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BJJ News | I ssue 8 | S eptember 2015
Social media and Orthopaedics Bridging the gap
A ‘faranji’ in Addis D. Jones
G. de Mel P. Nasr V. Khanduja
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Tick boxes, checklists and
G. de. Mel
Orthopod’s view Things I wish I’d known about orthopaedics when I started
Current concepts I don’t believe in: ‘Sagittal balance’ Social media and orthopaedics
P. Nasr V. Khanduja
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bridging the gap World Orthopaedic Concern, revisited A ‘faranji’ in Addis
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Tick boxes, checklists and proformas takes remarkably little skill, and even less thought, to put a tick in a box. It can be accomplished by any competent three-year-old who can lay hands on a writing implement and summon up a modicum of coordination. Why is it then that so much emphasis is placed on tick box forms in modern practice? Once upon a time, these didn’t exist: doctors wrote up their notes, usually concentrating on the important relevant findings, and nurses wrote a narrative description of the patient’s care and response to treatment. Of course, this meant that those looking after a patient had to understand what was important and what was unimportant. Have matters really changed so much? Now, when a patient is admitted to hospital, they become the subject of a booklet in which page after page of questions are to be answered by means of ticks (or a binary ‘yes’ or ‘no’). Because the booklet has to be comprehensive it is seldom tailored to the patient’s condition and many of the questions are irrelevant to the individual concerned. There is, consequently, the potential for key features of the patient’s history or care to be subsumed in a morass of irrelevant information. Just how much thought goes into eliciting a response to each question? Because of the number of boxes to be filled it seems inevitable that the concentration either of the practitioner or patient may waver, but not, one hopes, at the point where a key question is being addressed. There appears to be a view in some quarters that once all these questions have been answered, or rather that all the boxes have been ticked, a full picture has emerged of the patient’s history, subsequent care and outcome. This is less than convincing when one comes to analyse the records at a later date and particularly in cases of personal injury or alleged negligence. I am told by m’learned friends that a signed consent form merely indicates that a discussion has taken place but does not
indicate the nature of that discussion. How much less does a tick in a box indicate the response to a preset question? I am not aware that this has yet been tested in law, but when it is I am not reassured of a positive outcome. A tick most certainly does not indicate consent. Further problems arise when attempting to retrieve information from such forms. The information that can be derived is entirely dependent on the structure of the question. There is no flexibility to enter information that might be relevant but does not form part of the question. Indeed, to go into detail when there are so many questions to be answered might be perceived by those administering it as merely prolonging the process, and as such undesirable. So why do these forms exist? My suspicion is that someone in managerial office feels that such a document is comprehensive and, indeed, ‘ticks all the boxes’. It would be cynical to think that as the level of training and education in the NHS drops, practitioners of all sorts are less capable of assessing a clinical problem accurately thereby necessitating such a structured format. A proforma also has the effect of reducing both practitioner and patient to the status of automata and, en passant, probably detracts from the continuing education of the doctor or nurse administering the form neither of whom has to think to formulate the relevant questions. Of course, by being binary, the data generated is much easier to analyse by those without any clinical training. Fortunately, the failure to implement a nationwide NHS IT system has meant that we are not yet fully exposed to electronic health records. When they inevitably arrive, it is likely that the situation will deteriorate, to the detriment of patient care and the intellectual processes of those who have to administer them.
BJJ News | I ssue 8 | S eptember 2015
Things I wish I’d known about orthopaedics when I started
Fig. 1 Gordon Bannister
pursued a career in orthopaedics because, as a student, I preferred surgery to medicine and was very much influenced by Richard Batten, (Consultant Orthopaedic Surgeon at the Birmingham General Hospital), who treated students like human beings and conveyed his infectious enthusiasm for the subject to us. Between 1978 and 1979, I was his registrar on the Birmingham pre-FRCS rotation. I performed many internal fixations using the AO technique he had brought to the city and did around 20 total hip arthroplasties (THAs) under his supervision including five Bucholz one-stage exchanges for infection. In my first general surgery job on that two-year rotation, I personally carried out 269 operations including over 50 major procedures such as cholec ystectomy, thyroidectomy, mastectomy and axillary dissection, bowel resection, gastrectomy and five abdominoperineal excisions of rectum. My chief was in an adjacent coffee room to be called should the need arise. I called him for a carcinoma of the thyroid that was invading the trachea. By the end of the twoyear rotation I had performed over a thousand operations, and had a good grounding in patient assessment and operative technique. Before moving to Bristol as a middle-grade registrar, Nigel Tubbs advised me that I would get a lot of unsupervised trauma experience, which proved to be the case. I carried out over 1300 procedures during my first year at the Bristol Royal Infirmary as a trauma registrar, and was given the task of installing the AO
box which I had used with Richard Batten. The small fragment set followed, along with the Kinemax total knee replacement, arthroscopy, arthroscopic surgery, modern cementing technique for THA and closed intramedullary nailing of femoral fractures. These became standard practice within five years and posed mighty problems for senior consultant staff who had long since delegated acute trauma to their registrars. As a result, registrars acquired a wealth of experience and, on completion of my orthopaedic training in 1985, I had performed no more than 25 cases with a surgeon senior to me, of which three were demonstrating or assisting consultants who were undertaking their first Kinematic knee arthroplasty. At that time, all registrars and all but two of the consultants could perform two hip replacements in an afternoon list. I took up the post of Consultant Senior Lecturer at Southmead Hospital just before my 37th birthday on a five-year appointment which required that, with one afternoon list per week, I perform 60 THAs per annum and establish undergraduate teaching in the unit. I worked on two sites, had one preregistration house officer as junior staff and could not have been happier. I remained there until I retired at the age of 61. What do I wish I had known about orthopaedics? This question lends itself to the speciality itself, training and the enormous changes in external influences on clinical practice. There were never the changes in orthopaedics that
affected general surgery because the major advances had been made in the late 1970s and 1980s. One professor of general surgery devoted his life’s work to the surgery of peptic ulcers which was subsequently rendered largely redundant by imetidine. In 1987, orthopaedics already had reliable operations for osteoarthritis of the hip and knee. Trauma management had evolved from closed reduction, prolonged cast immobilisation or months of traction with consequent malunion and joint stiffness to internal fixation and early movement. Arthroscopy largely eliminated the carnage of normal meniscectomy. Training The junior workforce started to expand in 1989, to relieve on-call rotas. At that time a 1:2 rota was common: occasionally tiredness ensued. The numbers of trainees increased whilst their experience declined. The bedrock of British orthopaedics, hands-on clinical exposure, was serially eroded by the European Working Time Directive. In 1989, David Warwick, then SHO on the Bristol rotation, asked if he could take an unrecognised post as SHO3 with me to enhance his experience before being appointed as a middle-grade registrar. This proved very successful. A programme was developed which expanded both in numbers and duration. Eventually it accommodated 11 young surgeons, many on overseas placements and all under good trainers, who carried out at least 200 operations personally during their six-month attachment. Each
trainee produced a paper every six months and Matthew Hubble wrote six. A total of 200 trainees went through the programme before it was wound up by the current SpR programme and all but one achieved registrar and consultant posts. David’s six month appointment became a year-long rotation four years later as the experience obtained at SHO level declined. The demise of the firm The three-tier firm structure of consultant, registrar and house officer had evolved over the previous century and had immense wisdom. Lines of communication were short, all members knew their patients, and consultants knew their juniors and could deploy their strengths and address their weaknesses. The firm was destroyed by shifts followed by time off which diluted the time the firm spent together. The needs of the trainee became a matter for committee, endless forms and massive por tfolios which expanded in inverse proportion to the experience of the junior doctor. The firm was the basis of undergraduate teaching. Undergraduates were part of a team, clerked the patients, took blood and assisted in theatre. The skills acquired from the firm by seeing an experienced clinician elicit a history, make a diagnosis and communicate it sympathetically to a patient have been replaced by the received wisdom of ‘communication skills’ courses run by psychologists who may have never seen a patient. The outcome of all this has been a workforce deprived of experience, and approximately five years behind their peers of thirty years ago. The general orthopaedic surgeon with a special interest has become superspecialist manqué due to the paucity of general skills. The patient who fits neatly
into a recognised management pathway will be well-treated but those without a straightforward diagnosis will be shuttled from superspecialist to GP to another superspecialist with endless investigation and a delayed and uncertain outcome. NHS management In 1979, Patrick Jenkin, then Minister of Health, introduced a larger management structure to ‘save doctors’ paperwork’. Sadly, the opposite proved to be the case and a highly salaried body with no knowledge of medicine, and allegiance to itself rather than to patients, rose to rule over frontline staff. In 1987, before taking up my consultant post, the hospital and district general managers discussed with me how I could best serve the parish and how they could help me to do it within a constrained budget. By 1989, consensual delivery of an orthopaedic service became history. I carried out one evening and two lunchtime teaching sessions per week but found that I was perpetually waiting for patients in my elective clinic before one of them. Suddenly there would be a rush of patients around 12.30 and we would not be able to clear them for the next 45 minutes. The nurses and plaster room staff were detained for this time and the juniors missed their training. It became apparent that a trainee NHS manager had decided that she could avoid having to record delays between patient arrival and consultation by the expedient of listing very few patients between 9.00 and 12.30 then, after the official clinic had finished, bringing in six new patients at 12.31. This was supported by the new hospital manager, so this gamesmanship merely exploited the commitment of the clinical staff. We were left with no choice but to leave clinic at 12.30 and invite the management
trainee to explain matters to the patients. It stopped immediately. The trainee was extremely sore that her bonus would be adversely affected. Over the next decade, lists were being picked by managers who had no capacity to assess clinical priority. Patients were dispatched, without the knowledge of their surgeons, to distant units for operations by surgeons of unknown provenance and excessive complications that had to be treated at base. Finally, consultants pointing out deficiencies in the service were picked off, dismissed and gagged by the very personnel whose creation was designed to help them. The irony of all this is that while veterinary surgeons (184 4), doctors (1858) and dentists (1878) all had professional bodies to regulate their standards of practice, NHS management had assumed responsibility for patient care without any medical training or professional body to regulate them. Any doctor abusing her colleagues like the junior management trainee in 1989 would rightly have been reported to the GMC for failing to treat ‘with fairness and respect’. Conclusion The or thopaedics was relatively easy. Practice in the past was not per fect. General orthopaedic surgeons performed some procedures twice a year with poor results. The busy surgeon concentrating on patient care, teaching, and research is particularly vulnerable to stealth attacks by management. Sadly, morale amongst some of my younger former colleagues is now very low: this is unproductive and avoidable. A career in orthopaedics remains a wonderful one, if surgeons are allowed to practise the speciality for which they have been trained.
