BJJ News from The Bone & Joint Journal
Formerly known as JBJS (Br)
BJJ News | I ssue 7 | J une 2015
Bridging the gap
The Malawi National Joint Registry S. Graham
My Journey into Uncertainty F. Monsell
17th IOSUK ANNUAL CONFERENCE LIVERPOOL, 3rd â€“ 4th July 2015 Venue- BT Convention Centre at The Liverpool Waterfront. The IOS UK aims to bring British and Indian Orthopaedics together through training and education. The educational programme will briefly include - Pre-Conference Symposium for nonconsultant grades, Instructional course in trauma, MCh Orth. Liverpool Alumni program & dinner, free paper sessions, invited guest lectures, top tips from experts and academic symposium amongst other activities. There will be a workshop on Certificate for Specialist Registration (CESR) application for staff grade and associate specialists. An impressive array of international faculty, who are renowned key opinion leaders in their sub-specialties like Trauma, Hip & Knee Arthroplasty, Shoulder & Elbow, Hand & Wrist, Foot & Ankle etc have all confirmed. The BT Convention Centre is an award winning, purpose built, state of the art centre with excellent conferencing facilities. The Hilton at Liverpool One is the conference hotel. Liverpool has excellent rail and road links from all major cities in the United Kingdom.
Online registration and abstract submission - http://iosukliverpool2015.com Mr Vishal Sahni Chairman, Organising Committee
Mr Vijay Bhalaik Chairman, Scientific Committee
Why are we here?
My Journey into uncertainty
Things I wish I’d known when I
The Scottish Deerhound
The ‘blue bubble’
Robert Robins 1923-2015
Stephen Andrew Copeland 1946-2015
Andrew Sprowson 1974-2015
from The Bone & Joint Journal
The ideal orthopaedic training scheme: wishful thinking or a shifting
Bridging the gap The Malawi Joint Registry
notes from the road Reflections on BASS 2015, the Assembly Rooms, Bath Recreation and travel
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Edited by: Mr David Jones Honorar y Consultant Or thopaedic Surgeon, London
Mr Alistair Ross Consultant Or thopaedic Surgeon, Bath
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BJJ News from The Bone & Joint Journal
A Bone & Joint publication www.boneandjoint.org.uk
Why are we here? hat is the purpose of BJJ News? While the Bone and Joint Journal itself is, and indeed should be, almost purely academic in nature and publishes only the best of scientific papers submitted to it from around the world, BJJ News is there, perhaps, to address the more speculative aspects of the discipline and to represent ideas that cannot be expressed in purely scientific terms. It also reflects the interests and preoccupations of the orthopaedic community as a whole, reports on scientific meetings that some may have missed and addresses issues that affect the practice of orthopaedic surgery in developing countries. From time to time there are review articles on various aspects of orthopaedics, but these tend to address the uncertainties rather than the “known knowns”. Although not clearly expressed to date, we very much welcome articles on any subject of interest from orthopaedic surgeons whether in training, in practice or retired. The editors have wide-ranging interests! In this issue, Jeya Palan, the immediate past president of BOTA, lays out his ideas for the ideal orthopaedic training. It clearly differs somewhat from that which is currently in place and expresses a degree of practical nostalgia for the demise of the concept of the orthopaedic “firm”, something that will resonate with orthopaedic surgeons at all levels. This is followed by two articles from eminent and somewhat more senior colleagues who propose, in their contrasting styles, that things are not always as easy as they look at first sight. Tony Ward summarises debate at the recent Bristol course on the emergency management of pelvic fractures and clearly outlines the steps to be taken in
cases of overwhelming haemorrhage. Nick Birch gives an overview of the BASS meeting in Bath and two Americans, Joshua Carothers and James Browne, describe travelling the length and breadth of the United Kingdom as guests of the British Hip Society. Simon Graham describes the remarkable work being done in Malawi to establish and record the outcomes of their joint replacement service. David Jones, my co-Editor, continues to travel widely and take in the wonders of the natural world. Bill Ledingham makes Scottish deerhounds sound so delightful and easy to care for that the Journal should probably consider acquiring a couple for the Offices. Not everything can be so light-hearted. It is also our sad duty to record the seemingly inevitable passing of friends and colleagues. This is particularly prominent in this issue in which we record the deaths of three outstanding orthopaedic surgeons from three different generations. Robert Robins, who has died at the age of 91, was a pioneering hand surgeon in the South West of England, a Hunterian Professor and past president of the British Society for Surgery of the Hand; Steve Copeland, who sadly succumbed to a recurrence of lymphoma at the age of 68, was one of the world’s foremost shoulder surgeons of his generation and will be particularly remembered for his work on surface replacement of the shoulder joint; Andrew Sprowson, who died tragically young just short of his 41st birthday, had already been recognised as a rising star in academic orthopaedics and, as his obituarists note, is thought of as possibly one of the finest presidents the British Orthopaedic Association will never have. We mourn them all while celebrating their remarkable achievements.
BJJ News | I ssue 7 | J une 2015
The ideal orthopaedic training scheme: wishful
thinking or a shifting paradigm raining in surger y has traditionally been regarded as an apprenticeship, with long years and diligent hours spent repeating, honing and refining one’s surgical craft, in order to become a master. Indeed, the old medical axiom “see one, do one, teach one” rang true for many a young surgeon in training until quite recently. However, surgical training has faced a number of challenges in recent years, not least with the introduction of European Wo r k i n g T i m e R e g u l a t i o n ( E W T R ) restrictions on hours worked as well as higher levels of patient expectations in an increasingly litigious society, the publishing of individual surgeons’ outcomes after surgery, changes in working patterns and the loss of the traditional ‘firm’ structure. The end result, without question, is a reduction in the level of clinical skill and operative experience of surgical trainees when compared to their trainers. I commend to the reader the Walter Mercer lecture given by Emeritus Professor David Hamblen at the BOA Annual Congress in 1999.[] Professor Hamblen, using Valentin De Boulogne’s painting, The Four Ages of Man, to eloquently and succinctly depict the four stages in orthopaedic surgical training: the undergraduate medical student; the basic surgical trainee; the specialist registrar and finally, the orthopaedic consultant. Even after 15 years or so, the issues raised in his lecture still hold true and continue to pose significant challenges to orthopaedic training in the UK. In the last few years, there has been a change from time-based training to competency-based training.[] It has also been recognised that the UK system of training remains one of the longest training systems in the world, compared to those in other Western countries such as Australia, Canada and the United States.[] Workbased assessments (WBAs) have been introduced as a mandatory requirement for training, as have the eLogbook for recording operations and the use of the Intercollegiate
Surgical Curriculum Programme (ISCP). The role of simulation in surgical training has also attracted a great deal of publicity and indeed, has been hailed by some as the panacea for training in surgery.[] As the Immediate Past-President of the British Orthopaedic Trainees Association (BOTA), I have spent a considerable amount of time immersed in different training systems and have seen and thought about how training can best be delivered in such a fluid and ever-changing landscape. I propose a ‘wish list’ of ten guiding principles, as a framework for an ‘ideal’ orthopaedic training system. 1. The EWTR should be applied flexibly to surgical trainees, and the working limit of 48 hours should be increased to 56 or even 60 hours per week. This would enable trainees to gain more clinical experience and also allow rotas to be designed more flexibly, thereby removing full-shift patterns of working and returning to on-call rotas. Unfortunately, despite surgical trainees and the Royal College of Surgeons of England vociferously calling for the EWTR to be relaxed for surgical trainees, such pleas have until now, fallen on deaf ears. 2. Abolish full-shift work systems which have been shown to be detrimental to training and which disrupt the relationship between the trainee and trainer. Instead, encourage firm-based models of surgical teams with ‘ownership’ of junior colleagues, thereby encouraging trainees and consultants to work as a team. 3. Not all consultants should be trainers. Being a trainer is not an entitlement but a privilege. Trainers need to have the support and trust of their department in order to train. This support must take the form of time and specific training clinics and lists where training is given the same priority as service provision. A balance must be struck, however, between making the role of trainer too onerous in terms of regulation and paperwork, and letting anyone become a trainer without first demonstrating the commitment, passion and ability to train. It should also be noted that trainers may have
different but equally appropriate approaches to training. Some trainers may be better suited to having more junior trainees who need a greater level of supervision, while others should have more senior trainees who need less supervision. 4. Training lists for clinics and theatres. Trainers must be supported and relieved of some of their service commitments in order to allow them time to train: this needs to be recognised by the NHS. This means having specific clinics in which time is allotted to allow trainees to discuss cases with their trainers and enable Case-Based Discussions (CBDs) and other WBAs to be undertaken appropriately. Theatre lists which are deemed training lists should have less cases or a specific case-mix, based on the training needs of the trainee. This may mean that operating lists are reduced to provide extra time for training to take place. This will be balanced by the fact that consultants who are not trainers would be providing a more service-orientated role and be able to undertake more operations on their lists instead. Furthermore, time to complete the relevant WBA should be included in job planning for trainers so that they are undertaken in the spirit in which they were designed rather than as a tick-box exercise because of a lack of time or opportunity to complete them properly. 5. The role of simulation remains an important aspect of surgical training but cannot be used as a substitute for real operative experience. Simulation, while valuable as a learning tool, will not replace operative experience. Furthermore, access to simulation facilities is, at present, haphazard, and maintaining such equipment can be expensive. In an ideal world, regular access to cadaveric laboratories, sawbones workshops and arthroscopic simulators would be the norm. In this cash-strapped NHS, such lofty ambitions remain an aspiration rather than a reality. 6. Undertaking the appropriate number of WBAs. In London, trainees are expected to complete a minimum of 80 WBAs in one
year compared to the rest of the UK where the requirement is for a minimum of 40 WBAs a year, as set by the SAC in T&O. Such differences highlight the issue of WBAs becoming used as a tick-box exercise rather than being used to truly encourage reflection and improve surgical thinking. There should be a UK standard which is adhered to and trainers allowed time to engage and undertake such WBAs with their trainees. 7. Return to six-month training slots in Core Surgical Training with a mandatory requirement to undertake six months in Accident and Emergency. Four-month rotations, while appropriate for medical students, are not long enough for a basic surgical trainee to gain the necessary exposure in a particular surgical specialty. 8. Improving the quality of audit and research under taken by or thopaedic trainees by having departmental audit and research projects which have been peerreviewed and which provide the necessary logistical support to enable such projects to be completed, leading to better clinical practice. At present, most audit projects undertaken by orthopaedic trainees are never completed, or presented and rarely lead to a change in practice.[] The role of trainee-led research and audit networks may be one way to address this problem.
