (CLP) is an excellent opportunity to provide fellows with the support to develop their leadership capability whilst offering insights into how to accelerate service transformation and quality improvement within their given speciality. The programme consists of four two-day modules which focus on leadership effectiveness, context for improvement within T&O and the tools and methodology to support this, culminating in fellows presenting their improvement project as posters at the BOA Congress. Currently, there are three routes to apply, either individually, through your trust or via a specialist society sponsoring the programme. Applications open in autumn 2016 with further information available on the BOA website www.boa.ac.uk/training-education/clp.
Scaling Up Improvement
The BOA has partnered with Northumbria Healthcare and the Royal College of Physicians to run a quality improvement collaborative for patients with a hip fracture. The initiative is funded by the Health Foundation’s “Scaling up” programme for £500K and will bring together six acute hospitals aiming to improve care and mortality by a multidisciplinary approach. The programme launched on 6th September 2016 and will run for two years. For more information, please contact policy@boa.ac.uk.
Joint Action Challenge Events We would like to thank and congratulate Yusuf Mirza and Shiv Sha for participating and completing the British 10K London Run on Sunday 10th July and for reaching their fundraising targets. Huge thanks also to Edmund Ieong for taking part in the RideLondon-Surrey 46 on Sunday 31st July. This year is the first year that we have had these sought after places available. If you are interested in participating in either of these events (or the London Marathon) in 2017, contact jointaction@boa.ac.uk.
BOA Travelling Fellowships We are pleased to offer a number of Travelling Fellowships to our members for 2017. Fellowships offer a unique opportunity for members to visit centres of excellence overseas, gaining invaluable knowledge, experience and different cultural perspectives within trauma and orthopaedic surgery. Up to 20 fellowships will be available. Applications will open on 13th September 2016. For further information, please visit www.boa.ac.uk/ training-education/boatravelling-fellowships.
BOA Collaborating with NHS Right Care The BOA is pleased to announce that we have agreed to collaborate with NHS Right Care in their initial roll out of ‘hands-on’ support to CCGs across the country. Specifically, we will be linking together our network of Clinical Champions, recruited by the BOA to engage with commissioners at a local level, with Right Care’s ‘delivery partners’, who will be providing direct support to CCGs to redesign local care pathways. NHS Right Care is a programme designed to increase value in healthcare by reducing unwarranted variation. The programme uses the NHS Atlas of Variation and Commissioning for Value Packs to enable commissioners to compare, for example, hip and knee replacement rates to their peers. Following this comparison, Right Care supports commissioners to work with local clinicians and managers to establish whether variation is unwarranted and, if so, develop a plan to reduce the unwarranted variation.
For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.
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Advertiser’s Content
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Advertiser’s Content
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JTO News and Updates
BOTA Educational Congress 2016 At BOTA we do not like to do things by half and the Educational Congress this year was no exception. Unfortunately, owing to the new compliance rules that nearly scuppered last year’s Educational Weekend, a move
away from Carden Park was necessitated, with the event taking place at the Hinckley Island, Leicestershire. The Congress was opened by David Kuhns of the RCSI
Andy Carr and Ian McDermott in the Chamber Debate at the BOTA Educational Congress
giving detailed insight into PAs and their role in the future of T&O, with highlights of the workshops including Jeremy Field’s session on ‘mistakes in surgery and how to handle them’. The final session of the day saw intellectual heavy-weight, Andrew Carr go head-to-head with Ian McDermott in the inaugural BOTA Chamber Debate, on the subject of the role of arthroscopy for treatment of the degenerate meniscus. Both speakers put forward powerful arguments, but, by the tightest of margins, the rigour of academia lost out to the charisma of clinical experience. Friday saw a trainee-focused BOA update from Past President, Colin Howie, along with a well-attended TPD forum and address from BMA JDC Chair Johann Malawanna on the latest contract negotiations. David Woods, Severn Deanery, received the inaugural ‘Golden Hammer’ trophy for Trainer of the Year.
Saturday followed a new format this year, with a mix of podium presentation sessions and a BONE collaborative session chaired by Amar Rangan. Lengthier workshops ran in the afternoon, with delegates having the opportunity to obtain Good Clinical Practice training or attend sessions on human factors (courtesy of RCS) or even how to build memory palaces (Linguisticator). The Congress was wrapped up on Sunday by AOSpine, who provided faculty and materials for the first principles course to be held in the UK for a number of years, with the highly enthusiastic faculty providing stations covering case discussions and practical procedures, such as pedicle screw insertion and anterior cervical plating. The BOTA Committee would like to say a huge thank you to all the faculty, staff and delegates for making the Congress a thoroughly enjoyable event!
World Orthopaedic Concern UK 3rd Annual Conference WOC (UK) held its 3rd annual conference at Moor Hall Hotel in Sutton Coldfield on Saturday 4th June. Dinner on Friday 3rd June was a lively affair, with interesting discussions surrounding the relationship between political climate and healthcare in low and middle income countries (LMICs). Country reports were presented for Malawi, Tanzania and Ethiopia. There was much enthusiasm for the new flagship WOC project in Ethiopia, based at the Black Lion Hospital in Addis Ababa. Tony Clayson, Laurence Wicks, Deepa Bose and Saqib Noor have recently visited, funded by the Rotary Club
and the Bone & Joint Journal. A report based on these visits has been submitted to the BJJ in the hope that there will be continued support. There was a palpable buzz in the room during the Ethiopia discussions, and it is hoped that we can continue to facilitate orthopaedic training in this beautiful country. The keynote Arthur Eyre-Brooks memorial speech was given by James Fernandes, consultant paediatric orthopaedic surgeon, entitled “The Unit of Hope”, in which he explained the value of regular visits to one region. Tim Beacon from MedAid International, spoke on the challenge of supplying
Delegates and speakers at the 3rd annual WOC UK conference
necessary equipment to LMICs. Jon Warner from Smith & Nephew shared his experience on Nepal. Faith Muchemwa told us about her experience as a rare breed: a female plastic surgeon in Zimbabwe.
The day finished with registrar fellowship reports. It was a delight to see lots of “new blood” at the conference, and we look forward to an even more successful one next year.
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BESS Meeting - Dublin 2016 The last time Dublin hosted the annual scientific meeting for BESS in 1997 just 80 delegates attended. This year the society returned attracting over 560 people who made the trip across the Irish Sea to the outstanding Dublin Convention Centre. The programme was packed following the now welltrodden BESS format with early morning instructional courses run by the local organising committee. Opening the meeting was an Allied Health Professional symposium on the multi-dimensional management of persistent shoulder pain with guest lecturers Mary O’Keefe from Limerick and Prof Filip Struyf from Antwerp; and a scientific research symposium on proximal humeral fractures. There were the usual free paper sessions covering all the aspects of current shoulder and elbow practice as well as the
African experience”. During the meeting Prof Angus Wallace, who has recently retired from clinical practice, was bestowed the honorary membership of the society, only the sixth such award given in the society’s history.
Dr Basil Vrettos (Cape Town, South Africa) presented an engaging Presidential Lecture at the BESS meeting in Dublin
now traditional “hot topic session” on issues surrounding current medical practice. Delegates were also entertained by two eminent guest speakers who delivered their thought provoking
CAOS International 16th Annual Conference, Japan
The CAOS International Executive
lectures: Dr Jaap Willems from Amsterdam entitled “Arthroscopic shoulder instability: 25 years of arthroscopic instability repair: what did I learn?” And Basil Vrettos from Cape Town entitled “The challenging elbow and arthritis: an
Despite the packed programme it was not just work but the evenings were filled with both formal (the conference dinner being held at the Royal Dublin Society) and informal social events with time to sample the hospitality of the city of Dublin with colleagues and friends. With Ireland celebrating the centenary of Easter rising and the birth of the Republic, there were, in addition, many events and exhibitions of interest to all. Thanks to our Irish colleagues for hosting this most memorable conference as we now look forward to BESS 2017 in Coventry.
The conference was well attended and the breadth and quality of the podium and poster presentations was excellent. Authors from 19 countries submitted their research papers, of which 73 were accepted as podium presentations and 20 as special posters with two minute presentations in addition to posters. There was a robust review process with 20 key opinion leaders in the field, with an average of four reviewers per paper plus a meta review from lead reviewers. Dr Ferdinando Rodriguez Y Baena led the scientific programme committee.
A guest lecture was delivered by Dr Ichiro Sakuma on “CAS: Fusion of Robotics and Bioengineering for Advanced Therapies”.
Key topics discussed were surgical navigation systems (53), total knee arthroplasty (52), total hip arthroplasty (28), procedure planning (25), proof of concept lab studies (24), image acquisition and processing (23), smart instruments and sensors (13), biomechanical modelling (14), patient specific instrumentation (12), spine (10) and robotics (13) among others.
Industry demonstration workshops talked on latest developments including robotics and accelerometer based navigation by Stryker, Zimmer, Smith & Nephew, Ziehm Imaging GmbH & TOYO MEDIC, B.Braun Aesciulap and Siemens.
Panel discussions on special topics were arranged with leading figures in the field. “Computer-Assisted TKA” by Norberto Confalonieri & Tetsuya Tomita; “Pelvic Tilt in THA: How It Should Be Optimized Using CAOS Technology” by Yukata Inaba; “Current Status and Future of CAOS Around the World” by Philippe Merloz; “Can Statistical Shape Models Eliminate Individual 3D CT Images?” by Yoshinobu Sato.
Dr Stephen Murphy was awarded Medacta ME Muller award for excellence in CAOS.
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JTO News and Updates
CSOS Annual Meeting 12th-13th May 2016 This two day meeting, which is open to all serving and retired British military orthopaedic surgeons plus invited guests, brought together trainees and consultants, past and present from all corners of the UK to sunny Plymouth. The first day comprised an instructional course for registrars with updates on trauma, focusing on management in the deployed/austere environment to ensure the hard-won lessons from Afghanistan continue to be passed on the next cohort of military T&O consultants.
There was also a fantastic presentation from Mr Steve Bale (military liaison to the SAC) with particularly astute advice on how to approach the exam: having recently sat both parts, this struck home and I’m sure those approaching the exam will be significantly better prepared for it. The second day was a scientific meeting with multiple research presentations. The senior members of the audience, including past BOA Presidents, the current BOA CEO and Vice President, senior AO faculty
and multiple Professors all commented on the outstanding quality of both the presentations and their subject matter. Prizes were awarded to Major Taff Edwards (Philip Fulford award, best paper The Biomechanics of Blast Related Amputee Heterotopic Ossification: computational modelling and physical experiments), Surgeon Lieutenant Pippa Bennett (Pete Templeton award, best trainee - Combat hindfoot fractures in UK military 2003-2014: Injuries, management and short-
term outcomes) and Captain Sarah Stewart (Best clinical paper - Hip arthroscopy for femoroacetabular impingement in the military cohort). The meeting was rounded off with an outstanding formal dinner at the Royal Marines Barracks Stonehouse Officers’ Mess made unforgettable by the hosting Colour Sergeant. We look forward to our next meeting in May 2017 in Edinburgh and hope to see as many colleagues there as can make it.
Annual Meeting Indian Orthopaedic Society UK The 18th annual meeting of IOS (UK) was held at Leicester on 8th-9th July 2016. This meeting was attended by 150 delegates and invited speakers.
Ahrens) and lower limb (Prof Keith Willett, Ananda Nanu and Prof Colin Howie).
The highlights of Friday were Medico-legal (Claire Petts, Richard Power and Nikhil Shah) and Bone and Joint infection sessions (Mike Reed, Andrew Swann and Patrick Laing).
Saturday afternoon invited lectures included non-union (Badri Narayan), avascular necrosis (Prof Peter Giannoudis), controversies around hip (Martyn Porter) and knee (Prof Simon Donell). The clinical leadership lecture was given by Anthony Clayson. These talks were followed by invited guest speakers from India (Sudhir Kapoor, President Indian Orthopaedic Association and Dr S S Agrawal, President Indian Medical Association).
Saturday morning was dedicated to evidence-based Trauma and Orthopaedics for upper limb (Prof Joseph Dias, Prof Amar Rangan and Philip
The conference dinner was held at Marriott Leicester and included dance performances from various parts of world. It was announced by
There were three free paper sessions. The Best and second Best Paper awards were won by Manish Kiran from Liverpool and Veronica Roberts from Leicester. The Best Poster was awarded to Mr R S Khakha from Lewisham.
The organising team of IOS UK 2016 at the conference dinner in the Leicester Marriott
Anand Arya, President, Indian Orthopaedic Society UK that the name of this organisation will change in future to the British Indian Orthopaedic Society (BIOS).
This meeting received great feedback. Prof Colin Howie described it as an excellent meeting which was well attended with good questions from the participants.
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BOOS Meeting 2016 The 27th Annual Scientific Meeting of the BOOS was held at the spectacular setting of the Aviva Stadium, Dublin on 20th May hosted by Mr Gary O’Toole. The programme was put together by Gary with Rob Pollock and Paul Cool. Despite challenges relating to travel, this was the best attended BOOS meeting to date. The BOOS guest speaker was Dr Patrick Boland from the Memorial Sloan Kettering Cancer Center in New York, returning to his homeland, who gave a truly spectacular lecture on “The Evolution of Orthopaedic Oncology as a Surgical Subspecialty”. It was recognition of the society that a number of members present were mentioned in his talk as key players in the development of the subspecialty.
It was credit to Dr Boland himself that a number of his former colleagues attended the meeting to see him deliver his lecture. The society’s Immediate Past President, Max Gibbons, delivered his Hunterian Oration on “Orthoplastic Reconstruction in Sarcoma Surgery”. His collaboration, in particular with Henk Giele, has brought forward a new type of reconstruction following sarcoma resection, the aim being lifelong functional reconstruction. Free papers on primary bone and soft tissue tumours, metastases and basic science were delivered from tumour units from both the UK and further afield. A new section on innovative reconstruction for challenging cases
The 27th Annual Scientific Meeting of the BOOS
was well received and is likely to be present for years to come. Prizes were won by S. Hislop (RNOH) (basic science) and jointly to G. Sheridan (Dublin) and R. Khundkar (Oxford) (free paper). The best poster prize was awarded to Aurelie Hay-David (RNOH).
Where else but the Guinness Brewery could a society entitled BOOS hold its annual dinner? The next meeting will be held in Newcastle on 2nd June 2017 with Peter Ferguson, from Toronto, the guest speaker. A true Geordie welcome awaits you.
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JTO News and Updates
Lessons from the Hip Fracture Review Training Day Paul Dixon & Tim Chesser
The BOA has led multidisciplinary hip fracture reviews for the last few years and the results and structure of them were recently scrutinised at a Hip Fracture Review Training day. A key message from trusts reviewed to date was that reviews enabled them to get an overview of the whole system to deliver better joined-up care. More specifically, we heard that the clear structure of the recommendations led to significant improvement in length of stay, best practice
The Hip Fracture Review Training Day
tariff (BPT) achievement and reduction in mortality. There was some concern raised about the investment required for the reviews (though significantly cheaper than other colleges), but it was reassuring that this investment was rapidly recouped by the improvements in BPT rates.
The current review methodology was examined with representatives from the key stakeholders (National Hip Fracture Database, British Geriatric Society, Association of Anaesthetists and the Society of Orthopaedic Nurses) as well as representatives from the BOA Council. The process was compared with the recent Academy of Medical Royal College guidance on invited reviews and was largely compliant particularly in terms of clear governance and reporting structure. It was felt however that the introduction of patient and carer feedback plus more formal feedback from the reviewed trusts would be valuable additions to the programme. It has become apparent that reviews deliver the impetus needed to improve hip fracture care. Clinical Directors have fed-back that the reviews produce a ‘shopping list’ of improvements which the MDT and management will get behind far more readily than if suggested locally. The review programme has also shown that clear standardisation of clinical practice is the key operational
feature of good care, and that this should put in place in the context of a strong team working within an improvement-focused culture. This view was broadly held by surgeons, orthogeriatricians, anaesthetists and nurses attending the day. Moving forwards, a key priority for the programme is recruiting more reviewers: in particular AHPs and nurses. With the NHFD reducing the threshold for being at variance from the mean to two standard deviations, from three, we expect more demand from Trusts for reviews. In addition, the BOA has recently partnered with Northumbria Healthcare and the Royal College of Physicians for a Health Foundation Grant looking at a quality improvement programme for hip fractures. We encourage readers to express any interest in participating, as well as encouraging nurse and AHP colleagues to do so by contacting the BOA Policy Team. The key qualities needed to be a reviewer are a passion for improving hip fracture care, a sensitivity to the ‘politics’ of hip fracture care, and a high level of organisation. The key benefit to being a reviewer is the professional development it offers and the opportunities you will spot to improve care in your own Trust.
