Journal of Trauma & Orthopaedics - Vol 5 / Iss 2 by British Orthopaedic Association

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 05 / Issue 02 / June 2017 boa.ac.uk

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Read the News and Updates section for the latest from the BOA and beyond

In our Features section, you will find articles on an Introduction to GIRFT, NICE Trauma Guidelines, QALY’s and our regular features

For the latest update on our clinical issues, see our Subspecialty section; the focus of this issue is bone biology

News & Updates ––– Pages 02-15

Features ––– Pages 16-47

Subspecialty Section ––– Pages 48-57

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JTO News and Updates

From the Editor

Contents

Phil Turner This issue really should have something of interest for every orthopaedic surgeon. The breadth of our specialty is truly remarkable and the reports from our specialist society meetings demonstrate the energy of the organisers and participants, their international reach and the inclusion of the whole team. The steadily rising number of attendees at their conferences is a tangible measure of their success. We have articles on education, professional development and medico-legal issues, but the core theme is basic science. We provide you with up-dates on the fundamental process of fracture healing and the evidence to support our approach to articular cartilage regeneration. Professor Tim Board is the guest editor and has written on the continuing conundrum of avascular necrosis

of the femoral head where we still struggle to understand the causes or provide optimal treatment. The “Getting it right first time” programme now encompasses many specialties though orthopaedics led the way. Rachel Yates explains the rationale of the process that supports clinicians taking the lead to improve outcomes and reduce variation based on sound evidence. It is vital that we take responsibility for stewardship of our resources, but we need to understand how to assess the cost effectiveness of our surgery. Belen Corbacho explains the importance of the QALY and what data you should consider when assessing health technology interventions. Few things depress a surgeon more than a patient presenting with early infection after knee replacement. The impact on the patient can be catastrophic and it is vital that the right decisions are made as quickly as possible. Rhidian Morgan-Jones provides a clear and logical approach. There is no doubt that you will want easy access to your copy of “JTO” and refer back to previous editions. We are excited to announce that you can now download the journal via the JTO App – just search for JTO@BOA on the App Store or Google Play.

JTO News and Updates

02–15

JTO Features

16–47

An Introduction to GIRFT

NICE Trauma Guidelines

The use of QALYs in the economic evaluation of orthopaedics treatments

Bisphosphonate-associated femoral fractures: lessons learnt

FRCS(T&O): a trainee’s and educationalist’s perspective on exam preparation

Professional Development Plan for Surgeons

Operations I no longer do... Surgical retreats Open meniscectomy

How I... manage the acutely infected TKR?

Legg-Calve-Perthes Disease: 100 years of controversy: but could the answers be forthcoming? 34 Scrubbing Under the Influence: Alcohol-Based Surgical Hand Disinfectant Increases Estimated Blood Alcohol Levels on Breathalyser Testing

BOTA Census - The Good, the Bad and the Ugly

Propose Changes to Soft Tissue Injury [Whiplash] Claims Process 2017

Subspecialty Features

Biology of fracture healing - an overview

48–57 48

Controversies in Treatment of Symptomatic Osteochondral Defects of the Knee

Pathogenesis of atraumatic osteonecrosis of the femoral head

General information and instructions for authors

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JTO News and Updates

From the President Ian Winson, BOA President So I seem to find myself over 6 months into my Presidential year. I hope the phrase “I seem to see my life flashing before my eyes” doesn’t have the usual connotations. But it has been a year of reaction in many ways because of the number of issues going on. So time to stand back and try to get a view of the bigger picture.

The reality is that T&O is under pressure to continue to deliver a high quality, efficient service under circumstances where the system is being stressed by restricting its funding and changing its structure simultaneously.

