BJJ News from The Bone & Joint Journal
Formerly known as JBJS (Br)
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The Twente Lower Extremity Model (TLEM) N. Verdonschot
A Glimpse into Current Trends in Orthopaedic Oncology C. J. McDougall S. J. T. Patton
29th Edinburgh International Trauma Symposium and Trauma Instructional Course 17th - 21st August 2015
Trauma Symposium 19th-21st August 2015
Trauma Instructional Course 17th-21st August 2015
This internationally renowned annual meeting is aimed at established orthopaedic surgeons with an interest in trauma surgery. The three-day meeting will focus on areas of current interest and controversy, and will consist of instructional lectures, debates, discussion groups, and hands-on practical sessions. The course has been extensively re-designed to include illustrative case based discussions and workshops with world renowned experts. We aim to introduce live cadaveric surgery sessions for surgical approaches and percutaneous surgery.
This popular course provides a complete overview of orthopaedic trauma over a five-day course, including paediatric, adult and fragility fractures, and their management and complications. The course is suitable for established surgeons wishing for a general update, trainees approaching professional examinations in orthopaedics, new trainees requiring an overview of the subject, and senior nurses and physiotherapists. The format of the course includes lectures, small-group discussions and skills-labs. The course has been extensively re-designed to include illustrative case based discussions and hands-on workshops with world renowned experts. There will be a session on surgical approaches in the University cadaveric labs.
INVITED INTERNATIONAL FACULTY INCLUDE Prof Paul Tornetta from Boston, USA Prof Marc Swiontkowski from Minneapolis, USA Prof Cong-Feng Luo from Shanghi, China and Prof Jan-Erik Gjertsen from Haukeland, Norway Venue: Sheraton Hotel, Edinburgh, Scotland. Edinburgh is Scotland’s capital city, a World Heritage Site and has a proud history of medical education and research. It is a vibrant city famous for its hospitals, universities, International Festival and Fringe Festival.
Further information is available on our website or by email: email@example.com www.trauma.co.uk
The premier orthopeadic meeting returns
18th - 19th June 2015, Mermaid Conference Centre, London 2015 promises to be another bumpy year for arthroplasty surgeons across Europe. The industry is under pressure to reduce the cost of devices across the board, while surgeons are having activity and morbidity data made public. So the whole field is less profitable, and bad news is going to make headlines.
It is human nature to pay more attention to bad news than good – a trait that is shared by both patients and journal editors. Surgeons should not ignore the bad news, but need to temper with good news, and there is a lot to be excited about on the technology front.
The Great Debate exists to address that balance, exploring the evidence and debunking dogma where necessary.
Registration begins February 2015 For more information visit: http: //www1.imperial.ac.uk /msklab /courses THE FACULTY INCLUDES:
THE TOPICS INCLUDE:
Cruciate ligaments: spare them or substitute?
Joint line obliquity
Hip implant choice
De educatione chirurgi
from The Bone & Joint Journal
Orthopods view A Glimpse into Current
C. J. Mcdougall
Trends in Orthopaedic
S. J. T. Patton
The SICOT Young Surgeons
Bridging the gap SICOT/WOC Symposium in Rio
associations Balancing the Social Contract and the Role of the New Zealand Orthopaedic Association
Notes from the road Sixty-fourth New Zealand Orthopaedic Annual Scientific Journal Office:
Meeting, Tauranga, 19-22
22 Buckingham Street, London
WC2N 6ET, UK
SICOT/SBOT Congress, Rio de
Janerio, November 2014
Mr David Jones Honorar y Consultant Or thopaedic Surgeon, London
The Twente Lower Extremity
Mr Alistair Ross
Consultant Or thopaedic Surgeon, Bath
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A Somerset Cider Orchard
Letters David Jaffray; an appreciation A Bone & Joint Publicat ion THE BRITISH EDITORIAL SOCIET Y OF BONE AND JOINT SURGERY. Registered charit y no: 209299.
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Editorial o be appointed to the post of a full-time consultant in orthopaedic surgery in the NHS is not only the aim of most indigenous trainees but also the desire of a number of surgeons who have trained abroad or in other systems. This is entirely reasonable, but it is inevitable that those applying for such a post should fulfil certain criteria. These were laid out precisely, if not elegantly, in article 8(2) of the Postgraduate Medical Education and Training Order of Council 2010 which came into force on 1st April 2010. For those of you who have somehow failed to read this statutory instrument, it runs as follows: “a person (“S”) is an eligible specialist for the purposes of article 7 (1) (a) if S does not fall within paragraph (1) but has (a) undertaken specialist training; or (b) been awarded specialist qualifications in a recognised specialty and satisfies the registrar that that specialist training is, or those qualifications are, or both when considered together are, equivalent to a CCT in the specialty in question.” In practice, this means that an indigenous trainee has to have completed an accredited training scheme to a satisfactory standard and to have passed the FRCS (T&O). But what of the graduate from abroad who wishes to be appointed to a full-time consultancy in orthopaedics in the NHS? Precisely this question recently came in front of the Court of Appeal in the case of Nakhla v General Medical Council last year. The GMC’s Registration Appeal Panel (RAP) had turned down Mr Nakhla’s application to be registered as a specialist in Trauma and Orthopaedic surgery which is, in itself, a necessary precondition to being appointed a permanent NHS consultant. When this decision was appealed the judge in the first instance overturned the decision of the RAP on the grounds that Mr Nakhla had fulfilled the criteria of article 8 (2) by having passed his FRCS (T&O). She argued that there were three different ways in which an application could prove equivalence; by qualifications, by training or by a combination of the two. The applicant did not have to demonstrate equivalence by reference to training if relying on qualifications or by reference to qualifications if relying on training. The Court of Appeal disagreed. Lord Justice Lewison argued that the judge in the first instance appeared to conclude that passing the FRCS (T&O) was in itself sufficient to satisfy the requirements laid down in article 8(2) and that this was wrong because by accepting this she had failed to consider the second part of the criteria which was that the applicant should be able to demonstrate a range of generic medical skills equivalent to those that would have been required in order to obtain a CCT. These did not have to be identical, but equivalent, and this, in itself, was a value
judgement.The judge, however, was correct in saying that the ultimate objective of the enquiry was to determine whether the qualifications or training or both of an applicant were equivalent to a CCT. What is more, the GMC could not lawfully prescribe more onerous requirements than those laid down by article 8 (2). The specific outcome of this particular case is not in itself a matter for the profession. However, it appears to reinforce in law that to be appointed as a permanent consultant orthopaedic surgeon in the NHS, a candidate needs both to have passed the FRCS (T&O) and to have completed an accredited specialist training based on the syllabus of the day as approved by the GMC (now that the Postgraduate Medical Education and Training Board has been abolished or its equivalent). This makes complete sense to those of us who examine for the final intercollegiate FRCS (T&O). We are instructed in the clearest possible terms that the standard for the examination is that of a day one consultant in the NHS without experience of sub-specialist training. The examination is generally taken in year five of the six years of training, which in itself is an indication that training is incomplete. While knowledge, clinical skills and the ability to formulate a reasonable management plan are tested, there is currently no way in which operative skills can be assessed. This aspect of a candidate’s practice, along with a number of other practical details, need to be left to the judgement of the head of training and those for whom the candidate has worked. For those who apply from abroad, however, demonstration of the equivalence of training, in addition to their acquisition of the FRCS (T&O), would appear to be paramount.
References 1. Statutory Instrument 2010 No. 473. Health Care and Associated Professions: Doctors The Postgraduate Medical Education and Training Order of Council 2010 2. Matthew Brotherton, Barrister. Nakhla v General Medical Council.  EWCA Civ 1522;  WLR (D) 510. CA: Longmore, Lewison, Burnett LJJ: 28 November 2014 The Incorporated Council of Law Reporting for England and Wales
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A Glimpse into Current Trends in Orthopaedic Oncology Orthopaedic oncology presents challenges that involve an array of specialties working in close co-operation. Challenges exist in all areas, from diagnosis to rehabilitation and from basic science to improved surgical technique. Recent advances in drug therapy, implant design and image-guided technologies, as well as an increased focus on the ‘patient pathway’ will hopefully improve outcomes for these patients. Here is a snapshot of some current areas of interest in orthopaedic oncology.
Size still matters in Sarcoma…. The single greatest improvement in the survival of patients with sarcoma can be achieved by earlier diagnosis. Bone and soft-tissue sarcomas are rare and contribute approximately 1% of malignant cancers and 2% of UK cancer deaths per year. Treatment involves surgical resection and chemotherapy with or without radiotherapy. Although reconstructive options have resulted in improvements in function compared with the surgical interventions of 30 years ago, these remain life-threatening and life-changing diseases for the very young people they often affect.1 Prognostic factors include grade, site, size and evidence of metastases.