9. Role of Physician Assistants. There may need to be a greater reliance on Physician Assistants, who help with the day-to-day management of ward patients and can help support doctors, freeing up time for them to undertake training, especially in surgery. [] 10. The Annual Review of Competency to Progress (ARCP) process should be made more robust and capable of identifying trainees in difficulty earlier on, so that supportive measures can be put into place in a timely fashion. The current Chair of the SAC, Mr David Large, has recently introduced ‘waypoints’ at ST4 and ST6, which allows the ARCP panel to gauge the likely trajectory of a trainee in terms of meeting their training requirements: this is an important step in improving the ARCP process. The points made above only deal with postgraduate surgical training. It must not be forgotten, as highlighted by Professor Hamblen, that orthopaedic training starts at medical school. At medical school, the shift in emphasis to communication skills at the expense of core subjects such as anatomy needs redressing. Anatomy is a critical part of surgery and its teaching is of primary importance to all doctors, not least surgeons. In conclusion, I believe that a paradigm shift in the way we train orthopaedic
surgeons of the future is taking place. Some of the points raised above are already being implemented but there also needs to be a fundamental change in culture within the NHS, to recognise and value the role of training and trainers. This will ultimately lead to better patient care. References 1. Hamblen DL. Educating orthopaedic surgeons - the art of the impossible. The Walter Mercer lecture, delivered at the annual meeting of the British Orthopaedic Association in Glasgow 15 September 1999. J R Coll Surg Edinb 2000;45:387–391. 2. Cox M, Irby DM, Reznick RK, MacRae H. Teaching surgical skills - changes in the wind. N Engl J Med 2006;355:2664–2669. 3. Syed S, Mirza AH, Ali A. A brief comparison of orthopaedic training in English-speaking countries. Ann R Coll Surg Engl 2009;91:226–231. 4. Kneebone R, Aggar wal R. Surgical training using simulation. BMJ 2009;338:b1001–1. 5. Guryel E, Acton K, Patel S. Auditing orthopaedic audit. Ann R Coll Surg Engl 2008;90:675–678. 6. Jones PE, Cawley JF. Workweek restrictions and specialty-trained physician assistants: potential opportunities. J Surg Educ 2009;66:152–157.
Fig. 1 The Four Ages of Man
Jeya Palan ST7 Trauma and Orthopaedics (East Midlands Leicester) Immediate Past-President, BOTA Associate Editor, BJJ firstname.lastname@example.org
BJJ News | I ssue 7 | J une 2015
My Journey into Uncertainty
his journey began in my late teens when, as an optimistic but unexceptional child, I entered formal medical training. My memories of the initial experience are a mixture of excitement and bewilder ment as, beref t of emotional intelligence, I attempted to master the art of independent living. In the classroom, there was a language to be learnt that was a combination of Latin and Greek, coupled with a Victorian culinar y lexicon. There were times when the eponymous work of Mrs Beeton would have been more useful to me than that of Mr Gray, particularly when introduced to descriptors which included coffee ground vomiting. This would have been second nature to the cultured soul, but to someone who had never seen real coffee, the association was mysterious. If pathological analogies had involved rustic examples, focussing, for example, on boiled cabbage, I feel that I would have been in with a chance. I look back with great fondness on my undergraduate educational experience. I learnt to communicate with the sick, attempted to unravel the mysteries of ECG interpretation and struggled with the stethoscope, which in my hands and ears was only useful in confidently diagnosing halitosis. Five years on,
complete with totemic white coat, I presented myself ready for action on August 1st of the year of my graduation. During my house year, I drew large volumes of blood to diagnose conditions I was unable to spell, got very tired and never once succeeded in submitting an accurate typed operating list. Most importantly, I learnt avoid the intertriginous issues that were the greatest potential hazard of the 120hour week. The purpose of this period of apprenticeship was to enable me to become part of the apparatus which would allow me to train in surgery and on this basis I entered what became my ‘zealot phase’. A widely-held prejudice was that the hallmark of a surgeon was a mixture of egocentricity and eccentricity in approximately equal measure. I considered that I had these essential qualities with plenty to spare and as a true disciple, committed the canon laws associated with this craft to memory. I read the works of Prussian grandees and came to believe that their theories were the absolute truth. I studied the biomechanics of joints and firmly believed that a celestial watchmaker had applied a mechanistic approach to the human form. I performed operations with the certainty of youth but without the insight provided by follow-up: at
this stage of my career, in retrospect, I was probably at my most dangerous. As time passed, I began to re-evaluate some of the central tenets of my new creed and began to experience periods of hitherto unknown self-doubt. What if there wasn’t really a windlass in the foot? What if the A.O. dogma contained methodological flaws? What if Charnley was wrong about the trochanter? This uncertainty followed me into my consultant career; the realisation that I was now primarily responsible for the people nominally under my care was a rude awakening. My previous snapshot of between six and 12 months evolved into an opportunity to observe the true consequences of my ministration at close quarters. This fuelled my scepticism and I noticed that zealotry was gradually being replaced by agnosticism. I had evolved into a paediatric orthopaedic surgeon and some of the conditions that were regarded as stock-in-trade caused me a degree of intellectual dif ficulty. Whilst I understood the technique of reorientation osteotomy for Perthes’ disease, I was troubled that the primary pathology was not being addressed. I saw good and bad results after surgery for hip dysplasia, and created some appalling consequences in my attempts
to modify the natural history of the slipped epiphysis. I studied the scientific basis for all of these procedures, but this caused me further doubt and I drifted gently into an atheistic phase from which I have yet to recover. I began to realise that most of the theories I used to hold dear were destitute, and that few interventions were of predictable benefit. It was obvious that total replacement of the hip, intra-medullary stabilisation of long bone fractures in adults and the surgical management of intra-articular sepsis did not need to be decorated with scientific theory, and common sense dictated that these were worthwhile endeavours. I became unconvinced about the rational basis for other areas of my practice and began to adopt an heuristic method for navigating through the average working day. I tried to define a practical approach to management and was left with a five-point discriminator, which I continue to use. In my clinical universe, Type 1 patients are ‘normal’ and when they can be assigned to this group, they are encouraged to leave hospital without delay and retreat to a place of safety. One of the most dif ficult par ts of children’s orthopaedic surgery however, is confidently defining normality in its many guises. This is part of the dark art of the ‘Plasterpod’, and perhaps a subject for another day. Type 2 patients ‘can be made normal’ and as contemporary medical practice largely involves the management of chronic conditions, restoration of normality is a rare treat. As bone is
the only tissue which heals without scarring, this is possible in trauma care; giving evolutionary biology a nudge and taking all the credit is good work if you can get it. I have noticed, however, that I am complicit in an increasing number of interventions which may be unnecessary. There seems to have been a gradual drift towards a defensive practice of medicine in general, and orthopaedics in particular, and I am uncomfortable about subjecting a young child to general anaesthetic to straighten a minor bend in their wrist. Type 3 pat ients ‘can be made better’ and this is a matter of careful definition. One of the main reasons for dissatisfaction in current practice is the failure to meet patient expectation. This is due to the setting of over-optimistic goals and is part of the retained zealotry that I have discussed in previous paragraphs. This is essentially an exercise in the communication of complex ideas and one that is difficult if these tendencies are retained. The notion of the Surgeon Messiah remains in all of us who practice surgery but this has to be repressed when dealing with the informed public. The consequence of failing to define ‘better’ in a way that it is understood by both parties predictably leads to a successful surgical procedure, with an unsuccessful outcome. Type 4 patients ‘can be made worse’ and whilst this is a characteristic of all patients in all medical specialties, it is particularly obvious in surgery because of the inevitable breeching of the integument. This is also a fundamental part of the art of communication that
is required of a practicing surgeon: a degree of agnosticism is generally helpful to remind me of the limits of my skills. It also serves as a warning of the everpresent danger to my fellow citizens if I approach them or their progeny with sharp instruments or powered tools. Type 5 patients ‘can be left alone, at least for the time being’ and these are most of the patients in whom it is clear that there is no life- or limb-threatening ailment. Natural histor y will often prevail and difficult problems, parked for a suitable amount of time, will often resolve or become substantially more straightforward. I have deliberately or intuitively limited my practice to things I think are sensible and believe, without evidence, that bent bones are generally better straightened and that fractured bones are generally better splinted, whether from without or within. I am also convinced that any operation for Perthes’ disease, DDH and slipped epiphysis is only legitimate if it does not interfere with future replacement of the hip. As I float towards my dotage, I am sure that the profession I have chosen is intrinsically worthwhile. I think that the fundamental requirements of a good surgeon are a critical appraisal of conventional wisdom, an honest evaluation of personal skills and careful matching of patients to decisions that are made on an individual basis. This is probably no more than redefining egocentricity and eccentricity, but for me it is likely to be more productive than believing most of what I have read over the last three decades.
