Journal of Trauma & Orthopaedics - Vol 4 / Iss 1

The journal OF the British Orthopaedic Association Volume 04 / Issue 01 / March 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 women in orthopaedics, bullying and harassment in the workplace and the aftermath of the Nepal Earthquake one year on

For the latest updates on our clinical issues, see our Peer-Reviewed Articles; the focus of this issue is knees, plus our regular “How I…” piece

News & Updates ––– Pages 02-19

Features ––– Pages 20-43

Peer-Reviewed Articles ––– Pages 44-55

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JTO News and Updates

From the Editor

Contents

Ian Winson, BOA Vice President The first JTO of 2016 is here - lots to look forward to? The Carter report has been heralded by politicians and the press. Reading it there is a lot of influence from GIRFT. That in itself shows that if the profession stands up, takes action, it has an effect. I would argue that the thoughtful guidance on how to implement GIRFT produced by the BOA is actually the more important document, certainly for clinicians.

This issue of JTO is full of useful support to the clinician, not least in the peer-reviewed section (page 44) where the all-round thoroughness of revision knee surgery is so well explained. The three main articles in this section are linked by issues faced by surgeons undertaking revision knee replacement. In an era when implant technology has given us several solutions for both reconstruction and fixation, it is easy to overlook the essential topics of surgical exposure,

debridement and antimicrobial therapies all of which need to be addressed to achieve success when managing prosthetic joint infection of the knee.

The data position statement (page 12) gives a wide view of a difficult area evolving in our practices. Bullying in the work place challenges us to be aware of this problem (page 24). The realities of evolving an orthopaedic career as a woman need to have a sense of focus (page 26). For me, a major issue is the value of orthopaedics (page 30) and I am sure you will see more about this as the year progresses.

A final word of thanks to Rhidian Morgan-Jones for his efforts as Guest Editor and a prompt to say there will be a prize from the Editorial Team for the first letter that arrives that adds meaningfully to the debates of this issue. Of course the downside is that the arbiters of that will be the Editorial Team.

JTO News and Updates

02–19

JTO Features

20–43

Current Status of Meniscal Reconstruction Rare Diseases in Orthopaedics: The BOSS Study The Nepal earthquake orthopaedic relief effort - one year on Bullying and Harassment in surgery: Urgent Change Needed?

20 22

Women in Orthopaedics What do we know about the value for money of orthopaedic services within the NHS? Introduction of a novel Orthopaedic weekend handover system Trainee Engagement with NIHR Portfolio Research: examples from trauma trials Developing a professional network of international fellowship links Where expert evidence goes (seriously) wrong: Recent lessons from the court room

26

23 24

30 32 34 36 40

JTO Peer-Reviewed Articles 44–55

Exposure in Revision TKA: proximal soft tissue or distal bony?

Debridement: Defining something we all do Novel Antibiotic delivery and Novel Antimicrobials in Prosthetic joint infection How I Do…fixation of Hoffa Fractures

44 48 52 55

In Memoriam

58

General information and instructions for authors

60

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JTO News and Updates

From the President:

Whither Transparency?

Tim Wilton, BOA President

It is clear that, following the public outcry in the wake of the Mid Staffs debacle and other serious untoward incidents in the NHS, political intent has hardened and the clinical Transparency Agenda is here to stay. So what is it and what does it mean for orthopaedic surgeons?

This programme has been a gradual change in direction by Government covering all aspects of public life characterised by giving members of the public the right to see how their public services are doing. While there may be some overlap into the private sector such as banks, the impetus for this is undoubtedly to let people see where their taxes are being spent and to try to give feedback about whether this is being done better, or worse, than average in your particular locality.

Tim Wilton

The means of achieving this is to publish information about all of the services and the ultimate aim is clearly to put out such information at the end-user level. For us this means publishing both financial and clinical outcomes at least at unit level; although Government ministers would prefer all the latter to be at individual surgeon level.

There is a plethora of information sources available and many of these are already in the public domain. We can certainly not prevent them being published and therefore we must seek to make the best use of this new hunger for information.

There is clearly a temptation in some areas of Government to publish data whatever the quality of that data may be. This may be fed by the belief that publishing data will make the targets of that publication so keen to be properly represented that they ensure the data are robust and accurate.

Unfortunately, that may often be difficult or even impossible, because the quality of the data is affected by many things beyond our control and even outside the hospital system. Publishing regardless can undoubtedly have serious adverse consequences for individuals or for units.

How best to approach publication and transparency of information about us has taxed the profession and the BOA for several years but the issues have come to a head with the concomitant appearance of NJR output to each consultant, GIRFT reports about Trusts, and reports on MyNHS and Choices which produce data at both levels.

It is clear we have a professional responsibility to inform our patients about the likely outcomes of treatment, and that does mean

treatment in our hands rather than treatment by someone who may have invented the procedure somewhere else in the world! It is equally evident that the data collected by the NHS is often flawed even though it may nonetheless be published in some format. The BOA and our networks will continue to work to improve that data and to ensure people are alerted to its deficiencies, and we have had some notable successes in that regard lately.

As individuals we can only really protect ourselves though, by having our own data verified at source so that we can challenge inaccuracies that are made public.

The BOA has drawn up two extensive documents which we feel will really help in using and interpreting the data and publications that are now increasingly available about us all. The first is a BOA position statement about data use in general and gives detailed guidance not only about the sources of data but the rationale for many of the uses of that data

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both by the NHS and for individual surgeons and patients (see page 12).

The second is advice about how an individual and a department may go about implementing the advice produced in the GIRFT report and the regular reports which we are now anticipating at unit level from the GIRFT team www.boa.ac.uk/pro-practice/ implementing-getting-it-right-firsttime-in-england.

I can easily appreciate that some still feel the whole process is unnecessary, while others believe the data are so flawed that we should all ignore the whole business. Nevertheless, some of the GIRFT individual unit findings are startling, and even shocking, while some hospitals have already made significant changes to their practice, which appear good for them and good for their patients.

It seems to me that such information about us has a clear place in developing and improving our practice and we have to discuss the findings openly to challenge the oddities of our practice and modify our approach accordingly. Some consultants, perhaps especially those very early or late in their careers, may feel threatened by the open discussion of these matters with colleagues as their decisions and plans may be challenged. That discussion may undoubtedly be difficult but if it becomes part of our regular practice it should, in most cases, become clear that aggressive tactics by one colleague against another will ultimately be likely to backfire.

The usefulness of data, such as NJR reports, for individual consultants is clear. Most of us who predominantly

do arthroplasty have found it invaluable for our Appraisals and Revalidation as we can provide evidence that we are auditing our practice and hopefully acting upon it without any additional work apart from the routine data collection. For that reason it comes as a considerable surprise to learn that 40% of consultants currently doing hip and knee replacements have not looked at their NJR data this year despite the looming threat of Consultant Outcomes Publication!

I would love to be able to say that those 40% of consultants have much better data from their own detailed audits which make the data from the NJR irrelevant to their assessment. Sadly I doubt that this is so, and indeed the proportion of surgeons with unusually high revision rates amongst those 40% is much

higher than is the case for the rest. I don’t know who those surgeons are, but I do know that any professional regulator would take a much dimmer view of their omission to examine their audit data than they would take of the details of those comparative data alone.

I would like to re-iterate the strongly held view of the whole BOA Executive and Council that we will not support the publication of individual surgeon’s outcomes if the data are inadequate and the potential conclusions invalid, as currently seems to be the case for most of our national audit data.

While some may wish that the Transparency Agenda would wither, I think that is neither likely nor particularly desirable.

We probably therefore need to take the other road!

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JTO News and Updates

BOA Instructional Course 2016 Building on the success of the 2015 Instructional Course, the 2016 programme offered an exciting new array of case based discussions (CBDs) and lectures to delegates. The focus this year was on paediatrics and trauma, including: Painful spine in child, Necrotising fasciitis and Open fractures. In addition to the CBDs, the programme included a series of engaging lectures and case discussions on hip, paediatrics, knee, foot and ankle.

The committed faculty worked hard to deliver an exceptional programme to over 100 delegates, who, in turn, had dedicated time to prepare and study before the course. As per the 2015 programme, each participant had the opportunity to gain a number of CBDs over the course of the weekend.

This year saw the introduction of a new plenary lecture in memory of Andrew Sprowson.

We were delighted to welcome Leela Biant to deliver the first lecture, who spoke on the topic of ‘Articular Cartilage Injury, Repair and Regeneration’.

Other plenary highlights included Professor Andy Carr’s lecture on ‘Innovation in Orthopaedic Surgery; the journey from laboratory to operating theatre’, Deborah Eastwood’s Alan Apley Lecture, and David Limb’s lecture on the ‘Structure of the new exam’. The closing speech was delivered by the BOA President, Tim Wilton who gave an inspirational talk highlighting the significance and value of BOA membership and the wider political and clinical influence of the BOA.

Faculty members (L-R) Raj Verma, Deborah Eastwood, Lisa Hadfield-Law, Pete Milner, Rex Michael, Manoj Ramachandran, Mike Reed

We are thrilled with the continued popularity and value of the course, and are pleased that once again, the course sold out well in advance of the registration closing date. Registration for

the 2017 course will open this summer. Please keep your eye on our website www.boa.ac.uk/ events/instructional-course to find out more.

BOA Travelling Fellowship in South Africa: Six months at Ngwelezana Hospital Sam Weston-Simons, ST7 Gaining enough experience throughout training is often quoted as a trainee concern, which can be true particularly with regards to trauma. As a result, I volunteered at Ngwelezana Hospital (a 550 bed unit that provides orthopaedic services for three million people and covers an area the size of England) for six months.

The unit has a long history of British trainees due to the departmental head, Dr Paul Rollinson, having trained originally in the UK along with the use of similar instrumentation.

The department was extremely busy with daily fracture clinics and operating lists. Generally, acute presentations fell into three categories: • Those from car accidents (including many pedestrians with high energy injuries)

• Trauma related to assaults (often gun related but occasionally due to knives) • Infection related (predominately paediatric osteomyelitis and hand sepsis) Trauma lists included daily long bone fractures (both simple and complex), a wide variety of intraarticular fractures and soft tissue reconstruction with a variety of flaps. There were often open injuries that took a few days to reach the unit, which presented interesting and unique operative challenges. In six months I did the JCST requirements for intramedullary nails.

As well as trauma, the unit saw a wide range of adult and paediatric pathology and ran a regional club foot clinic. The latter provided an

Sam Weston-Simons in the club foot clinic

excellent opportunity to be exposed to paediatric orthopaedics as often other pathology would present to this clinic. In summary, I feel it was an invaluable experience

and one that any trainee would benefit hugely from and I would like to thank the BOA for providing support which allowed me to benefit fully from the placement.

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JTO News and Updates

BOFAS 40th Annual Scientific Meeting This year’s meeting was held from 11th-13th November 2015 at G-Live in Guildford, Surrey, in a large theatre-style auditorium for the first time. This format ensured the interaction which we have become accustomed to at BOFAS events.

The BOFAS Council and Committees with President, Anthony Sakellariou, have worked hard to produce a programme packed with scientific and instructional sessions. The meeting was thoroughly enjoyed

by over 400 delegates, despite being tinged with sadness at the recent death of founding member, Professor Leslie Klenerman.

The main objective of the Society has always been to promote the exchange of knowledge between professionals engaged in the care of foot and ankle pathology. This year there were contributions from many UK foot and ankle surgeons, Allied Health Professionals and surgeons from across Europe and the United States.

The individual sessions (educational and scientific) are too numerous to detail in this short review - nevertheless all generated much interest and thought.

The Conference Annual dinner on Thursday evening at Mercedes Benz World, with a brief talk from ‘The Stig’, was a great success providing a relaxed and entertaining evening at a wonderful venue.

importance of the links between the specialist societies and the BOA. The last of the keynote speakers, Roy Lilley, delivered an entertaining and thought provoking session looking at the NHS from a non-medical angle.

We are all looking forward to the next meeting in Bristol on 2nd4th November 2016.

On Friday morning, Tim Wilton, BOA President, emphasised the

The BSSH Autumn Meeting good and bad, giving a more balanced view than traditional scientific reports.

Susan MacKinnon, also a plastic surgeon, has done extensive work on nerve repair and transfers. She gave two beautifully illustrated talks on nerve transfers. Whether the concept of supercharging a nerve with an end to side transfer will become common practice is unclear, although some of her work on nerve transfers will be used more widely. She also showed some fabulous online technique videos.

Dr Shecker with BSSH President Vivien Lees and other former fellows from the Kleinert institute at the meeting

The Autumn Meeting of the British Society for Surgery of the Hand was held at the Institute of Engineers on 15th-16th October.

The meeting consists of free papers, seminars, expert lectures and society business, including the AGM and time to network in the trade exhibition.

There were two major speakers Luis Scheker from Louisville and Susan MacKinnon from St Louis. Luis Scheker, a plastic surgeon, studies the distal radio-ulnar joint (DRUJ). He has worked with the current BSSH President, Professor Vivien Lees. Dr Scheker presented his

insightful work and thoughts on the DRUJ as well as the results of his DRUJ replacement, which has given reliable results in a number of centres - the implant seems to have a role in complex DRUJ problems. Dr Scheker has also developed a website which allows patient feedback, both

The last session on the Friday was dedicated to “how I do it”. This is very instructive for both junior and senior surgeons.

Despite being the last session, it was well attended.

The meeting was stimulating and informative. We are very grateful to Professor Lees, for her hard work as BSSH President.

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The Society for Back Pain Research Annual Scientific Meeting The meeting was held on 5th-6th November in Bournemouth. A debate entitled ‘Low back pain is a valid concept’ was held. The 100 interdisciplinary delegates initially voted with a majority in favour.

Speaking for the motion, Professor Charles Greenough stated that diagnosis was associated with a five-fold increased risk of chronicity, warning against treating MRI abnormalities and highlighting

The debate (L-R) Professor Wim Dankaerts, Nick Birch, Elaine Buchanan, Prof Charles Greenough

how false labelling destroys lives. Elaine Buchanan warned against over-diagnosis and concluded that non-specific low back pain remains an honest and valid concept.

Speaking against the motion was Professor Wim Dankaerts (University of Leuven, Belgium) who explained that the concept is based on a diagnosis of exclusion and fails to recognise the specific drivers of pain.

Nick Birch highlighted that the correlation between scan findings and symptoms for degenerative conditions was modest at best. He concluded that in 2015, patients know too much about the spine to be ‘fobbed off’ with a diagnosis of non-specific low back pain.

The concluding vote showed the margin had narrowed considerably, with a small majority supporting the motion.

Other highlights from the meeting included keynote presentations from Professor Maurits van Tulder on ‘The biopsychosocial model: Time for a new back pain revolution?’; Professor Sally Roberts on ‘Disc degeneration: The how and why’; Dr Judith Meakin on ‘Back pain – too many degrees of freedom?’; and Professor Mark Hancock from Australia on ‘Challenges in researching the importance of biology in back pain’.

The next meeting will take place in Preston on 3rd-4th November 2016 and the theme will be ‘New trends’.

Orthopaedic Trauma Society 3rd Annual General Meeting The 3rd OTS Annual Meeting was held in Warwick in January, with Bob Handley in the chair.

One hundred and twenty trauma enthusiasts from trauma units and major trauma centres enjoyed the programme, which was arranged

by Mike Kelly. The audience consisted mainly of orthopaedic consultants and senior trainees.

Highlights from the first day included a morning debating the care of open fractures, with experiences from Newcastle, Nottingham, Oxford, Coventry and Bristol being shared. The TARN data has shown that 87% of open tibial fractures are now treated in major trauma centres, 74% are debrided and stabilised within 24 hours and 58% are covered within

72 hours. Whilst work continues to establish orthoplastics units around the country, the results of established units was presented and tips given to units where orthopaedic and plastic surgeons work independently.

The second day examined systems of trauma care in the UK. Speakers from Scotland, England, Wales, Northern and Southern Ireland updated the ups and downs, the data, the politics, the roadblocks and successes from the last year.

Lunchtime industry symposia were well attended. Topics presented include adjuncts in complex fracture fixation, proximal and distal tibial fractures, setting up limb reconstruction and trauma

Roaming mic in action - quarterback Chesser passes to wide receiver Costa

services in an MTC, innovations around periprosthetic fractures and the future of external fixation.

The OTS members showed great enthusiasm at this year’s

meeting, which was tangible both during the meeting and in the bar in the evenings. It was even commented that this year’s meeting was “like last year’s but on steroids”!

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JTO News and Updates

BOA Latest News BOA Clinical Champion Network continues to grow CCGs value clinical engagement and working with CCGs is critical to improve patient care. Given this, we are pleased to report that approximately 80 Acute Trusts in England now have a BOA Clinical Champion. As you may recall, BOA Clinical Champions represent individual Trusts and hospitals, and work alongside BOA Regional Advisers to engage with CCGs. Our network is growing in strength and has had success across the country.

If you are interested in becoming a BOA Clinical Champion please contact policy@boa.ac.uk with details of the Trust or hospital you would be representing.

There is no formal time commitment to the role and a full role description is available on request.

SAS Surgeon Survey

The BOA recognises SAS surgeons as a vital competent of the Trauma and Orthopaedic specialty. As a reflection of this, the BOA has a SAS surgeon representative on its Council and is expanding SAS representation across its committee structure. BOA Travelling Fellowships are also now open to SAS surgeons, more details are available here www. boa.ac.uk/training-education/boatravelling-fellowships.

The BOA is committed to adding further value on behalf of SAS surgeons. To enable this, we have produced a survey to enable SAS surgeons to tell us about their aspirations and how we can support them. We would encourage all SAS surgeons to complete the survey at www.boa.ac.uk/pro-practice/ supporting-sas-surgeons-survey.

The results of this survey will be shared with our members and will inform the BOA’s support to SAS surgeons going forwards.

BOA Clinical Leaders Programme (CLP) Applications now open!

Following on from the success of the first Clinical Leaders Programme, the BOA has opened applications for the 2016/17 programme. The CLP offers further educational support with a specific focus on developing leadership within the Trauma and Orthopaedic field.

