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BJJ News | I ssue 2 | M arch 2014

Issue 2

The history of orthopaedics in Hong Kong

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Also in this issue: Trainee corner p2

Non-technical skills J. Buchanan S. Khan

Bridging the gap

Consensus report

The infected knee replacement

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R. F. Kallala, M. A. Khan, R. Morgan-Jones, F. S. Haddad

The Glasgow Fracture Pathway P. J. Jenkins, A. Gilmour, O. Murray, et al

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BJJ News

Issue 2

Journal Office:

Advertising enquires:

Edited by:

22 Buckingham Street, London

Dr Pam Noble

Mr David Jones

WC2N 6ET, UK

ADmedica

Honorar y Consultant Or thopaedic Surgeon, London

bjjnews@boneandjoint.org.uk

pnoble@admedica.co.uk

Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath

March 2014 Editorial

Notes from the road

1

Head, hand and heart revisited

18 Travels of our Journal

D. Jones, A. Ross

C. Galasko

20 Orthopaedics in Ireland

Trainee corner

2

Non-technical skills

J. Buchanan, S. Khan

D. Jones Bridging the gap

22 The Glasgow Fracture Pathway: 3

P. J. Jenkins, A. Gilmour, O. Murray, et al

The history of orthopaedics in Hong Kong

a virtual clinic

Orthopaedic history

G. K. Shea, K. M. C. Cheung

Fellowships

24 BOSTAA / Arthrex travelling

6

Genius, creativity & madness

J. Noble

9

Threshing, combing and yelming

J. Shepperd

fellowship 2013

Orthopod’s view

Consensus report

D. Kader

26 The American & British Hip Society travelling fellowship

V. Khanduja, T. Board Honours, awards and prizes

28 The Arnott Lectureship

10 Reflections on the new International

V. Mahadevan

Perthes’ Study Group

S. Thomas

12 The infected knee replacement: international consensus and future trends

R. F. Kallala, M. A. Khan, R. Morgan-Jones,

Obituary

Oliver Ross Nicholson O.B.E. 1922-2013

G. Tregonning

F. S. Haddad

A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299. All ar t icles within BJJ News are published under the Creat ive Commons Attribut ion License (CC-BY 3.0)


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Editorial

Head, hand and heart revisited t has long been appreciated that a good surgeon needs head, hand and heart. The first recognises knowledge and experience, the second, operative skills and the third those qualities which are difficult to define but are easily recognised: they include professionalism, leadership, stamina, probity and selflessness.

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In this issue we are pleased to publish a timely article by Jamie Buchanan on the ‘hear t’ of or thopaedic surgery. When we were younger, knowledge was o b t a i n e d f ro m b o o k s , j o u r n a l s a n d m e e t i n g s . O pe r at i ve sk ill s we re h anded dow n from one generation to another: we learnt from our seniors and taught our juniors. The experience needed to decide how and when to operate, and more importantly how and when not to, was gained through many hours of apprenticeship. Consequently, it was relatively easy for a consultant to identify those trainees with that bit extra for whom surgery was a way of life rather than a means to an end. Hence the value of a confidential telephone conversation before an interview. This world has certainly changed. Our knowledge base has moved into the electronic era: there are computers in every clinic which give us instant access to internet sources and innumerable journals. Indeed our patients have often been there ahead of us. The mystery in medicine is disappearing. The argument that operative skills can only be learned in theatre is also becoming weaker. We now have courses ranging from basic techniques using simple models through complex fixations on dry bones and arthroscopic surgery on simulated joints to formal operations on fresh frozen cadavers. Taking a cue from the aviation industry, simulation has given us mock theatres in which any intra-operative complication can be presented to the surgical team. We are now entering the era of the virtual theatre where, for example, in ophthalmology, there are already wet labs which use pig’s eyes and a simulator to enable a surgeon to under t ake a computer- gener ated operation. This is a powerful tool which allows the trainee to practice in safety before being exposed to a live patient. Orthopaedics will surely follow.

All these advances are welcome and will most likely improve the knowledge and operative skills of surgeons at ever y level. Modern training and examination systems have adapted well to an environment in which trainees have restricted hours of work and reduced clinical and operative experience. However, these systems do not address the other two essential facets of a surgeon, clinical experience and attitude. In order to operate comfortably and safely, numbers count, and it is the responsibility of both trainer and trainee to ensure that the latter gets wide exposure to operative and non-operative care of the patient. In practice, this means that both trainers and trainees have to confront those regulatory and organisational barriers to gaining experience and challenge rather than accept the system. In Britain, surgeons are under threat of becoming apparatchiks in a system imposed by those with little knowledge of surgery but a desire for control. As a profession, we have the knowledge, skills and experience to resist these threats. Fortunately, in the current generation, there are orthopaedic surgeons of character who are engaging with government and acquiring increasing influence for our specialty. It is also reassuring that there are many senior surgeons at a local level who are role models for the next generation by demonstrating not only outstanding operative skills, but also attitude, compassion and character: these cannot be taught in the classroom. Medical students and young trainees are just as intelligent and committed as their predecessors but are born into a system which makes it difficult to gain experience and easy to lose heart. So, for the highest standards of surgery to be maintained, we must be able to recognise and nurture those younger surgeons who have all those qualities which we summarise as ‘heart’ and who share a common motto with their seniors, namely ‘illegitimi non carborundum’*. Let’s hope that Jamie Buchanan’s comments may spur orthopaedic surgeons in other countries to relate their experiences in how we sustain the head, hand and heart of our specialty. *Dog-Latin for ‘don’t let the bastards grind you down’. No decent classicist would countenance it!

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Trainee corner

Non-technical skills urgery, particularly trauma and orthopaedics, has become an increasingly technical profession. A knowledge of available implants and their application is essential to the success of any operation and the complexity and variety of modern implants has partly been responsible for the drive towards super-specialisation. It is not surprising, therefore, that our trainees are focused on gaining experience and knowledge of the steps required to perform these operations and that they record their progress by the numbers of procedures undertaken. The FRCS (Tr & Orth) exam has broad themes based on diagnosis, basic sciences, clinical examination and the description of different operations. Successful career progression has increasingly focused on the presumed acquisition of a sub-set of technical skills. It also troubles me that, at interview, we judge our trainees’ fitness to progress to the next level by inspecting the numbers of audits and papers they have produced. Candidates are assessed on their ability to sew pieces of pig gut together and how they deal with various clinical scenarios, both of which are seen as markers of suitability for the speciality. The old practice of one consultant phoning another on the night before interview is outlawed as we strive for “openness and transparency”. Instead, blinded panel interviews at remote football stadia, ranking the next generation of trainees objectively and without prejudice, are supposed to herald an era of meritocratic progression within surgery. These ideals may be laudable and I understand that my role in the education of these individuals is to help them gain the skills to manage the surgical patient both in and out of the operating theatre, as well as facilitating their opportunities to engage in clinical research and audit. However, it is of concern that the qualities which make a top-flight colleague go unsung. Sterile “mass production” recruitment centres have led to a discord between the dayto-day performance of a trainee and their career progression. There is an increasing impression among prospective trainees, irrespective of how good a surgeon they may be or how well they engage with their trainers or firms, their careers may hinge on whether they know a specific technical skill or can enamour a panel of strangers in 15 minutes.

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When surgeons are probed about the qualities they require from a colleague, answers usually include the phrases, “utterly reliable, honest, thoughtful, on time and communicates well”. Their technical abilities are almost ‘a given’ as six years of higher surgical training will develop most of the skills needed as a dayone consultant. It is therefore somewhat illogical that such “non-technical” skills have no role in current recruitment systems. The consultant phone call of yesteryear often served to affirm these attributes rather than to perpetuate clandestine nepotism. I therefore feel the need to champion the nontechnical skills required of an effective orthopaedic surgeon. It is not enough to be technically excellent while remaining socially inept, rude, selfish, silent or unappreciative. These characteristics are established long before medical school but are hard to perceive at interview. Structured references are ineffective as the intensely personal feelings of the referee have little space on such a form. It is interesting that in similar professions these skills are actively pursued. The City is well known for examining a candidates “cultural fit” and vast sums are spent on knowing as much as possible about an individual’s reputation before interview. The Armed Forces also appreciate that non-technical skills are qualities which make candidates most suitable for promotion. Indeed, in other arenas it would be unacceptable if the opinions of a past employer held no sway over a future appointment. So, what can we do? I feel that training an individual to perform a manual skill is moderately straightforward. Some learn quicker than others and some end up as better performers, but ultimately the skill is usually mastered. The task of teaching ones juniors to “run the show” is harder. Generally speaking, more senior surgeons, confident in their abilities, have an easier time organising the running of an operating theatre. The trainee, younger and less confident, may have difficulty undertaking a pre-operative team briefing and can meet barriers when requesting a particular piece of equipment. More importantly, the positioning of the patient, image intensifier and staff, and how these relate to the anaesthetist are often left to chance. Optimal positioning is achieved empirically but this knowledge filters down by osmosis rather than by active transport, as is the

J. Buchanan S. Khan case with most apprenticeships. All staff need to be aware of the importance of pre-operative planning, as it’s very difficult to put a screw into a scaphoid, no matter how beautifully exposed, when the image intensifier is only half-way to the theatre! By making the pre-operative briefing compulsory and part of normal procedure this problem is immediately resolved. It is the responsibility of more senior staff to embrace this practice to the extent that it would be wrong to proceed in its absence, and thereby pass these leadership skills onto the trainee. It is imperative that these skills must not only be ingrained early in surgical training but that they must also be actively sought as an entry-level requirement. The theatre atmosphere is dependent on the manner in which the staff interact: the tone is often set by the surgeon. Here I believe we can take note of the airline industry where a rule of “no non-operational chat below 10,000 ft.” is applied, for below this height you are taking off, landing or crashing. Certain periods of an operation are “below 10” and it amazes me how often staff fail to recognise this situation. I now warn my team when I am “below 10” and I also expect those around me to recognise the hallmarks of such moments. For the more junior surgeon, greater periods are “below 10” and all present need to be aware of this. I think it even more important that when the less experienced are operating that music is quiet, mobiles are off and non-operational chit-chat is forbidden. These small matters of behaviour are key to the smooth running of an operating theatre. Moreover, they are essential components of an effective, efficient and safe service. Outside the theatre suite other qualities are vital in the complex world of a hospital. Persistent tardiness makes a colleague a menace to a team. Failure to see a task through to conclusion, the expectation that another will pick up the pieces and the lack of ability to engage in departmental dialogue are other traits which make a trainee almost unemployable. Yet these aspects are given lip-service only when we try to confirm which of our very bright juniors should be given national training numbers in their chosen specialty. In the current climate of the NHS where resources are strained, morale is stunted and


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litigation rife, these non-technical skills must not be understated. Surgeons increasingly need to appreciate their role not only in minimising and mitigating their own errors but also the errors of those around them. As team leaders they must imbue members with worth, assign them goals and seek to diminish the apathy that has crept into many NHS structures. Such non-technical skills serve to minimise risk, avoid error and waste and are requisites of good clinical governance. If recr uitment systems cont inue to undermine the value of surgical apprenticeship and longitudinal appraisal by focusing purely on snap-shot assessments of certain skills, then surgeons who are able to lead teams with clinical efficiency will become a rare breed.

I think that national recruitment and ranking at central interview should be abandoned. Not only is it daft to post an individual for six years to a variety of regions around the country, thereby making family life difficult to organise, it also means that an area cannot appoint those it knows and trusts. Surely local trainees who have served a region well deserve local promotion? Recurrent restructuring of the NHS has eroded the influence of surgeons at ground level and an increasing number of decisions are being made centrally, with recruitment a prime example. If surgeons are going to impart their experience and non-technical skills effectively they must have some personal and emotional investment in those they train

rather than be presented with their trainees as a fait accompli. In our drive for fairness and transparency we have lost the ability to judge the next generation on the qualities which are going to make them superb and effective surgeons. These nontechnical skills have been myopically bartered in the search for good technicians. A uthor

details

Jamie Buchanan Conquest Hospital, East Sussex, UK Shah Khan Royal National Orthopaedic Hospital, Stanmore, UK jamiebuchanan@hotmail.co.uk

Orthopaedic history

The history of orthopaedics in Hong Kong he history of orthopaedics in Hong Kong is interwoven with its political, social and economic development. This past century has seen the modernisation of Hong Kong from a colonial trading outpost to a manufacturing hub, and finally the international financial centre that it is today. The health care system has undergone a similar revolution, and our city now boasts the longest life expectancy in the world as a result of the vast improvement in its public and private health care systems. Our areas of expertise and renown within the realm of orthopaedics reflect our focus and resourcefulness in tackling the salient problems of the times. Here, we aim to highlight important events in this specialty’s history from our perspective at the University of Hong Kong. This is by no means a comprehensive history of the entire orthopaedic fraternity in Hong Kong, but we aim to address the key dates and developments which demonstrate the evolution of our specialty together with that of Hong Kong as a whole. The first milestone in the development of orthopaedics was its recognition as a distinct specialty. In 1951 Dr Arthur Ralph Hodgson was appointed head of the newly-established Orthopaedics Unit within the Department of Surgery at the University of Hong Kong. Orthopaedic cases had previously been managed

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by general surgeons or ‘bone-setters’, those traditional practitioners of Chinese medicine trained by apprenticeship to deal with common musculoskeletal conditions including fractures and dislocations. The Japanese invasion and occupation of Hong Kong from 1941–1945, highlighted the gross inadequacies of the health care infrastructure at that time. The University of Hong Kong had to serve as an emergency relief hospital due to the lack of facilities and orthopaedic expertise which meant that emergency field surgery was the order of the day. The Chinese civil war broke out after the end of the Second World War, and Hong Kong found itself home to a sudden influx of refugees from the mainland, many living in squatter camps. The overcrowding and poverty resulted in a large burden of tuberculosis and poliomyelitis. Cases of spinal tuberculosis reached over 500 per year, and it was by tackling this Herculean task that Hong Kong made its mark in the international arena. The ‘Hong Kong operation’ (Fig. 1), essentially radical anterior debridement of the spine followed by bone grafting, was a collaborative effort between Dr Hodgson and Professor Francis E. Stock, then Head of Surgery at Queen Mary Hospital. First reported in 1956,1 this novel approach would be further consolidated in a multicentre prospective clinical trial initiated by the Medical Research

G. K. Shea K. M. C. Cheung An overview from the perspective of an academic centre

Fig. 1 The Hong Kong Operation Council, as well as by many other prospective studies, comparing it with the more conventional and conservative treatments of the time.2-4 Dr Harry Fang, lecturer at the Orthopaedics Unit at the University of Hong Kong, served as surgical assistant during the first Hong Kong procedure. He would expand on the initial Hong Kong operation by developing transoral and transcervical approaches to the anterior cervical spine. In 1955, the Sandy Bay Home for Crippled Children was established by the Columbian sisters. Originally a convalescent hospital, ►

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it was upgraded over the ne xt decade under the directorship of Dr Jim O’Brien, an Australian orthopaedic s u r g e o n , to b e c o m e a fully-fledged hospital with 200 inpatient beds and operating suites. A formal visit by Katherine, Duchess of Kent, presaged its formal renaming as the Duchess of Kent Children’s Hospital (DKCH, Fig. 2). Its focus was on the management and rehabilitation of paediatric conditions. Consequently, Fig. 2 The Duchess of Kent Children’s Hospital the hospital dealt with spinal tuberculosis and poliomyelitis, and as these cases began to dwindle, cerebral morning of formal case discussion, teaching and palsy and congenital abnormalities. Dr O’Brien, fellowship. together with Dr Arthur Yau, who would Hong Kong under went a period of eventually succeed Dr Hodgson at the University industrialization in the 1950’s which continued of Hong Kong, went on to develop halo-pelvic into the 1970’s. The Chinese civil war, alongside traction to correct childhood spinal deformities5 trade embargoes resulting from the Korean War, (Fig. 3). They would also adopt the Hong had reduced trade between China and the rest Kong operation to treat spinal infections and of the world. A burgeoning local manufacturing abnormalities in childhood. The DKCH developed sector developed, predominately in textiles an international reputation for excellence and and clothing. This led to a surge in industrial attracted a regular supply of overseas fellows for accidents, particularly hand injuries. In dealing surgical training. Over the years, more than 300 with these cases, Hong Kong began to develop fellows from 40 countries around the world have an international reputation for excellence in hand benefitted from this exchange and DKCH remains and microvascular surgery. Key dates included the the only paediatric hospital in Hong Kong. first hand replantation at the wrist level in 1976 by In 1961, the orthopaedic unit formally Dr PC Leung at Kwong Wah Hospital, and the first separated from the Department of Surgery and successful thumb replant in 1977 by Dr SP Chow the Department of Orthopaedics was founded at Queen Mary Hospital. Dr PC Leung would at the University of Hong Kong with Professor become the founding chairman of the Department Hodgson serving as its chairman (Fig. 4). By of Orthopaedics at the Chinese University of Hong 1963, a second orthopaedic unit would be Kong. Dr SP Chow, who had trained under the established at Kowloon Hospital under the inimitable Alfred Swanson, continued a lifelong leadership of Dr Harry Fang. The fledging passion to develop and perfect an artificial finger orthopaedic community would continue to joint for the Asian population. His efforts translated grow. In 1965, the Hong Kong Orthopaedic into many successful patent applications and Association (HKOA) was founded. One of its more recently, promising results in clinical trials.6 key roles was to organise academic activities, Professor John Leong succeeded Dr Arthur Yau in particular hosting eminent visiting speakers as head of the Department of Orthopaedics and from overseas. In 1968, Hong Kong played host Traumatology at the University of Hong Kong in to the Second Congress of the Western Pacific 1981. Professor Leong continued the tradition of Orthopaedic Association. By 1981, the HKOA developing innovative techniques in spinal surgery would start hosting its own annual scientific and was the first to describe wedge decancellation conference and another tradition initiated by the osteotomy for correction of kyphotic deformity, HKOA for the local fraternity was the Saturday the precursor of pedicle subtraction osteotomy morning interhospital meeting. Originally currently used.7 scheduled as a quarterly meeting, it has By the 1980s, the Hong Kong post-war evolved to a weekly event and brings together population had more than doubled to five orthopaedic surgeons at all levels of seniority million and there was continued expansion from the public and private sectors for a fruitful of medical facilities to meet their needs. Apart