Fergal Monsell Consultant Orthopaedic Surgeon, Royal Hospital for Children, Bristol email@example.com
BJJ News | I ssue 7 | J une 2015
Things I wish I’d known when I started Having recently been ‘defrocked’, it seems opportune to look back on the lessons of a long career in orthopaedics. The choice of a surgical career is a mixture of chance and serendipity. As a medical student I never had any doubts that I wanted to be a surgeon, for I had been dissecting worms and frogs from the age of six, but what did concern me was what field of surgery to undertake. Having qualified, I looked at surgeons: at that time cardiac surgeons were the ‘glamour boys’ and I could not resist the temptation to join them. How do you go about becoming a cardiac surgeon? I concluded the way forward was to visit the Mecca, at that time Houston in Texas. On the cardiac unit in Texas there was no shortage of drama: the atmosphere was both challenging and unpredictable and at times depressing. However the cardiac surgeons were different. Does the speciality breed personality or is it the other way about? I sought in vain for humility and insight but this did not seem to exist in the infancy of open-heart surgery. I came home convinced that it was not the speciality for me. When I was training, there always seemed to be time to reflect and make career choices. It took fifteen years to become a consultant, during which time we were exposed to many subspecialties and gained a very broad perspective of surgical opportunities. I decided I would become a neurosurgeon. Six months as a neurosurgical trainee was challenging, unpredictable and often depressing. Sadly, only too few patients seemed to benefit from intervention. The neurosurgical response was to become eternally optimistic, unfailingly confident and with even a touch of the deity. I felt I did not fit, so what next? Having sailed all my life and loving water I considered urology, but found that triangulation is not a natural gift: I spent many frustrating hours finding my way back to pathology, fleetingly glimpsed in the gloom. At this stage I was exposed to orthopaedics, and thus ended my dilemma. Orthopaedic surgeons were different, a happy, outgoing breed, cheerful and unfailingly optimistic despite setbacks. I came to appreciate that nature and growth could easily destroy success but at the same time could turn a sow’s ear into a silk purse. There was an immediate synergy; I had always felt comfortable in the pub after a long frustrating clinic. I had not, however, appreciated how diverse a speciality orthopaedics is; was I going to be a trauma surgeon, a microsurgeon or even an arthroscopist? At just this time, the freedom to plan one’s future career was lost when we were all assigned to training rotations. As a rotating registrar, the worry about unemployment was removed at the expense of the freedom to research and plan your future. Just as a six-month assignment became interesting and you became a valued member of the team you were moved to another unit, which was inevitably never going to fire the enthusiasm. Training rotations are set up with the aim of satisfying service needs, not necessarily a chosen pathway
designed to train, stimulate and enhance. A trainer’s ability to excite and stimulate interest in a sub-speciality is dependent on a broad knowledge of the subject, a solid research background and an ability to demonstrate technical skills, a combination difficult to achieve and to quantify. Now that nobody swears the Hippocratic oath, the ability and responsibility to pass on knowledge to the next generation is being lost. Orthopaedics has never come to terms with evaluating surgical skills, so much a part of surgery. The manual skills of engineers and airline pilots are regularly assessed but, for some reason, those of surgeons are not. As my registrar passed a needle through my finger whilst operating on a patient known to be HIV and hepatitis E positive, I was able to accept that I was not a very good judge of technical skills either. In the past I have advised a trainee that they lacked the necessary manual skills, and that this would inevitably have an impact on their future. To have raised this during training was justified recently when a past trainee wrote to me on his retirement as a professor of pathology thanking me for diverting him into a speciality that had given him immense pleasure and satisfaction. Before embarking on a medical career I worked as an engineer. The skills learnt at the bench stood me in good stead and laid a foundation of biomechanics and wear properties. Later, I was involved in designing a spinal implant but soon learnt that commercial pressures do not sit comfortably with medicine. Commercial relationships with implant companies need to be strictly monitored; there are too many pressures on clinical time and too many financial temptations to resist. The partner to freedom is the need to respect clinical commitments. When I was exposed to spinal surgery, I realised that I had been lucky enough to find my niche, however that exposure was by pure chance. A balance of challenge, innervation and risk that I found invigorating was combined with a mix of orthopaedics and neurosurgery. When you take on the responsibility of becoming a consultant, it is difficult to appreciate that with it comes worry and uncertainty for surgeons, patients and relatives, as well as the pleasures of success. It is no easy task to train in empathy when you are so intimately involved. A surgical career is both a celebration but also an addiction. There is no doubt that one’s family suffers as patients intrude into your life and it is at times like this when one is grateful for the teamwork and support of colleagues and staff, and, of course, the administration. It is always said that an orthopaedic surgeon is as strong as an ox and twice as intelligent. After a long career I will embrace that view with no regrets. A uthor
Tim Morley Formerly Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital firstname.lastname@example.org
Bridging the gap
The Malawi National Joint Registry
ackground Joint replacement registries play an impor tant role in monitoring and improving outcomes around the world. However, out of forty members of the International Society of Arthroplasty Registries (ISAR) there are only three national joint registries in lowincome countries, including our registry.  The number of total joint arthroplasties (TJAs) performed in a low-income setting, such as Sub-Saharan Africa, is increasing. There are various reasons for this, including the wider availability of surgical expertise and resources. There is also an increase in the use of arthroplasty surgery to provide a social businesses platform in the healthcare setting. A social business is a non-loss, not-for-profit, non-dividend company that is financially self-sustainable; the profits realised by the company are reinvested in the company. In other words, the hospitals provide a private elective surgical service that funds free healthcare for those most in need. An example of this model is Beit CURE International Hospital (BCIH) (fig.1)in Blantyre, Malawi – ‘Adults pay a fee, so that children can walk free’. Little is known about the long-term results of TJA in low-income countries, and how they compare with results from highincome countries. The age of the patients and the indications for joint replacement differ considerably from those in the developed world, and include a larger proportion of HIV-positive patients. Patients are commonly younger and continue to work in physicallyactive jobs after their operation. Furthermore, facilities, resources and the training of operating surgeons are substantially different to those of a high-income country.
S. Graham N. Lubega W. J. Harrison
Fig. 1 Beit CURE International Hospital The Malawi Nat ional Joint Registr y The BCIH was built in 2002 and included a dedicated arthroplasty service. Before this, only a small number of TJRs had been performed in Malawi and on an infrequent basis. The Malawi National Joint Registry (MNJR) registry was started in 2005 in order to ensure that patients who had undergone a TJR in Malawi were followed up and the surgical and functional outcome of their procedures were accurately recorded for purposes of both clinical governance and research. Over the last 10 years it has evolved to include other centres in the country: it is now the only national joint registry (NJR) in SubSaharan Africa, and one of the only registries in the world in a low-income country. In partnership with the MNJR, some units in Malawi now offer annual TJR ‘camps’, where visiting surgeons provide a free arthroplasty service for a select number of patients. All of these patients are then followed up and the outcomes are recorded on the MNJR. To date, 265 total hip arthroplasties (THAs) and 163 total knee arthroplasties (TKAs) have been entered into the registry: 22% of THRs
(58) and 2 % (4) of the TKRs are in HIV-positive patients. The reason for the difference in these numbers is due to the high incidence of osteonecrosis of the femoral head as a result of HIV and its treatment (highly active anti-retroviral therapy – HAART). The primary indications for THA and TKA in our registry are respectively osteonecrosis of the femoral head and osteoarthritis. The mean age of the patients who have undergone TKA is 65 years (24 – 84) and that of patients who have undergone THA, 55 years (15 – 88). Fully trained arthroplasty surgeons perform all the TJRs. All patients are assessed pre-operatively and consented for inclusion in the registry. After counselling and consent they are tested for HIV: a determination of the CD4 level in those who test positive and the use of HAART treatment are recorded. Routine preoperative tests include a full blood count and a blood slide for malarial parasites. Patient recorded outcome measures (PROMS) are recorded, including EQ-5D-5L scores, Harris Hip Score (HHS) and Oxford Hip Score (OHS) for patients undergoing THR, and an Oxford Knee Score (OKS) for patients undergoing
BJJ News | I ssue 7 | J une 2015
Chipliro Moffat (Ar throplasty Research nurse under taking a 6 month follow-up appointment with a 84 year old old patient af ter a total knee replacement
TKA. Standard pre-operative knee or pelvic and hip radiographs are also undertaken. Most THAs per formed in the country are cemented Charnley prostheses with either a flanged or roundback femoral stem, and a standard long posterior wall or Ogee cemented acetabular component (DePuy). Uncemented Biomet Taperloc stems are used in selected patients with an Exceed shell. DePuy PFC Sigma cemented TKAs are the primary prosthesis used for the knee arthroplasty. All patients are given preoperative antibiotics and thromboembolus detergent (TED) graduated compression stockings: low-dose aspirin is used for thromboprophylaxis all patients (Fig.2). Patients are followed up postoperatively at six weeks, six months, one year, two years, five years and then five-yearly. Radiographs are carried out at each follow-up appointment and PROMS data is recorded. Patients have a telephone appointment on a yearly basis, between face-to-face followup appointments. HIV-positive patients have their CD4 count rechecked annually as well as a record of their current treatment. The preliminary results of the ten-year follow-up of the TJAs in Malawi have shown very positive functional outcomes, and PROMS data appears to reflect results of arthroplasty in high-income countries. The final figures will be published in the near future. All the information is entered and stored on a secure central registry database.