The Birmingham group has shown a linear relationship between increasing tumour size and the presence of metastases at diagnosis and overall prognosis (Figs 1 and 2). At diagnosis, a sarcoma with a diameter under 5 cm has less than a 5% risk of metastases, compared with a sarcoma of over 10 cm which has a greater than 10% risk of metastases. Tumour size can perhaps become a controllable risk factor if it can be improved by early diagnosis. Today, in the UK, a bone sarcoma is 10.7 cm and a soft-tissue sarcoma 9.4 cm at diagnosis. Guidelines from the UK Department of Health and the National Institute for Health and Care Excellence (NICE) were introduced in an attempt to reduce morbidity and mortality from all cancers, and yet ten years later, only minimal improvement has been made in the size of sarcoma at diagnosis. In this, we underperform considerably when compared to Scandinavia, Italy and Australia, where the average size of a sarcoma at diagnosis is less than 7 cm. Why do we do so poorly? The answer is not straightforward, but increased general awareness at many levels is an essential component. Delay in presentation can occur at the patient level, in primary care and in hospital-based care. Improved awareness of both patient and primary care has the potential for the biggest gains.
Fig. 1 Tumour size vs Presence of Metastases at Diagnosis (from Grimer R et al)
C. J. McDougall S. J. T. Patton
The rarity of these tumours ensures that the average general practitioner may not see one in their lifetime. Renowned medical educator and General Practitioner, John Murtagh founded the concept of “Restricted Rule Outs” as a diagnostic model. It requires the consideration of the most common cause of a presenting problem, the probability diagnosis, then includes, secondarily, the serious diagnoses that must be ruled out and which must not be missed. We need to embrace this style of thinking when dealing with bone and softtissue lumps. Improved early diagnosis can transform tumour size into a controllable risk factor. Rob Grimer has been instrumental in the slogan “Size Matters in Sarcoma”. In his Hunterian Lecture in 2004,2 he introduced the golf ball as a trigger (Fig. 3). At 4.2 cm, a golf ball-sized lump is 2 cm larger than the average breast cancer at diagnosis, but still 5 cm smaller than the average soft-tissue sarcoma. Understanding this simple message could lead to an improvement of up to 20% in survival for patients with sarcoma. A lump the size of a golf ball must have a diagnosis. It is malignant until it is ruled out. Size matters in sarcoma.
Fig. 2 Kaplan Meier Survivorship Analysis: Tumour size (from Grimer R et al)
Denosumab - A breakthrough in the medical treatment of Giant Cell Tumour?
There is no evidence or suggestion that this treatment can prevent recurrence, and now, after more than a year of clinical use, questions remain about the duration of treatment and the effect of long-term treatment on bone quality. However, this drug has the potential to alter the early management of this benign aggressive bone tumour significantly, and we watch with eagerness as more results become available.
Giant Cell Tumour (GCT) is a rare, aggressive osteolytic tumour which affects young adults. It is usually benign but, due to its juxta-articular location, is often associated with significant morbidity. The treatment of choice is either intralesional curettage with adjuvants or en-bloc resection. Local recurrence rates of between 10% and 50% are reported, and proven medical therapies have been limited. The pathophysiology of GCT makes it appropriate for targeted drug therapies. Several studies into GCT have identified neoplastic stromal cells which express high concentrations of Rank Ligand (RankL): these activate Rank-positive osteoclasticlike giant cells, ultimately resulting in osteolysis and bone destruction. Bisphosphonates inhibit osteoclastic-mediated bone resorption and have been used in the treatment of GCT, but little established data exists about their effectiveness. Denosumab is a human monoclonal antibody which inhibits RankL and therefore Fig. 3. A lump the size of a golf ball must have a diagnosis interferes with the RankLâ€“Rank interaction. Sant Chawlaâ€™s group in Santa Monica has released the second phase of their study investigating the safety and efficacy of using Denosumab for the treatment of Giant Cell tumour with promising results.3 The patients were divided into two groups, one with surgically unsalvageable disease, and a second group which had surgically salvageable disease, but with a known high morbidity. All patients received subcutaneous Denosumab and were followed for a median of 13 months and 9 months, respectively. Some comFig. 4 Navigation Intraoperative plications were noted: these included osteonecrosis of the jaw, hypocalcaemia and hypophosphateamia, but overall the safety profile was satisfactory. What is most en- Navigate to find the way. couraging is the potential to affect disease progression. The emergence of computer-based, imageIn the first group, with surgically unsalvage- guided technologies and robotics is already able disease, 96% had no progression of dis- revolutionising many surgical specialties and ease after treatment with Denosumab. In the has an expanding role in the surgery of orsecond group, with surgically resectable dis- thopaedic oncology. The use of three-diease, 74% had not required surgical resection mensional CT and MRI images merged with at the time of latest follow up, and for those computer navigation systems can assist both who did have surgery, 62% had an operation in pre-operative planning and operative techthat was smaller and less invasive than origi- nique and is increasingly being used for comnally planned. plex tumour procedures.
The aim of computer-assisted surgery (CAS) is to achieve optimum bone resection without compromising oncological outcome, subsequent reconstruction or morbidity related to the damage of surrounding structures.4 The process involves creating a three-dimensional virtual model of the anatomy of the patient from a series of radiological images. Segmentation occurs whereby each volume element (voxel) of the imaging data is assigned to a particular tissue and then reconstructed into a three-dimensional image which can be visualised and manipulated. Once the image has been created, planning occurs to determine the appropriate resection margins and reconstructive options. Intra-operatively, landmarks, distinct from the resection area, are identified on the patient, registered and then correlated with the virtual image allowing the surgeon to refer back to the computer image for assistance with orientation. Selected navigated instruments e.g. osteotomes, drills, saws and diathermy can be viewed on the computer in relation to the anatomy of the patient to inform osteotomy and resection. (Figs 4 and 5) The use of CAS in pelvic resection for sarcoma has shown promising early results in the literature and in future we hope to use this technology increasingly in the reconstruction of bony defects created by tumour resection. No computer is a substitute for detailed anatomical knowledge, surgical technique and good decision-making, but in complex procedures, where the risks are high and the margin for error slight, any adjunct that can assist in making the procedure safer and more reliable is a welcome addition. Navigation and other computer-based technologies will play a considerable role as we move forward. Implant Technology: Is a Silver Surface Infectionâ€™s Silver Bullet? Tumour patients have risk of up to 11% of developing periprosthetic infection. Infection around a megaprosthesis significantly compromises outcome and limb salvage. Patients are frequently immunosuppressed and their condition is often further compromised by the addition of radiotherapy. Amputation rates after infection approach 25%.5 The concept of different implant materials having different rates of infection was
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subspecialty of enormous interest. Advances in research, greater understanding of pathologies and better communication and cooperation both within and outside the speciality will herald improvements in outcome for this devastating area of disease.