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Fig. 3 Halo- Pelvic Traction at DKCH from the construction of new acute and convalescent hospitals, a second medical school was established at the Chinese University of Hong Kong. During this decade, postgraduate orthopaedic training underwent a revolution. Trainees in Hong Kong had previously followed the Royal College of Surgeons pathway by sitting for the general surgery examination. Although it was possible to complete training in four years, there was relatively little exposure to orthopaedic cases. Led by Dr David Fang, members of the local orthopaedic community had the foresight and dedication to tackle these deficiencies. The Hong Kong College of Orthopaedic Surgeons was established in 1987, with a key objective to develop a comprehensive and standardised pathway for specialist training. Formal training requirements, including a six-month rotation to a different training centre during higher surgical training and a year-round syllabus of tutorials and workshops, were established. The Hong Kong College held its first exit examination in 1994 and, since 1997 the College has held an annual conjoint exit examination with the Royal College of Surgeons of Edinburgh. The spectrum of disease underwent a dramatic revolution as Hong Kong approached the new millennium. Its population had become increasingly affluent as Hong Kong found its niche as a financial centre. The manufacturing sector shrank, then vanished, migrating north into China and other areas in Asia where costs were substantially lower. Pathology related to degeneration and recreational injury began to take the limelight. These were old foes in the developed world, but often, the, techniques developed for Caucasians did not work optimally in the Orient. After detailed CT osteometry studies by Dr David Fang, the Asian Total Hip System, was developed to


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cater better for local anatomical variations.8 Health care took on a preventive and pre-emptive role. In 1995, the pioneering efforts of Professor Keith Luk at the University of Hong Kong resulted in the adoption of territory-wide scoliosis screening amongst school children, the most comprehensive and effective programme of its kind worldwide.9-12 With their experience in the detection and surgical correction of scoliosis, Professors Luk and Cheung described the fulcrum bending technique to predict post-operative correction of the curve as well as an aid to pre-operative planning.13,14 The turn of the 20th century has been marked by an information explosion with the advent of the Internet, and rapid advances in the biological sciences. We live in a knowledge-based economy, and, as never before, have the tools in molecular biology and genetics to address questions about the aetiology, progression and therapeutic strategies of disease. Hong Kong’s contribution to orthopaedic research during this period was enhanced by reorganisation towards subspecialisation amongst tertiary referral centres, as well as by receiving generous government funding on projects designated as ‘Areas of Excellence’ (AOE). The AOE-funded project on ‘Developmental Genomics and Skeletal Research’ began in 2004 as a multidisciplinary and multi-institutional collaboration initiated by the Departments of Orthopaedics and Biochemistry at The University of Hong Kong. Since its inception this collaboration has been immensely productive, with exciting discoveries particularly in regard to genetic risk factors leading to degenerative disc disease15,16 and the regulatory mechanisms in chondrogenesis.17 Since the handover of Hong Kong to Chinese sovereignty in 1997, the opportunity for collaboration with the mainland China has been ripe. Particularly strong academic liaisons are already in place in spinal and joint replacement surgery. An early innovation resulting from collaboration with the Navy General Hospital in Beijing, led by Professor Luk, showed in a small patient cohort that cadaveric intervertebral disc allografts could be transplanted to treat disc degeneration.18 In 2012, a clinical service began at the University of Hong Kong – Shenzhen Hospital, a public tertiary referral centre with 2000 beds. Although funded by the mainland government, the hospital is managed by the University of Hong Kong, thereby offering abundant opportunity for cross-border medical services, training and exchange of knowledge. With a strong research emphasis, basic science laboratories are also operational, and spinal deformities have been highlighted as a key area of clinical

service as well as a focus for research. These exciting new developments hold unlimited promise in regards to shared breakthroughs in clinical treatment and translational research. When reflecting on progress the Fig 4. The Depar tment of Or thopaedics in 1969. Pictured are remarkable changes Dr Ar thur Yau (f irst row, second from lef t), who would in orthopaedics in be its second chairman, and chairman Prof Ar thur Hodgson (f irst row, third from lef t). John C . Y. Leong Hong Kong from (second row, third from lef t), became the chairman. modest beginnings are characterised by the resilience, resourcefulness and ingenuity of 9. Fong DY, Lee CF, Cheung KM, et al. A meta-analysis of its people. As our founding department at the the clinical effectiveness of school scoliosis screening. Spine University of Hong Kong has recently celebrated 2010;35:1061-1071. its 50th anniversary, the orthopaedic community 10. Lee CF, Fong DY, Cheung KM, et al. Referral can add maturity to its list of attributes. With the criteria for school scoliosis screening: assessment and significant achievements made and the potential recommendations based on a large longitudinally followed that lies ahead, we look forward to continuing cohort. Spine 2010;35:E1492-1498. our tradition of excellence locally, regionally, and 11. Lee CF, Fong DY, Cheung KM, et al. Costs of school internationally. scoliosis screening: a large, population-based study. Spine 2010;35:2266-2272.

References

12. Luk KD, Lee CF, Cheung KM, et al. Clinical effectiveness

1. Hodgson AR, Stock FE. Anterior spinal fusion a preliminary

of school screening for adolescent idiopathic scoliosis: a

communication on the radical treatment of Pott’s disease and

large population-based retrospective cohort study. Spine

Pott’s paraplegia. Br J Surg 1956;44:266-275.

2010;35:1607-1614.

2. No authors listed. A controlled trial of anterior spinal fusion

13. Cheung KM, Luk KD. Prediction of correction of scoliosis

and debridement in the surgical management of tuberculosis of

with use of the fulcrum bending radiograph. J Bone Joint

the spine in patients on standard chemotherapy: a study in Hong

Surg [Am] 1997;79-A:1144-1150.

Kong. Fourth report of The Medical Research Council Working

14. Cheung KM, Natarajan D, Samartzis D, Wong YW,

Party on tuberculosis of the spine. Br J Surg 1974;61:853-866.

Cheung WY, Luk KD. Predictability of the fulcrum bending

3. No authors listed. A 10-year assessment of a controlled

radiograph in scoliosis correction with alternate-level

trial comparing debridement and anterior spinal fusion in

pedicle screw fixation. J Bone Joint Surg [Am] 2010;92-

the management of tuberculosis of the spine in patients on

A:169-176.

standard chemotherapy in Hong Kong. Eighth Report of the

15. Song YQ, Cheung KM, Ho DW, et al. Association of the

Medical Research Council Working Party on Tuberculosis of the

asporin D14 allele with lumbar-disc degeneration in Asians.

Spine. J Bone Joint Surg [Br] 1982;64-B:393-398.

Am J Hum Genet 2008;82:744-747.

4. Hsu LC, Leong JC. Tuberculosis of the lower cervical spine (C2

16. Song YQ, Karasugi T, Cheung KM, et al. Lumbar disc

to C7): a report on 40 cases. J Bone Joint Surg [Br] 1984;66-B:1-5.

degeneration is linked to a carbohydrate sulfotransferase 3

5. O’Brien JP, Yau AC, Smith TK, Hodgson AR. Halo pelvic

variant. J Clin Invest 2013;123:4909-4917.

traction: a preliminary report on a method of external skeletal

17. Leung VY, Gao B, Leung KK, et al. SOX9 governs

fixation for correcting deformities and maintaining fixation of

differentiation stage-specific gene expression in growth

the spine. J Bone Joint Surg [Br] 1971;53-B:217-229.

plate chondrocytes via direct concomitant transactivation

6. Chow SP, Lam KW, Gibson I, et al. A novel artificial prosthetic

and repression. PLoS genetics 2011;7:e1002356.

replacement for the proximal interphalangeal joint of the hand:

18. Ruan D, He Q, Ding Y, Hou L, Li J, Luk KD. Intervertebral

from concept to prototype. Hand Surg 2005;10:159-168.

disc transplantation in the treatment of degenerative spine

7. Leong JCY, Ma A, Yau A. Spinal osteotomy for fixed flexion

disease: a preliminary study. Lancet 2007;369:993-9.

deformity. Orthop Trans 1978;2. 8. Fang C, Chiu KY, Tang WM, Fang D. Cementless total hip arthroplasty specifically designed for Asians: clinical and radiologic results at a mean of 10 years. J Arthroplasty 2010;25:873-879.

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details

Graham K. Shea Kenneth M. C. Cheung cheungmc@hku.hk

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Orthopod’s view

Genius, creativity & madness

J. Noble

lato and Aristotle believed that all geniuses were mad.

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The inference remains with us even today. Byron said of poets, “We of the craft are all crazy.” He was no more than following Richard Burton (the other one) who, in the 17th Century, declared that all poets were mad. Much more recently Harold Nicolson, writing in The Lancet in 1947, described poetic madness as a poetic invention. That, I suspect, is too facile although this diplomat turned journalist was no stranger to poetry, with his acclaimed biographies of Tennyson, Byron and Verlaine. The real question is whether artists need their art to resolve their disturbed psyches or whether eccentric behaviour, which we would label “artistic”, is merely a cover for an inner creative drive. To unravel these rather philosophical problems we need to look at the nature of madness, type of creativity, even genius, of which we speak. Doing so is important because the proposition that mental illness fuels creativity is widespread in its acceptance. So how are they mad? Aristotle noted that many outstanding contributers in philosophy, poetry and the arts are melancholic. The American psychoanalyst, Professor Kay Jamison, has written a most readable book, based on medical and literary research, alongside some of her own scientific work. In “Touched with Fire” (a Byronic reference) she wisely quoted the great British psychiatrist, Anthony Storr who warned that the more we delve into famous people’s lives, the more obvious do vagaries of character appear, not least because biographers just won’t let them rest in peace. Commenting on Mozart’s life in the medical literature, Storr admirably deplored a tendency to pathologise great men’s lives. However, we must recognise that creative types can bring about some of their own reputation and may do so deliberately. Sir George Pickering was Professor of Medicine in Oxford and once memorably recognised that the history of medicine was a monument to human folly. He also wrote a provocative book, “Creative Malady”. Herein were enshrined biographies of Charles Darwin, Florence Nightingale, Mary Baker Eddy and others. Pickering’s point was that their apparent invalidism was, in all probability, feigned in order to be able to escape the formalities and strictures of Victorian social life and thereby concentrate, without house guests or tea parties, on the serious job in hand. In 1970, Vernon, in his “biography” of creativity concluded that personality was at least as important as intelligence, emphasising traits such as persistence, courage, drive and a capacity for hard work. Pickering, in a similar vein, had also mentioned the effect of luck. His example was the penicillium mould which contaminated Fleming’s agar plate. His genius was to think laterally from the primary observation which I believe is, in many ways, the entire history of science. Anyway, Alexander Fleming was a very sane man, so let us return to the question of madness. A favourite counter-argument to the picture of a loopy genius is the bourgeois sanity of Einstein, Shakespeare or Joseph Haydn. So, is there a statistically demonstrable incidence of mental disorder amongst the highly creative, and even geniuses? Perhaps a classic study was that of Adele Juda, a German psychologist, who undertook an in-depth study of 113 German artists, writers, composers and their first-degree relatives. These were compared with 181 scientists who had been nominated by their peers for their eminence. The main conclusion was that about 65% of both

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Fig. 1 Jeremiah Clarke, English baroque composer and organist groups were psychologically normal. However, a quarter of both groups were said to be “psychopathic”. In another key study, Post studied 291 famous men with whose qualifications for an ascription of genius few of us would quarrel. He concluded that, whereas minor psycho-pathology was common, madness was not. Anyway, ‘psychopath’ meant very different things in Dr Juda’s time. Probably significant was the higher incidence of suicide, neurosis and insanity amongst the 113 artists and their relatives. This was most conspicuous amongst the writers and especially the poets. However, I hesitate to use the word ‘significant’ with its scientific and statistical connotation, because I am unsure about the arbitrary nature of Dr Juda’s selection of subjects, the random nature of her controls, let alone the significance in comparing small sub-groups of an original cohort of 113. During my presidency of the Knee Society, we tried to set up a trial of DVT prophylaxis and were advised that we would need to recruit 28,000 entries to generate significant data, or indeed to be assured of the lack of it. But suspicion lingers. In a keynote lecture, psychiatrist Arnold Ludwig showed a two- or three-fold increase in psychosis, cyclothymia and suicide attempts amongst artistic subjects compared with an otherwise similar group of businessmen and scientists. What is perhaps most germane here is the preponderance of poets and writers and also of manic depressive and suicidal tendencies. Kay Jamison’s famous study of 47 British writers and poets revealed a high incidence of depressive or bipolar disorders, which


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are two very different illnesses. The incidence of suicide amongst famous poets was truly appalling. It is here that I must declare a vested interest, for my own study of nearly 300 famous composers revealed only two suicides, namely Jeremiah Clarke (Fig. 1, of ‘Trumpet Voluntary’ fame) and Peter Warlock, and his remains questionable. Of course Schumann, who almost certainly suffered from bipolar disorder, was rescued from a suicide attempt when he jumped into the Rhine. It is often held that Tchaikovsky committed suicide. If he did, so the story goes, he was coerced into doing so because of the shame of his homosexuality. Detailed examination of all the accounts I can find in English has led me to the prosaic conclusion that he caught cholera during a massive epidemic and died of it. Otherwise, composers as a group are much more distinctive for their bravery in adversity, moral courage and sheer dogged persistence. Beethoven is the paragon. Anthony Storr believed that artists (in the broad sense) used their work to save their souls and minds. Perhaps this is the reciprocal of biographer Leon Edel’s view that there is within creative artists an indigenous melancholia or sadness. The composer Berlioz actually turned to music to control his wild mood swings. Tennyson wrote: ‘But, for the unquiet heart and brain, A use in measured language lies; The sad mechanic exercise, Like dull narcotics, numbing pain’. Schubert (Fig.2) said that when he sat down to write songs of love, he wrote songs of pain and when it was to be songs of pain, he wrote songs of love. But perhaps that is to highlight Schubert’s sadly inadequate love life rather than to illustrate a generalisation such as SAD (Seasonal Affective Disorder), in which Jamison’s data pointed to mania peaking in September and depression in February. There is much less information regarding creativity in relation to season, although Jamison found that Van Gogh’s output peaked in June/July and troughed in February and November. If we consider this on an atavistic or evolutionary basis, then surely it is not surprising. In Kenneth Graham’s wonderful classic “The Wind in the Willows” creatures like Badger, Ratty and Mole, even transmogrified into Edwardian gentlemen, are very subject to the seasons and the important point is, instinctively so. Perhaps the perfect musical study into mood and creativity was that from the Maudsley by Slater and Meyer, who demonstrated huge fluctuations in output from Robert Schumann, so productive when hypomanic, but silent when depressed. I believe we should accept that creative people, let alone geniuses, are naturally, or normally, more emotional and probably labile than Joe Average. Surely what we are seeing with many are intrinsically normal facets of expression becoming over-developed. This is no more surprising than the obvious observation that professional footballers have overdeveloped thigh muscles. We should return here to Storr or Stone, deploring our tendency to pathologise the great, especially if they are dead. However, by comparing the classic studies of Juda, Jamison, Post, Ludwig, Andreasson and others of artists, many of whom are writers or poets, with my own of classical composers, one must acknowledge that suicide,