Fig. 3 Simon Graham and Chipliro Moffat outside Beit CURE International hospital
An annual MNJR report is published and available to the public through the CURE Internationals website. Since 2014, The John Charnley Trust has become the primary funder of the registry; prior to this, funding was provided by the British Orthopaedic Association Joint Action Fund. Clinical benefits of the registry Having a NJR in a low-income country encourages other countries in the same position to start registries of their own. Comparative registries will highlight strengths and weaknesses, help to focus training and the development of clinical practice, and thus optimise the clinical governance of joint arthroplasty in low-income countries. Our results provide a benchmark against which other hospitals in low-income countries can compare their outcomes. Currently the only benchmarks are from high-income countries and which may not be comparable. For the wider international orthopaedic community, the MNJR provides a unique cohort of HIV-positive patients who are under long-term follow-up after a TJA. In the past, HIV has been considered an independent risk factor for infection, raising questions about the safety of carrying out joint arthroplasties on HIV-positive patients. Previous studies have focused on TJA in HIV-positive patients with haemophilia [3-6] and intravenous drug use (IVDU).[7-9] However, these conditions are independent risk factors for developing infection and complications following TJA.
[5,7,10] The reported long-term complication rates and functional outcome of TJA in HIVpositive patients without haemophilia or IVDU are contradictory and only describe small numbers of patients. However, recentlypublished data from the MNJR demonstrates that it is safe to perform THRs in HIV-positive patients, with good short-term functional outcomes and no apparent increase in the risk of infection in 43 THAs at a mean follow-up of three years and six months. The long-term outcome, however, remains unknown, but in future the MNJR will allow us to address this yet unanswered question. Furthermore, the results of TKA in HIV-positive patients are unconfirmed, but from our initial data the outcomes are equally as encouraging. The Future Due to funding, resource and organisational problems there are no other national joint registries in Sub-Saharan Africa. Funding is a problem our registry has had in the past, and there is a danger that if this is a not addressed, registries such as ours will not continue. Consequently the benefits such registries bring to the wider orthopaedic community, particularly in relation to HIV, would be lost. Recently, there has been an increase in the number of joint arthroplasties being carried out by visiting surgical teams in low-income countries. These surgical teams may not have the experience of operating in a low-income setting, and on occasions
Fig. 4 Dr Dave Burgess under taking a primar y TKR at Beit CURE International Hospital.
no follow-up is provided, even in the short term. Joint replacement surgery should be performed by a multi-disciplinary team, with established pre- and post-operative protocols and experience of undertaking such surgery in a low-income environment. Not following such guidelines can result in devastating consequences for the patients and their families. Within the next 12 months our study group intends to publish the ten-year outcome of TJA in Malawi. This will be the longest and largest follow-up study of its type in a low-income countr y. Over the next five years we will also report, for the first time, the medium- to long-term outcome of TJA in HIV-positive patients. A long-term goal is to establish partnered registries in neighbouring countries, to create a Southern Central African Joint Registr y. However, the problems of funding have restricted this long-term goal. Conclusion The aims of an African Hip Registry are very different from those of a western Registry, as the comparison of implants and
techniques is not the priority. Consideration of the different health, social and economic settings, the impact of HIV disease and high activity are of particular interest. We have encouraged other countries in our region to establish Joint Registries and, by pooling data, conclusions about long-term outcomes may be derived earlier. Furthermore, comparative registries will also highlight strengths and weaknesses in an arthroplasty service, including TJA ‘camps’, and help to focus training or the adjustment of clinical practice and thus optimise good clinical governance for joint ar throplast y in the region.
haemophilia: a 27 year single center experience during the HIV epidemic. Haemophilia 2005;11:233–239. 5. Goddard NJ, Mann HA, Lee CA. Total knee replacement in patients with end-stage haemophilic arthropathy: 25-year results. J Bone Joint Surg 2010;92:1085–1089. 6. Habermann B, Eberhardt C, Kurth AA. Total joint replacement in HIV positive patients. J Infect 2008;57:41–46. 7. Lehman CR, Ries MD, Paiement GD, Davidson AB. Infection after total joint arthroplasty in patients with human immunodeficiency virus or intravenous drug use. J Arthroplasty 2001;16:330–335. 8. Mahoney CR, Glesby MJ, DiCarlo EF, Peterson MGE, Bostrom MP. Total hip arthroplasty in patients
with human immunodeficiency virus infection:
1. No authors listed. ISAR International Society
pathologic findings and surgical outcomes. Acta
of Arthroplasty Registers http://www.isarhome.
org/directory (date last accessed 26th April 2015).
9. Tornero E, García S, Larrousse M, et al. Total hip
arthroplasty in HIV-infected patients: a retrospective,
2. No authors listed. The Malawi National Joint
controlled study. HIV Med 2012;13:623–629.
Registry (last updated April 24th 2015).[[bibmisc]]
10. Rodriguez-Merchan EC. Total knee replacement
3. Hicks JL, Ribbans WJ, Buzzard B, et al. Infected
in haemophilic arthropathy. J Bone Joint Surg
joint replacements in HIV-positive patients with
haemophilia. J Bone Joint Surg 2001;83:1050–1054.
11. Graham SM, Lubega N, Mkandawire N,
4. Powell DL, Whitener CJ, Dye CE, et al. Knee
Harrison WJ. Total hip replacement in HIV-positive
and hip arthroplasty infection rates in persons with
patients. Bone Joint J [Br] 2014;96-B:462–466.
Simon Graham Specialist Registrar Orthopaedics and Trauma, Mersey Deanery. Past Trauma Fellow, Queen Elizabeth Central Hospital, Malawi email@example.com
BJJ News | I ssue 7 | J une 2015
Notes from the road
Reflections on BASS 2015, the Assembly Rooms, Bath
Fig. 1 Bass 2015 Eclipse over Bath
elestial bodies aligned to create a lunar eclipse of the sun
but could not dim the brightness that shone from the Assembly Rooms, Bath during the British Association of Spinal Surgeons (BASS) meeting, held 18-20 March 2015. In 2011, Otto von Arx and Maurice Paterson, two of the local orthopaedic spinal surgeons and BASS members, successfully bid for the right to hold the annual meeting of the British Association of Spinal Surgeons in Bath. They booked an impressive venue at the Assembly Rooms, which, although built in the 18th century, is ideally suited to a modern conference. In all, 320 spinal surgeons, 50 trainees and allied healthcare professionals (AHP), and 90 staff representing 21 companies attended the three-day event. The BOA had an impressive stand and Colin Howie, its President, gave a forward-looking talk entitled ‘Horizon Scanning’. Mike Kimmons, CEO, was present during the meeting and was of great assistance in helping orthopaedic spinal surgeons understand the present role of the BOA in national healthcare. There were 64 podium and 44 poster presentations covering a wide range of topics related to spinal surgery. These were of a very high standard, many given by impressively-assured junior trainees and AHPs.