Gordon Bannister Retired Consultant and Professor of Orthopaedic Surgery. email@example.com
BJJ News | I ssue 8 | S eptember 2015
Current concepts I don’t believe in: ‘Sagittal balance’
erhaps it would be more accurate to say that I don’t believe in sagittal balance as an indication for surgery in adult degenerative
scoliosis. When I was training in spinal surgery in the late seventies, life, as with most things, was simpler! We learnt about deformity (or scoliosis as it was then called) from the scoliosis surgeons, and degenerative spinal disorders from the ‘low back’ surgeons. Scoliosis meant largely the management of adolescent idiopathic scoliosis in young people, with some exposure to congenital and neurological types of scoliosis in children. Fusion was achieved with Harrington rods, and later with sublaminar wiring. There were no pedicle screws at this time. As a result, we were well aware of sagittal balance and its importance when treating adolescents with idiopathic scoliosis. We used all the fairly simple apparatus available at the time such as plumb lines, and at Stanmore we also had access to full-length standing radiographs. On the degenerative side, we saw decompressions for stenosis, discectomies and simple posterior fusions for low back pain usually achieved with screws using the Boucher technique. Spondylolisthesis was treated by both groups of surgeons principally with a posterolateral (Wiltse) fusion. There was really no surgery for what is now known as adult spinal deformity’(ASD); one has to ask where it came from. I believe two things happened. One was that, in the 1980s and 1990s, there was a big increase in the number of deformity surgeons, particularly in the United States, but also in Europe. I do not believe that the incidence of adolescent idiopathic scoliosis has
changed much, and therefore surgeons started to look at the use of fusion for deformity in adults. The second was a simultaneous improvement in the quality of the fixation available for the lumbar spine. With the advent of pedicle screws, the whole approach to fusing the spine changed. With it came big advances in the actual instrumentation used to implant the screws, meaning that bigger and better reductions were achievable. With the increasing use of spinal instrumentation, it became clear that further studies were needed in order to avoid fixing the spine in poor alignment. Papers started to appear on the radiological improvement of sagittal plane alignment. Jackson and McManus 1 published a paper on this which compared asymptomatic volunteers to those with low back pain, and suggested that there was a loss of lordosis in the back pain patients compared to agematched asymptomatic volunteers. Subsequently, Glassman et al 2 looked at the impact of positive sagittal balance in adult spinal deformity and showed that the higher the deviation of a C7 plumb line, the worse the Oswestry Disability Index. Subsequently, there were a whole raft of papers over the next ten or 15 years relating sagittal spinal balance to surgical results, the implication being that pre-operative planning would lead to more successful outcomes. Many of these papers addressed the clinical outcomes after fusion for degenerative or dysplastic spondylolisthesis, and I would not argue with this. Clearly there is a change in sagittal balance with these types of deformity. However, adult deformity has to be divided into two groups; first, those with actual long-standing deformity such as spondylolisthesis or previously untreated adolescent
idiopathic scoliosis, and second, a separate degenerative group. The second group are patients who did not have any underlying scoliosis until they started to age. We know that as the general population is getting older, we are going to see more degenerative spinal disease and there is no doubt that, with osteoporosis and the natural degeneration of discs, one gets progressive sagittal malalignment. There is also no doubt that lumbar degeneration results in a loss of the normal lumbar lordosis and therefore to increasing sagittal imbalance. The body can compensate for this to enable one to maintain an erect walking stance. However, I take issue with the inclusion of sagittal spinal measurements into the surgical decision-making process in this elderly group of patients with degenerative scoliosis. Indeed, some papers from Europe would suggest that the pre-operative assessment of sagittal balance is the main indication for surgery. 3 There is an excellent review on the implications of spinal pelvic alignment for the spine surgeon by Mehta et al 4 which looks at the quality of the papers in favour of the importance of sagittal balance. Many of the papers are retrospective and lack cohort controls. With the advent of new methods of performing simultaneous AP and lateral standing whole body radiographs at low radiation dose (EOS for example), and with computer programmes being able to superimpose measurement systems, it is possible to rapidly work out any patient’s pelvic inclination, lumbar lordosis, etc (Fig. 1). There is even an iPhone App (SagittalMeter) which gives the figures by aligning the phone with the radiographs! As one might expect, there are also courses on sagittal balance
Fig. 1 The sacral slope is the angle between the superior sacral endplate and a horizontal reference line, and the pelvic tilt is the angle between the line connecting the midpoint of the superior sacral plate to the centre axis of the femoral heads and a ver tical reference line. PI is the sum of the sacral slope (SS) and the pelvic tilt (PT ). SS and PT var y based on pelvic position, while PI is a f ixed parameter. Image reproduced with permission from Oâ€™Brien et al: Radiographic Measurement Manual. Memphis, Tennessee: Medtronic Sofamor Danek: 20 04. sponsored by the equipment companies (Fig. 2). I was always taught, and I passed on to my trainees, that our job is to treat patients, not radiographs! There is an impression in certain parts of Europe that the opposite is the case: the surgeons sometimes do not really know what the patientâ€™s symptoms are, but that they are going to correct their deformity and the symptoms will be relieved by realigning the spine! Another paper, by Videbaek et al, 5
reported a randomised trial, with eight to thirteen yearsâ€™ follow-up comparing posterolateral fusion with and without anterior support (PLIF or ALIF). This paper suggested that improved results came from anterior support and that there was no difference between the two groups in terms of sagittal balance. I, and many others, have always thought that the reason why patients with spinal stenosis have problems with standing and walking is due to the lack of volume in the spinal canal and pressure from the enlarged facet joints and thickened ligamentum flavum on the dura. The patients therefore naturally adopt a flexed posture to maximise the volume of their spinal canal. Most surgeons have also noted the improvement in standing and walking after a satisfactory spinal decompression. If these patients had been measured pre-operatively using the latest alignment techniques, they would clearly have been shown to have a poor sagittal balance. I was therefore delighted to see a recent paper in Spine 6 suggesting that patients with symptomatic degenerative spinal stenosis benefit significantly from decompression regardless of their sagittal spinal balance and that the authors do not believe that restoration of sagittal balance is recommended. There is a also a paper by Dr Fujii et al, 7 in Spine, which retrospectively reviewed sagittal balance and clinical outcomes in patients who had undergone a decompression for stenosis. They noted that, following decompression, the sagittal vertical angles decreased and the lumbar lordosis increased: all these differences were statistically significant. Interestingly enough, 43% of patients with pre-operative imbalance had resolution of their radiological abnormalities post-operatively (Fig. 3) This implies that sagittal balance may well, in a lot of cases, be flexible. The perceived sagittal imbalance is therefore postural and not fixed and is correctable by simple decompressive surgery. With the increase in the elderly
population, we can expect more elderly patients to present with a painful spine. However, there is also the question of the high complication rates that accompany these complex procedures in an elderly population. Some surgeons are advocating long
Fig. 2 Typical alignment change af ter decompression without fusion. fusions, multiple osteotomies and other major interventions. It has already been reported that patients who undergo fusion have a reported complication rate nearly twice that of those who have surgery without fusion. Others have found that increasing age, and the number of levels fused, are significant risk factors in patients over 65. A recent study from the Washington Group 8, which has taken a major interest in sagittal balance and adult spinal deformity, showed that the overall complication rate in a group of patients with a mean age of 67 was 37%, and the major complication rate was 20%. Increasing age was a significant factor in predicting the presence of a
BJJ News | I ssue 8 | S eptember 2015
complication: patients aged over 69 had even more complications. Despite this, I know from my Royal College of Surgeons visits that the number of patients on waiting lists for the treatment for adult spinal deformity has increased exponentially in the last few years. The final question that must therefore be asked is whether these procedures are cost-effective? There is no UK data for this, but there is from the United States. In the US, expenditure relating to spine care is estimated to account for $86 million annually. The policy makers there have set a cost-effectiveness benchmark of less than $100 000 per quality-adjusted life year (QALY). It is for surgeons in the US to defend their choices from an economic point of view. A recent study 9 on the surgical follow-up of adult spinal deformity procedures at five years showed that 40% of patients were below the threshold of prudentiality. The factors associated with greater cost-effectiveness were patients with greater pre-operative disability, a diagnosis of idiopathic scoliosis rather than degenerative scoliosis and fewer fusion levels. There have also been papers which suggest that the complication rate is much lower with a one- or two-level fusion than with a multiple-level fusion. In conclusion, no one would argue about the importance of sagittal balance in surgical outcomes for patients with adult idiopathic scoliosis, spondylolisthesis and conditions like ankylosing spondylitis. However, sagittal imbalance seems to be becoming a diagnosis rather than a measurement and I do not believe in the use of sagittal balance as a sole indicator for surgery in adult spinal deformity which is purely degenerative.
References: 9. Terran J, McHugh BJ, Fischer CR et al. 1. Jackson RP, McManus AC. Radiographic Surgical treatment for adult spinal deformity: analysis of sagittal plane alignment in projected cost effectiveness at 5-year followstanding volunteers and patients with low up. Ochsner J 2014 Spring;14:14-22. back pain matched for age, sex, and size: a prospective controlled clinical study. Spine 1994;19:1611-1618. 2. Glassman MD, Bridwell K, Dimer JR et al. The impact of positive sagittal balance in adult spinal deformity. Spine 2005;30:20242029. 3. Le Huec JC, Faundez A, Dominguez D, Hoffmeyer P, Aunoble S. Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review. International Orthopaedics (SICOT) 2015;39:87-95. 4. Mehta VA, Amin A, Omels I, Gokasian ZL, Gottfried ON. Implication of spinopelvic alignment for the spine surgeon. Neurosurgery 2012;70:707-721. 5. Videbaek TS, Bunger CE, Henriksen M, Neils E, and Christensen FB. Sagittal spinal balance after lumbar spinal fusion: the impact of anterior column support: results from a randomised clinical trial with an eightto thirteen-year radiographic follow-up. Spine 2011;36:183-191. 6. Bayerl SH, Pohlmann F, Finger T et al. The sagittal balance does not influence the 1 year clinical outcome of patients with lumbar spinal stenosis without obvious instability after microsurgical decompression. Spine 2015;40:1014-1021. 7. Fujii K, Kawamura N, Ikegami M, Niitsuma G, Kunogi. Radiological improvements in global sagittal alignment after lumbar decompression without fusion. A uthor details Spine 2015;40:703-709. 8. Daubs MD, Lenke LG, Cheh G, Stobbs Jonathan Johnson Consultant Orthopaedic and G, Bridwell KH. Adult spinal deformity Spinal Surgeon surgery: complications and outcomes in firstname.lastname@example.org patients over age 60. Spine 2007;32:22382244.
Social Media and orthopaedics he recent Statistical Bulletin published by the Office for National Statistics of the United Kingdom illustrates how the use of computers, the Internet and social media have grown over the past decade. 1,2 Sixty-seven per cent of adults in Great Britain use computers daily, compared with 45% in 2006. A total of 80% of households have internet access, a 23% increase since 2006. 2 This indicates that the use of computers, Internet and social networking is expanding rapidly. This rapid expansion of social networking is markedly evident amongst 16 to 24-year olds; in 2014, 91% of Internet users in this age bracket used social networking sites such as Facebook or Twitter as an important method of communicating with each other. 1,2 These trends are not limited to the younger age groups. Almost nine in every ten adults have used the internet in the last 3 months in the UK. 1 This sheds light upon the significance of the use of the internet and social networking as a novel communication platform (Fig.1). Over the years, people’s perception of social networking has been transformed, as technological advances have enabled the public to access information, and communicate more easily and effectively over a variety of platforms. Broadly speaking, social networking is defined as a set of technology tools that facilitate ‘bringing people together’, as a method of dialogic communication. 3 It was initially introduced as a method of socialising and sharing online information. However, fast growth in this sector has meant it has become increasingly popular as a platform for professional communication, collaboration and interaction. These developments are not limited to the general population, but are apparent in the world of medicine and surgery. Social networking is a well-established mode of communication amongst medical students and young doctors, 4 and the use is growing as a tool for professional networking. Novel networking technologies can be used as a platform for medical education, presenting case studies, as a valuable research tool to enhance the peer review process, a platform for knowledge exchange and problem solving or a platform to discuss and brainstorm new ideas. This technology can play an important role in improving the overall quality of patient care. Social networking is already widely used in mainstream media, politics, public relations, advertising, education, marketing and healthcare. 3 In healthcare, social networking is a solid platform where doctors, nurses, allied health staff and students communicate, collaborate, share information and opinions, formulate innovative ideas and share common interests. In clinical medicine, it can be utilised as a platform to demonstrate best practice using an evidence-based approach and clinical excellence in a primary care, specialist or multidisciplinary setting. The focus of this article is to investigate current technologies that are available to facilitate this inter-professional networking, particularly in the field of orthopaedic surgery.
G. de Mel P. Nasr V. Khanduja
Types of social media There are numerous highly interwoven formats of social media technologies currently in use. These include blogs, microblogs (such as Twitter), social networking sites (Facebook and LinkedIn, for example), podcasts, and multimedia sharing sites (such as YouTube and Flickr). 3
Fig. 1 Household internet access has rapidly grown from just 9% in 1998 to almost 85% of the households in 2014 Source: Of fice for National Statistics- Internet Access 2014 Households and Individuals statistical building Blogs Blogs are a form of online journal where authors and followers can voice their opinions on a specific topic of discussion. 3 Blogs can provide a platform to share stories, present evidence and novel findings, broadcast news and updates in text form and other formats such as videos, photos and files. A number of healthcare-related organisations including the Mayo Clinic use blogs widely. The ‘Sharing Mayo Clinic’ blog provides a virtual place for patients to connect and share their experiences. 5 The ‘Health in Motion’ blog, an initiative by the Center for Orthopedic and Spine Care of St. Joseph’s Hospital in New York, is another excellent example. This blog provides up-to-date information about the latest research and innovations in the world of orthopaedics. It was launched in 2011 and has weekly or fortnightly updates, which provide excellent material for fellow surgeons and medical students to follow. These are usually presented by experts in a sub-specialised area of orthopaedics, using short videos. ‘Life in the Fast Lane’ is another example of a successful and very popular medical blog. 6 It is run by a group of Australian emergency physicians and provides information and education. It is free to access and provides valuable education and exam support for peers and medical students interested in emergency medicine and intensive care. For instance, their ECG library provides comprehensive information and education on various real-life ECG scenarios. People can discuss ECG interpretations, and follow progressive changes of a particular ECG case over time. Micro-blogs Micro-blogging is also widely used in healthcare, 3 Twitter being the most popular platform. Twitter is more popular as a professional social networking platform. Many specialists and academics have a group of subscribers to their Twitter-sphere, where they can have personal discussions about a particular topic and receive advice and opinion. Although the tweets are limited to short messages of 140 characters, selected information can be broadcast to subscribers around the world within a matter of seconds. Other examples of Twitter use include our own journal (@bonejointj), the British Orthopaedic Association
BJJ News | I ssue 8 | S eptember 2015
and Medscape Orthopaedics, who use Twitter as a medium to provide information on latest advances, research, orthopaedic conditions, drug references and education. Furthermore, Tweets are widely used in public health, health promotion and marketing as a way of connecting professional communities and the general public. Social media sites Social media sites such as Facebook, Google+ and LinkedIn are based on networks of personal, corporate and community profiles, respectively. They provide a platform to build interlinked personal and professional profiles that can be used to share information, updates, multimedia and information about personal and professional interests. Other sites such as YouTube and Flickr provide a platform to share photos, videos and other online media that can be valuable particularly in terms of medical education and health promotion.
Fig. 2 Sample screenshot from SERMO (Courtesy SERMO, Inc.).