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BOA Membership UKITE
The BOA provides access to the United Kingdom and Ireland In-Training Examination (UKITE) held every December within training programmes. UKITE is a national online examination providing immediate results to trainees with similar formatted questions based on the UK T&O curriculum. We currently have over 1,000 trainee members and we encourage them to use this powerful tool for self-assessment. UKITE 2016 will run from 9th-16th December. In order to receive free access to the UKITE, new membership applications must be submitted by 31st October and subscription payments for new and existing members must be completed by 14th November in order to receive your UKITE login details. Non-BOA members who sit UKITE will be charged a fee of £150. This year we are delighted to welcome trainees from the South African Orthopaedic Association to sit UKITE. To find out more about UKITE and other benefits available to members of the BOA visit www.boa.ac.uk/membership/benefits.
Connect with us... Keep up-to-date with the latest news from the BOA by following us on Twitter, LinkedIn and Facebook. Connect with us and our 2,800 followers on LinkedIn, “Like” our Facebook page (3,400 Likes) and join us on Twitter where we have over 8,000 followers. Twitter: @BritOrthopaedic LinkedIn: British Orthopaedic Association Facebook: British Orthopaedic Association @BritOrthopaedic
Save the date! Quality and Innovation
BOA Annual Congress 2017 19th-22nd September, Liverpool
We are excited to be returning to Liverpool for the 2017 Annual Congress for four days of lectures, discussions and debates focused on Quality and Innovation. Liverpool is a city of culture, proud of its rich heritage and renowned for its friendly people. We look forward to hosting the BOA Congress at the award-winning ACC again. Keep an eye on the Congress website for abstract submission information and further details of the engaging programme that can be expected – congress.boa.ac.uk.
BOA Annual Congress 2016 Welcome to Belfast!
We are delighted to welcome you to Belfast for the 2016 Congress. We are excited by the extensive range of eminent speakers, experts and lecturers including former Royal Airforce Pilot, Mandy Hickson and Senior Clinical Research Fellow from the University of Oxford, Professor James Wright. Each day has been designed to include a combination of plenaries, broader professional topics and revalidation sessions. We are honoured to have the Lord Mayor of Belfast, Brian Kingston, join Tim Wilton to open the Welcome Drinks Reception and we encourage delegates to take full advantage of all that Belfast has to offer. Please remember to download the BOA Congress App before you arrive and make the most of your Congress experience. The App will allow you to view the details of 100+ sessions, create your own itinerary, navigate around the venue and exhibition areas, view podium and poster presentations and connect with other delegates. The App will ensure that you have all the information you need at your fingertips for an enjoyable Congress.
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JTO News and Updates
BOA Orthopaedic Surgery Research Centre Update Dr Catriona McDaid, Senior Research Fellow and BOSRC lead at YTU It is two years since the BOA Orthopaedic Surgery Research Centre at York Trials Unit started. Two new projects are getting under way this autumn following successful research grant applications. Paul Baker from South Tees NHS Foundation Trust is leading the NIHR-HTA funded project, OPAL: Occupational Advice for Patients Undergoing Arthroplasty for the Lower Limb, a 27-month project. The aim is to (i) develop an occupational advice intervention to support early recovery to usual activities including work, which is tailored to the requirements of patients
undergoing hip and knee replacements and (ii) to test the acceptability, practicality and feasibility of the intervention within current care frameworks. The intention is that further funding will be sought to then test the effectiveness of the intervention in a randomised controlled trial (RCT). The second project is a Fellowship, being undertaken by Helen Ingoe, on the topic of surgical treatment for rib fractures. The two-year fellowship, which is based at York Trials Unit, is funded by Orthopaedic Research UK (ORUK). Two further projects, both large RCTs, are due to
commence later in the autumn, though contract details with the funder are still to be finalised and we will provide more details in our next update. We are still also awaiting the outcome from several of the applications. It has been a busy year for the centre working with surgeons making applications for research funding. In the past year we have submitted nine grant applications to the NIHR HTA programme: six expressions of interest (EOI) and three full applications. Five of the six orthopaedic surgeons we have worked with on grant
applications over the past year are first-time chief investigators (CIs). They also come from a wide geographical spread: Bristol, Leicester, Hull, South Tees and London. In the year ahead we will be working with CIs getting newly funded projects underway, while seeking funding for new research projects. We will be at the BOA Annual Congress in Belfast if there is anything you would like to discuss or we can be contacted at bosrc@york.ac.uk. Further details about BOSRC are available at www.boa.ac.uk/ research/bosrc.
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Caption Competition Thank you to everyone who entered our caption competition from the last issue – we enjoyed reading your witty captions. Unfortunately, there can only be one winner and that person is Mike Carmont, whose caption
was: “Gee, Des Lynam has shrunk, and planning for more” – a prize is on its way to you, Mike, well done! We would like to encourage you to send photos into us for future issues whether they are taken at conferences, meetings, work or at social events. Here is our latest photo. Enter the competition and also send photos to jto@boa.ac.uk with the subject: Caption Competition (if your photo is larger than 5MB please send via www.WeTransfer.com).
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JTO News and Updates
The American British Canadian Fellowship 2016
Jonathan Miles, William Eardley, Sam Oussedik, Ajay Malviya The ABC Fellowship is designed to encourage high class clinical care, translational research and teaching. Their integration is the most obvious marker of a successful unit but we experienced many different strategies to achieve them. We had informative discussions about recruitment, the pros and cons of internal appointments and the balance between the need to conform against the risk of stifling innovation. The United States has introduced bundled care models which has focused the larger units on assessment of outcomes and prevention of complications. There were high variances in the models adapted throughout the units in achieving a predictable outcome. The Campbell Clinic is rapidly moving to a day-care arthroplasty model through case selection and minimal post-operative input, aided by recruitment of a family member to provide nursing and therapy. This
The ABC Fellows visiting the Mayo Clinic
L-R: Jonathan Miles, Cameron Anley, Michael McAuliffe, Will Eardley, Ajay Malviya, Sam Oussedik and Andrew Graydon – the Fellows wearing their new ABC ties
requires more pre-operative input but is realising significant savings. The Mayo Clinic and University of Calgary had more traditional models, using volume and pathway control to deliver more consistency of outcome. Our countries are all re-evaluating the need for expensive investigations and implants in patients as the cost burden rises.
The North American model of funding for research is a mixture of centrally controlled funding, donations, industry sponsorship and institutional funding. There was a higher emphasis on animal modelling than in the UK. There could be tensions in salaried units where those with a higher volume clinical output subsidise the more academically active. The best leaders had addressed these concerns directly and ensured that everyone benefited through enhancement of the institutional reputation. Dan Berry and Bernard Morrey at The Mayo Clinic were highly instructive on this balance. The North American model of teaching has a tendency to focus on a single institution and overall training time is shorter than in the UK. There are similar challenges in a week curtailed by working hour regulations. We noted the Canadians favoured international fellowship whilst the USA residents almost all stayed within The States. There was a
tendency to centres appointing the majority of physicians from their own resident programme. This may contribute to an inward looking philosophy but helped to ensure alignment of the whole team with their stated goals and values. We had many debates as to where the line should be drawn between minimising costs and accepting risks. There was universal agreement that healthcare costs, as a proportion of GDP, are too high in the developed world. The strategies to address this must not be too biased against patient care or overly detrimental to training. We conclude that the ABC Fellowship is as relevant now as ever. The sharing of techniques and surgical skills can now be achieved through the multitude of internet and journal outlets. The philosophies of healthcare governance are far more suited to discussion than didactic styles.
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JTO News and Updates
Letters to the Editor Dear Editor,
Re: Volume 4 / Issue 2 - Virtual Fracture Clinic article response Virtual fracture clinics remain controversial, but are becoming established as standard practice in many units. We therefore welcome the two papers published in the last edition of the JTO which give us good evidence that when planned, resourced and audited appropriately these clinics can deliver a high standard of care to patients. The BOA has never been against the setting up of these clinics, indeed one of the authors of the published articles, John Keating, is a member of the BOA Trauma Group. However, as set out in the BOA position statement published last October, the standards of BOAST 7 should still apply. The concerns of the BOA Trauma Group centre on the parts of the patient pathway
over which we, as trauma and orthopaedic surgeons, now have no control. In a virtual setting we must rely on the initial assessment of the patient, documentation and imaging being appropriate and of an adequate standard so that decisions we make without the benefit of a personal consultation are appropriate. We must also be confident that any treatment provided is of adequate quality and that the patient has been given the correct information in terms of diagnosis and expected recovery, if they are discharged after the initial consultation. Some units are no doubt very fortunate in that the above criteria are already in place. Staff members undertaking the initial assessment are adequately trained, treatments are standardised and safety nets are in place to allow patients appropriate access, should they have concerns. Unfortunately, this is by no means universal.
Often patients presenting to fracture clinics come from a variety of different assessment units, each working with staff from varied backgrounds/training and experience, using different protocols/documentation and crucially there is no common governance structure. In view of this, any form of virtual clinic has to be carefully set up, addressing all of the above issues and ensuring that the service has the best interests of patients at its heart. In most cases this will require collaboration between a number of assessment units, spanning both primary and secondary care. In addition, consideration has to be given to how the clinic is commissioned, financed and resourced in terms of personnel, IT equipment, job plans and communication with both patients and other members of the team. We would welcome further evidence on those robust systems, which have been developed, along with strategies, which have been employed to overcome obstacles to the successful implementation of virtual fracture clinics. Yours sincerely, Paul Dixon Trauma Group Chair
Dear Mr Editor,
Re: Volume 4 / Issue 2 The June issue is great. Congratulations on style and content. A breath of fresh, surgical air! You have introduced an element of wit long absent; even the mug-shots are less stuffy. Kind regards, Michael Laurence
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JTO News and Updates
Wisepress Book Review BOOK OF THE QUARTER
ALSO AVAILABLE
Selected References in Trauma and Orthopaedics
Orthopaedic Biomechanics Made Easy
Author/s: Bowyer, G; Cole, A ISBN: 9781447146759 Publication Date: 17th September 2013 Price: £31.99 An essential study tool for all those preparing for the orthopaedic FRCS (Tr & Orth). Compiled by examiners, ‘Selected References in Trauma and Orthopaedics’ will provide candidates with an awareness of the literature which will boost grades and enhance learning ability.
Author/s: Malik, S S; Malik, S ISBN: 9781107685468 Publication Date: 28th May 2015 Price: £37.99
The Knee
Orthopedic Secrets Author/s: Namdari, S; Pill, S; Mehta, S ISBN: 9780323071918 Publication Date: 16th October 2014 Price: £29.99
Author/s: Sgaglione, N A; Lubowitz, J H; Provencher, M T ISBN: 9781617119996 Publication Date: 30th December 2015 Price: £99.95
CONFERENCE LISTING: Organisation
Conference/meeting
BSS (British Scoliosis Society) www.britscoliosissoc.org.uk
13-14 October 2016, Middlesbrough
BSSH (British Society for Surgery of the Hand) www.bssh.ac.uk
13-14 October 2016, Cardiff
BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk
2-4 November 2016, Bristol
SBPR (Society for Back Pain Research) www.sbpr.info
3-4 November 2016, Preston
BTS (British Trauma Society) www.bts-org.co.uk
9-10 November 2016, Birmingham
OTS (Orthopaedic Trauma Society) www.orthopaedictrauma.org.uk
12-13 January 2017, Coventry
BHS (British Hip Society) www.britishhipsociety.com
1-3 March 2017, London
BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk
9-10 March 2017, Glasgow
BASS (British Association of Spinal Surgeons) www.spinesurgeons.ac.uk
15-16 March 2017, Manchester
BLRS (British Limb Reconstruction Society) www.blrs.org.uk
23-24 March 2017, Leeds
BASK (British Association for Surgery of the Knee) www.baskonline.com
28-29 March 2017, Southport
CSOS (Combined Services Orthopaedic Society) www.csos.co.uk
11-12 May 2017, Edinburgh
EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org 31 May-2 June 2017, Austria BOOS (British Orthopaedic Oncology Society) www.boos.org.uk
2 June 2017, Newcastle
WOC (World Orthopaedic Concern) www.wocuk.org
10 June 2017, Wigan
CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org
14-17 June 2017, Germany
BESS (British Elbow and Shoulder Society) www.bess.org.uk
21-23 June 2017, Coventry
BIOS (British Indian Orthopaedic Society) www.britishindianorthopaedicsociety.org.uk
7-9 July 2017, Penrith
BORS (British Orthopaedic Research Society) www.borsoc.org.uk
4-5 September 2017, London
BOA (British Orthopaedic Association) www.boa.ac.uk
19-22 September 2017, Liverpool
BOTA (British Orthopaedic Trainees Association) www.bota.org.uk
November 2017, TBC
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JTO Features
Why Opt In? Amar Rangan, BOA Research Committee Chair
In 2014, the BOA’s research focus moved from funding small projects to concentrating our resources on infrastructure and facilitating future research. This has been game-changing, with its true impact becoming increasingly apparent!
The funding of the York Trials Unit commenced two years ago. There has been significant progress, as you may have read in the BOA Orthopaedic Surgery Research Centre (BOSRC) update on page 16. Two new projects begin this autumn. The first is a 27-month project, which received funding from the NIHR-HTA (the National Institute for Health Research – Health Technology Assessment Programme) to develop advice on occupation for patients undergoing lower limb arthroplasty. The second project is a two-year fellowship, based at the York Trials Unit, funded by Orthopaedic Research UK, on the surgical treatment for rib fractures. With more projects in the pipeline, we would like to continue funding the essential work that BOSRC are doing in advancing clinical research.
Amar Rangan
In collaboration with the James Lind Alliance Priority Setting Partnerships and our subspecialist societies, we have been identifying key research priorities in various areas of practice. Following the publication of the top research priorities in hip and knee arthritis, we part-funded the Surgery for Common Shoulder Problems Priority Setting Partnership1. We are now working with the Orthopaedic
Trauma Society (OTS) to establish the top ten questions in lower limb fragility fractures and we will also be working with OTS and Keele University to establish a Priority Setting Partnership in upper limb fragility fractures. In a fiercely competitive environment, prioritising topics for research has proved very effective in attracting substantial research funding to our specialty. There is growing international recognition that the UK is now leading the way in generating high quality, practice-changing evidence with large pragmatic, multi-centre, clinical trials. We need your help to sustain and fund this and to consolidate the UK’s global position as the leader in high quality T&O clinical research. Funding research is not an obligatory part of the BOA subscription. Last year, we sent out a survey to members who had previously opted out. Fiftyseven per cent of responders said they opted out to reduce their subscription payment. Many of our donors spread the cost of their donation over the year by monthly standing order; perhaps this is something you could consider? When your next subscription renewal arrives, please consider ‘opting in’. Your donations have already led to practice-changing
research with international acclaim. Opting in will help us sustain this research activity. Our external donors are grateful for the work you do and show their thanks by financially supporting our orthopaedic research appeals. Some give regularly by standing order, others leave a legacy in their Will, and yet more organise and participate in sponsored events. Our non-orthopaedic donors value our contribution - maybe we should aim to match their enthusiasm. There are other ways you could help - running in the London Marathon or leaving a bequest? Maybe you could encourage family and friends to help or donate? We can achieve so much more with your help. However you decide to support us, investment in clinical research has allowed an increasing number of BOA members to get actively involved in research. The work funded by your donations has truly ‘pump-primed’ T&O research - thank you. n Professor Amar Rangan is a Consultant Shoulder Surgeon and Clinical Professor at the James Cook University Hospital, Middlesbrough and Chair of the BOA Research Committee. He has considerable experience with clinical effectiveness and translational research and is committed to help enhance the UK T&O profile internationally by promoting high quality research.