The keynote speakers came from around the world, including Europe, Scandinavia, North America, Australia, South Africa and the UK, and the attendees were highly appreciative of the time and effort they spent to bring their expertise and wisdom to the conference. The UK guest speakers’ talks were excellent, but David Jaffray from Oswestry, a past Trainer of the Year, won the Home Speaker Oscar when he captivated the audience with an amusing and sobering talk described his experience of managing spinal problems throughout a long and illustrious career. In the conference programme his abstract consisted of two sentences: “Millions of years of evolution have failed to produce a lumbar spine fit for purpose. Neither have I.” A sobering thought and one on which young and enthusiastic surgeons might wish to reflect. A wide range of topics were covered by speakers from Europe including the management of spinal tumours by Professor Stefano Boriani, a giant in the world of orthopaedic oncology; a presentation describing the difficulty of achieving sacral and pelvic fixation by Professor Brice Ilharreborde from Paris and a masterly examination of the evidence for specific timing in the surgical treatment of spinal cord injury by Dr Joost van Middendrop from the Netherlands. For many, however, it was Professor Peter
Fig. 2 Conference in the Assembley Rooms Fritzell’s forensic examination of the clinical effectiveness and cost-effectiveness of lumbar spine surgery that stood out. As the manager of the Swedish Spine Registry, the oldest and best of the all the spine registries, for the past 15 years, Professor Fritzell is in a unique position to be able to comment on whether the treatments we offer patients are as good as we would like to think. He did this in an exemplary fashion: perhaps his data might give some surgeons pause for thought when reaching for the latest high-tech gadget to treat a patient with a problematic lumbar spine. Dr Frank Feigenbaum occupies a most singular position in the spinal world as a well-established neurosurgeon from Dallas, Texas who also has busy practices in Kansas City, Missouri and Nicosia in Cyprus. More importantly, his practice is devoted almost entirely to the treatment of Tarlov cysts, diverticula of the arachnoid that many clinicians consider clinically irrelevant. But from the evidence of over 500 cases, by far the largest series in the world, Dr Feigenbaum was able to show the audience that there is utility in surgically managing these entities: for many this might represent a Damascene moment in their appreciation of this orphan disease that blights the lives of many patients. Our three Commonwealth guests, Professor Richard Williams from Brisbane, Professor Robert Dunn from Cape Town and Professor Michael Fehlings from Toronto are well-known to home spinal surgeons from the many visits to their units by Fellows and their visits to the UK. They were welcomed to Bath as old friends. Fascinating talks about fractures of the odontoid peg and the treatment of spinal infection from Professors Williams and Dunn were very well-received. For the many delegates who stayed to the very end of the conference though, the last keynote speech
by Professor Fehlings on the timing of surgery for spinal cord compression and the options for spinal cord regeneration and repair was outstanding and holds up a beacon of hope for those unfortunate enough to sustain a spinal cord injury. The social programme included a Spinal Speed Dating event as the Welcome Reception in the Assembly Rooms, and a formal dinner at the Pump Room and Roman baths. Both events were well-attended and highly regarded. The day before the main conference started, 60 trainees and consultants attended a lively pre-conference Instructional Course at the Bath Royal Literary and Scientific Institution. Topics discussed included the role of surgery in back pain in the light of the results of the SPORT studies; managing cauda equina syndrome; decision-making in spinal surgery; sacro-iliac joint pain and its treatment and the treatment of spondylolisthesis. Maurice Paterson gave a masterclass on how he does a microdiscectomy and the Society was honoured by the participation of one of its most illustrious emeritus members, Professor Alan Crockard, who shared his thoughts on the “Big picture in medicine and spinal surgery”. The sun shone during the three days of BASS in Bath, showing off this remarkable town in all its finery. We had a wonderful conference, by many considered the best BASS annual meeting since the Society was founded in the late 1990s. The members of the Society and its Executive are thoroughly appreciative of the work done by Otto and Maurice as well as Julia Bloomfield, the Executive Assistant of the UKSSB, and the BASS event management partners Archer Yates Associates in putting together a remarkable and memorable meeting. A uthor
Nick Birch Honorary Treasurer BASS and UKSSB Bone and Joint Journal Specialty Editor for Spine firstname.lastname@example.org
BJJ News | I ssue 7 | J une 2015
recreation and travel
The Scottish Deerhound
“The most perfect creature of Heaven” Sir Walter Scott (1771 – 1832)
Fig. 1 Bill Ledingham and deerhounds on a walk beside Crathes Castle
“I’ve to do a short piece on deerhounds”, I said to Ramsay, the eldest of my three hounds, as I walked into the kitchen. The response was a muted and barely perceptible flicker of one eyebrow as he lay beside the Aga on his memory foam mattress (extra large). The other two deerhounds, Olivia and Grace, were similarly unimpressed. The Deerhound breed originates from Scotland as its name indicates - The Royal Dog of Scotland. It is of massive size with a very large powerful body, greyhound-like shape and graceful build. It was bred originally to hunt stags. Robert the Bruce was very fond of hunting. An interesting story is that relating to the family of St. Clair. King Robert Bruce, in following the chase across the Pentland Hills, had often started a ‘white faunch deer’, which always escaped from his hounds. He asked his nobles if any of them possessed dogs that they thought might prove more successful. Naturally, there was no one so bold as to affirm his hounds better than those of the
sovereign, until Sir William St. Clair came forward. He would wager his head that his two favourite hounds, ‘Help’ and ‘Hold’, would kill the deer before she could cross the March burn. Bruce, evidently of a sporting turn, at once wagered the Forest of Pentland Moor, to the head of the bold Sir William, against the accomplishment of the feat. The deer was roused by the slow, or drag hounds, and St. Clair, in a suitable place, uncoupled his favourites in sight of the flying hind. St. Clair followed on horseback, and as the deer reached the middle of the brook, he in despair, believing his wager already lost, and his life as good as gone, leaped from his horse. At this critical moment, Hold stopped her quarry in the brook, and with Help coming up, the deer was turned, and in the end killed within the stipulated boundary. The King, not far behind, was soon on the scene, and, embracing his subject, “bestowed on him the lands of Kirton, Logan House, Earncraig, etc., in free forestrie.” The tomb of Sir William St. Clair, on which he appears sculptured in armour, with
a deerhound at his feet, is still to be seen in Rosslyn Chapel world famous now as a result of ‘The Da Vinci Code’. Rosslyn Reiver is the sire of our latest bitch, Grace. (Chuilinn Bathsheba at Ledingard). The Deerhound breed is very ancient: the earliest names for it it are so inextricably mixed that it is impossible to tell whether the Deerhound was at one time identical to the ancient Irish Wolfdog and, over the course of centuries, bred to a type better suited to hunt deer, or whether, as some claim, he is the descendant of the hounds of the Picts. The earliest names were used to identify the purpose of the dog rather than to identify species. We find such names as ‘Irish Wolf Dog’, ‘Scotch Greyhound’, ‘Rough Greyhound’, ‘Highland Deerhound’. Dr. Caius, in his book Of Englishe Dogges (1576) speaking of Greyhounds, relates: “Some are of the greater sorte, some of a lesser; some are smoothe skynned and some curled, the bigger therefore are appointed to hunt the bigger beastes, the buck, the hart, the doe.”