For further details on the programme, including how to apply, please visit www.boa.ac.uk/training-education/ boa-national-clinical-leaders-fellowships-programme.

BOA Professional Guidance to Implement Getting it Right First Time in England The BOA’s Professional Guidance on Getting it Right First Time (GIRFT) in England has now been published by the BOA. www.boa. ac.uk/pro-practice/implementing-getting-it-right-first-time-in-england.

The BOA consulted widely with specialist societies to develop this guidance, which has now been widely circulated to BOA members and Trust T&O clinical leads.

Central to the implementation of GIRFT will be regular departmental discussion about the relevant aspects of unit practice, utilising the data provided by the GIRFT dashboards and by the NJR. GIRFT also makes a number of specific recommendations on a number of aspects of practice: With regard to procedure volumes, we recommend that surgeons who are performing low volumes of a specific procedure examine their practice with particular care, but we do not prescribe a simple minimum figure for any procedure. For implant selection, the BOA is clear that some variation is acceptable - provided it is not detrimental to patient outcomes or Trust finances. However, in some units change will be necessary. In such cases, any decision to change implants must have clinical support and any discussion to alter implant selection should consider the potential adverse consequences of doing so. For infection, the GIRFT recommendations should be implemented in full if the data provided, once validated, highlights an infection problem within a unit.

BOA Simulation Award

Each year, the BOA offers an award for excellence in Innovation in Simulation. The aim is to create some form of simulator which replicates for training purposes, one teachable component of trauma and orthopaedic surgery.

The award is open to all trainers and trainees and the award will be presented during the BOA Congress in Belfast in September.

Please submit your abstracts by 15th May to policy@boa.ac.uk.

The abstracts should be no longer than 300 words and in the form of a word document.

The shortlisted candidates will be asked to present their projects in September when the prize will be awarded.

For more information, please see the BOA website www.boa. ac.uk/training-education/boasimulation-award.

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Professor Keith Willett appointed Commander of the Order of the British Empire in the New Year Honours The BOA is delighted to announce that Professor Keith Willett has been appointed a CBE. Professor Willett is the National Director for Acute Episodes of Care to NHS England and Professor of Orthopaedic Trauma Surgery at the University of Oxford.

Congratulations to Professor Willett from all at the BOA. We can also report that Professor Christopher Bulstrode, Emeritus Professor of Orthopaedic Surgery, University of Oxford was appointed a CBE for services to humanitarian medicine.

Dr Colin Currie was honoured with an MBE for his work with the National Hip Fracture Database (NHFD) and Ailsa Bosworth, founder of the National Rheumatoid Arthritis Society (NRAS) was also awarded with an MBE.

BOA Commissioning Guide Review

BOA Policy Update The BOA is currently working on a number of projects to promote a supportive environment for T&O surgery. These include: • Examining the relationship between the prevalence of Osteoarthritis in CCG populations and the corresponding rates of Hip and Knee Replacement, with a view to better understanding the scope of any potential unwarranted variation; • Developing a narrative promoting the BOA’s view of the value and future of orthopaedic surgery, to communicate the needs of the specialty to all stakeholders; • Examining the value of intermediate MSK triage services for patients with orthopaedic symptoms, to establish whether these services are adding value for patients; • Promoting the BOA’s undergraduate syllabus and the broader need for improved training in MSK at undergraduate level study, to create an environment where future GPs would be better equipped to support orthopaedic patients.

This year, the BOA will be reviewing four of its Commissioning Guides, in order to maintain NICEaccreditation and credibility with commissioners, as well as ensure the documents remain topical.

The review is following a NICE accredited process led by a Guideline Development Group with a broad range of stakeholders. The reviews will involve a public consultation on the amended drafts of the documents, which is currently expected to take place between March and April.

Joint Action integration in BOA website Joint Action (the orthopaedic research appeal of the BOA) has now integrated its website into the BOA’s site to give it a brand new feel and to keep in line with the BOA’s branding. You can have a look now at www.boa. ac.uk/joint-action.

For further information about any of the news items here, please contact policy@boa.ac.uk.

AMRC Peer Review Audit 2015 The British Orthopaedic Association passed the 2015 audit with the Association of Medical Research Charities (AMRC) and confirms that we continue to be compliant in our peerreviewing processes. It also demonstrates a commitment to the highest standards of accountability and probity in allocating grants and awards for research.

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JTO News and Updates

Running for President?

Tim Wilton, BOA President

Many of our readers would undoubtedly make an outstanding BOA President, but most will never even contemplate doing the job.

This may be for many reasons but amongst them could be concern that they might not be suitable in some way, or perhaps that the process is too shrouded in mystery and they wouldn’t know how to begin. I would therefore like to set out some basic requirements in order to encourage those who might be both willing and eminently suitable to come forward.

Firstly, it is a requirement that anyone who is to be considered for election should at some time have been elected and served on Council as a Trustee of the Association. For those who have not yet done so, this needs to be the first step. The serving Trustees have the responsibility for election of the President: I assure you that this is not a fix, rather it is due to the fact that Council is uniquely placed to assess who would make a good President in the light of the prevailing circumstances at the UK level.

Once eligible for election you have to allow your name to go forward at election time with the support of two fellows of the BOA, and both the fellows and yourself will need to be in good standing with the BOA and the GMC. Before doing this it is of course wise to consider the requirements of the post and how these may impact on your ‘day-job’ and also on your family life.

Tim Wilton

Four years is spent on the Presidential line (the two years before taking over the reins allow ample opportunity to familiarise with high level NHS business

and the many issues at hand) and while the time pressures are undoubtedly greatest during the Presidential year, there are still significant calls on you during the other three years, so these must be factors that you can accommodate satisfactorily. All members of the Executive Group are expected to attend 10 Executive meetings and five Council meetings a year, as well as attending and assisting with the running of Congress.

Some Vice Presidents will be JTO Editor for two years, some will be Chairman of the Professional Practice Committee and one every four years will be the BOA representative on College Council which is now a four year appointment and carries with it significant college and liaison duties.

This may all sound like a very significant and heavy workload, but it has to be born in mind that the BOA has an energetic and diligent professional staff who are there to help with all aspects of this work. They are dedicated and highly motivated and their ways of lightening the load are myriad!

The actual year as President also involves travelling, with your partner, if appropriate, to all of the Carousel Congresses at which you may be asked to lecture, moderate sessions, attend Presidents’ council meetings and perhaps other involvement. There are many opportunities for networking, making new friends and contacts, and even attending the odd dinner

or reception! This takes about six weeks of travelling and there are sometimes additional Congress invitations such as those I have had to India and China.

Clearly, your Trust has to be behind you in this enterprise and most of them are delighted to have a consultant from their hospital in this sort of high profile role. The Executive has also agreed that in order to lessen the impact on the Trust due to these absences, the President can apply to the BOA for payment of one PA salary equivalent to the employing Trust.

While this represents a small proportion of the time away it would help alleviate some of the pressure and most Trusts are very happy to release people since most of the work is so clearly of general benefit to the NHS. The intention of this article is to encourage rather than to discourage and it should be borne in mind that this is a rewarding and enjoyable enterprise despite the fairly heavy workload. If you feel you have something to offer and feel you could consider performing this role, I would really like to encourage you to put your hat in the ring….apply to be President if you already qualify, or for the Honorary Secretary post if you feel that would suit you, or apply for Council to get the ball rolling.

Anyone who wishes to discuss an aspect of these matters in more detail is welcome to phone or email me!

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BOA Membership Update UKITE

All programmes across UK and Ireland sat UKITE 2015 and 534 trainees in total successfully completed the exams.

We are delighted to announce that the highest score in an invigilated setting was 82.5% by Saqib Masud from Wales.

Development plans have started for UKITE 2016 which will take place from 9th-16th December.

Subscription offer to SAS surgeons from the BJJ

Discounted Private Health Insurance for you and your family!

General & Medical Healthcare are delighted to be the chosen provider of private health insurance for the British Orthopaedic Association. They are able to offer substantially discounted private health insurance, exclusively for you and your family. A wide range of policies are available from those that provide only in-patient benefits to fully comprehensive schemes. Your discount is only available by visiting www.generalandmedical.com/BOA or calling General & Medical Healthcare on 0800 9804601 or 01733 362872.

Please remind your SAS colleagues that new members must join the BOA before 31st March to receive a personal subscription to the Bone and Joint Journal and Bone and Joint 360 (print and electronic access) for 2016. For more information on this offer please visit www.boa.ac.uk/ membership/bone-and-joint-journal.

To join the BOA new members must complete the online membership application www.boa.ac.uk/ membership/join-today.

BOA Annual Congress 2016 13th-16th September, Belfast Waterfront Underpinning the Congress programme this year is ‘Clinical Leadership and Engagement’.

Sessions will be built around this theme which we hope will spark discussion and dialogue amongst members about the significance of this topic in both clinical and professional matters.

In addition to the annual plenary lectures such as the Howard Steel and Robert Jones, the programme will include a vast array of broader professional sessions on topics including consent, tariff, GIRFT, commissioning and leadership.

A plenary lecture on the current political landscape will explore

many of the topical political issues affecting the profession.

Other sessions will be dedicated towards specialist topics including trauma, spines, NJR, patients, medico-legal issues and many others. As per previous years, delegates will also have the opportunity to attend free paper sessions lead by many of the BOA’s specialist societies.

We are also delighted to announce that for the second year running we will include a series of all day sessions on Education and Training. Sessions will be of interest to all levels from Medical Students to Consultants.

FREE* BOA member registration will open on Monday 4th April Non-BOA member registration will open on 1st June

*Terms and Conditions apply, please see website for details - congress.boa.ac.uk

Congress videos from Liverpool 2015 Take a look back at last year’s Congress and view sessions online congress.boa.ac.uk/liverpool-2015

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JTO News and Updates

Outcome data, T&O surgeons and units: a background and position statement from the BOA Executive Summary In recent years there have been various drivers for more collection, use and transparency of data on outcomes. T&O has been at the forefront of this, primarily because of the existence of wellestablished major datasets in our specialty. This is demonstrated by the inclusion of the National Joint Registry (NJR) in the first round of Consultant Outcome Publication (COP) in 2013.

In the past, the data that was collected was typically held and used within the profession.

However, it is clear to us that the culture is changing and greater transparency is becoming the norm - we need to influence and engage with this to ensure the right balance and message.

As a specialty association we feel a professional obligation to support and champion collection and use of data. Only if we know our outcomes can we monitor and improve them, pick up and act on issues, and help patients consider and decide what is right for them. Furthermore, collecting and reporting data often leads to improved outcomes for patients in and of itself. However, it also raises a range of challenges and

issues. We have reflected on this topic at some length, and have developed this document in which we present a BOA position on the following issues: • Encouraging surgeons and units to contribute data to audits and use the data that results; • The importance of data quality within all registries and audits and the NJR’s current activities regarding this; • ‘Outlier’ or ‘variance’ analysis; and • Outcome publication, and in particular our view that unit-level publication is more appropriate that consultant-level publication.

Introduction Patient outcome data, its collection, use and public reporting have been a topic high on the agenda for T&O in recent years. It is a topic that has been regularly discussed at the BOA and in which we are actively involved. In this article, we aim to outline the current context and discuss the BOA position on the issues raised. The position statement at the end of this article is intended as a stand-alone document, but the background and context are provided here to introduce this topic.

Background and context In recent years there have been various drivers for more collection, use and transparency of data on outcomes. Certain major examples are outlined here: • The Darzi report ‘High Quality Care For All’, published in 20081, included the following: “For the first time we will systematically measure and publish information about the quality of care from the frontline up. Measures will include patients’ own views on the success of their treatment and the quality of their experiences.

There will also be measures of safety and clinical outcomes.

All registered healthcare providers working for, or on behalf of, the NHS will be required by law to publish ‘Quality Accounts’ just as they publish financial accounts.”

• Revalidation for doctors began in 2012. GMC guidance on revalidation explains one of the elements required of doctors: ‘For the purposes of revalidation, you will have to demonstrate that you regularly participate in activities that review and evaluate the quality of your work’2. Participation

in clinical audit is identified as one of the main ways in which to fulfil this requirement, through following a process of actively participating in the audit, evaluating and reflecting on the results, taking action and subsequently demonstrating the outcome.

• ‘The power of information: Putting all of us in control of the health and care information we need’ was published by the Department of Health in 20123.

This report described that “Better quality information and sharing information is critical to modernising the NHS and care services”. Its conclusions included: • “Alongside the Government’s core role, a wide range of organisations will be encouraged to take a broader role in making information accessible and usable for people.”

• “More information will be publicly available about care at clinical or professional team level and information that enables [patients] to ‘benchmark’ services, such as clinical audit data.”

• “An information-led culture where all health and care professionals - and local

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In the past, the data collected was typically held and used within the profession. However, it is clear to us that the culture is changing and greater transparency is becoming the norm - we need to influence and engage with this to ensure the right balance and message.

bodies whose policies influence our health, such as local councils - take responsibility for recording, sharing and using information to improve our care.”

• The 2013 Francis report into Mid-Staffordshire4 made 290 recommendations, of which 13 relate to collecting, analysing and using data. One section focused on these issues reads: “There is an urgent need in many areas for measures to be developed to allow the effectiveness of a service to be understood. In some areas, such as cardiac surgery, this is better developed than in others.

It should be considered the duty of all specialty professional bodies to develop measures of outcome in relation to their work.

While this will be more difficult in some areas than others, it should be possible in all. It should no longer be acceptable for treatment to be offered to patients without information being available on how effective it is and what it is reasonable to expect as an outcome. The rate at which such outcomes are in fact achieved by units and individuals can then be better understood, and, where necessary, corrective measures

taken. The more such information is available to the staff providing treatment, the more likely is a culture of striving for evidence-based excellence to be adopted.”

(Para 20.213) • The ‘Consultant Outcome Publication’ (COP) initiative from NHS England was announced in late 2012 and first publication occurred in 2013. This was designed to pre-empt the publication of the Francis report and began with 10 specialties publishing outcomes on their audit website, including the NJR. The initiative expanded in 2014 and 2015, now covering 13 specialties, more outcome measures and including publication on NHS Choices as well as the audit website. The NJR also published expanded unit-level dashboards in early 2015.

Where are we in trauma and orthopaedics?

Trauma and Orthopaedics has a strong track record in collection and use of data, with the NJR, National Hip Fracture Database (NHFD), Trauma Audit

Research Network (TARN) and the Scottish Arthroplasty Project (SAP) already being well-established. Nine further registries are currently in development across the T&O field (listed in Table 1).

Our strengths in this area are something that we as a profession can be proud of.

They also mean that we at times are among the trailblazers in this area, as for example with COP. This is a position that is not always comfortable.

We recognise that the publication of individual NJR data in particular has been challenging, and as the NJR was one of the first audits included in COP, this has impacted our specialty from an early stage. We also recognise that outcome publication from the NJR has raised important issues, particularly regarding data quality and completeness, and publication at unit vs consultant level, and so on (these issues are covered in the next section). The BOA (along with specialist societies) has been heavily engaged on these issues, and continues to influence and champion them, though we appreciate that these things are not fully resolved.

In the past, the data collected was typically held and used within the profession. However, it is clear to us that the culture is changing and greater transparency is becoming the norm - we need to influence and engage with this to ensure the right balance and message.

This includes the publication on NHS Choices of certain audit information, and in future the Private Healthcare Information Network (PHIN) plans to publish information for the private sector, having received a mandate from the Competition and Markets Authority to ensure customers have greater information about outcomes. Another development for T&O comes from across the globe in Australia, where there has been recent high profile criticism of the joint replacement registry by an eminent Judge who accuses them of ‘failing patients by refusing to expose incompetent colleagues’5. This particular example highlights the importance of ensuring that data is used and acted upon where concerns may exist - again a topic that is covered in the next section.

Overall, the Francis report in particular and the wider changing culture of the NHS more >>

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JTO News and Updates

We recognise that the publication of individual NJR data in particular has been challenging, and as the NJR was one of the first audits included in COP, this has impacted our specialty from an early stage.

generally, places a responsibility on professional bodies such as the BOA in the area of collection and transparency of data (as highlighted in the quote above). Our view is that we the BOA and the profession have an important obligation to act upon this. We would like to see our specialty continuing at the forefront in this area: continuing to strive to understand patient outcomes following our procedures and how these can improve; continuing to detect areas of concern with implants, units or surgeons and support individuals and teams to identify and act on any issues; and continuing to use the data for review, reflection and improvement as widely as possible. Fundamentally, we see it as being in the patients’ interests to do so. Only if we know our outcomes can we monitor and improve them, pick up and act on issues, and help patients consider and decide what is right for them.

Furthermore, collecting and reporting data often leads to improved outcomes for patients in and of itself.

Given the importance of these issues, we have set out the following principles as the BOA’s position statement regarding data collection and use. Comments on this position statement are welcome.

BOA Position Statement Regarding Collection and Use of Data Regarding the role of individual clinicians and units in data collection and use Principles: • All surgeons/teams should submit data to any registry that is relevant to their area of practice, whether or not submission is ‘mandated’.

This comes from a professional obligation to ensure clinicians ‘review and evaluate the quality of your work’.

• All surgeons should present their individual data from the audits such as NJR for reflection and discussion at their annual appraisal. Where there are other audits on a national basis which are sufficiently wellestablished to give meaningful data on which to reflect, these should also be presented and discussed at the appraisal, e.g. those listed in Table 1. Where the appraiser is not familiar with this type of output or comes from another specialty, it would be appropriate for such discussions also to occur within the T&O department itself, with the Lead Orthopaedic clinician or other senior member of the specialty.

• All units should regularly review and reflect upon the data for that unit, and data for all individuals within the unit should be shared internally for the purposes of peer-to-peer review and support within the unit - for example at a sixmonthly GIRFT/audit meeting.

This should include discussion of unit-based audits such as NHFD, TARN and Infection data as well as the more surgeon specific audits. Some units already have such internal sharing and review processes, and typically find these very useful, and we consider that all units should undertake this sort of regular review.