Fig. 2 Franz Schuber t , Austrian composer

alcoholism and psychotic illness are alarmingly common in Anglo-American writers, especially poets, whereas composers as a group are frequently down in the dumps and a number have problems of intermittently drinking to excess by today’s standards (e.g. Sibelius, Brahms, Schubert, Tchaikovsky). Nevertheless, very few were true alcoholics, using W.H.O. definitions of that metabolic illness, Mussorgsky, Satie and possibly Glazunov being the rare exceptions. Indeed, I believe that alcoholism and great musical composition are almost mutually exclusive. The same sadly cannot be said of poetry. Thus, it becomes clear that very different impedimenta may either motivate or suppress creativity. Of mental illness in great scientists there is much less evidence, as exemplified in Juda’s paper. But there are exceptions. To my mind, Stephen Hawking’s supreme achievement is that of a wonderfully original and vital mind of almost cosmic range locked into a totally failed body. He has said that this somatic failure has, in some ways, facilitated his intellectual development and achievement. This should surprise us less than it might have done ten or twenty years ago. Verified MRI scan techniques have revealed hypertrophy of areas of sensory reception in the brain, following destruction or disease of other areas. This principle perhaps finds its apogee with autistic savants. For all the relative domestic normality of men such as Nils Bohr, Einstein, Max Planck or even our own John Charnley, many great scientists have been psychologically very abnormal people, none more so than that greatest ►

7


BJJ News  |  I ssue 2  |  M arch 2014

Fig. 3 Isaac Newton, English physicist and mathematician A uthor

details

Jonathan Noble

Cheltenham, Gloucester, UK joanlnoble@btopenworld.com

of all English scientific geniuses, Sir Isaac Newton (Fig. 3). He was pathologically secretive and possibly exhibited features of paranoia. The major subject of his invective was Robert Hooke who, late in his career, became mentally ill, not least under the influence of Newton’s hatred. Of course, inter-personal jealousy and rivalry have been meat and drink to the history of science. Michael Frayn’s brilliant play “Copenhagen” explores theories as to what passed between Heisenberg and Bohr in Copenhagen in 1943. But perhaps the best meeting of science and theatre came in Friedrich Durremnatt’s great play, “The Physicists”, sadly unfashionable today, where a Swiss lunatic asylum houses several physicists, diagnosed by the ‘kindly’, female elderly psychiatrist as schizophrenic. They believe they are Newton, Galileo and the rest. Well they don’t actually. These are facades behind which they hide from the outside world, because they have made discoveries in atomic science almost too awful to live with. There is a real parallel here with Robert J Oppenheimer. The un-mad scientists then discover that the kindly old psychiatrist is actually analysing them to discover their awful secrets so that she may gain world domination and bring about Armageddon! We also saw this escape from society behind convenient sickness with Darwin and Nightingale. Might we also have discovered such dissembling with Leonardo Da Vinci on his travels? For some men and women, being born a genius becomes a heavy, even unbearable, burden with which to live. In today’s society we seem to have an almost insatiable lust for celebrity. Perversely, we also love to see duchesses pushing trollies in Waitrose or hear that Stephen Hawking enjoys ‘The Simpsons’ and that some great classical musicians allegedly enjoy pop music. What we must learn is that creativity and genius over-develop parts of the brain and personality to the extent that there is danger of that personality spilling over at the edges, producing features sometimes correctly and sometimes incorrectly regarded as mental illness. At least some of that alleged illness is just an over-development of personality traits beyond the scope or ken of many of us lesser mortals. Creative geniuses, sick or well, need their space and for us to make allowances for them in daring to be different.

Academic Orthopaedic Oncologist Mount Sinai Hospital, Toronto, Canada The Sarcoma Program at Mount Sinai Hospital is a world-renowned leader in health care, research and teaching in musculoskeletal oncology. We are seeking to recruit a full-time academic orthopaedic oncologist to join our multidisciplinary sarcoma team at Mount Sinai Hospital and Princess Margaret Hospital, academic health science centres affiliated with the University of Toronto. The successful candidate will be eligible for an academic appointment at the University of Toronto. The candidate must be eligible for certification with The Royal College of Physicians and Surgeons of Canada (or its equivalent), and licensure with the College of Physicians and Surgeons of Ontario. This position requires advanced surgical skills and clinical experience in musculoskeletal oncology. Fellowship training in orthopaedic oncology is essential. Responsibilities include patient care, teaching and research. It is anticipated that the successful candidate will have a research background sufficient to develop an independent research program leading to major improvements in understanding sarcoma biology or in clinical care.

Interested candidates should submit a letter of application and curriculum vitae, together with names and contact information for three references by March 15, 2014 To: Barbara Carlyle, Administrative Assistant to the Surgeon-in-Chief, Mount Sinai Hospital, Email: bcarlyle@mtsinai.on.ca

The University of Toronto is strongly committed to diversity within its community, and especially welcomes applications from visible minority group members, women, Aboriginal persons, persons with disabilities, members of sexual minority groups and others who may contribute to further diversification of ideas. All qualified candidates are encouraged to apply, however, Canadians and permanent residents will be given priority.

BJ-MtSINAI-SARCOMA-1.14.indd 1

16/12/13 9:09 pm


BJJ News

Orthopod’s View

Threshing, combing and yelming

J. Shepperd

In our series highlighting the versatility of orthopaedic surgeons outwith ‘the day job’, John Shepperd explains the craft of thatching e live in a disappointing age

thatch”, Old Norse oak, Old Frisian thek,

of brain-dead hyperspecialists,

Middle Dutch dak “roof,” Old High

constantly subjugated to

German dah, German Dach “roof.” The

quar ter-competent

objective is to put stuff on the roof and

managers, lawyers, or patients full of

keep the rain out. When repairing, it was

black ingratitude. (My glass is half

usual to leave the underlying material

empty!). Now, it’s all about “Leave it to

undisturbed. Some roofs have been

the expert”, regardless of whether they

found to be six feet thick, and date back

know what they’re doing. This has

seven or eight centuries. Thatch can be

generated an unhealthy mentality of dim-

undertaken using any material: straw

witted dependency.

was most readily available, but heather,

W

I am firmly from the school of self-

flax, bracken, faggots, wood peelings,

sufficiency. This is a matter of necessity

potato peelings have all been found in

when ocean sailing and farming.

the ancient layers of much re-coated

In the good old days we were taught

roofs. Terracotta tiles were favoured by

that a properly trained surgeon could turn

Romans, but unaffordable for any but

his hand to anything, and make a good

the poshest people (I do have tiles on my

fist of it. So, obviously, when I needed a

house!). Most “professional” thatchers

roof over my Georgian stable some 26

don’t know how to thatch properly with

years ago, I turned my hand to thatching.

long straw.

Fig. 1 The author with a hazel yoke, loaded with bottles of maris piper drawn from a soaked bed, at the commencement of re-coating a stable, last thatched by him 25 years ago A few definitions:

The first requirement was to grow a

Nowadays, everyone wants concrete

crop of long straw wheat. It all went very

tiles. Keeping the house dry is someone

YELMING

well until October 15th, 1987 – remember

else’s responsibility, or an insurance claim.

The straw is laid in a heap on the ground, and a few buckets of

the great storm? It destroyed my rick,

Idiots! Fat lot of good that attitude will do

water are thrown over it. The straw and wet help to pull out straight

and sadly I was forced to buy in Norfolk

you on a desert island.

straw from the bottom. A bundle of yelmed straw is then tied into a

reed which is different in appearance

So being a traditionalist, I am in the

bottle with a diameter of around 15” (none of this European metric

from long straw thatch. Fine for twee

process of re-coating that original stable,

nonsense here). About seven yelms are held in a split hazel yolk,

chocolate box “Rose Cottage”, but not

as well as other buildings in the farmyard

and transported to the roof.

appropriate for farm buildings in rural

next to my house. I have just re-erected

EAVES

East Sussex (although Pevensey castle

three reclaimed oak framed buildings; a

In order to provide a tilt to the eaves, bundles of material are laid

was thatched with local reed in the 14th

17th century granary, 18th century long

horizontally at the bottom, and held in place with spars (split hazel

century). Listed building bureaucrats

barn, and a cart shed. These are likewise

“staples”).

(more ignoramuses) have finally cottoned

queuing up for their roofs. So it’s back

COATING

on, and long straw futures are currently

to growing long straw wheat. I have

The long straw yelms can be laid vertically, which avoids repeatedly

looking bright. My reed thatch had always

the binder. Then comes the threshing,

moving a long heavy ladder. The process goes from eave to ridge,

rankled, but I had no choice at the time.

combing and yelming. Hours with a spar

with successive courses overlapping. A sway (usually ¼” steel,

“Only 16 professional thatchers are left

hook making sways and spars, gathering

or split hazel) is fixed over the upper third of each course, and

in the country”. What twaddle. We’re

sedge for the ridge, and so on.

concealed by the next course up. Jiggling is required to line up the

all potential thatchers. A core value of

If there are any traditional well-

altering contours at hips, barges and at the ridge, where the straw

human survival is maintaining a roof over

trained surgeons out there, come along

is bent over the top. It is protected here with a sacrificial sedge

your head: it is built into the genes, if you

and have a go.

overcoat.

believe a word of Darwin. Two options for a leaking roof: get up there and repair it, or die of pneumonia. Since at least the Bronze Age, thatch has been the most common method of covering a roof. Old English þæc “roof,

DRESSING AND FINISHING A uthor

details

John Shepperd

Conquest Hospital, East Sussex, UK rona.drennan@esht.nhs.uk

Irregularities are trimmed with shears (as are the eaves and barges), and then combed – like a grand scale coiffeur. The ridge and bottom course are fixed with exposed hazel or willow sways, sparred down and made into a pattern. And there you have it.

9


BJJ News  |  I ssue 2  |  M arch 2014

Consensus report

Reflections on the new International Perthes’ Study Group

S. Thomas

Simon Thomas reports on his experience in Dallas. “I stood where Oswald took his shot, in my opinion there’s a bigger plot” (Kelly Jones, Stereophonics)

n 7 March 2012 an invited group of 50 surgeons, mainly North American, met at the Texas Scottish Rite Hospital for Children (TSRH) in Dallas for the inaugural meeting of the newly-formed International Perthes’ Study Group (IPSG). Within the small European contingent were myself and Professor Nick Clarke from Southampton I have stood, or more often sat, many times as various enthusiasts have taken their shot at justifying containment surgery for Perthes’ disease. I remain less than wholly convinced. One of the driving forces behind the IPSG is the conviction that there is a broader argument to be explored in dampening the effects of the disease, examining more closely the metabolic processes underlying femoral head collapse and how these might be manipulated favourably. The leading researchers in this field are David Little in Sydney and Harry Kim, formerly of Florida but more recently transferred to Texas. Harry heads up the group, bravely moving from the controlled world of basic science and animal studies into that of clinical studies in an attempt to translate some of the progress that he made in the laboratory. The IPSG was formed along similar lines to a group convened in the 1980s by Tony Herring, now Chief at the Alma Mater, which led to the seminal report of outcome in Perthes’ disease with surgical or non-surgical management. Thirty years later the agreed ‘mission statement’ of the IPSG is to collaborate in multi-centre clinical studies into the aetiology, pathology and treatment of Perthes’ disease. As a father of three young children there is some guilt attached to big international trips such as these, heading off alone to rack up

O

10

Fig. 1 ISPG Core Planning Group Front Row (L to R): Tony Herring, Harr y Kim, Ben Joseph Back Row (L to R): Ola Wiig, Harish Hosalkar, Pablo Castaneda, Klane White, Josh Hyman, Simon Thomas expenses that would cover the cost of a modest family holiday. Arriving in Dallas, I took the competitively-priced airport shuttle bus serving the various motels and guest houses. There was a ripple of excitement on board when we pulled up at the imposing Warwick Melrose Hotel: Harry’s academic secretary had booked me a room here and it was a sign of things to come. The TSRH, founded in 1921, is a 100-bedded facility exclusively for children with orthopaedic and some related neurological conditions. It is state-of-the-art, well staffed and lavishly appointed. There is a great tradition here of hospitality; every meeting, however informal, was accompanied by an ice and ‘soda’ filled bowl, fresh coffee on tap and platters of gleaming fruit or wrapped delicacies (mostly snaffled and smuggled out for the trip home). Another ritual, in a hospital largely funded by freemasonry, is that of standing up after dinner to explain who you are and what you like to do,

medicine aside. After a couple of characteristically exuberant and no less entertaining life vignettes from Americans preceding me, I dropped the ball entirely when my turn came and mumbled something about missing home: very poor. Professor Clarke fared rather better with a quip about being in his third trimester of orthopaedics and giving birth to a new generation. British pride restored. My favourite, though, came from Ola Wiig, a personable and self-effacing Norwegian who wrote up their registry of Perthes’ disease and who turns out to be a keen road cyclist. He recounted the story of Tom Simpson, a British rider in the 1960s who had recently turned professional and taken his young family to live in France where he was competing in the Tour. Such was the pressure on him to perform that he found himself on the early, but nonetheless harsh, gradients of Mont Ventoux which he attacked with some vigour. Artificially fuelled by an unorthodox mix of brandy and


BJJ News

amphetamines, the result was predictable. Lesser known is that, as he lay doubled up and dying by the side of the road, his last words to supporters were “Put me back on the bike”. This type of spirit, Ola exhorted, might be required to maintain momentum within the IPSG in the months and years ahead. For the second time that evening I felt proud to be British. In a city made famous for shooting its own President I could not resist a visit, before the meeting started, to the Texas schoolbook depository. It is now a museum to that hideous event which took place just below the hairpin intersection of Elm and Main Streets around which JFK drove to his death. A more perfect amphitheatre for an assassination is hard to imagine. The road drops away from a cluster of low-rise buildings before the infamous, elevated ‘grassy knoll’ to one side and a railway bridge to the other. An impromptu street guide had introduced himself as a ‘no strings attached’ xenophile but left 30 minutes later with too many of my dollars in exchange for his views on the single bullet theory. He made a convincing case, however, that four separate vantage points harboured assassins that day and that Lee Harvey never touched his gun (at least not until later, to shoot a policeman). White crosses on the road mark the lethal spot. We strode from these across some 80 yards of grass to unmarked turf on which resided, so my new best friend insisted, the furthest flung chunks of JFK’s grey matter. At that moment it was hard to argue with his conspiracy viewpoint and I reluctantly parted with my banknotes. On, then, to the meeting, which began in earnest with a discussion of novel approaches to Perthes’ disease. These included perfusion MRI scanning for early diagnosis and prognosis, and bisphosphonates injected directly into the femoral head to protect against resorption and collapse. Harry Kim had also done a recent study of amputee, and therefore non-weight bearing, piglets whose surgically-induced Perthes’ disease fared better than their fourlimbed controls. I have relayed this particular piece of science a few times since to families but will probably discontinue that practice as the thread of relevance is sometimes misunderstood. As time passed, some momentum was lost in revisiting old ground such as comparisons of different containment procedures. We struggled,

at times, to find common ground in terms of indications for surgery. After a day and a half, the options for study were beginning to gravitate to the development of an international Perthes’ registry, which seemed rather a repetition of the existing data collection exercises and long since reported in the US and Norway, or a trial of different types of containment surgery. It was at this point, as heads and hearts were beginning to drop and images of a depleting Tom Simpson on Mont Ventoux flashed into my mind, that the excellent Andrew Howard from Toronto reached for the microphone and addressed the group. His eloquently elaborated view was that to consider containment surgery as a state of ‘equipoise’, ripe for expensive and timeconsuming clinical trials, was to totally miss the point. If there is a big benefit from containment we would have shown it by now. Major advances in orthopaedic surgery have not generally been made through clinical trials. He urged us instead to be braver, moving forward with novel treatments of injected bisphosphonates or bone anabolic agents to the forefront. To do this as part of a rigorous trial process would be nighon impossible against the barriers of risk-averse management, funding and ethical bodies. Rather it would take small groups within the IPSG to conduct careful case series from which to gather data about safety, feasibility and early efficacy. These should then be fed back to the group for consideration as to whether a study should be taken further. Although this viewpoint can be criticised on many levels, not least because it takes us back full circle to the orthopaedic stereotype of uncontrolled cases series, I found it really rather refreshing at this point. It was no surprise to learn that the members most commited to advancing the disease had already set out upon a similar path. It will be interesting to see how this relatively large group progresses. There is a general sense that multicentre studies, such as those conducted by the Canadian Orthopaedic Trauma Society, are the model towards which we should be working. There is a recently formed international group, similar to the IPSG, to advance research into DDH, and on which Professor Clarke also sits. Similarly, in the UK we have formed a SCFE study group, supported by ARUK, to frame and design studies around the important research questions for this condition.