References 1. www.jla.nihr.ac.uk/prioritysetting-partnerships/surgery-forcommon-shoulder-problems/ top-10-priorities
RELEASED ON 14th OCTOBER
Paediatric Orthopaedics: An Evidence-Based Approach to Clinical Questions has been edited by a team of surgeons with an interest in evidence-based practice who have brought together a group of international experts to produce this timely book. A wide spectrum audience including paediatric orthopaedic surgeons, trauma surgeons, orthopaedic residents, emergency department doctors, general practitioners and medical students looking for an evidence based approach to paediatric orthopaedics will find this book to be an essential guide for clinical practice.
www.springer.com | Available on Amazon.co.uk
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JTO Features
Inspiring the best to be better: The BOA Clinical Leadership Programme Hiro Tanaka & Mike Reed
“Before you are a leader, success is about growing yourself. When you become a leader, success is about growing others” - Jack Welch
Fellows at the BOA Congress
Where are we now? The BOA Clinical Leadership Programme (CLP) is now in its third year and this year there has been a dramatic increase in the interest and number of applications. The word is spreading regarding the benefits of learning about clinical leadership in the final year of training. To quote one of our previous fellows: “I’ve learnt more about myself in 12 months than in 32 years of my life; I’m going to be a better consultant”. The fellows showcased their quality improvement projects at the BOA Congress - many of which could lead to significant changes within the NHS. The structure of the programme remains unchanged and starts
every October. It consists of four, two-day modules over a 12 month period and takes place in Newcastle-Upon-Tyne. This is associated with targeted leadership coaching and completion of a highlevel quality improvement project (JTO article Volume 3/Issue 4). Specialist Society sponsorship As well as trust-funded and self-funded fellows, a number of specialist societies are now sponsoring fellows through a competitive application process. This competition ensures that the best trainees, who would benefit most from the programme, are selected. It also results in quality improvement being spread across a range of specialties. In the
longer term the society may gain from engaging the fellows in the activities of the committees. The selection criteria are based upon the personal statement, CV and, where possible, by direct observation, such as BOFAS who run an Advanced Fellows Forum on an annual basis. The societies taking part in the 2016/17 programme are: British Limb Reconstruction Society, British Orthopaedic Foot and Ankle Society, UK Spine Societies Board, British Society for Surgery of the Hand, British Association of Surgery to the Knee, British Orthopaedic Oncological Society and British Orthopaedic Research Society. Looking forward We are pleased to announce that we have appointed the fellows for 2016/17. The programme begins in autumn 2016.
Hiro Tanaka
Mike Reed
All previous CLP fellows will be invited to join the alumni to establish a network to provide support and forward learning for future generations. The quality improvement projects and successes of the fellows will continue to be recognised and showcased annually at the BOA Congress. The best of these will be asked to present their project and outline what they have learnt from their leadership journey.
Why should you apply? The shift from an individual clinician to the leader of a team is a significant one, which requires a change in selfimage, values, behaviour, skills and knowledge. Learning the science of leadership and quality improvement not only prepares a trainee for life as a consultant but helps them excel in that role. Health organisations and CCGs are increasingly recognising that these skills are necessary to promote positive change within the NHS. In keeping with the BOA’s motto, effective clinical leadership ultimately results in improvement in the care of patients. Applicants should be post-CCT clinical fellows, senior trainees (ST8 or above), newly appointed consultants or SAS surgeons when they enter the programme. So, if you are passionate about wanting to improve yourself as a clinician, build effective teams and care for your patients, then take the plunge and apply. n Hiro Tanaka is a Consultant Foot and Ankle Surgeon at Aneurin Bevan University Health Board. He is a member of the Education Committee for the BOA and BOFAS. He is a Health Foundation Fellow and is passionate about promoting Clinical Leadership. Mike Reed is an Orthopaedic Surgeon for Northumbria and a Senior Lecturer with the University of Newcastle.
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Regional Spinal Networks Ashley Cole
Spinal services are struggling to meet demand, especially in the South of England where some hospitals are closed to elective spinal referrals. Through the Trauma Programme of Care Board, NHS England is supporting a Transformation Programme called the ‘Improving Spinal Care Project’.
The project started in January 2016 and has two parts: 1. Implementation of Regional Spinal Networks 2. CCGs adopting the National Back and Radicular Pain Pathway The implementation for this project is supported by a Transformation Manager, Project Manager and Clinical Champions from Orthopaedics, Neurosurgery and Physiotherapy. Regional Spinal Networks (RSNs) are Operational Delivery Networks similar to those for Major Trauma and Critical Care aimed at co-ordinating spinal care across the region and encouraging the implementation of the National Back and Radicular Pain Pathway. There are 15-20 planned RSNs. The proposed structure of the RSNs will be: l Spinal ‘Hub’ Hospital(s):
Ashley Cole
a hospital offering a 24/7 spinal emergency service; l Spinal Partner Hospital(s): a hospital where spinal surgery (specialised and/or nonspecialised) is performed but there is no 24/7 emergency service;
l Non-spinal Partner Hospital:
a hospital where there is an Emergency Department but no spinal surgery performed; l Any Qualified Provider: a hospital or provider performing elective spinal surgery in the independent sector. The Spinal Hubs, Spinal Partners and Non-Spinal Partners will produce protocols and pathways to ensure safe and timely management of spinal emergency patients co-ordinated across the Region. There will be protocols for emergency MRI, repatriation and electronic communication between hospitals. The aim will be to manage as many spinal emergencies as close as possible to the patient’s home and transferring those patients where optimal management of their spinal problem requires the facilities available in the Spinal Hub. The RSN will also ensure a high quality and cost-effective elective spinal service available across the Region with equality of access. Commissioners will work with the RSNs to monitor waiting lists and referral to treatment times. Regional co-ordination of waiting lists and workforce will allow support for existing spinal services and prevent further
erosion of provision or at least allow the RSN to agree the best way to deliver the service. The Spinal Surgeons will meet three to four times a year to discuss the RSN work plan, complex cases, clinical audits and any clinical risk management issues. The Network will improve cooperation between Orthopaedics and Neurosurgery both for clinical delivery and education. Collection of outcome measures in the British Spine Registry (PROMs and PREMs) will be central to the process. The RSN structure will enable easier implementation of lessons learnt from the Spinal GIRFT programme and will form part of the Network assessment. A CQUIN, which can be selected by Trusts, is available for 2016/17 and will be available next year for 2017/18 to help fund the RSNs. For further information about RSNs visit www.ukssb.com. n Ashley Cole is a Consultant Orthopaedic Spinal Surgeon at Sheffield Children’s Hospital. He is the Spinal Services Clinical Reference Group Chair for NHS England and Clinical Lead for the development of Regional Spinal Networks as part of the ‘Improving Spinal Care Project’.
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JTO Features
From CT scan of a bone to 3D printed model, using Open Source software and a desktop printer Boyd Goldie
Although commercial 3D models can be made from a patient’s CT scan, this is usually reserved for special cases, such as neurosurgical skull reconstruction or planning correction of malunion in the extremity. These models are produced by commercial companies, take as long as two weeks to produce and are costly. A distal radius might cost in the region of £250. However, 3D printers are becoming affordable for either an individual or a small department. This article details a low cost and speedy alternative utilising open source (free) software and a desktop printer.
how to make something. It instructs the machine tool where, how fast and through what path to move. For 3D printing, this software is referred to as slicing software. Cura is open source slicing software, which has been developed by Ultimaker and converts .STL into G-Code. Cura is reputed to be the fastest slicing software currently available. Using an Ultimaker2 printer I have made models that have subsequently helped plan surgery and inform patients.
How to convert DICOM to G-Code
Material and method Digital Imaging and Communications in Medicine (DICOM) is the standard for handling, storing, printing and transmitting information in medical imaging1,3. Many PACS software programs can produce on-screen volume or 3D images, but they generally cannot export the information in the file format required for a 3D printer. STL (STereoLithography) is a file format native to the stereolithography CAD software created by 3D Systems. STL is also known as Standard Tessellation Language2. Boyd Goldie
Some software to convert DICOM to STL is commercially
available, although it is costly and presumably aimed at institutions. By contrast, 3D Slicer is a free, open source software package for visualisation and image analysis. 3D Slicer is designed to function on multiple platforms, including Windows, Linux and Mac Os X1. It is very powerful and has the capacity to create a 3D model from either a CT or MRI scan. The model can then be exported in a .STL file. In order to print a .STL file, it has to be converted by software into G-Code. G-Code is a programming language used in computer-aided manufacture to tell computerised machine tools
Most radiology departments are able to produce a CD/ DVD that contains the DICOM files of a patient’s CT scan. It is best to copy and paste the folder containing all the DICOM subfolders and files to a new folder on your computer. Rename the folder something other than just DICOM. The 3D Slicer software can be downloaded from www.slicer.org. The software is not particularly intuitive. However, a good tutorial for using it is available on YouTube at http://youtu.be/ MKLWzD0PiIc. The technique for selecting the part of a bone to be printed differs from how most PACS software makes a volume on screen. With PACS software, one
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filament is extruded onto a heated glass plate in 0.15mm thick layers. The model is built up layer-by-layer. If there are overhangs on the model, the slicing software adds supports, which can be removed after printing.
Figure 1: Screenshot showing 3D Slicer software
Some commercial printers use a different technique called selective laser sintering (SLA). These printers fire lasers into a bed of powdered nylon, fusing or ‘sintering’ it. Another layer of powder is then deposited on the surface and it is laser sintered once again. The process is repeated until there are enough layers to complete the build. This technique is much better for hollow models, such as a skull.
Printing a bone model on the Ultimaker2 printer
Figure 2: Screenshot showing Cura software with distal humerus
subtracts elements of the image repeatedly on-screen, until one is left with the bone area required. With 3D Slicer, one defines a “region of interest” that includes the selection that you want to print (Figure 1). Then the bone that is of interest is isolated from its neighbours. Once the on-screen rendition of the bone model to print has been obtained, it is saved in .STL format. If you are going to print the model yourself you then have to convert the .STL file to G-Code using the Cura slicing software. Cura can be downloaded from http:// software.ultimaker.com. Once downloaded, set the make and type of printer to be used. If using an Ultimaker2 printer you can use most of the default settings.
With the heated build plate, it is best to coat the glass build plate with a very thin layer of PVA glue. The model cannot be built unsupported, and it is important to support the model on a raft so it is stable during the build. For parts of the model that are not touching the glass build
plate, the slicing software will insert vertical supports, which can be snapped off the model upon completion. When you rotate the model in Cura, it is important to use widest part as the base. For the proximal humerus, this may mean printing it upside down with care taken to ensure the model is vertical and not leaning. Alternatively, a humerus can be printed on its side. Within the rotate menu, there is the option to “lay flat”. Use this to maximise the contact between the model and the plate. Once you are happy with the on-screen visualisation of the model within the virtual printer, you save the model as G-Code onto an SD card. The card is then put into the printer. Printing a bone is a slow process. A full-sized adult clavicle takes four hours, uses 34 grams of PLA and costs in the region of £1.50. One can increase the print speed, but this reduces the quality of the print. A real-time video of the print of a tibia is available at http://youtu.be/Q3-8t5UPn4c. A time-lapse video of printing an elbow is at http://youtu.be/ JHMsURKb_gM. >>
Converting a .STL file for a hollow bone takes a minute or two. Converting the STL for a solid bone such as the calcaneum may take 30 minutes (Figure 2)!
3D printers 3D printing can be done by a variety of methods. Desktop printers are relatively simple. The print material is a 3mm diameter filament. There are various materials used for 3D printing, but for printing a bone model Poly Lactic Acid (PLA) is best. PLA is essentially cellulose and is supplied on a reel. The filament is fed into a print head that runs at a temperature of 190o to 260o. The molten
Figure 3: Scaphoid non-union: The scaphoid is small and the model was printed at 200% size. On the pre-operative CT is not easy to appreciate the non-union, it is only with the model that the plane of the non-union is clearly shown. This changed the surgical approach from volar to dorsal
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Conclusion 3D printing of a bone model is now possible and affordable. There is a learning curve, as with any other new technology. Desktop printers are not yet “plug and play”. One does need to be an enthusiast, but with a small amount of effort is it possible to admit a patient with a fracture, get a CT scan and then produce a bone model a few hours later.
Acknowledgement The Ultimaker2 printer was supplied by Ultimaker UK. I have no financial interest in Ultimaker and have received no payment from Ultimaker. n
Figure 4: Upper humeral fracture - this model shows the displacement of the humeral head that was correctable with a plate
Figure 5: Scapula: The model clearly shows the configuration of the fracture, and was frequently referenced during fixation. The model was printed ½ size to reduce printing time. This did not diminish the usefulness of the bone model
If you do not own your own printer you can get models printed from the .STL file. There are plenty of companies who offer this service on eBay under ‘3D Printing Services’. They are affordable for smaller bones (a metacarpal costs £7) and many companies will return the model within five working days. Obviously, this is acceptable for a patient undergoing an elective procedure, but not for a patient with a fracture.
Figure 6: Coronoid fracture: An unusual fracture of the coronoid process of the ulna, in which modelling allowed plate fixation to be planned
On several occasions I have been able to show the model of a fracture to the patient. This has greatly facilitated their understanding of the proposed surgery. Some patients have even purchased the model of their fracture.
Boyd Goldie is a Consultant Orthopaedic Surgeon specialising in problems of the Upper Limb. Until recently he was a Consultant at Whipps Cross University Hospital. He is now Honorary Consultant at Barts Health NHS Trust and in independent practice in north-east London.
References: 1. http://en.wikipedia.org/wiki/ DICOM 2. http://en.wikipedia.org/wiki/ STL_(file_format) 3. Fedorov A., Beichel R., Kalpathy-Cramer J., Finet J., Fillion-Robin J-C., Pujol S., Bauer C., Jennings D., Fennessy F., Sonka M., Buatti J., Aylward S.R., Miller J.V., Pieper S., Kikinis R. 3D Slicer as an Image Computing Platform for the Quantitative Imaging Network. Magn Reson Imaging. 2012 Nov;30(9):1323-41. PMID: 22770690.
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Hip Fracture Research: The WHiTE study and beyond Matt Costa & James Masters
Whichever level you choose to look at it, caring for patients with hip fractures is an enormous challenge. The incidence continues to increase with its associated cost burden1. What are these challenges and how should they be addressed?
Patients with hip fractures may be considered a paradigm of the modern NHS patient; they have multiple co-morbidities, require input from many specialist teams and often require complex after hospital care. Surgery is a small, but important, part of a larger picture. The current evidence base for surgical treatment is largely from non-randomised single centre sources. However, efforts to address this with an increasing number of randomised trials to understand the clinical and cost-effectiveness of surgical interventions2-4 are underway. Crucially, these studies include patients with cognitive impairment,
Matt Costa
who may account for 40% of all hip fracture patients. The World Hip Trauma Evaluation (WHiTE) is a comprehensive cohort study of hip fracture patients currently running across 15 centres in the UK. WHiTE is both an observational study and a vehicle for delivering randomised trials. Early results of the cohort study have shed some light on the natural history of health related quality of life (HRQOL) for those who suffer from this injury. Immediately after injury, patients typically report a HRQOL below 0. This equates to a quality of life worse than death. The HRQOL does recover in the first four months, but never returns to the baseline.
James Masters
The overall decline is similar to that seen with severe neuromuscular disorders such as multiple sclerosis and Parkinson’s disease. WHiTE is not the only prospectively collected dataset for hip fracture. The National Hip Fracture Database (NHFD) has allowed routinely collected datasets to be used to understand the service delivered to patients and compliance with national guidance5. WHiTE works synergistically with the NHFD, using the same outcome framework but adding patient reported quality of life data. How then to improve the outcomes for patients with a hip fracture? The ongoing trials within WHiTE have looked to answer questions about the use of cement in hemiarthroplasty, the use of the X-Bolt as an alternative to the sliding hip screw and dual mobility as an alternative to total hip replacement. It is not clear that these interventions will deliver the ‘big wins’ needed for these patients. The recent meeting of the WHiTE participating centres discussed a number of research priorities. Refreshingly, even the surgeons in the room were looking to address non-surgical problems, with rehabilitation, pain control, patient priority and nutrition all featuring. The only surgical priorities were complications and patient priority.