• Registry data can be enormously valuable for quality improvement and we encourage individuals and surgeons to consider ways that they could use their data for improvement purposes.

Regarding registries and audits role in data governance, data quality and reporting Principles: • Registries and audits should make reporting readily available to the individual clinicians and the hospitals that submit the data. This should be available in a timely fashion and should as a minimum enable comparisons

with others and overall trends.

Suitable methods of analysis and presentation should be developed as appropriate to the subspecialty area.

• All registries and audits should track the quality of the data held and implement measures to improve data quality as needed.

Data quality monitoring should include rates of compliance, which should be available alongside any reports.

• The BOA supports the NJR’s work on data quality and we urge all members, their teams and hospitals to regularly review their data and contribute to NJR data quality initiatives; for each round of COP we publicise to members the opportunity to validate their data and strongly encourage them to undertake this.

• Registries and audits must ensure data governance and security is in place that is appropriate to the sensitivity of the data held and satisfying all relevant legislation and NHS principles of best practice.

Regarding variance issues One use of registry data is to look at issues of variance, for example where performance is particularly strong or weak or where particular patterns of >>

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JTO News and Updates

All surgeons/teams should submit data to any registry that is relevant to their area of practice, whether or not submission is ‘mandated’. This comes from a professional obligation to ensure clinicians ‘review and evaluate the quality of your work’.

outcomes emerge. Many clinical audits use the term ‘outlier analysis’ for this approach.

The BOA considers that it is preferable to describe this as ‘variance analysis’, and to look at both positive and negative variation from the norm. There may be different reasons for any variance and depending on the reason this may or may not be a cause for concern and further action. We are conscious that the term ‘outlier’ can be seen to have a stigma associated with it, but the principle of variation is entirely to be expected and warrants further assessment, but should not in itself be seen as a problem. We are also keen to promote the concept that many individuals or units may have variation from the norm, perhaps not as significant as being an ‘outlier’ but which still warrants further understanding and assessment. Overall, we hope to foster a culture in which variation analysis is a routine part of data review, with the focus always on understanding it and, if appropriate, addressing it for the purpose of patient benefit. Where variance analysis identifies problems, we are keen to provide support to those affected, particularly where they are BOA members, and see this as part of our role as a specialty association.

Principles: • All registries should, once sufficient data of adequate quality is collected, undertake analysis of variance in

outcomes between units and (where collected) between individual consultants. This is a professional obligation of those running registries to ensure that variance issues can be highlighted to those affected for assessment.

• All individuals or units that are highlighted as having variance issues in the registry’s analysis must act upon this information to review their data, consider the reasons for variation and whether any further action or alteration to practice is required.

• The BOA intends to make available support to individuals and units that have data variance issues, which will include general support about how to approach this initially and support from senior clinicians regarding any specifics of a particular situation and handling of these.

Regarding publication of data There is a clear culture change towards increasing publication of outcome data, and the BOA feels that we as a profession must step up to the plate alongside colleagues from all specialties. However, publication must be handled sensitively and providing context and information to aid understanding.

Principles: • For elective orthopaedic surgery, the BOA strongly believes that open publication at unit level is far more appropriate than at individual surgeon level.

We have widely communicated this view as part of the COP programme. This is for three main reasons: • Patients are more likely to have opportunities for choice over the hospital or unit where they will be treated, than over the individual surgeon, and therefore a patient choice argument for consultant-level publication is difficult to justify; • Surgeons do not work in isolation but are always part of a team; • The data available at the unit level is generally more robust, and therefore more reliable and relevant for comparative uses. Recent input we have received from both Prof. David Spiegelhalter and Prof. Paul Aylin has cast considerable doubt on the capacity of much of this data at Consultant level ever to reach the level of statistical significance required to make legally robust comparisons between surgeons functioning satisfactorily and those functioning poorly, and therefore publication of such comparisons could be misleading.

This should not be used as an excuse to ignore such data for the purposes of professional review.

There may very well be clear and important differences in the level of outcomes achieved by surgeons operating in the best portion of the graph in comparison to those at the less good end, and it is vital to make use of such information for positive improvement of outcomes.

• Regarding trauma, we do not feel that consultant level publication is appropriate for NHFD and TARN, but we strongly support hospital level publication. This is for two reasons: • The results of both major trauma and hip fractures procedures are generated by a multidisciplinary team. Major trauma patients present with multisystem pathology, and neurosurgeons, T&O surgeons, general surgeons and plastic surgeons are often involved in their care.

In addition, anaesthetists and intensive care units often play a pivotal role.

As such the results are dependent on a team functioning at the highest level; • These databases are based on patient disease rather than patient intervention (such as joint replacement surgery or cardiac surgery), they are conditions that present as emergencies and patients do not have the choice of where they are treated.

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• Before publication, consideration must be given as to the robustness of the data and analysis to ensure that it will be helpful and not misleading. For this reason, with new registries it may be some considerable time before any information is published as the amount and quality of data matures.

Name

Website or contact

Remit

National Ligament Registry (NLR)

uknlr.co.uk

(Currently) Primary Anterior Cruciate Ligament injury, repair and reconstruction

British Society for Surgery of the Hand (BSSH) Audits

bssh.nuvola.co.uk

Basal thumb arthritis; dupuytrens; ulnar nerve decompression in elbow; wrist joint salvage for inflammatory arthritis; wrist joint salvage for non-inflammatory arthritis

Non-arthroplasty hip registry (NAHR)

britishhipsociety.com/ main?page=NAHR

Any type of hip condition and/or surgery other than arthroplasty and the treatment of acute fracture (including those who do not have surgery). Predominantly arthroscopic treatment of femoroacetabular impingement and labral tears but also includes predominantly open surgery for the adult consequences of childhood hip disease such as hip dysplasia and Perthes’ disease.

British Spine Registry (BSR)

bsrcentre.org.uk

All spinal procedures

UK Knee Osteotomy Registry (UKKOR)

www.ukkor.co.uk

Knee osteotomies (High Tibial Osteotomies – HTO; Distal Femoral Osteotomies – DFO)

British Orthopaedic Foot and Ankle Society (BOFAS) registry

www.bofas.org.uk/ Outcomes

1- First MTPJ fusion; 2-ankle fusion

British Society for Children's Orthopaedic Surgery (BSCOS) audit

bscos.org.uk/registry

1- Slipped Capital Femoral Epiphysis, 2- Ponseti Management of Club feet, 3- Supracondylar fracture of humerus (Future release planned to cover: 4- Developmental dysplasia of the hip, 5- Perthes’ Disease and potentially one further area regarding treatment of cerebral palsy)

Conclusion We would like to see our specialty continuing at the forefront in the area of collection and use of data: continuing to strive to understand patient outcomes; continuing to detect areas of concern with implants, units or surgeons and support individuals and teams to identify and act on any issues; and continuing to use the data for review, reflection and improvement as widely as possible. This is because we see it as being in patients’ interests to do so.

Not yet launched for data collection, but enquiries welcome British Limb Reconstruction Society (BLRS) audits

James Fernandes, President of BLRS, James.Fernandes@ sch.nhs.uk

1-Fibular hemimelia; 2-Tibial Pilon fractures; 3-Tibial non-unions; 4-Intramedullary limb lengthening nails

National Bone & Joint Infection Registry

Mike Reed, mike. reed@nhs.net

1- Chronic community-acquired, post-trauma, or healthcareassociated ‘native’ joint or bone infections;

We are very aware of the challenges and issues that are posed by this, and that care must be taken to get the policies and messages right. We therefore hope this background article and position statement on the BOA’s views is helpful in outlining the issues and where we stand on them.

References

We warmly welcome comments regarding this, and envisage that this position statement may continue to evolve as the landscape further develops.

1. www.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf 2. General Medical Council (2012) Supporting information for appraisal and revalidation 3. www.gov.uk/government/uploads/system/uploads/attachment_data/file/213689/dh_134205.pdf 4. www.midstaffspublicinquiry.com 5. Coverage in The Australian, under heading ‘Surgeons slammed for failing to report rogues’, 17 October 2015.

Table 1: Emerging registries in T&O

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JTO News and Updates

Wisepress Book Review Book of the Quarter

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Pediatric and Adolescent Knee Surgery Author/s: Cordasco, Frank; Green, Daniel ISBN: 9781451193350 Publication Date: June 2015 Price: £160.00

Conference listing: Organisation

Conference/meeting

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

10-11 March 2016, Aylesbury

BHS (British Hip Society) www.britishhipsociety.com

16-18 March 2016, Norwich

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

16-18 March 2016, Liverpool

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

30-31 March 2016, Liverpool

BRITSPINE www.britspine.com

6-8 April 2016, Nottingham

COMOC (Combined Orthopaedic Associations) www.comoc2016.org

11-15 April 2016, Cape Town

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

28-29 April 2016, London

CSOS (Combined Services Orthopaedic Society) www.csos.co.uk

13 May 2016, Plymouth

BOOS (British Orthopaedic Oncology Society) www.boos.org.uk

20 May 2016, Dublin

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org

1-3 June 2016, Geneva

CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org

8-11 June 2016, Japan

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

16-19 June 2016, Hinckley

BESS (British Elbow and Shoulder Society) www.bess.org.uk

22-24 June 2016, Dublin

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

8-9 July 2016, Leicester

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

13-16 September 2016, Belfast

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

13-14 October 2016, Middlesbrough

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

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JTO Features

Current Status of Meniscal Reconstruction Tim Spalding Co-authors: Ben Parkinson, Rachel Milner, Nick Smith

Meniscal tears are the most common knee injury and arthroscopic partial meniscectomy is the single most frequent orthopaedic procedure performed in developed countries1,2.

It is now well recognised that the meniscus plays a crucial role in protecting the articular cartilage and in providing secondary stability to the knee.

Meniscal repair and preservation is performed whenever possible, in an attempt to avoid the longterm degenerative consequences of total or subtotal meniscectomy.

Unfortunately, many young patients still undergo resection of a large proportion of the meniscus and some of these patients will consequently develop pain and early degenerative change. Meniscal scaffolds and meniscal allograft transplantation has been shown to provide significant functional and symptomatic improvement to these individuals3,4. This article details the current indications and outcomes of meniscal reconstruction.

The Menisci

Tim Spalding

The menisci improve congruence and stability of the tibiofemoral joint secondary to their shape and structure. Only the outer 10-30% of the meniscal tissue is vascularised, the remainder is nourished through synovial fluid; this limits their capacity to heal following injury5 (Figure 1).

The lateral meniscus transmits 70% and the medial meniscus

transmits 50% of the load through their respective compartments, and complete loss of meniscal function results in peak contact pressures increasing by up to 235%6. Historically, total meniscectomy was a common procedure but as the importance of the menisci has become better recognised, there has been a shift towards meniscal preserving surgery whenever possible.

There is a higher incidence of osteoarthritis and resultant total knee replacement following a total meniscectomy4,7.

Meniscal tears are classified as either degenerative or traumatic, and are further subdivided according to their orientation within the meniscus (Figure 2).

Figure 1: Anatomy of the Menisci

Repair of acute traumatic meniscal tears in young individuals is strongly advocated but sometimes meniscal preservation is not possible, such as following a chronically displaced bucket handle tear or a complex, deformed discoid meniscus.

Figure 2: Meniscal Tear Patterns

Indications for Meniscal Reconstruction Some patients will develop persistent activity-related pain or swelling following meniscectomy.

Patients should have had symptoms for at least six months despite appropriate rehabilitation before considering reconstruction.

There is currently no evidence to support prophylactic meniscal reconstruction at the time of initial meniscectomy. Depending on the pattern of meniscal tissue loss, the options for reconstruction are either synthetic meniscal scaffolds or meniscal allograft transplantation.

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Meniscal Scaffolds Meniscal scaffolds (Actifit or Collagen Meniscus Implant CMI) are used in patients with partial meniscal defects if the following specific criteria are met: 1) intact anterior and posterior horns to allow stable fixation of the implant to host tissue, 2) a complete intact peripheral rim of the native meniscus to support the hoop stresses, 3) articular cartilage wear up to International Cartilage Repair Society (ICRS) grade 3A (partial thickness loss greater than 50% but not down to bare bone). Meniscal scaffold reconstruction is contra-indicated in the presence of a meniscal root tear, a complete radial tear, or if the meniscus is extruded outside the joint margin, as the implant does not provide circumferential continuity and support. Full thickness articular cartilage defects (ICRS grade 3B or greater) are a relative contra-indications as the joint surface is likely to be too abrasive against the scaffold, limiting the regenerative potential. The results of combining articular cartilage repair procedures with an implant in this situation are unclear.

The technique of implanting a meniscal scaffold involves trimming the remaining tissue to give a rectangular defect within the healthy meniscal tissue. The vascularised outer zone of the meniscus should be reached, but not breached. The length of the defect is measured and a 10% oversized implant is fixed into the defect with conventional meniscal repair techniques (Figure 3a-d).

Studies have reported improved clinical outcomes in the short to medium term, with an average failure rate of 10%4.

Figure 3: Meniscal Scaffold a) Meniscal defect prepared; b) Defect measured; c) Scaffold inserted; d) Scaffold sutured in place

arthroscopic assisted techniques.

The meniscal roots are fixed to the tibia with bone blocks or sutures through bone tunnels, with the peripheral margin of the meniscus sutured to the capsule (Figure 4a-d).

Post-operative rehabilitation should lead to a return to normal activity at approximately 9-12 months, although patients are usually advised to avoid high impact sports because of the risk of tearing the allograft.

Conclusion

Meniscal Allograft Transplantation Meniscal allograft transplantation is performed in patients with postmeniscectomy symptoms and a history of a total meniscectomy.

The ideal candidate for meniscal allograft transplantation is a young to middle aged patient, without advanced arthritis. Malalignment, ligament instability and chondral deficiency can be addressed at the time of transplantation or in a staged procedure. The presence of full thickness chondral loss has traditionally been reported as a contra-indication to meniscal allograft transplantation, but recently surgeons have stretched the indications to selectively include such patients, accepting a slightly higher failure rate by combining meniscal allograft transplantation with articular cartilage repair procedures, osteotomy and ligament stabilisation. Similar functional outcome has been achieved to patients with preserved articular cartilage8.

Meniscal allograft transplantation involves implanting an appropriate size and side matched donor meniscus by a variety of

relieve pain, restore function, and hopefully prevent progressive chondral damage and osteoarthritis.

High quality long-term follow up studies are currently lacking, but early to midterm evidence, based upon plain radiographs and MRI, indicates that meniscal allograft transplantation may offer some chondroprotective benefit11-13.

However, the evidence is of limited quality and further studies are needed to address this hypothesis.

Figure 4: Meniscal allograft transplantation a) Meniscal deficient lateral compartment; b) Allograft prior to insertion; c) Meniscal allograft in-situ; d) one year post-operative graft appearance

Systematic reviews of the outcomes following meniscal allograft transplantation show clinically meaningful improvements in all patient-reported outcome measures at final follow-up. A recent systematic review reported that the mean change in the Lysholm knee score was from 55 before to 81 following surgery3. The average patient age at time of meniscal allograft transplantation was 34 years and the usual upper limit is 50 years. The average complication rate is reported to be approximately 10%3. There are relatively few studies that report long term survival but a 50% graft survival at approximately 15 years has been9,10.

The intended outcomes of meniscal allograft transplantation are to

The importance of the menisci in protecting the knee joint is now well understood. Current surgical aims are to preserve and repair as much of the native meniscus as possible. In the event of a subtotal or total meniscectomy, meniscal reconstruction has been shown to relieve pain and improve quality of life in a young patient population.

Tim Spalding is a specialist knee surgeon at University Hospitals Coventry and Warwickshire NHS Trust, and Honorary Associate Professor at the University of Warwick. He has been involved with meniscal reconstruction since his fellowship with John Cameron in Toronto in 1995 and subsequent work with Rene Verdonk, one of the pioneers of meniscal transplantation.

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

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JTO Features

Rare Diseases in Orthopaedics: The BOSS Study Daniel Perry

A nationwide study of rare diseases in orthopaedic surgery is shortly due to begin recruitment - the British Orthopaedic Surgery Surveillance (BOSS) Study.

The BOSS Study is a nationwide reporting mechanism to determine the epidemiology and outcomes in rare orthopaedic diseases.

The BOSS Study is based on other successful reporting systems in obstetrics (UKOSS) and Paediatric Surgery (BAPS-CASS), which have had a significant impact in their specialties.

This study initially focuses on two rare diseases, Slipped Capital Femoral Epiphysis and Perthes’ Disease, and will be expanded to other diseases if successful.

Aims of the BOSS study • To enable the conduct of prospective parallel cohort and descriptive epidemiological studies • To inform the development of randomised controlled trials

• To improve prevention and treatment and allow for more effective service planning.

Why study rare diseases?

• They are under-researched • Understanding of them is often poor • Interventions used in current clinical practice are rarely based on robust evidence • Routine sources of information are limited or unreliable • Comprehensive studies require a large collaboration to identify relatively small numbers of patients.

Support for the BOSS study The BOSS study was setup by a collaborative group of 35 UK consultant orthopaedic surgeons, and now includes over 100 consultants; with most hospitals represented. The study is led by the Liverpool Clinical Trials Collaborative. It is funded by the National Institute of Health Research as part of a Clinician Scientist award. Academic involvement includes clinical trialists, statisticians, epidemiologists and orthopaedic surgeons.

It has support from the British Orthopaedic Association (BOA), the British Society of Children’s Orthopaedic Surgery (BSCOS) and patient support groups.

BOSS Study Methodology

Daniel Perry

The BOSS study is a nationwide service evaluation, and nested cohort-study of rare disease in orthopaedics. It aims to capture

ALL new UK cases of the rare diseases over a one year period, and will support follow-up for two years. The study has nationwide ethics approval, new nationwide NHS research approval (via the Health Research Authority) and is on the NIHR Research Portfolio.