Multimodal platforms Many novel platforms have been specifically designed to incorporate all these technologies to create an interwoven social networking ecosystem. There are emerging platforms such as Yammer, Sermo, OrthoMind, VuMedi and Figure 1 that are specifically designed and aimed at clinicians for interprofessional networking: Yammer - www.yammer.com Yammer is a free enterprise social network owned by Microsoft. It is designed for networking within organizations and their members to enhance collaboration, file sharing, knowledge exchange and team efficiency. Launched in 2008, Yammer is the first enterprise social network. Yammer can be accessed from any internet-enabled computer, smartphone or devices such as iPads. Users can share and discuss documents, images, videos and presentations. All these data will be stored on a Cloudbased system, therefore can be accessed from any device with internet access. Yammer is already being utilised by MayoClinic as an enterprise platform. Sermo - www.sermo.com Sermo is a US-based, physician-only, professional online community with a member profile of over 125 000 US-registered physicians. It is a well-established social network platform that enables professional knowledge sharing. 7 It was first established in 2006 as a physician-only social network and remains exclusive to US physicians. Sermo comes with a web-based platform and iPhone/iPad App which allows members to share clinical images such as photos, ECGs, radiographs, and to ask questions to capture feedback and advice from colleagues anywhere across the United States. Furthermore, it can work as an online blogging platform to share evidence-based insights and expertise on clinical cases, practice management, healthcare policy and research. Members can follow discussions on topics of interest in general healthcare or a specific specialty. Currently there are over 100 000 discussions on thousands of real life clinical cases presented, discussed and critically analysed on Sermo (Fig.2). VuMedi - www.vumedi.com VuMedi is a video-based social network where orthopaedic surgeons, radiologists, interventional cardiologists, neurosurgeons, and other physicians can share and watch expert videos, interact in discussions, participate in live webinars, and receive continuing medical education (CME) points (Fig.3).
Fig. 3 Sample screenshot from VuMedi (Courtesy VuMedi, Inc.). Healio - www.healio.com/orthopedics Healio is a website which provides in-depth information and news specific to a field of interest in medicine and surgery. It uses multimedia, question-and-answer columns and other educational material for specialists and students. This site also uses a multimodal platform which includes built-in blogs and other social networking platforms. There is a specific section in this site dedicated to orthopaedic surgery, with subspecialist focus including trauma, sports medicine, reconstruction surgery and arthroscopy to name a few. OrthoInfo – www.orthoinfo.aaos.org Orthoinfo is a multimodal platform run by the American Academy of Orthopaedic Surgeons. It is an online network for specialists in orthopaedic surgery to access information about the latest techniques used in theatre, discover information on the latest research and news, and also provides frequent ‘featured topics’ in text and video format. It contains various patient education modules for orthopaedic surgeons about informed consent, and various booklets and brochures that can be provided to their patients on various topics such as arthroscopy. The articles are provided with the endorsement of the American Academy of Orthopaedic Surgeons and have been put through an extensive peer-review process. OrthoMind - www.orthomind.com OrthoMind is an exclusive social networking platform for orthopaedic surgeons. It is designed to provide a customised knowledge distribution platform where orthopaedic surgeons can collaborate, share research and learning, and understand new technologies and emerging trends in orthopaedic surgery. Access is restricted to validated orthopaedic surgeons.
Fig. 4 Sample screenshot from Figure 1™ (Courtesy Figure 1, Inc.) Orthobullets™ - www.orthobullets.com Orthobullets is specifically designed as an educational resource for orthopaedic surgeons. It provides high-quality clinical cases, videos and sample exam questions targeting sub-specialist areas of orthopaedics including trauma, spine, paediatrics and reconstructive surgery. Interactive cases can be uploaded and discussed. Orthobullets is very popular amongst US- and Europebased orthopaedic trainees.
Figure 1- www.figure1.com Figure 1 is an iPad, iPhone and Android-based free multimodal platform that enables clinical photo sharing and multidisciplinary case discussions. Anonymous clinical images can be uploaded with patient consent, a relevant history, examination findings and investigation results. These are shared amongst the Figure 1 community, which includes over 150 000 healthcare professionals extending over 100 countries. This can be particularly useful in discussing specialist cases and cases that are endemic in one part of the world and rare in another. Image sharing is not only limited to patient images. Users can share anything that can be captured using their smartphone such as electrocardiograms (ECGs), cardiotocograms (CTG), slit-lamp images, retinal photographs, histology slides, or even investigation results such as blood gas findings. This can be particularly useful in orthopaedic surgery in sharing radiograph images, ultrasound, CT and, MRI scans or intra-operative images in order to recognise pathologies, or even identify novel surgical techniques. This has proven to be not only a great way to improve diagnosis, treatment and overall patient care, but also a valuable teaching and learning tool. It has many built-in features such as ‘paging’, which allows users to contact a specific specialty of verified users, and ‘automatic face-blocking’ which detects faces and automatically blocks them in order to reinforce privacy requirements (Fig. 4). Discussion Communities outside North America, especially in the UK and Australia, are relatively limited in the number of multimodal networks that specifically target orthopaedic surgeons. It is evident that there is a delay in embracing the already available communication technologies when it comes to healthcare. This limited access arises for a variety of reasons. Some of these include medico-legal barriers such as patient privacy, confidentiality, and
accountability. Others include the lack of available guidelines about the use of social networking in medicine and surgery, and the fear of adverse implications on patient care. As a result, most of these novel platforms are only exclusively available in the USA. While these obstacles slow down the use of social networking, it is evident that social networking can be developed further as a valuable tool, particularly in orthopaedic surgery. In our opinion, the most important potential of social networking is the ability to form an innovative platform which can provide a superior model of evidence-based medicine, replacing the current process of a peer-review-based model. Innovative technologies that can deliver a stronger social network can enable large groups of experts to link with each other, in order to create a more powerful way of presenting, processing and ranking information. It has the potential to allow important research findings to be classified and ranked in a similar way to YouTube and Google. By creating a network of orthopaedic surgeons, subspecialists can meet over the internet to discuss evidence-based practices, surgical techniques and novel developments in their field of surgery. When a novel research finding is presented to this network, it can be identified and ranked by a panel of experts, in order to identify the most significant research. Highly-ranked research can be presented to each and every individual in that social networking group, which gives a novel and robust approach to selecting important research information and fast-tracking it into practice. This should become an important way in which medical and surgical journals can incorporate the use of social networking, in order to transform their presence within cyberspace. References 1. No authors listed. Office for National Statistics, Statistical bulletin: Internet users, 2015. http://www.ons.gov.uk/ons/rel/rdit2/ internet-users/2015/stb-ia-2015.html (date last accessed 4 August 2015). 2. No authors listed. Office for National Statistics Internet access - households and individuals 2014. http://www.ons.gov.uk/ons/rel/ rdit2/internet-access---households-and-individuals/2014/stb-ia-2014. html (date last accessed 4 August 2015). 3. Eckler P, Worsowicz G, Rayburn JW. Social media and health care: an overview. PM & R 2010;2:1046-50. 4. Mansfield SJ, Morrison SG, Stephens HO et al. Social media and the medical profession. Med J Aust 2011;194:642-644. 5. No authors listed. Mayo Clinic: sharing Mayo Clinic (blog).. http://sharing.mayoclinic.org (date last accessed 4 August 2015). 6. No authors listed. Life in the fast lane (blog). http:// lifeinthefastlane.com (date last accessed 4 August 2015). 7. Bray D, Croxson K, Dutton W, Konsynski B. Sermo: a community-based knowledge ecosystem. SSRN http://papers.ssrn. com/sol3/papers.cfm?abstract_id=1016483 [[bibmisc]]
Gihan De Mel Gihan.deMel@monashhealth.org Pierre Nasr email@example.com Vikas Khanduja Consultant Orthopaedic Surgeon firstname.lastname@example.org
BJJ News | I ssue 8 | S eptember 2015
The Barbers Company Sir Roger Vickers, immediate past Master Barber, describes the history and activities of the Worshipful Company of Barbers, one of London’s oldest livery companies
Fig. 1 The Master (Sir Roger Vickers), Deputy Master (Lord Ribeiro) and Wardens of the Barbers’ Company 2014/15
he Worshipful Company of Barbers, to use its full title, developed in the Middle Ages, as one of the Guilds of tradesmen in the City of London. The first official record is from the Court of Aldermen, who appointed Richard Le Barber as the first Master of the Company in 1308. His role was to keep records, and to keep order amongst his colleagues, and if anyone misbehaved, or for example, “became a brothel keeper”, they would be reported and fined. Trade was regulated within the City and in Westminster and in due course the Guilds became known as Livery Companies, as they each wore recognisable uniforms, or livery. Barbers and surgeons developed together, particularly as Pope Innocent lll had decreed in 1215 at the fourth Lateran Council that members of the clergy who had developed medical and early surgical skills, should not shed blood. Since it
was the barbers who possessed the sharp knives, they took on bloodletting, or phlebotomy, and early surgical procedures. The barbers and surgeons developed alongside one another, in the joint Company of Barbers and Surgeons. They were given further recognition by the Royal Charter of Edward IV in 1462, and even more recognition by Henry Vlll’s Act of Union of 1540, which stated that barbers in The Company should only do barbery, such as shaving or cutting hair, and that the surgeons in The Company should perform only surgery, but that both groups could let blood, and both could remove teeth. More importantly, however, the Act also stipulated that The Company would be allocated four bodies a year from Tyburn, the place of judicial execution, for dissection and the teaching of anatomy to the surgeons in The Company. The Act of Union is portrayed in the great Holbein Portrait, painted in 1541, of Henry Vlll presenting the Act
of Union to Thomas Vicary, his Serjeant Surgeon, and the surgeons and barbers of the Company. This great picture is still in Barber-Surgeons Hall today, and its almost contemporaneous copy will be known to many orthopaedic surgeons as it hangs in the Edward Lumley Hall of the Royal College of Surgeons of England. An anatomy theatre, based on the one in Padua, and designed by Inigo Jones, was built at Barber-Surgeons Hall in 1640, and was in fact the only part of the Hall that was not burnt down in the Great Fire of 1666. The Hall was rebuilt over a few years, and both barbers and surgeons remained as the joint Company of Barbers and Surgeons, for almost another century. In 1745 the Surgeons pet it ioned Parliament, and were allowed to leave The barbers, and they formed The Company of Surgeons, taking with them their librar y and anatomy teaching,
Fig. 2 Barber-Surgeons’ Hall
eventually becoming in 1800, The Royal College of Surgeons of England. The Company of Barbers remained on their own in Barber-Surgeons Hall, though relatively impoverished, and needing from time to time to rent out part of their building, and sell some of their books, and silver. The records remain, however, and it is clear that over the next century one or two surgeons became members of the Barbers’ Company, perhaps for historical reasons. In 1919 however, a joint lectureship was established, with the Royal College of Surgeons, to be held annually in honour of Thomas Vicary, who had been instrumental, as Serjeant Surgeon to Henry Vlll and Master Barber at the time of the Act of Union, in obtaining both full recognition of the joint Company at that time, but also and more importantly, the establishment of anatomical teaching for the surgeons. The Vicar y Lecture, usually on an anatomical topic, and often of an historical nature has continued ever since, apart from during the last war, and it was the giving of the 92nd Vicary Lecture which stimulated David Jones, the 2014 Vicary Lecturer, to record, in a letter to BJJ News, the coincidence that he was giving the
Lecture, as an orthopaedic surgeon, and that the President of The Royal College of Surgeons, Clare Marx, is an orthopaedic surgeon, as am I, as Master of The Barbers’ Company. It is worth pointing out that neither Clare nor I had made the choice of David to be the lecturer, as neither Clare nor I had been elected when that choice was made. Many of the great names of surgery in London, including Thomas Vicary and Charles Bernard were members of The Company of Barbers and Surgeons. John Caius was probably the first Reader of Anatomy before he went to Cambridge. Edward Arris, Thomas Gale, William Clowes and William Cheselden were all BarberSurgeons, as was the great herbalist, John Gerard who was Master in 1607. The Barbers Company today is made up of about 240 liverymen, and 45 Freemen, and about one third are medical, of whom most are surgeons, or dental surgeons. The Company, now more than 700 years old, is one of the oldest of the 110 Livery Companies in the City of London. Of the old Companies, only 35 still have their own Halls, as so many were lost in 1666 and then again in The Blitz of 1940.