Ian Winson

Of course as President you do have to represent the BOA widely and to form a broader view, and perhaps the most interesting comment on the healthcare scene was made by Stephen Forbes of Forbes Magazine in his guest address at the American Academy. In a lengthy discourse the stand out comment was “why is it uniquely that amongst all of human activity, which defines that gross national product, healthcare is regarded as an economic drain rather than a productive economic activity”. His point was primarily the reality that healthcare is aimed at keeping the population healthy and therefore economically viable. His second point was that healthcare represents a great deal of human activity with the straight forward implications of people being employed, paying taxes, generating purchasing power

etc. It is true that T&O scores economic points all round. This is not the main stream rationale behind our professional existence but something we need to fight our corner about nevertheless. The reduction in the monies being spent on T&O during the next two years is in truth inexplicable. Driving efficiency by reducing the tariff on each case has a bit of logic to it. Reducing the total amount spent does not. Ultimately we have to defend patients’ interests by making sure we deliver accuracy of care. As ever T&O surgeons tend to be involved in leading this and we are getting into a position where we can consistently claim that we are setting the highest standards. But there continue to be issues. The allocation of resources continues to be unevenly distributed. Using Unit level review processes will help with this. On the other hand, the current evolution of the STP process is paying no attention to the structuring of networks of care that make

sense. If you look at most of the best healthcare systems in the world keeping the size of your healthcare system under control seems to bear fruit, but it has to be sufficiently sized to ensure that the critical mass gets the right patients in the right place at the right time. The BOA is pursuing this issue as often as it can. There is a growing awareness that if you are to make care accurate it has to be possible to embrace change. This covers many areas of practice but none more so than our straightforward clinical front line skills. We have to get over the idea that if you want people to be able to change their practice you have to invest in them being trained to do that. Life long learning has to be a growing pressure point. I don’t think I have heard of anyone being sent a post appraisal email from their Medical Director saying you have x amount of funding allocated to achieving your PPD for the year please let me know if you need more! My eternal optimism is not quite that great, but if we can get the trusts to accept that there is a need to allocate the resource of time to this, then it might bear fruit for everyone. And finally, as this issue of the JTO will be published ahead of the General Election on the 8th June, I would like to take the opportunity to state that the BOA will be following the events of the election closely, and will be seeking to proactively engage with the new government. n

From the President Prevee-Prep

for use with disposable & re-useable tourniquet cuffs Prevee Prep is a tourniquet cover that: l Helps

to prevent the migration of prep solutions tourniquet cuffs from contamination from the surgical site l Comes in a full range of sizes from paediatric to XXL l Protects

l Designed with reference to NHS safety notice

SAN(SC)99/33 Medical Devices Surgical Cuffs - Risk of Burns

l Comes in boxes of 100 l Latex free l One use only l Comes flat packed (for ease of storage)

TELEPHONE 01652 657200 FAX 01652 657009 EMAIL info@oakmedicalservices.co.uk WEB www.oakmedicalservices.co.uk ADDRESS Oak HQ, Unit 5A Albert Street Brigg, North Lincolnshire DN20 8HQ

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JTO News and Updates

British Orthopaedic Travelling Fellowship Award (Zimmer-Trauma) Derek Cawley

I would firstly like to extend my gratitude to the BOA and Zimmer for providing this award. I travelled to Switzerland during December 2016 to visit Dr John Duff at CHUV, Lausanne and Dr Deszo Jeszenszky at Schulthess Clinic, Zurich. I was warmly welcomed by the spinal teams at both centres and I am very grateful to them.

Derek Cawley

My objectives were to complement my training in spinal surgery with pathology and techniques that I have not had as much exposure to previously. Like Ireland where I have trained as an orthopaedic surgeon, there

is an increasing prevalence of elderly patients with pathologic fractures from osteoporosis or from metastatic tumor, both conditions disproportionately affecting the vertebral column. Minimally invasive techniques have an increasing role in these cases. I had a superb exposure to complex spinal pathology and procedures. The health system in Switzerland is highly organised with efficient access to imaging techniques and inter-speciality referral. Patients are efficiently dispatched to after-care services. Learning procedures from the surgeons who first described

them in the literature impressed me, such as C1C2 cage insertion, TLIF and cemented pedicle screw insertion. Despite cutting edge technology and techniques, I still observed the referral of cases to these centres which haunt all spine surgeons such as infected prostheses, proximal junctional kyphosis and post-operative neurological deficit. Visitation to specialised units is a worthwhile exercise. Published literature frequently does not capture real-life learning points that visiting a specialised centre does, particularly through observation and through informal discussion.