Consultants If a new case of the rare disease is seen, we ask you to complete a simple data collection form detailing information about the case. This form is available online, and as a mobile phone app. The ethics committee and national NHS confidentiality advisory group have confirmed that patient consent is not required as only minimal patient identifiers are collected (IRAS 190754). On completion of the form a study number is generated, which will be recorded against the patient details and held in the study folder.

This will enable us to later request details of the case without sharing any patient identifiers.

Registrars If you identify (see or hear) of any new cases, we ask you to complete a very brief form online or on the app. We can then ensure that we are capturing the maximum number of cases.

Collect every case?

To ensure that all cases are collected we are asking both consultants and trainees to participate in case identification.

We are also using nationwide data (i.e. HES). We will contact the

relevant clinician should it appear that a case has not been reported.

Nested-cohort study Through hospital registration and patients contacting us through the website, patients will be invited to become part of a consented prospective identified cohort.

Within this cohort PROMs will be collected up to two years after diagnosis. NHS numbers will also be recorded to enable future linkage to the National Joint Registry.

Benefits to contributors Contributors will become part of the BOSS collaborative group.

They will receive a certificate acknowledging their contribution to national research and will be invited to the BOSS contributors’ workshop. Contributors will be invited to suggest future topics for investigation using this reporting mechanism, which may involve any rare orthopaedic disease or surgery.

More information is available at www.BOSS.surgery, or e-mail BOSS@liverpool.ac.uk.

Daniel Perry is a consultant paediatric orthopaedic surgeon at Alder Hey Hospital in Liverpool.

He is an NIHR Clinician Scientist and Senior Lecturer at the University of Liverpool. He has an academic interest in epidemiology and clinical trials relating to rare diseases. Daniel is the chief investigator for the British Orthopaedic Surgery Surveillance (BOSS) Study.

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The Nepal earthquake orthopaedic relief effort - one year on Steve Mannion

A 7.8 magnitude earthquake hit Nepal on 25th April 2015, with an epicentre in Gorkha District, 120 km North-West of the capital, Kathmandu.

The earthquake resulted in over 8,000 deaths, 16,000 injuries (mostly orthopaedic in nature) and over 300,000 homes destroyed or damaged. Recognising the scale of the disaster, the UK Government’s Department for International Development (DFID) mobilised the United Kingdom International Emergency Trauma Register (UKIETR) in order to provide UK healthcare professionals to assist in the response to the crisis. I was the clinical lead of the team of 20 clinicians in a project hosted by Save the Children (UK) which included fellow orthopaedic consultant, Colin Walker.

The initial focus of the UK team was at Nepal Medical College in Kathmandu and from there secondary care elements of the UKIETR team (anaesthetists,

Steve Mannion

orthopaedic surgeons, plastic surgeons, ODPs and theatre nurses) were able to offer assistance and increase capacity at several hospitals in Kathmandu.

Meanwhile, the primary care/prehospital members of the UK team (paramedics, GPs) were tasked to conduct healthcare assessments by road and helicopter in the more remote rural areas where the impact of the earthquake had been most severe. When patients who would benefit from hospitalbased care were identified, the team facilitated their evacuation to Kathmandu.

The model for orthopaedic care was to transfer patients in need of surgical intervention back to Kathmandu, where fairly sophisticated orthopaedic care was already available in hospitals which, for the most part, had escaped significant earthquake damage. Initial treatment often consisted of plaster immobilisation or external fixation, allowing soft tissue wounds to be treated, with conversion to internal fixation when the soft tissue envelope allowed. Locking nails and plates, inserted with image intensifier guidance if necessary, were widely available in Kathmandu and the Nepali government offered to meet the cost of treatment for all earthquake victims.

Although after two to three weeks most of the UK clinicians withdrew from Nepal there remained an ongoing support project to the Nepal Spinal

Injuries Centre in Kathmandu.

This involved specialist UK spinal injury nurses and physiotherapists helping to treat over 200 spinal injuries from the earthquake. An ongoing primary healthcare project aimed at restoring primary health services in the areas devastated by the earthquake was hosted by Save the Children (UK) was also established.

Deficiencies in the orthopaedic care of pelvic and acetabular fractures and orthoplastic reconstruction was identified in Nepal. In order to address this, a senior orthopaedic trainee from Nepal Medical College, Dr Animesh Joshi, undertook a sponsored observership in pelvic and acetabular fractures at St George’s Hospital in London in October 2015. Professor

Ram Shah, from the College, also joined the faculty of the Surgical Training for the Austere Environment (STAE) course at the RCS in London in July, with a view to running the orthoplastic elements of STAE back in Nepal.

The UKIETR is a database of clinicians prepared to assist in the wake of natural disasters anywhere in the world. It is hoped that prospective arrangements with employing NHS Trusts will allow timely release of such volunteers for future disasters, with back-filling funding to cover the cost of absence. More details can be found on the website www.uk-med.org.

Steve Mannion combines a half time appointment as a consultant orthopaedic surgeon in the NHS with up to six months a year undertaking orthopaedic education and training projects in the less developed world. He has established clubfoot treatment projects in many less developed countries, is a lead clinician in the UK response to International Disasters and Chairman of World Orthopaedic Concern (UK).

Colin Walker in surgery at Nepal Medical College

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JTO Features

Bullying and Harassment in Surgery: Urgent Change Needed?

Paul Burke Co-authors: Emily Boyle, Marguerite Carter

A growing body of literature has shown that bullying and harassment is a significant problem amongst surgical trainees.

• Bullying is defined by the GMC as “words, actions or other conduct that ridicules, intimidates or threatens and affects individual dignity and wellbeing” 1.

• Harassment is defined in the UK Equality Act as “Unwanted conduct related to a relevant protected characteristic, which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual” 2.

Protected characteristics include gender, race, religion, civil status, family status, sexual orientation, age and disability.

• Undermining is defined as conduct that “subverts, weakens or wears away a person’s confidence, and may occur when one practitioner intentionally or unintentionally erodes another practitioner’s reputation or intentionally seeks to turn others against them” 3.

Paul Burke

These three behaviours are a problem in surgery. The Royal College of Surgeons of Edinburgh (RCSEd) training survey in 2014 found that three out of every five surgical trainees had been victims

of bullying or undermining, with 90% observing it first-hand. Trainee surgeons were three times more likely to be victims of bullying than anyone else in the NHS. Only a third of the respondents felt able to report it as trainees remain embarrassed about or reluctant to report incidents, for fear of affecting career advancement 4.

Prof Grigg, chairman of the expert advisory group appointed by the Royal Australasian College of Surgeons (RACS), viewed bullying and harassment as “the scourge of the modern workplace” 5. The Surgical Royal Colleges in Britain and Ireland have also reiterated their commitment to improve the working and teaching environment of their surgical trainees, responding to several national training surveys highlighting the issue 6,7,8.

Are these issues relevant to orthopaedics as well as other surgical subspecialties? Dr Dewhurst, President of the RCSEd, stated in 2014 that “one person’s bullying may be another person’s stiff talking-to or constructive criticism”9. Some surgeons might argue that the reason there is more reported bullying within their specialty is because of the

popular perception of the “surgical personality”. This perception may influence the interpretation of a surgeon’s behaviour by a young trainee10. Traditionally, orthopaedic surgery is often viewed as a “boy’s club”, and indeed in Ireland and the UK, women still make up less than 10% of the consultant orthopaedic workforce11. Orthopaedic surgeons are also renowned for their capacity to do large volumes of demanding work, for this a more aggressive personality may be advantageous12.

Certainly any group with a stereotypic image should ensure that this does not lead to misperceptions of their behaviour.

Gender-based Discrimination Overt sexual harassment is uncommon in the surgical setting13.

Gender-based discrimination does remain an issue for many female surgeons. Although literature on this is sparse, a female consultant urologist recently publicly described operating theatres as “a hostile environment for women surgeons” 14 and cited a social media experiment in which the BMJ asked women doctors for examples of sexism15. The risk of gender disparity may be increased in specialities with a marked disparity between female and male consultant numbers, as is the case in orthopaedics. Particular obstacles to female surgeons include a lack of female role models and negative attitudes towards them from other doctors16 and patients, many of whom still have

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difficulty accepting that a female in scrubs is not a nurse17. Maternity leave and work-life balance also contribute to the ever-present glass ceiling18.

Sexual harassment can take many forms including inappropriate jokes and advances19. One US study revealed that 30% of female surgeons felt denigrated on the basis of gender, and as many as 75% had experienced gender-based discrimination20.

The issue of sexual harassment was particularly topical in 2015, when a senior Australian-based female vascular surgeon provoked outrage by publicly saying that she would advise her female trainees to submit to sexual advances from senior colleagues if they felt career progression depended on it21. This led to the RACS survey which found that 90% of sexual harassment originated from men, and in 75% of cases the offender was a surgical consultant. These findings were echoed in a large meta-analysis published in 2014, which found that female trainees were significantly more likely to experience sexual harassment.

Senior doctors were the chief perpetrators of such behaviours22.

Does the high male to female ratio at consultant level in orthopaedic surgery predispose to an environment where stereotypical masculine behaviour is accepted, causing offence to female colleagues and trainees?

This could ultimately make orthopaedics less attractive to female trainees.

Impact and Causes of Bullying and Harassment Bullying, harassment and undermining also place a significant financial burden on the health system23. Bullying has been shown to negatively impact on productivity and motivation.

The resulting unpleasant working environment will ultimately lead to compromised patient care. It may also be an important cause of trainee attrition24.

There is no doubt that surgery takes place in an environment where bullying and harassment could thrive. High patient expectation against a background of health cuts, staff shortages and litigation create a pressurised environment.

In addition, the high stakes nature of the job, particularly during surgical procedures, may lead to heated exchanges with accusations of bullying.

Furthermore, changes in work patterns with more “shift work” leaves trainees feeling isolated.

They have less contact with their trainers resulting in reduced understanding and trust25.

Eradicating bullying behaviour?

Recognition of the problem is an important first step - if harassment is perceived, then it is harassment. This is particularly important with racial and sexual harassment, where a majority group may

not appreciate that a colleague or trainee is feeling harassed.

We should promote a cultural change to ensure that unprofessional behaviour is not tolerated and, if it occurs, trainees feel empowered to report it and action results.

Guidelines by professional organisations26,27 provide an outline of acceptable workplace behaviour and trainees should be made aware of these. There are also clear complaint and resolution procedures at both hospital and professional levels.

Supervisors can sometimes be the perpetrators of these behaviours, which can intensify trainees’ fear of negative consequences from reporting abuse28. In general, the development of less hierarchical, team-based approaches, mentoring programmes29 and spending time with colleagues away from the stresses of a clinical setting may all help to address the problem.

Addressing the gender imbalance in surgery will undoubtedly help reduce the problems encountered by female trainees and their families.

Gender imbalance is particularly pronounced in orthopaedics, and many factors have been identified in an effort to redress the balance30. These include a better attitude towards maternity leave, the ability to work flexible hours or job share, better child care facilities and more female role models.

Conclusion Although bullying and harassment are significant issues in surgical training and practice, several recent initiatives have documented the problem and recommended solutions. It is our responsibility, as a profession, to openly discuss these problems and seek to promote an atmosphere in which all are supported.

Paul Burke is a consultant general and vascular surgeon at University Hospital, Limerick and St John’s Hospital, Limerick.

He has been Chairman of the Irish Association of Vascular Surgeons and a council member of the European Society for Vascular Surgery and the Endovascular Society. He is an examiner in the Intercollegiate Fellowship Examination and is on the council of the Royal College of Surgeons in Ireland.

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

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JTO Features

Women in Orthopaedics Helen Vint, Anna Prasthofer Chapman, Karen Daly

Challenges in Training Helen Vint Registrar training in trauma and orthopaedics is an exciting and challenging time. We are all busy maximising training opportunities, studying, research and having a life. After speaking to many trainees from throughout the UK certain challenges seem to be common.

Starting a family Many surgical trainees want to start a family during their registrar training. The pressure of balancing work, publications and studying for exams in the run up to ST3 applications

means that many trainees would rather wait until they have secured a long term registrar contract before getting pregnant. Taking time out for maternity is certainly not the taboo it once was, with many pausing their training not just for maternity leave, but also for research and higher degrees.

Taking significant time out of programme can disrupt the flow of surgical training, and some suggest that the best time may be near the start in ST3/4.

Nevertheless it is certainly feasible to take time out at any stage. Shortening the amount of time you are off, by returning to work slightly earlier but part-

time or continuing to maintain some clinical work whilst doing a PhD can help reduce the feeling of deskilling.

The confidence gap Talking to trainees I am often struck by how the confidence of many female registrars does not match their extraordinary academic and surgical achievements. It is difficult to be sure why this is, but it is certainly a phenomenon that is well recognised in business as ‘imposter syndrome’. This is where high achievers believe they are not bright and have merely fooled their colleagues. This syndrome is often thought to

contribute to women not realising their full potential and to the low number of women progressing to senior management positions.

Perhaps this will begin to change as more female trainees graduate into consultant trainers. Talking about it is the best antidote to imposter syndrome!

Balancing act Sleep deprivation seems to be the number one problem for most trainees approaching the FRCS exam. By that stage many have a young family and combining study with full time clinical work is inevitably exhausting. The best-prepared trainees are inevitably those who have not just been working hard clinically but also studying hard throughout their training. It is crucial in the year running up to the exam to have no other major distractions. Clearly this year is not the time to attempt any major research nor embark on life changes. It is the time to say no to additional responsibilities.

Choice of Subspeciality and Life as a New Consultant - Anna Prasthofer Chapman

Helen Vint

Anna Prasthofer Chapman

Karen Daly

There are perceptions that women choose certain subspecialties such as hands, foot and ankle or paediatrics, which are thought to involve less “heavy” work. In my experience,

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both women and men choose the subspecialty they are most interested in, the one in which they have worked for an inspiring trainer and the one they feel will offer them the lifestyle they desire. There are women represented in all subspecialties and if there are inequalities in distribution, it may just be a reflection of what appeals to an individual, in the same way that men and women tend to pursue certain hobbies or sports.

Establishing a new consultant practice is an exciting time.

I set up my practice at the same time as both male and female colleagues and was reassured to find that we all experienced similar challenges. The majority of our senior colleagues were supportive, but it is well known that new consultants may experience some “hazing” or have difficulty with senior colleagues, within their speciality or from allied specialities, who may be threatened by a new colleague, particularly when it disrupts the status quo. I have noticed that women may be more self-critical in this situation and are less likely to readily brush off such behaviour. Peer support and the guidance of a consultant mentor can help ease these transient issues.

One issue that can be unique to new female consultants, but is reported in women with senior

leadership roles generally, is the difficulty in asserting authority and being taken seriously as the leader of the team. Assertiveness in men is perceived as a positive trait, whereas assertive behaviour in women tends to be perceived more negatively.

This can be frustrating. There are training courses to help negotiate this challenge and it is worth remembering that this phenomenon is not unique to orthopaedics, or even surgery!

Orthopaedic surgeons have been subject to “brash and bullish” stereotypes. Although there may be individuals who fulfil the stereotype, the majority are insightful and supportive of their female consultant colleagues and welcome the skills their new colleagues bring to a department. It is fortunately no longer acceptable to treat female colleagues differently. I would not have chosen, or succeeded in, my career without the support of both male and female orthopaedic colleagues, and in fact, when choosing my surgical speciality, I found the orthopods to be the most welcoming and supportive of a woman interested in pursuing a surgical career.

The decision to pursue private practice seems to come down

to personal preference and is always an option, but may depend on factors including geographical location, spousal occupation and childcare arrangements for those with families.

Female orthopaedic surgeons with children may experience the challenges of balancing a career and childcare, enjoying both their home and work lives. Daily life as a surgeon requires flexibility and robust childcare arrangements have been recognised as an essential to help manage the occasional lack of predictability of the career. Support and care needs to be integral with job planning and job sharing may be an option.

Addressing the Imbalance - Karen Daly On the 2015 review by Lord Davies of his 2011 report “Women on Boards”, Melanie Richards, Vice Chairman of KPMG states, “We must continue our focus on gender and look at the true diversity of those leading our businesses. In order to remain relevant to our clients and communities, we need leaders who come from a wide range of backgrounds, each bringing different skills and views to the table”. That statement could equally well be made about orthopaedic

surgery. We have considerable ethnic diversity at leadership level in orthopaedics but are yet to achieve representative gender diversity. In 2012, 5% of orthopaedic Consultants (and 18% of trainees) were women and yet they are not represented in leadership and management roles in even that proportion.

I am the only woman out of 27 on the BOA Council and the councils of the BHS and BESS have none.

In my opinion there is no dispute as to whether women add value. The question that needs to be answered is what can we do to address the imbalance?

The facts tell us that women are less likely to put themselves forward for leadership roles than men. The hotly debated topic of whether this is due to “nature” or “nurture” is of interest but not relevant to this article. My experiences as a mother to three girls and as a school governor suggests it can arguably be traced back to the time before students apply to medical school, at least. Henceforth it cannot be influenced by senior orthopaedic surgeons in the workplace.

Surgery is commonly perceived as more difficult than other specialties. Have surgeons perpetuated this idea? In my early years of training I was >>

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JTO Features

there is no dispute as to whether women add value. The question that needs to be answered is what can we do to address the imbalance? The facts tell us that women are less likely to put themselves forward for leadership roles than men.

often subject to advice such as, “you do know it’s really difficult (for a woman)” and “you won’t be able to have a family”, etc.

I understand from trainees they still hear such things. So I became a surgeon, married another surgeon and raised a family. My experience and that of many others would suggest those advisors are wrong. It is my experience that women have equal opportunities in our profession and will be rewarded for equal commitment and effort in training. If we are going to encourage these bright and talented young women to compete we must be more positive in our messages about surgery as a lifelong career.

Traditionally, in our society, it was common to see a woman stepping back from her career in favour of her husband.

However, one of the most distressed trainees I managed as a TPD was a committed and talented male trainee who decided to give up core surgical training because his wife was a registrar in another specialty.

As society changes, we risk losing able young people of both genders unless the message about working life balance changes.