Fig. 5 Navigation Intraoperative discussed by George Gosheger in 2008, 6 when he showed that titanium megaprostheses had a lower rate of infection than cobaltchrome implants. Silver has been known for its bactericidal properties for millennia. Recently, it has been developed for use in orthopaedic implants either as a surface coating or as a surface modification. The introduction of a silver treatment to tumour and revision endoprostheses has shown some promising results. In a recent study which compared highrisk patients managed with either a silvertreated endoprosthesis or a standard endoprosthesis, the silver-treated group showed a reduction in the risk of prosthetic infection of up to 30% as well as a better success rate with two-stage revision after a minimum of 6 months follow-up.7 If these results can be maintained, the improvements in morbidity associated with implant infection will easily offset any additional cost. Extracorporeal irradiation Limb salvage and reconstruction can be challenging after en-bloc resection of malignant or aggressive bone tumours. Various options exist for the management of bone defects. Prosthetic replacement or allografting are frequently the treatments of choice, but depending on the site, have loosening rates of up to 57% in some studies. In some anatomical areas, like the pelvis, options can be
limited. In the ideal situation, a purely biological solution is preferred, but is often very difficult to achieve. Extracorporeal irradiation of resected bone has been used in many centres since the 1990’s, and more recently several outcome studies have been published.8 It is a process whereby, after en-bloc resection, the excised bone and tumour are sampled, sent immediately for high-dose irradiation, which is lethal to the tumour cells, and then returned to the operating theatre for re-implantation as a dead, acellular anatomical bone graft. The aim is for the graft to become reincorporated within the host. A study from Paul Stalley and the NSW Bone and Soft Tissue Sarcoma Service in Sydney, reviewed 50 patients who had undergone extracorporeal irradiation after en-bloc resection for malignant bone tumours.9 After a mean 38 months follow-up, 84% of patients were disease-free. Of that group, 73% had excellent or good functional results on the Mankin score and most had achieved bony union. Complications specific to the graft included avascular necrosis and bone resorption. Encouragingly, there were no reports of tumour recurrence specific to the reimplantationof the bone graft. Some concerns remain about its use for highly radioresistant tumours such as chondrosarcoma. Extracorporeal irradiation is a useful adjunct to the management of bone defects in the patient with musculoskeletal tumour. Orthopaedic oncology is a growing surgical
REFERENCES: 1. Smith G, Johnson G, Grimer R, et al. Trends in presentation of bone and soft tissue sarcomas over 25 years: little evidence of earlier diagnosis. Ann R Coll Surg Eng 2011;93:542-547. 2. Grimer R. Hunterian Lecture: Size matters for Sacoma. Ann R Coll Surg Eng 2006:88:519–524. 3. Chawla S, Henshaw R, Seeger L, et al. Safety and efficacy of denosumab for adults and skeletally mature adolescents with giant cell tumour of bone: interim analysis of an open-label, parallel- group, phase 2 study. Lancet 2013;14:901-908. 4. Young P, Findlay H, Patton J, et al. Computer Assisted Navigation in Musculoskeletal Oncology. Orthop Trauma 2014;28:294-302. 5. Jeys L, Grimer R. Carter S, et al. Periprosthetic Infection in Patients Treated for an Orthopaedic Oncological Condition. J Bone Joint Surg [Br] 2005;87-B:842-849. 6. Gosheger G, Goetze C, Hardes et al. The Influence of the Alloy of Megaprostheses on Infection Rate. J Arthroplasty 2008;23: 916-920. 7. Wafa H, Grimer R, Carter S, et al. Retrospective Evaluation of the Incidence of Early Periprosthetic Infection with Silver-Treated Custom Endoprostheses in High Risk Patients: Case Control Study. Presentation ISOLS Conference Bologna 2013. 8. Poffyn B, Sys G, Mulliez A, et al. Uyttendaele. Extracorporeally irradiated autograft for the treatment of bone tumours: tips and tricks. Int Orthop (SICOT) 2011;35:889-895. 9. Davidson A, Hong A, McCarthy S, et al. Enbloc resection, extracorporeal irradiation and reimplantation in limb salvage for bony malignancies. J Bone Joint Surg [Br] 2005;87-B:851-857. A uthor
Sam Patton Consultant Orthopaedic Surgeon, Royal Infirmary of Edinburgh Sam.Patton@luht.scot.nhs.uk Catherine J McDougall FRACS, Orthopaedic Fellow, Royal Infirmary of Edinburgh firstname.lastname@example.org
The SICOT Young Surgeons Committee
Fig. 1 Young Surgeons Committee members from left to right: Samer Mahmoud, Mohsen Azam, Mohamed Sukeik, Ahmed Abdelazeem, Fatih Kucukdurmaz and Bassel El-Osta
he SICOT Young Surgeons Committee (YSC) was established in 2001 and has been chaired by several surgeons since then, including Dr Cyril Toma, Professor Hatem Said and, for the last two years, Dr Fatih Kucukdurmaz. The aim of YSC is to provide a platform for young SICOT members to work together, have a say in their education and training, propose new ideas and build a network with experts around the world. There are two categories for YSC membership, associate and full (Table I) and we currently have 20 active members. A number of subcommittees have been developed to enhance productivity of members with different interests including: SICOT Global Network E-Learning (SIGNEL), Webinars, SICOT Congress, Social Media and Women in Trauma & Orthopaedics. Some of the YSC accomplishments over the last few years include:
1) Arranging a number of Vumedi Webinars such as: Controversies in Hip Arthroscopy, organised by Professor Hatem Said who invited experts including John Oâ€™Donnell, Ali Bajwa, Soshi Uchida, and Nicholas Boni. Another webinar was titled Infection in THA, moderated by Dr Fatih Kucukdurmaz, who invited experts including Rajesh Malhotra, Javad Parvizi, Lehner Burkhard, Remzi Tozun and Craig J Della Valle. 2) Congress activities for this year included a number of symposia organised and delivered by YSC members at the XXVI SICOT
Mohamed Sukeik reports on the evolution of an initiative by trainee orthopaedic surgeons
Triennial World Congress held in Rio de Janeiro, 19-22 November 2014 such as: a) Consensus on Periprosthetic Joint Infections (PJIs) moderated by Dr Kucukdurmaz and Professor Javad Parvizi where world experts including Daniel Berry, Fares Haddad, Gehrke Thorsten, Henrik Malchau, John Callaghan, Ian Stockley and Ibrahim Tuncay were invited to discuss and debate management of interesting cases of PJIs. b) Meet the Experts-My Preference in Total Hip Arthroplasty was moderated by Dr Kucukdurmaz and Professor Jacques Caton. A faculty of world renowned surgeons including Burak Beksac, Eric Smith, Fares Haddad, Javad Parvizi, Jean Prudhon, Moussa Hamadouche and Patrice Mertl debated cemented versus uncemented, large versus small heads and anterior versus posterior versus lateral approaches in THA.
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c) Leadership and Management led by Mr Mohamed Sukeik who proposed the idea to the SICOT Headquarters after undergoing special training on the subject in the UK. The symposium was well received by attendees. d) Avoiding Malpractice in the Era of Patient Safety led by Mr Samer Mahmoud and Dr Eric Tortosa.. This session was also well attended with good feedback. e) A YSC Symposium which included lectures on Balancing Life for a Clinician-Scientist: Learning from Experience delivered by Professor Parvizi, SICOT Fellowships delivered by Professor Hatem Said and Dr Ahmed Abdelazeem, SICOT Young Surgeon as Part of a Team delivered by Mr Mohamed Sukeik. 3) Organisation of the 21st SICOT Trainees Meeting 1-2 June, 2014 in London which was led by Mr Bassel El-Osta, Mr Mohamed Sukeik and Mr Samer Mahmoud. This was a great event which attracted national and international orthopaedic trainees. A series of invited lectures by world renowned speakers were delivered, practical workshops prepared and trainees presented their research work and competed for the best three podium presentation prizes. A social event was also organised on board of a restaurant boat moored on the River Thames, opposite the London Eye. 4) The SICOT Educational Day was one of the most prestigious and important accomplishments of YSC when it began four years ago and has evolved into an essential part of the annual SICOT educational programme. The Educational Day Committee has now
become a separate committee with a YSC representative and is led by Mr Vikas Khanduja. The committee has produced great educational programmes every year covering various subspecialties of Trauma and Orthopaedics, and with keynote lectures by internationally renowned speakers 5) Contribution of YSC members to the SICOT E-Newsletter as part of the editorial board or regular submission of reports. 6) The SICOT Facebook and social media pages were initiated by Professor Hatem Said They have become popular and contain regular contributions from YSC members. 7) Professor Hatem Said also involved YSC in the SICOT Fellowships programme which later developed into a separate committee led by him. This committee is the main body assessing the annual applications for various SICOT Fellowships committee and deciding on appropriate candidates and requirements for each Fellowship. 8) The SICOT fun night, initiated by Professor Hatem Said and run by the YSC committee for four years, has become a regular event in the programme of the SICOT annual congress.. The YSC philosophy can be summarised with the African proverb: “If you want to go fast go alone; if you want to go far go together”. We have a long way to go, and we always seek energetic and enthusiastic members. So, please join us at the next SICOT annual meeting to be held in Guangzhou, China, 17-19 September, 2015.
Table I: Membership Categories for the SICOT Young Surgeons Committee (YSC) Regular Member - Young Surgeon in SICOT
1) Being a SICOT member 2) Being under 40 years
Associate Membership of YSC
1) Being a SICOT member 2) Being under 40 years 3) Participation in one YSC Symposium 4) Application for Associate membership of YSC during the annual symposium
Full membership of YSC
1) Being a member of SICOT 2) Being under 40 years 3) Attending at least 2 YSC Symposia within three consecutive congresses 4) Being active in YSC activities Full membership is subject to election by full members of YSC at the AGM
Mohamed Sukeik ST6, The Royal London Rotation email@example.com
Bridging the gap
SICOT/WOC Symposium in Rio David Jones reports on a Symposium held during the SICOT/SBOT Congress in Rio de Janeiro in November 2014 he SICOT organisation, in conjunction with World Orthopaedic Concern (WOC), is making a major effort towards charitable activity for the developing world: to this end Mike Laurence and I were asked to convene and co-chair a symposium which would invite senior figures to cover examples of charitable activity in orthopaedics. This information would then be available to SICOT/WOC to help them plan their strategy and allocate resources. The title of the symposium ‘Bridging the Gap’ highlights the gap between need and resources. Six speakers were each allowed 10 minutes in which to get their message across. As an introduction, David Jones (UK) traced the development and scope of charitable activity in orthopaedics over the past 25 years and summarised ways in which resources could be directed as follows: building relationships; supporting models of affordable health care; teaching and examinations locally; maximizing the internet; funding Fellowships (? examinations) abroad and encouraging and facilitating research and publication. Ashok Johari (Mumbai), Chairman of Education-SICOT, described the organisation’s role in bridging the gap through education and training. He highlighted that ignorance was the major factor in poor patient management and the reason why education of the orthopaedic surgeon is one of the most important objectives of SICOT. He showed examples of what SICOT was doing worldwide through its global network of education (SIGNED). These include congresses and trainee meetings; CME programmes (e.g. educational days); regional courses and training programmes; webinars; other e-learning projects (e.g. SIGNEL) and scholarships and awards. He also described how SICOT had established Education Centres in many parts of the world with others to follow (Fig. 1).