BHS 2017 Annual Meeting, London Five topics were covered in focus sessions, the topics covered ranged from Hip Preservation Surgery through Hip Instability to a review of contemporary Surgical Pathways and Consent. There were 54 podium presentations, including a joint session with The British Orthopaedic Research Society, 105 posters on display, and an overlapping meeting of The Arthroplasty Care Practitioners Association. This was always going to be a busy couple of days! Highlights included contributions from our guests representing The American Association of Hip and Knee Surgeons, most notably a masterly Presidential Address from Professor Craig Della Valle from Rush University Medical Centre in Chicago on “Prevention, Diagnosis and Management of Early Periprosthetic Hip Infection”. There really was something for everyone. An emerging surgeons session covered various aspects

Guest Speaker, Sir Clive Woodward, at the BHS Dinner.

of professional life and once again this meeting represented an opportunity for shared learning and genuine professional development. Whilst most papers hailed from the UK, contributions were welcomed from Sweden, Argentina, Switzerland, China and North America.

Held at Central Hall, Westminster, this was the best attended BHS Annual Scientific Meeting to-date with well over 400 delegates. The icing on the cake was at the BHS Dinner when our truly outstanding Guest Speaker, Sir Clive Woodward, shared his thoughts on “The DNA of a Champion”

before taking questions and answers from BHS members. Next year’s British Hip Society Annual Scientific Meeting will be held in Derby Arena, and will run from 14th to 16th March 2018 put it in your diary now! You are all invited.

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JTO News and Updates

Combined Meeting of the British and Swedish Paediatric Orthopaedic Societies, Glasgow The first combined meeting of the British and Swedish Paediatric Orthopaedic Societies was hosted in Glasgow by David Rowland in the Grand Central Hotel. A friendly welcome from our host was followed by a “team talk” from Jacques Riad, President of the Swedish Society.

capital femoral epiphysis. The discussions produced as many questions from the speakers, as from delegates. This highlights the deficit of good evidence, and reinforces the need for studies such as the British Orthopaedic Surgery Surveillance Study.

After a broad-ranging and animated clinical case session there was time to visit the stands of our sponsors and to prepare for dinner, which included a ceilidh. Day two addressed reconstruction of the adolescent hip. There was

The meeting’s focus was the management of problems affecting the adolescent hip. Dr Oliver Birke from Australia shared his experience with clarity and wit. He was joined by invited speakers from both societies. All provided informative and thought-provoking contributions. Day one focussed on the various presentations of the slipped

Professor Colin Howie delivering his talk “Just Gonnae Naw Do That”.

Dr Oliver Birke from Sydney receiving a commemorative quaich from Mr Mark Flowers, President of BSCOS.

a range of interesting and, at times, controversial topics. Professor Colin Howie brought us back to reality with a clear outline of things that might compromise later interventions – “Just Gonnae Naw Do That!” There were two sessions of excellent free papers, and updates on research. We learned how the Swedes have developed their own government funded registries, with multidisciplinary cooperation and pilot groups. The Combined meeting was a great success and we look forward to future combined international congresses. The next BSCOS meeting will be in Stoke and will be hosted by Mr David Emery and his colleagues.

BASS 2017 Annual Meeting, Manchester The biennial meeting for the British Association of Spine Surgeons was held in Salford, on the 14th-17th March 2017. The Manchester weather was kind and the delegates were greeted with spectacular views of the Salford Quays. The meeting was preceded by a cadaveric course and Masterclass. The cadaver course was held at the Manchester Surgical Skills centre. The Masterclass was held in the Lowry and was centred around the discussion of difficult surgical cases. The cases were shared before the meeting and Salford University provided software and support allowing easy accessibility to the cases and images.