How do we encourage women to put themselves up for leadership positions? I strongly believe

in the metaphorical “tap on the shoulder” and it made a difference for me. Perhaps as women we are waiting to be asked and afraid to fail. In addition there is still a common perception that leaders are born not bred. One of the most powerful changes senior orthopaedic surgeons could affect is to tell female colleagues when they believe they’re capable of leadership, facilitate some training for them and be a mentor. Your encouraging words will make all the difference.

On the whole, our current trainees are very different people to those of us in senior positions. Sometimes dubbed Millennials or Generation Y, they are products of their times.

“Millennials look for versatility and flexibility in the workplace, and strive for a strong work-life balance in their jobs”. There is also some evidence that gender differences are becoming less pronounced in this group so perhaps this article will only be of historical interest in a short time. Practical support and advice, encouragement and positivity should be available to all trainees from an early stage and throughout their careers otherwise we risk a shortage of able young people of both genders looking for a career in orthopaedics let alone as leaders.

Helen Vint is an ST5 trauma and orthopaedic trainee in the Northern Deanery. She is the representative for women in orthopaedics for the British Orthopaedic Trainees Association Committee.

Anna Prasthofer Chapman is a Consultant Trauma and Orthopaedic Surgeon with a specialist interest in Foot and Ankle Surgery at University Hospitals, Coventry and Warwickshire. She was Education Lead for Trauma and Orthopaedics in her first Consultant post at Heart of England NHS Trust and is currently a member of the British Orthopaedic Foot and Ankle Society Education Committee.

Karen Daly is a Paediatric Orthopaedic Surgeon who works at St Georges Hospital in Tooting.

She is married to a general surgeon with whom she has six children aged between 25 and 15, two of whom have left home.

She was a Core Surgery TPD from 2007-2012 and now sits on the SAC. She is Associate Medical Director for HR at St Georges.

She is a school Governor of a mixed senior school.

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JTO Features

What do we know about the value for money of orthopaedic services within the NHS? Belen Corbacho

Economic evaluation supports decision making in prioritising the allocation of limited health care resources. Evidence on costs and QALYs based on data from pragmatic Randomised Controlled Trials (RCTs) is increasing in the speciality of orthopaedics, which provides rigorous evidence about the value for money of what is done routinely by the NHS orthopaedic services1.

During the period between 2004 and 2015 the National Institute for Health and Clinical Research (NIHR) funded eleven musculoskeletal RCTs that incorporated cost-effectiveness analysis2-12. Table 1 shows a cost per QALY league table that ranks the assessed interventions by their average cost per QALY estimate.

However, this league table is of limited help in informing decision makers as to how to spend a fixed budget to achieve the maximum health benefit for the global population.

Belen Corbacho

In order to assess whether or not these interventions provide good value for money we have plotted the cost and QALY estimates in the form of a cost-effectiveness plane (Figure 1). This allows for visual assessment of the extent of cost-effectiveness or dominance combination (greater cost with no greater benefits, or lower benefits with no smaller costs, for the

alternatives being compared).

Each point on the plane represents one trial (A to N). The vertical axis shows the average incremental cost estimates from the different trials. The horizontal axis shows the changes in

health (QALYs) as a result of the new interventions. For this example we focus solely on the incremental cost effectiveness ratio (ICER) point estimates, without considering the uncertainty around these figures. The plane shows that more than half of the orthopaedic interventions are found to be associated with higher costs but also with higher health gains (northeast quadrant). Hence it is necessary to determine whether the additional health gain is worth the additional cost.

This is particularly important as costs are allocated to one intervention, the opportunity to obtain the benefits from alternatives are reduced.

All points in the north-east

Figure 1: Cost-effectiveness plane for orthopaedic trials

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quadrant to the right of the diagonal line - NICE threshold - involve an acceptable tradeoff and hence are considered cost-effective (all trials except one); the points to the left in the north-east quadrant (trial A) require an unacceptable trade-off and therefore are not considered a cost-effective use of NHS resources. Orthopaedic interventions in the south-west quadrant are cost-saving and less effective than their comparators.

These potentially increase the amount of health generated by

NHS treatments, by releasing resources that could be invested in other health treatments that provide greater health gains to patients than those lost by using the less effective treatment. For instance, the results of the KAT trial suggests that all-polyethylene tibial components (D3) are less costly (would save £10) but also less effective (losing 0.293 QALYs) than metal-implant. This implies £34 is being saved to the NHS per QALY lost. Therefore despite the potential saving, all polyethylene components still

represent poor value for money for the NHS as they should save at least £20,000 per QALY lost to be considered cost-effective.

Another important point to be highlighted from the plane is that the average ICER is around £14,370 per QALY gained, which is lower than £20,000 to £30,000 per QALY threshold required currently by NICE to make positive recommendations.

This sample of trials is an illustration that pragmatic RCTs with economic evaluation are

possible in orthopaedics and can help in making choices in health care. They also show that overall, orthopaedic interventions are good value for money - this is crucial information for commissioners who wish to optimise the value their budget delivers.

Belen Corbacho is a health economist with special interest in the assessment and appraisal of health technologies. Her research interests include methods to deal with missing data and sources of data (HES, PROMs) to conduct economic evaluation alongside clinical trials. She has worked in diverse disease areas, with a recent focus on orthopaedics and trauma (ProFHER, REFORM and UK-FROST trials).

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

Table 1: Cost per QALY league table: orthopaedic trials funded by the NIHR (2004-2015)

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JTO Features

Introduction of a novel Orthopaedic weekend handover system James Jefferies

The implementation of the European Working Time Directive and subsequent evolution of shift patterns has meant that effective handover between shifts is vital in ensuring patient safety and continuity of care1.

Despite this, there is dissatisfaction amongst hospital doctors regarding the standard of handovers currently practiced2,3. Over a weekend, shift doctors may look after patients, with whom they have had no prior day-to-day contact, making the handover process of paramount importance to continuing safe and effective clinical care.

The Trauma and Orthopaedic department at the Royal Infirmary of Edinburgh admits around 4500 patients per year to a 145-bed unit4,5. Junior doctors are organised into several teams caring for patients with diverse ages, co-morbidities, and acute medical and surgical issues.

At weekends they are fewer in number and care for patients out with their usual teams.

Effective handover is therefore vital but considering the wealth of information to be handed over, this can be challenging.

James Jefferies

Juniors believed the pre-existing weekend handover lacked guidance as to what constituted a safe hand over. As a result, the

quality of weekend handovers was variable. Problems identified in particular included inconsistent patient identifiers, locations, diagnoses, task prioritisation, no clarity on how to act on findings, and having too many written pieces of paper. This affected the time available for doctors to review patients and complete tasks, and was a common source of stress.

Using a standardised handover process is beneficial in the disclosure of significant information of patients6,7. For this reason The Royal College of Surgeons (RCS) recommends a minimum requirement of information which should

form safe and effective patient handover7. This includes: • Patient name and age • Date of admission • Location • Responsible Consultant surgeon • Current diagnosis • Results of significant or pending investigations.

A five-week audit cycle in AugustSeptember 2013 identified that of 197 patients handed over during weekend periods, only 13% included a date of admission, and 49% a diagnosis. Other aspects of information handed over fared better, with nearly all patient names, locations, consultants, and details of significant or pending investigations included.

On disclosure of these figures it was felt that this process could be improved.

Method The principal intervention was to create a standardised orthopaedic online weekend handover tool, made available on the

Figure 1: The new Orthopaedic weekend handover Template

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departmental computer network (Figure 1). This allowed it to be securely accessed from multiple locations when required. The system included headed prompts to be completed and space for further information if necessary.

All junior staff were informed of the new handover template on the network and agreed a set time to handover patients using the system before the weekend shift.

For a further five-week period, completed handover templates were documented for their completeness against the RCS minimum handover guidelines, and analysed using simple statistical methods.

All junior doctors then completed a questionnaire asking them to evaluate the impact and effectiveness of the new weekend handover tool.

Results Uptake of the new handover template by the House Officers was 100% (n=14). Pre-intervention,

197 patients were handed over to staff as requiring tasks or reviews completed over the weekend. Post-intervention, 158 patients were handed over.

Pre-intervention, 13.2% of handovers included a date of admission, and 48.7% included their diagnoses. Following the introduction of the new system documentation of date of admission increased to 93%, whilst inclusion of diagnoses for each patient increased to 86%. Both of these values are significant (p<0.05). All patient handovers included their names, location, consultant, and significant or pending investigations.

All junior doctors (n=14) completed a questionnaire two months following the intervention (Figure 3). All “agreed” or “strongly agreed” that with the new system they better understood patients conditions; patient needs were identified early; staff productivity increased; and perceived patient safety was enhanced.

Figure 3: Junior Doctor weekend handover questionnaire results

Discussion For junior doctors, caring for patients who they do not know at weekends can be a daunting prospect and the pre-existing handover format did not ease this pressure. The resulting handover system however, has been met with overwhelming approval.

With defined headings and prompts it is simple to complete and has significantly improved the recording of key patient information required for effective handovers.

It clarifies patients’ needs and tasks prior to the weekend, which juniors believe has augmented patient safety.

Furthermore, the computerbased system allows easy and secure access and has contributed to streamlining the workload of junior staff over the weekend.

Figure 2: Comparison of percentage completion of weekend handover pre- and post-intervention against RCS minimum handover guidelines

The weekend handover has been overhauled to produce an effective, reproducible and auditable system. Further improvements are currently being developed. These include the

introduction of an online ‘traffic light’ system to further identify and prioritise patients’ needs over the weekend. Future junior doctors arriving to the unit are educated in the handover process to ensure the system’s continuing use.

The development of this online handover system demonstrates how simple interventions by junior staff can have positive and reproducible impacts on the provision of safe care.

James Jefferies is an orthopaedic registrar in trauma and orthopaedics based in Glasgow.

His interests include medical education and developing ‘shop floor’ patient safety improvements.

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

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JTO Features

Trainee Engagement with NIHR Portfolio Research: examples from trauma trials Alex Sims Co-authors: Paul Baker, Xavier Griffin, Matthew Costa

The National Institute for Health Research (NIHR) hold a ‘Portfolio’ of research which it has adopted and supports through its Clinical Research Network. The NIHR Portfolio covers most of the large clinical research projects in the UK, including the multicentre trials in musculoskeletal trauma.

Historically, it has been difficult for surgical trainees to become involved with NIHR Portfolio research. During their training programme, trainees typically rotate through a range of surgical subspecialties at a number of different centres. The short periods of time (typically six months) spent at each centre can make it difficult to set-up new research projects and engage with existing projects. Therefore, the exposure of surgical trainees to portfolio research is often limited and certainly varied.

Alex Sims

Involvement in the delivery of NIHR studies allows trainees to contribute to the large scale projects which determine clinical practice, but also allows them to gain valuable research experience. The NIHR Trainees Coordinating Centre1 supports several formal research training opportunities, such as NIHR Academic Clinical Fellowships and Clinical Lectureships.

However, it is important that all trainees have the opportunity to get involved in NIHR research activity to help develop the next

generation of researchers and produce the ‘research ready’ workforce which the NHS needs.

Despite some barriers to trainee involvement in NIHR portfolio research, there have been a number of recent NIHR studies which have not only involved trainees, but have been successfully led by trainees.

WHiTE 3: HEMI WHiTE 3: HEMI (17502)2 is embedded within the WHiTE cohort study. The WHiTE study is an ongoing multicentre cohort study examining the care of hip fracture patients. A number of centres had expressed an interest in participating in this study, including several in the North of England. However, these centres use a prosthesis for hip hemiarthroplasty which is the subject of ongoing debate and is currently not approved

by NICE. From this debate, the WHiTE 3: HEMI trial was conceived. WHiTE 3: HEMI compares two different types

of hip hemiarthroplasty for patients who have sustained hip fractures, the Exeter® hip prosthesis with Unitrax® head (NICE approved) versus the Thompsons prosthesis (NICE non-approved). This trial commenced in February 2015 and aims to recruit 964 patients in five units across the North of England and the Midlands. I currently co-ordinate this project which is being run in conjunction with the North East orthopaedic trainee research group (CORNET (Collaborative Orthopaedic Research NETwork)). The trial’s management is through the Warwick Clinical Trials Unit.

The Chief Investigator for WHiTE 3: HEMI is Mike Reed, the Training Programme Director for HENE. Mr Reed was keen that the CORNET orthopaedic trainee collaborative, based in HENE, be involved in the WHiTE 3: HEMI Trial. The trial has also received great support from the local SAC, principal investigators and orthopaedic consultants within the participating trusts. These individuals have encouraged trainees to take an active role in participant recruitment. Key to the success of the project has been the full-time availability of the trainee lead who is able to offer advice, organise training, and co-ordinate study related issues in each of the study centres.

This strategy for trainee involvement has provided trainees with an opportunity to recruit to an NIHR Portfolio

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study, improve communications between research teams, increase engagement with research and maximise patient recruitment. This has ensured that all eligible patients are considered, even when research associates are unavailable.

Unlike research associates trainees are always present and have the opportunity to recruit patients who may have previously “slipped through the net”.

Overall, utilising and encouraging members of a trainee research collaborative to take an active role in patient recruitment has improved cohesiveness and the productivity of the project. The evidence for this is impressive as the WHiTE 3: HEMI project is recruiting nearly twice as many patients per month as we had originally predicted.

With the WHiTE 3: HEMI trial running ahead of schedule, we are hopeful that there will be

interesting and novel evidence on hemiarthroplasty of the hip by the end of 2016.

WHiTE 1 & WHiTE 2 Further examples of trainee led trials include WHiTE 1 & WHiTE 2.

WHiTE 1 was a pilot randomised controlled trial comparing the X-bolt and the Sliding Hip Screw for pertrochanteric fractures of the hip. The WHiTE 2 study was a randomised controlled trial of dual mobility against standard total hip replacement in the treatment of displaced intracapsular fractures of the hip. Both of these trials were led by Xavier Griffin, at the time, a trainee in the West Midlands Deanery.

WHiTE 5 Looking forward, the WHiTE 5 trial is awaiting funding confirmation. This will be a

pragmatic randomised controlled trial examining cemented vs uncemented modern stem designs, this study will again be led by a trainee (Miguel Fernandez of the West Midlands Deanery).

Further Opportunities There are other opportunities for trainee engagement within the NIHR musculoskeletal Trauma Trials Network, in conjunction with the NIHR Clinical Research Network Injuries and Emergencies Specialty Group3 and the Royal College of Surgeons of England Surgical Trials Initiative4. As experience has shown that trainee-led surgical trials are feasible and the ethos of trainee engagement in research gains popularity, now is an ideal time for trainees to take advantage of the opportunities which are opening up for them.

Conclusion

Figure 1: WHiTE 3: HEMI Cumulative Vs Projected Recruitment

There are a number of benefits for trainees involved in recruiting to NIHR Portfolio studies.

There is a drive towards patient recruitment in REC approved studies as part of CCT (completion of training).

These studies are the perfect opportunity for the trainees to be able to add this component to their portfolios. Active engagement with reseach also leads to a better understanding of methodology and an interest in outcomes. This means

that new clinical knowledge is translated to the bedside more rapidly, hopefully improving patient outcomes. Through trainee engagement, recruitment is a 24/7, 365 days per year process. Therefore, far more patients have the opportunity to take part in clinical research.

Thus recruitment is quicker than expected, maximising efficiency and reducing costs. Finally, engagement with large-scale clinical research projects is fun; some trainees get ‘hooked’ and become the research leaders of the future.

Alex Sims is a Specialty Trainee in Trauma and Orthopaedic Surgery based in Health Education North East (HENE, previously the Northern Deanery) and Chairman of the CORNET trainee research collaborative.

References 1. NIHR, NIHR Trainees Coordinating Centre. www.nihr. ac.uk/about/about-the-traineescoordinating-centre.htm. 2015.

2. WHiTE 3: HEMI. http:// white3hemi.org.uk. 2015.

3. NIHR Clinical Research Network Injuries and Emergencies Specialty Group. www.crn.nihr. ac.uk/injuries/contacts. 2015.

4. The Rosetrees and the RCS Surgical Trials Initiative. www. rcseng.ac.uk/surgeons/research/ surgical-research/surgical-clinicaltrials. 2015.

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JTO Features - Trainee Section

Developing a professional network of international fellowship links Pramod Achan, Prakash Jayakumar, Mustafa Rashid

Clinical fellowships are an important step in the careers of many UK Orthopaedic surgeons, to hone their specialist skills in a subspecialty. They allow the development of maturity in decision-making, experience in leading a team, the fostering of independent clinical practice, the learning of techniques that are not available locally, and the furthering of academic ambitions.

In 2012, a survey of UK Trauma and Orthopaedic senior trainees and CCT holders1, 42% had completed one fellowship, and 41% had completed two fellowships. Of those who had undertaken a fellowship (n = 165), 32% had been completed overseas. Many trainees state that influencing

factors for their fellowship location being abroad include reputation, research opportunity, and operative experience.

Additionally, many trainees feel that an overseas experience will give them a new dimension and increased employability for their consultant appointment.

This article aims to share some insights as to the practicalities and potential benefits of a training programme developing a professional network of international fellowship links. All three co-authors are involved with the Percivall Pott Orthopaedic Rotation in London, and have different perspectives on the benefits of an international professional network to trainees.

The Training Programme Directorâ&#x20AC;&#x2122;s Perspectiveâ&#x20AC;Ś (Pramod Achan) As a trainee developing both personal and strategic networking skills will help throughout your career. The benefits of building professional networks are well established.

When applied to surgical training, they bring opportunities for collaboration, transfer of information, education and collective intelligence.

As a training programme director, there is an opportunity to create a brand around which this network can be centred.

This should then engage all its trainees, past and present, to extend the network benefits beyond that achievable by any individual.

Pramod Achan

Prakash Jayakumar

Mustafa Rashid

Professional networks can be operational, personal, and strategic. As a trainee, a personal network improves career prospects and your personal portfolio. It is most

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Pott trainees and invited Consultant trainers listen to BOTA 2014 Trainer of the Year, Pete Bates, talk about tricks in nailing distal tibial shaft fractures at the Pott Club Scientific Meeting

effective when it builds an interpersonal relationship based on trust and loyalty; this trust and loyalty, if then transferred to your rotation, enables fellow trainees to benefit from that relationship.