Barber-Surgeons Hall was destroyed again in 1940, and rebuilding was not allowed immediately by the City of London Corporation who had plans to develop the site, in Monkwell Street, as it then was, as part of the Barbican Centre of apartments, galleries, and schools. However, in 1965 The Corporation decided that BarberSurgeons Hall could be rebuilt, but no longer was it to be attached to the old Roman Wall, as it had been for over 500 years. They agreed that it could be rebuilt 30 feet away from the wall, to the South, in a new square, to be called Monkwell Square. The New Hall was completed and opened by The Queen Mother in 1969. Like many other rebuilt Livery Halls it was rebuilt with lettable space in its upper floors, which produces useful income. Some of the older Companies, and most of the so-called Modern Companies, stipulate that Liverymen should pay a subscription, known as Quarterage, but in the Barbers’ Company a ‘fine’ is paid on entry, and it is expected that members should contribute to the Company’s Charities. Like most other Livery Companies in the city, and indeed in other great cities of the country, and of Scotland, the sole purpose of the Company is charitable
BJJ News | I ssue 8 | S eptember 2015
giving. Indeed it is estimated that the livery Companies of the City of London together give about £40 million a year to good causes, in most cases related in some way to their original foundation. The Worshipful Company of Barbers has never been one of the richer companies, but is able to make charitable donations totalling about £150 000 a year, mostly to various medically-connected causes. For example the Company is the major donor to the Barbers’ Professorship of Anatomy at the Royal College of Surgeons. The Company gives an annual grant to the Phyllis Tuckwell Hospice in Farnham, founded in 1979 by Sir Edward Tuckwell, a past Master Barber and surgeon at St Bartholomew’s Hospital, in memory of his first wife. The Company supports medical students who are doing medicine as a second degree and who are often struggling to sur vive as they are not entitled to a state grant except in their final year. It also supports the Extended Medical Degree programme, at King’s, set up some years ago for youngsters from central London schools from which they would not normally be able to study medicine. I became a member of the Company, initially as a Freeman, 12 years ago. Candidates for Freeman need to be
proposed by a Liver yman, and by a member of the Court of Assistants of the Company. The Court is responsible for the governance of the Company, and the day- to-day management is by the Clerk, who is a retired senior military officer, and a small office team, including an archivist, and a beadle who runs the Hall. The Hall is let commercially for dinners, lunches and other meetings when not required for Company events. I was elected Master of The Company last year on the second Thursday in August (the date laid down in the statute of 1462), and will step down again this year when my successor is elected. I succeeded Lord Ribeiro, a general surgeon, and a recent President of the College. His two predecessors as Master had been an accountant and a retired banker respectively. My probable successors will be a retired solicitor, and the following year a university professor of history. I am only the second orthopaedic surgeon to be Master Barber, the first being Alan Lettin in 1990. I am the sixth holder of the office of Serjeant Surgeon to The Queen to be Master Barber. As I write this I have only a month remaining as Master. It has been a most enjoyable and interesting year. I have
attended 195 events so far, both in our own Hall, and at other places, mostly in the City. I have eaten some 80 lunches or dinners in many other Livery Halls and at the Mansion House during the last year, and have become more confident, and I hope more competent, at after-dinner speaking. I have attended a number of other very special events, including the Lord Mayor’s Show, several huge services in St Paul’s Cathedral, and the Magna Carta event at Runnymede. My wife and I were guests at The Master ’s Feast at The Cutlers of Hallamshire, which was particularly enjoyable for me as I was born and brought up in Sheffield. We spent a weekend in Glasgow for dinner at Glasgow Trades Hall, as the guest of the Deacon of the Incorporation of Barbers of Glasgow, Marc Bransby-Zachary, who is, like me, an orthopaedic surgeon. It has been a wonderful, fascinating and exhausting year, and I am looking forward to August when I can resume relatively quiet retirement and have more time for sailing, whilst still enjoying the Barbers’ Company, the perspective of a past Master!
Fig. 3 The Great Hall of the Barber-Surgeons’ ready for dinner on Election Day. The Holbein hangs at the far end.
Sir Roger Vickers Consultant Orthopaedic Surgeon email@example.com
Bridging the gap
World Orthopaedic Concern, revisited he ethical foundation of World Orthopaedic Concern, first enunciated from the footsteps of Oriel College, Oxford in 1976, is a philosophy difficult to disagree with, but very hard to act upon. It tries to put into practice the general regret that the human condition is shot through with appalling inequalities. The evidence comes home with the pictorial images of the ‘Jungle’ camp outside Calais, on its way towards Dover. Are we waiting for them to camp outside Canterbury; and thence through to the Home Counties? It impacts on our profession, in that trauma in all its shameful extremities, reflects the fact that men (and even more, mothers) will fight tooth and nail when sheer survival is threatened. ‘Panic stricken multitudes’ do not go away. They return with more bloody weapons. Herein lies the root cause of mass migration; or war. Viewed more intimately, it explains why so many graduate doctors from sub-Saharan Africa leave their counties for Western socalled democracies. These are the very people on whose skills life and limb depend. Of course this is only one small aspect of the global cause, but it illustrates the quantity of inequality, which turns peaceful citizens into Gaderine swine. An example of one attempt to address the root cause is to take part in the training of doctors to care for the major pathology of the last century, road traffic trauma and accidents in the workplace. Two common responses are financial donation, and the offer of scholarships to doctors who show the enthusiasm to learn about modern medical techniques. But even when this is possible, young doctors will then be trained to use equipment which is not available ‘at home’, and to manage conditions which do not exist, at home. If they become very good at ‘modern’ techniques they will find themselves fit only for Western work.
A pilot study in Zimbabwe A small group of orthopaedic surgeons made a brief (three week) visit to Harare
and Bulawayo. It took the form of a reconnaissance, to assess the present situation in a country that has been out of the limelight for a considerable period of time. In the distant past, Zimbabwe had the foundation of a sound ‘colonial’ medical ser vice, which foundered on political turmoil, sequentially by Ian Smith (1965), and later, Robert Mugabe. Doctors fled south (or abroad) leaving behind well-ordered, efficient, single story district hospitals, with an educated nursing profession. These district hospitals are exactly like the RNOH, Stanmore, but stagnant – scrupulously cared for, but architecturally old-fashioned. They are spurned by the new medical profession as out-of-date, but the equipment is exactly what you and I (well, I anyway) were brought up on fifty years ago; basic principles on which our ingenuity built. In spite of adverse journalistic reports, the levels of literacy and all aspects of primary schooling have been universally preserved in Zimbabwe. As a result, the hospitals are run by a quite outstanding nursing profession which maintains an excellent level of cleanliness, comparing well with anything in sub-Saharan Africa. Operating theatres are spotless and the instruments regularly sterilised and dated. But their well-kept records of surgical activity reveal that few procedures are perfomed, except that is, for Caesarean section. One has the impression that obstetrics is the chief reason for the continued maintenance of the operating theatres! This reduced level of activity gives a slightly sad feeling to these washed, painted and well-preserved suites; as if in mothballs. Wonderful nurses wait, like brides deserted at the altar, hoping that the surgeons will return. Meanwhile the trickle of new young doctors are down the road, in clinics converted from empty hotels, busy breaking arthroscopes, in private practice! The medical schools in Harare and Bulawayo are eagerly productive, but time to train competes with the demands for service. These medical schools too have an oldfashioned atmosphere, which is by no means to be criticised. For example the anatomy
departments are packed with embalmed bodies for formal dissection. Very few modern Western medical schools have preserved this enlightened practice. This was quoted at the funeral service this week of Professor Leslie Klenerman who reverted to the teaching of anatomical dissection, where that practice has sadly faded. This is personal impression, by no means universal. We encountered many regional hospitals where quite excellent conservative and operative work is being done, often by ‘general’ surgeons breaking the mould of premature specialisation. Too often patients are left untreated for want of ‘modern’ and sometimes inappropriate technology. These ‘dated’ tools (nails like those of Kuntscher and Rush) are just waiting for yesterday’s experienced surgeons to revive their training and revert to fundamentals. Few experiences can match the pleasure of restored youth! And then, finally, there are opportunities to advance the practice of reconstructive surger y, in the form of est ablished scholarships to centres of excellence abroad for the selected few, chosen to be the leaders for their own country. At the heart of all these gestures is the creation of orthopaedic care for the community, in the community. This is no more than a model for all aspects of medicine and also industry, whereby a measure of stability develops through confidence in a nation’s future. There is a debt of mutual gratitude for warm invitations from the host countries, who need no reminder that this most valuable contribution can be made by mature and reluctantly retired surgeons who retain youthful energy (by virtue of pharmacology and surgery, on themselves).
Michael Laurence firstname.lastname@example.org
BJJ News | I ssue 8 | S eptember 2015
Bridging the gap
A ‘faranji’ in Addis ddis Ababa is a huge, polluted and noisy city, where you can take your life in your hands crossing the road, ride uncomfortably in a 40-year-old Lada taxi and where they test banknotes to destruction; some are indecipherable. Excellent draught beer is 50p a pint and clean shoes are a matter of personal pride, hence the countless shoeshiners in poor and wealthier places alike. More importantly, as an effect of Ethiopia’s firm government, it’s safe to walk the streets, even at nights, unlike the mess in surrounding countries. As a ‘faranji’ (foreigner, expatriate) this was reassuring and, although harrassed by the usual street vendors and beggars of such a city, I never felt threatened. Ethiopia has endured poverty, famine and the horrors of the Mengistu regime during living memory and emerged with a strong national identity and a will to do well in the world. As a consequence, it is important to recognise the country’s attitude to faranjis.
Their contribution to Ethiopia’s needs should be by local request and complementary to existing facilities and skills. Between 5-18 May 2015, I visited the Black Lion Hospital (BLH) on behalf of World Orthopaedic Concern (WOC). During that time I attended departmental meetings, taught residents and medical students, lectured on their training programme, participated in clinics and ward rounds and visited theatres. I stayed in the WOC apartment which is very basic, but spacious, safe, secure and within the hospital compound. WOC has had a presence and influence at BLH since the time of Ginger Wilson in 1990, a founder of the department, closely followed by Geoffrey Walker and with continuing visits by him and others, whose portraits hang high on the walls of the departmental meeting room (Fig. 1). A par ticular contributor was Fintan Shannon, whose portrait refers to him as
‘A Dedicated Orthopaedic Surgeon’, as well it might, for Fintan has given outstanding voluntary service at considerable personal expense to BLH and other institutions in Addis over many years. However, the relationship with BLH was discontinued several years ago, and I was asked to explore possible ways in which co-operation between BLH and WOC might be restored. Although arriving at midnight, the Turkish Airlines flight was good value and with a short connection at Istanbul. I travelled visa-less, as the system for getting a business visa in the UK failed in spite of prompt earlier action by Rick Gardner, who coordinated my visit and represents WOC out there. However, I got a tourist visa on arrival and was not bothered thereafter on that front. Rick’s driver met me and took me to the hotel I had booked from the UK. Rick picked me up in the late morning (a public holiday) and after a pleasant
Fig. 1 Depar tmental meeting at BLH Por traits of previous Heads of Depar tment and Visiting Consultants around the walls.
Fig. 2 Drs Bahiru and Ephrem. No shor tage of smar t phones in Ethiopia!
Fig. 3 A section of the dark and crowded Emergency Depar tment .
Fig. 4 A typical consultant ward round with residents and medical students.
Fig. 5 A clinic at BLH. Large open space with multiple simultaneous consultations.
Fig. 6 Young man awaiting amputation for a fungating neglected sarcoma.
Fig. 7 Baby showing irretrievable Volkmann’s ischaemia af ter failure to remove tourniquet following venipuncture. introductory lunch, went on to the CURE Hospital. This is hugely impressive, delivering state-of-the-art children’s orthopaedics, with a private ward from which adult arthroscopy and arthroplasty help fund the children’s work.
I started at BLH the following day and was introduced to Head of Department, Dr. Bahiru and Senior Resident, Dr Ephrem (Fig. 2), along with other consultants and a roomful of residents, around 50 in all. As a background for those unfamiliar with BLH, it is the main government hospital in Ethiopia. Its orthopaedic department has to deal with an overwhelming and challenging workload against impossible odds. Patients with major injuries may wait for days in the crowded emergency department (Fig. 3) before gaining access to the overloaded orthopaedic department, which also has to train all of the orthopaedic residents (around 60 in total) for the whole country. For example, Dr Ephrem has just been appointed as a consultant to a southern city (Awasa), where he will be the only orthopaedic surgeon for 13 million people. Notwithstanding these difficulties, there is a genuine mood of optimism in the orthopaedic fraternity towards bringing the best of orthopaedic care to the country. They’re a savvy bunch regarding computers and smart phones and know what’s possible throughout the world. They’ve seen how the introduction of the SIGN nail (they don’t have a C-arm) and Ponseti treatment to their department can transform care, and last year Australian Doctors for Africa built a modern, four-theatre operating suite at BLH. With these theatres and the inherent skills of local surgeons, it is possible to give high quality care. The Aussies also run a basic fracture course here and their leader, Graham Forward, from Perth, hopes that a British orthopod could join the faculty for the next course in April 2016. The residents and medical students are keen to learn and crowd into the busy ward rounds and clinics where there is no shortage of diverse pathology of every grade of severity (Figs 4-8). In particular, the residents want to contribute to the medical literature. I gave them a session on writing and reviewing a paper, which went down very well. A highlight of my visit was to spend a day out with the whole department in
celebration of its 25th anniversary. It was a most convivial event, with a prize-giving, good food including raw meat (I declined), and frenetic dancing, all helped by lashings of beer and honey wine (Fig. 9). The BLH wants to have visiting surgeons to help them and, after my time there, I am assured that relations with WOC are restored. They particularly want help in aspects of trauma, wherein vascular and plastic surgery are not represented. Bone tumours are also sorely under-resourced. On the positive side, although children’s orthopaedics is also a huge problem, Addis has a CURE hospital where state-of-the-art treatment is undertaken. The consultants, with Rick Gardner to the fore (Fig.10), contribute to the BLH training programme, and give their residents experience. So, with this experience, and with the understanding that WOC has established potential relations with SICOT and the Bone & Joint Journal (both organisations keen to contribute to orthopaedic care in developing countries), I made the following proposals to Professor Keith Luk, President of SICOT, and Professor Fares Haddad, Editor-in-Chief of the BJJ. I had three requests for SICOT: 1. The first was that SICOT should offer free membership to orthopaedic residents of low-income countries. This membership would allow the 60 Ethiopian trainees to become part of The SICOT Young Surgeons Committee and make them eligible to apply for Fellowships abroad, usually elsewhere in Africa. 2. Second and following that, SICOT should consider funding a specific Fellowship for Ethiopian trainees. 3. Third, success in the SICOT examination might, in time, be a useful qualification for countries like Ethiopia where the exit examination for trainees is a local affair and there is no international recognition of their knowledge and problem-solving abilities. However, outwith any association with SICOT in relation to examinations, it might make more sense if Ethiopian trainees became more aligned with the College of
BJJ News | I ssue 8 | S eptember 2015
through the internet. The visit should be aimed for next November. The second bursary would be for a consultant to be part of the faculty for the fracture course next April, working with Australian Doctors for Africa, and to stay on to share in the work and teaching of the department. The value of each bursary would cover flights and accommodation in a good hotel, as the apartment at BLH is very basic and likely to be a challenging distraction to someone from an affluent country.