Such groups initially generate more controversy than consensus and keeping discussions on track can be challenging. More than 12 months after this inaugural IPSG meeting we have reconvened twice and are making steady progress. The initial enthusiasm has not noticeably waned although, perhaps inevitably in so large a group, some individuals are more productive than others, corresponding usually with how strongly their viewpoints are reflected in the studies being prioritised. Ethical approval and preliminary funding for multicentre surgeon-randomised trials of containment and prolonged post-operative weight-bearing restriction are in place. Data on early perfusion MRI scanning for prognosis are being collected. Novel interventions remain a work in progress with continuing concerns about the inhibitory effects of bisphosphonates on osteoblasts and the exuberant ossification seen in animal models treated with BMP. Are the stated aims of this and similar groups the shape of the future? Participation in trials takes us out of our comfort zone when talking to families and admitting that our decision making sometimes boils down to chance. It will undoubtedly be ver y t ime-consuming. Blindingly obvious successes in surgery do not require a trial for proof, but examples of these are few. Funding bodies need to recognise and accept that surgeons, who are instinctively more pragmatic than academic, will often fall short of the highest methodological standards in conceiving surgical studies with a realistic chance of completion. Many experienced surgeons will stick with what they believe works in their hands, even in the face of so-called Level 1 evidence to the contrary: indeed it is a difficult to argue against this modus operandi. While I still have some coloured hairs amongst the receding grey I remain optimistic that these recently formed collaborative groups in children’s orthopaedics will find traction and in time report useful answers to important questions. I certainly hope so.

A uthor

details

Simon Thomas

Bristol Royal Children’s Hopsital, UK simon.thomas@uhbristol.nhs.uk

11


BJJ News  |  I ssue 2  |  M arch 2014

Consensus report

The infected knee replacement: international consensus and future trends

R. F. Kallala M. A. Khan R. Morgan-Jones F. S. Haddad

Report of a symposium held in Cardiff, 2013 he spectre of prosthetic joint

surgery. The national rate of infection following

of its evolution. Some of the answer lies in the

infection (PJI) is an increasingly

TKR is currently between 2% and 4%, with a lower

origins of antibiotics; produced by environmental

dif ficult challenge facing

rate of 0.2% quoted for specialist orthopaedic

moulds and fungi to kill bacteria, it is thought that

orthopaedic surgeons today and the

hospitals.8 Centralising revision procedures in SOHs

for every antibiotic in use or to be discovered there

most devastating both in terms of cost and patient

would result in a reduction in the rate of infection

already exists resistance to varying degrees between

outcome (Fig. 1). 1 Over 5,100 revision knee

with an associated cost-saving of £170 million per

bacteria. Greater selectivity in the use of antibiotics

procedures were recorded in the UK in 2011 with

year.8 Revision hip and knee procedures would

is required, as despite this increasing bacterial

infection accounting for 23% of cases.2 This increase

be the responsibility of surgeons undertaking a

resistance, development of newer antibiotic agents

is reflected globally with similar trends in the US,

minimum of 100 revision cases per year, with centre

is slowing down. Therefore prevention of infection

Nordic and Australasian national registries. 3,4 If

selection based on trust infection rates, NJR and

and tailoring antibiotic regimens to local patterns

projections prove to be correct, an estimated 3.48

litigation data. This would not only reduce the rate

of sensitivity is crucial.

million primar y knee replacements will be

of infection and its associated morbidity but also

performed in the US by the year 2030. The burden

allow for the procurement of revision equipment

DIAGNOSIS

of PJI associated revision is therefore likely to

as a network, saving further on costs.

Infection should be the main differential when

T

increase significantly over the coming years.5 The A N E V O LV I N G O R G A N I S M

replacement (TKR). High risk patients include

current treatment strategies and emerging

With improvements in theatre practice and national

those with diabetes, obesity, immunocompromise,

international consensus on the management of PJI.

campaigns on hand washing and reduction of

or inflammatory arthropathies. Patients will often

MRSA infection, the cohort of bacteria and pattern

complain that the knee was ‘never right’. Pain

THE ECONOMICS OF INFECTION

of resistance is changing. Although gram-positive

throughout the range of motion is a useful sign

The costs of revision surgery on the NHS are

bacteria are still the primary organisms responsible

and typically patients will complain of pain at night.

some of the least regulated in orthopaedics.

PJI, the incidence of candida, pseudomonas and

The wound must be thoroughly assessed for signs

The relatively low unit price quoted for primary

gram-negative infection is increasing. In addition,

of infection and inflammation. Fever is a common

procedures (bought in bulk by trusts) does

physicians are witnessing the emergence of

response to infection, and must not be confused

not extend to revision procedures. Smaller low

ever more resistant and virulent pathogens – an

with the physiological rise in temperature often

volume units often do not have revision kits ‘on

example being the inducible Amp C resistant

seen in the first five days after TKR.11 In our centre

the shelf’ and must hire them on a case-by-case

Serratia Marsecaans and Enterobacter. ‘Amp C’

any patient with a pyrexia beyond day five post-

basis which further adds to cost. The annual NHS

is a gene coding for a bacterial cephalosporinase

operatively or a leaking wound enters a protocol

musculoskeletal budget is currently £10 billion,

which will degrade cephalosporins, penicllins and

for further investigation (Table 1).

with musculoskeletal operations accounting for

related antibiotics and is produced in response to a

Osteolysis is visible on radiographs, particularly

25% of all hospital procedures and 80% of costs

specific antibiotic substrate. Unlike other methods of

at the medial plateau, but this a late sign and not

attributable to the provision of care.6,7 There has

resistance acquisition, this trait is not acquired, but is

useful as an early screening tool. To date there

been an exponential increase in the number of

part of the bacterial genetic code, merely repressed

is no single ‘best test’ and, as such, diagnosis

primary total hip and knee replacements performed

when not needed. A further example is the normally

relies on a ‘weight of evidence’ approach. The

in the UK, with a commensurate increase in revision

controllable bacterium E Coli, which was recently

announcement by the American Association of

procedures. Registry data shows a 92% increase in

found to have developed a highly virulent, multi-

Orthopaedic Surgeons (AAOS) of guidelines for

the number of revisions for TKR in the last 5 years,

drug resistant strain. Extended spectrum beta

the diagnosis of PJI aims to establish standard

with the cost of procedures now reaching up to

lactamase (ESBL) E.coli, is a cefotaximase producing

diagnostic criteria.12 However, the uncertainties

£75,000 per case.

Although a substantial amount

bacterium capable of destroying every class of

often encountered in clinical practice mean that

is associated with inpatient length of stay and ward

antibiotic except the carbopenems. Worryingly,

surgeons will have differing criteria for defining

based care, it is the responsibility of surgeons to

there is now evidence that ESBL is developing

infection and indeed these vary from hospital to

take early measures to curb this ballooning expense.

immunity to this class of antibiotic as well.10 It is

hospital. Increasingly, joint aspiration is considered

One such measure has been the recent proposal of

not entirely clear why or how an environmental

the closest we have to a ‘gold-standard’, whether

a network of specialist orthopaedic hospitals (SOH)

bacterium would retain a gene coding for a hitherto

to detect intra articular C-reactive protein (CRP)

responsible for revision and complex arthroplasty

only recently used antibiotic over millions of years

or cell counts.13,14 Della Valle et al compared cell

2,8,9

12

investigating a painful primar y total knee

aim of this paper is to provide an overview of


BJJ News

Current recommendations support the use of a glycopeptides such as Vancomycin, or Teicoplainin in MRSA positive patients. However, evidence is still sparse in terms of which antibiotic carries the greater advantage and if there is merit in adding a cephalosporin.28,29 Research suggests that the effect of preoperative antibiotics on false negative results from samples obtained intra-operatively is minimal. Prophylactic antibiotics reduce infection risk without compromising the yield from harvested cultures; therefore standard use of prophylactic antibiotics is recommended.30 It was agreed that all patients should be screened pre-operatively for both MRSA and Staph. aureus and that mupirocin treatment should be used in identified carriers.

counts from aspirations of knees with suspected acute infection with findings at surgery.15 Significant differences in white cell counts with percentage of neutrophils were found between infected and non-infected knees. A synovial fluid white blood cell (WBC) count greater than 3000/uL was the most precise test; with a sensitivity of 100%, specificity of 98%, and accuracy of 99%.15 When joint aspirates are combined with intraoperative samples, a multicentre study by Parvizi et al reported 100% specificity and 100% positive predictive value.16 Mean values of 85 mm/hr for erythrocyte sedimentation rate (ESR) and 110mg/L for CRP were found in patients with infected TKR’s but it is important to bear in mind that 4% of infected patients had a normal ESR (< 20 mm/hr) and CRP (< 5 mg/L). As a result, current consensus is that in the painful primary TKR with elevated serum

A biological seal

ESR and CRP, articular aspirations should be taken for both CRP and white cell count and that these

The use of sutures for wound closure is

combined with tissue samples results in the best

recommended over metal clips, with the use of clips

chance of diagnosis.17 Leukocyte esterase strips,

associated with a lower patient satisfaction, and a

ASO titres and lipid S have all been proposed as

four-fold increase in infection rates.31 Some surgeons

future tests but at present are more commonly used

now advocate the use of haemostatic, bactericidal

Fig. 1a

as research tools than in clinical practice.18 Frozen

and bacteriostatic properties of cyanoacrylate

section, especially when combined with other

adhesive for sealing wounds in addition to suture

diagnostic modalities is a useful tool, but there is

closure. 32-34 Its impact on the duration of the

significant inter-observer variability, with results

procedure is minimal. However, cost is an issue,

depending on subjective decisions made in the

with the use of cyanoacrylate adhesive incurring

laboratory.19-21 Nuclear medicine is of limited use

an extra £20 to £30 per case. In addition there

since bone scintigraphy alone cannot distinguish

have been reports of allergic reactions as well as

between infection and aseptic loosening.22,23 The

a prolonged drying time if an excess of adhesive

role of the multi-disciplinary team (MDT) is crucial

is applied.

for successful treatment, with close collaboration

Top tips: The Morgan-Jones Approach

between microbiologists and the surgical team essential for co-ordinating sampling, diagnosis

Rhidian Morgan-Jones from Cardiff presented his

and treatment.

experience of revision knee surgery, recommending a multi-faceted approach. Instead of advocating a

PREVENTION BETTER THAN CURE.

single strategy, several approaches in combination

Antibiotic prophylaxis

are needed to minimise the risk of infection

The importance of antibiotic prophylaxis at

following TKR. Preventative measures such as

anaesthetic induction was reiterated and is based

alcohol hand rubs between hand washes35 and

on the original research by Burke et al in 1961

surgical site cleaning in the anaesthetic room with

demonstrating the relationship between timing of

alcoholic chlorhexidine were described, as well as

antimicrobial administration and the effectiveness of

a plea against the use of forced air warming. 36

prophylaxis in animals. Later research by Classen

Importantly, a closed-door policy was advised

et al demonstrated that antibiotic prophylaxis

during procedures, critically as the prosthesis is

administered two hours pre-operatively reduced the

implantated, something echoed by all members of

rate of infection by 81%.25 The most recent literature

the faculty.37 The use of tourniquets is generally to

24

reviews show maximal effects if prophylaxis is

be avoided but if used, disposables were advocated

Fig. 1b

administered within 60 minutes of skin incision and continued for the first 24 hours post-operatively.

Thus, as is common across the UK, the practice of ‘one dose pre- and two post-’ is appropriate and evidence-based. A further dose is recommended when surgery lasts greater than four hours, or there is a greater than 1.5 litre blood loss.27

during revision surgery.38 In addition, the routine use of 1 gram of intravenous (IV) transexamic acid

26

Fig. 1 A 79-year-old with discharging sinus after a failed two-stage revision for infection.

at the star t and end of a procedure was recommended with the aim of reducing haematoma formation and subsequent infection. Suturing of the capsule was described, using two continuous sutures overlapping in the central section, ►

13


BJJ News  |  I ssue 2  |  M arch 2014

thereby minimising knotting, preferably with

centre, patients complete a five day post-op course

single- and two-stage revision.47-49 The consensus

absorbable, antibiotic-eluting sutures. A case was

of IV teicoplainin whilst tissue cultures are awaited.

from the faculty, including international speakers,

made for not disturbing wound dressings within

Once microbial sensitivities are available, a six week

was that in selected patients single stage revision

the first ten days post-operatively, with the use of a

course of IV antibiotics is commenced. These are

is a valid treatment choice, with clear economic

front-slab to prevent interference in wounds where

then stopped and serum inflammatory markers

and functional advantages (Table 4). However,

compromised healing is anticipated.

monitored.

in complex patients, two-stage revisions with

The timing of the second procedure is

Surgical Options

controversial. However an interval of between six

surgical management.

With regard to debridement, antibiotics and

and eighteen weeks between stages is advocated.

implant retention (DAIR), William Jackson presented

Some studies report a lower recurrence rate of

T H E I N T E R N AT I O N A L V I E W

findings from the Nuffield Hospital in Oxford.

9-14% if the second procedure occurs at six weeks

H e i ko G ra i c h e n ( R e g e n s b u rg ) d i s c u s s e d

Their study compared outcomes following DAIR

as opposed to 22% at 22 weeks, but the timing of

management in Germany. Although centres

in age and co-morbidity matched cohorts with

the second procedure remains debatable.41-43 It is

such as the EndoKlinik overwhelmingly use

controls. Their treatment protocol relied on an

generally agreed that serum ESR, CRP and WCC

single-stage revision in suitable patients, the

expert surgical debridement and up to one year of

must be within normal limits before proceeding

economic and legal emphasis for much of the

antibiotic therapy. This as yet unpublished study

to the second stage. Although widely accepted,

rest of Germany is on two-stage revision. As yet

demonstrates that DAIR is a viable treatment option

there are several problems arising from two-stage

there is no defined guidance on the management

with an 89% success rate at one year. Functionally,

procedures. Foremost is the poor clinical function

of PJI and treatment protocols vary from hospital

DAIR outcomes were similar to primary non-infected

of the joint between stages, with unstable spacers

to hospital, although consensus is emerging and

cases, but ten year mortality (42%) and revision

leading to inflammation and rendering eradication

largely supports the recommendations of the

rates (16%) were high.

of infection difficult. Depending on whether

musculoskeletal infection society.50

articulating or fixed spacers are used, there can be

David Dalury (Baltimore, USA) presented the

difficulty with joint stiffness and in regaining length

US perspective and interestingly supported many

The aim of revision surger y is to eradicate

at the second procedure.40 Lastly, the prolonged

of the opinions expressed at the meeting. There

infection, ensure a durable fixation and restore

inpatient stay and resulting increase in morbidity

is increasing emphasis on prevention of PJI and

knee function. Currently, a two-staged revision

and cost are other significant factors associated with

control of risk factors, including less well recognised

with an antibiotic loaded spacer is the gold

the two stage technique.44

contributors such as malnutrition and anaemia.

Two-stage revision

standard, with a success rate of between 85% and 100%.39 The principles underpinning successful

Frequently unrecognised, particularly in revisions,

“2-in-1” stage revision

malnutrition should be assessed pre-operatively by

treatment are radical debridement and removal

Richard Parkinson from the Wirral University

measuring serum transferrin and albumin. Anaemia

of all necrotic tissues, prostheses and cement,

Teaching Hospital presented his experience with

was highlighted as an important factor in a paper

which are sent for microbiology. The importance

the ‘2 in 1’ method (Table 2), reporting on 20

by Greenky et al 2012 in which anaemic patients

of a thorough debridement was stressed, with the

patients who had undergone the procedure. At

experienced a statistically significant increased

recommendation that the debriding surgeon be

a minimum of 12 months follow up, all patients

length of hospital stay following arthroplasty. 51

present at the second stage procedure, therefore

were cured of infection, with excellent relief of pain

Interestingly, many of the opinions expressed by

providing insight into the amount of bone loss, soft

and good function, demonstrating significantly

the faculty were supported by the US perspective,

tissue cover and joint stability.

improved WOMAC scores. The advantage of this

with an emphasis on minimising surgical time

A repeated cycle of curettage, intramedullary

single longer procedure is a reduced length of

and a ‘closed-door’ policy being repeated. This is

reaming and pulse or carbon dioxide lavage

hospital stay and cost, avoiding the morbidity

supported in a paper by Panahi et al 2012, where

is advocated, with more radical debridement

associated with the use of cement interval spacers

foot traffic was found to disrupt airflow, increasing

involving osteotomy of the tibial crest. Pulse lavage

and two staged procedures.45

infection risk. Average door-openings were 60 times

should continue until tissue membranes become oedematous, allowing for easier subsequent

14

antibiotic eluting spacers remains the mainstay of

during primary joint replacement and 135 in revision

Single-stage revision

cases, approaching 20 minutes of total open door

removal with a scalpel. An antibiotic-eluting

The single stage revision procedure popularised

time.37 Wound irrigation with pulse-lavage was

spacer, articulating or not, should be used to

by the Endo-Klinik in Hamburg,

relies on the

advocated as a preventative measure and when

deliver antibiotics locally at concentrations above

same principles used in two-stage procedures;

combined with diluted betadine solution of 0.35%

the minimum inhibitory concentration (MIC)

that of adequate debridement and peri-operative

had been shown to decrease infection rates from

of infective bacteria. Clinically, cement spacers

antibiotic therapy, but with shorter inpatient

0.97% to 0.15%.52 The overwhelming majority of

maintain leg-length, minimising shortening as a

stays and decreased cost. Contraindications to

revision procedures for PJI in the US are two-staged,

result of soft tissue contractures. The choice of an

single stage revision are summarised in Table 3.44

with only a limited number of surgeons offering

articulating versus static spacer is controversial,

Rhidian Morgan-Jones reported his experience of

single-stage revision.

as is the duration of post-operative antibiotic

single stage revision with a consecutive series of

treatment. Typically, intra-operatively implanted,

49 patients. At a mean follow up of 25 months,

P O LY M E T H Y L M E T H A C R Y L AT E

articulating cement spacers such as the PROSTALAC

91.5% of patients were free of infection. Further

(PMMA) CEMENT

system (De Puy, Warsaw, Indiana) are used with a

support from the literature comes from studies

The low cost, availability and familiarity of PMMA

combination of vancomycin and gentamicin to

demonstrating promising ten year infection-

cement makes it an attractive option for use

cover for the most common pathogens.40 At our

free rates and no difference in infection between

in reconstruction following debridement. The

46


BJJ News

additional benefits of antibiotic delivery and

demonstrated excellent tibial bone integration

and revision procedures and mostly involving

reduced fracture risk in porotic bone mean that the

with tantalum cones over time; hoop stresses

retrospective data from old studies. Bengtson and

majority of revision knee procedures involve either

are generated when tantalum is loaded and its

Knutson68 in 1991 used systemic antibiotics alone

fully cemented or hybrid implants.

porous nature allows for bony ingrowth.