The benefits of accessing your programmeâ&#x20AC;&#x2122;s network can be educational, training opportunities, observerships, research, and eventually even fellowships or consultant jobs. With current levels of competition in orthopaedic training, the chances of securing the next step of career progression, with direct approaches or cold calling, are limited.

Access to that network as it grows and becomes more robust, is of great value through training and into consultant life. Education on building and sustaining a professional network and using it to benefit patients, is a valuable skill that I feel all trainees should develop.

The Percivall Pott Programme has been developing its professional network since its inception in 1969 both nationally and internationally. Percivall Pott trainees have benefitted from the network with opportunities to some of the most influential names in orthopaedic surgery.

Thoughts from a senior traineeâ&#x20AC;Ś (Prakash Jayakumar) The Percivall Pott Rotation provides a variety of opportunities to explore, develop and build strong international links to develop a dynamic career in trauma and orthopaedic surgery. There are some key factors:

Vision Broad experience of the global practice of trauma and orthopaedics is essential before learning the workings of a particular centre, area of specialist expertise or deciding on the fellowship offerings at various units. This cannot be stressed enough and is actively encouraged early in the training programme through clinical observerships, mini-fellowships, and attendance at international and national courses and conferences. Seeking aspects of clinical and academic orthopaedics that resonate and inspire is vital before taking the next steps.

Engagement Engagement with the programme director and clinical leaders in the local network is key in

forging links and building the channels of communication with the target institution or specialist. Apart from advice and knowledge sharing, this is an important means of achieving and maintaining successful contact. Engaging with the specialist at the centre and their administrative team, allows clearer definition of the opportunity, the requirements, and funding.

secured a scholarship, I ventured to the Harvard School of Public Health (Boston, USA) for a 10day intensive programme. I was inspired by my time abroad and a drive to develop my academic portfolio. I planned an academic out of programme placement (OOP). Engaging with the Pott network, my programme director, and surgeons I had met during experiences abroad, I was able to facilitate this.

Planning

I undertook a clinical research fellowship with the hand and upper extremity service at Massachusetts General Hospital and AO trauma fellowships in upper extremity trauma in Innsbruck, Austria and Bern, Switzerland. These experiences integrated with my current PhD, studying patient-focused health outcomes in upper limb trauma at the University of Oxford.

Once an opportunity is defined, clear plans should be made, whether this is a clinical or an academic placement.

Planning naturally involves thorough consideration from the personal, clinical, and academic perspectives. How does this fit with my partner/family? How will this affect my practical skills? What do I hope to gain clinically or academically during this time?

My personal experience began through observerships in the US during my early training, funded by bursaries from the AO foundation. During the third year of training, I developed an interest in patient-focused outcomes in orthopaedic surgery and upper extremity. Having

The journey so far has led to working in a unit and environment with excellent infrastructure and culture to produce high quality clinical and basic science research. The Percivall Pott rotation is well placed to generate and support its trainees in embarking upon exciting opportunities around the world. >>

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JTO Features - Trainee Section

me learn about how a different healthcare system works, and allowed me the opportunity to travel to exciting places. More importantly, they have allowed me to better understand my own goals from my post-CCT fellowship. I have kept in touch with all three surgeons I visited, and all are willing to have more Pott trainees visit them. I would highly recommend that trainees consider international visits to learn more about fellowship opportunities, and DO NOT be put off by being “too junior”.

Take-home message…

A culture of building an international professional network and relationships will benefit not only yourself but fellow colleagues for generations to come.

43rd Annual Pott Club Scientific Meeting. Pictured are the Pott Club committee, Pramod Achan (TPD), and invited guest speakers on the bottom row (L-R) Ralph Hertel (Bern, Switzerland), Freddie Fu (Pittsburg, USA), Mohit Bhandari (Toronto, Canada), Andrew Carr (Oxford, UK), and Shanmuganathan Rajasekaran (Coimbatore, India)

How junior trainees benefit… (Mustafa Rashid) In researching which programmes to rank during National Selection I was intrigued by the strong reputation the Percivall Pott Orthopaedic Rotation had with international fellowship links.

This was reinforced at my first meeting with the Training Programme Director, Pramod Achan, where we took an hour to discuss my aspirations in training, as well as his expectations of me.

He encouraged me to use leave to visit overseas centres of excellence to help build my own professional network and broaden my horizons.

In my ST3 year I arranged to visit Dr. Stephen Burkhart (San Antonio, Texas) and Dr. Brian Cole (Chicago, Illinois). It was not my first time on an international observership as I had visited the Hospital for Special Surgery (HSS) in New York as a Core Trainee. This time, as a ‘resident’ it was different.

I had a little bit more knowledge and had a clear vision of my path to becoming a trauma and orthopaedic consultant. I found

the experience awe-inspiring.

Both Dr. Burkhart and Dr. Cole welcomed me in observing their clinical practices. I learned a tremendous amount, such as how to mobilise a retracted massive rotator cuff tear and how to ensure a secure reattachment of supscapularis in a shoulder arthroplasty. These surgeons are at the pinnacle of their skills and it was inspiring to see what they achieved, gaining a glimpse of how they became renowned experts in their field. I took the opportunity to pick their brains about everything from patient treatment to their general philosophies on rehabilitation.

Additionally, the US system is very different from the NHS and I learnt about how they utilise Physician Associates (PAs) to maximise their patients’ experience.

In my ST4 year I visited Dr. Peter Millett at the Steadman Clinic (Vail, Colorado). This was after I had the opportunity to hear him speak at our 42nd Annual Scientific Pott Club Meeting where he talked on the advances in rotator cuff repair surgery. I chatted to him in the pub afterwards and it was clear he felt welcome at the annual Pott

Club meeting. He invited me to visit, an opportunity I grasped.

This led to a very rewarding visit.

The Steadman Clinic was different to anything I had experienced before. The entire ground floor of the building was dedicated to the Howard Head Rehabilitation Centre where patients would receive one-to-one physiotherapy sessions every day, starting at four hours post-op! They treat a huge number of elite athletes from all other the world, and I recognised numerous signed jerseys from Brits in many different sports whilst walking through the “Athena Hall of Champions”. The lower ground floor also houses their research facility, which had everything from cadavers for simulation training to Instron tensile testing machines for biomechanical testing. Dr. Millett generously took the time to take me through his philosophy in treating athletes, the benefits of early appropriate rehabilitation, as well as the best ski runs to try on the mountain!

My international observership experiences have inspired me, broadened my horizons, helped

Pramod Achan is Clinical Director and Consultant Trauma and Orthopaedic Surgeon at Barts Health NHS Trust. “Prim” as he is affectionately known to the Pott trainees is the Training Programme Director - Percivall Pott Orthopaedic Rotation.

Prakash Jayakumar is a ST7 Orthopaedic Specialist Trainee in Trauma and Orthopaedic Surgery (Percivall Pott Orthopaedic Rotation), with a clinical interest in upper extremity conditions and professional development in outcome measurement in musculoskeletal medicine, value in surgical healthcare, and technological innovation in Orthopaedics.

Mustafa Rashid is a ST5 Orthopaedic Specialist Trainee (Percivall Pott Orthopaedic Rotation) and the current President of the British Orthopaedic Trainees Association (BOTA). He is currently reading a PhD at the University of Oxford investigating predictive modelling for rotator cuff repair integrity.

References 1. Kazi H, Kahane S, Palan J (2012) Ann R Coll Surg Engl (Suppl); 94: 246–48.

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JTO Medico-Legal Features

Where expert evidence goes (seriously) wrong: Recent lessons from the court room Giles Eyre

Providing expert medical evidence for the purposes of civil litigation is an interesting and rewarding activity, intellectually and financially. It might appear an easy field of work to enter, and simple to maintain as a parallel practice to clinical work.

However reported court decisions continue to act as a very public reminder, for some a painful one, of where things can go wrong.

Although orthopaedic surgeons have not featured recently in this public ‘naming and shaming’, the learning points are very relevant to all. No surgeon seeking to develop, or to maintain, a medico-legal practice can afford to receive such a public lesson.

Independence

Giles Eyre

The expert must be independent1.

An easy requirement to comply with, you might have thought, and yet instances continue to come to light, following evidence in court, in which a judge is left doubting the expert’s independence, with

the result that the expert’s evidence is rejected in its entirety. An expert (a midwife) was found to be “overly keen to find arguments to support the Claimant’s case”, and to seek unfairly “to nit-pick at the care given the quality of note-taking without making any allowance for the fact that standards of note-taking etc. were somewhat different 24 years ago”2. An obstetrician “appeared to forget his duty to the court and seemed illegitimately to stray into creative advocacy for the Claimant’s cause … tailored his evidence to argue the case … sought to side-step the evidence”3. Many a barrister has learnt that once

under cross-examination there is little that can be done to control your expert witness, but the expert who understands that the written report should contain all of the points to be made, and the reasoning in support of them, should not enter into such dangerous “uncharted waters”.

An expert who puts forward, in support of his/her opinion, a medical paper without revealing that it has subsequently been the subject of substantial criticism, particularly if that is a matter of which he/she must by implication have been aware, seriously damages any appearance of his/her independence4. While the legal team might not automatically carry out research to ascertain such criticism, the team’s expert witness can be expected to (and should) do so.

Conflict of interest Related to the need for independence is the need for the expert to avoid a conflict of interest or the appearance of possible bias. The specialist medical world is small and inevitably experts know one another or even know the doctor the subject of criticism in the litigation. It is therefore important for expert and lawyer alike to identify any potential conflict of interest. Not to reveal that the defendant’s expert had worked with the defendant doctor for

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many years and had “guided and inspired his practice” was unforgivable, even more so you might think where the defendant doctor had recommended the expert to his legal team. The burden is on the party instructing that expert to provide details of the connection “from the outset” - it is not for the opposing party to have to investigate for a potential conflict5. The expert must therefore reveal any such potential conflict to his/her legal team at the earliest opportunity.

The consequence of such a conflict of interest could well be that the expert evidence will be ruled inadmissible, but in any event it is unlikely to carry much weight in the light of a conflict of opinion6.

Legal tests A clinical negligence claim stands - and falls - on the quality of the expert evidence, and more particularly, the quality of the expert him/herself. Sometimes weaknesses in the expert’s evidence are apparent to the lawyers at an early stage in proceedings from the written report or in conference when the expert opinion is under close scrutiny from the barrister, or in the fallout from a joint discussion and an unsatisfactory joint statement. But sometimes, as reported cases continue to demonstrate, it is not until trial that it all goes wrong. It is

reasonable to assume that in each of the examples referred to below the party seeking to rely on the expert believed, until that moment in the trial, that its case would be supported by the evidence of that expert.

That experts on occasions have difficulty with legal principle and in applying legal tests, and have difficulty in understanding what carries weight with the court and what does not, is not entirely surprising given the nature of the required training and qualifications of medical experts - nil training and nil qualifications other than medical (although some form of certification described as ‘accreditation’ - will be introduced next year for low value whiplash claims). Part 35 to the CPR, the Practice Direction to Part 35 and the Guidance7 do not address these issues.

Experts therefore acquire this necessary knowledge through experience or through voluntary specialist training or self-study.

The Bolam test is of course at the heart of a clinical negligence claim if the standard of care is in issue. It is easy to state as a test, particularly in the process of writing a report, but somewhat more difficult to apply on the facts of any particular case.

However, the test remains the test, and if seeking to establish that no reasonably competent doctor would have failed to take some particular step, it is not

helpful if the expert explains, under questioning in court, that it would have been “wise” and consistent with the standard of a “good doctor” to do so, or that “it was not mandatory but the wise doctor would have done it”8. Many doctors, while critical of another doctor’s actions or inactions, may find it difficult in court, orally and on oath, to castigate a colleague for failing to do something which no reasonably competent doctor in that field would have failed to do, whatever criticism they may have been prepared to make in their report or in conference.

Therefore, it is essential to ensure that as an expert witness, however experienced, you really do understand Bolam and that the words of the test really reflect your opinion before asking the lawyers to rely confidently on your report.

Joint discussions Joint discussions vary a great deal in their nature and, from a lawyer’s perspective, in their usefulness. Whether it is through a lack of appreciation of the role of the joint discussion and statement, or because of communication issues at the meeting, the joint statement frequently fails to assist the lawyers to focus on, and to understand, the real areas of disagreement between the experts, and the logical basis for them.

Developing or expanding the expert’s opinion at the joint discussion, let alone at trial, is rarely a good idea. The court and cross-examining barrister not unreasonably consider that the thinking should have been done and the reasoning provided before the joint discussion, even more so if there has been two previous reports from the same expert. An obstetrician (a different one from the one referred to earlier in this article) who, following two reports, introduced an important explanation and new concept (of “non-reassuring” and/or “atypical” accelerations) for the first time at the joint discussion (and who was unable or unwilling at the meeting to disclose the origins of these terms) cannot be surprised if the judge forms the view that all of that expert’s evidence should be treated with “considerable caution”, a position made worse by the expression of other non-orthodox views in evidence9. If you have something significant to add to the opinion reflected in your written reports, perhaps after seeing the other side’s report, then that should be carefully considered, and provided in writing before the joint discussion10.

Nature and manner What for the advocate is perhaps most difficult to guard against is the expert’s nature >>

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JTO Medico-Legal Features

A clinical negligence claim stands - and falls - on the quality of the expert evidence, and more particularly, the quality of the expert him/herself.

and manner, particularly when the expert is under pressure.

Leading professionals in many fields are not always the easiest people to get on with, let alone disagree with, whether it is in a barrister’s robing room, a multidisciplinary team meeting, a joint discussion or the courtroom.

Personal attacks on the other side’s experts, failing to engage with the medical issues, obfuscation and withdrawal from the joint discussion are not to be recommended and a judge’s finding that the expert’s evidence “was not given in a manner consistent with an expert witness seeking to engage seriously with evidence being put forward” can only result in that expert’s evidence being rejected by the court11. Failing to answer questions in the joint discussion and in cross-examination, however ill-formed or ill-informed the expert may consider them to be, will not endear the expert to the court12.

The medico-legal mind The medical expert must understand fully the role and the duties of a court expert, and must demonstrate a “medico-legal mind”13. Acting as an expert medical witness is not simply an extension of medical practice. An expert, and the legal team, would be well-advised to (re-) read the words of Lord Justice Stuart Smith in Loveday v Renton14

which gives insight into a judge’s decision making process when considering expert evidence, and which often causes surprise (and consternation) in experts when they see the wide range of factors a judge will take into consideration: “The court has to evaluate the witness and the soundness of his opinion. … this involves an examination of the reasons given for his opinions and the extent to which they are supported by the evidence. The judge also has to decide what weight to attach to a witness’s opinion by examining the internal consistency and logic of his evidence; the care with which he has considered the subject and presented his evidence; his precision and accuracy of thought as demonstrated by his answers; how he responds to searching and informed cross-examination and in particular the extent to which a witness faces up to and accepts the logic of a proposition put in cross-examination or is prepared to concede points that are seen to be correct; the extent to which a witness has conceived an opinion and is reluctant to re-examine it in the light of later evidence, or demonstrates a flexibility of mind which may involve changing or modifying opinions previously held; whether or not a witness is biased or lacks independence […] There is one further aspect of a witness’s evidence that is often important; that is his demeanour in the witness box.”

Conclusion Accidents will of course (unfortunately) continue to happen, in expert witness work as in other fields. However, accidents can have serious consequences, and can prove fatal to an expert’s medico-legal practice. It is not enough for the lawyers who are instructing medical experts to understand what should not happen. It is essential for the medical expert to have the skills, knowledge and understanding necessary to reduce the risk of them happening in the first place.

Giles Eyre 9 Gough Square London EC4A 3DG

Giles Eyre is 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 was appointed a Recorder in 2004.

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.

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

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Medico-legal Book Review: Writing Medico-Legal Reports in Civil Claims an essential guide by Giles Eyre & Lynden Alexander Mike Foy It seemed appropriate to review the second edition of Giles Eyre and Lynden Alexanderâ&#x20AC;&#x2122;s book when the senior author (an experienced barrister in the field of medical litigation) was contributing to the medicolegal section of the JTO. For newly appointed orthopaedic consultants trying to break into the medico-legal marketplace there is precious little guidance on the actual process of litigation or how to write medical reports and how to present expert evidence.

This book provides a good introductory background for the newly appointed consultant and is a good reference source for

more experienced practitioners.

It explains how the medicolegal mind-set is rather different from the conventional clinical mind-set. In clinical practice we are used to accepting what the patient tells us. In medico-legal practice we have to adopt a more forensic approach to the account given by the claimant.

The book covers the legal background to claims including an update on recent changes in the law. It contains an extensive section on the roles and duties of an expert witness which is essential reading, particularly for those new to medico-legal practice. There is a clear

explanation of the differences in requirements for personal injury reports versus medical negligence reports. There are guidelines on report writing, including suggested templates for both personal injury and negligence. In the section on negligence, the importance of not analysing the case with the benefit of the retrospectoscope is emphasised, which in the reviewers experience, is an all too common failing of some experts.

Overall, I believe that this is an essential addition to the bookshelf of any orthopaedic surgeon who is carrying out medico-legal work. It will serve both as an introductory guide and a reference source.

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JTO Peer-Reviewed Articles

Exposure in Revision TKA: proximal soft tissue or distal bony?

Andrew Porteous & Ammar Abbas

Adequate and safe exposure is essential in revision TKA to allow thorough debridement in infected cases, removal of old components and implantation of the new prosthesis without risking the devastating complications of either extensor mechanism rupture or fracture1. Factors affecting ease of access in the revision surgery include: number of previous operations, obesity, patella baja, soft tissue contracture, previous plastic surgery flaps, pre-operative range of motion and the length of time for which the knee has been stiff.

Difficult exposure is a particular problem in infected cases, where static spacers have been used in two-stage revision.