Fig. 2 In the Land Rover
All this is relatively unimportant when we can definitely identify the breed we now know as Deerhounds as early as the sixteenth and seventeenth centuries. From then on, the term Deerhound has been applied to the breed, which of all dogs has been found best suited for the pursuit and killing of the deer. At all times great value has been set on the Deerhound. The history of the breed teems with romance increasing in splendour through the Age of Chivalry when no one of rank lower than an earl might possess these dogs. A leash of Deerhounds was the fine whereby a noble lord condemned to death might purchase his reprieve. Records of the Middle Ages allude repeatedly to the delightful attributes of this charming hound, his tremendous courage in the chase, his gentle dignity in the home. Some of the finest pictures of deerhounds both in repose and in the hunt are by Sir Edwin Landseer (1802 – 1873). Living (as a commoner) with deerhounds
Fig. 3 Ramsay enjoying the deep snow
is not dull. They never cease to surprise. Although large and muscular they think of themselves as lapdogs. They take up less space than one might expect but clearly believe they belong in front of a crackling log fire in a baronial hall. Carole and I started sharing our lives with a deerhound eight years ago having had other breeds all our married life. We now have three. Just getting a deerhound is not as easy as it might sound. Only about a hundred are born in the UK each year and the breeders are invariably particular about to whom they entrust their precious puppies. We had to make three visits to Bridget and Duncan Robertson (Chuilinn Deerhounds) in the Borders before we were deemed suitable. Ramsay (Chuilinn Argent) was the result. Deerhounds are not suitable for every family but will adapt quite happily to life in a fairly small house or apartment. Content to spend large portions of the day lying on their beds, or more characteristically a couch or chair in the
living room, they need at least one blast of exercise or an hour’s walk with their owner each day. Some love children, others are indifferent to them but they are never unkind. All are very fond of their adult companions, fiercely loyal, and very affectionate. You never hear of a deerhound savaging a child and I have never heard of one biting a human at all. As guard dogs they are next to useless but their large stature might just deter a burglar who didn’t know the breed. They are mannerly but not easily trained to be obedient, to do tricks or really anything at all. Our experience of them is that if what they want to do fits in well with what you want them to do they can appear fairly biddable. Sometimes it feels as if there is no dog on Earth more stubborn than a deerhound. On a walk they are easy on the lead, virtually never pull or tug and if left off the lead like nothing better than to trot beside their owner bumping into the thighs from time to time to let them know they are still there. They love
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leaning against people and respond sensually to having their ears rubbed, otherwise known as the ‘eargasm’. They have a keen sense of smell as with all dogs but they are primarily ‘Sighthounds’ or ‘Gazehounds’ of the same family as Greyhounds, Whippets, Salukis, Borzois, Afghans and Irish Wolfhounds. They are pipped at the post by Irish Wolfhounds for size, but make up for that with their agility and athleticism. They have big litters, up to 12 pups, and their puppies are slow to mature. They are therefore best left with their mothers to learn manners until 12 weeks. Puppies vary in their behaviour: Some are diggers, chewy and sometimes very destructive. Some are angelic from the word go. A crate in the kitchen is to be recommended. Because they are so large, it is easy to think of them as older than they are and that they should be better behaved. Dogs are easier than bitches unlike many other breeds. Generally healthy, they can have medical problems. As with other large dogs they can develop bone sarcomas, bloat and cardiomyopathy and all deerhound puppies should have a blood test for liver shunt which is always fatal if not surgically treated. As they mature, they settle easily into family life. They like to be part of the ‘pack’ and although laid back and lazy, can sense from a deep sleep the picking up of the Land Rover key, the slipping on of a jacket or the lacing up of boots. Ours have all been good travellers, a boon if they are making the pilgrimage to the annual Deerhound Show. We have taken ours to Dunblane, Cheltenham, Norwich, Blackpool and last week Cumbernauld. It is always held in a large, dog-friendly hotel
and the sight of over 200 deerhounds strolling around with little or no argy-bargy is quite inspiring. More experienced deerhound owners and breeders are always helpful and interested in the pedigree of any new litter. They are very low maintenance dogs and require only weekly brushing. They cast very little. If they get muddy, which they do regularly, they can be left to dry and the dirt brushed off. They are at home in the snow, never seem to get cold, love the open country, love trees and long runs on the beach. They scan the horizon in a characteristic way. In short, there is much to recommend them; very few owners have only one, and most will continue with deerhounds for as long as they are able to keep a dog. There is magic and enchantment in the breed and looking into their deep brown eyes is like looking back to earlier times. This ancient legend sums it up: “In Wales, long ago, when the trees were still young, in a palace of stone on the banks of the Conwy, lived Llywelyn ap Iorwerth - Llywelyn Fawr - Llywelyn the Great - Lord of Snowdon, and his wife - Joan - daughter of the King of all England. When Princess Joan first came from England she brought Prince Llywelyn a royal gift from King John as part of her dowry - a magnificent Hound, Gelert - with legs long and limber, back sturdy yet supple, and the strength of all Scotland in its strong Scottish paws. A dog that terrorised the wild wolves for miles around and gently teased the stately palace cat. Llywelyn and Gelert became inseparable companions. Prince Llywelyn, his retinue and his pack of deerhounds often stayed at a
hunting lodge in the mountains, and in the autumn they would hunt deer amongst the steep wooded valleys. One day when Llywelyn was out hunting his faithful hound Gelert went missing, and Llywelyn returned to the lodge alone. He found Gelert there: limping, panting; his jaws dripping, drooling; his black coat clotted and matted with blood. And in the far corner of the room the cradle of Llywelyn’s baby son was overturned and empty; the baby’s fur coverings shredded and torn; the worn flagstones smeared with fresh blood. Prince Llywelyn stood tall and grim. He withdrew his sword from its scabbard and held the sword high and his eyes tightly closed. The blade flashed down, plunging deeply into the treacherous hound that had killed his small boy. But Gelert’s dying cry was answered by the cry of a child. Llywelyn searched and found his son, alive and unharmed, hidden by the cradle. At the side, slain by Gelert in a fierce struggle to protect the baby, slumped the body of a mighty wolf, its shaggy throat ripped and yawning with the blackest of blood. The sad prince buried Gelert with honour in a meadow by the River Glaslyn not far from the lodge. He erected two large stones, one at the dog’s head and one at its feet, to mark the grave. Then Llywelyn built a church close by, dedicated to St Mary, as an offering to God for the saving of his son. But the village which grew up around the church took its name from the grave of Gelert - Bedd Gelert in Welsh - and in the long years after Gelert’s death Prince Llywelyn, it is said, never smiled again.” An ancient breed: gentle, loyal, athletic and above all, fun.
Bill Ledingham Consultant Orthopaedic Surgeon Aberdeen Royal Infirmary email@example.com
recreation and travel
The ‘Blue Bubble’ David Jones reports on a unique phenomenon during a recent visit to Iceland
Fig. 1 The Great Geyser which erupts infrequently and unpredictably
wife and I have just returned from a ‘one-of f ’ voyage which included the Faroe Islands, an eclipse of the sun in mid-Atlantic, the Northern lights and a circumnavigation of Iceland, the volcanic landscape of which was stunning, albeit chilly in March. Among others, Iceland has given us Viking sagas, Björk the mega pop star and Eyjafjallajökull, the volcano whose eruption in 2010 tested newsreaders worldwide and blocked air travel across Europe. The country has also given us the word ‘Geysir’, from the area of that name, which contains a unique combination of geo-thermal activity. Hot springs come in all shapes and sizes, from steaming, sulphurous emissions through boiling surface pools to eruptive geysers which can throw a column of steam and water high into the air. All hot spring activity results from surface water draining through the ground until it meets rock heated by magma. The geothermally heated water returns to the
Fig. 2 Little Geysir, a natural hot spring, bubbles contentedly but not a true geyser.
surface by convection through porous and fractured rock. Unlike non-eruptive hot springs, a geyser differs in its subterranean structure which comprises an underground reservoir of water connected to a relatively narrow vent at the surface by one or more thin tubes. As the geyser fills, the water at the top of the vent cools off, but because of the narrowness of the channel, it cannot cool the water below but presses down on it, like the lid of a pressure cooker, thus allowing the water in the reservoir to become superheated, whereby it remains liquid at temperatures well above boiling point. However, when temperatures near the bottom of the geyser rise to a point where boiling begins, steam bubbles rise to the top of the column. As they burst through the geyser’s vent, water overflows and reduces the weight of the column and pressure on the water underneath. With this release of pressure, the superheated water undergoes a process where it instantaneously flashes into steam, creating a violent froth of expanding steam and hot water
which erupts from the geyser. Much of the water falls back to the geyser, the reservoir begins to fill again and the whole cycle is repeated. Unsurprisingly, geysers are relatively rare. Throughout the world - be it in Yellowstone, Rotorua, Iceland or more inaccessible areas of Russia or Chile geysers are a powerful attraction to scientists and tourists alike. The duration of, and time between, eruptions varies greatly from geyser to geyser as a trip to Google will confirm, and it is easy to understand how an enthusiast with a scientific bent might get hooked into the minutiae of the world of geysers. I have no intention of becoming an expert on geysers and boring the pants off anyone who might be weakened into listening to my new-found knowledge of different eruptions around the world. However, our visit to Geysir allowed us to observe a range of geothermal activity and to witness the star of the show, namely the Strokkur geyser, which erupts obligingly every ten minutes or so. The eruption lasts only a few seconds but
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Fig. 3 The eruption begins with the early signs of the bubble
Fig. 5 Stokkur flashes into steam
during the process demonstrates a unique phenomenon among geysers, namely the ‘blue bubble’ which occurs in that instant just before the flashing of the superheated water. It is difficult to appreciate the bubble with the naked eye because the eruption is over so quickly, but by observing several eruptions and photographing furiously during each, we were able to capture the whole process with simple cameras. When I asked a geologist, ‘why is the bubble blue?,’ I was told ‘it is blue for the same reason the sky is blue’. In order to remind myself why this is so, I went to the NASA website for their helpful explanation. In summary, the spectrum of white light from the sun is scattered in all directions by the gases and particles of the atmosphere.
Fig. 4 The bubble increases
Fig. 6 The height of the eruption
Blue is scattered more than other colours because it travels as shorter, smaller waves. That is why we see a blue sky most of the time. The same rules would apply at Strokkur, where, inside the bubble, more blue waves than others are refracted/ scattered by the boiling water. The spectacle of Strokkur was only one of the magnificent sights we were able to take in during our short time in Iceland. Orthopaedic travellers are strongly advised to visit the countr y; they will not be disappointed. A uthor
D. Jones Co-Editor BJJ News firstname.lastname@example.org
obert Henry Cradock Robins, who was
born on 7 August 1923, died on 23 February 2015. His father was a bank manager in High Wycombe, and he attended school at Gayhurst, then Aldenham in Hertfordshire. He won a place at Queens’ College, Cambridge to study medicine, and spent his clinical years at St Bartholomew’s Hospital, London. He qualified MB B.Chir in 1947, and was House Surgeon at Barts. He was a senior house officer in orthopaedics at Bath, and then served in the Merchant Navy as Ship’s Surgeon with the Royal Mail Line on the route to South America. On returning in 1949 he spent a year as SHO in general surgery at the Royal United Hospital, Bath. He then won the Luccock Research Fellowship from
Durham University in the Department of Surgery, Newcastle-upon-Tyne. In 1952 he spent two years as registrar at the Princess Elizabeth Orthopaedic Hospital, Exeter, where he first came under the influence of Norman Capener. In 1954 he moved to Oxford as registrar at the Nuffield Orthopaedic Centre, and then in Accident Surgery at the Radcliffe Infirmary. He became senior registrar in orthopaedics at PEOH, Exeter from 1956-60, latterly becoming first assistant. During his training, Robert achieved various honours including the James Berry Prize (RCS, 1952), and a Hunterian Professorship (RCS, 1954). In 1958 he was the Council of Europe Travelling Fellow to Sweden and France, and in 1960 BOA Exchange Fellow to North America. In 1961 Robert was appointed as consultant in orthopaedics and trauma at the Royal Cornwall Infirmary, Truro. In the same year, his textbook ‘Injuries and Infections of the Hand’ was published. Robert was a very accomplished all-rounder in the practice of orthopaedic and trauma surgery, but soon developed his particular interest in the surgery of the hand. In 1956 he was one of the five founders of the Second Hand Club. It was in 1952 at the Athenaeum Club in London, of which Robert subsequently became a member, that the original Hand Club was formed. The two groups combined in 1964, and in 1968 became the British Society for Surgery of the Hand. Robert was involved in the editorial and management committees of the Journal for many years, and became President of the BSSH in 1979. He was a keen member of the British Orthopaedic Association, and served on the Executive Committee between 1966 and 1967. He was a British Council Special Fellow, visiting Czechoslovakia in 1975 and Hungary in 1978. He became an examiner for the FRCS (Orth) RCS (Ed), 1982-90, and represented hand surgery on the Presidential Board of Surgical Specialties RCS (Eng), 1982-90.