Fig. 8 Boy recovering af ter bilateral post-traumatic amputations. Surgeons of East, Central and South Africa (COSECSA) and took their examination, which would carry much more weight in this part of the world. However, that would be for local decision. With regard to the BJJ, I made the following two requests: 1. Would BJJ be prepared to give free online subscriptions to the residents of Black Lion Hospital? They would therefore be up to speed with the literature and everything else the BJJ has to offer. 2. Would the BJJ be prepared to fund two bursaries for established British consultants to spend two weeks at BLH? A particular problem for BLH is pelvic trauma, and the first bursary would be for a consultant with a broad experience of trauma and a special interest in pelvic and acetabular fractures. The visit would be coordinated by Dr Geletaw, a young surgeon with a special interest in the subject and who recently became Head of Department. They could prepare their programme beforehand
Fig. 9 Black Lion Hospital Or thopaedic Depar tment on its 25th anniversar y.
Fig. 10 The CURE consultants (lef t to right): Mesf in Etsub, Rick Gardner, Tewodros Tilahun and Tim Nunn.
In summary, I had a rewarding, enjoyable, sometimes uncomfortable but always interesting time in Addis. I am particularly grateful to all the staff at BLH for making me feel welcome, and to Rick and Anne Gardner for their outstanding hospitality. It is pleasing that relations between BLH and WOC are restored, and I was hopeful that my proposals would be seen as modest but constructive ways forward. I did not have long to wait. SICOT responded first and delivered all that was requested. Ethiopian trainees may now be part of that organization at no cost, and will be particularly welcome to its Young Surgeons Committee. The British Editorial Society of Bone & Joint Surgery recently agreed to provide free online subscriptions to all Ethiopian residents, and to fund two bursaries of £2000 each, which will allow two surgeons to visit and work hands-on at BLH next November and April. These visits will be a collaborative effort between the BJJ and WOC and along the lines requested by BLH. As a further example of its charitable objectives, the British Editorial Society of Bone and Joint Surgery is funding a separate orthopaedic project at Gonder, in northern Ethiopia. This will be a collaboration with Leicester Royal Infirmary, and was largely brought about through the efforts of Laurence Wicks, a senior trainee there who is already dedicated to improving orthopaedic care in Ethiopia. All this news has been warmly received in the Ethiopian orthopaedic community, and I am optimistic that during the coming months, these pages, and the websites of BJJ and SICOT, will carry positive reports of locals and faranjis working together.
David Jones Honorary Consultant, Great Ormond Street Hospital For Children, London, UK email@example.com
R. Gandhi R. H. Brophy S. Kakar H. H. Luu K. Mulpuri A. Patel S. Shah
notes from the road
ABC Travelling Fellows
Fig. 1 The Fellows hosted by the British Or thopedic Association for a welcome lunch.
he American-BritishCanadian (ABC) Travelling Fellowship started in 1948 as an exchange of fellows between the United Kingdom, Canada and the United States; South Africa, Australia and New Zealand joined in subsequent years. It is an invaluable opportunity to build collaborations, share knowledge, and develop friendships across the world. We are privileged to present the experiences of the 2015 ABC Travelling Fellows. During our five-week tour, we visited the United Kingdom, Australia and New Zealand. We were greeted with the kindest of hospitality and friendship throughout. We learned that, as a global community of orthopaedic surgeons, we share the common challenge of providing high quality, value-based care. We were inspired to continue to improve how we train and educate residents, think about important
Fig. 2 The Fellows visiting the Hunterian Museum with our hosts in Glasgow.
research questions, and provide the best care for our patients. United Kingdom Upon our arrival in London, we were graciously welcomed by the British Orthopaedic Association (BOA) and The Bone & Joint Journal. Our UK tour was meticulously organized thanks to David Limb (BOA honorary secretary), Hazel Choules, and Emma Storey (Fig. 1). In London, we were able to visit a number of prominent academic and clinical centres. Our first visit was to the Institute of Sport, Exercise and Health, a collaborative effort between the National Health Service and University College London, directed by our host, Professor Fares Haddad (ABC alumnus), the Editor-in-Chief of the BJJ. Together, we discussed the critical issues in academic medicine including authorship for large, multicentre RCTs, poor quality science, and how to approach big data
from national registries. We were later hosted by Professor Tim Briggs (ABC alumnus), Past President of the BOA and Mr Robert Pollock (ABC alumnus). Together, over a traditional English breakfast, we discussed issues of access, outcomes, quality, training, registries and costs of care. At the Royal National Orthopaedic Hospital in Stanmore, we were greeted by Mr William Aston (ABC alumnus) and Professor Alistair Hart as guests of the 25th Annual Seddon Society chaired by Professors Briggs and Hart. We learned that Sir Herbert Seddon was a worldrenowned authority on the brachial plexus, polio, TB and congenital dislocation of the hip, as well as being an orthopaedic surgeon to Sir Winston Churchill. We were then hosted by Mr Pramod Achan (ABC alumnus) at the Royal London and St. Bartholomewâ€™s Hospital. For the main academic session of the day,
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Fig.3 The Fellows at the Royal College of Physicians and Surgeons of Glasgow. all the available trainees and consultants participated in a lively discussion about health care innovations. Mr. Achan further presented us with a history of the ABC and its links to the orthopaedic departments of St Bartholomew’s and The Royal London Hospitals. Our visit to London also included a number of historic visits including the Churchill War Rooms and Westminster Abbey. We next visited Oxford and learnt of the rich history of the city and university. We were warmly greeted by Professor Andy Carr (ABC alumnus) and Mr. Duncan Whitwell (ABC alumnus). We were taken for a tour of the Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the Kennedy Institute. During the academic session, Professor Chris Lavy, a Lancet Commissioner, detailed the global health issues in orthopaedic surgery
and the disparities that exist worldwide, especially within Africa. Professor Keith Willett taught us how to implement a quality framework effectively so as to drive improvement; Professor David Murray presented his experience with the evolution of the Oxford Unicondylar Knee Replacement and Professor Carr educated us about his work in randomised controlled trials in shoulder surgery. After Oxford, we travelled to East Anglia where we were greeted by Professor Simon Donell. We learned of the history of the hospital and the evolution of the Norwich Research Park, a place where musculoskeletal research is carried out using the expertise within the University of East Anglia and the Norfolk and Norwich University Hospitals. Our next journey took us to Leicester, where we met Mr Rob Ashford (ABC fellow 2014). We were honoured to attend the Leicester Tigers annual award ceremony (professional rugby team) where we sat with players during their celebrations and were acknowledged by the team. We had fascinating discussions with Professor Angus Wallace (ABC alumnus), Professor Dias (past president of the BOA), Mr Jeya Palan (past president of the British Orthopaedic Trainees Association) and Mr Alwyn Abraham (consultant paediatric orthopaedic surgeon), Leicester University) on issues ranging from differences in training systems, challenges facing trainees and consultants, and how to recruit trainees to enter academic career paths within University systems. Heading north to Glasgow, Scotland, we were greeted by Mr Sanjeev Patil and Mr Dominic Meek (ABC alumni). Together, we visited the Hunterian Museum and Art Gallery where we learned about William Hunter (17181783), who played a major role in Britain’s 18th century scientific, cultural
Fig. 4 The Fellows hosted at the Hexam General Hospital. and social sciences (Fig.2). Later, we proceeded to the Adam Smith lecture theatre within the University of Glasgow for an academic session hosted by Mssrs. Patil & Meek. The evening festivities included a dinner reception at The Royal College of Physicians and Surgeons of Glasgow, founded in 1599, and where, dressed in traditional Scottish kilts, we met other previous ABC fellows including Mr Huntley, Professor Hamblen and Miss Catherine Kellet (Fig. 3). On arriving in Edinburgh, we were met by previous ABC fellows Professor Hamish Simpson, Miss Leela Biant, and Mr John Keating. Professor Simpson hosted us for dinner in his house, where we enjoyed a delicious home-cooked meal courtesy of Helen Simpson. We relaxed with previous fellows and enjoyed Scottish hospitality at its finest. Despite some damp weather, our spirits were not dampened as our gracious hosts took us to visit the home of golf, the fairways of St Andrew’s golf course. After returning, we enjoyed dinner at the Balmoral Hotel where we donned our Scottish kilts and were greeted by numerous past ABC fellows including Professor Charles Court-Brown, Professor Margaret McQueen, Professor McMaster, Miss Julie McBirnie, Mr John Keating, Professor Simpson, Miss Leela Biant, and BOA President, Professor Colin Howie. For the academic portion, we visited
the Chancellors Building in the Royal Infirmary of Edinburgh. The meeting included several impressive lectures from orthopaedic trainees who had completed their PhDs in orthopaedic research. After a quick train ride to Newcastle, we were met by past ABC fellow Mike Reed and his wife, Alex. After a guided tour of the Roman town of Corbridge, we proceeded to Hexham General Hospital which is one of 15 hospitals that make up the Northumbria NHS Trust. We had an enthralling academic session comprised of lectures by the local trainees, consultants and the ABC fellows (Fig. 4). On our last day in Newcastle, we attended the Combined Services Orthopaedic Society annual conference at Fenham Barracks, Newcastle upon Tyne, hosted by Professor Simpson and Lt Col David Cloke. We learned of important research work being done within the military. Dinner was an event that we will never forget. It was a black tie occasion with the armed forces (RAF, Army & Navy) dressed in full military evening dress. It took place at Anzio House, Royal Marine Reserve, Quayside in Newcastle and as civilians, we were very honoured to attend. Our last day in England was spent in London. After an exciting football match between Crystal Palace and Manchester United (courtesy of Professor Haddad), we retired to the Royal College of Surgeons of England before heading to Australia (Fig. 5). Australia On arrival in Perth, any remnants of jetlag fast disappeared as we were greeted by Professor Piers Yates (ABC fellow 2012) and a white sandy beach! After spending the morning with our clinical mentors, we enjoyed surfboat
rowing at North Cottesloe beach where we learned the nuances of this sport and the emphasis on team work. The academic session (chaired by Professor Yates & Professor Richard Carey Smith) was at the Fiona Stanley Hospital and was attended by the faculty and trainees. On arrival in Sydney, we met with Professor David Little (ABC alumnus) and took part in the Sydney Harbour Bridge Climb. This was a climb of over 7000 steps reaching 450 meters above sea level and provided unprecedented views of downtown
and the welcome extremely warm. After checking in at our hotel, we headed for our academic session at the Royal Australasian College of Surgeons in East Melbourne. The attendance and academic value was first rate (Fig. 6). A highlight of the tour was our visit to Melbourne Cricket Ground to attend an Aussie Rules Football match between Melbourne and Hawthorne. This was a special afternoon as we were hosted in one of the corporate hospitality boxes where we had a chance to meet many of the trainees. Later, we had a specially arranged dinner menu of traditional Australian cuisine including kangaroo meat and barramundi fish. We were joined by former ABC fellows Mr. Jonathan Rush (1978), Professors Kerr Graham (1992) & Richard de Streiger (1998), Alasdair Sutherland (2008) and Phong Tran (2014). This was a tremendous opportunity to see how the ABC fellowship has shaped careers and friendships.
Fig. 5 The Fellows hosted at a football match in London. Sydney. We had dinner with Professors Little and Bruce Foster (ABC alumnus and recipient of the Order of Australia), who kindly came from Adelaide to be with us. We had a fascinating academic session at the Childrenâ€™s Hospital at Westmead, where we met numerous consultants and trainees and discussed important innovations in health care, including 3-D printing. Upon arrival in Melbourne, we were met by our local host Mr. Phong Tran (ABC 2014) and his assistant, Sarah. The attention to detail was palpable
New Zealand Then it was on to Queenstown, New Zealand and we were immediately struck by its sheer beauty. We were surrounded by snow-capped mountain tops and beautiful lakes and met our NZ hosts including Brendan Coleman (ABC fellow 2014) and Gordon Beadle (ABC fellow 2012). There was a leadership forum where we discussed issues such as teamwork, identifying and facing up to onesâ€™ fears, balance and behavioural issues, training, education and methods of
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Fig. 6 The Fellows hosted in Melbourne
identifying and setting up safeguards in the management of underperforming trainees. Activities included bike riding, a 50m bungee jump off the Kawarau suspension bridge and golf. After we arrived in Christchurch, we learned about the recovery from the earthquake that hit the area several years ago. We visited Leinster Orthopaedic Centre at St Georges Medical Centre and met Professor Gary Hooper (ABC alumnus, previous president of NZOA). During lunch, we discussed the public/ private set up, the no-fault liability system within the public system and the insurance system to cover trauma care. We attended further academic sessions at the University of Otago, Christchurch hosted by Mr Gordon Beadle and Professor Gary Hooper. We were warmly received and heard excellent talks from the ABC fellows, trainees and faculty including Professors
Alastair Rothwell (ABC alumnus) and Professor Hooper. After a fun round of golf at Christchurch Golf Club, we went for dinner at “The Local” in Riccarton House. The camaraderie shown by our hosts typified the superb hospitality we received during our visit to the South Island of New Zealand. When we arrived in Auckland, greeted by Brendan Coleman (ABC fellow 2014) we were taken sailing on a boat designed for the 2003 Americas Cup race in the Waitemata harbour. For our final day on tour, we enjoyed a stimulating academic session at Auckland City Hospital. We were joined by the faculties from Middlemore, Auckland City, North Shore and Starship Hospitals. Collectively, they boast 15 ABC fellows from 1956 to 2016. After the academic day, we all prepared for the long journey home.