The chosen exposure should lend itself to a secure repair, an unrestricted postoperative rehabilitation protocol, and rapid healing. Although a medial parapatellar capsulotomy coupled with release of adhesions provides adequate exposure in many cases, large series have shown that additional soft tissue or bony releases of the extensor mechanism were required in up to 73% of knee revisions1-4.

Proximal soft tissue options: a personal perspective (Andrew Porteous) Andrew Porteous

Ammar Abbas

Planning your exposure is a key part of the preoperative planning

for revision TKA and the necessary expertise in both proximal soft tissue and distal bony approaches is essential. In most cases however, soft tissue exposure alone will be adequate. In a personal series of over 500 revision soft tissue exposure has been sufficient to allow exposure in over 90% of first time revisions.

Therefore, my standard technique for revision surgery (Figures 1, 2, 3) includes a medial parapatellar approach, release/debridement of the fat pad, circumcision of the patella and synovectomy of the pouch and gutters until normal, flexible tissue is encountered.

Cycling the knee through a range of movement 10-20 times will usually provide range over 90 degrees. Removal of the polyethylene liner creates further slack in the tissues to enable safe removal of the implants.

Each step creates more space, allowing the next step. During this process excessive retraction on the patella or extensor mechanism should be avoided.

A subperiosteal medial peel further enhances exposure, although the posterolateral tibia can still be difficult to reach. If the above exposure is almost enough the addition of a quadriceps snip will usually provide the necessary additional exposure if the extensor mechanism or access to the posterolateral tibial plateau is a problem. This is a quick, low risk intervention, although rarely there is a small increase in the residual extensor lag. It is unusual to need a full traditional quadriceps turndown.

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© 2016 British Orthopaedic Association

Journal of Trauma and Orthopaedics: Volume 04, Issue 01, pages 44-46 Title: Exposure in Revision TKA: proximal soft tissue or distal bony?

Authors: Andrew Porteous & Ammar Abbas

Figure 1: Black line indicating the medial parapatellar approach and the proximal “Quads Snip” extension

In the most severe cases, where there is extensive bone loss and where distal femoral or proximal tibial replacements are considered, exposure may be challenging until the implants are removed, but the space created allows adequate access for re-implantation. The difficult cases are the ones with stiff soft tissues, patella baja and a long standing arc of motion of <60 degrees. In these cases following the synovectomy and fat pad release we progress directly to a tibial tubercle osteotomy (TTO) as the exposure required will not be provided by a simple proximal soft tissue approach. The flowchart for access and decision is shown in Table 1.

Standard Revision

Figure 2: Adhesions around the patella and fat pad restrict exposure

Figure 3: Release of pouch and gutters together with a medial subperiosteal peel. Note the pin protecting the tendon insertion on the tubercle

TTO is not without its problems.

It adds time, metalwork, risks tubercle fracture, skin necrosis, delayed or non-union, and the need for metalwork removal5,6,7.

Significant complications are reported in 5–10% of cases8 with a mean time to union of 12 weeks, which increases to 21 weeks if the intra-medullary canal is breached9. Della Valle reported a standard approach being adequate in 92% of cases with a quads snip in 7% and a TTO or quads turndown in only 1%10. My experience is similar to Della Valle, with an extensile approach being required in less than 5% of simple revisions, although this rises to 25% in the complex, multiply revised cases.

Chronic restricted ROM ROM< 60 degrees Severe Baja Expected difficult tibial extraction

Medial parapatellar approach Clear gutters and pouch/synovectomy Release fat pad Circumcise patella Cycle Knee

If 90 degrees achieved, but access not sufficient then medial peel +/- Quads snip

Proceed straight to TTO

If 90 degrees cannot be achieved, progress to TTO

Table 1: Flowchart for Access & Decision Making

The quads snip has been reported not to affect the quadriceps strength, compared to the contralateral knee with a TKA, although it does reduce quadriceps strength compared to a normal control knee11,12. TTO does provide excellent exposure and access to the tibial canal for removal of well cemented tibial stems, especially if the use of offset couplers or deeply grooved stems prevents extraction of the stem from the cement mantle8,13,14,15.

In summary, in the majority of simple first-time revisions, adequate exposure is obtained with standard incision, medial para-patellar approach, synovectomy, explantation and occasionally quads snip. In the more complex and multiplyrevised knees there is a greater need for extensile approach and a lower threshold for early TTO.

Distal Bony Options: an alternative perspective (Ammar Abbas) In revision TKA infection and stiffness represent the commonest scenarios that prompt surgeons to use extensile exposures16,17. In the first stage of a two-stage revision for infection, an extensile approach is mandated to provide adequate access to infected material. Le Moulec noted that TTO was required in 65 of 100 revision TKRs, of these 39 were infected and 26 were not infected18. During the second stage, extensive scarring and >>

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JTO Peer-Reviewed Articles

tissue contractures are often encountered regardless of the type of spacer used. Mendez et al noted that two-stage revision TKA for infection may be the best indication for TTO19. Recent data has shown reduction in the rates of infection and stiffness as reasons for revision TKR, in contrast to the steady decline of wear-related complications20,21,22. Consequently, the need for extensile exposures is expected to increase.

The quadriceps snip technique is often described as a relatively low risk technique that does not alter the postoperative rehab12,23. However, its limitation in safely providing the necessary exposure in certain clinical situations is well recognised. Sun et al observed a higher incidence of partial patellar tendon avulsion in the quadriceps snip group compared to the TTO group in revision knee arthroplasty for infection24.

The V-Y quadricepsplasty is a more extensile proximal soft tissue technique25,26. In a report of seven patients with severely stiff or ankylosed knees, Scott et al demonstrated an improvement in the average range of motion of 49 degrees11. Subsequent workers reported only a modest increase in the range of motion27.

More importantly, the technique has the notable limitations of a restricted rehabilitation protocol, and a high incidence of postoperative extension lag28.

Using gait analysis, Tsukamoto et al reported on four patients (five knees) who had undergone V-Y quadricepsplasty during revision TKA. They demonstrated several functional limitations including quadriceps weakness, extension lag, and reduced knee flexion during the stance phase29. Another disadvantage of the technique is the risk of injury to the lateral superior genicular artery and the potential for patellar avascular necrosis.

Radiographic changes suggestive

of patellar osteonecrosis were demonstrated in 28% of knees in one study30.

Although, accurate data on current rates of knee re-revisions is lacking, a recent registry-based study of knee revisions for causes other than infection showed a failure rate of 14%31. Re-revision rates for infection are likely to be higher32 and exposure is one of the most challenging technical aspects of re-revision surgery. Progressive scarring and contracture of the extensor mechanism, prior quadriceps snip or v-y quadricepsplasty, patella baja, and the presence of large implants are factors that pose particular risk to the extensor mechanism33,34,35,36,37.

Tendons heal by formation of scar tissue, a feature common to all dense connective tissue38. This is in contrast to bone healing, which results in full restoration of normal histology and architecture. Several animal studies have shown inferior biomechanical properties of healed tendons39,40. Therefore, the surgical exposure should be strategically planned in order to preserve the integrity of the extensor mechanism should a subsequent re-revision becomes necessary.

The TTO has the advantage of allowing direct access to the tibial metaphysis, thus facilitating explantation and subsequent implantation. Additionally, secure primary stability is often achieved allowing an unrestricted rehabilitation protocol. Bruni et al recently demonstrated higher functional outcome scores in the TTO group in a prospective study comparing quadriceps snip to TTO in two-stage revisions for infection5.

Since the first description of TTO by Dolin, the technique has undergone several modifications intended to address the reported complications of mal-union, non-union, fracture

and symptomatic hardware41,42.

Whiteside used osteotomes to fashion longer and wider osteotomy fragments, and reported 100% union rate. Additionally, and in order to minimise the risk of proximal migration, he advocated passage of the fixation wires through the osteotomy fragment13.

We have employed Whitesideâ&#x20AC;&#x2122;s principles of low-energy osteotomy and wide healing surfaces (i.e. crest versus tubercle osteotomy),

Figure 4: Low-energy osteotomy using multiple osteotomes

and further modified the technique by introducing non-absorbable suture repair, thus eliminating hardware complications (Figure 4, 5, 6). We have recently published our results demonstrating satisfactory clinical and radiological outcomes in a large series43.

Reports of repeat TTO have shown satisfactory clinical and radiological outcomes. Choi et al used TTO sequentially in the first and the second stage revision TKA for infection in 13 knees. The Knee Society scores improved from 39 to 78, and the mean range of motion improved by 33 degrees44.

Satisfactory clinical outcomes were similarly reported in another series of 51 TTOs (13 patients), 15 of which were done sequentially in both the first and second stage revision TKA for infection45.

Andrew Porteous is a Consultant Orthopaedic Surgeon running the knee injury service at Frenchay Hospital and leads the knee revision service at North Bristol NHS trust.

Ammar Abbas is a Consultant Trauma and Orthopaedic Surgeon at Wishaw General Hospital, Lanarkshire. He is an experienced lower limb arthroplasty surgeon and fellowship trained in revision knee replacement.

Figure 5: Wide exposure with intact lateral soft tissue sleeve

Correspondence Email: andrew.porteous@nbt.nhs.uk Email: ammaridris@hotmail.com

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

Figure 6: Intraosseous suture repair using 5-Ethibond

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Debridement: Defining something we all do Wasim Khan & Rhidian Morgan-Jones

In the modern management of orthopaedic infection, debridement and the ritual of the reproducible steps that go with it are paramount. Debridement is defined in the Oxford Dictionary of the English Language as ‘the removal of damaged tissue or foreign objects from a wound’. It derives from the original French debridement (1835-45), literally to take away the bridle.

The ‘ritual of the surgical operation’ was described by Lord Moynihan almost 100 years ago1. All aspects of surgery can be enhanced by ritual or, as we would see it today, a repetition of a defined technique to achieve reproducible outcomes.

Debridement of the infected total knee replacement (TKR) is no different.

Wasim Khan

Rhidian Morgan-Jones

We strongly believe that the debridement is the most important determinant of successful infected TKR surgery, whether it is performed to retain implants as part of a DAIR (debride, antibiotics and implant retention) procedure, or performed for a

single- or two-stage revision procedure. The re-infection rate following a single-stage revision TKR is falling2, and one possible reason for this is the better understanding of, and greater attention to debridement.

Debridement can be divided into superficial and deep3,4,5.

Superficial wound debridement can be sub-divided into autolytic (hydrogels and auto-enzymes), enzymatic (streptokinase and collagenase), and biological (maggot therapy). Deep wound debridement is subdivided into surgical, which includes explantation and sharp dissection, mechanical, curettage and reaming, power lavage and optionally hydrogen peroxide (H2O2), and chemical, such as acetic acid and honey.

It is important to appreciate the soft tissue envelope as failure to do so may lead to poor wound healing and subsequent compromise of deep tissues6,7.

It is also important to appreciate that debridement is separate from this and must not be compromised by thoughts of reconstruction. In this article we will concentrate on the role of deep debridement in the management of the infected knee replacement.

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Journal of Trauma and Orthopaedics: Volume 04, Issue 01, pages 48-50 Title: Debridement: Defining something we all do Authors: Wasim Khan & Rhidian Morgan-Jones

1. Surgical debridement An adequate debridement of an infected knee requires an extensile approach which accommodates previous skin incisions. As a general rule, previous incisions are used if adequate, and extended proximally and distally as needed. The senior author favours a Tibial Crest Osteotomy to improve access to both explant and debride all corners, whilst protecting the extensor mechanism8. Broad scars should be excised in a mobile joint but caution is required in the stiff and tethered knee. Sinuses in the line of incision should be excised.

Isolated sinuses elsewhere

should be curetted and the deep sinus tract excised. All curetted sinuses will heal if adequately debrided and the source of infection removed. Occasionally, plastic surgical coverage must be planned for when potentially non-viable or necrotic skin is present; a medial gastrocnemius rotational or pedicle flap is generally sufficient.

When dealing with infected arthroplasty, explantation is akin to sequestrectomy and must include all implants and necrotic bone. Flexible osteotomes are best to take down the implantcement interface, although sharp rigid osteotomes should be available. Sharp dissection

Deep Surgical

Explantation, sharp dissection

Mechanical

Curettage, Reaming, Lavage, H2O2

Chemical

Acetic Acid, SurgiHoney

involves a thorough synovectomy and excision of all visible infected membrane or biofilm. Blocking the medullary canals with a swab prevents debrided material from entering them. Ligaments are vascular structures and do not routinely need to de excised.

Only when explantation and sharp dissection has been completed can the next stage of debridement begin.

All tissue removed at debridement has the potential for bacteriological sampling. Again a consistent protocol is useful to improve sensitivity and specificity.

The authorsâ&#x20AC;&#x2122; protocol is to obtain the following samples in order: 1- joint aspirate, 2- synovial samples (x2), 3- femoral joint surface tissue, 4- tibial joint surface tissue, 5- tibial canal membrane, 6- femoral canal membrane.

A total of 6 to 7 samples are obtained with non-contaminated instruments.

2. Mechanical debridement

Superficial Autolytic

Hydrogels, auto-enzymes

Enyzmatic

Streptokinase, Collagenase

Biological

Maggot therapy

Table 1: Methods of debridement

Mechanical debridement has several distinct stages. The femoral and tibial joint surfaces and intra-medullary canals are curetted of any residual membrane, avascular bone

and cement residue. The preoperative radiographs are useful to identify material invisible to the naked eye. The femoral and tibial intra-medullary canals are then carefully power-reamed to remove persistent neo-cortex and membrane in a compartmental debridement as described by Lautenbach9,10,11,12.

Hydrosurgical debridement is performed next with highpressure fluid, commonly sterile saline. All joint surfaces and canals are lavaged under power using the appropriate nozzle attachments. Lavage of the soft tissues, joint surfaces and the intra-medullary canals must be performed in a sequential manner. Most surgeons prefer saline but other solutions with added chemicals or antibiotics can be used according to preference. The volume of pulse lavage fluid used is less important than where and how the operative field is lavaged.

Pulse lavage has a tidal effect of washing loose debris away from the operating field but more importantly lavage under power makes any infected membrane adherent to bone oedematous.

Oedematous membrane is easier to both see and to debride with a further cycle of curettage and reaming. Mechanical

>>

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We strongly believe that the debridement is the most important determinant of successful infected TKR surgery, whether it is performed to retain implants as part of a DAIR (debride, antibiotics and implant retention) procedure, or performed for a single- or two-stage revision procedure.

debridement should be seen as cyclical with a minimum of two, and possibly three cycles required to achieve adequate mechanical debridement (Figure 1).

Hydrogen peroxide is used for the mechanical effect of oxygen release producing effervescent cleaning and theoretical biofilm degradation and cell wall penetration13. Controversy remains over the risk of air embolus whilst using hydrogen peroxide, although this risk is mitigated by the use of a tourniquet. If hydrogen peroxide is used the authors recommend its use after the cyclical mechanical

Figure 1: Cyclical debridement

debridement and prior to chemical debridement, allowing the biofilm and organisms to be presented for a chemical onslaught.

3. Chemical debridement Chemical debridement is the final part of deep debridement and seeks to create a hostile chemical environment that further degrades residual biofilm, as well as killing and preventing further bacterial growth. Although several options are available, the senior author prefers 3% Acetic Acid14,15 which lowers the environmental pH and has activity against both

Gram negative and positive microorganisms. Generally a 10 to 20 minute acetic acid soak before reimplantion is sufficient. Another option is SurgiHoneyâ&#x201E;˘16,17 which works by a local osmolar effect but also produces hydrogen peroxide. SurgiHoneyâ&#x201E;˘ also has the potential to be used as an antibacterial coating after re-implantation. Other potential chemical debridement agents include alcoholic betadine, chlorhexidine and hypochlorite.

Conclusion Debridement is as much a formal part of any revision as is the reconstruction of bone loss and soft tissue balance. By having defined stages which include surgical, mechanical and chemical debridement, a throrough and reproducible debridement is possible. It is important to understand that achieving adequate clearance of infection in a single pass may not be possible and this underpins the concept of repeated cyclical debridement.

Finally, debridement should be seen as separate from reconstruction, which should not be prejudiced by inadequate debridement.

Debridement is the most important step in a sequence of events, but all the other components of management including a multidisciplinary approach, optimisation of the patientâ&#x20AC;&#x2122;s medical comorbidities, appropriate antibiotic sampling and therapy, and definitive implantation are all also essential to ensure a good result.

Wasim Khan is a Post CCT Orthopaedic Fellow with an interest in Knee Surgery and Research.

Rhidian Morgan-Jones is an orthopaedic Consultant and Honorary Lecturer at the University Hospital Llandough, Cardiff. He specialises in revision knee replacement and infection.

Correspondence: Email: wasimkhan@doctors.org.uk Email: rhidianmj@hotmail.com

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

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Novel Antibiotic delivery and Novel Antimicrobials in Prosthetic Joint infection Peter Mihok, James Murray, Rhodri Williams

Prosthetic joint infection (PJI) is rare occurring in 0.5-2% of hip and knee arthroplasties, nevertheless the large numbers of arthroplasties undertaken means that more than a thousand patients are affected each year in the UK alone. Concern regarding multi-drug resistant organisms makes national headlines with recent reports confirming resistance to colistin, a polymyxin. This is currently a ‘reserve antibiotic’, although already used in PJI1.

Despite the strict aseptic and antiseptic precautions that are routinely performed, including patient preoperative decolonisation, surgeon’s hands and patient’s skin disinfection, sterile instruments and operating theatres with laminar flow, the use of prophylactic antibiotics in the perioperative period remains a critical part of avoiding infection in primary arthroplasty.

The bacteria causing infection often originate from the patient’s own skin, as well as that of the operating theatre personnel.

As there is no way to completely eliminate risk, innovative solutions are required to prevent and treat orthopaedic infections.

Novel Antibiotic Delivery Local antibiotic delivery can achieve a much higher concentration than achievable systemically, maximising efficacy, minimising toxicity and potentially reducing the risk of resistance.