62-64

to eradicate infection in knee arthroplasty patients

supported its use for antibiotic delivery and as an

Sleeves as a modular option designed to deal with

and reported a 19% eradication rate. The main

augment in small bone defects less than 5mm, with

metaphyseal bone loss in femurs and tibiae can

factor preventing successful eradication with this

or without bone graft.55

achieve cementless fixation over a relatively wide

treatment method is the production of a biofilm by

area 65 and early experience has demonstrated

bacteria, which forms between 36 hours and three

M E TA P H Y S E A L C O N E S A N D

good short-term outcomes. 66,67 The unique

weeks post operatively.69

SLEEVES

stepped metaphyseal components compensate

Lee Jeys from the Royal Orthopaedic Hospital

for substantial defects, compressively loading the

TUMOUR PROSTHESIS

Birmingham presented his experience with

bone and provide a strong foundation for implant

Tim Briggs (Royal National Orthopaedic Hospital

metaphyseal cones and their increasing use in

stability.67 Furthermore, the combination of trays,

Stanmore) described the use of custom-made

revision knee surgery.56 Cones are designed to

augments and stem options allows the surgeon to

hinged cement spacers70 and the endoprostheses

transfer load from a deficient plateau to the shaft,

preserve the patient’s natural joint line and gain

for the definitive second stage. 71 The Stanmore

replacing metaphyseal bone, and are independent

implant stability regardless of bone quality.

Modular Individualised Lower Extremity System

53,54

The faculty

of the stem. Traditionally, tibial defects have been treated with bone graft in the form of allograft or impaction grafting,57-60 or tumour endoprostheses.

(SMILES) consists of a custom made rotating hinged S A LV A G E

Suppression not recommended

knee joint and is used in patients with severe bone loss or ligamentous instability following infection

All these techniques have good midterm outcomes,

The role of suppression in the management

in primary knee replacement or tumour resection.

but there are concerns regarding graft disease

of infected TKR is limited, with the faculty

It is offered as a preferable alternative to arthrodesis

transmission, immune reaction to allograft, graft

recommending its use only in patients with a well-

and amputation and is demonstrating promising

resorption and the inability to modify the construct

fixed prosthesis, who were not fit for surgery and

results with statistically significant improvements

intraoperatively. Trabecular metal addresses

infected with an organism of low virulence. Current

in knee society scores and no evidence of loosening

these concerns and has a growing pedigree in

evidence on the use of suppression is poor with

five years post procedure. 71 It provides several

revision knee surgery. Indeed, DEXA studies have

studies often combining hips and knees, primary

advantages allowing for use in combination ►

61

Table 1

Table 3

Table 5

Diagnostics

Relative contraindications to single

Arthrodesis

• • •

Serum WWC, ESR and CRP

stage revision

Indications

If serum ESR & CRP raised aspirate joint

Local

Send aspirate for white cell count,

neutrophil fraction and CRP

significant soft tissue compromise bone

Significant bone loss, disruption / loss of extensor mechanism or extensive skin

loss precluding cemented reconstruction

soft tissue loss

Take multiple, odd numbers of

intraoperative speciments for culture and

Host

frozen section

• •

immunocompromise or suppression concurrent sepsis

• •

systemic disease

Relative contraindications

reinfection MRSA / MRSE

• • •

Polymicrobial infection

Absolute contraindications

Atypical commensals/resistance/infective

• • •

2-3 positive samples required to confirm diagnosis of infection

Table 2

“Two-in-one” stage revision First stage:

peripheral vascular disease

Explant prosthesis

organisms

Debride and irrigate Close wound and bandage

Immunocompromised, chronic infection, recurrent deep infection, failure of

Organism

• • •

previous treatment High demand younger patient Continued infection Social needs e.g. driving and travel Osteoarthritis affecting contralateral knee Ipsilateral hip or ankle osteoarthritis Contralateral limb amputation Large segmental bone loss

Table 4 Table 6

Deflate torniquet 15 to 20 minute interval

Patient criteria for single stage revision

• • •

No immuno-compromise

Patient healing capacity

Second stage:

Healthy soft tissues

Type A = normal

Minimal / moderate bone loss

Type B = locally or systemically compromised

• • •

Organism known

wound (diabetes, obesity)

Sensitivities known

Type C = severely compromised healing (life-

Appropriate antibiotic(s) available

threatening infection, multiple failed revisions,

New instruments New drapes

• •

Re-inflate torniquet Implant revision prosthesis

low chance of successful healing)

15


BJJ News  |  I ssue 2  |  M arch 2014

with cones or sleeves. Further development of the

loss, it should be fused in 15°of flexion to allow toe

silver-coated prostheses and the practice of single

system has yielded a new silver coated design with

clearance during the swing phase of gait. If there

stage revision in appropriate patients were

enhanced antibacterial properties. This novel

is more than 3cm of shortening arthrodesis should

supported by the faculty. However, two stage

surface modification is being used in tumour and

be in extension, taking care to ensure correct

procedures still remain the gold standard in the

non-tumour implants to treat and prevent deep-

rotation and 5-7° valgus in all cases. One of the main

majority of patients.

seated infection. Silver exhibits bactericidal

difficulties associated with arthrodesis is achieving

properties, low toxicity and prevents the formation

sufficient bony contact and compression. Therefore,

of a biofilm.72 A prospective case-control study

in cases with less than 50% contact area the use

comparing the use of silver coated mega-prostheses

of autologous bone grafting is recommended to

with non-coated implants in infection is currently

try to achieve bony fusion. Another significant

underway at Stanmore, with preliminary results

problem is leg shortening and if this is clinically

demonstrating a statistically significant reduction

significant, distraction osteogenesis may be used

in CRP immediately after surgery and good

to achieve equal leg length. Despite these measures

functional outcome at six month follow-up

patient satisfaction remains poor and arthrodesis is

(personal communication).

generally not well tolerated.

A uthor

details

Rami F. Kallala Muhammad A. Khan Rhidian Morgan-Jones

Fares. S. Haddad University College Hospital London, UK rami.kallala@gmail.com AC K N OW L E D G E M E NT S : Dave Barrett (Southampton), Ivan Brenkel (Fife), Tim Briggs

A R T H R O D E S I S A N D A M P U TAT I O N

Amputation There are approximately 6000 major limb

(Newcastle), Heiko Graichen (Regensburg, Germany),

revision attempts remain ar throdesis and

amputations carried out in the UK every year, with

Alberto Gregori (East Kilbride), Fares Haddad (London),

amputation. Although arthrodesis is still preferable

70% of all lower limb amputations being performed

Brendan Healy (Cardiff), Will Jackson (Oxford), Peter James

to amputation, changes in public perception mean

for critical ischaemia.84 Patients with diabetes are

(Nottingham), Lee Jeys (Birmingham), Rhidian Morgan

that amputation is increasingly an acceptable

fifteen times more likely to need an amputation

Jones (Cardiff), Richard Parkinson (Wirral), Andrew

outcome. The opinion of Wade in 1984 that “it is

than the general population and 50% of all

Porteous (Bristol), Andrew Price (Oxford), Richard Spencer-

generally agreed that arthrodesis is preferable to

amputations are in the over 70s, with men twice as

Jones (Oswestry), Ian Stockley (Sheffield), Andrew Toms

amputation or to the long term use of a caliper” is

likely to need one as women.84 Despite changing

(Exeter), Rob Townsend (Sheffield), HartleyTaylor Medical

no longer necessarily the case, and the increasing

perceptions in the general population, amputation

Communications.

function of amputees is exemplified by charities

remains a devastating complication following TKR

such as “Help For Heroes” and the London 2012

and one that is associated with significant disability

References

Paralympics.

and morbidity.85 The overall risk of an above knee

1. Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS.

amputation (AKA) following TKR is low (0.14% and

A financial analysis of revision hip arthroplasty: the economic

0.36%).85,86 Poor function in patients with an AKA

burden in relation to the national tariff. J Bone Joint Surg [Br]

Arthrodesis represents a small proportion of the

is linked to a shorter stride length, greater energy

2012;94-B:619-623.

total number of patients who undergo revision

requirements and overall slower cadence.87 As a

2. No authors listed. National Joint Registry for England and

knee arthroplasty; therefore studies on the subject

result, independent function is seldom attained,

Wales, 2012. www.njrcentre.org.uk

are usually under powered and retrospective. By

with 50% of patients confined to a wheelchair

3. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee

the time patients require an arthrodesis, they are

following AKA for infected TKR.88 The key factor

arthroplasty volume, utilization, and outcomes among medicare

often in poor health and suffering from multiple

in determining suitability is the patient’s healing

beneficiaries, 1991-2010. JAMA 2012;308:1227-1236.

co-morbidities which probably contributed to the

potential, and amputations are not recommended

4. Robertsson O, Bizjajeva S, Fenstad AM, et al. Knee arthroplasty

original failure; consequently outcomes are poor.

in type C patients (Table 6).

in Denmark, Norway and Sweden. Acta Orthop 2010;81:82-89.

such as serum albumin are useful in determining

R E C O M M E N D AT I O N S

primary and revision hip and knee arthroplasty in the United

the patient’s nutritional state. The indications for

The faculty called for international collaboration

States from 2005 to 2030. J Bone Joint Surg [Am] 2007;89-A:780-

arthrodesis are summarised in Table 5, and include

between joint registries, with greater integration in

785.

significant bone loss, chronic infection and loss of

the way data is collected to allow for easier

6. No authors listed. Healthy & Social Care Information Centre.

the extensor mechanism e.g. through quadriceps

amalgamation of registry data.89 There was a call

Hospital Episode Statistics. www.hesonline.nhs.uk

tethering. Various techniques have been used to

for greater international consensus on strategies for

7. No authors listed. Statistics OfN. Health Resource Allocation.

achieve arthrodesis, with rates of union ranging

diagnosis and therapy for PJI, which the AAOS

UK: National Audit Office.

from 29% to 100%.68, 73-76 Uni-planar external fixation

guidelines go some way to address. However, more

8. Briggs TW. Getting it right the first time. Improving the quality

is the least successful technique, with rates of union

ef fort should go into broader preventative

of orthopaedic care within the National Health Service in England.

as low as 29% reported,75 whereas intramedullary

measures, such as an internationally agreed

UK: NHS, 2012.

nailing is the most successful, with reported

protocol for pre-operative prophylaxis in knee

9. Oduwole KO, Molony DC, Walls RJ, Bashir SP, Mulhall KJ.

rates of fusion between 88% and 100%.77-80 An

arthroplasty. The faculty endorsed the principle of

Increasing financial burden of revision total knee arthroplasty.

intramedullary nail, however, should only be used

revision surgery being undertaken in high volume

Knee Surg Sports Traumatol Arthrosc 2010;18:945-948.

after the infection has been satisfactorily treated.81-83

centres by experienced surgeons and strongly

10. Rawat D, Nair D. Extended-spectrum β-lactamases in Gram

The interval between removal of a prosthesis and

recommended the formation of MDTs specifically

Negative Bacteria. 2010;2:263-274.

resolution of infection may be as much as 40 weeks.

for the purpose of infection post arthroplasty. The

11. Shaw JA, Chung R. Febrile response after knee and hip

If the indicated limb is mostly intact with little bone

gradual incorporation of new technologies such as

arthroplasty. Clin Orthop Relat Res 1999:181-189.

Arthrodesis

Peri-operative health must be optimised and markers

16

(London), David Dalury (Baltimore, USA), David Deehan

The final options in the management of failed

5. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of


BJJ News 12. Parvizi J, Della Valle CJ. AAOS Clinical Practice Guideline: diagnosis and treatment of periprosthetic joint infections of the hip and knee. J Am Acad Orthop Surg 2010;18:771-772. 13. Parvizi J, McKenzie JC, Cashman JP. Diagnosis of periprosthetic joint infection using synovial C-reactive protein. J Arthroplasty. 2012 Sep;27(Suppl):12-16. 14. Parvizi J, Jacovides C, Adeli B, Jung KA, Hozack WJ. Mark B Coventry Award: synovial C-reactive protein: a prospective evaluation of a molecular marker for periprosthetic knee joint infection. Clin Orthop Relat Res 2012;470:54-60. 15. Della Valle CJ, Sporer SM, Jacobs JJ, et al. Preoperative testing for sepsis before revision total knee arthroplasty. J Arthroplasty 2007;22(Suppl):90-93. 16. Parvizi J, Ghanem E, Sharkey P, et al. Diagnosis of infected total knee: findings of a multicenter database. Clin Orthop Relat Res 2008;466:2628-2633. 17. Bedair H, Ting N, Jacovides C, et al. The Mark Coventry Award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res 2011;469:34-40. 18. Wetters NG, Berend KR, Lombardi AV, et al. Leukocyte esterase reagent strips for the rapid diagnosis of periprosthetic joint infection. J Arthroplasty 2012;27(Suppl):8-11. 19. Tsaras G, Maduka-Ezeh A, Inwards CY, et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg [Am] 2012 19;94-A:1700-1711. 20. Aggarwal VK, Tischler E, Ghanem E, Parvizi J. Leukocyte esterase from synovial fluid aspirate: a technical note. J Arthroplasty 2013;28:193-195. 21. Meermans G, Haddad FS. Is there a role for tissue biopsy in the diagnosis of periprosthetic infection? Clin Orthop Relat Res 2010;468:1410-1417. 22. Love C, Tomas MB, Marwin SE, Pugliese PV, Palestro CJ. Role of nuclear medicine in diagnosis of the infected joint replacement. Radiographics 2001;21:1229-1238. 23. Love C, Marwin SE, Palestro CJ. Nuclear medicine and the infected joint replacement. Semin Nucl Med 2009;39:66-78. 24. Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50:161-168. 25. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-286. 26. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283. 27. Nagasao T, Ogata H, Miyamoto J, et al. Alveolar bone grafting for patients with unilateral complete alveolar and palatal clefts improves the bony structure of the nose. Cleft Palate Craniofac J 2009;46:9-18. 28. Smith EB, Wynne R, Joshi A, Liu H, Good RP. Is it time to include vancomycin for routine perioperative antibiotic prophylaxis in total joint arthroplasty patients? J Arthroplasty 2012;27(Suppl):55-60. 29. Periti P, Stringa G, Mini E. Comparative multicenter trial of teicoplanin versus cefazolin for antimicrobial prophylaxis in prosthetic joint implant surgery: Italian Study Group for Antimicrobial Prophylaxis in Orthopedic Surgery. Eur J Clin Microbiol Infect Dis 1999;18:113-119.

30. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty: The OSIRIS Collaborative Study Group. J Clin Microbiol 1998;36:2932-2939. 31. Smith TO, Sexton D, Mann C, Donell S. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ 2010;340:c1199. 32. Howell JM, Bresnahan KA, Stair TO, Dhindsa HS, Edwards BA. Comparison of effects of suture and cyanoacrylate tissue adhesive on bacterial counts in contaminated lacerations. Antimicrob Agents Chemother 1995;39:559-560. 33. Rocos B, Blom AW, Bowker K. Cyanoacrylate dressings: are they microbiologically impermeable? J Hosp Infect 2010;75:144-145. 34. Romero IL, Malta JB, Silva CB, et al. Antibacterial properties of cyanoacrylate tissue adhesive: Does the polymerization reaction play a role? Indian J Ophthalmol 2009;57:341-344. 35. Parienti JJ, Thibon P, Heller R, et al. Handrubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30day surgical site infection rates: a randomized equivalence study. JAMA 2002;288:722-727. 36. McGovern PD, Albrecht M, Belani KG, et al. Forced-air warming and ultra-clean ventilation do not mix: an investigation of theatre ventilation, patient warming and joint replacement infection in orthopaedics. J Bone Joint Surg [Br] 2011;93-B:1537-1544. 37. Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS. Operating room traffic is a major concern during total joint arthroplasty. Clin Orthop Relat Res 2012;470:2690-2694. 38. Thompson SM, Middleton M, Farook M, et al. The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery. Ann R Coll Surg Engl 2011;93:589-590. 39. Vanhegan IS, Morgan-Jones R, Barrett DS, Haddad FS. Developing a strategy to treat established infection in total knee replacement: a review of the latest evidence and clinical practice. J Bone Joint Surg [Br] 2012;94-B:875-881. 40. Haddad FS, Masri BA, Campbell D, et al. The PROSTALAC functional spacer in twostage revision for infected knee replacements: prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg [Br] 2000;82-B:807-812. 41. Lieberman JR, Callaway GH, Salvati EA, Pellicci PM, Brause BD. Treatment of the infected total hip arthroplasty with a two-stage reimplantation protocol. Clin Orthop Relat Res 1994;301:205-212. 42. Colyer RA, Capello WN. Surgical treatment of the infected hip implant: two-stage reimplantation with a one-month interval. Clin Orthop Relat Res 1994;298:75-79. 43. Toms AD, Davidson D, Masri BA, Duncan CP. The management of peri-prosthetic infection in total joint arthroplasty. J Bone Joint Surg [Br] 2006;88-B:149-155. 44. Oussedik SI, Dodd MB, Haddad FS. Outcomes of revision total hip replacement for infection after grading according to a standard protocol. J Bone Joint Surg [Br] 2010;92-B:12221226. 45. Mereddy P, Pydisetty R, Howard K, Kay PR, Parkinson RW. “2-in-1” single stage revision for infected total knee replacaement: the Wirral And Wrightington experience. Paper presented at: BOA Annual Meeting, Liverpool 2008.

46. von Foerster G, Kluber D, Kabler U. Midto long-term results after treatment of 118 cases of periprosthetic infections after knee joint replacement using one-stage exchange surgery. Orthopade 1991;20:244-252 (in German). 47. Buechel FF. The infected total knee arthroplasty: just when you thought it was over. J Arthroplasty 2004;19(Suppl):51-55. 48. Bauer T, Piriou P, Lhotellier L, et al. Results of reimplantation for infected total knee arthroplasty: 107 cases. Rev Chir Orthop Reparatrice Appar Mot 2006;92:692-700 (in French). 49. Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res 2002;404:125-131. 50. Workgroup Convened by the Musculoskeletal Infection Society. New definition for periprosthetic joint infection. J Arthroplasty 2011;26:1136-1138. 51. Greenky M, Gandhi K, Pulido L, Restrepo C, Parvizi J. Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 2012;470:2695-2701. 52. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty 2012;27:27-30. 53. Sah AP, Shukla S, Della Valle CJ, Rosenberg AG, Paprosky WG. Modified hybrid stem fixation in revision TKA is durable at 2 to 10 years. Clin Orthop Relat Res 2011;469:839-846. 54. Fehring TK, Odum S, Olekson C, et al. Stem fixation in revision total knee arthroplasty: a comparative analysis. Clin Orthop Relat Res 2003;416:217-224. 55. Hanna SA, Aston WJ, de Roeck NJ, GoughPalmer A, Powles DP. Cementless revision TKA with bone grafting of osseous defects restores bone stock with a low revision rate at 4 to 10 years. Clin Orthop Relat Res 2011;469:3164-171. 56. Villanueva-Martínez M, De la TorreEscudero B, Rojo-Manaute JM, Ríos-Luna A, Chana-Rodriguez F. Tantalum cones in revision total knee arthroplasty: a promising shortterm result with 29 cones in 21 patients. J Arthroplasty 2013;28:988-993. 57. Bradley GW. Revision total knee arthroplasty by impaction bone grafting. Clin Orthop Relat Res 2000;371:113-118. 58. Lotke PA, Carolan GF, Puri N. Impaction grafting for bone defects in revision total knee arthroplasty. Clin Orthop Relat Res 2006;446:99-103. 59. Clatworthy MG, Ballance J, Brick GW, Chandler HP, Gross AE. The use of structural allograft for uncontained defects in revision total knee arthroplasty: a minimum five-year review. J Bone Joint Surg [Am] 2001;83-A:404411. 60. Engh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg [Am] 2007;89-A:2640-2647. 61. Long WJ, Scuderi GR. Porous tantalum cones for large metaphyseal tibial defects in revision total knee arthroplasty: a minimum 2-year follow-up. J Arthroplasty 2009;24:1086-1092. 62. Meneghini RM, Lewallen DG, Hanssen AD. Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement: surgical technique. J Bone Joint Surg [Am] 2009;91-A(Suppl):131-138.

63. Findlay DM, Welldon K, Atkins GJ, et al. The proliferation and phenotypic expression of human osteoblasts on tantalum metal. Biomaterials 2004;25:2215-2227. 64. Welldon KJ, Atkins GJ, Howie DW, Findlay DM. Primary human osteoblasts grow into porous tantalum and maintain an osteoblastic phenotype. J Biomed Mater Res A 2008;84:691-701. 65. Azam A, Agarwal S, Morgan-Jones RL. Use of metaphyseal sleeves in revision total knee replacement. J Bone Joint Surg [Br] 2012;94-B(Suppl XXIX):86. 66. Alexander GE, Bernasek TL, Crank RL, Haidukewych GJ. Cementless metaphyseal sleeves used for large tibial defects in revision total knee arthroplasty. J Arthroplasty 2013;28:604-607. 67. Ahmed I, Maheshwari R, Walmsley P, Brenkel I. Use of porous stepped metaphyseal sleeves during revision total knee arthroplasty. J Bone Joint Surg [Br] 2012;94-B(Suppl XXIX):55. 68. Bengtson S, Knutson K. The infected knee arthroplasty: a 6-year follow-up of 357 cases. Acta Orthop Scand 1991;62:301-311. 69. Gulhane S, Vanhegan IS, Haddad FS. Single stage revision: regaining momentum. J Bone Joint Surg [Br] 2012;94-B(Suppl):120-122. 70. Macmull S, Bartlett W, Miles J, et al. Custom-made hinged spacers in revision knee surgery for patients with infection, bone loss and instability. Knee 2010;17:403-406. 71. Back DL, David L, Hilton A, et al. The SMILES prosthesis in salvage revision knee surgery. Knee 2008;15:40-44. 72. Zhao J, Feng HJ, Tang HQ, Zheng JH. Bactericidal and corrosive properties of silver implanted TiN thin films coated on AISI317 stainless steel. Surf Coat Tech 2007;201:5676-5679. 73. Bose WJ, Gearen PF, Randall JC, Petty W. Long-term outcome of 42 knees with chronic infection after total knee arthroplasty. Clin Orthop Relat Res 1995;319:285-296. 74. Hagemann WF, Woods GW, Tullos HS. Arthrodesis in failed total knee replacement. J Bone Joint Surg [Am] 1978;60-A:790-794. 75. Stulberg SD. Arthrodesis in failed total knee replacements. Orthop Clin North Am 1982;13:213-224. 76. Oostenbroek HJ, van Roermund PM. Arthrodesis of the knee after an infected arthroplasty using the Ilizarov method. J Bone Joint Surg [Br] 2001;83-B:50-54. 77. Lai KA, Shen WJ, Yang CY. Arthrodesis with a short Huckstep nail as a salvage procedure for failed total knee arthroplasty. J Bone Joint Surg [Am] 1998;80-A:380-388. 78. Puranen J, Kortelainen P, Jalovaara P. Arthrodesis of the knee with intramedullary nail fixation. J Bone Joint Surg [Am] 1990;72:433-442. 79. Vlasak R, Gearen PF, Petty W. Knee arthrodesis in the treatment of failed total knee replacement. Clin Orthop Relat Res 1995;321:138-144. 80. Wilde AH, Stearns KL. Intramedullary fixation for arthrodesis of the knee after infected total knee arthroplasty. Clin Orthop Relat Res 1989;248:87-92. 81. Petty W, Bryan RS, Coventry MB, Peterson LF. Infection after total knee arthroplasty. Orthop Clin North Am 1975;6:1005-1014. 82. Donley BG, Matthews LS, Kaufer H. Arthrodesis of the knee with an intramedullary nail. J Bone Joint Surg [Am] 1991;73-A:907-913. 83. Rand JA. Alternatives to reimplantation for salvage of the total knee arthroplasty complicated by infection. J Bone Joint Surg [Am] 1993;75-A:282-289.

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BJJ News  |  I ssue 2  |  M arch 2014

C. Galasko

Notes from the road

Travels of our Journal Charles Galasko, an inveterate traveller, made an unexpected discovery on a visit to Chile

uring a recent cruise from Costa Rica to Santiago, our ship stopped off at Iquique, a port city of about 250,000 inhabitants and capital of the Tarapaca region in northern Chile. I q u i q u e w a s v i s i t e d by C h a r l e s Darwin in July 1835 who described it as a town “Very much in want of everyday necessities, such as water and firewood”, these necessities having to be brought in from considerable distances. It suffered devastating earthquakes in 1868, 1877 and in 2005 an earthquake measuring 7.9 on the Richter scale. Today it is a modern city, to the west of the Atacama Desert with sand dunes overlying the city, which make it a centre for paragliding. Its beach climate attracts North American and Australian immigrants, who currently comprise 9.2% of the population. It is one of the largest duty-free ports in South America. Its average rainfall is only a couple of millimetres per annum. From Iquique, we travelled 48 km east across one of the driest parts on earth to Humberstone, a ghost town and UNESCO World Heritage Site in the Atacama Desert (Figs 1 and 2). The town was built to serve the saltpetre works of Santa Palma which became one of largest in the Tarapaca region. Here lie the greatest deposits of sodium nitrate (aka Chile saltpetre or Peru saltpetre to distinguish it from ordinary saltpetre, or potassium nitrate) in the world.  The region and works were originally in Peru, but became part of Chile after the War of the Pacific between Chile and a united Bolivia, during which the decisive Battle of Iquique was fought in the harbour in 1879. The war arose from disputes over the mineral-rich Peruvian provinces of Tarapaca, Tacna and Arica and the Bolivian province of Antofagasta.  It lasted five years, ending in 1881 with Peru ceding

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Fig. 1

Fig. 2


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Fig. 3

1940, demand declined rapidly in the 1950s and the works and the town of Humberstone were abandoned in 1960.  Sodium nitrate is now used as a preservative and colour fixative in cured meats and poultry (E251): there have, however, been suggestions that it may be associated with a higher risk of colorectal cancer.1 In its day, Humberstone was a self-contained community, including living quarters, dining rooms, shops, hospital, school, swimming pool and theatre. There were separate living quarters for officials, their families and single workers. A trip to Google or Wikipedia will illustrate dramatically and clearly how life might have been and how the area is worthy of its status as a UNESCO World Heritage Site. In the hospital museum I came across an apparently well-used copy of the 1948 – 1952 JBJS [Br] index (Figs 3 and 4) along with a surgical journal and lists of patients. These tell us who the patients were, but unfortunately there is no information about their diseases or injuries. We can only surmise that, as in other historical close-knit communities, there would have been a wide range of medial and surgical conditions with which to contend. The BJJ claims to be a world orthopaedic journal rather than a British Journal. The finding of this quinquennial index in Humberstone’s hospital museum gives credence to this claim. It might also be reassuring to note that those who were caring for the musculoskeletal disorders and injuries of the people of Humberstone were up to d ate wit h or t hopaedic k nowledge worldwide. Reference

Fig. 4

1. Cross A J, Ferrucci L M, Risch A et al. A large prospective study of meat consumption and colorectal cancer risks; An investigation of potential mechanisms underlying this

the province of Tarapaca to Chile in the 1883 Treaty of Ancon. Chile’s national treasury grew by 900% between 1879 and 1992 through taxes from the newly acquired lands, bountiful as the source of ‘white gold’, namely saltpetre. Following that war, British involvement and control over the industry rose significantly. However, profits fell sharply with the development of the synthesis of ammonia, thereby resulting in the industrial production of fertilisers. Also, during World War I, Germany began to convert ammonia by this process into a synthetic Chilean saltpetre which was as effective as the natural product in the production of gunpowder and other munitions. When the saltpetre mines closed or became unprofitable, British companies left the country with the loss of many jobs. In 1934 a practically bankrupt Santa Palma was acquired by COSATAN which tried to produce a competitive natural saltpetre by modernising the works. Although this led to it becoming the most successful saltpetre works in

association. Cancer Res 2010;70:2406-2414.

A uthor

details

Charles Galasko

Emeritus Professor, University of Manchester, UK carolgalasko@aol.com

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BJJ News  |  I ssue 2  |  M arch 2014

D. Jones

Notes from the road

Orthopaedics in Ireland David Jones reports on the Irish Orthopaedic Association annual meeting June 2013, Galway, Ireland

have always been a fan of orthopaedics in Ireland, where the standards of care and training are high, and so it was a gre at honour to be invited as Richard Wallace’s Presidential Guest Lecturer to the recent meeting of the Irish Orthopaedic Association in a glorious June in Galway. The IOA, like its rugby counterpart, represents both North and South and its annual meeting, heavily supported by industry, is the showcase event for orthopaedic surgery in Ireland. The IOA meetings are traditionally held in upmarket hotels or resorts with conference facilities, all of which allow a nice balance between academic and recreational activity, not to mention plenty of time not only for the craic, but also for animated discussion on the past, present and future of orthopaedics in the Emerald Isle. The whole event for 200 or so delegates and accompanying persons is organised singlehandedly each year with amazing efficiency, good humour and tolerance for wayward registrants by Emer Agnew (Fig. 1). She could teach many larger organisations a few tricks about maximising income and minimising the expense of a large event. I like the format of the meeting, which concentrates on the trainees and starts with a pre-conference Trainees Trauma Day, generously sponsored by Smith & Nephew. Spinal and limb trauma are included through didactic lectures and small-group case discussions. This year’s programme included James Scott, Editor Emeritus of The Bone & Joint Journal who talked on how to get a paper published and, with Gerry McCoy, the new Vice-President of the IOA, held discussion groups on how to evaluate a paper (Fig. 2). The day was rounded off nicely by Iain McFadyen, whose advice on organising a regional trauma service could be summarised as: 1) Join the Trauma Audit and Research Network (TARN), 2) Plan according to population, not on a map, 3) Don’t let pre-hospital care dictate the agenda; the only proven life-saver in hospital is time to surgery, 4) Play to the hospital’s strengths, 5) Focus on inhospital recognition of major trauma. The whole day was well received by the 30 or so trainees who were then able to join the evening reception for the main meeting over the following three days. The majority of the meeting consists of five-minute papers by trainees and medical students, along with excellent invited instructional lectures, which this year included arthroscopic hip surgery (Kevin Mulhall, Dublin) and elbow fractures (James Elliott, Belfast). My contributions were ‘Keeping it simple in children’s orthopaedics’ and ‘Bridging the gap’, in which I presented many of the ways in which orthopaedic surgeons, through charitable activity, have been able to bridge the gap between need and resources in developing countries. We also had an interesting historical lecture on the medical aspects of the carnage at the Battle of Gettysburg,

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Fig. 1 Emer Agnew with Michael Stephens, one of her past presidents

given by Dr Edward McDevitt who was attending the meeting along with several other members and spouses of the Irish American Orthopaedic Society (www.iaos.net), founded in 1978 and whose members are regular attendees at IOA meetings. The trainees delivered 60 papers, each session ending in robust discussion between presenters and audience. These wide-ranging scientific sessions confirmed that orthopaedic surgery throughout Ireland remains state-of-the-art but it is impossible in this report to cover them all. There were many useful messages. As examples, the Limerick Hospital Hip Fracture Score was shown to be useful in several presentations, a gait analysis paper from Dublin suggested that in cerebral palsy combined medial and lateral hamstring release was superior to medial release alone and the reduction of the legal blood alcohol level in Ireland from 80 mg to 20 mg per 100 ml showed a trend towards a reduced incidence of spinal injuries from road traffic accidents. This report, as ever, contains good and bad news. The former is the confirmation that the IOA is in good heart, continues to aspire to the highest standards of orthopaedic care and training and maintains good relations with Industry. Richard Wallace has been an excellent President (Fig. 3) and his worthy successor, Ray Moran (Dublin, Fig. 4), followed in two-years’ time by Gerry McCoy (Waterford) will continue a distinguished presidential line. As a fly on the wall at a single meeting one cannot hope to have comprehensive understanding of what goes on outwith the event.