A core outcome dataset for hip fracture trials has begun to be developed in an effort to reflect the interests of patients and those who care for them6. This dataset will provide a reference in the reporting of future hip fracture trials, and allow comparison and robust summative evidence synthesis. The March 2014 NICE guidelines on hip fracture care reflect similar areas for research. This guidance is currently being updated; we look forward to reading their recommendations and future directions for research. n Matt Costa is Professor of Orthopaedic Trauma at the University of Oxford and Honorary Consultant Trauma Surgeon at John Radcliffe Hospital. His research interest is in clinical and cost-effectiveness of musculoskeletal interventions and he is Chief Investigator for a series of randomised trials and associated studies supported by grants from the National Institute of Health Research and Musculoskeletal Charities. James Masters is Clinical Research Fellow and DPhil student at Oxford Trauma, newly holds the joint Royal College of Surgeons/Dunhill Medical Trust research training fellowship and is an ST3 on the Warwick specialist training programme.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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What’s your innovation?:
From our Specialist Societies British Hip Society
Hip joint preservation: There is now a clear understanding that anatomy and motion influence degenerative disease in the hip. There are now validated interventions for both impingement and dysplasia; and progress in advanced imaging in order to characterise cartilage function and natural history. The role of exercise in early osteoarthritis increasingly recognised. Arthroplasty: The second coming of limited trauma approaches such as anterior and direct superior; modern bearings including highly cross linked polyethylene. Enhanced recovery including day-case arthroplasty. Cross sectional imaging after arthroplasty. Infection prevention and algorithms of management. Technology: Virtual reality training; virtual surgery; 3D printing; the coming of age of navigation and robotics. Systems of care: Improved understanding and use of registry data; Networks for complex procedures.
British Association for Surgery of the Knee The 3D printing revolution has come to post-traumatic deformity. By combining the planning platforms for high tibial osteotomy, and for knee replacement, Dr Susannah Clarke and her team in Imperial College have come up with a one-stop solution for the knee surgeon who sees post-traumatic deformity and secondary arthrosis. From a CT scan, they can deliver a plan and cutting guides that ensure both the arthroplasty and the osteotomy are performed accurately and that they match each other, resulting in a straight limb. The technique has already allowed eight people to avoid a TKA.
British Orthopaedic Foot and Ankle Society
British Society for Surgery of the Hand
There have been many innovations around foot and ankle surgery of recent times. One of the most interesting has been the development of arthroscopic procedures.
The greatest innovation in hand surgery is development of a detailed research programme led by Prof Tim Davis in Nottingham. This includes a funded chair, a James Lind Alliance project and clinical trials.
Over the last few years the scope of arthroscopically assisted procedures has been extended to include fusions of the hind and midfoot. More recently arthroscopic transfer of the flexor hallucis longus tendon to the calcaneus for the treatment of patients with symptomatic chronic Achilles tendon rupture has been added to this growing list.
Collagenase has changed practice and thinking in the treatment of Dupuytren’s disease. Its eventual role is unclear. Supporters believe it will largely obviate fasciectomy; others believe that needle fasciotomy does the same but more cheaply and as effectively. There is an increasing emphasis on minimal access (percutaneous) surgery including screw fixation of scaphoid fractures and some non-unions, finger osteotomies, trigger finger releases and small joint arthrodeses.
Although the long term outcomes are still under evaluation it does offer the advantage of soft tissue preservation which is of particular benefit in cases where there is concern over the skin and healing potential.
Arthroplasty has advanced most with ulnar head replacements which are firmly established even if the indications are debated. Pyrocarbon was seen as the “new” material for small joint arthroplasty but is associated with high failure rates. Wrist arthroplasty is popular in some centres but not yet widespread.
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British Scoliosis Society
Society for Back Pain Research
In recent years the magnetic growth rod has been the most innovative spinal implant for surgical management of early onset scoliosis (EOS). This device can be lengthened on an outpatient basis hence avoiding the need for surgical lengthening. It addresses the two main challenges in management of EOS i.e. curve correction and spinal growth. The early results are extremely favourable. But like every new technology there is need for close governance. Although the device is an exciting innovation for the above reasons, there are certain complications indigenous to it which we, the British Scoliosis Society have been monitoring closely.
A recent example of an innovation in the way in which low back pain is assessed and managed is stratified care. This involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment or underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment-related benefit, reduce harm and increase healthcare efficiency by offering the right treatment to the right patient at the right time. From being called the ‘Holy Grail’ of back pain research over a decade ago, stratified care is now being subjected to increasingly rigorous research with some approaches showing promise in terms of clinical outcomes for patients and cost-effectiveness for healthcare systems. Three key examples of approaches to stratified care for low back pain patients include those based on prognostic factors, those based on likely response to treatment and those based on underlying mechanisms.
British Association of Spinal Surgeons Spinal Surgery continues to be one of the leading innovators in surgery. This is evidenced by the fact that, over the last few years, a number of technologies have been developed with a view to improving patient outcomes and safety as well as minimising longer-term costs. Arthroplasty (disc replacement), Minimally Invasive Surgery (MIS), Endoscopic Discectomy, and Computer-Aided Navigation are all examples of such advances. The focus on Stem Cell Therapies, not only for Spinal Cord Injury but also for degenerative spinal conditions, remains a major focus in 21st Century Spine Research, along with other exciting innovations such as Robotic Surgery.
British Elbow and Shoulder Society
Shoulder pain is the third commonest orthopaedic problem to present to general practitioners. Currently 10,000 patients annually in England have torn rotator cuff tendons that require surgical repair and this number is increasing. Unfortunately, around 40% of these surgical repairs fail, which can result in long term disability. A team in Oxford has used a process known as electrospinning to develop a new type of degradable scaffold that mimics normal tissue. The biomimetic nanofibres promote much better healing in laboratory and animal models. The Oxford team are funded by the Wellcome Trust and the National Institute for Health Research (NIHR) to undertake human clinical trials with the support of members of the British Elbow and Shoulder Surgery Society (BESS). BESS has been instrumental in the success of a number of randomised controlled trials of surgery in the UK.
British Society for Children’s Orthopaedic Surgery Guided growth techniques in children have revolutionised the management of paediatric skeletal deformity. This simple yet powerful manipulation of the growth plate can avoid the need for osteotomy completely. Often used in the management of lower limb coronal deformity, its application has been expanded to include sagittal deformities such as fixed flexion contractures of the knee and ankle equinus. Trochanteric-entry nails provide stable fixation in a younger age group when dealing with rotational or other deformities amenable to acute correction. Self-lengthening nails present a more acceptable option for treating short segments than ring fixators although the cost remains an issue.
Orthopaedic Trauma Society
Orthopaedic Trauma surgery is a craft skill, based on copying one’s seniors and applying principles. Innovation and change of practice involved the refinement of implants, imaging modalities or surgical techniques to better apply the principles. The innovations can be tested in clinical trials. In this context there are two types of trials explanatory and pragmatic. An explanatory trial carried out under ideal conditions tests whether an intervention works. A pragmatic trial tests effectiveness or benefit of in clinical practice. The NHS and clinical research networks provide an ideal environment for pragmatic trials. Orthopaedic Trauma surgeons have provided the enthusiasm to run them. The results of pragmatic trials have guided the treatment choices of individual surgeons but also as a guide to the effectiveness of interventions in the real world are influencing the development of guidelines, protocols and commissioning. In Orthopaedic Trauma pragmatic trials are the innovation resulting in change.
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New Guidelines for Diabetic Feet Fred Robinson Co-author: Kevin Varty, Consultant Vascular Surgeon, Addenbrooke’s NHS Trust
The cost of diabetic foot care is estimated to be £615 million per annum; or £1 in every £150 spent in the NHS is on the diabetic foot - a truly shocking figure! We cannot ignore this group of patients financially or on grounds of need - it is estimated that 50% of patients with a diabetic foot ulcer die within five years.
Centralisation of vascular services into a hub and spoke model has been implemented to improve the quality of care, facilitate training and support sustainable rotas. The centralisation of major arterial interventions has the potential to disrupt service provision unless managed carefully. This has been a major concern to many involved in the treatment of patients with diabetic foot disease. Vascular networks aim to deliver local diagnostic, daycase and rehabilitation care, with transfer to the arterial centre being reserved for higher risk invasive procedures. For vulnerable diabetic foot patients, the question is, can such arrangements still deliver care of an appropriate quality in their local hospitals? We believe the answer to this question is yes, if appropriate structures are put into place.
Fred Robinson
The BOA, BOFAS, the Vascular Society, Diabetes UK, the Association of British Clinical Diabetologists, Foot in Diabetes UK and the British Association of Prosthetists and Orthotists have collaborated to produce a consensus document – ‘Operational Delivery of the Multidisciplinary Care Pathway for Diabetic Foot Problems.’ These
guidelines can be found on the NHS England, the BOA and the BOFAS websites. It is hoped that these guidelines will help, and not hinder, the development of your services - if you had a structure that works - keep using it! The guidelines have the following points at their core: l The Vascular Society accepts
that the vascular network has a duty to maintain a significant presence in the spokes so that a vascular opinion is readily available on site for the nonemergency cases; l Many cases do not need immediate intervention and will continue to be admitted for antibiotic treatment and elevation, wherever they present; l Those patients with ischaemia will need urgent discussion with the vascular services. It is important that the pathways for discussion are easily accessible; l Patients without vascular compromise presenting to the spoke hospital with an abscess or collection in the foot will need intervention, occasionally as an emergency out of hours. For these cases it is anticipated that orthopaedic surgery will provide the acute surgical service;
l At times this will mean non-foot
and ankle specialists draining foot abscesses. The BOA and BOFAS are working together to produce a one-page guideline on the surgical treatment of a patient with a foot abscess; l The BOA’s Training Standards Committee is working on producing a critical case-based discussion on the acute diabetic foot. Central to this will be the swift taking over of care of these patients by the diabetologists and foot and ankle surgeons after the night/weekend on call. We hope that you, either as a foot and ankle specialist, or not, find these guidelines helpful. We are sure that you will agree that this is an important group of patients who deserve orthopaedic care. With appropriate structures in place and clear pathways, we can hopefully save both life and limb. Please take the time to read the document. n Fred Robinson is a Consultant Orthopaedic Surgeon at Addenbrooke’s Hospital, Cambridge. He has run the foot and ankle service for 15 years. He is Past President of BOFAS and is a trustee of the BOA.
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Care Quality Commission (CQC) Inspections Nick Aresti Co-author: Mike Zeiderman, National Professional Advisor for Surgical Services, CQC
As the CQC’s first round of NHS Trust inspections draws to a close, we can look back at the impact upon hospitals, assess whether the new regulatory system has worked and suggest what the future may hold for the inspection of orthopaedic departments.
Currently orthopaedic departments are inspected as part of the ‘surgery’ core service. Inspection teams consist of multiprofessional CQC inspectors and specialist advisors (SPAs), of which only a minority have a background in orthopaedics (25 surgeons and 20 nurses, out of 2,719 SPAs). Ratings are made on the basis of the inspection and review of various data sources, including PROMs, RTT data, and cancellation and complication rates. Most of this data is currently supplied by the Trust, HES and Dr Foster, supplemented by data from the NHFD, NJR and GIRFT.
Nick Aresti
Now that a comprehensive inspection of Trusts has been completed, how will the CQC proceed in the future? Whilst the strategy is not yet finalised, it is likely that future inspections will be more focused and will target areas of concern. In order to identify these areas, good intelligence is needed, and to obtain good intelligence, the correct questions need to be asked. To this end, the CQC is engaging with external groups such as the BOA, HSCIC and national clinical directors to determine quality standards which should be used
to inform the inspection of orthopaedic services. The most likely strategy will see annual, often unannounced, inspections of trusts, where their ‘well-led’ domain is reviewed, as well as a proportion of core services, which will have been highlighted as needing reinspection following the original comprehensive inspection or identified as ‘at risk’ by CQC intelligence. Comprehensive inspections will be reserved for poorly performing trusts and new mergers or acquisitions. Having completed the inspection of NHS Trusts, the CQC is ramping up its efforts in the private hospitals. The past decade has seen an explosion of NHS orthopaedic work being provided by the independent sector. It is known that many of the complications are returned to the NHS and it is important that the CQC develops systems that capture these patients, ensuring that private hospitals provide the same standards as those expected from the NHS. No matter how well-informed, non-specialist inspectors will never have the insight to
understand the nuances of clinical practice. Therefore, we feel it important that the inspection of clinical services should be undertaken by a team, including a number of clinically active, respected specialists. We would ask that those who wish to help in the inspection of orthopaedic services visit the CQC website and enrol as inspectors. Visiting other organisations may actually give you ideas on how to improve your own practice! n Nick Aresti is a Clinical fellow to the Chief Inspector of Hospitals and T&O ST6 on the Percivall Pott rotation (NE London).
Correspondence: Email: nick.aresti@cqc.org.uk
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Self-Perception in Orthopaedic Trainees: Is there a Gender Difference? Aparna Viswanath Co-authors: Helen Chase, Lora Young, Susan Deakin
Over the last 20 years there have been, at least, as many women as men entering medical school, but little has changed in the training environment. Although more women are entering orthopaedics, there are still the physical aspects of the job2 and the “jock-like culture”7 which are perceived as reducing the number of women taking up the career. It has also been recognised that highachieving women tend to have feelings of inadequacy and chronic self-doubt – a ‘syndrome’ known as Impostor Phenomenon1.
In this paper we hypothesise that female trainees often underestimate their performance and many feel that they are not as competent as their male colleagues. We propose that these traits might be evident in the multi-source feedback (MSF) tool. Changes to training may give rise to a better environment for all trainees.
Results Seven female and 12 male trainees, from a range of training years, responded to the survey. MSF assessment includes self and external ratings of good clinical
practice. The ratings are: not undertaken by me/not assessed, outstanding, satisfactory, or development required. There are also two free-text sections for areas where trainees perceive their performance as outstanding or requiring development. Only 17% of men and 14% of women rated themselves as outstanding overall. Nevertheless, 58% of men ranked themselves outstanding in at least one of the subsections of performance, compared with only 14% of women (Figure 1). Trainees were also asked whether an external comment had been made in the free-text section suggesting that more confidence was needed. 57% of female trainees had such comments compared with only 8% of male trainees.
Methods A web-based survey was sent to all East of England trauma and orthopaedic trainees as a pilot study. We analysed the last two MSFs and also included six questions from the Harvey Impostor Phenomenon scale4. All answers were anonymised.
Aparna Viswanath
A similar survey was sent to the eight female consultants in the region, as well as matched male consultants. The consultant survey aimed to establish perception of trainers towards their trainees.
Figure 1: Graph showing the range of self-ratings in the MSF by male trainees (blue) and female trainees (pink)
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Respondents were asked to rank six questions from the Harvey impostor phenomenon scale (Figure 2a) and answers were weighted with 1 point being given for ‘never true’ and 4 points for ‘always true’. For each of the six questions, female trainees scored higher (Figure 2b).
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a subconscious slight underconfidence becomes a selfperpetuating insecurity. So what can be done to support both men and women through a long training programme? Faculty diversity10, interactions with female surgical faculty7,8,11, and provision
of mentorship6 can all help. In a UK regional audit, 37% of higher surgical trainees had a mentor, and meeting with the mentor helped transition into a new post3. Our pilot study has limitations with small numbers of respondents and the inherent bias of anonymised
In the consultant survey there was an overall feeling that female trainees gave the impression of being less confident, possibly by verbalising their doubts more.
Orthopaedic training in the UK is long and arduous. Clinical and educational supervisors have defined roles, but the mentorship of one consultant guiding one or two trainees throughout training may be helpful. With the introduction of national selection, greater emphasis needs to be placed on pastoral care, as trainees can be posted away from their social support network. A mentor-mentee relationship could help ease changeovers and be a constant guide during the six-year programme.
Discussion This regional pilot study has shown that there are significant differences both in the way female and male trainees perceive their own performance and in the way trainers perceive them. Female orthopaedic trainees tended to receive external comments suggesting that they needed more confidence.
Figure 2a: Questions used taken from the Harvey Imposter phenomenon scale
Women also score higher on the modified impostor scale as they harbour more feelings of inadequacy with a fear of being ‘found out’ as not competent. Impostorism is not just a set of character traits that have no consequence. It is associated with burnout in residents5 and it has been claimed that women tend to attribute their successes to luck or effort, as opposed to men who attribute success to their own ability1. It has been shown that in orthopaedic residency there are no differences in exit exam results, OITE scores or faculty evaluations between men and women9. If underestimating ability is a female character trait and this apparent ‘lack of confidence’ is pointed out repeatedly in formal and informal assessments, then
surveys. We were also not able to look directly at comments or phrases that may highlight over-confident or self-critical views and include this in our data. We used only six of the original twenty questions from the Harvey Impostor Scale, thus our score is not validated, but it does give an insight into the general tendencies of trainees.