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Robert wrote chapters and articles in various textbooks on orthopaedics and hand surgery, as well as a number of original papers in major journals. He was a corresponding member of the ‘Groupe d’etude de la main’ and the American Society for Surgery of the Hand. In 2001 he was nominated as a Pioneer of Hand Surgery by the International Federation of Societies for Surgery of the Hand. Regionally and locally, Robert’s contribution was immense. He served on the South West Regional and Area health authorities, the Medical Advisor y Committees of Or thopaedics and Plastic surgery, and was a member of the Bristol University Liaison Committee. Robert was the senior consultant in Orthopaedics and Trauma in Cornwall for many years, and was an excellent teacher and trainer as well as supporting his younger consultant colleagues. He arranged for the Exeter Senior Registrar Training Rotation to include a year in Truro. This was a much-valued period for trainees near the end of the rotation to obtain extra practical experience and confidence prior to seeking a consultant post. Robert stimulated interest by arranging visits to Truro of prominent clinicians and groups. Kit Wynn Parry made regular visits for some years to assist with particularly difficult hand cases. Later, Robert was able to persuade the hospital trust to fund the post of a Consultant in Rehabilitation. We had visits by the ABC Fellows, a meeting of the BSSH, and members of the Royal Ballet for a South West Orthopaedic Club meeting, all arranged by Robert. He also established a system of superspecialisation in Cornwall well before many other centres. He was on the founding committee to raise public funds for the Duchy Hospital, Cornwall’s only private hospital, which was opened by the Queen Mother in 1981, andwas later Chairman of the Hospital Council. In 1990 the hospital was sold, allowing capital to be put into the Duchy Health Charity, which Robert helped to set up. Robert retired from his NHS post in 1988, but continued for a while working on waiting list
initiative work. He also remained busy with his private practice, and for years had been much in demand for medico-legal work, which he continued well into his eighties. He was a regular attendee at BSSH meetings, and supported the BOA as a Senior Fellow and the South West Orthopaedic Club. He was an active Trustee of the Duchy Health Charity and served as President for several years until 2014. He was organiser and fundraiser for the Norman Capener Travelling Fellowship (RCS Eng). He was elected Freeman of the Worshipful Company of Barbers, and usually stayed at the Athenaeum Club when visiting London. Robert met Shirley at PEOH, Exeter, where she was working as a physiotherapist, and they married in 1953. Robbie somehow found time for a number of interests outside surgery. He was both very keen and knowledgeable about his beautiful garden, which was occasionally open to the public. He was a long-time member of the Cornish Gardens Society, the Georgian Group and the Trevithick Society. He enjoyed following rugby and particularly cricket, and was a member of the MCC. He enjoyed fishing for salmon in the Tamar and from his old working boat in the local coastal waters. He was a very keen follower of the arts, culture and fine dining, and regularly attended the ballet at Covent Garden with Shirley. More locally, he was a Patron of the Tate St Ives. Holidays in France and Italy enabled visits to galleries and historic sites. Another interest was folk music and Morris dancing, and Robert helped to found three separate Morris Rings in Cambridge, Exeter and Cornwall. He was also a member of the English Folk Dance and Song Society. Robert lived a long and full life, achieving so much, but giving so much as well. His scholarly and amusing speeches will be much missed by us all, as will his caring attitude and interest in his protégés. He is survived by Shirley, his four children, nine grandchildren and one great-grandchild. A uthor
Peter Peace Formerly Consultant Orthopaedic Surgeon Royal Cornwall Hospital, Treliske, Truro email@example.com
Stephen Andrew Copeland
Pioneer in shoulder arthroscopy and the ‘father’ of shoulder resurfacing and stemless arthroplasty
tephen Copeland passed away peacefully on April 10, 2015 at his home in Henley-on-Thames, surrounded by his loving family, after fighting bravely for the last 18 months against a relapse of
lymphoma. Steve was a true leader in shoulder surgery, known worldwide for his unique and innovative approach, as one of the pioneers of shoulder arthroscopy and as the ‘father’ of shoulder resurfacing and stemless arthroplasty, which has been literally life-changing for many thousands of suffering patients. Steve was born on May 7, 1946, in Shropshire and grew up in Cheshire. He was educated at Nantwich Grammar school and studied medicine at St Bartholomew’s Hospital Medical School, London between 1965 and 1970. After general surgical training
he returned to Bart’s to join the Percivall Pott rotation. In 1977, he was appointed Lecturer in Upper Limb Surgery at the Royal National Orthopaedic Hospital, London with Professor Lipmann Kessel. Working with “Lippy” Kessel stimulated his natural curiosity about the shoulder, and initiated his interest in what was quite a ‘neglected’ joint at that time. He started investigating and researching the field of shoulder surgery, studied the results of the ‘Stanmore Shoulder’ and described the technique and studied the results of thoracoscapular fusion for fascioscapulohumeral dystrophy (FSHD) while working with Mr Richard Howard at Norfolk and Norwich Hospital. Steve was one of the pioneers of the use of arthroscopy, both of the knee and its potential for use in the shoulder. He began research into shoulder arthroscopy and developed simple and reproducible techniques for arthroscopic subacromial decompression (ASD) and arthroscopic acromioclavicular joint (ACJ) excision arthroplasty. He continued, together with his colleagues and fellows, to develop many other more complex procedures for arthroscopic shoulder reconstruction. In 1979, at the age of 33, he was appointed Consultant Orthopaedic Surgeon at The Royal Berkshire Hospital, Reading and in 1982 he was awarded the ABC Travelling Fellowship to the USA and Canada by the British Orthopaedic Association. This ABC fellowship and visit to the USA had a significant effect on his career. During the fellowship he met Charles Neer, at Columbia Presbyterian Hospital in New York, and they instantly became very good friends, which evolved into very close lifelong friendship. On his return from the ABC fellowship, he organised the first Reading Shoulder course, which was the first of its kind in the world. Both Lippy Kessel and Charlie Neer were guest speakers in this course. Only Steve Copeland, with his inspirational character, could get these two giants of shoulder surgery together! The Reading Shoulder course has continued to run biennially since then and is regarded as one of the leading shoulder courses in the world. In the early 1980s, Steve started to develop his surface replacement prosthesis, which differed from all other shoulder implants at the time. The first ‘Copeland shoulder’ was implanted in 1986. Initially, the ‘shoulder world’ would not accept that prosthesis for arthritis does not need a stem. Only daring orthopaedic surgeons used the Copeland surface replacement.
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Fig. 2 Steve Copeland teaching
Fig. 3 Steve tr ying out a Formula 1 car He could not get his results published in the orthopaedic journals. It was not until the late 1990s, after we managed to publish excellent results of the Copeland shoulder resurfacing with more than ten years’ follow-up, that the tide started to turn. Nowadays, it is a wellaccepted principle and most shoulder implants are going shorter if not stemless. He was the game changer! Steve was a founding member and subsequently president of the British Elbow and Shoulder Society (BESS), one of the first members of the European Shoulder and Elbow Society (SECEC) and its president from 1999 to 2001. He was invited to be the first international non-American corresponding member of the American Shoulder and Elbow Surgeons (ASES) in 1986 for his outstanding contribution to the field of shoulder surgery. He was also the third chairman of the International Board of Shoulder and Elbow Surgeons (IBSES, 2004-2010). He was made an honorary member of the shoulder surgery societies of Australia, Spain, Argentina, South Africa, Korea and Japan; an honorary fellow of the Royal College of Surgeons of Edinburgh in 2004, and the Robert Jones Lecturer for the British Orthopaedic Association in 2005. He wrote four books on shoulder surgery and many scientific papers and was invited to lecture worldwide.