Arindam Banerjee (Kolkata) described a silent revolution in orthopaedic trauma over the past 20 years whereby India had made up for 50 years deficiency and has standards of care equal to any advanced centre in the world. The challenge was to develop the infrastructure whereby such standards could best be offered to the 1.2 billion population of India. He showed that, of all trauma, 60% of was RTA-related and 50% was orthopaedic. He emphasised that poverty does not equate to destitution or ignorance and poor people will not accept the cheapest option. They will migrate to better facilities. Good infrastructure to cope geographically with all types and severity of orthopaedic trauma demands well-trained personnel throughout the orthopaedic team and first-rate equipment and implants. The former can be achieved through innovative training schemes and community follow-up programmes and the latter by manufacture of indigenous equipment and implants at a fraction of international costs. The funding and delivery of this service will largely be from the private sector through subsidies within private hospitals and medical insurance. India had 55 million people insured in 2004. The projected figure for 2015 is 635 million. The impact of private payment is to keep prices down, force the development of indigenous alternatives and recognise that the consumer demands value for money. In summary, developing countries such as India have to find their own solution to their infrastructural woes. Knee-jerk, imported solutions and charity do not work. The solution lies in a holistic approach encompassing finance, manufacturers, doctors, technicians and equipment and technical training at every level. The rapid progress in India is neither sponsored by the state nor centrally planned. It is the cumulative effect of individuals and societies who tried to better themselves and in the process took health care to the next level.
Fig. 1 SICOT Education Centers, current and in preparation
Fig. 2 Prof Rajasekaran delivers an emotive presentation to improve the carnage on India’s roads.
However, there were other areas where there was room for improvement, such as multimedia learning centres, simulation labs, DVDs of operative techniques, slide libraries, cheaper publications for developing countries, guidelines and algorithms for management and mentor interaction. For the future, SICOT needs a well-coordinated Education, Training and Examination Department. The educational and training needs of different parts of the world need to be identified and, with a well devised programme. SICOT needs to intensify its efforts to increase penetration and impact in areas of need. Finally, SICOT must take a pro-active role rather than rely on passive efforts by its membership
As an example of how collaboration between doctors and other organisations helped to improve orthopaedic trauma care, Rajasekeran Shanmuganathan (Coimbatore, Fig. 2) highlighted the carnage on India’s roads. India has 1% of the world’s vehicles but 7% of RTA deaths. There are 75 000 annually, one every six minutes currently and projected to occur every three minutes in 2020. For every death, 10 people are permanently disabled. More than 60% of accidents are due to rash driving: many of the victims are the innocent party (Fig. 3). The State had hitherto borne no social responsibility for these appalling figures: to address this, The Ganga Hospital and local Rotary Clubs formed the Peoples Movement against Road Accidents, which they called AYIR (Life). The
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Fig. 3 Two sad stories, through no fault of their own Movement’s activities included accident-awareness and first-aid programmes for all types of road user, vehicle safety checks, speed checks and enforcement of safety measures such as seat belts and helmets. The Movement also brought a successful High Court action against the Government, making them take responsibility for implementing road safety measures Patricia Fucs (Sao Paolo) described the deficiencies of care and resources in rural Brazil, highlighting the huge differences in the provision of hospital facilities and orthopaedic expertise between rich and poor areas (Figs 4 and 5). In the Brazilian Constitution, health care is a citizen’s right and should be provided by the State. Nevertheless the inequality between urban and rural health care has become a major problem. The characteristics of health care in
rural areas were lack of human resources, difficult access, huge geographical distances, few people with access to health insurance, a high turnover of doctors and professionals, poor equipment and lack of a career plan. In order to address the problems, the Declaration de Brasilia was established with the goals of keeping doctors in rural areas by improving infrastructure, creating interregional health networks, introducing rural health in postgraduate education and promoting residency programmes, higher degrees, professional development and international exchange of knowledge. All these proposals are in the early stages of implementation: their longer-term effects are not yet available. John Dormans (Philadelphia), the incoming President of WOC International, described the important American contribution towards service and training. He began by highlighting that contributions by individual
Fig. 4 Brazil 2013. Hospitals/Clinics per State and ratio of doctor per inhabitant .
countries or societies need to be compatible with those of others, including international aid organisations such as WHO and MSF. Duplication of effort and competition should be avoided. That said, he listed many American contributors to bridging the gap, such as Orthopaedics Overseas (OS), Health Volunteers Overseas (HVO), individual universities, medical student associations and several orthopaedic societies (AAOS, POSNA, SRS, COA). As an example of all this effort, the Scoliosis Research Society (SRS) undertakes courses worldwide, carries out global outreach projects to teach local surgeons and funds travelling fellowships. He continued by showing how Americans had contributed significantly to the SICOT educational programme and concluded by suggesting ways how SICOT/ WOC can help bridge the gap through growth of activity within SICOT and expanding relationships with other professional societies (e.g. AAOS), surgical implant networks and collaboration with international organisations such a WHO and MSF. In discussion, Dr Jamie Quintero spoke on behalf of the AO Socio Economic Committee which undertakes courses and funds Fellowships for developing countries. He expressed his support for the SICOT/WOC initiative and thought it likely there could be collaboration with AO-SEC Foundation. In his summary and proposal for the future role of SICOT and WOC, Keith Luk (Hong Kong), incoming President of SICOT, highlighted the organisation’s strength as a global non-profit making association of highly qualified surgeons, recognized by WHO and having a good relationship with AO-SEC. The influence of SICOT already spreads to more than 130 member countries which include the developed, developing and underdeveloped world. In order for SICOT to bridge the gap, the financial, human and networking resources of the organization need to be harnessed to a strategy which addresses particular areas of need. These include the identification of models of care which need support, helping to improve infrastructure, guiding politicians and administrators, training orthopaedic personnel through courses and fellowships and public awareness programmes. To these ends SICOT needs to identify a champion and core group. They will take stock, determine the strengths of key players and set realistic and sustainable targets. All this should be achieved before the next SICOT Congress in Guangzhou, China in September, 2015.
Fig. 5 Brazililian Or thopaedic and Traumatolog y Society (SBOT ). Distribution of its 1050 0 active members
David Jones, Co-editor, BJJ News firstname.lastname@example.org
Balancing the Social Contract and the role of the New Zealand Orthopaedic Association Society puts its trust in the medical profession. This is a fundamental, vital and essentially unseen aspect of treatment, diagnosis and healing. In exchange for this trust, society has allowed the profession autonomy in its decision making: this includes self-regulation. Self-regulation is a privilege rarely offered by regulators and is only available to a few professions. It has substantial benefits for the profession and is balanced by equally substantial responsibilities. This is often referred to as ‘the social contract’, an arrangement whereby each medical professional is allowed to make independent judgements within their scope of practice. To ensure that the ‘social contract’ remains balanced, this autonomy must be matched by accountability. This article describes how the NZOA fulfills its obligations. Orthopaedic surgeons in New Zealand have a mandatory responsibility to be registered by the statutory regulator, the Medical Council of New Zealand (MCNZ). Amazingly over 98% of these surgeons also voluntarily belong to the New Zealand Orthopaedic Association: which was founded in 1950. The Association has always taken its members’ obligation to retain transparent autonomy and selfregulation very seriously. This is reflected in the historically thorough and enjoyable book Orthopaedics in New Zealand by long-term member Colin Hooker, who describes the early commitment of the Association’s members to
Flora Gilkison, describes how NZOA upholds high standards of orthopaedic practice ensuring that the art and science of orthopaedic surgery is a trusted and highly-regarded specialty. This book was used to source much of the Brief History of Orthopaedic Surgery in New Zealand published in BJJ News in June 2014. The Association has quantified the requirements of its members to ensure that ‘best practice’ is widely promulgated and practised: these methods also support the privilege of self-regulation. It is salient to note that when the latest programme to promote diligent and rigorous selfregulation was introduced, the membership voted unanimously to adopt it.