This study shows that women are less willing to boast their excellence and may be perceived as being under confident. We propose that the implementation of mentorship in a thought-out, structured manner is a way of supporting all trainees. n Aparna Viswanath is an ST6 trainee in Trauma and Orthopaedics on the East of England training rotation, currently working at the West Suffolk Hospital, Bury St Edmunds.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
Figure 2b: Responses to Imposter phenomenon questions by male trainees (blue) and female trainees (pink)
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Variability in Trauma and Orthopaedic Training Programmes: Two perspectives David Large & Marshall Sangster
The TPD Perspective The GMC-approved curriculum for trauma and orthopaedics requires trainees to be trained within the generality of the specialty, and to the standards defined within it. Therefore, one would expect that wherever their training programme, a trainee’s exposure to the generality of the specialty should be broadly similar. In theory, the standards within the curriculum should eliminate, or at least reduce, variability in
David Large
training. In practice, however, there are many external factors, which influence the delivery of T&O training. This results in an inevitable variation in the experience that can be delivered.
The Sources of Variation Table 1 and Figure 1 show the locations, number of trainees, number of hospitals, and population base, of the UK programmes - all figures are approximate. Training programmes vary enormously in their geographical size; the population base that they serve;
Marshall Sangster
the number and type of hospitals providing the training; as well as the number of trainees they have. All of these factors can have a significant effect on trainee experience. For example, not every training programme has a major trauma centre (MTC) within its rotation. This results in differing trauma exposure from one programme to another. It’s not just the distribution of MTCs which do not match training programmes. The distribution of bone tumour surgery, spinal deformity and other highly specialised areas of practice are all unrelated to training programme location. Other geographical influences also lead to variability in training. For instance, where training is delivered across a number of relatively small hospitals, all of which have to maintain a compliant rota, there is unavoidable competition for experience between trainees and the non-trainees appointed to keep the rota compliant. Therefore, a programme that has a small number of trainees for the size of the population it serves, may not necessarily be giving each of its trainees more experience. Much of the potential experience is lost to non-trainees. On the other hand, intense on-call rotas in busy departments can require compensatory rest which compromises regular daytime training.
Politics can also have an influence on training delivery. There are regions in the country where musculoskeletal services are purchased from other providers, most notably the purchasing of foot surgery from podiatrists. Such contracts may significantly reduce trainees’ exposure. It is not just in clinical volume and service delivery that training experiences vary. Programmes also differ in the way that they are managed. There is no standard remuneration for programme directors. It is inevitable, therefore, that the amount of time and effort that can be put into running a programme varies. As a result programmes may differ in the length of attachments (six or 12 months), how placements are chosen (by programme director, trainee or hospital), as well as in the way they organise formal teaching and annual review of competency progression (ARCPs). Any variation in programme geography and organisation will be compounded by another variable - the trainer. Not every trainer recognised as an arthroplasty surgeon will provide the same volume or level of supervision in joint replacement surgery.
LETB / Deanery HE East Midlands
No. of Trainees
No. of Hospitals / Trusts
No. of Programmes
Approx. Population (million)
59
9
2
4.5
HE East of England
51
16
1
5.8
HE KSS
51
15
3
4.5
HENCEL
110
21
4
HE North West London
65
16
1
HE South London
93
18
2
HE North East
71
12
1
3.4
HE North West (Mersey)
56
8
1
2.5
}
8.2
HE North west (North west)
60
15
1
4.5
HE South West
91
15
2
5.3
HE Thames Valley
38
8
1
2.4
HE Wessex
49
9
1
2.8
HE West Midlands
104
23
3
5.6
HE Yorkshire & Humber
81
17
1
5.3
South-east Scotland
36
4
1
1.1
East of Scotland
14
3
1
0.6
North-east Scotland
18
4
1
0.8
West of Scotland
56
12
1
2.6
Wales
36
12
1
3.1
Northern Ireland
29
6
1
1.8
Table 1: Location of UK Programmes
Figure 1: Location of UK Programmes
>>
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JTO Features
Figure 2 shows how surgeons in the West of Scotland vary, both in the numbers of hip replacements they undertake with trainees and the degree to which they take trainees through cases. Trainers also differ in the amount of feedback they will give to trainees; this is a reflection of their commitment to training.
Measuring Variation While variation in the delivery of training is inevitable, it is not all bad. To quote W Edwards Deming, the American statistician and management consultant; “Uncontrolled variation is the enemy of quality�. It is, therefore, important that we have ways of measuring the training process. This is the only way that we will build a better understanding of why there is variation, and in turn improve quality. Perhaps the most obvious place to start measuring training is to look at the logbook. PennBarwell et al.1 looked at logbook data to try and ascertain how achievable the SAC indicative
numbers were for trainees on each of the UK programmes. Figure 3 is an example of one of the graphs that they produced. Although there are methodological concerns about this study, it demonstrated that the indicative numbers were broadly achievable. However, it also showed significant variability in the ease with which the numbers were achieved. This was also born out in the BOTA linkman survey of training programmes. While it is easy to demonstrate variability in logbook numbers, it will take much more in-depth analysis to get a true understanding of the causes. The current redevelopment of the electronic logbook will improve its reporting functions and facilitate such analysis. There is, of course, more to the training process than simple logbook numbers. As the intercollegiate surgical curriculum programme (ISCP) dataset matures and links more closely with the logbook database, we should get access to many more measures of the
Figure 2: Trainer Variation in Total Hip Replacement
Anonymised data Figure 3: Number of operations per year for trainees by programme
training process. Data such as the numbers of workplace based assessments (WBAs) undertaken, the degree of feedback they contain, and, most importantly, how trainees progress in them will all become available with time. This data can be combined with other indicators of quality, such as the numbers of publications and higher degrees.
training that comes from liaison member reports and from the GMC (Figure 4) and JCST trainee surveys. These qualitative data sources will continue to be useful, even when more quantitative data becomes available, as they will aid the understanding and interpretation of these new measures.
These large database sets and the quantitative information that they can provide, have huge potential for the measurement of training. The realisation of this potential is, however, still a year or two off. At the moment our measurement of training is still heavily dependent on the qualitative information about
Effects of Variation Although our current methods of measuring training are still at an early stage of development, there are readily available statistics on training outcomes. The variation in these outcomes may be a reflection of variability in training experience.
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2014 Programme Group
Overall Satisfaction
Clinical Supervision
Handover
Induction
Adequate Experience
Work Load
Educational Supervision
Access to Eductional Resources
Feedback
Local Teaching
Regional Teaching
Study Leave
Trauma and orthopaedic surgery
2015 Programme Group
Overall Satisfaction
Clinical Supervision
Clinical Supervision out of hours
Handover
Induction
Adequate Experience
Supportive environment
Work Load
Educational Supervision
Access to Eductional Resources
Feedback
Local Teaching
Regional Teaching
Study Leave
Trauma and orthopaedic surgery
Figure 4: GMC Survey before and after inspection
Anonymised data
Figure 5: 1 year exam pass rates from GMC website
Both the GMC and the intercollegiate board publish exam pass rates on their websites. The GMC website2 shows exam pass rates for each programme a year at a time (Figure 5). The intercollegiate board website3 publishes data over a longer period which allows the five yearly pass rate for a region to be calculated (Figure 6). In addition to exam results, the same GMC website also shows ARCP outcomes for trainees by training programme (Figure 7). While this shows significant differences in the frequency of adverse outcomes between programmes, this cannot be interpreted as being entirely due to the variability in training. Although the waypoint assessments for ST4 and ST6 in T&O4 were designed to improve the consistency of ARCP assessments, it is clear that programme directors differ in the degree to which they use adverse outcomes to drive training.
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JTO Features
Conclusion While it is inevitable that there will always be variation in training, the overall standard of trauma and orthopaedic training in the UK remains high. It may seem that the current system of quality assurance, based on surveys, followed up by targeted visits to potentially problem units, is blunt and insensitive. In practice, however, it works well. It identifies units where there are known concerns, the resultant visits do produce improvement. In the future, logbook and ISCP data will add to our ability to identify uncontrolled variation and thereby allow us to improve the already high quality of training.
Acknowledgments With thanks to Ms C Santos of the JCST secretariat for her help in compiling Table 1.
The Trainee’s Perspective This aim of this article is to highlight factors affecting trainee preferences and discuss regional variations in training.
What is BOTA? The British Orthopaedic Trainees Association (BOTA) is a democratically elected professional committee. It represents trauma and orthopaedic trainees across England, Scotland, Wales and Northern Ireland. BOTA has a current membership of approximately 1,000 Specialty Registrars and newly appointed consultants.
Background Reviewing the FRCS trauma and orthopaedics examination
results on the Joint Committee of Intercollegiate Examination (JCIE) website shows that the average pass rate for part 1 between February 2009 and January 2016 was 87% amongst trainees and 85% for part 2. Non-training grade doctors had a pass rate of 50% and 31% respectively. These figures would suggest that training within the UK is world class. On the whole BOTA would agree that the UK provides excellent generalist training in trauma and orthopaedics. However, not all rotations are equal.
The Current State of Training BOTA has a varying degree of engagement amongst the UK training regions. The same is also true for the Training Programme Directors (TPDs).
BOTA has found that the least engaged TPDs are more likely to be from training programmes where trainees have concerns. The highly rated regions on the other hand, with good GMC survey results, have a much greater tendency to be engaged with the TPD forums and national TPD meetings. Does this matter and what do the regions do differently? During my tenure on the committee the disparity of regional training has been a recurring topic for concern. In 2015, BOTA’s annual publication “JOINT” contained two articles that might help shed some light. Laura Johnston and Malin Wijeratna, from the Peterborough City Hospital, published the findings of an online survey with a focus group of Specialist Training applicants. The findings of the survey were that location of immediate family is likely to be the most important factor when choosing a deanery, with location of Core Training the second most important factor. Half of all applicants to ST3 ranked all deaneries, implying they would take a national training number anywhere in the UK. This suggests that location, rather than quality of training, is the biggest driver for those applying for training posts. Only a quarter of respondents said that information on FRCS pass rates would alter their preferences. Therefore, if trainees choose a training programme on location rather than quality, it is essential that all programmes are of an equal standard to meet the trainees’ educational needs.
Anonymised data
Figure 6: 5 year exam pass rate by region
The second article highlights regional variation, and has led to concern. The Linkmen Roadshow Project was the brainchild of Mustafa Rashid and Peter Smitham (former BOTA Presidents). One-hour teleconferences with 28 orthopaedic registrars were arranged. A comprehensive
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JTO Features
Anonymised data
In an era when the European Working Time Directive has reduced the time in training, bad training posts should not be tolerated even if “things even out in the end”. There are plenty of enthusiastic consultants, young and old, who relish the opportunity to teach, guide and hone the skills of their consultant colleagues of the future.
Figure 7: ARCP outcomes by deanery from GMC website
view of training in the UK has been produced. The most satisfied trainees were in regions where the trainers provided one-on-one teaching, over and above well-organised, regular teaching sessions. General themes emerged which were common to the best teaching programmes. Teaching that was overseen by an educational lead, with specific terms, using a variety of teaching methods was best. Mock exams featured heavily throughout the discussions. Trainees felt that weekly, half-day teaching provided the best opportunity for attendance and engagement. These sessions had to be protected, covered and bleep free. Some larger regions found that moving to a day each month improved attendance, whereas other regions ran the programme on two sites. Possibly one of the most important factors was the opportunity to give honest, anonymous feedback. The regions which hold mock exams are popular with trainees. Some hold exams four to five times a year, with a full exam
run through each year. Other regions put pre-exam trainees in the ‘hot seat’ with 30 minutes of history, examination and image interpretation. This provides excellent learning opportunities, with desensitisation of trainees to the stressful FRCS viva. In some regions the newly appointed ST3’s attend separate induction training for up to eight weeks with an emphasis on getting up to speed with the extra responsibility and skills required to contribute effectively to the on-call team. Post-FRCS trainees can also be included, with leadership and management training. Each training programme is only as good as its trainers. Clinical experience and skills acquisition is essential for craft specialties, and should be the focus of the Educational and Clinical Supervisor. The majority of trainees meet the JCST recommended minimum number of procedures of 150 cases in six months. Sadly most of the trainees within the rotations where numbers fall beneath this recommendation are unaware of the regional variation.
Allocation of training post is one of the most important tasks of the TPD. Ideally the right trainee is placed with the right trainer, in the right environment, at the right time! This requires the TPD to understand the qualities and needs of the trainer and trainee. How this is fulfilled varies from region to region, with the greatest satisfaction coming from trainees who feel they can influence their allocations.
Final words BOTA firmly believes that the UK leads the way in training. This article has concentrated on the positives in orthopaedic training in the UK. Training relies on dedicated, hard-working young doctors who want to learn and are supported by their TPD and educational lead. The network of consultants, in the UK and abroad, who provide fellowships training, can further raise standards. Engaged TPDs who have a rapport with their trainees, in an environment that is honest, supported and allows feedback will ensure the highest standards of training. If training falls below a proper standard, this may need addressing by moving a trainee to another consultant or linking one trainer with a second. BOTA is currently running a census of orthopaedic training in the UK to quantify the differences between regions, and address some of the deficiencies raised in this article. The ultimate aim is to improve the
quality of training across the UK. If we can reduce the variability of training, trainees will be able to work in a geographical region, which suits their lifestyle and family ties, without concern for their training and its outcome. n David Large has been a Consultant Orthopaedic Surgeon at Ayr Hospital since 1992. He is Honorary Clinical Associate Professor at the University of Glasgow and Chairman of the SAC in Trauma and Orthopaedics for the UK and Ireland. Marshall Sangster is currently the Bristol Orthopaedic Registrars Group Chairman in the Severn deanery. He is about to commence his final year in training before embarking on fellowship. Marshall was on the BOTA committee as the BMA representative (2013-2015) and more recently the SAC representative (2015-2016).
References 1. Penn-Barwell, J.G., Bennett P.M., Wood A.M, Reed M. Is there variation in orthopaedic operative training experience between deaneries? BJJ 97-B SUPP 8/22 2. www.gmc-uk.org/ education/14105.asp 3. www.jcie.org.uk/content/ content.aspx?ID=9 4. www.jcst.org/qualityassurance/certification-guidelines
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JTO Features - Trainee Section
Incorporating leadership and professional skills training into a T&O regional teaching programme Ibrar Majid, Aqeel Bhutta and Daniel Redfern
Leadership and professional skills continue to be a key part of every surgeon’s day-to-day work, regardless of specialty or setting. The General Medical Council consider these skills to be essential for all doctors1. Following Ara Darzi’s ‘Next Stage Review: High Quality Care for All’2, the Academy of Medical Royal Colleges (AMRC) in conjunction with NHS Institute for Innovation and Improvement developed the Medical Leadership Competency Framework (MLCF) in 20083. The MLCF describes five domains, each of which contains four competencies, which doctors
Ibrar Majid
need to become more actively involved in the planning, delivery and transformation of health services. These competencies have been embedded into all surgical curricula, including the Specialist Training in Trauma and Orthopaedics curriculum, since 2010. Despite the introduction of these competencies into the T&O
Aqeel Bhutta
surgical curriculum more than five years ago, most trainees in the United Kingdom complete their training with very little formal instruction or opportunity to develop these skills before they embark on life as independent practitioners. The majority will attend a three-day management course at the end of the training, prior to CCT, and very little else.
Daniel Redfern
Professional Behaviour and Leadership and Learning Skills (PB & LLS) The North West T&O Surgical Training Committee identified this gap within its own training programme in 2012. A pilot was started to teach these competencies within the T&O Higher Surgical Teaching Programme. Initially, we devised a nine-week module to be delivered to all ST3 trainees at the start of their rotation. This module covered all the domains within the MLCF. Over the last four years we have refined the programme and have now developed an early and late module. The early module is for all new starters at ST3 level and covers topics relevant to the start of higher surgical training, including career development, resilience, understanding learning styles, reflective learning, research methods, medico-legal and ethical issues. The later module is for ST8 trainees as they enter their final year of training and covers topics of relevance to their future as consultants in the NHS. These include developing new services, writing business plans, understanding how the commissioning process works, simulation, human factors training and appraisal. Both modules run concurrently at the start of the academic training year and trainees attend these sessions in lieu of the local fouryear rolling teaching programme.