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Fig. 2 Gerr y McCoy (right) and James Scott (second right) conduct a paperevaluation session for trainees

However, during informal discussions, I was made aware of significant difficulties in the provision of orthopaedic services on both sides of the border. Although the orthopaedic fraternities share the same standards and are part of the Intercollegiate Specialty Advisory Committee and Examination systems of The British Isles, the two are governed separately, with the Republic of Ireland a sovereign state in the Eurozone and Northern Ireland part of the United Kingdom. In the Republic the main problems relate to a country in recession and a lack of dialogue between orthopaedic surgeons and an unsympathetic Health Service Executive. The IOA, as a Charity, has no political clout. The Institute of Orthopaedics is only responsible for training and nominates representatives to the Royal College of Surgeons in Ireland for service on the SAC and Intercollegiate Examination Board. The RCSI has some dialogue with Government which, however does not easily talk to professional pressure groups such as The Irish Hospitals Consultants Association and, through the HSE, is unilaterally cutting services and salaries. For example, the salary of an orthopaedic surgeon in 2008 was €179 000 p.a. This was cut to €156 000 in 2010 and €109 000 in 2013. With taxation above 50%, along with a 6% pension levy and other professional obligations, it will be financially very difficult for a newly-appointed surgeon in Ireland, not to mention the iniquity of doing the same work as earlier-appointed colleagues who are on much higher salaries. Also, the intellectual property for innovation in the health service is to revert to the HSE, rather than the developer. All this adversely affects the morale of trainees who might feel less inclined towards research and not return

Fig. 3 Outgoing IOA President Richard Wallace in demob-happy mode

home from fellowships abroad. Indeed, the Irish trainee ge t s much more ope r at ive e x p e r i e n ce t h a n t h e i r U K counterpart and these manual skills are well recognised by overseas institutions. With regard to the North, I was told the political system makes it difficult for or thopaedic developments. The Northern Ireland E xecutive tends t o b e i s o l a t e d f ro m p u b l i c Fig. 4 The new IOA President , opinion, is hamstrung by Ray Moran (right) with John We s t m i n s t e r a n d t h e l o c a l Knight , President of The government is a compulsor y Irish American Or thopaedic coalition of opposing parties. Society However, as Northern Ireland is represented on the BOA Council and there is increasing involvement of orthopaedic surgeons in NHS development, perhaps this might give some clout to orthopaedic opinion in the province. Anyway, back to the good news. The final session on spinal disorders on Saturday finished just in time for the Lions vs Wallabies rugby test match, which left us in good heart as we departed from a very successful conference. The next IOA meeting is in June 2014 in Kilkenny, details of which can be obtained from irishortho@gmail.com I promise you the trip would not be wasted. A uthor

details

David Jones

Editor, BJJ News davidhajones@hotmail.co.uk

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BJJ News  |  I ssue 2  |  M arch 2014

Bridging the gap

The Glasgow Fracture Pathway: a virtual clinic SUMMARY

We redesigned the process for the nonoperative management of our fractures. This has significantly reduced attendances at the fracture clinic by avoiding unneccessary visits, thereby increasing the time available for improving standards of patient care, teaching and training without the need for additional resources. INTRODUCTION

The non-operative, outpatient management of trauma includes 75% of all limb fractures, and has remained unchanged despite the evolution in orthopaedic practice elsewhere. The unnecessary review of simple, stable injuries which are often needlessly immobilised, still occurs, diverting resources from patients with more complex injuries. This tendency is not new and was noted by Charnley1 in the 1950s: “How often we see plaster of Paris applied merely because X-ray examination has revealed a small crack or undisplaced fracture! On many such occasions the surgeon would probably have treated a case without plaster had he used his clinical sense alone…patients are frequently prevented from returning to work by plasters which are not essential.” Some units have developed triage systems run by healthcare professionals other than doctors,2,3 but the universal principle of face-toface consultation two to three days post-injury has been retained. Although well-meaning, it is often difficult for patients to attend a clinic during the most painful and functionally restricted period of their recovery and frequently no new information or change in management results. The consultation is often brief, as fracture clinics traditionally serve many patients. Trainee doctors make a major contribution to the fracture clinic service but recent and future changes in the medical workforce will reduce their input. The NHS is also under significant pressure to provide an evidence-based, costeffective service. Elsewhere, the redesign of outpatient clinics for the management of other acute and chronic diseases have shown quality improvement and cost saving.4,5

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We h ave wo r ke d c l o s e l y w i t h o u r Emergency Department (ED, Fig. 1) to develop a comprehensive, evidence-based protocol (Glasgow Fracture Pathway) for the management of orthopaedic injuries. THE GLASGOW FRACTURE PATHWAY

The new process, introduced in October 2011, comprises two main components. Patients with simple, self-limiting stable fractures (fifth metatarsal, fifth metacarpal, distal radius, torus, minor radial head/elbow fat pad sign, mallet finger, child’s clavicle) are given structured verbal advice at their original presentation to the ED and are not automatically followed up (ED Direct Discharge). The selection of this core group of injuries is based on an extensive evidence base for excellent outcomes with early mobilisation and without the need for regular review.6-13 The advice in the ED is reinforced by a patient information leaflet which explains the injury, treatment and expected recovery. It is backed up by a telephone help-line provided by the orthopaedic department during working hours, and the ED at other times. Removable Velcro splints are supplied where required.

P. J. Jenkins A. Gilmour O. Murray I. Anthony

M. P. Nugent A. Ireland L. Rymaszewski

Pat ients with fractures that do not require immediate admission are referred to the Virtual Fracture Clinic (VFC). This is a regular multidisciplinary meeeting, led by an orthopaedic consultant, where the history, examination and ED radiographs are reviewed. The resulting management plan is outlined and agreed with the patient by telephone immediately afterwards. There are three possible outcomes from this “virtual” assessment: telephone advice alone with discharge from follow-up (VFC Direct Discharge), review in a nurse-led fracture clinic (NLC), or review in a sub-specialty clinic (SSC - shoulder and elbow, hand and wrist, foot and ankle and knee). RESULTS

In the first year (2011-12) the ED managed and discharged 2115 of 6385 patients (23%) who would previously have been referred to a fracture clinic. The remaining 4270 (67%) were reviewed at the VFC (Fig. 2). Of these 1687 (26%) were discharged after virtual review by an orthopaedic consultant, followed by a nurse-led telephone consultation. This left 1889 patients (29%) to be reviewed in sub-specialty clinics and 395 (6%) in the nurse-led clinic. There were 233 patients (4%)

Fig. 1 The real team behind the vir tual clinic


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Orthopaedic trauma not requiring immediate admission (n = 7056)

Resident outside area (n = 146) Discharge to other unit/follow-up (n = 525) Study group: eligable for management via new process (n = 6385, 100%)

All percentages are of the eligible study group n = 6385

ED Direct Discharge (n = 2115, 23%)

Virtual Fracture Clinic Review (n = 4270, 67%)

Referred to other specialty* (n = 32, 1%)

Further imaging prior to Specialty Clinic (n = 233, 4%)

Urgent admission arranged (n = 3, 1%) 1889 (29%) referred directly to Specialty Clinic

Telephone discharge (n = 1687, 26%)

Nurse-led Clinic (n = 395, 6%)

Specialty clinic (n = 2122, 33%)

Fig. 2 Flow char t demonstrating the pathway of patients through the redesigned fracture clinic process who were referred directly for further imaging based on the VFC discussion (mostly suspected scaphoid fractures) and subsequently followed up in the NLC or SSC. Only 34 patients discussed at the VFC required semi-urgent admission for surgery (Figs 1 and 2), mostly for fractures of the distal radius. The overall rate of ED and VFC discharge, without further face-to-face review, was 3802/6385 (60%). The total direct cost of reviewing all these patients in a consultant-led fracture clinic would have been £585,951. Under the redesigned system, the overall cost was £429,780, leading to a saving of £156,171 for the period of study. This saving allowed more consultant time to be devoted to complex cases, and to release other resources to respond to clinical pressures.

These changes brought benefits both to patients and the department but did not require additional investment. Self-care was promoted and medicalisation of benign injuries avoided, as with the management of low back pain. Patients suffered less discomfort and inconvenience, as they only attended a fracture clinic for “something to be done”, either for assessment or treatment at the appropriate sub-specialist clinic at a suitable time. The need for attendance was also reduced with the routine use of removable splints rather than plaster casts and backslabs. At a service level, significant benefit was derived from freeing up clinical and administrative time. We examined patient satisfaction and the clinical outcome in sub-groups managed with the new protocol. In patients with suspected and

definite radial head fractures (Mason 1 and 2), 90% were managed by direct discharge from the ED.14 The satisfaction rate ranged from 87% to 95%. Only two patients needed surgery for a late complication after they recontacted the fracture clinic when their pain and stiffness did not settle in the period that had been discussed with them during their initial visit to the ED. A separate comparison of fractures of the fifth metatarsal treated before and after the new protocol showed an overall reduction in total appointments from 491 (1.76 per patient) to 102 (0.32 per patient).15 There was no difference in the rate of subsequent open reduction and internal fixation for nonunion (OR 0.72, 95% CI 0.17 to 3.07, p = 0.735), suggesting that these were adequately detected with this protocol. The modernised system has brought reduct ions in both direct and indirect costs. In addition to the savings described, reduction in attendance gives further, less easily quantifiable, gains for services such as patient transport, secretarial support and a reduction in unneccessary radiographs. There are also cost savings to the patient and society from reduced absence from work, transport and hospital parking. The nursing support for the VFC and the telephone consultation afterwards was met through reallocation of resources as the numbers of staff required to run traditional clinics fell. The redesigned process also improves training as trainees can attend the VFC, participate in decision making16 and are therby better prepared for subsequent face-to-face consultations and providing advice to the ED when on-call. As there is less pressure than in a fracture clinic discussion of diagnosis and treatment can be more comprehensive. The beneficial effect on training of consultant review of all the new cases prior to the clinic has been described in another unit. BARRIERS TO REDESIGN

Inevitably, there were a number of barriers to overcome during the implementation of this new protocol. Face-to-face review of every patient a few days after a fracture was traditionally believed to be the safest, most effective form of management. This has led to a reluctance to discharge simple, stable, fractures at first presentation to the ED. An essential step in the modernisation programme was for all the ED and orthopaedic consultants to agree regularly-updated, local treatment protocols. The development of evidence-based patient informat ion leaflets, using simple, ►

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unambiguous language allowed the documentation needed for the two departments to achieve a consensus. A real-time database allowed regular audit to establish confidence in the process and rapid resolution of any problems. False-positive referrals to the virtual clinic are managed by an appropriate telephone conversation, and false-negatives are mitigated by correlation with timely radiological reporting and an effective system of recall. Patients who fail to achieve the expected recovery can contact the telephone advice line for help and review if required. The availability of removable splints in preference to plaster backslabs and casts has allowed us to promote patient self-care and removed the need for patients to make frequent hospital trips for plaster checks or removal.

REFERENCES

11. Martin

1. Charnley J. The Treatment of Common Fractures

unnecessary

AG.

without Plaster. In: The Closed Treatment of Common

2004;35:805-808.

Fractures. London: Sapiens Publishing, 1950:55.

12. Symons S, Rowsell M, Bhowal B, Dias JJ.

2. Beiri A, Alani A, Ibrahim T, Taylor GJ. Trauma

Hospital versus home management of children with

rapid review process: efficient out-patient fracture

buckle fractures of the distal radius. A prospective,

management. Ann R Coll Surg Engl 2006;88:408-411.

randomised trial. J Bone Joint Surg [Br] 2001;83-

3. Williams SC, Hollins D, Barden-Marshall S, Harper

B:556-560.

WM. Improving the quality of patient care: patient

13. Hamilton TW, Hutchings L, Alsousou J, Tutton E,

satisfaction with a nurse-led fracture clinic service. Ann

Hodson E, Smith CH, Wakefield J, Gray B, Symonds

R Coll Surg Engl 2003;85:115-116.

S, Willett K. The treatment of stable paediatric

4. Mark DA, Fitzmaurice GJ, Haughey KA, O’Donnell

forearm fractures using a cast that may be removed

ME, Harty JC. Assessment of the quality of care and

at home: Comparison with traditional management

financial impact of a virtual renal clinic compared with

in a randomised controlled trial. Bone Joint J 2013;95-

the traditional outpatient service model. Int J Clin Pract

B:1714-1720.

2011;65-10:1100-1107.

14. Jayram PR, Bahattacharyya R, Jenkins PJ,

5. Hunter J, Claridge A, James S, Chan D, Stacey B,

Anthony I, Rymaszewski LA. Patient satisfaction

Stroud M, Patel P, Fine D, Cummings JR. Improving

following management of radial head and neck

Weber

fracture

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ankle

clinic

fracture:

burden.

an

Injury

outpatient services: the Southampton IBD virtual clinic.

fractures in a virtual fracture clinic. J Shoulder Elbow

THE FUTURE

Postgrad Med J 2012;88-1042:487-91.

Surg 2013;In Press.

The literature provides us with an excellent understanding of the natural history of many simple, stable injuries. There is a need to justify our clinical management and follow-up processes to deliver seamless, evidence-based patient-focused services that are completely. The financial and staffing pressures facing the NHS make the status quo unsustainable. Orthopaedic departments embarking on redesign can use these principles to analyse local problems and implement safe and effective processes for managing most fractures. The website www.fractureclinicredesign.org is useful in this regard.

6. Bansal R, Craigen MA. Fifth metacarpal neck

15. Ferguson K, McGlynn J, Kumar CS, Madeley J,

fractures: is follow-up required? J Hand Surg Eur Vol

Rymaszewski LA. 5th Metatarsal fractures: how a

2007;32-1:69-73.

change in protocol has influenced our service. British

7. Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, De

Orthopaedic Association Congress. Birmingham, 2013.

Vries MR, Van Der Elst M, Schepers T. Demographics

16. Murray O, Christen K, Marsh A, Bayer J. Fracture

and outcome of metatarsal fractures. Arch Orthop

clinic redesign: improving standards in patient care

Trauma Surg 2011;131-2:241-5.

and interprofessional education. Swiss Med Wkly

8. Calder JD, Solan M, Gidwani S, Allen S, Ricketts DM.

2012;142:w1363

Management of paediatric clavicle fractures--is followup necessary? An audit of 346 cases. Ann R Coll Surg Engl 2002;84-5:331-3. 9. Duckworth AD, Watson BS, Will EM, Petrisor BA, Walmsley PJ, Court-Brown CM, McQueen MM. Radial head and neck fractures: functional results and predictors of outcome. J Trauma 2011;71:643-648.

The editors would welcome letters discussing the contents of this article bjjnews@boneandjoint.org.uk

10. Egol K, Walsh M, Rosenblatt K, Capla E, Koval KJ. Avulsion fractures of the fifth metatarsal base: a prospective outcome study. Foot Ankle Int 2007;28:581-583.

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Paul J. Jenkins Alisdair Gilmour Odhran Murray Iain Anthony Margaret P. Nugent Alastair Ireland Lech Rymaszewski

Glasgow Royal Infirmary, UK paul@jenkinsnet.org.uk

D. Kader

Fellowships

BOSTAA / Arthrex Travelling Fellowship 2013 any colleagues have asked what motivated me to apply for a BOSTA A (British Or thopaedic Spor ts Trauma and Arthroscopy Association) Fellowship after practising as an orthopaedic consultant for over eight years, providing a broad range of knee services locally, including specialised patella and painful knee arthroplasty clinics. Surely fellowships were for newly-appointed consultants with new techniques to learn? Despite this, in many ways

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I believe an established consultant may benefit more from such an experience. It is easy to become complacent and remain in one’s comfort zone without taking on new challenges or techniques. It is even easier to be sceptical and dismissive of any new developments in knee surgery. Also, a more established surgeon has the benefit of maturity of practice, knowing which surgical techniques generally work and the