Infusion pumps have been used to deliver antibiotic locally into infected prosthetic joints. Such infusions are used along with one or more surgical debridements and exchange of any modular components. Treatment with infusion is suitable for some acute infections2,3.

Peter Mihok

James Murray

Rhodri Williams

Devices loaded with antibiotics which elute into the joint space or an infected area have advantages. Antibiotic release

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Journal of Trauma and Orthopaedics: Volume 04, Issue 01, pages 52-54 Title: Novel Antibiotic delivery and Novel Antimicrobials in Prosthetic Joint infection Authors: Peter Mihok, James Murray, Rhodri Williams

is continuous and depending on the vehicle substance can last for weeks to months.

Antibiotic loaded polymethylmethacrylate (PMMA) cement is well established in arthroplasty, primary and revision, and osteomyelitis. The antibiotic loaded PMMA cement within the bone cavity and/or joint4-6. One of the important factors is that the eluted antibiotic is kept at the minimal inhibitory concentration throughout treatment - this is not always achieved. PMMA cement can also act as a foreign body, upon which microbes produce a biomembrane or biofilm, protecting them against the antimicrobial activity of the antibiotics7-9. The PMMA cement is also non-resorbable and a second surgical intervention to remove cement is necessary.

Biodegradable vehicles represent an alternative to PMMA cement.

They gradually resorb and may even act as a matrix for bone growth. With their degradation, additional release of antibiotics occurs, prolonging their action and not allowing biomembrane formation on their surface10.

Cancellous bone autograft, or morsellised bone allograft, impregnated or soaked in antibiotic solution can also be utilised, although the elution is very short-lived11,12. Impregnated osteoinductive biomaterials show rapid release of antibiotics and aid new bone formation13; calcium

sulphate is used commercially14,15 and calcium phosphate is under investigation. Calcium hydroxyapatite combined with an antibiotic can be used for coating non-cemented implants, creating an antibacterial coating16-19. Covalently tethered antibiotics, such as vancomycin, on titanium can also serve the same purpose20. This technology holds great promise in developing so called â&#x20AC;&#x153;smartâ&#x20AC;? implants, which may well demonstrate self-protective attributes against infection. Bioactive glass is another example of a biomaterial which can be impregnated antibiotics21.

Collagen, fibrin and thrombin are all naturally occurring materials which can be fabricated into a mesh-like structure creating a scaffold or allowing the direct binding of antibiotics which are released as the structure is broken down, usually within days22-25. Their use is more common outside orthopaedic surgery, but their biocompatibility and quick degradation are valuable properties26. On the other hand biodegradable synthetic polymers, mainly from glycolide and lactide, have been used in orthopaedics for several decades as a suture material27, 28.

Modifying their structure by selection of copolymers, crystalline structure and molecular weight controls their degradation and also antibiotic release. Synthetic polymers

could be used as antibiotic carriers; unfortunately they are not suitable because of their quick loss of integrity and mechanical properties29, 30.

Other antibiotic delivery systems include plaster of Paris, which can act as a vehicle for many antibiotics. It is well tolerated and easily absorbed by tissues31, 32.

There are also several gel-like carriers, such as hyaluronic acid or mono-olein-water gel, which can be loaded with antibiotics33,34.

Antibacterial hydrogel coating of non-cemented press-fit implants as a short-term prophylactic method in animal models has also been trialled35. Various biomaterials derived from marine organisms, with differing grades of porosity, show the potential to act as osteoconductive bone substitutes, making them promising candidates for antibiotic delivery systems in the future10.

Novel Antimicrobials The real threat of multi-resistant bacteria has forced us to look for different strategies and options for treating and preventing implant related infection. New and novel non-antibiotics with antimicrobial properties should be considered.

An example is Chitosan, which is used in military medicine as a field dressing to promote thrombus and reduce blood loss. It is also antiseptic, aids healing and is biocompatible. When loaded with

gentamicin it seems to be useful in the treatment of orthopaedic infections36.

Many drugs whose primary role is in non-infectious disease, from neurotropic to antihypertensives, possess antimicrobial properties37-40.

Some of these drugs are routinely used in orthopaedics either as general or local anaesthetics, painkillers and anti-inflammatory drugs. Studies looking at infection rate and the usage of these particular drugs for anaesthesia and pain relief would be interesting.

The antimicrobial action of two different substances combined does not automatically guarantee synergistic action. One study has shown that bupivacaine and gentamicin combine to give a synergistic antimicrobial action against Staphylococcus aureus41.

It has also been shown that some antidepressants and their isomers have a synergistic effect when combined with conventional antibiotics40. The same had been found for magnesium and zinc against a variety of human pathogens42.

Bioactive antimicrobial peptides are proteins formed by the nonspecific humoral mechanisms of eukaryotic and prokaryotic organisms. These peptides have antimicrobial activity and their derivatives have been produced synthetically. They can be used

>>

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Devices loaded with antibiotics which elute into the joint space or an infected area have advantages. Antibiotic release is continuous and depending on the vehicle substance can last for weeks to months.

be used in combination with hydroxyapatite to coat implants.

They have the potential for clinical application43,44. Several other substances and metallic elements were tested in vitro and in animal models. Silver, copper, iodine and chlorhexidine have the potential to be incorporated into the outer nano-layers of prostheses, and have shown evidence of antimicrobial action45-49. They can be added onto the titanium, stainless steel and calcium phosphate surfaces of orthopaedic implants.

Changing the surface properties of implants is an area of focus to try and prevent, or reduce, biofilm infections50. Among metals with antimicrobial activity, silver has excellent antimicrobial activity and low toxicity51. Hardes et al introduced silver-coated femoral and tibial megaprostheses in sarcoma patients and compared the results with uncoated titanium prostheses over a five year period. The infection rate in this series was reduced from 18% in the uncoated to 6% in the silver-coated group52.

The use of silver-coated, extendable endoprostheses has also been reported with some success53. The mechanism of the bactericidal action of silver is still unclear. Although when silver ions penetrate into cells, the DNA is condensed and loses its ability to replicate, leading to cell death. Silver ions may also inactivate proteins by reacting with the thiol groups in cysteine residues54,55,56. Silver nanoparticles have been shown to penetrate bacteria, react with

proteins and DNA, interrupting the respiratory chain and cell division, leading to cell death57.

Successful treatment of PJIâ&#x20AC;&#x2122;s is ultimately all about clearing bacteria in biofilms. Bacteria embedded in extracellular polymeric matrix form a biofilm which attaches to the surface of a prosthetic joint58. Biofilmassociated bacteria are highly resistant to antibiotics. Bacteria in biofilm behave differently, especially in their response to antibiotic treatment59. The complicated structure of biofilm with extracellular polymeric matrix may prevent antibiotics from reaching the bacteria.

Bacteria in biofilm also slow their physiological turnover, making them more resistant to the antibiotics, which target active cellular processes60.

Within the biofilm, bacteria are protected from antimicrobial killing and host responses rendering PJIâ&#x20AC;&#x2122;s difficult to eradicate61. Any strategy to prevent the attachment of organisms to the surface of the implant, prevention of their proliferation or stopping molecular communications between the organisms may help in the battle against PJI62.

Although, not yet fully understood, several techniques have been recently described which have the potential to supersede our reliance on antimicrobials. Acetic acid (AA), or vinegar, has been used in the management of infection since the time of Hippocrates, and is one such novel chemical debridement agent. AA has a bactericidal

spectrum covering gram-positive and -negative organisms. It is frequently used to treat ear and complex wound infections. In vitro analysis has demonstrated complete eradication of mature gram-positive and gram-negative biofilms at physiologically tolerable concentrations of AA. The proposed mechanism is not due to its acidity and proton dissociation, but due to the nondissociated form63.

Another chemical agent that has been used for millennia in the treatment of infection is honey. Medical-grade honey has broad spectrum antimicrobial characteristics with activity against gram-positive and -negative, and multi-resistant organisms64. Bee defensin-1, hydrogen peroxide and methylglyoxal (in Manuka honey) have been suggested as having antimicrobial activity; although understanding of the antimicrobial mechanism is incomplete65,66.

Conclusion Many of these novel antimicrobial agents and carriers for them show promise. Nevertheless, they have often only been tested in vitro and we need to exercise caution in extrapolating the results from the laboratory bench to the clinic. In the age of antibiotic resistance with the daunting prospect of the post-antibiotic era, we need to maximise the effectiveness of current antibiotic delivery but also investigate the potential of alternative, novel antimicrobial therapies.

Pete Mihok finished core training in orthopaedics in Bristol and now works with Knee Specialists at the Spire in Bristol. He has presented his initial work on local anaesthetics to EORS and will start an MD into the use of continuous perioperative local anaesthetic in TKR. James Murray is a Consultant Orthopaedic Surgeon working at the North Bristol NHS Trust.

He is a fellowship trained knee surgeon specialising in soft tissue, arthroplasty and revision knee replacement.

Rhodri Williams is a fellowship trained consultant primary, complex primary and revision hip and knee arthroplasty surgeon at Hywel Dda Health Board, West Wales. In addition to having high volume practice, he has a keen interest in surgical education.

Correspondence Email: petmihok@hotmail.com Email: james.murray@doctors.org.uk Email: rhodri@mail.com

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

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© 2016 British Orthopaedic Association

How I Do…fixation of Hoffa Fractures Hussein Taki Co-authors: Arman Memarzadeh, Peter Hull, Joel Melton

Based on a tip from Mr Joel Melton.

Coronal fractures of the femoral condyle are rare injuries and were first described by Hoffa in 1904. They account for 0.65% of all femoral fractures1 with 7885% being of the lateral femoral condyle (Figure 1)2. Medial and bi-condylar fractures have also been described but are rarer.

These are high-energy fractures, involving the weight bearing part of the joint and are susceptible to displacement on axial loading and knee flexion. If treated nonoperatively there is a high rate of non-union; therefore surgical fixation is usually indicated.

The aim of surgery is to anatomically reduce the fragment and fix it with absolute stability.

There are several techniques described in the literature with the majority of case series using medial or lateral para-patellar approaches. Direct lateral, Swashbuckler and Gerdy’s

Hussein Taki

Figure 1: Sagittal CT of kneeidentifying Hoffa Fragment

tubercle osteotomies have also been described3.

We suggest a posterolateral approach to the knee to fix lateral Hoffa fractures. These fractures are often associated with injuries of the lateral collateral ligament and posterolateral corner. This approach allows ligamentous reconstruction to be performed at the same sitting.

The posterolateral approach (Figure 2) is best performed with the knee flexed. A curvilinear incision is made lateral to the edge of the patella down to Gerdy’s tubercle. The plane between the iliotibial band anteriorly and biceps femoris tendon posteriorly can be used as one ‘window’ to assess reduction and the plane between biceps femoris and the common peroneal nerve as another more posterior ‘window’ for access to enable screw fixation. The anatomy is usually very consistent; with the

Figure 2: Cadaveric dissection showing the surgical approach - the plane between the iliotibial band anteriorly and biceps femoris tendon posteriorly can be used as one ‘window’ to assess reduction and the plane between biceps femoris and the Common peroneal nerve as another more posterior ‘window’ for access which enables screw fixation

common peroneal nerve always posterior to the biceps femoris tendon4. A blunt retractor can be placed under the lateral head of gastrocnemius to protect the popliteal artery and vein. A lateral parapatellar arthrotomy can also be useful to confirm fracture reduction.

The fracture is reduced using large pointed reduction clamps and a visual check can ensure congruity

of the articular surface. Fixation of the fracture is achieved using headless compression screws or countersunk small fragment screws in a posterior to anterior direction (Figure 3). Posterior to anterior lag screws provide better biomechanical fixation, when compared to anterior to posterior fixation from an anterior approach.

Hussein Taki is the Junior Trauma Fellow at Addenbrooke’s Hospital, Cambridge. He completed his core surgical training on the Birmingham rotation and is keen to pursue a career in trauma surgery.

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

Figure 3: Intraoperative XR of posterior to anterior screw fixation

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In Memoriam

Frank Horan

24th July 1933 - 4th November 2015 Frank Horan was educated in Torquay having moved from Manchester during the Second World War. He entered his beloved St Mary’s Medical School and, after a rocky start, he never really left.

He undertook a fellowship in Canada before being appointed consultant orthopaedic surgeon at Cuckfield Hospital in Sussex in 1976. Although he described himself as a “simple country bonesetter”, he developed orthopaedic services and became medical director at the new Princess Royal Hospital.

Frank Horan

His area of academic interest was dysplasia of bone and he wrote many papers on the subject with his old St Mary’s friend, Peter Beighton, subsequently Professor of Genetics at the University of Cape Town.

He was always fair with patients but could be combative with his peers. His help and support for trainees (and junior consultant colleagues) was unstinting and his quotes and anecdotes are remembered by all (“fan with hat, dear boy”). However, if his advice was ignored, you knew about it.

him to Lord’s for a day’s cricket was in for a busy and highly entertaining time.

He loved sport - he played rugby at St Mary’s and tales of his exploits are well recorded.

Manchester United was the only football club. He was a member of the medical committee of the British Olympic Association and medical advisor to the Great Britain basketball team. He loved cricket, played enthusiastically and was a committee member for Sussex County Cricket Club and an honorary life member of the MCC. Anyone accompanying

Frank was a great editor of The Journal of Bone and Joint Surgery, having being appointed in 1998, and was a proponent of plain and simple English which could be understood by ‘the man in Mandalay.’

He was a stalwart of SICOT, becoming associate editor of International Orthopaedics in 1982 and chairman of the editorial board in 1995. His editorial skills were outstanding.

Time spent with Frank was never boring, always entertaining and highly instructive. He leaves his wife, Cynthia (a St Mary’s nurse) and three children, Tom, John and Julia.

Book Review

Human Anatomy – A Very Short Introduction by Leslie Klenerman In the last issue of JTO, Prof Klenerman’s obituary stated that he was working on this book, however, we can confirm that Prof Klenerman had actually finished it. We therefore felt that the book deserved a review; which has been written by Stephen Bendall.

would achieve its aim, but it is well structured and is a proper textbook in every sense, including a comprehensive index.

This is an addition to the Very Short Introduction series with the target audience being ‘anyone wanting a stimulating and accessible way into a new subject’.

It is well written in a punchy style with a good smattering of illustrations. It covers an awful lot of ground. There is a good introduction discussing anatomy across the ages along with sections on the current clinical relevance of anatomy - including mention of the sprinter Usain Bolt’s feet!

It is a slim tome and opening it I really wondered how it

In my opinion this little book fulfils its aim and the author

deserves congratulations.

The sadness here is the author is Leslie Klenerman, who passed away recently. I am sure this text will stimulate and inform an audience outside the usual medical readership of anatomical texts. This book is aimed at the general public, but would be a useful addition to the library of medical students and non-surgical medical practitioners.

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Thinking of the future The work you do is incredibly important and affects the lives of so many people suffering from musculoskeletal disorders throughout the UK. You selected orthopaedics over any other specialty which means you believe in helping and advancing this field of medicine.

We have shifted our focus from funding multiple pumppriming grants to funding one targeted, larger grant with the BOSRC, which we believe will have an even bigger impact, by successfully multiplying available research funds. By doing this,

we hope to achieve a step change in research â&#x20AC;&#x201C; with more trials, at more centres, looking at treatments for more orthopaedic conditions. This change means that we need your support more than ever.

To continue this valuable work and to benefit future generations, please consider leaving a legacy in your Will to the Orthopaedic Research Appeal of the BOA. You can make a difference.

For more information visit www.boa.ac.uk/research/ leaving-a-legacy.

Feeling active?

We are looking for people to run the

British 10k London Run - Sunday 10th July 2016 Will you raise money for Trauma & Orthopaedic research?

If youâ&#x20AC;&#x2122;re interested in taking part in this race, email l.rich@boa.ac.uk or call 020 7406 1767.

We have a limited number of spaces available.

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Imprint

JTO: Information for readers, advertisers & potential authors

JTO Editorial Team l l l l l

Ian Winson (Editor) Fred Robinson (Deputy Editor) Michael Foy (Medico-Legal Editor) Mustafa Rashid (Trainee Section Editor) Rhidian Morgan-Jones (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)

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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

BOA Staff Executive Office Chief Executive.............Mike Kimmons CB Personal Assistant to the Executive........................ Celia Jones Education Advisor ........ Lisa Hadfield-Law

Policy & Programmes Director of Policy & Programmes ..................Rayshum Notay Policy & Programmes Officer ................................Matthew Barker Policy & Programmes Officer ................................. Phoebe Jones eLearning Officer .................. Silvia Bianco

Communications & Operations Director of Communications & Operations ........................ Emma Storey JTO & Joint Action Officer ..... Lauren Rich Membership & Marketing Officer ............ Rebecca Snabel Office Co-ordinator......Natasha Wainwright

Quality Outcomes Programme Director ............... Julia Trusler

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

Events & Specialist Societies Director of Events Management ....................... Hazel Choules Exhibition Manager ....................Janet Mills UKSSB Policy Officer .......................... Lenka Nahodilova

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

Director of Information Systems . .............................Melanie Knight Information Systems Assistant.................................Claire Wilson

Instructions for authors

Future publications

Authors wishing to submit a news item, feature article or peer-review article for the JTO should, in the first instance, submit a synopsis of 120 words explaining what the article is and its relevance within the JTO. This should be emailed to JTO@boa.ac.uk. This will then be passed on to the Editorial Team for confirmation that the subject matter will be appropriate for publication. You will receive an email from the JTO team indicating their decision. The JTO does not publish audits or case reports.

JTO is published quarterly.

Word Limit

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information:

News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 and must include an image.

We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 200 words and should include a photo. Feature articles and Peer-Review articles should be no longer than 1,500 words.

Please be aware that the Editorial Team reserves the right to reduce the content where appropriate.

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

Images

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

These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title.

An indication within the article should identify where the image should be inserted. The article should state a short title/caption for each image.

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

Peer-Review

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

Important items to note

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

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

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

Advertising

Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820

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

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

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

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Mike Reed, Bill Harries, Grey Giddins, Lisa Roberts, Stephen Bendall and Marc Patterson.

Copyright Copyright© 2016 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

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