The excitement we felt on returning to see our long-missed friends and family was offset with the realism that today marked the end of a trip of a lifetime. We had embarked upon this journey five weeks before. During this time, we were treated royally by all the staff at the COA, AOA, BOA, BJJ AuOA, NZOA, trainees, consultants, local hosts and past ABC fellows. Through the alumni and experiences of the ABC fellowship we have learned the true meaning of the tour, namely leadership, inspiration and collaboration. As one sits back and reflects on the five weeks, the true meaning of friendship comes to the fore, both towards the people we met but also amongst each other. We truly have become friends for life as we embark upon the next part of the journey, together, as the 2015 ABC fellows.
Rajiv Gandhi Rajiv.Gandhi@uhn.ca Robert H. Brophy firstname.lastname@example.org Sanjeev Kakar Kakar.Sanjeev@mayo.edu Hue H. Luu email@example.com Kishore Mulpuri firstname.lastname@example.org Alpesh A. Patel email@example.com Suken A. Shah Suken.Shah@nemours.org
notes from the road
The Mark Patterson Travelling Fellowship, 2015
S. Konan G. Grammatopoulos J. Barnes
clinic as well as witness membrane-induced osteosynthesis surgery first-hand. We are most grateful that Professor Bégué made every effort to ensure that the trip was educational, despite the strikes taking place in his hospital. In the evenings we had the chance to meet all the members of the team and to discuss several aspects of life in France whilst appreciating the local cuisine, red wine and sights of Paris. The midnight cycle towards the lights of Eiffel tower will stay forever in our memory, reminding us of the student life we left behind years ago!
Fig. 1 Paris. he Mark Patterson Travelling Fellowship 2015 began on 18th May, and concluded with the 16th annual congress of EFORT on 29th May. The three Fellows selected for this year’s Fellowship were Sujith Konan from University College London, George Grammatopoulos from Oxford and James Barnes from Bristol. We all had different backgrounds and aspirations, but shared a common interest in hip preservation surgery and pelvic osteotomy. This fellowship gave us all an excellent opportunity to meet European colleagues, learn from them and build strong working relationships in Paris, Dresden and Bern. We were told of our successful applications in January 2015 which gave us ample time to schedule our work commitments well in advance. The EFORT Administration & Project Coordinator, Sanni Hiltunen was responsible for all arrangements for our two-week fellowship, and kept us posted of all developments.
Paris The Fellowship started in the Hôpital Antoine-Béclère, hosted by Professor Thierry Bégué. We joined the orthopaedic team for their trauma meeting in the morning, and then followed Professor Bégué to the operating theatres and clinics. Our visit to Paris gave us the opportunity to benefit from his particular expertise in trauma. We were able to discuss complex patients and share our opinions in a specialist
Dresden From Paris we travelled to Dresden in the east of Germany where we were hosted by Professor Gunther and his team. A fantastic clinical and social schedule was awaiting us. We took part in peri-acetabular osteotomies, hip arthroplasties through the anterior approach and open arthrotomies of the hip. Being so involved with the cases allowed us to discuss the indications, techniques and experience that Dresden had with these techniques, and we certainly feel that we left with some good advice and tips that we will all use in our practice. We had the opportunity to discuss the results of both past and ongoing research at a departmental conference arranged by the professor in which there were presentations from us, and from the local surgeons. James presented work on the long-term outcome of Salter osteotomies on acetabular morphology; George presented his work on cup orientation in hip arthroplasty, and Sujith on how the functional outcome of joint arthroplasty can be measured. Professor Gunther had arranged the schedule in such a way that the Fellows’ talks alternated with those of the host surgeons on concordant themes, thus generating interesting discussion. Consequently, it was an excellent opportunity to swap ideas, discuss cases and advance the theory behind different treatment concepts. The city of Dresden is very picturesque and, thankfully with the weather on our side, we were treated to several outdoor activities by our host including a guided tour of the city, hiking, cycling, a steamboat trip and of course the traditional Saxon Switzerland dinner washed down with a variety of local and not so local beverages. Professor Gunther was also kind enough to host us at his house, where we met the whole team and discussed the German system of education and training. Furthermore, on the Friday evening, we were invited to a modern ballet at the Dresden Opera. The show was unique and one that we will remember forever. Professor Gunther’s punctuality and attention to detail both at work and leisure will never be forgotten. Bern From Dresden we went to Bern, in order to witness what it was like at the birthplace of the peri-acetabular osteotomy and the unit where Professor Reinhold Ganz first described the Bernese periacetabular osteotomy. We had the opportunity to meet Professor Siebenrock, the current Head.
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Fig. 2 Dresden
Although we could not spend time with him due to his busy commitments at the EFORT conference, we had followed his team and were able to discuss theories and beliefs behind the initial success of the peri-acetabular osteotomy, their ongoing research into refining the technique and the new 3D-modelling software being developed to aid pre-operative planning. We also had the chance to visit a Swiss-based implant company where we were shown the manufacture of the unique non-modular, titaniumbacked cementless acetabular component and developed a greater appreciation for the methods, machining and effort that go into making the implants we use daily. After some fierce clinical discussions and an entrecôte or two in town it was time for the fellows to depart to Prague for the 16th Annual EFORT Congress. This gave us a chance to meet our hosts once again as well as the teams that put such hard work into organising everything. Sujith and George presented some of their work at the conference before enjoying refreshments at the BJJ reception where we also met the organising committee of the Fellowship and expressed our gratitude.
Fig. 3 Paris dinner
Overall, this Fellowship was an excellent experience for us. We would urge other young surgeons, specifically those with complex or unusual practices, to apply and take advantage of opportunities such as this. We all found it incredibly enlightening to meet and develop links with our European colleagues and to get to grips with their methods and type of work. Furthermore, we learned how they organised their practices and departments. We understand better the training and clinical practices in the centres we visited. We realise how, despite being so close to us, the practices in each of these countries were unique. Although trainees across all European countries face the similar difficulties and challenges, the orthopaedic training seems very diverse. This fellowship was also a great opportunity for three young surgeons with common interests to meet and have time to discuss life, orthopaedics and acetabular version! We aim to maintain our friendship and strengthen it in the future by collaborating in both the clinical and research fields.
George Grammatopoulos firstname.lastname@example.org
notes from the road
A comprehensive review course for trainees around the world: The SICOT Educational Day
Fig. 1 Faculty at the Educational Day in Dubai, 2013.
ICOT, the Société Internationale de Chirurgie Orthopédique et de Traumatologie, is an international non-profit association of orthopaedic surgeons incorporated under Belgian law. The aim of the organisation is to promote the advancement of the science and art of orthopaedics and traumatology at international level and, in particular, for the improvement of patient care, and the fostering and development of teaching, research and education. There are 110 member nations from all over the world. The SICOT Educational Day was an initiative developed by the SICOT Young Surgeons Committee and was launched for the first time at the SICOT Triennial World Congress in Prague. This short article discusses the concept, aims and objectives, current state and future of this new venture.
Concept The needs of orthopaedic residents, fellows and practising orthopaedic surgeons around the world are constantly evolving. At the same time, evidence-based knowledge in orthopaedics is rapidly expanding. Moreover, all residents around the world need to take an exam at some stage in their career to mark the completion of training and/or to show that they are competent. Most practising orthopaedic surgeons also have to undergo some form of appraisal or revalidation at regular intervals to demonstrate fitness to practice. In both these scenarios, acquiring and updating the appropriate knowledge in a short span of time is essential. The SICOT Educational Day was conceived with exactly this purpose in mind. Aims & objectives The aim of the day is to provide a comprehensive review course for residents and an evidence-based update for practising surgeons on a specific theme at each SICOT
Fig. 2 Lecture in Progress at the Educational Day in Hyderabad, 2014.
Congress. The theme is selected in such a way that it is mutually beneficial to the resident in their exams and to orthopaedic surgeons in their daily practice. The themes are based on the syllabus of the FRCS (Tr & Orth) exam in the UK, the EBOT exam in Europe and SICOT Diploma Exam. These themes have been planned to run in a six-year cycle (Table 1). All clinically relevant and important topics for the exam are selected in each theme and the programme for the day is so arranged that it would cover the basic science and trauma topics related to that specific theme e.g. the ‘knee’ theme encompassed the basic science of articular cartilage and also tibial plateau fractures. Table 1: SICOT Congress themes
Shoulder & Elbow
Wrist and Hand
Paediatric Orthopaedics & Foot and Ankle
Current State The event is held on the first day of each SICOT Congress and is reasonably-priced for the residents and surgeons in training with attractive offers of membership to SICOT. The format consists of four to six short lectures (10 to 15 minutes) in each section followed by ample time for discussion and debate during coffee breaks. New sections
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5th SICOT Educational Day - Programme
The 5th SICOT Educational Day Venue: Baiyun International Convention Centre, Guangzhou, China Date: Wednesday, 16th of September 2015 Theme: Wrist & Hand, Spine Chairman: Mr. Vikas Khanduja, Cambridge, UK
Fig. 3 Programme for the Educational Day in Guangzhou, 2015
on case-based discussions have been introduced to ensure audience participation and have been very popular. Dedicated teachers, a mixture of the younger and the older generation from around the globe, are bought together to lecture on their area of expertise. The aim is to try and get as much global participation as possible and also have a couple of key opinion leaders lecturing on the day. Along with this, we ensure that we have at least four to six members from the local faculty contributing to the course. This enhances local participation especially at the level of residents. There have been four such educational days so far (Table 1) and the response to these has been overwhelming with excellent feedback. Over 200 delegates attended the event at the last SICOT congress in Rio. The popularity of these days has ensured that this has now become a regular event at each SICOT congress and a separate Educational Day Committee has been formed to ensure that the event runs smoothly. The members of the Committee are dedicated educationalists from around the world and include Dr Emmanuel Audenaert from Belgium, Dr Eric Tortosa from Panama, Dr Peter Yau from Hong Kong, Professor Mandeep Dhillon and Professor Ashok Johari from India and Prof.essor Patricia Fucs from Brazil.
The Future It is a challenging task to provide comprehensive and focussed orthopaedic education for a group of international surgeons at different stages of their career. However, the popularity of the event indicates that it is hitting the right note! Plans are afloat to further improve the educational content of this course and efforts are being made to include surgical techniques in the form of videos and hands-on workshops for future meetings. The themes for the forthcoming SICOT meeting in Guangzhou, China are ‘Hand & Wrist’ and ‘Spine’ and the day will focus on all the elements of hand, wrist and spine surgery from the anatomy and surgical approaches to discussion of complex cases. Dedicated faculty along with key opinion leaders from over 15 countries will be lecturing on the course. The members of the educational day committee have worked extremely hard to produce a well-balanced and interesting programme. So, if you wish to learn, share, debate and discuss ideas and surgical techniques in an exciting environment with a group of international surgeons in one room, the Educational Day in Guangzhou is the place for you. We look forward to seeing you there!
Notes from the road
Generics, registries and surgeon choice: the Great Debate 2015
Fig. 1 The faculty
he hot topics at this year’s Great Debate were more political than ever. Three issues recurred throughout the meeting: how do conclusions from registries impact on decision-making, what should drive a surgeon’s choice of procedure and implant, and how as a profession should we compare generic and branded devices? Following a combined meeting with EFORT in Docklands last year, the 2015 Debate returned upriver to the Mermaid Conference Centre, London, where four brief presentations acted as the catalyst for 35 minutes of debate, drawing in presenters, faculty and delegates, who used Twitter and 2poll to let the faculty know their opinion. Under direct questioning, experts had to admit whether they practiced what they preach. This year, Professor Ashley Blom won over the audience by admitting that he only uses cement half the time on the acetabular side, despite giving a registry-focussed tour de force in favour of cement for everyone and everything. Day one belonged to the knee. The audience involved itself from the start, using a mobile-friendly web tool to vote on forthcoming points of discussion. This provided a useful barometer for the faculty; to be forewarned is to be forearmed. Simultaneously, the Twitter feed sprang into life, and provided direct contact between audience and chairmen. The first session focussed on the design of total knee prostheses, with Jan Victor (Ghent, Belgium) in the PCL-retaining corner, Tom Schmalzried (Los Angeles, USA) in the posterior-stabilised corner, and William Walter (Sydney, Australia) contending that a medial pivot design was ready for prime time. Adolph Lombardi (Ohio, USA) admitted a direct conflict of interest when reporting on the bicruciate-retaining TKA. Preliminary results of his multicentre trial suggested no better or worse results than in patients with a cruciate-retaining knee design at this early stage of the trial, while the superior AP stability of the medial pivot was convincingly demonstrated using delegate-rated videos of Lachman, and anterior drawer tests. This prompted a discussion about the limitations of PROMs to detect differences between implants and techniques, and a consensus demand for more sensitive
J. Cobb G. Jones A. Shimmin
Fig. 2 GIRFT and TGD
patient-specific outcome measures as well as a greater emphasis on objective measures of outcome, such as gait analysis. Next up was surgical technology and planning. Using the 2poll system, almost 90% of those voting saw no future for robotics in arthroplasty. This set the scene for Jan Victor who predicted that a new generation of user-friendly software, increasingly compact equipment and an intuitive workflow, would lead to a renaissance in the use of navigation, but not robotics. Dr Lombardi then made a persuasive argument for using patient-specific instruments instead which, in his hands, improved alignment and enhanced operating room efficiency. Wolfgang Fitz (Boston, USA) contended that efforts to improve prosthesis alignment alone have been superseded by custom implants based on patients’ native anatomy. It is a truism that technological advances designed to help surgeons execute a pre-operative plan will be limited by the quality of the plan itself. In this context Robert Barrack (St Louis, USA) argued persuasively for a more physiological alignment of TKAs, cutting the tibia in three degrees of varus. However, Adolph Lombardi and Jan Victor both felt that the human eye can judge 90° to the vertical more easily than it can 87°. So, arguably, unless technology is being used to guide bone cuts, a 90° cut combined with a lateral to medial sloped polyethylene insert, as used by Professor Victor, may be a safer option. The session on the unicompartmental knee (UKA) had speakers from France, Germany and Southampton; the word “Oxford” was barely mentioned… surely a first. Jean-Noel Argenson (Marseilles, France) reported on the 30-year results of UKA in terms of function and durability. Klaus Schutter-Brust (Cologne, Germany) reported his minimum 10-year results of uncemented meniscal bearing UKAs, which were even more successful on the lateral side than the medial. David Barrett explained that any difference in the performance of fixed and mobile bearings was dwarfed by the importance of recognising that there was a place for the procedure, and actually carrying it out correctly.