Fig. 1 Members and guests at the NZOA Annual Scientific Meeting 2014
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New Zealand, like all other developed countries, is faced with an increasingly ageing population with all its attendant musculoskeletal problems. Along with this are the rapidly rising cost of health care and the need to ensure that resources are adequately prioritised. As a surgeon, a member’s main responsibility is to their patients, both to ensure that they receive the best possible care and to be their advocate. The budgetary constraints of management must be weighed against surgical best practice, which requires clinical leadership to come to the fore. The Association’s members understand the need to be leaders in deciding what, how and where operative practice is implemented. This demand, recently described by the British Orthopaedic Association as a ‘tsunami of orthopaedics on the horizon’, must be managed to ensure that the needs of the patient are adequately met and forms an important aspect of the ‘social contract’. At times, the responses of health managers are not necessarily the best way forward. Engaging in clinical governance can bring better results, resources can be optimised and the outcome of the patient improved. The Association’s philosophy is for its members to engage actively in clinical governance. There are many examples of past and present clinical leadership. The Association acknowledges there are complex competing pressures. Surgeons have to keep performing at their very best, to be strong advocates for patients, to enable operating teams to work effectively and to maintain the confidence of the public, while living within the budgetary pressures imposed by management. This is one side of the ‘social contract’. The balancing aspect is the autonomy in decision- making and self-regulation given to the profession, which also results in social prestige and an ability to receive high financial reward. To maintain this balance, explicit, clearly enunciated, and transparent self-regulation practices are needed. There are four key practices of the NZOA which assist effective quality self-regulation. The first is an audited online Continuous Professional Development (CPD) programme which requires members to undertake 70 hours of study each year to retain their Annual Practising Certificate, awarded by the MCNZ. It includes 20 hours of effective practice reflection and 50 hours of continuous professional development. The former is a mixture of peer review audit meetings, regular X-ray meetings, department meetings, morbidity and mortality reviews, and the latter teaching, examining, journal clubs, research publications and attendance at conferences (Fig.1). The Association has also set compulsory requirements for CPD. These include four peer- reviewed audit meetings, the maintenance of credentialing for each hospital a member works in and, if undertaking arthroplasty, lodging the required data for all primary and revision procedures in the New Zealand Joint Registry from both public and private practice, including a peer-reviewed meeting on the annual results. The other mandatory requirement is to participate in the Association’s Practice Visit Programme, usually on a five-year rolling basis. The latter deserves further mention as it is an effective 360° process which ensures that members are practicing effectively and are aware of the latest best practice. The Practice Visit Programme involves two surgeons visiting another surgeon for one or two days. The preparation beforehand is extensive with the surgeon being assessed having to obtain at least 20 confidential patient surveys, 10 peer surveys including theatre staff, physiotherapists, anaesthetists and practice managers. The surgeon must also provide their last three months surgical records and their Joint Registry results. The visiting surgeons review the visited surgeon’s consulting rooms, their record keeping and observe at least two procedures in a full operating theatre. At the end of the visit a debriefing is undertaken by all three
participants and a graded report written. An A grade means the member has shown no area for concern, a B shows the member may have some areas to improve and a follow-up visit in the next year may be required, a C grade gives rise to some serious concerns with a follow-up visit in the short term and a D grade would mean in all likelihood that the concerns being raised are so serious the visiting surgeons should raise these with the MCNZ. These recommendations are all followed up. The programme requires high levels of trust and confidence by the members and is seen by others and the MCNZ as a superb example of professional self-regulation. The third area supporting self-regulation is through the establishment of a Research Foundation to encourage trainee and full members to engage in research to ensure that the art and science of orthopaedic surgery is advanced. The fourth area is a constitutionally authorised Ethics Committee. This is commonly referred to as ‘the three wise men’ and can be formed when a member raises a legitimate concern with the President that another member may be in breach of the Association’s code of conduct; for example, acting unethically or displaying behavioural problems. The committee usually comes from the Presidential line which is a four-year term and which so far in the Association’s history has consisted only of men, but this situation is likely to change in the future. The key defining feature of orthopaedic surgeons, the one that gives the public confidence to allow ‘the social contract’ to work, is shared transparent ethical standards. It is interesting to note that surgeon ethics is an international issue and one the EFORT team is also endeavouring to quantify. Colin Hooker’s book shows how strong, shared consistent ethical standards have helped to maintain New Zealand orthopaedic surgery as a well-respected specialty. Honesty and integrity are the first two essential ethical standards. When these are mixed with altruism, appropriate decision making and compassion for patients and their families, they form the basis for the Association with its collective desire to ensure these standards are upheld by all. When a member becomes aware of a colleague who is not performing well, the balance of the ‘social contract’ and the requirements of the wider profession need to be considered. Members are encouraged to resist openly criticising a colleague’s work and to endeavour to show objectivity and balance. It is important, however, that if there is a concern about a colleague then the Association gives an appropriate and timely response. The possible actions range from a conversation with the colleague to a request to the President for an ethics committee to be formed. The continuum is wide with many options along the way. The important aspect in the philosophy of the Association takes the privilege of self-regulation very seriously. The ‘social contract’ needs to remain in equilibrium. Patients need to trust their surgeons and the profession and to know that all is done with integrity. As external pressures build, budgets and resources become more stretched, demand grows exponentially and frustrations emerge. A great strength of New Zealand orthopaedic surgeons is that they know they have a supportive Association and one of whose key roles is to ensure consistent collaborative ethical practise. This is what gives efficacy and legitimacy to the ‘social contract’.
Flora Gilkison Chief Executive New Zealand Orthopaedic Association email@example.com
Notes from the road
Sixty-fourth New Zealand Orthopaedic Annual
Scientific Meeting, Tauranga, 19-22 October 2014 Matt Costa recounts a memorable visit to New Zealand The 64th New Zealand Orthopaedic Annual Scientific Meeting was held on the 19-22 October 2014 in Tauranga, a rapidly developing city on the North Island with a large port and thriving industrial heart. However, it is also a tourist’s dream, with long golden beaches and the iconic Mount Maunganui, all set against the backdrop of the beautiful Bay of Plenty. The meeting was run by the NZOA in conjunction with the local organising committee led by meeting convenors and local orthopaedic surgeons, Vaughan Poutawera and Andrew Stokes. The NZOA ASM meeting is open to members of the NZOA and invited guests. Compared with other international meetings it is small in scale, but what it lacks in numbers it more than makes up for in quality. Guests this year included an illustrious group of international orthopaedic association presidents and their wives; Dr Josh Jacobs from the American Academy, Dr Larry Marsh, American Orthopaedic Association, Dr John Tuffley from Australia, Mr Colin Howie from Britain, Dr Bas Masri from Canada and Professor Mac Lukhele from South Africa. Other invited speakers this year included Professor David Sonnabend from Australia, Professor Constance Chu from the USA, Dr Hiro Sugaya from Japan and (the somewhat less illustrious) me.
The meeting also welcomed travelling fellows Dr Alec Hung, Dr Soe Naing, Dr Ng Wuey Min and Dr Hoang Khac Xuan, from the Hong Kong, Myanmar, Malaysia, and Vietnam Orthopaedic Associations, respectively. The meeting was officially opened by NZOA President, Mr Mark Wright. This was followed by an entertaining presentation from Martin Sneddon, former New Zealand cricketer and chief organiser of the Rugby World Cup in 2011. On behalf of the English, I soaked up some well-deserved ribbing but at least I wasn’t an Aussie guest. The remainder of the first day of the meeting was punctuated by keynote presentations and papers from a number of invited guests and New Zealand surgeons. Concurrent sessions on the following days covered the orthopaedic subspecialties: there were several panel discussions of interesting and complex hip, knee and shoulder cases. The educational sessions usually paired prominent NZ surgeons and invited guests. Included for the first time at an NZOA ASM were sessions and symposia on ‘outreach and disaster orthopaedics’, ‘current issues in orthopaedics’ and education. These sessions proved successful and, as well as the panel discussions, provoked much lively discussion and debate amongst delegates.
It will be of no great surprise to those of you who have visited New Zealand, that a key part of the ASM is the associated sporting programme. On the Sunday afternoon before the opening of the formal meeting, a large number of delegates enjoyed golf, mountain biking, clay pigeon shooting, and paddle boarding. I am still getting the mud out of my nose and ears after a particularly wet mountain bike trip to Rotorua. The visiting partners’ programme included visits to art galleries and restaurants, a kayak trip, a walk up Mount Maunganui and a trip to Hobbiton, one of the Lord of the Rings film sets. The highlight of the social programme was the formal gala dinner (Fig. 1) capped with an inspiring presentation from Olympic gold medallist and America’s Cup sailor, Rob Waddell. I felt privileged to be invited to speak at the NZOA Scientific Meeting. I thoroughly enjoyed the lively debate and educational sessions, as well as the mountain biking, of course. I would strongly encourage invited speakers to take the opportunity to attend this event and take advantage of a beautiful and welcoming country. I would like to express my thanks to Vaughan and Andy who organised a fantastic meeting, and to my friend and fellow ABC traveller, Dawson Muir and his family for looking after me so well.