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Figure 1: The five domains of the Medical Leadership Competency Framework (AMRC, 2010)4
We have built in some shared competencies between the two modules and this has allowed us to deliver sessions to the two groups collectively. Shared topics include self-awareness, emotional intelligence and understanding personality types, including the use and feedback on the Myers Briggs Personality Type Indicator, risk management, patient safety, and an understanding of the history, structure and function of the NHS.
Feedback Pre- and post-module surveys confirm that all the trainees had a better understanding and knowledge of leadership competencies following the training. They were more familiar with those aspects of the NHS which would be vital for their roles as consultants in the future. In the first three years of the
programme we had a response rate of 59% to all the surveys. Eighty-nine per cent of trainees felt that the PB & LLS module covered the professional and leadership component of the T&O curriculum. Trainee comments include “Excellent module helps to introduce trainees into specialist training beyond just the surgery!” and “The module lays an excellent foundation to develop your interest in leadership and management within the NHS, which is becoming critical in our everyday practice.”
Challenges and future directions Delivering these programmes on an annual basis, to two separate cohorts, has brought its own challenges. Many
of the topics we cover have not traditionally been taught in a postgraduate surgical training programme. We are unaware of any surgical training programme in the UK that has been able to embed the competencies required from the MLCF into their programme. Some of the content is even beyond the expertise of our T&O trainers. The faculty is therefore comprised of local T&O colleagues with an interest in leadership and personal development, senior T&O leaders from the region, colleagues from Health Education England (North West) and individuals from local Clinical Commissioning Groups, community and hospital NHS Trusts within the North West. Some skills needed to deliver the programme (e.g. administration of Myers Briggs Type Indicator) have required formal training of the trainers. The ST3 2012 pilot cohort of trainees will be entering the ST8 year in August 2017 and we will use this opportunity to formally evaluate the impact this programme and six years of T&O surgical training programme has had on the trainees behaviour, personality and learning type. We believe this programme is a valuable addition to T&O higher surgical training and allows us to develop more rounded surgeons who are ready to take on the future challenges of working as consultants in the NHS. We think that the programme covers all of the competencies in the MLCF and gives our trainees the opportunity to reflect on their behaviour and practice at an early stage of their career. We welcome the opportunity to disseminate our model to the wider T&O community and other surgical specialities. n
Ibrar Majid is a Consultant in Paediatric Trauma and Orthopaedic Surgery at the Royal Manchester Children’s Hospital. Ibrar is an alumnus of an NHS Clinical Leadership Fellow Scheme and designed the PB & LLS programme. He is co-lead for the PB & LLS module and delivers training on personal development, self awareness and leadership both nationally and internationally. Aqeel Bhutta is a Consultant Orthopaedic Knee Surgeon in the North West. He was an STC trainee representative and has led numerous clinical change projects including enhanced recovery which fuelled his interest in leadership as a new consultant. Aqeel is currently Clinical Director for Orthopaedics at Pennine Acute NHS Trust and co-lead for the PB & LLS module. Daniel Redfern is a Consultant in Trauma and Orthopaedic Surgery at Lancashire Teaching Hospitals. He is the Regional Director of Professional Affairs for the Royal College of Surgeons of England.
References 1. General Medical Council. (2013) Good Medical Practice. London: GMC. 2. Department of Health. (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: TSO. 3. Academy of Medical Royal Colleges. (2008). Medical Leadership Competency Framework: Enhancing Engagement in Medical Leadership. 1st ed. London: NHS Institute for Innovation and Improvement. 4. Academy of Medical Royal Colleges. (2010). Medical Leadership Competency Framework: Enhancing Engagement in Medical Leadership. 3rd ed. London: NHS Institute for Innovation and Improvement.
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JTO Medico-Legal Features
The Importance of Recognising the Different Kinds of Expert Surgical Evidence Giles Eyre
It is generally assumed that surgeons instructed to provide expert reports for use in court are hired only in order to provide expert opinion evidence, and only for that purpose. That assumption is wrong. Expert evidence is multi-faceted, and recognition of that fact will impact on the approach to report writing and the manner in which the report is constructed by the expert.
Expert opinion evidence is only one aspect of expert evidence
Giles Eyre
Typically an expert is instructed in litigation to provide opinion evidence – has the standard of care fallen below that reasonably to be expected of a reasonably competent expert in that field, or has any injury, loss or damage been caused by a breach of duty, or what is the extent of injury, loss or damage resulting from an accident or other adverse event? But that is not the full picture and there are other types of expert evidence which may be just as important to lawyers and to judges hearing the cases, and which are frequently contained within an expert’s court report.
It is important to be aware of the different roles that an expert may have as a court expert and the separate, but often overlapping, reasons why the expert may have been instructed. The recent Supreme Court decision in Kennedy v. Cordia (Services) LLP1 was concerned with the evidence of an engineer in relation to a slipping case and although dealing with an appeal from Scotland, the Court’s observations are equally applicable to England and Wales and to medical experts.
The Kennedy v. Cordia case The case itself was relatively straightforward in medical terms. Tracey Kennedy, a home carer,
slipped on an icy path fracturing her wrist while visiting an elderly patient. She claimed damages against her employer. An expert witness on Health and Safety opined that she probably would not have slipped and fractured her wrist if she had been provided with a clip on attachment for her shoes called “Yaktrax”. He was of the opinion that Cordia had not properly assessed the risk of such an event occurring. Cordia objected to the expert’s opinion arguing that it was inadmissible as he had no relevant special skill or specialised learning. The initial court ruling was that Cordia were liable but this view was overturned at appeal and Ms Kennedy and her legal representatives asked the Supreme Court to overturn this ruling. The Supreme Court obliged.
The expert as witness of fact Like any other witness the surgical expert may be an expert of fact giving evidence of what he or she observed, so long as it is relevant to a fact in issue in the case. So a surgeon may give evidence of an examination of
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JTO Medico-Legal Features
WHAT IS ALWAYS ESSENTIAL IS THAT THE EXPERT EXPLAINS THE BASIS OF HIS OR HER EVIDENCE WHEN IT IS NOT SIMPLY EVIDENCE OF PERSONAL OBSERVATION OR SENSATION. MERE ASSERTION CARRIES LITTLE WEIGHT.
the claimant, or the appearance or movements of the claimant on arriving or leaving the consulting room. Like any other witness of fact, it is important, particularly if the evidence may be challenged, that in addition to giving the factual evidence, the medical expert also gives evidence as to the circumstances in which the facts were ascertained. So, for example, in relation to the clinical encounter with the claimant, the report should include the time spent, together with any information supportive of the reliability of the experts account. In the case of other observations, information as to how long the claimant was observed, from what distance, whether the view was unobstructed and in what lighting conditions.
The expert as witness of expert facts As a skilled witness, a surgical expert may also give evidence based on his or her knowledge and experience of a subject matter, drawing on the work of others, such as the findings of published research or the pooled knowledge of a team of people with whom he or she works. A medical expert may therefore, for example, give evidence as to how a joint functions and the potential impact on the joint or on bone of a particular fracture or disease, or of what is found to be present but not immediately apparent (for example by palpation). This may well not be opinion evidence, but evidence of facts known to and shared by similar experts. For such
evidence to be admissible from the witness, the same rules that govern admissibility of expert opinion evidence also apply. Therefore, to be permitted to give this evidence, the skilled witness must set out his or her qualifications, by training and experience, to give expert evidence (most probably in the CV section of the report) and also say from where he or she has obtained information if it is not based on his or her own observations and experience. This expert factual evidence may be given by itself or in combination with, or as the basis for giving, opinion evidence.
The expert expressing opinion as to ‘missing’ facts Sometimes the expert is required to, or identifies the need to, express opinion as to what the facts were (on the balance of probabilities). For example there may be missing observations or readings in the medical records or missing or absent x-rays or other images, the content of which might be important in providing an opinion. Based on other information or data, and expert knowledge, the surgeon may be able to express an opinion as to what that absent fact was (on the balance of probabilities). To provide such an opinion as to the ‘missing’ fact the expert has to be able to justify his or her expertise to do so. That is probably covered by the
expert’s standard CV section of the report, but if not, then the expertise must be expressly addressed.
The expert giving ‘pure’ opinion evidence ‘Pure’ opinion evidence, in contrast to expert factual evidence, will address, for example in medical expert evidence, condition and prognosis, causation or standard of care. This is what is normally thought of when referring to expert evidence.
Rules as to admissibility of expert evidence Whether giving skilled evidence of fact or expert opinion the admissibility of the skilled evidence is governed by the same four considerations: 1. Will the evidence assist the court in its task? 2. Does the witness have the necessary knowledge and experience? 3. Is the witness impartial in the presentation and assessment of the evidence? 4. Is there a reliable body of knowledge or experience to underpin the expert’s evidence? But opinion evidence, in contrast to factual evidence, is only admissible if it is necessary, rather than merely of assistance, for the court to have such evidence in order to resolve the matter in dispute. Medical expert opinion evidence
to address condition and prognosis, causation or standard of care is normally necessary and that it is necessary is obvious. Medical expert opinion to address missing facts is not necessarily obvious and should be justified – the report should spell out why it is necessary to establish the missing fact, as well as justifying the expert’s expertise to provide it.
Provide reasoning, not just assertions What is always essential is that the expert explains the basis of his or her evidence when it is not simply evidence of personal observation or sensation. Mere assertion carries little weight. Quoting from a South African case in Kennedy v. Cordia Services LLP the Supreme Court stated: ‘Except possibly where it is not controverted, an expert’s bald statement of his opinion is not of any real assistance. Proper evaluation of the opinion can only be undertaken if the process of reasoning which led to the conclusion, including the premises from which the reasoning proceeds, are [sic] disclosed by the expert.’ And quoting from a Scottish case, the Supreme Court stated: ‘As with judicial or other opinions, what carries weight is the reasoning, not the conclusion.’
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Writing the report The surgical expert, in writing a court report, should bear these points well in mind: 1. When giving evidence of factual matters observed by the expert, then the circumstances in which they were observed, and therefore their reliability, should be spelt out. That may well include details of the length and circumstances of the clinical encounter with the claimant or the distance from which the claimant was observed when leaving the consulting room; 2. When giving evidence of factual matters known only as a consequence of having the particular skills for which reason the expert has been instructed, in addition to providing the appropriate expert credentials to justify the status as the appropriate expert, the expert must provide clear statements as to the reasoning process which led to each conclusion reached; 3. When giving an opinion on missing facts, in addition to providing the appropriate expert credentials to justify the status as the appropriate expert, and the ability to provide the opinion, the expert should explain the importance and relevance of the missing facts, and provide a clear explanation of the reasoning process by which the missing facts may be deduced; 4. When giving an opinion on condition and prognosis, causation or standard of care, in addition to providing the
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appropriate expert credentials to justify the status as the appropriate expert, and the ability to provide the opinion, it is the reasoning process which carries weight with the judge and which must therefore be fully spelt out within the expert report2. Giles Eyre has recently retired from practice after 40 years as a barrister specialising in clinical negligence and personal injury claims. He is a contributing editor to ‘Clinical Negligence Claims - A Practical Guide’ (2015). He is a mediator and continues to sit as a Recorder. Giles is co-author of a manual for medico-legal experts and those instructing them, ‘Writing Medico-Legal Reports in Civil Claims - an essential guide’ (2nd edition - September 2015) (www.prosols.uk.com). He frequently gives seminars and workshops, and provides training for medical experts and those instructing them in medico-legal report writing, giving evidence and other medico-legal issues. Giles blogs as Medico-legal Minder on topics of interest to the medical expert witness.
Editorial Comment from Mike Foy It is true to say that as experts we focus on causation, condition and prognosis in our personal injury reports as liability is not usually our preserve. In contrast, liability is of fundamental importance if we are asked to give an expert opinion in a case of alleged negligence. Giles Eyre introduces us to another facet of expert evidence drawn from the recent Kennedy v. Cordia case. We would all, no doubt; give a clear and concise account of the claimant’s description of the injury and our objective findings on examination. We would also, where appropriate, give our views on the claimant’s veracity and any inconsistencies regarding their account of the past history and continuity of post-accident symptoms when cross referenced against the medical records. Currently, it is not common expert witness practice to record the time spent with the claimant. The “missing facts” position is interesting. Sadly, it is not unusual for records to be incomplete. The more difficult scenario arises when the records are complete and there is no complaint of any relevant symptoms for a prolonged period of time despite the claimant insisting that problems persisted throughout. Here the expert needs to take an informed view on the basis of his experience of dealing with the condition under consideration in clinical practice together with his understanding of the pathophysiology and
epidemiology of that condition, the veracity of the claimant and the expected recovery period from the injury. If assertion alone is insufficient without reasoning, how then do we rationalise the concept of advancement or acceleration of symptoms if that position on causation is believed by the expert to be appropriate? A bald assertion of six months, five years or twenty years is unlikely to help or satisfy the court unless some justification can be given for the reasoning behind the position that has been taken. Some guidance on this has appeared elsewhere3. Food for thought, indeed. n
References 1. Kennedy v Cordia (Services) LLP [2016] UKSC 6 2. An extended discussion on the implications of Kennedy v Cordia Services LLP between Giles Eyre and Kevin Connor SC of New South Wales Kevin Connor can be found at https://benchmarkinc. com.au/web/television/ single/164358713 3. Foy, M A: Advancement and acceleration in medico-legal practice. What’s it all about? Bone and Joint 360 Apr 2016, 5 (2) 37-38
Correspondence Giles Eyre Associate Member Chambers of Andrew Ritchie QC 9 Gough Square London EC4A 3DG
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JTO Peer-Reviewed Articles
Innovations in Trauma and Orthopaedic Surgery: 3D Printing Shalin Shaunak Co-author: Wasim Khan
In recent years, 3D printing (3DP) has found a multitude of applications in Trauma & Orthopaedic surgery.
These techniques fall into four main categories1: 1. Pre-operative templates 2. Implantable Scaffolds 3. Intraoperative guides 4. Implants and prostheses In all cases, a 3D model is constructed through computeraided design often from existing radiological images, commonly CT or MRI. The resulting model is then printed. There are a
Shalin Shaunak
variety of methods of 3DP which include selective laser sintering (SLS), stereolithography (SLA), fused deposition modelling (FDM) and direct metal laser sintering (DMLS)2. We will briefly discuss the four categories outlined earlier and give examples of their clinical applications.
Three-dimensional printing is also useful in complex pelvic surgery, where appreciation of the anatomy is crucial. The use of pre-operative templates has been shown to increase accuracy9 and can alter the approach and surgical technique to allow the
Figure 1: Volume rendered CT scan of a patient with ulna malunion
Pre-Operative Templates Pre-operative planning is key to all successful interventions in orthopaedic surgery. The construction of patient specific pre-operative models, or templates, is useful as it allows computer assisted planning. This includes the selection of the appropriate intervention and approach, prediction of the risks associated with an approach or technique, as well as assessment of the anatomy and pathology. A number of papers have demonstrated that the use of 3DP templates in spinal surgery gives a greater appreciation of the anatomy and pathology in complex cases3-5. There is evidence that 3DP reduces operative time, blood loss, transfusion requirements6, fluoroscopy exposure and screw malposition rates in spinal surgery7,8.
Figure 2: 3D modelling images of the same patient
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Journal of Trauma and Orthopaedics: Volume 04, Issue 03, pages 56-58 Title: Innovations in Trauma and Orthopaedic Surgery: 3D Printing Author: Shalin Shaunak; Co-author: Wasim Khan Division of Trauma and Orthopaedics, University of Cambridge Arthritis Research UK Tissue Engineering Centre
pre-bending of plates and help in determining screw trajectory10,11. This potentially reduces operative time, bleeding and facilitates recovery. Patient specific pre-operative templates have been shown to improve results in upper limb malunion surgery, allowing the construction of intraoperative guides and plate precontouring12,13. The technology has also proven useful in complex calcaneal fracture fixation14 and the correction of lower limb malunion15. The first author has direct experience printing templates for the pre-operative planning of scaphoid and ulnar malunion surgery (Figures 1-5). The
templates help inform and involve the patients, facilitating the consent process, as well as surgical planning.