He was a masterful teacher, excellent surgeon, great friend and a caring family man. Above all, Steve was a true gentleman whose natural humility belied his eminence. Despite his normally gentle nature, behind the wheel of a sports car he became a ruthless racing driver. He always had passion for sports cars and racing and was well known for his Aston Martin, whose acceleration was experienced by every fellow or visiting surgeon. When I suggested that he join my VIP invitation to the F1 Grand Prix in Monza, he didn’t hesitate for a second despite objections from Jenny: he was also awarded the accolade of the “world’s fastest shoulder surgery racing driver”, racing a go-cart during the closed SECEC meeting in Frankfurt in 2007, where he ruthlessly overtook us all. After his retirement, he replaced the Aston Martin with a red Ferrari and built a kit racing car, planning to race it in different circuits around the world. Unfortunately, he could race it only once before his disease returned. He was inspirational to everyone that touched his life and certainly to me as well as to the many fellows, trainees, colleagues and visitors that came to Reading over the years. I was Steve’s shoulder fellow in 1997, on a one-year sabbatical from my university hospital in Israel. I extended my stay for another year, at his request, as we had such a great time working together. Working with Steve was like a dream. He was my mentor and my good friend. His clear thought, knowledge and excellent surgical skills made every complex operation seem so simple in his hands. Unfortunately, it was then that the disease first struck him, but after several months fighting the disease and various treatments, he recovered and returned to work. In 1999 we established the Reading Shoulder Unit as an international centre of excellence for shoulder and elbow surgery, striving to continue to lead the cutting edge of our field, introduce innovation and continue with research and education. A great innovator, time and time again ahead of his time, but always with practicality and reason, Steve taught us that simplicity is the ultimate sophistication, and that who dares wins. Even after his retirement in 2010, he was always available for advice and guidance with his wisdom and kindness. In spite of being so busy and productive in his work, as well as being involved in the activities of many national and international societies, he was a very loving and dedicated family man, in recent years taking great pride in playing with his grandchildren. Throughout his career Steve was supported by his loving wife, Jenny, whom he met at medical school. Steve leaves Jenny, two children, Sara and Matthew, five grandchildren, a mother, a brother and a sister. Steve will be profoundly missed by his family, friends, colleagues, and, indeed, by anyone that knew him throughout the world. We will continue to observe and cherish his legacy. A uthor
Ofer Levy Consultant Orthopaedic Surgeon, Royal Berkshire Hospital, Reading firstname.lastname@example.org
K. Rankin, M. Reed, D. Griffin, M. Costa
r i g i n a l l y s c h o o l e d i n h i s n a t i ve Manchester and following a pre-med year, Andrew Sprowson entered medical school at the University of Dundee in 1994. He was soon one of the most popular students in his class due to his sharp wit and excellent social skills. He was certainly not one to be overawed by the most respected tutors. At one of the medical school dinners he greeted Professor Charles Forbes (a leading international figure in the field of vascular medicine) and his wife with the memorable words: “Oi Forbesy, is this your bird?”
Many firm friendships were formed in Dundee, and after a brief period in Glasgow for house jobs the next move was to Newcastle upon Tyne to embark on basic surgical training. It was during this time that Andrew’s exceptional clinical abilities and remarkable intellect started to become apparent. Recognising the importance of basic science research he secured funding for an MD, initially from the Newcastle upon Tyne NHS Trust Healthcare Charity followed by the Shears Foundation/Royal College of Surgeons of England Research Fellowship. He successfully defended his thesis on ‘The role of truncated matrix extracellular phosphoglycoprotein in bone formation:
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its application to the bone/implant interface’ in 2006. Higher Specialist Training in Orthopaedic Surgery beckoned, and during his time at Northumbria NHS Trust he realised his research talents were bestsuited to clinical trials. In collaboration with Mike Reed, Andrew set up and successfully delivered two randomised controlled trials, which accrued over 3000 patients between them on a modest budget. On the national scene as British Orthopaedic Trainee Association Academic Representative, Andrew started to influence research strategy, building a network of contacts around the UK. Towards the end of his training it became apparent that Andrew’s surgical skills were as outstanding as his research abilities and that his would be no ordinary career. On completion of training he undertook a six-month fellowship in soft tissue knee surgery with David Wood in Sydney and a further six months with Tim Briggs at Stanmore. Andrew learned a huge amount from his time in Sydney, although he was somewhat bemused that staff sporting facial hair would not be allowed to work in this clinic and had to shave off his trademark goatee! On his return to the UK he became Tim Briggs’ fellow and was soon excelling at complex ar throplasty and endoprosthetic replacement. Again, not afraid to speak his mind, he would engage in lively debate with his senior colleagues and is remembered fondly at the RNOH. With a formidable surgical skillset and ambitious ideas about research, the ginger wizard was an attractive candidate for academic units around the country and, with Warwick ready to recruit, his appointment there as Associate Professor in 2012 came as no surprise. Andrew made rapid progress in his first year. He was one of the highest-volume arthroplasty surgeons in the Trust and, together with his colleague Pedro Foguet, was soon taking on the most complex of cases. He quickly and inevitably became the most
popular member of the Trauma and Orthopaedic Department at University Hospital Coventry and Warwickshire. Respected and loved by surgical colleagues, trainees, secretaries and nursing staff alike, Andy was never short of a joke or ‘blatantly rude gesture’ to lighten the mood or cheer up the clinical team. On the research front he was a gifted clinical trialist and was quick to secure NIHR funding, with his first trial up-and-running just 18 months after his appointment. This trial exemplified Andy’s research and clinical interests by investigating ways to reduce pain and improve the mobilisation of patients after knee replacement. Andy also set up research projects with industry and, following a very successful visit to Melbourne, had an active research collaboration with the team at Monash University. Andy was a prolific publisher, with many articles about arthroplasty and research methodology. He was also a dedicated supervisor and trainer. He was lead supervisor for three PhD and post-doctoral students and an inspiration to many more junior academics. In fact he was more than a supervisor; he was also a friend and role model. This was recognised by the University and Hospital when Andy took on the leadership of the NIHR Academic Training Programme in Trauma and Orthopaedic Surgery at University of Warwick – the largest such programme in the country. As his career gathered momentum the orthopaedic community was looking forward to watching, and in many cases participating in Andrew’s endeavours. He died at 5am on the way to work. His loss will be irreplaceable: in many minds he is thought of as the best president the BOA will never have. Our thoughts go out to his family- his wife Louise (they were together since their teenage years), their children James and Hannah, his parents, brother, sister, relatives and all the many, many friends he made. We are all bereft.
Kenny Rankin Consultant Orthopaedic Surgeon Freeman Hospital, Newcastle email@example.com
Surgical eLearning Opportunities in partnership with the Royal College of Surgeons of Edinburgh PART-TIME ONLINE DISTANCE LEARNING PROGRAMMES FOR SURGICAL TRAINEES |ChM in Trauma and Orthopaedics| |A part-time online distance learning programme for advanced trainees in Orthopaedics| Delivery This two year part-time Masters programme in Trauma & Orthopaedics, taught entirely online, is offered by the Royal College of Surgeons of Edinburgh and the University of Edinburgh, and leads to the degree of Master of Surgery (ChM). Based on the UK Intercollegiate Surgical Curriculum, the programme supports learning for the Fellowship of the Royal College of Surgeons (FRCS) examinations. Trainees will be taught by experienced tutors, all leading clinicians in their field, and will have access to a large structured learning resource of educational materials, including an unparalleled online library facility. Each module includes discussion boards based around relevant surgical cases covering technical skills and procedures as well as core knowledge. This programme provides a quality assured, flexible, and advanced training for the next generation of Orthopaedic surgeons, linking an academic degree to the Intercollegiate Fellowship examination, and further develops the trainee’s academic portfolio and facilitates surgical research projects. Flexible online learning Students on this programme will be part of an online community of Orthopaedic surgeons from all over the world. All you need is internet access and 10-15 hours per week of study which is carried out in a flexible modular manner. Entry requirements UK trainee applicants should have completed initial (ST[specialist training years]1-2) or (CT[core training years]1-2) and early intermediate (ST3-4) phases of their training programme at the time of commencing the course. Applicants would normally be commencing Intermediate Phase (ST5-6) of their training so that the curriculum would be directly relevant to their ‘in the work-place’ experience and prepare them for the FRCS examination which would be completed during Final Phase (ST 7-8). Applicants from outside the United Kingdom or those not within a recognised training programme would require to demonstrate that the course was directly relevant to their Orthopaedic surgery training, and applicants should be able to demonstrate a minimum of 4 years training in Trauma and Orthopaedics before enrolling for the ChM.
Recruiting now for September 2015 entry! Contact us: email: firstname.lastname@example.org
www.orthochm.rcsed.ac.uk Trauma_Ortho_213x275.indd 1
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29th Edinburgh International Trauma Symposium and Trauma Instructional Course 17th - 21st August 2015
Trauma Symposium 19th-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.
Trauma Instructional Course 17th-21st August 2015
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 Shanghai, China and Prof Jan-Erik Gjertsen from Haukeland, Norway Venue: Sheraton Hotel, Edinburgh, Scotland. About Edinburgh: Edinburgh is Scotlandâ€™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: www.trauma.co.uk or by email: email@example.com