Fig. 1 Guests at Gala Dinner. MC is four th from lef t
Matthew Costa Consultant-Orthopaedic Surgeon, Warwick Clinical Trial Unit Matthew.costa@ warwick.ac.uk
BJJ News | I ssue 6 | M arch 2015
Notes from the road
SICOT/SBOT Congress, Rio de Janeiro,
November 2014 Fares Haddad reports on an outstanding meeting
Fig. 1 Copocabana in the morning. A great place to run
his brief report summarises a quick but very enjoyable visit to Rio de Janeiro this November for the combined Societe Internationale de Chirurgerie Orthopaedique et de Traumatologie / Sociedade Brasileira de Ortopedia e Traumatologie meeting. This was a large affair with more than 4000 SBOT and almost 1500 SICOT delegates in attendance The highlights included beautiful weather, great hospitality with a warm welcome from our hosts, and the opportunity to run along the Copacabana beach every morning (Fig. 1). The Bone and Joint Journal was well represented by a number of editorial board members on the podium, in particular, Andy Carr, who delivered an impressive Plenary Lecture on ‘Improving Evidence for Orthopaedic Surgery; a Global Challenge’. We also had a splendid, well-located stand where we had the chance to meet many our authors, reviewers and readers. The SICOT meeting was busy and included a number of tailored programs that had been set up independently. My commitments started on Wednesday with an excellent full day of
hip and knee reconstruction run by the AO group in collaboration with South American colleagues. I chaired it with Bas Masri, the President of the Canadian Orthopaedic Association (Fig.2). The morning was focused on knee surgery and provided a wonderful mix of talks about knee preservation which included an update on the role and modern techniques for osteotomies around the knee, the management of varus and valgus deformity and strategies for articular mal-unions. We discussed innovations in total knee arthroplasty which included the role of mobile bearings, enhanced polyethylene and patient-specific instruments. This was followed by a lively case discussion. Another session focused on revision knee arthroplasty and included a presentation on porous metals from one of the rising stars of North American orthopaedics, Matthew Abdel. We covered various modes of treatment of periprosthetic infection, once again followed by detailed discussion. The afternoon sessions were centred on the hip. A highlight of the day was Professor Reinhold Ganz who presented his indications for, and the limitations of periacetabular osteotomy (Fig. 3).
We next had a state-of-the-art session on femoral neck fractures which covered the indications for fixation, replacement and osteotomy. The rest of the afternoon was spent considering the optimisation of hip arthroplasty and included lectures on approach, component selection and position, the role of modularity, bearing choices and revisions for a variety of indications. A talented international faculty covered the full breadth of complex hip surgery quickly and efficiently. On Thursday, there was an excellent session organised by Vikas Khanduja on the indications and outcomes of hip arthroscopy. Some outstanding presentations were delivered and I was able to highlight the superb outcomes of this intervention in the short term in expert hands. However, the lack of long term data, absence of Level 1 studies, and the reality that this is merely one form of intervention for hip preservation should not take the emphasis away from careful decision-making based on history, examination and appropriate imaging. I was also able to highlight some of our data which suggests that full-thickness chondral damage may be associated with poor outcomes, potentially further narrowing the indications for intervention
for femoro-acetabular impingement. Ultimately, the focus needs to be on a critical consideration of hip anatomy, biomechanics and physiology, and a clear understanding of the full range of interventions available, as well as a greater knowledge of the natural history of the conditions we are treating, rather than the overzealous application of arthroscopic techniques. In the afternoon, Jay Parvizi organised an excellent afternoon session on the infected arthroplasty with John Callaghan, Dan Berry, Ian Stockley, Young-Soo Park and me as a panel. We covered a number of contentious areas which
illustrated how much more work is needed before we reach a genuine worldwide consensus. On the Friday morning, I joined an excellent collaborative session with colleagues from International Orthopaedics to cover the current state of the art in publication. This included consideration of key issues such as peer review, the open-access revolution, improving the presentation and language in papers, and the future of orthopaedic publication (Fig. 4). It was a very high quality session with an excellent discussion. The International Hip Society also held an open session on Friday 21st November which was split into two sections. The first
section, moderated by Paul Beaulé and Michael Leunig, covered the increasingly topical area of hip joint preservation. The second, which I moderated with John Callaghan (Figs 3 and 4), was centred on issues in primary and revision THA including some very controversial areas such as the anterior approach, the role of resurfacing and optimal fixation. All in all it was an extremely busy but rewarding three days in Brazil. The meeting itself provided a unique blend of high quality expert presentations with a very international flavour of free papers and a friendly social programme in a beautiful setting.
Fig. 2 Symposium with Bas Masri (lef t), Pierre Hoffmeyer, Matthew Abdel and three local AO surgeons
Fig. 3 John Callaghan (lef t) in conversation with Rheinhold Ganz
Fig. 4 Editorial group. From the lef t , Andrew Quaile, Fares Haddad, Marco Pecina, Marius Scarlet , Cyril Mauffrey A uthor
Fares Haddad Editor–in–Chief, BJJ firstname.lastname@example.org
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The Twente Lower Extremity Model (TLEM)
he Twente Lower Extremity Model (TLEM), developed at the University of Twente is used to predict muscle and joint reaction forces during movement. M u s c u l o s ke l e t a l m o d e l s h ave m a ny applications in different fields, such as ergonomics, spor ts performance and orthopaedics. TLEMsafe is a project funded by the Seventh Framework Programme (FP7) of the European Commission, and seeks to build on the foundations of the original TLEM model to conduct operations safely and more predictably for patients who need extensive surgery. The objective of TLEMsafe is to integrate this musculoskeletal model with the MRI of a p a t i e n t t o s i mu l a t e s u r g e r y a n d i m p ro ve f u n c t i o n a l r e c o v e r y. Similar technology can already be used to plan anterior cruciate ligament reconstruction and meniscal surgery. These are smaller interventions, but for cases which involve the excision of a substantial tumour or the implantation of a prosthesis, the process becomes much more complex. In these circumstances, it is more difficult for a surgeon to formulate a precise operative plan and accurately predict recovery. For example, a patient may suffer from a tumour in the knee and is advised that it should be resected. Until now, surgeons have been unable to determine with any degree of accuracy how much of the surrounding muscle and bone can safely be removed while maintaining the function of the leg,
or even if the leg should be amputated. The surgeon will, of course, explore every avenue in an attempt to prevent amputation and will probably recommend an implant. Problems can arise, however, such as infection, or if the leg becomes non-functional. TLEMsafe aims to avoid this and increase the chance of performing limb-salvage surgery by improving the safety and predictability of complex musculoskeletal surgery using a patientspecific navigation system. Workflow Principles (Fig 1) Starting from MRI scans at the Radboud University Medical Center, essential individual
patient-specific model to simulate different operative scenarios. For example, in the case of a tumour located close to the knee and affecting the quadriceps muscle, the surgeon could choose to transfer a muscle from the back of the thigh to the front to help the weakened quadriceps. Using this virtual system, the surgeon can transfer different muscles to different positions and predict the effect of each surgical option. Once the surgeon has reviewed the MRI scan and exploited the software to develop the best surgical plan, they can place that into a navigation system, developed by Brainlab, and perform the operation. The 3D system guides the surgeon in the operating theatre on the basis of the plan d e t e r m i n e d p re - o p e r a t i ve ly to achieve the best functional outcome for the patient. This work is still in the early stages, but we have proved the workflow principles on a cadaver. The next challenge is to apply it to patients. We are hoping to undertake this in the near future. Lastly, we have also developed a complex method to measure muscle metabolism using volumetric glucose consumption. We modelled this by injecting a patient with 18F-fluorodeoxyglucose, asking the patient to perform a walking exercise, and using a PET scan to measure muscle energy consumption in terms of the glucose metabolised. We are the first in the world to do this. By 3D mapping, we can accurately determine which muscles consume energy, and exactly how much. This is our most significant achievement towards the validation of these musculoskeletal model predictions.