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Patellofemoral joint (PFJ) disease was next on the agenda, with Jonathan Eldridge (Bristol NHS Trust, UK) presenting data which oddly suggested more favourable results in younger and older age groups when compared to those in middle-age. David Barrett (Southampton, UK) used extensive video evidence to advance the view that treating the knee compartmentally, with, for example, a UKA and patellofemoral joint arthroplasty (PFJA) results in better kinematics and function than a TKA. Dr. Fitz agreed with this philosophy, but suggested that a patient-specific combined UKA and PFJA might be preferable to individual components. The topic of registry data was hotly debated on both days. Of those present, 75% said that fear of the registry changed the way in which they practiced surgery. Ashley Blom (Bristol, UK) tasked with defending the usefulness and validity of registry data, argued that it provides information based upon real-life results, as opposed to designer or high-volume surgeon series. Widely-voiced concerns by both faculty and audience regarding the limitations of the NJR and its lack of data on basic confounders led to Ashley’s confession that he actually used cementless devices much of the time… Fares Haddad (London) sharpened concerns about the future implementation of limited implant choice within the NHS, and the role registry data might play politically. ‘Generic’ implants were debated on both days, with interest resting on whether there would be a requirement to undergo the same rigorous clinical trials expected of all new implants under ‘Beyond Compliance’. The first day concluded with David Morgan (Queensland, Australia) using an old TV series format, ‘The Hypotheticals’, as a vehicle to explore the murky world of industry and marketing pressures in orthopaedic surgery. With a star-studded cast of world experts all playing a predefined comedy role, a light-hearted medium allowed a serious exploration of the potentially serious conflicts of interest that exist in our profession. Day two started with a discussion on the relative merits of short and long hip stems, including when exactly these terms should be used. Johan Witt (UCH, London) talked delegates through his decision-making process when choosing a hip prosthesis, building a convincing argument for why one stem does not ‘fit all’. Nonetheless, everyone seemed to be in agreement with Tom Schmalzried, who delivered a consistent message throughout a number of these debates - do the operation that has the most reliable results in your hands. Bearing couples were also explored with John Skinner (Stanmore, UK) reviewing registry data results, and Bill Walter presenting his own data supporting the use of ceramic on ceramic. Orhun Muratoglu (Boston, USA), provided an insight into the highly crosslinked polyethylene he has developed, with clinical data supporting significantly improved wear rates at 10 years. He outlined the role vitamin E might have to play, supported by in vitro data, and early clinical results. On the topic of the ideal femoral head size, Bill Walters suggested that the anatomical size was ideal, although there was some discussion as to whether this was necessary given the superior head/neck ratio offered by prosthesis. Iliopsoas impingement was proposed as a significant issue by Orhun Muratoglu, who presented cadaveric data on the use of a novel design of femoral head which tapers towards the neck, potentially reducing deflection of
the iliopsoas tendon. Bill Waters was first to point out that this deflection occurs in the native hip, where it acts as a natural fulcrum for iliopsoas, suggesting that it was something we might wish to avoid. As this device had not yet reached clinical trial, a yellow card was produced, requesting a pause in this discussion until human data was forthcoming. Technology was considered helpful in the knee, but the audience were less convinced of the need for it in the hip. Robert Barrack reported using a single intraoperative digital radiograph to improve acetabular positioning without detailed planning. Jean-Yves Lazennec (Paris) provided an insight into his extensive use of functional EOS scans, to assess pelvic attitude and lumbar spine mobility as a mechanism to identify patients at high risk of dislocation. Jon Bare (Melbourne, Australia) explained how he now uses three static functional radiographs to create a dynamic model of acetabular loading as a means of personalising acetabular placement to minimise edge loading. Once again a yellow card was raised pending clinical results. For this audience, the popularity of hip resurfacing remained undiminished, with almost 90% of delegates wanting a resurfacing, as long as it was not metal on metal, particularly for active men. A quick-fire video presentation by Mr. Derek McMinn (The McMinn Centre, Birmingham, UK) on the results of his large designer-surgeon series claimed a learning curve of 1000 patients, and again highlighted the difference between this type of highly successful patient series, and the NJR data presented by Ashley Blom. The final debate of the conference centred on productivity and approaches to the hip, in particular the rise of the anterior approach. Adolph Lombardi’s experience in his high-volume practice was that it no longer slowed him up, and patients are able to go home later the same day irrespective of whether he used a lateral or anterior approach; however his impression was of a faster recovery period in the anterior approach group, with similar radiological results. Fares Haddad presented a recent meta-analysis he had conducted on evidence for the anterior approach. In his opinion, any slight early functional benefit was not sufficient to warrant surgeons switching to the anterior approach. Johan Witt explained why he sometimes went anterior and sometimes posterior, while Peter Aldinger (Stuttgart, Germany) told us how he and two colleagues managed 3000 joints a year, by using the same Rottinger anterolateral approach, every time for all-comers. Delegates were all impressed by the industry of both Lombardi and Aldinger, each of whom replace a thousand joints a year, and still have time to come to meetings. Both had staff motivated by productivity. Who knows what the hot topics next year will be? After hearing from highly productive surgeons, doing over four times the number of cases a year, delegates all felt that they could and would work harder, performing more joint replacements in a day, in the right incentive structure. That productivity gain would more than make up for surgeons’ strongly felt desire to use the implants of their choice. So - no to generics, and let us work harder. A good message to take away, until the next Great Debate. A uthor
Professor Justin Cobb email@example.com
notes from the road
6th National Orthopaedic Infection Forum, 24 June 2015
D. A. George R. Morgan-Jones
School of Oriental & African Studies, London, UK
Fig. 1 Best poster winner: Dr Rana Mehdi receiving her prize from Prof Peter Thomas.
he 6th National Orthopaedic Infection Forum (NOIF) was held in London on 24 June 2015. Over the last six years, NOIF has become a staple in the calendar, offering a forum for debate, controversy and the sharing of experiences across specialities from those, nationally and internationally, who struggle to manage that most difficult of orthopaedic problems: infection. This year the faculty represented America, Italy, Pakistan and the UK. The meeting was aimed at orthopaedic surgeons and microbiologists, both trainees and consultants. The meeting was chaired by Mr Rhidian Morgan-Jones (Cardiff, UK), Dr Vanya Gant (UCH London, UK)
Fig. 2 Faculty members (from lef t); Dr Ed McPherson, Prof Fares Haddad, Mr James Murray, Dr Harriett Hughes, Dr Lorenzo Drago, Dr Vanya Gant , Mr Rhidian MorganJones, Mr Imran Ali Shah, and Prof Peter Thomas.
and Prof Fares Haddad (UCH London, UK). Dr Vanya Gant began the meeting with an enthralling insight into what is currently possible through genomics and advanced computing using nextgeneration sequencing to identify organisms, both known and unknown. 1 This view of the future was wisely tempered by remembering Louis Pasteur’s comments on the importance of the host. Dr Lorenzo Drago (Galliano Institute, Milan) complemented Dr Gant’s lecture by discussing current diagnostic dilemmas and introducing a new, soon to be available tissuesampling bag to minimise contamination and increase microbial yield. 2 The second section looked at novel
antimicrobial therapies. Mr James Murray (Bristol) discussed the potentiation of antibiotics by the addition of bupivacaine, a local anaesthetic which helps to lower pH. 3 Mr Rhidian MorganJones (Cardiff, UK) presented his clinical experience of using acetic acid as part of his defined debridement protocol and the early use of Surgihoney® as a novel antimicrobial coating in the salvage of infected total knee arthroplasties. 4 Dr Lorenzo Drago returned to the podium to discuss the use of bioactive glass as both an antimicrobial and antibiofilm agent. 5 Interestingly, bioactive glass raises the pH in contrast to the acetic acid and bupivicaine discussed by the previous speakers. This highlights the possibility that a changing pH in
BJJ News | I ssue 8 | S eptember 2015
Fig. 3 Presenting: Dr Ed McPherson.
either direction affects the chemical environment and may be hostile to microorganisms. Dr Harriett Hughes (Cardiff, UK) then presented an update on antibiotics, discussing emerging resistance, new options and retroantibiotics. The delegates debated this important topic and the suggestion of antibiotic ‘crop-rotation’: leaving some antibiotics ‘fallow’ or unused for several years, gained favour and will be a topic for a future meeting. The NOIF was delighted to have Dr Ed McPherson (Los Angeles, USA) speaking on the American MusculoSkeletal Infection Society (MSIS) host staging in prosthetic joint infection. 6 Dr McPherson then talked on his technique for debridement (“go where the money is”) and the concept of the ‘Biofilm Kill Zone’ using high dose local antibiotics delivered by bio-absorbable calcium sulphate pellets (Stimulan®). 7 His clinical experience, insight and rationale impressed everyone. The trainees’ free paper section once again produced variety and debate. This year’s topics covered Synovosure® as a diagnostic tool, Stimulan® as an adjunct to debridement, antibiotics and implant retention, spinal surgical site infection, and a case report of disseminated Mycobacterium. The prize for best presentation went to Mr Sajjad Mushtaq from the Lister Hospital (Stevenage,
UK). He discussed the infection burden of hip and knee arthroplasty, and the subsequent improvement of infection rates after a reorganisation of the elective joint replacement service in his hospital. The best poster prize went to Dr Rana Mehdi from Cumberland Infirmary (Carlisle, UK) who reviewed the use of leucocyte esterase reagent strips to diagnose prosthetic joint infection. The final two keynote lectures were given by Mr Imran Ali Shah (Karachi, Pakistan), and Professor Peter Thomas (Stoke, UK). Mr Shah presented his unique experience of treating advanced, chronic paediatric osteomyelitis in Pakistan. His cases were extreme, but he showed that by adhering to clearlydefined surgical principles of radical debridement and staged reconstruction, even the worst cases can be managed successfully. Professor Peter Thomas concluded the day with an overview of the history of chronic osteomyelitis and its management, introducing the key names and nomenclature associated with the disease. Once again the faculty are indebted to the sponsors and the course secretariat, Hartley Taylor, without whom the NOIF could not succeed. References 1. Naccache SN, Peggs KS, Mattes FM et al. Diagnosis of neuroinvasive astrovirus
infection in an immunocompromised adult with encephalitis by unbiased next-generation sequencing. Clin Infect Dis 2015;60:919-923. 2. Drago L, Signori V, De Vecchi E, et al. Use of dithiothreitol to improve the diagnosis of prosthetic joint infections. J Orthop Res 2013;31:1694–1699. 3. Mihok P, Hassaballa M, Robinson J et al. Antimicrobial properties of local anaesthetic bupivacaine in combination with gentamicin. Bone Joint J 2014;96-B (supp 5):2. 4. Cooke J, Dryden M, Patton T, Brennan J, Barrett J. The antimicrobial activity of prototype modified honeys that generate reactive oxygen species (ROS) hydrogen peroxide. BMC Research Notes 2015;8:20. 5. Drago L, Romanò D, De Vecchi E et al. Bioactive glass BAG-S53P4 for the adjunctive treatment of chronic osteomyelitis of the long bones: an in vitro and prospective clinical study. BMC Infectious Diseases 2013;13:584. 6. McPherson EJ, Woodson C, Holtom P, et al. Periprosthetic total hip infection. Outcomes using a staging system. Clin Orth Relat Res 2002;403:8-15. 7. McPherson EJ, Dipane MV, Sherif SM. Dissolvable antibiotic beads in treatment of periprosthetic joint infection and revision arthroplasty. The use of synthetic pure calium sulphate (Stimulin®) impregnated with vancomycin and tobramycine. Joint Implant Surgery and Research Foundation. Reconstructive Review 2013; 32-43.