Implantable Scaffolds The construction of patientspecific, implantable scaffolds with control of porosity, pore size and macroscopic structure, has led to novel advances. Titanium is widely used as a result of its inherent inertness and biomechanical strength. The ideal porosity (500µM) is a compromise between that required to maintain mechanical strength and that required to encourage bony ingrowth16. Patient-specific,
implantable scaffolds reduce operative time, infection and the number of screws required compared with commercially available meshes17. Whilst the inert nature of titanium reduces in-vivo inflammation and fibrous ingrowth, its reduced biological activity compromises the osteoinductive properties of the scaffold. This is addressed by calcium phosphate (CaP) coating18,19. Alternatively, magnesium based scaffolds can be used, as they have favourable osteoconductive behaviour20. CaP based ceramics have both osteoconductive and osteoinductive properties, and are biodegradable over time. Their main disadvantage is their reduced mechanical strength, however,
this can be offset by reducing the porosity of the scaffolds21,22 or incorporating calcium sulphate23, zinc or silica oxide24 powders into the ceramic to increase the overall compressive strength. Bioglasses are inherently bioactive25, although it is only recently that manufacturing techniques have developed to give the requisite strength for use in 3DP scaffolds. Nevertheless, it is only with a much smaller pore size of 100µm, and therefore reduced porosity, that the bioglasses are strong enough for in-vivo use26,27. Polymers, both synthetic (e.g. polyƐ-caprolactone) and natural (e.g. starch-based), can also be used; they have favourable compressive strength and biocompatibility28,29. >>
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JTO Peer-Reviewed Articles
Figure 3: Virtual design ulna non-union
Intraoperative Guides The ability to fabricate patientspecific, intraoperative guides allows the surgeon to navigate and accurately place their implants, screws or devices. This technology, like preoperative templating, is of particular benefit in complex cases. These guides have been developed in spinal surgery to accurately insert pedicle screws. They have been shown to reduce fluoroscopy time, improve the accuracy of screw placement30,31, reducing operative time and blood loss32. Intraoperative guides are also used in pelvic and hip surgery for curved peri-acetabular osteotomies33, complex total hip replacements34 and pelvic tumours. The use of guides can be supplemented with patient specific instruments35. The improved accuracy of 3DP intraoperative guides has also been shown, in total knee replacement, to reduce the blood loss and operative time36. It has also been reported in a single case of mosaicplasty of the knee with favourable results37.
Implants and Prostheses There are large variations in patient anatomy, as well as of the trauma or pathological process. Therefore, the fabrication of patient-specific implants and prostheses is of interest.
Figure 4: Pre-operative simulation using polyethylene model
Upper Limb Surgery Implants to replace eroded glenoids following total shoulder replacement surgery have produced excellent results38. Furthermore, replacement of the entire scaphoid or lunate, following avascular necrosis has shown favourable clinical results39. The replacement is modelled on the contralateral wrist. Further applications in hand and wrist surgery include customised wrist splints for hand therapy40. Lower Limb Surgery In total hip replacement customised acetabular cages have been used with success41. Creating models of commercially available prostheses allows pre-operative simulation and helps make a decision as to the most appropriate implant42. In knee replacement customised titanium augments for large defects43 and patello-femoral joint replacement44 have been performed. As with hip replacement, a 3D model of the patient’s knee can be matched to a library of commercially available implants to establish the most anatomically appropriate implant45. Customised guides and implants have also trialled in unicompartmental knee replacement46. Patient-specific foot and ankle orthoses have been shown to better align and match patient anatomy. These include AFOs47,48 and in shoe orthoses49,50. Tumour Surgery Patient-specific proximal tibia hemiknee implants using computerassisted design, computer-assisted modelling and 3DP has been
described for tumours51. Similarly, the normal half of the pelvis can be modelled and used to reconstruct the pelvis in patients undergoing hemipelvectomy for pelvic malignancy52. In upper limb malignancy, polymethylmethacrylate implants have been manufactured to replace the proximal and distal humerus following bone loss. This gave favourable results when compared to conventional intramedullary nailing53. Trauma Surgery Cadaveric studies using patientspecific external fixators optimise reduction and increase stability54. Ongoing developments include fabrication of patient-specific sockets for lower limb amputation surgery. These are anatomical55 and give an increase in the overall strength and durability56,57. There are ongoing attempts to construct sockets with inbuilt cooling channels to reduce skin maceration and breakdown58. Furthermore, a combination of 3DP components and robotics has allowed the advent of functional prosthetic hands59,60.
Conclusion In conclusion, 3DP has allowed advances in Trauma and Orthopaedic surgery. The clinical applications are increasing. The technique gives obvious benefit in pre-operative planning, as well as intraoperatively providing guides, implantable scaffolds and
Figure 5: Intra-operative images of ulna malunion surgery
implants. The role of 3DP is not limited to the operating theatre as it can help in the manufacture of better orthoses. Whilst initially the products of 3DP were used for complex cases, it is now becoming routine, and is likely to have a significant impact on all of our practices in the coming years.
Acknowledgements We are grateful to Miss Shamim Umarji, Consultant Orthopaedic Surgeon at St George’s Hospital, London, for permission to use images from her patient. n Shalin Shaunak is a Speciality Registrar in Trauma and Orthopaedics in the KSS deanery. He has an interest in 3D Modelling and Printing and wants to develop this interest and translate it into clinical practice.
Correspondence Email: shalin.shaunak@doctors.org.uk
References References can be found online at www.boa.ac.uk/publications/ JTO or by scanning the QR Code.
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Advances in osteoarthritis imaging: What will make it into clinical practice? Stephen McDonnell Tom Turmezei, Martin Graves, Andrew McCaskie & Joshua Kaggie
Osteoarthritis is one of the fastest increasing global health problems, causing pain and disability. End stage disease is treated effectively with joint replacement, but the number of replacements is increasing year-on-year, with increased costs for already stretched healthcare systems.
population, less than 1% by mass. Therefore, compositional techniques rely on the ability to quantitatively measure changes in this macromolecular environment. A critical question is whether these techniques will have relevance to global joint health and treatment decisions in future clinical practice?
Structural imaging Surgical interventions for early stage disease, such as regenerative treatments1, are currently limited, in part due to the lack of diagnostic imaging methods to accurately quantify disease severity and select patients for treatment. Looking ahead, cutting-edge imaging technologies may provide detailed assessments of the arthritic joint at an early stage, allowing the development and improvement of treatment strategies in early disease.
Stephen McDonnell
Improvements in regular clinical imaging techniques, such as x-ray, computed tomography (CT) and magnetic resonance imaging (MRI) will give more detailed anatomical resolution and be combined with assessment of biological function. In this review article we explore imaging techniques likely to impact on clinical practice, focusing on plain radiography, CT and MRI. Other techniques such as ultrasound and nuclear medicine may also play an important role.
The difference between structural and compositional imaging One important distinction in imaging osteoarthritis is whether the technique provides structural or compositional information. Structural imaging is the basis of current clinical imaging and depicts joint morphology from a limited range of tissue characteristics such as mineralisation, fat and water content. This can be used to assess the early features that might predispose to later disease, or for monitoring progression towards end-stage joint failure. Compositional imaging techniques assess joint tissue characteristics beyond the macroscopic structural level, identifying early changes, prior to cartilage loss, that would otherwise be considered irreversible (OARSI grade IV2). Cartilage is an avascular, aneural and alymphatic extracellular matrix formed predominantly from collagen and glycosaminoglycans (GAG) networks, with a small chondrocyte
X-ray Radiography Planar X-rays have been the mainstay of clinical and research osteoarthritis imaging. It is low cost, accessible, quick and relatively easy to interpret. Thus it will continue to inform clinical assessment and decision-making, particularly in monitoring progression and following up therapies, such as joint replacement. However, compared to other modalities its two-dimensional nature makes it insensitive to structural change and unlikely to have an extended role. Computed Tomography (CT) CT is excellent at imaging bone. As such, it has mainly been used as a tool for the pre-operative planning of surgery, for example alignment, dysplasia, patientspecific implants. Similar to radiography, CT is low cost, accessible and can be acquired rapidly. Although the relatively higher exposure to ionising radiation compared to radiography, is a concern, particularly if planning multiple exposures for follow-up
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Journal of Trauma and Orthopaedics: Volume 04, Issue 03, pages 60-63 Title: Advances in osteoarthritis imaging: What will make it into clinical practice? Authors: Stephen McDonnell, Tom Turmezei, Martin Graves, Andrew McCaskie & Joshua Kaggie Division of Trauma and Orthopaedics, University of Cambridge Arthritis Research UK Tissue Engineering Centre
Figure 1: Quantitative measurement of cortical thickness at the hip in 3D from clinical CT imaging data using Stradwin software (http://mi.eng.cam.ac.uk/~rwp/stradwin) displayed as a colour map on a 3D mesh framework. Note increased thickness compared to other articular regions at the femoral superior subchondral bone plate, a key load-bearing site
imaging or if used in a younger population. Increasingly low-dose protocols are being developed that will make this less of an issue3. CT can also be used to quantitatively map structural features of disease such as subchondral bone thickness, density, and joint space width (JSW) in three-dimensions (Figure 1)4. Given their association with recognised tissue changes in the development of osteoarthritis5, changes in these parameters are likely to be meaningful in disease progression or response to therapy. Magnetic resonance imaging (MRI) MRI has traditionally been used to supplement radiography in the clinical evaluation of osteoarthritis, mainly in the characterisation of structural joint damage and cartilage health. One of the main strengths of structural MRI is its ability to evaluate early soft tissue features, such as synovitis6 and bone marrow edema7 whilst also detecting ligament, fibrocartilage and hyaline cartilage damage. Semi-quantitative systems exist for scoring these features, but these scores are mainly used as research tools. The MOCART system has been used to assess cartilage repair technique viability and is likely to be become more familiar as these surgical techniques
become more established. We refer readers with an interest in semi-quantitative MRI scoring on to an in-depth review by Guermazi et al.8. In addition to observergenerated scoring, there are a variety of 3D MRI methods that can create contrast between cartilage and bone, allowing 3D visualisation and structural quantification9,10. These can be used for measurement of cartilage thickness and volume (Figure 2). Such measures are likely to become increasingly important with the advent of whole joint therapies, which look to reverse deterioration in cartilage health. Compositional/Physiological Imaging MRI is the forerunner in compositional imaging. Although many compositional techniques are not used clinically as a result of the lack of early osteoarthritis management options, this is likely to change as new therapies become available. There is a range of techniques that have been validated in small, specific cohorts of early osteoarthritis which are beginning to be used in clinical practice: here we look at the most relevant#.
dGEMRIC Delayed Gadonlinium Enhanced MRI with Contrast (dGEMRIC) measures the T1 relaxation time in cartilage before and 90 minutes after the intravascular injection of a gadolinium-based contrast agent12-14. Damage to articular cartilage is associated with Glycosaminoglycans (GAG) loss, so decreased GAG levels allow greater penetration of gadolinium from synovial fluid into the cartilage matrix, leading to reduced T1 relaxation times. dGEMRIC has proven ability to identify cartilage damage relevant to disease outcome before structural changes13-17. However, the long times required for joint perfusion has so far kept it from widespread clinical application. dGEMRIC’s use of gadolinium is also a concern due to recently discovered retention in the brain and established toxicity in patients with renal impairment18.
As a result, non-gadolinium-based measures of cartilage integrity may well play a wider role (Figure 319). Proton Relaxation MRI: T2, T1rho and T2* mapping Other types of quantitative MRI acquisition are sensitive to compositional changes that can be probed through relaxation time measurements. Four main relaxation times can be measured: T1 (as in dGEMRIC), T2, T1rho, and T2*. Each of these creates different image contrasts between tissues types, with additional post-processing to give quantitative results that can be mapped in 2D or 3D. T2 mapping using spin echo based MRI sequences has been the most common method for identifying changes relevant to osteoarthritis (Figure 4)20,21, with >> T2 values shown to correlate
Figure 2: Quantitative cartilage thickness at the femoral articular surface in 3D as measured from segmentation in a 3D T1-weighted MRI series using Stradwin software. The tibial articular surfaces are shown in grey
# For in depth reading into the full range of compositional MRI techniques currently available, we refer readers on to a recent review by Guermazi et al.11
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MRI systems, and while T1rho is becoming increasingly available it does require additional specialised software.
Figure 3: dGEMRIC of articular cartilage at the knee joint (sagittal). Note the increased T1 values at the weight-bearing surfaces of the femur and tibia (dashed lines) compared to the rest of the cartilage19
with water levels in cartilage, synovial fluid, and muscle22. The underlying principle is that since damaged cartilage has increased water content, T2 values will be higher in unhealthy regions. However, changes in these values are not correlated with acute injury. T1rho images appear similar to T2, but use a special technique that measures relaxation dominated
by macromolecular correlation times. It has the advantage over T2 of being more sensitive to early microscopic change23, and more repeatable in one study involving anterior cruciate ligament injuries24. Both T2 and T1rho correlate with age, which is a strong indication of their sensitivity to related proteoglycan changes25,26. T2 maps can be acquired on many
Figure 4: Sagittal T1rho image (a) and map (b, T2 image (c) and map (d), and T2* image (e) and map (f) in a healthy knee. All three techniques can be used to quantitatively assess the state of cartilage health. Maps can be masked to provide values exclusive to cartilage regions
The principle of T2* mapping is similar to T2 mapping, except that it is based on gradient-echo based MRI sequences that demonstrate susceptibility to local magnetic field inhomogeneities. Using a similar effect as harnessed in T2 mapping, T2* maps similar properties of cartilage as T2 but using much faster acquisitions. T2* mapping is available on many clinical imaging systems, and as with T2 and T1rho mapping, we are likely to see this in clinical practice once the clinical relevance of these quantitative cartilage measures is established. Ultrashort Echo Time (UTE) MRI MRI signals decay rapidly (T2 < 10 ms) in bone or near the bonecartilage interface27-29 so they are unseen on conventional MR images. Ultra-short echo time (UTE) MRI captures this fast-decaying signal by using novel acquisition methods30,31. UTE MRI can therefore image the deep cartilage layers31. Subtracted UTE images can also be used to highlight differences at the osteochondral junction (Figure 5)31. UTE techniques are becoming more clinically available, although commercial implementation has been slow partially due to increased computational requirements30,32. The relevance of UTE imaging is yet to be established in disease progression.
Sodium MRI Instead of using hydrogen atoms as the basis for tissue signal, it is possible to use other atoms. Sodium MRI can create image contrast not available with other standard protonbased methods33,34 (Figure 6). Positively-charged sodium is attracted to negatively charged proteoglycans, such that healthy cartilage contains more sodium than osteoarthritic cartilage35-37. Sodium MRI requires specialised software and hardware that is not widely available on clinical MRI systems, but these can be found at various research institutions38,39 and is likely that it will ultimately be used in disease assessment40.
Conclusion Orthopaedics is continually evolving and is our diagnostic resource. Even the very familiar MRI examination will, as 3T field strength imaging becomes routinely available, provide quantitative structural and compositional imaging techniques described here, which will in turn provide realistic diagnostic and prognostic options. In the coming decade it is likely that patients with early osteoarthritis will have access to quantitative imaging methods. This will be an unprecedented opportunity for the clinician to refine and develop new treatments for cartilage repair and early osteoarthritis.
Figure 5: Sagittal UTE image of a healthy knee. The short TE of the first image (32 Âľs) allows UTE structures to be visualised; these signals have decayed by the late echo image (4.5 ms). The subtraction image shows the delineation of deep cartilage (arrow), which is usually an undefined low-signal structure in standard MRI
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Journal of Trauma and Orthopaedics: Volume 04, Issue 03, pages 60-63 Title: Advances in osteoarthritis imaging: What will make it into clinical practice? Authors: Stephen McDonnell, Tom Turmezei, Martin Graves, Andrew McCaskie & Joshua Kaggie Division of Trauma and Orthopaedics, University of Cambridge Arthritis Research UK Tissue Engineering Centre
Figure 6: Standard sagittal proton T2 image (a), sodium MRI image (b), in a healthy knee. The sodium image gives an indirect measurement of proteoglycan content, which has been shown to be an indicator of cartilage health
Acknowledgements
Correspondence
The UTE images are courtesy of Dr. James MacKay. Dr. Joshua Kaggie is funded by GlaxoSmithKline. The work was supported by the Addenbrookeâ&#x20AC;&#x2122;s Charitable Trust and the NIHR comprehensive Biomedical Research Centre award to Cambridge University Hospitals NHS Foundation Trust in partnership with the University of Cambridge. n
Email: sm2089@cam.ac.uk
Stephen McDonnell is a University Lecturer and Honorary Consultant Orthopaedic Surgeon in Cambridge. He has an interest in early arthritis phenotypes, novel radiology techniques, patient stratification and treatments.