Professor Dr Nico Verdonschot, Project Coordinator of the TLEMsafe project, discusses an innovative patientspecific surgical navigation system used for pre-operative planning and execution of complex musculoskeletal
surgery details of the patient’s musculoskeletal system are extracted, using innovative algorithms specially developed by Materialise. All these data are then integrated by researchers at the University of Twente into the new version of the TLEM model and implemented into the modelling system provided by AnyBody Technology, in order to build a patient-specific musculoskeletal model. A n i n n o v a t i ve p re - p l a n n i n g s y s t e m developed by the Warsaw University of Technology allows the surgeon to use the
Fig. 1 Workflow principles
The TLEMsafe project has been very successful in meeting its goals in a relatively short time, but the team at the University of Twente and Radboud University Medical Centre could not have come so far on their own. Their wide-ranging collaborations with project partners outside The Netherlands have been part of the secret to their success. O ve r t h e l a s t ye a r o f o p e r a t i o n s , collaborators at the Warsaw University of Technology, Poland have been responsible for developing knowledge and software for 4D imaging of the human body for use in the
data collection process, as well as developing the virtual reality interface, Surgery Planning Environment 3D (SPE3D) to be used in TLEMsafe. Materialise NV, Belgium is a company concerned with 3D printing and computeraided design and medical image processing software. Their expertise made them the ideal candidate to develop software tools to extract the maximum information from 3D medical image data, using segmentation and morphing tools to determine patient-specific muscle volumes and attachment points A uthor
AnyBody Technology A/S, Denmark has been active in the field of orthopaedics for a long time and is responsible for the development of one of the leading software systems for simulating the mechanics of the live human body â€“ a great asset to the project. Brainlab AG, Germany specialises in the development, manufacture and marketing of medical technology. In the TLEMsafe project they were responsible for the surgical navigation portion of the system.
Professor Dr Ir Nico Verdonschot Project Coordinator Laboratory of Biomechanical Engineering Faculty of Engineering Technology MIRA Institute University of Twente The Netherlands email@example.com
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A Somerset Cider Orchard
Chris Ackroyd, now retired from orthopaedic practice, shares with us his second career as a cider apple farmer
he drinking of apple juice and cider goes back several thousand years. Apples trees were growing in the United Kingdom well before the Romans arrived in 43 AD but it was they who introduced organised cultivation. Northern France was renowned for its orchards and vineyards as indeed was southern England. These areas became less suitable for the growing of grapes due to climatic changes and gradually cider began to replace wine in the United Kingdom. After the Norman Conquest in 1066 changes were introduced which led to an increased popularity of cider and new varieties of apples were developed. It became the drink of the people and its production spread rapidly. By the 14th century cider production was well established in many of the counties of southern Britain and had spread even as far north as Yorkshire. Cider was produced in substantial quantities on farms and by the 18thcentury it was customary to pay a farm labourer’s wage in cider. A typical allowance would be three to four pints a day although at harvest time the allowance was considerably increased. In the western counties of England a farm worker could receive up to one fifth of his wages in cider. One might question what this did for productivity! In the latter part of the 19th century a campaign to stop payment in the form of alcoholic beverages led to its prohibition in the Truck Act of 1887. By the end of the First World War cider drinking was in decline. Beer was becoming more accepted and the growth of French wine drinking was hitting sales hard. Cider making was becoming restricted to parts of Kent and the West Country including Gloucestershire and Herefordshire. In France and the UK, cider apples tended to be grown towards the western extremities where the climate and soil conditions are most suitable. Under the influence of the Gulf Stream the weather is relatively mild and the area has a fairly high annual rainfall. After the war, in 1924, a young Bristol University graduate, Redvers Coate, took a year`s unpaid job at the newly founded Long Ashton Research Station and was inspired to open a cider works at Nailsea with help from family and friends. He was just 23 years of age and so was born “Coates Cider of Nailsea”. Redvers Coate had installed the most up to date equipment including three glass-lined vats holding ten thousand gallons each. At the end of the first year Coates Cider took three prizes in the National Cider Competition.
Fig. 1 May blossom
Fig. 2 Sheep grazing, April to September
By the star t of the Second World War, Coates was beginning to make a name nationally and sales rose in wartime due to beer rationing. The company expanded and by the 1960s Coates was exporting widely and buying apples from more than a thousand Somerset farmers. However, by the 1980s cider drinking had once again become less popular due to increased production and the better quality of wines from North and South America, Australia and New Zealand. The large brewing companies had concentrated on beers and had bought up a number of pubs and restaurants leading to control of sales. Nevertheless the tradition of cider apple growing in Somerset and Herefordshire continues and there has been a recent upsurge in cider drinking due to skilful advertising campaigns, particularly the Irish firm which produces Magners cider and, in the West Country, Thatchers Gold. There are hundreds of different varieties of apples and the Long Aston Research Station was responsible for helping to develop newer varieties. This is what stimulated Redvers Coate in his quest to develop cider making and shortly after the Second World War when the business was expanding he planted out an experimental orchard of 1,500 trees on a twenty acre site near his home in Abbots Leigh, Bristol. All of this history was unknown to me in the early part of this century when I retired from some of my orthopaedic practice. I was interested in purchasing woodland and in 2005, with the help of a legacy from my mother, the local land agent persuaded me that a fifteen acre cider orchard in Abbots Leigh would fulfil my ambitions. The trees, which had originally been half standard, had been allowed to grow and were now anything from 20ft up to 45ft. The orchard had been planted out by Redvers Coate as an experimental orchard in the spring of 1951. The rows were 36ft apart and the trees 18ft apart. There were eighteen different varieties of cider apple tree, four rows being the Ashton Brown Jersey apple which was developed at the Long Ashton Research Station. Thus began an ongoing ten-year romance with cider apples and the trees. The orchard year begins on 17thJanuary with the Wassailing Ceremony. The word comes from the Anglo-Saxon toast “waes hael” meaning “be thou in good health”. The Lord of the Manor would give food and drink to the peasants in exchange for their blessings and goodwill and the purpose of the ceremony was to awake the cider apple trees and scare away evil spirits to ensure a good harvest of fruit in the autumn. In addition to consuming quantities of cider and food, the ceremony also sometimes involved the firing of a 12-bore into the tree, something which has not occurred with my trees! The trees remain dormant throughout the winter and into the early spring. Replanting of new trees takes place in February or March. The leaves do not begin to appear until mid to late April and the blossom occurs in May, usually about the third week (Fig. 1) The 2014 season was unusual in that weather conditions were such that the blossom started in early May and continued throughout the month. This extended flowering season allowed the bees and other pollinating insects more time to do their work, resulting in a massive crop of fruit and an exceptional year for honey.
By mid-June I had taken off at least 150 lbs from three hives. For those readers who are not beekeepers I would normally get 20-30 lbs of honey from each hive by August or September. Throughout the summer there is little for the farmer to do other than to pray for sun and rain. Due to the relatively dry summer of 2014 and the exceptional activity of the bees, there was a massive crop of very small apples which did not start swelling until late in the season. It is normal for some of the smaller apples to drop in June or July allowing the trees to concentrate on the maturation of the remainder. The sheep are allowed to graze the orchard between April and September and act as fertilising lawnmowers (Fig. 2) Harvest comes in the autumn and by early September the apples are beginning to mature and starting to fall from the trees. By mid-October there is a carpet of apples on the ground (Fig. 3) and the first of two
Fig. 3 October apple carpet
Fig. 4 October apple harvest . Chris Ackroyd in control
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harvests is carried out. Traditionally, harvesting was by hand and the apples were either picked from the trees or from the ground. There are now massive machines capable of shaking and collecting the apples from the larger trees but in Far Orchard we use a mechanical harvesting machine which sweeps the apples up from the ground similar to a golf ball collecting machine (Fig. 4). The apples are then transferred to lorries for transportation to the cider factory. By mid-November, between 60 and 70% of the apples have fallen and a second harvest is carried out in late November. Weather conditions at this time are usually terrible. It is cold, wet and the ground is extremely treacherous especially on the sloping areas of the orchard which are particularly difficult and dangerous to harvest. Several varieties keep their apples on the trees well into December and even January, particularly the Ashton Brown Jersey variety. Thus one can still be harvesting on a cold, crisp January morning but the apples keep perfectly in the soft grass almost like a domestic refrigerator. The bulk of the apples go to Thatchers, a traditional family cider maker, who stop their activities at the end of November. The remaining apples go to several of the many specialist and farm cider makers throughout Somerset. The 2014 season has been good with a harvest of at least 100 tons of apples which sell at about £120 per ton. The cider making process is simple and similar for dealing with a few kilograms or hundreds of tons of apples. These are first washed then shredded to mash (Fig 5). This is pressed and the pure apple juice flows out in abundance (Fig 6). There are many devices for pressing from old Victorian machinery to modern hydraulic
Fig. 5 Shredding the apples
Fig. 6 Pressing the apples
balloon presses. The residual apple pomace is traditionally fed to pigs or sheep or used for compost. The juice can be drunk within a couple of days or pasteurised to keep for up to two years. The cider is fermented under a water lock, usually with the natural yeasts in the juice. After a few weeks when the fermentation has died down the cider is wracked off and bottled. A sparkle can be produced with carbon dioxide, or a pinch of sugar will allow a natural sparkle to develop. Throughout the year there are a number of jobs to be fitted in, such as pruning, re-staking and cutting up the fallen trees and removing the stumps. Generally the trees can be expected to live between sixty to a maximum of one hundred years. We expect to lose between five and ten trees each year through old age, disease and storms. After 64 years the majority of trees are still in extremely good health. The main section of the orchard has about 1,000 trees of which 100 have been replanted in the last ten years. At present there are probably about twenty gaps which will be replanted after a fallow period. Ancient orchards such as “Far Orchard” fruit on a two-yearly cycle. There is also about a ten-year cycle of greater or lesser harvests depending to a considerable extent on weather conditions. Thus the cycle of the seasons brings us back to the Wassailing ceremony in early January. It remains only to taste the fruits of our labours (Fig 7). We do our own pasteurising of the apple juice which is delicious and will keep for many months. The cider will be fully fermented and ready for drinking in six to nine months from harvest. Good health to all!