Rhidian Morgan-Jones firstname.lastname@example.org
Sir, may I offer a brief reflection on two contrasting pieces in the June BJJ News? J e ya Pa l a n , a n S T 7, p r o v i d e s something of a wishlist in his ‘The ideal or thopaedic training scheme: wishful thinking or a shifting paradigm’1, which sits neatly alongside Fergal Monsell’s beautifully written rumination entitled ‘My journey into uncertainty’2, on what our professional lives as orthopods should be. Much of what Mr Palan seeks in training is sensible, and chimes with what many other trainees and consultants are saying. However, one has to be pragmatic. Despite what many surgeons, from Sir Norman Williams3 down, have been saying, there seems at the moment to be no chance that the European working time directive (EWTD), and the equally problematic New Deal, will be lifted for surgeons in training. Trainees might hate working shifts, but every single clinical episode is a potential learning opportunity – whether or not a trainer is present – and the nightmare of trying to run a clinical out-of-hours service with what is currently regarded as a compliant rota, is a treat in store for the trainees of today, once they achieve a consultant post. Shift systems will continue to exist, but I agree, they are not ideal for formal training. The emergence of consultants also working shifts in various parts of the country may help mitigate the training issues. Basing training assessment around workbased assessments (WBAs) is indeed the current paradigm, and it may seem hard to believe that we all managed perfectly well without it at one time. The old system did not require a particularly long training period – elderly senior registrars were a function more of job availability than the need for extended clinical exposure – but the intensity of experience was certainly greater than it is now, and to a large extent
the assessment of ability was informal. That’s still the case of course, but we cover it with a veneer of WBAs, etc., because that’s the deal, like it or not. The annual assessment in the previous system was virtually the same as the annual review of competency to progress (ARCP) process, and did a very good job. One of the failures of the new bureaucratic NHS is not trusting the consultants more. It is in nobody’s interest for a quorate group of consultant surgeons to promote a poor trainee; it never was. The trouble with WBAs is that they are pretty much a ‘tick box’ exercise. Of course every now and then the process will specifically identify an important learning point or problem, but even the best trainers can struggle to make it a meaningful exercise. Many consultants’ inboxes contain a backlog of easily generated requests for person-based assessments (PBAs) and related assessments, which over time can become a little demotivating. The very fact that there is an expected number – which as Mr Palan points out, seems to vary between deaneries – makes it more likely to be a humdrum and imprecise tool. When it was brought in, a lot of consultants expressed genuine misgivings about the usefulness of the new process, but their views were generally rubbished by the great and the good. The current trainees of course, have known nothing else. I remain agnostic at best about surgical simulation, which seems to have arisen in part from an unholy mix of industry involvement and the EW TD/New Deal nexus. I sense Mr Palan also feels an unease about the way it is being promoted in surgical training. It seems to link with the endless trite comparisons made these days between delivering healthcare and being an airline pilot. Ultimately I imagine surgical simulation is as realistic as simulated sex, although I can’t speak from experience.
My real problem with Mr Palan’s piece though is that it reads as if the training process is mainly about operating and technical skills. Outpatient clinics are only really mentioned in the rare scenario of having specific training clinics with reduced patient numbers. More alarmingly, ward care, which is the bread and butter of being a hospital doctor (including surgery), is demoted to a plea for more physicians’ assistants. There is a rude shock awaiting any current trainees who may have got into the habit of minimising their ward commitments. The continuity of care on the wards is mainly provided by consultants these days, yet it is the ward that will produce a disproportionate number of the complaints and clinical crises that you will encounter. If you ever feel ‘too busy’ at work, you should do a ward round, the soothing effect of knowing that all your inpatients are being appropriately managed is remarkable, and if they’re not, then at least you can now do something about it.4,5 Which leads me to the cliché, that good surgical practice is not at heart about operating, it’s about judgement, decisionmaking, and knowing oneself. The fourth attribute would be the elusive virtue of humility, which is where Mr Monsell’s essay comes in, beginning with its entirely apt title. I will not reprise it here, but every single surgical trainee – not just in orthopaedics – would gain from reading it and absorbing its many pearls of wisdom. The ‘five types of patients’ theory is as clear a message about good surgical practice as you could hope for. Discourses like this and those previously published by other surgical luminaries, such as Joel Matta6, Leon Wiltse7 and Leo Gordon8, contain some of the very best advice for all of us, whether trainees or consultants, and in their way are worth more in practical terms than the last five years of the BJJ (wonderful though that publication
BJJ News | I ssue 8 | S eptember 2015
is). Be aware that there are lessons to be learnt not only from outside our particular orthopaedic interests, but also from outside our specialty. The great Leo Gordon, for example, is a general surgeon. In case anyone is wondering, at 52, although ageing rapidly, I am not a particularly old fart, and I am far from being a surgical Luddite. I am delighted that BJJ News now provides a platform for those issues which matter to all of us, but which extend beyond our usual published remit of scientific clinical endeavour
2. Monsell F. My journey into uncertainty. BJJ
J Orthop Trauma 2005;19:432-434. http://journals.
News 2015;7: 4-5.
issue_7(last accessed 23 July 2015)
Improve.14.aspx (last accessed 23 July 2015).
3. No authors listed. EU regulations stopping
7. Wiltse L. My first 80 years: NASS Presidential
doctors getting trained, warns top surgeon
guest speaker address. Spine 1995;20:1751-
Daily Telegraph 28 January 2013. http://www.
Presidential_Guest_Speaker.2.aspx (last accessed
warns-top-surgeon.html (last accessed 23 July
23 July 2015).
8. Gordon L . Cut to the chase: 100
4. Teale K. What’s wrong with the wards? BMJ
matrix pearls for doctors. TFM Publishing:
Shropshire, 2006. https://books.google.co.uk/
pdf+html (last accessed 23 July 2015).
5. Kmietowicz Z. Restore ward rounds to former
glory to improve patient care, say colleges. BMJ
lessons&f=false (last accessed 23 July 2015).
1. Palan J. The ideal orthopaedic training scheme:
wishful thinking or a shifting paradigm. BJJ News
full.pdf+html (last accessed 23 July 2015).
6. Matta J. Excellence in clinical practice. How to
bjj_news_issue_7 (last accessed 23 July 2015).
improve your clinical results
Yours faithfully, Benedict Clift
We want your views! E- m ai l : b jjn ew s @b o n ean d j o i n t. o r g. u k
Benedict Clift Consultant Orthopaedic and Trauma Surgeon email@example.com
on Huckstep was born in Chefoo, Northern China on 22 July 1926. His early years were spent in Shanghai where his teacher parents lived; his father was the Director of Education. The looming war prompted his father to have his matriculation students complete their examinations with carbon copies: these were subsequently dispatched to England, a move that proved very useful at the end of the war. Placed under house arrest with his family in 1941, Ron was able to start his studies in engineering at a French university. Using a special pass he was able to ride his bicycle across the city to attend classes. He maintained a lifelong interest in
engineering and material science, which he brought to his subsequent orthopaedic practice. By 1943, Ron and his family had been placed in an internment camp, where he remained for the rest of the war. He and several other promising students were assisted by Dr Donald Cater who provided them with further education, in particular, secret medical studies. The boys were so emaciated that they were able to carry out anatomical studies on their own bodies, the bones being so prominent. Following repatriation to the UK in 1946, with Dr Cater’s recommendation and his previously forwarded examination results, Ron was offered a place to read Medicine at Cambridge University. Clinical placements were completed at the Middlesex Hospital, leading to work as a House Officer. In an effort to improve his exposure to surgery, and as his parents had ‘retired’ there to continue teaching, he went to Kenya in 1952. Overcrowding in the camps that had sprung up as a result of the Mau Mau uprising led to an outbreak of typhoid. From his management of these patients, the meticulous recording of his results and the development of better protocols, Ron was awarded a Doctorate of Medicine by Cambridge University. This formed the basis for his book about typhoid, which was used throughout the world for many years afterwards. This work also formed the basis of his Hunterian Professorship of the Royal College of Surgeons of England in 1959. Returning to England he furthered his surgical training in various disciplines, obtaining Fellowship of the Royal College of Surgeons of England and undertook further training in orthopaedic surgery at The Royal National Orthopaedic Hospital and St Bartholomew’s Hospital, London. In 1960 he married Ann (née Macbeth) and returned to Africa, where he took up a Senior Lectureship at Makerere University in Kampala, Uganda. He shortly became Professor of Orthopaedics, developing the department and its services throughout the country. A significant proportion of his work was directed towards the management of polio and the considerable challenge of helping people where there were severely limited resources. The principles he developed were implemented throughout
BJJ News | I ssue 8 | S eptember 2015
Africa and in other developing countries in the years to come, as was his handbook on the management of polio. In recognition of his work in 1970 he was created Companion of the Order of St Michael and St George, receiving the award in 1971. This year also saw his family’s hurried exit from Uganda with the deteriorating political situation under Idi Amin. During his time in Uganda, he started several other projects aiming to solve a number of orthopaedic problems. These included the development of lightweight skelecast frames to immobilise fractures in a tropical climate using fibreglass and other plastic materials. He also started developing a locked intramedullary femoral nail. This was initially made of stainless steel and called the ‘Kampala nail’, but subsequently in titanium it was renamed the Huckstep nail. He also wrote a medical student handbook, A Simple Guide to Trauma, to help teach medical students in the developing world. In 1972 he took the position of Foundation Professor of Orthopaedic and Trauma Surgery at the University of New South Wales, Prince of Wales Hospital, Sydney. The Chair was endowed by Hugh Smith and he set about developing and expanding the depar tment. A comprehensive undergraduate teaching programme in orthopaedics was developed, supported by several further editions of his handbook, and the development of A Simple Guide to Orthopaedics. His lectures were well attended and richly illustrated by his expanding slide collection that had been started in Africa. Ron continued to explore the possibilities of using different materials for implants. These included the development and use of titanium for his nail, which was produced in a variety of sizes for other bones, and some for veterinary use. He saw the potential for ceramics, developing spacers for volume defects and culminating in the development of a hip prosthesis with a surfacing for bone ingrowth. He also developed a plan for disaster management, initially for the hospital but later for other areas such as Sydney Airport. He served on the Road Trauma Committee for many years, as well as on a variety of other university, hospital and government committees
from time to time. He was Vice President of the Australian Orthopaedic Association in 1982. He travelled widely and frequently. Many of these trips were to developing countries to assist in the development of orthopaedic services, but he also travelled widely to lecture, particularly in North America. Ron maintained close links with the United Kingdom throughout his life. He remained an active member of the British Orthopaedic Association and frequently attended meetings and gave presentations. A lifelong interest in developing countries resulted in him being a Foundation Member of World Orthopaedic Concern, and he continued working in this area throughout his life. The rule of three developed somewhere along the course of his work and is probably the thing that he is remembered for most by his many students. This was that there were three possible answers for every question (or 6 or 9 or 12 and so on). This was reflected in the number plate of his British racing green Triumph Stag – RLH 333. Retirement in 1993 allowed him time to develop other teaching commitments on a part-time basis at the University of Sydney, to continue to travel and to master new technology in the form of computers. Through this he was able to translate his prodigious slide collection onto CD and DVD which allowed the development of new teaching tools and their easy dissemination across the internet. It also enabled him to spend more time with his growing family, and in particular his grandchildren. His latter years were marred by increasing immobility resulting from hip problems that arose from a fracture some years before. This frustrated him greatly but his mind remained sharp and active. Ron Huckstep’s influence touched six continents. A comment by the late Tom Ness in 1986, “That man has helped more people worldwide than the rest of us put together” is exemplified by the many facets of his life. Ron is survived by his wife Ann, his children Susan, Michael and Nigel, his six grandchildren and his brother John.
James Powell firstname.lastname@example.org
J. N. Powell
ordon Hunter was born in London, England. He was educated at Epsom College, Surrey, and began his medical career aged 17 at University C o l l e g e L o n d o n , g ra d u a t i n g i n 1 9 6 0 . Postgraduate training included appointments at the Birmingham Accident Hospital and University College Hospital in England, and at the University of the West Indies in Jamaica. Gordon received several prestigious awards, notably the Gold Medal in Medicine (University College Hospital, London) and the Begley Prize in Surgery (Royal College of Surgeons of England) in 1960, the Otto Aufranc Award (the Hip Society of North America) in 1976, and the Bruce Tovee Award in Surgical Education (University of Toronto) in 1986. He married Virginia (Gini) in Felixstowe, Suffolk, in 1965, and they emigrated with two young children to Toronto, Canada in 1969. Gordon joined the staff of Sunnybrook Health
Sciences Centre in Toronto as a Consultant Orthopaedic Surgeon in 1970. He had a distinguished career as a Senior Orthopaedic Surgeon at SBHSC, spanning a period of 30 years. He became a Professor in the Department of Surgery, University of Toronto in 1986, gaining Professor Emeritus status in 2002. Gordon was a renowned educator, travelling nationally and internationally to lecture on various orthopaedic topics, principally trauma, hip and knee arthroplasty and foot and ankle problems. He was highly regarded as a teacher and mentor by his students. He provided exemplary care to a particularly disadvantaged member of society, the amputee. Gordon studied and published extensively in the areas of hip surgery and amputation surgery. He was a doctor in the true sense of the word â€“ committed to the care of each and every one of his patients. Friends and colleagues knew him as a quiet man with a dry sense of humour. He had a tremendous ability to take a complex problem, analyse it and recommend a solution that seemed obvious after he had given his opinion. Gordon had a keen interest in world events. In earlier years he enjoyed tennis, sailing and swimming, and he was an avid gardener. As time began to slow him down, he took pleasure in reading, jigsaw puzzles and watching cricket and rugby. He loved a good conversation and to the end he was both curious and well-informed. Above all, Gordon relished spending time with his family and his treasured dog Benji. He and Gini celebrated their golden wedding anniversary this February, and he was an adored father and grandfather. He was very much at home in the countryside and spent many happy times in the outdoors with his children and five grandchildren on both sides of the Atlantic, and more recently, on both sides of Canada. Despite a full and rewarding life in Toronto, Gordon ever remained an Englishman, with fond memories of his frequently visited home country of Suffolk. Gordon will be remembered for his breadth of knowledge, clarity of decision making, dedication to his patients and devotion to his family. He will be greatly missed.
James Nelson Powell email@example.com
BJJ News | I ssue 8 | S eptember 2015
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