BJJ News

experience of some unsatisfactory outcomes and changes in practice for the tibial tunnel drilling inside out, with almost no chance of guide in the light of that experience. Consequently, I was delighted when wire and drill advancement. BOSTAA kindly offered me the Fellowship. It was interesting to note that in Austria the image intensifier is I had the privilege of spending t wo weeks visiting three operated by theatre staff rather than a radiographer and that intensifier dif ferent centres, st ar ting in st ar ted May 2012 in Chicago in Rush Surgicenter was safe enough for the staff not to wear lead aprons! with Dr Brian Cole, Chairman of the Department of Surgery, My final stop was Lyon, where I have visited on several occasions Rush Oak Park Hospital and Professor of the Department of to learn about the patellofemoral joint from Dr Dejour. This time Anatomy & Cell Biolog y. He is a pioneer of spor ts surger y I had the privilege of meeting him for a catch-up only. My host was and one of the very few surgeons who has performed a large Dr Bertrand Sonnery-Cottet at the Centre Orthopédique, Santy, number of meniscal allografts.1 Of the different methods, Dr Lyon, FIFA Medical Centre of Excellence. The week started with a Cole prefers the bridge-in-slot technique for both menisci. This very busy clinic full of athletes and celebrities. We discussed the high relatively simple technique permits concomitant procedures infection rate among professional athletes, chondrolysis after lateral and secure bony fixation while maintaining the natural anterior meniscectomy and various techniques for reconstruction of the and posterior horn attachments. anterolateral ligament of the knee. Dr Sonnery-Cottet kept printing Dr Cole is knee surgeon me articles with every to many high profile athletes discussion we had. We from various teams in spent the next two days Chicago including the Bulls in theatre. There were a nd W hi t e S ox . A we e k 10 to 12 patients each before my visit he was on day. In Lyon I began to television after operating on reconsider the principles one of their leading players. of re cons t r uc t ion of I was thoroughly impressed the ACL and associated by the effectiveness of his injuries. Since my team and the spectrum fellowship with Dr Leo of procedure s . E ach d ay Pinczewski nine years they per formed 10 to 12 ago, there have been knee operations including minor changes in the anterior cruciate ligament o pe r at i ve t e c hniq ue . (AC L) re cons t r uc t ion , Most knee surgeons Fig 1. I am the foreign-looking handsome guy second from the right , opening wedge high tibial recommend lower Dr Sonner y-Cottet is on my lef t and the two guys on my right os t e ot omy, me nisc al femoral tunnel placement work for Ar threx. repair and medial patellarto control pivot shif t fe mor al lig ament (M PF L) and agree that there are reconstruction. Dr Cole operated in two theatres with four no major differences among various ACL autografts. However the assistants! I am lucky if I have one in private practice. dilemma of variable pivot shift with ACL rupture can only be logically My next stop, in June 2013, was in Feldkirch in Austria. My host explained by the associated injury to the anterolateral ligament of the was Prof. Dr. Karl P. Benedetto at the Department for Trauma knee. 2 Therefore, in Lyon, extra-articular reconstruction, described Surgery and Sports Medicine. The system is very similar to the by Marcel Lemaitre in 1967, combined with ACL reconstruction, is German style of organisation where there is a Chief as the main still a popular procedure. decision maker. Prof Benedetto is an excellent surgeon. I saw a Most knee surgeons are familiar with the pattern of bone bruising variety of interesting techniques in ligament reconstruction and and vertical tears of the posterior horn of the lateral meniscus after trauma including the frequent use of quadriceps tendon graft, an ACL injury. However, lateral meniscal root avulsion and medial “outside-in” and “all-inside” ACL reconstruction using an Arthrex meniscal ramp lesions or vertical tears of the posterior horn are not Flip Cutter and retrodrill in open physis, all-inside onlay posterior well identified. Dr Sonnery-Cottet demonstrated several massive cruciate ligament reconstruction, triple plating of a tibial plateau “hidden lesions” of the posterior horn of the medial meniscus in fracture, combined open wedge high tibial osteotomy and ACL seven of the 12 ACL injuries I saw. These lesions are generally difficult reconstruction and all-inside meniscal repair. to diagnose from the front. They can only be seen through the notch Although I am aware that standard tunnel hamstring graft ACL posteriorly and are easily missed by standard arthroscopy. They are reconstruction in the skeletally immature is successful, the idea of an also missed on MRI as all the scans are performed with the knee in all-epiphyseal all-inside reconstruction is appealing in children. The extension. Dr Sonnery-Cottet repaired the “hidden” and ramp PCL procedure was very different from the way in which I learned lesions through the posteromedial portal using an outside-in to do it. Usually most surgeons will use the longest possible graft, technique. The ACL reconstruction was performed paying close passing it from the tibial tunnel into the joint and then into the attention to preservation of the ACL remnant and minimum femoral tunnel. Prof Benedetto uses a 7cm quadriceps tendon graft disturbance of the notch. The “outside-in” femoral tunnel drilling passed into the joint through the medial arthroscopic portal. The was crucial to avoid excessive dissection of the notch. Most of the technique is relatively simpler and possibly safer, using the retrodrill autografts were covered by a sleeve of the partially attached ►

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ACL remnant. He explained that it made sense to leave the well vascularised and innervated tissue undisturbed. There is, however, no evidence to date to show its actual benefit. The centre at Santy despite being a private clinic, had relatively few patients listed for simple arthroscopy and meniscectomy. Only 10% of patients had arthroscopy as the main procedure. Most degenerate tears were treated with a steroid injection first. This is in sharp contrast to the UK’s previous figures that showed only 6% of knee arthroscopies are for ligament reconstruction. 3 I was invited to present different parts of my research portfolio in each unit I visited. This initiated stimulating discussion and enabled us to exchange many ideas. This travelling fellowship has been a wonderful experience. It has certainly energised me, given me many new ideas to improve my practice and has provided valuable insights into orthopaedic practice in different countries. I have also made many friends, exchanged views on many different topics and discussed future research collaboration. Shortly after returning to the UK I was fortunate to receive a visit from Dr Sonnery-Cottet kindly came to the north-east to perform a biological ACL reconstruction on one of my patients. We had a fantastic day in theatre which hopefully will become the first of many such exchanges. I would like to thank my hosts, Professor Brian Cole, Professor Karl Benedetto and Dr Bertrand Sonnery-Cottet who gave up time

in their very busy working days to allow me to join their units and demonstrate their surgical techniques and skills. I am also very grateful to Arthrex for their outstanding support for the Fellowship and the board of BOSTAA for awarding me this opportunity. I strongly encourage BOSTAA members to apply for this fellowship. It is an excellent opportunity for young surgeons to broaden their horizons, both surgically and geographically. References 1. Saltzman BM, Bajaj S, Salata M, et al. Prospective long-term evaluation of meniscal allograft transplantation procedure: a minimum of 7-year follow-up. J Knee Surg 2012;25:165-175. 2. Claes S, Bellemans J. VuMedi: The Pivot Shift Unraveled: Why We Disagree With Dr. Fu. http://www.vumedi.com/video/the-pivot-shift-unraveled-why-we-disagree-with-dr-fu (date last accessed 6 February 2014). 3. Jameson SS, Dowen D, James P, et al. The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg [Br] 2011;93B:1327-1333.

A uthor D etails

Deiary Kader

Northumbria University, Newcastle upon Tyne, UK deiary.kader@btinternet.com

Fellowships

The American & British Hip Society travelling fellowship

V. Khanduja T. Board

n 2000, David Hamblen conceived the idea of a travelling fellowship to the United States. A meeting was set up by the Honorary Secretary, with John Callaghan, Charles Engh and Dick Brand representing the AHS and the arrangement was confirmed at the AAOS meeting in Dallas. It was decided that two young surgeons from the UK would visit centres of excellence in North America and Canada biennially for three weeks in early autumn. In the alternate years, two young surgeons from the US would visit similar centres in the UK. The Fellowship began in 2003 and the first Fellows from the UK were Fares Haddad and Dave Sochard. So, when Tim and I were offered the Fellowship after a gruelling interview at the BHS in Torquay, we were delighted to be following a group of distinguished predecessors from both societies It took a lot of preparation to get the paperwork ready for the US and taking three weeks away from a busy practice also needs some serious planning. However, we must acknowledge that the communication with US and UK were excellent. Two individuals need to be formally thanked. Olga Foley from the AHS and Fares Haddad from the BHS kept us regularly updated and ensured that the Fellowship was extremely well co-ordinated. It was not uncommon to receive an email from Fares at 0430 hrs asking us to get our Hepatitis B titres ready: the only issue was that he expected a reply at 0431! The first stop was London, Ontario. Tim attended this part of the Fellowship alone. I joined him in Philadelphia at the Rothman Institute and from there we travelled together to The Joint Implant Surgeons Centre in New

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Fig 1. Vikas and Tim at sea Albany, Massachusetts General Hospital in Boston, the University of Maryland in Baltimore, The Hospital for Special Surgery in New York and back to The Joint Implant Surgeons Centre in New Albany for the closed meeting of the American Hip Society. Each centre offered us unique educational and social experiences, the details of which are beyond the scope of this report. However, we have highlighted a few special aspects. As soon as we landed it was immediately apparent that ‘cement’ was off the agenda as far as surgery was concerned, but there was plenty of discussion about it. In one of our talks, I attempted to “show the evidence” about cement from the UK NJR and how it guided our practice, but it seemed to fall on deaf ears, as one might have expected. There was a wealth of opportunity to pick the brains of our hosts, some of whom were responsible for historic contributions to hip surgery, such as Bill Harris at Boston and Dick Rothman in Philadelphia. We spent about an hour with Bill Harris in his office, arguing about polyethylene, cement and head sizes. We clearly were not going to change his mind about these issues but even to be given the opportunity to have such a discussion is unique. Similarly Dick Rothman was very keen to show Tim a letter from Sir John Charnley that was part of the correspondence they had shared on the “new approach” to the hip, which Rothman subsequently took up and Charnley, obviously, did not. The tone of Sir John’s letter clearly showed his strong views on the matter. As a Wrightington surgeon, Tim was slightly abashed to admit to neither, being a surgeon who uses the posterior approach.

One of the most remarkable things that becomes apparent as you got through this fellowship is the effort our hosts put into our visits. Whether it was hosting us at their residence (Bill Hozak and Matt Austin from Philadelphia) or taking us sailing on their boat (Mathias Bostrom from New York, Fig. 1), all were always extremely generous with their time and the treatment we received was first-class. The attendance at our lectures was always good, the dinners well attended, and we were made to feel as if our visit was important to them as well as us. This feeling just seemed to escalate as the weeks passed, culminating in the show that was the few days we spent with Adolph Lombardi in New Albany, Ohio. To be picked up from the airport by your host, having brought with him two very expensive Italian supercars (one with a horse on the front, the other a bull) and then to be thrown the keys and told to “just get in and drive” is an unexpected experience to say the least. We drove (rather slowly, it has to be said) to the hospital, where they had laid on a lecture session with a packed auditorium, on a Sunday! They really did make us feel valued. Adolph personally picked us up from the hotel each morning to take us to the hospital (in a very British car, this time with a winged lady on the front). However, despite the cars, the abiding memory was the surgery – 14 arthroplasties in two theatres between 6.30a.m. and 3 p.m., including two revisions: good quality surgery with Adolph on the phone most of the time (Bluetooth headset permanently attached and in use, even while operating). We certainly had the experience of a lifetime. It was a unique opportunity to meet and learn from key opinion leaders in hip surgery, to be able to share their passion and to be inspired by these individuals to advance ourselves, our departments and our Society. The fellowship allowed us to focus on productivity, the method of delivery of care, research effectiveness and collaborative research and to open up channels for our trainees to train in these centres of excellence. The time away also helped us to think, discuss and re-evaluate our priorities in terms of clinical and research work whilst maintaining a healthy work-life balance. It was a lot of travel and a significant time away from home and if it were not for Tim, I would not have enjoyed the tour as much. Finally, we would like to sincerely thank the British and the American Hip Societies and all our hosts from the AHS for supporting this tour, being so generous with their time and for going out of their way to provide us with this unique experience which we will cherish forever. A uthor

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Vikas Khanduja Cambridge Orthopaedics, Cambridge, UK Tim Board Wrightington Hospital, Lancashire, UK vikaskhanduja@aol.com

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Honours, awards and prizes

The Arnott Lectureship

he Arnott Lectureship (formerly Demonstration) is named for James Moncrieff Arnott (1794 – 1885) who endowed these demonstrations in 1850, the year of his first Presidency of the Royal College of Surgeons of England. James Moncrieff Arnott was a distinguished surgeon, a very active member of the College and one of its original 300 Fellows, being elected to the Fellowship in 1843. He was born in Fife, Scotland. He began his medical studies in Edinburgh and continued his medical education in London, Vienna and Paris. He became a member of the Council of the Royal College of Surgeons of England in 1840 and served four terms as Vice President and two as President; the first in 1850 and the second in 1859. He also served as a Member of the Court of Examiners from 1847 to 1865. He was elected to the staff of the Middlesex Hospital in 1831 and was one of the founders of its Medical School in 1836. He subsequently occupied the Chairs of Surgery successively at King’s College and University College, London. He was one of the earliest advocates in Britain for specialisation in surgery. Throughout his career, Arnott had a deep interest in the study of anatomy and pathology. He was passionate about the specimens housed in the Hunterian Museum, and was instrumental in obtaining a grant of £ 15,000 (a not inconsiderable sum at that time) from the government of the

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day to refurbish the museum. Indeed, the initial terms of the Demonstration required that it should be on a specimen or specimens in The Hunterian Collection. The Arnott Lectureship is awarded by the College and the lecturer is expected to deliver a lecture/presentation on a theme in anatomy. Only one Lectureship is awarded each calendar year. While the award carries no monetary gift, it comes with a handsome, inscribed College medal and, of course the kudos that goes with joining the ranks of numerous luminaries who have won the award in the past. It was my pleasure to attend the 2013 Congress of The British Orthopaedic Association in Birmingham on behalf of the Council of RCS and present the Arnott Medal to Mr Vikas Khanduja following his excellent lecture on ‘The Arthroscopic Anatomy of the Hip Joint’ Those wishing to be considered for the award may contact the Research Department of the Royal College of Surgeons of England www.rcseng.ac.uk for an application form and information about the Lectureship.

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Vishy Mahadevan

Royal College of Surgeons of England, UK vmahadev@rcseng.ac.uk


BJJ News

Obituary

Oliver Ross Nicholson O.B.E.

G. Tregonning

1922-2013

hen Ross Nicholson passed away in Auckland on the 13th July 2013, New Zealand orthopaedics lost a true leader, a “giant” with an outstanding influence over 50 years. He was educated at Auckland Grammar School, then at the University of Otago Medical School, graduating in 1947. His orthopaedic training was in Auckland and London at the Royal National Orthopaedic Hospital under Professor Sir Herbert Seddon. On his return to New Zealand he became a consultant orthopaedic surgeon at Middlemore Hospital from 1957 to 1987. In 1956, he was the first New Zealand ABC Fellow. Some have described him as one of the founders of modern orthopaedic surgery in New Zealand. In particular, with his interest in hip and spine surgery, he developed the first scoliosis unit in New Zealand at Middlemore Hospital. With the late John Morris, he pioneered the introduction of the Charnley total hip replacement to New Zealand. He also established the Otara Spinal Unit for patients with severe spinal injuries. With his particular interest in academic orthopaedic surgery and the education of young orthopaedic surgeons, he developed the Orthopaedic Academic Unit in the Department of Surgery at the University of Auckland, was an inaugural member of the Education Committee of the New Zealand Orthopaedic Association and, as such, developed the orthopaedic training programme in its current form. He also established the Sir William Stephenson Personal Chair in Orthopaedic Surgery, occupied by Professor Harley Gray in 1975. As would be expected of a person with his energy, ability and commitment, he held every office in the New Zealand Orthopaedic Association, culminating in becoming its 17 th President in 1982/3. He received every major award from the New Zealand Orthopaedic Association and the Royal Australasian College of Surgeons, including the Louis Barnett and Gillies Medals, and was a Wolfson Travelling Fellow.

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His invitations as Visiting Professor and Guest Speaker were numerous and, as such, he was the face of New Zealand Orthopaedic Surgery in many prestigious units in North America and the British Commonwealth. The contacts he made became invaluable for the training of young New Zealand orthopaedic surgeons (myself included) in other parts of the world. He had many other interests and held prestigious positions in the Auckland Rugby Union, was a life member of the Auckland Racing Club and the Barbarian Rugby Club, and a Northern Club Trustee and President. In addit ion he was Chairman, Tr ustee and committee member of many other organisations. It is not surprising that he was awarded an O.B.E. in 1976 and many believe he deserved some higher recognition. He was always engaging with a great sense of humour. It was fortunate that a number of his younger colleagues were able to honour Ross on the occasion of his 90th birthday last year. Many told stories and paid tribute to the great man and he himself made a memorable speech. He set very high standards for himself and for others but was always fair and encouraging. He was a man of great integrity, drive, high intellect and warmth. He was indeed unique in his lifetime devotion to Orthopaedic Surgery and with his ability to embrace new technology, retained an interest and influence right up to near the end. He left as his legacy the annual Ross Nicholson Lectureship of the Auckland Orthopaedic Society. At his funeral the Society sent a message stating that “A mighty Kauri tree has fallen”. Fortunately the tree has left many flourishing young seedlings to take its place. Ross was predeceased by his loving and very supportive wife Pauline some years ago, and he is survived by his daughter Caroline and Mike Thorburn and their family. We salute a truly great man, Oliver Ross Nicholson.

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Garnet Tregonning

Robyn.Lynch@middlemore.co.nz. 

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Medial Rotation Knee User Group Meeting & Dinner TM

Celebrating 20 Years

Welcoming new and existing users, the meeting will focus on the medial ball and socket philosophy 速 knee portfolio. We encourage you to join us for what is and the evolution of the MatOrtho of Clinical Excellence promised to be an interesting and informative meeting, presented by distinguished orthopaedic surgeons and professionals from around the world. Tuesday 3 June, 2014 | Meeting Start Time - 4pm | Novotel ExCel, London (coinciding with EFORT 2014) For more information and to register your place, please visit the MatOrtho速 Education link on our home page or contact your local representative.

Special guest Professor Michael Freeman

Confirmed faculty Mr Chris Evans | Professor Justin Cobb | Mr Simon Lewthwaite | Mr Gil Railton | Dr Andrew Shimmin | Mr Mike Tuke

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BJJ News Issue 2