Fig. 7 Chris Ackroyd with the fruits of his labour
Christopher Ackroyd, MA firstname.lastname@example.org
BJJ News | I ssue 6 | march 2015
David Jaffray; an Appreciation
I thought you should be notified of a significant day in the history of The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, namely an event to mark and celebrate Mr David Jaffray’s contributions and achievements during his career, particularly his impact on the many trainees who have passed through the hospital. That he was held in such esteem and affection by so many of his colleagues and trainees was borne out by the many who contributed to his portrait and, of those, the large number who attended a celebration of his career on 14th November. As one of his earlier trainees, I had the pleasure of organizing and coordinating the event which I’m sure presented a reflection of David’s influence and achievements, particularly at Oswestry, but also, nationally and
internationally. It also captured the spirit of humour, dedication and compassion that accompanied his efforts. The afternoon in the Institute of Orthopaedics started with a clinical conference and culminated with the unveiling of his portrait. It was agreed that Peter Edwards, the artist, had done an outstanding job in capturing David’s likeness and character (Fig. 1) The clinical conference was the usual Friday afternoon affair of high quality educational content mixed with humour and moments of reminiscence. As ever, David’s unique and direct vocabulary, along with his anecdotal skills, were to the fore. That evening, a dinner was held in his honour, the dress code being pullovers. More stories and memories were forthcoming, none more so than from
David Jaffray beneath his por trait
David himself (Figs. 2.3.4). This was a wonderful event and I would like to thank all those that attended, whilst also apologising for not being able to find a date that everyone who had contributed could attend! David Jaffray has had an outstanding career as a spinal surgeon, caring doctor, teacher, mentor, examiner, anatomist and supporter of the tradition and heritage of Oswestry. This celebration was a fitting tribute to a great man. He is now in the autumn of his career, but I suspect there are many orthopaedic trainees who hope to benefit from his wisdom for many years to come.
Yours sincerley, Dan Howcroft
Fig. 2 David in full flow af ter dinner
BJJ News | I ssue 6 | M arch 2015
David with Peter Edwards, the ar tist
Fig. 4 David, seated with his wife Dawn beside him and the dinner guests
Dan Howcroft email@example.com
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Michael Laurence remembers a legend of Irish rugby who, for 37 years, became the only surgeon in a 500-bed missionary hospital, in Chigole, Zambia. November 28th 2014, Jackie Kyle, one of the sportsmen in the history of Rugby n greatest football, died at the age of 88. In the Englishspeaking World of International Sport, nothing attracts quite so much flamboyance, in fans as much as players, as Rugby football. In this last year we lost two of the greatest players of all time, both of them artists who created the modern game seemingly out of nothing. Both died in their eighties; neither made a living out of playing the game. Very peripherally, I met one of them, and knew the other. Both were entirely ignorant of their ability; neither could be drawn into discussion of their achievements. Jackie Kyle, born in 1924, and Cliff Morgan, born in 1930, dominated the half-backs of the fifties. They met for the first time on the pitch in a game between Wales and Ireland. It was Morgan’s first international cap; Kyle already the star. He put his arm round the youngster, bid him welcome for his first cap, and hoped he was to have an enjoyable game. During that decade they were to change Rugby football out of all recognition. Neither was a goal kicker, but each an inspirational tactician and try scorer.Those they didn’t score, they constructed.Their build was slight; they did not power themselves through the opposition. Their running style was unique, evading tackles by sheer speed from a standing start or by deviation through an acute angle. Neither was ever severely injured; they were rarely ever caught. In the fullness of time, Cliff Morgan said how much he admired the other, saying that he, Jackie, was “the greatest fly-half ever to play the game”. That in itself was an amazing statement from one who was bred in the fly-half factory of Wales – through Glyn Davies, Phil Bennett, Barry John and later, Jonathan Davies. Kyle, unphased by such a statement, adroitly side-stepped the compliment “No. no, Cliffie; that title belongs to you.”
Fig. 1 Jack Kyle
BJJ News | I ssue 6 | M arch 2015
These were the days of the amateur game. Analysis with By the 1990s, 80% of his patients were suffering from HIV/ slow-motion replay would be taking the whole thing far too Aids. seriously. I recall an interview with a dedicated investigator He took us to lunch, at the golf club – “expat. indulgence” who asked him about his preparation – whether he lead with -- but I was unable to steer the conversation towards the his left foot when approaching a defender from the right,-goal-posts. He would smile - perhaps a recollected match and how did he plan to wrong-foot full backs, &c &c . The – quickly to fade, without a semblance of nostalgia. The reply was typical. “To tell the truth I don’t know a great deal games of yesterday’s childhood were set aside together about the game. I just sort of play it.” There was no sarcasm with his OBE, the Grand Slam for Ireland (1948) the Triple in the remark. He played with the instinct of which he Crown (1949) the home countries Championship (1951); an expressed ignorance. Bob Scott, the great All Black fly-half, Honorary Doctorate from Queen’s University, membership against whom Kyle scored a famous try at Dunedin on the of the International Rugby Board’s Hall of Fame, and a British Lions tour of 1950, lifetime achievement award said: “Of all of them there from the Royal Academy of has never been, nor ever Medicine of Ireland. was, anyone to touch him.” The number of his patients So it was when he in Zambia, with ever y type abandoned both Rugby of surgical need, was greater and Ireland, in favour of even than those who cheered his proper (or daytime) his genius from the terraces job. Trained as the most of Lansdowne Road or general of surgical Twickenham. A literate and practitioners, he left these quietly religious man, Kyle islands for the Copperbelt would read poetry before a of northern Zambia to be match if he wasn’t taking a the only surgeon in a 500nap, which he often did before bed missionary hospital, a game. Even on the pitch he in Chigole, near Kitwe, had a relaxed, almost somnolent close to the Congolese air, until, as Frank Keating Fig. 2 In action against England border. There he worked described, “with a dip of his hips for 37 years. His work and an electric change of gear, was by modern standards he would leave the floundering uncomplicated and cover, rooted like trees, as he “general.” Just as a fly-half, touched down under the posts”. he was clever enough rarely He took the Rubaiyat of Omar to get into surgical trouble, Khayyam on the Lions tour. He but instinctively to find his said the greatest compliment way through anatomical he ever received was from the difficulties. Irish poet Louis MacNeice who, I visited him in Chigole, when asked if he could make in the late seventies. He one wish, replied: “I would like s h owe d m e ro u n d t h e to have played rugby like Jackie wards and discussed cases, Kyle.” Fig. 3 With Brian O’Driscoll (lef t) at Ireland’s in spite of my personal One of the sadnesses of a Grand Slam victor y, Cardiff, 20 09. Jack Kyle wish to talk about rugby. long life is that so many of those was a member of the only other Irish Grand He described his work with who would have cheered the Slam team in 1948 typical modesty: “I’m just like loudest are themselves already an old country surgeon in rural Ireland, 60 or 70 years ago – dead. Cliff Morgan, many of whose opinions are set down nothing remotely sophisticated, I’m afraid”. here, predeceased Kyle by a few months. He too, excelled There were cases of hernia, spinal fracture, vascular injury, in the years following his stardom on the pitch. A man of caesarean section, tibial fracture, undiagnosed tumours and immense natural generosity, Cliff leaves a son who is an osteomyelitis. Problems of pathology paled into pathos. eminent orthopaedic surgeon. A uthor
Michael Laurence Past- President, World Orthpaedic Concern firstname.lastname@example.org
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