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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The use of stem cells in articular cartilage defects: Where are we now? Wasim Khan Co-authors: Prof James Richardson & Prof Andrew McCaskie
The management of injuries of the knee cartilage has evolved over the years with advances in minimally invasive surgical techniques, cell-based therapies and sophisticated rehabilitation. These therapies have been augmented by greater knowledge of biomechanics and tissue engineering1.
Tissue engineering aims to construct biomaterials, using in vitro and in vivo techniques, capable of integrating bioactive molecules and cells2,3. Tissue engineering has four critical elements. Any given therapy does not always include all four:
4. Biomechanical force stimulation: such as shear or strain stress using a bioreactor, which can also promote the proliferation and differentiation of stem cells.
1. Stem cells or progenitor cells: These cells are at varying levels of maturity, ranging from embryonic stem cells to adult multipotent cells, which are further down the differentiation pathway;
It is important to distinguish cell therapy in general from stem cell therapy in particular. ‘Cell therapy’ includes many cell types, for example a chondrocyte in autologous chondrocyte implantation but stem cell therapy uses stem cells, which have different properties, such as self-renewal and the potential to differentiate into varying cell types4. Stem cell behaviour is demonstrated by embryonic stem cells, where the blastocyst cells are pluripotent and able to give rise to a vast array of the body’s cells5. Pluripotency can also be induced in adult somatic cells – induced pluripotent stem cells (IPSC)4.
2. Matrices or scaffolds: These organic or inorganic structures promote cell attachment and cell growth;
Wasim Khan
3. Induction using signalling proteins, cytokines and growth factors: biochemical signals trigger the proliferation and differentiation of stem cells;
What is a stem cell?
At the current time, clinical practice is focused on the role of another type of adult stem cell - mesenchymal stem cells (MSC). Originally called bone marrow stromal cells, MSCs were popularised in the 1990s, as they are multipotent and can differentiate in the laboratory into bone, cartilage and fat, so-called trilineage differentiation6,7. There is a question over whether the MSCs should be considered a stem cell, or simply a cell therapy, because it has other important properties in relation to immunomodulation and has recently been renamed a “medicinal signalling cell” 8,9. These cells are identified by the expression of various cell surface markers (Figure 1). Whether acting as a stem or signalling cell the ease of acquisition and apparent safety profile have made the MSCs a popular target for cell therapy. This review will focus on this type of cell. >>
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STEM CELL THERAPY OPENS UP MANY THERAPEUTIC OPPORTUNITIES IN CARTILAGE REPAIR AND HAS THE POTENTIAL TO DEAL WITH SYMPTOMATIC LESIONS AT THE CELLULAR AND MOLECULAR LEVEL.
Stem cell therapy opens up many therapeutic opportunities in cartilage repair and has the potential to deal with symptomatic lesions at the cellular and molecular level. The limited healing capacity of cartilage and its avascular, aneural and alymphatic structure make it an ideal target for tissue engineering and regenerative medicine. There has been a gradual increase in the clinical evidence over the years including some early well-designed comparative clinical studies. Laboratory-based cell culture studies, gene transfer techniques, biomechanical analysis of
scaffolds and small animal models, although important, have their limitations. The cell culture techniques to preserve the expression of certain stem cell surface markers, and enhance the gene expression of lineagespecific markers of differentiation may show how best to form cartilage tissue in the tightlyregulated incubator. However, the question remains, will all these factors still be relevant in the complex human body with its myriad of internal and external factors? Small animal models are useful to investigate some aspects of a tissue-engineered meniscus, but how relevant are these to a patientâ&#x20AC;&#x2122;s joint? There
is a shift from laboratory studies to pre-clinical studies, from small animal models to large animal models, and from pre-clinical studies to clinical applications.
Clinical Studies Exploring Stem Cell Therapy for Cartilage Repair Some of the recent clinical studies into cartilage repair are illustrative. Kim et al.10 showed better results in talar osteochondral lesions in patients over 50 years treated with adipose-derived MSCs and marrow stimulation when compared to patients treated
Figure 1: MSCs derived from synovial tissue that are positive (left), variably positive (middle) and negative (right) for a range of different cell surface markers on cell surface staining (top panel) and on flow cytometry (bottom panel)
with marrow stimulation alone. The patients receiving intraarticular MSCs had a better VAS, AOFAS, Roles and Maudsley, and Tegner activity scale scores, especially for defects greater than 109mm2. Wong et al.11 conducted a prospective randomised controlled trial studying 56 patients with unicompartmental knee osteoarthritis and genu varum. All patients underwent microfracture and a medial opening high tibial osteotomy, some were also treated with culture-expanded bone-marrow derived MSCs injected into the knee. The patients receiving the MSCs had better Lysholm, Tegner, IKDC and MOCART scores. Koh et al.12 showed that culture expanded adiposederived MSCs were effective in cartilage healing, reducing pain, and improving function in 30 patients aged over 65 years with grade 2 or 3 knee osteoarthritis in multiple compartments. Stem cell injections were combined with arthroscopic lavage. Outcome measures included the Knee Injury and Osteoarthritis Outcome Scores, VAS, and Lysholm score. All clinical results were significantly improved at 2-years when compared to 12-month follow-up. Only five patients demonstrated worsening of Kellgren-Lawrence grade. At a second-look arthroscopy in 16 patients, 14 had improved or
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Journal of Trauma and Orthopaedics: Volume 04, Issue 03, pages 64, 66-67 Title: The use of stem cells in articular cartilage defects: where are we now? Author: Wasim Khan Co-authors: Prof James Richardson & Prof Andrew McCaskie Division of Trauma and Orthopaedics, University of Cambridge Arthritis Research UK Tissue Engineering Centre
maintained cartilage at 2-years post-operatively. None of the patients underwent total knee arthroplasty during this 2-year period. In a more recent study13, 1,128 patients with Kellgrenâ&#x20AC;&#x201C;Lawrence grades IIâ&#x20AC;&#x201C;IV osteoarthritis underwent standard liposuction under local anaesthesia. The stromal cells were isolated and injected into one to four large joints, mainly the knee and hip. 1,114 patients were followed for a mean of 17 months. No serious side effects, systemic infection or cancer was associated with the cell therapy. Modified knee and hip scoring confirmed that most patients gradually improved for three to 12 months following therapy. A greater than 50% improvement in the score was documented in 91% of patients, 12 months after cell therapy.
improvement after stem cell treatment. However, the more comprehensive evaluation indices, such as the American Knee Society Score, the HSS Knee Scale and the IKDC Score were not improved by stem cell treatment. Thus we need to better evaluate this technology. When assessing the quality of stem cell-based studies, important considerations are the study design, the evidence level and the outcome measures. A number of studies described in the literature combine stem cells with additional procedures, and these confounding variables make interpretation difficult. The nature of the lesion, its size and location, have a significant effect on the outcome. It is also important to note the stem cell harvest procedure and implantation technique. It is also important that any adverse effects are reported.
Evaluating Clinical Stem Cell Studies
Conclusions
The first author conducted a review of clinical, cell-based studies for cartilage repair in 201314 and concluded that more high level human trials were required to evaluate the true effect of such techniques in repairing human cartilage defect. A recent meta-analysis15 on the effect of MSCs on articular cartilage degeneration treatment concluded that clinical symptoms and cartilage morphology showed significant
Regenerative therapies using stem cells represent a promising treatment option for cartilage defects. Our knowledge base of stem cells, growth factors, scaffolds and bioreactors is expanding. These techniques are beginning to be translated into daily clinical practice, with early evidence of safety and efficacy. There is considerable uncertainty as to the precise mechanism by which these
therapies work, and extensive translational bench to bedside research is required. Although the early studies have shown positive outcomes, additional, well-designed and appropriately powered clinical trials are needed to confirm the efficacy and long term safety of stem cell treatment. n Wasim Khan is a University Lecturer and Honorary Consultant Orthopaedic Surgeon in Cambridge. He has an interest in stem cells and tissue regeneration. He aims to identify better ways of treating cartilage and meniscal lesions.
Correspondence Email: wasimkhan@doctors.org.uk
References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.
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Š 2016 British Orthopaedic Association
How Iâ&#x20AC;Ś fix a Monteggia variant injury with a radial head fracture Paul J Jenkins Co-author: Lech A Rymaszewski Monteggia variant injuries have similar features to the classic lesion, with the addition of features such as a radial head fracture1. The aim of treatment is to achieve anatomical reduction of the fracture, congruent reduction of the joint and elbow stability2. Where the ulna is fractured around the coronoid (Figures 1a and b), internal fixation of the ulnar and radial head replacement is usually required (Figures 2a and b). The patient can either be positioned lateral with the elbow flexed over a holder, or supine with the arm across the chest. We have found that the supine position allows optimum intra-operative fluoroscopy, as the elbow can be extended to take images, as required. It also avoids difficulties positioning the obese or multiply-injured patient.
Paul J Jenkins
A posterior midline incision is used. The ulnar nerve is identified, to prevent iatrogenic damage, and decompressed, to prevent compression from post-operative swelling. Angulating the ulnar fracture posteriorly facilitates access to the radial head and neck. This avoids a second approach to the radial head through, or releasing the lateral collateral ligament complex. The radial head fragments are removed. The pre-operative radiograph should be scrutinised and any loose fragments removed. The coronoid fragments are fixed via a subperiosteal medial approach, prior to radial head replacement, taking care to preserve the insertion of the anterior band of the medial collateral ligament. The radial head is then replaced, using the resected head and the sigmoid notch as a guide to size and placement. In our experience, the radial head is usually in more than two fragments. We do not advise fixation. We use a smoothstemmed metal replacement, which acts as spacer. No attempt is made to repair or reconstruct the annular ligament. The role of the replacement is to restore elbow stability, while neutralising the forces acting on the coronoid and ulna. The ulna is then reduced and internally fixed with an anatomical, extended plate to achieve secure proximal fixation. Locking screws are not routinely used. The surgeon should always be aware of the possibility of associated injuries including the Essex-Lopresti lesion and more extensive elbow instability. Another common pitfall is
Figure 1a & b: Radiographs of a proximal ulnar fracture with an associated radial head fracture
Figure 2a & b: Reconstruction with an anatomical olecranon plate and radial head replacement
malreduction of the ulna, leading to persisting radiocapitellar incongruence. A follow-up radiograph should be performed at one to two weeks to ensure that fixation is secure and the elbow is congruent. With secure fixation, immobilisation beyond 14 days is usually unnecessary. n Paul Jenkins is a Consultant Orthopaedic Surgeon at Glasgow Royal Infirmary. He has an extensive research interest and has received funding from the Scottish Government to study the quality, safety and effectiveness of fracture clinic redesign.
Correspondence Email: paul.jenkins@glasgow.ac.uk
References 1. Jupiter JB, Leibovic SJ, Ribbans W, Wilk RM. The posterior Monteggia lesion. J Orthop Trauma. 1991;5(4):395â&#x20AC;&#x201C;402. 2. Scolaro JA, Beingessner D. Treatment of Monteggia and Transolecranon FractureDislocations of the Elbow: A Critical Analysis Review. JBJS Reviews. The Journal of Bone and Joint Surgery; 2014 Jan 7;2(1):e3.
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In Memoriam
Remember them fondly It is with great sadness that we report the passing of the following members. Our thoughts are with their families and friends at this time.
Eileen Arnold 1944-2016
Roger Freeman Reefat Hassanein Christopher Spivey Peter Weston
Eileen Arnold
Eileen Arnold (1944-2016) joined the BOA in 1986, after a career as a medical secretary at the RNOH, Stanmore. With this grounding and familiarity with the work and interests of the orthopaedic community in the UK, she quickly became a valuable member of staff, taking on responsibility for organisation of the BOA Congress and the Instructional Course. She became a familiar figure at the registration desk and was highly regarded for her easy approachability and efficiency. In addition to Congress demands, she also served the Education
Committee and the Casting Committee. She will also be fondly remembered by many ABC Fellows for her impeccable organisation of the annual fellowship. She retired at the end of 2000 and she and her husband moved to Braunton, near Barnstaple. She continued her orthopaedic connection, working for a consultant at Barnstaple Hospital. Eileen had a passion for Christmas Markets and over the years visited many in Europe. She passed away on 15 July, after a battle with cancer. She leaves her husband, Peter, and sons Mark and Neil and their families.
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Sponsored Content – Sponsored Content Training and Recruitment
The Cuschieri Skills Centre, Dundee has developed a comprehensive new orthopaedic course portfolio to include courses suitable from FY2 to ST6 levels matching key areas of the BOA curriculum. For the remainder of 2016; l Principles of Hand and Forearm Surgery - Thiel cadaveric course 22nd November 2016.
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• Intensive Course in Basic Science in Orthopaedics (January 2017)
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Sponsored Content – Sponsored Content Training and Recruitment
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They are also suitable for a number of podiatry cases, and for protecting post-operative dressings. Fully watertight and completely submergible, the protectors are available in adult and child sizes, in short and long lengths. Next day delivery is available from bloccs.com and boots.com
Faculty Philippe P. Hardy, Paris Joseph P. Iannotti, Cleveland Jon J.P. Warner, Boston Ernst Wiedemann, Munich Course Chairmen Christian Gerber, Professor and Chairman Dominik Meyer, Professor
interaction between a number of different specialities: orthopaedics, anaesthetics, critical care, pain, radiology, plastic surgery, dermatology and general practice. The programme is suitable for consultants and senior trainees. The format is informal and sessions include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees.
BBiOrth® course is held at The Royal Society of Medicine, London. It is delivered over one day with a mixture of lectures and small group break out sessions. The material is covered by a range of speakers, who are keen to relate the theory to surgical examples. Venue: The Royal Society of Medicine 1 Wimpole Street, London W1G 0AE
In April 2016, Bloccs received a Queen’s Award for Enterprise, for Innovation. Email: info@bloccs.com Website: www.bloccs.com Tel: +44 (0)1454 318197
Venue Department of Orthopaedics, University of Zurich, Balgrist Hospital, Forchstrasse 340, 8008 Zurich Please visit our website for full details and online registration: www.balgrist.ch/congresses or contact us at kongresse@balgrist.ch Telephone: +41 44 386 38 33
Each day concludes with a lecture of general interest by an eminent guest speaker. We have an excellent orthopaedic faculty lined up and the programme will be available at www.doctorsupdates.com when confirmed.
For further information: www.bbiorth.co.uk info@bbiorth.co.uk @bbiorth Basic Biomechanics in Orthopaedics Course Next course Saturday 17 December 2016
Volume 04 / Issue 03 / September 2016
Page 72
boa.ac.uk
Imprint
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JTO Editorial Team l l l l l l
Ian Winson (Editor) Fred Robinson (Deputy Editor) Michael Foy (Medico-Legal Editor) Mustafa Rashid (Trainee Section Editor) Wasim Khan (Guest Editor) Stephen McDonnell (Guest Editor)
BOA Executive Tim Wilton (President) Colin Howie (Immediate Past President) Ian Winson (Vice President) Ananda Nanu (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 l
Tim Wilton (President) Colin Howie (Immediate Past President) Ian Winson (Vice President) Ananda Nanu (Vice President Elect) Don McBride (Honorary Treasurer) David Limb (Honorary Secretary) R. Adam Brooks Grey Giddins Ian McNab Philip Mitchell David Clark Simon Donell Mike Reed Fred Robinson Stephen Bendall Karen Daly Bob Handley John Skinner
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Special thanks We are grateful to the following for their contributions to this issue of the Journal: Danny Ryan, Deepa Bose, Mike Thomas, Kamal Deep, Fred Picard, James Singleton, Maneesh Bhatia, Rob Ashford, Fares Haddad, Justin Cobb, Bill Harries, Grey Giddins, Nicolas Nicolaou, Mark Flowers, Bob Handley, Sashin Ahuja, Sherief Elsayed and Lisa Roberts.
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