“Lots of laughter” thanks to Dr Kevin Jones at the conference dinner at the IWM North.

his experience in making complex spine surgery safer for patients. In a keynote lecture Dr Jean-Charles Le Huec, from Bordeaux, shared the French experience in the treatment of degenerative spine conditions. Dr F. Todd Wetzel, the President of the North American Spine Society (NASS), attended. He expressed his wish to bring our two societies closer together.

For the first time BASS had a full day meeting for the Extended Scope Practitioners with contributions from spinal surgeons and therapists.

The BASS 2017 meeting was one of the most successful, with 200 abstracts submitted and 60 papers accepted for podium presentation and 30 posters presented. There were over 400 delegates, which exceeded the numbers in previous years. The conference dinner was enjoyed by 250 guests and was held at the Imperial War Museum North. There were plenty of laughs provided by Dr Kevin Jones.

The highlight of the main meeting was, Dr Rajiv Sethi, from Seattle, who shared

The next meeting, in 2019, is in Brighton.

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BLRS 2017 Annual Meeting, Leeds The terror attack in London of the 22nd of March was a sombre backdrop as 180 delegates gathered in Leeds for the 2017 British Limb Reconstruction Society AGM on the 23rd and 24th March. Subsequent news footage of a brave survivor with a circular external fixator applied for a tibial injury brought a public display of limb salvage techniques for life changing fractures. Conference host, Mr Patrick Foster, and the Leeds team delivered the best ever attended meeting. There was discussion of the Masquelet technique, by the local team, and of use of the ‘Diamond concept’ by Professor Peter Giannoudis. Tom Battye’s gave an excellent presentation of his own limb reconstruction; his experience rang true for many of us empathetic to the patient’s journey.

Tim Nunn’s work in Ethiopia was a tour de force of treating severe neglected clubfoot and post-burns contractures. Other speakers included Dr. Dimitry Popkov from Russia and Dr. Stephen Quinnan from the USA, both of whom shared techniques for improving regenerate creation and consolidation. From the UK Peter Calder shared the Stanmore experience of modern lengthening nails; James Fernandes provided an update on the pelvic support osteotomy and President, Durai Nayagam, explained the vagaries of NHS tariffs for limb reconstruction procedures. Ian Winson, President of the BOA, attended to share his vision of the journey and challenges ahead. The President attending was a first and created a greater sense of unity with the BOA. The next meeting is in Southampton on the 15th and 16th of March 2018.

Main conference hall, BLRS Leeds 2017.

The BASK 2017 Annual Meeting, Southport The British Association for Surgery of the Knee held their Annual Meeting at the STCC, Southport, 28th-29th March. It was very well attended with nearly 400 delegates and 150 trade participants. The two-day

meeting achieved a good balance between free paper sessions and instructional lectures. The first morning session was split equally between ‘arthroplasty’ and ‘soft tissue’ knee surgery,

The British Association for Surgery of the Knee held their Annual Meeting at the STCC.

a range of high quality scientific papers were presented. Followed by a very moving talk on “The History of the Victoria Cross”, by Mr Christopher Ackroyd whose grandfather Harold Ackroyd, VC hailed from Southport, a medical doctor, honoured with the Victoria Cross medal for his gallantry displayed in battlefields of Somme and Ypres in World War I. Mr Steve Bollen gave an excellent talk on “The History of ACL reconstruction” with a tribute to Ernest Hey-Groves, one of the founding fathers of modern orthopaedics. The day ended with instructional sessions on “Decision making in young arthritic patients” and “medicolegal aspects” of orthopaedics. The second day commenced with free papers sessions on arthroplasty and soft tissue knee surgery. This was followed by a “rapid-fire poster presentation”, amazing to see how much

information can be imparted within the short span of two minutes. The registry session discussed the progress made and the challenges face by different registries relating to the knee joint. Highlight of the second day was the “Lordon Trickey lecture” delivered by Dr John Bartlett, eminent knee surgeon from Australia. He gave his perspective on the changing trends in the knee surgery. The lecture was full of pearls of wisdom and learning points for all knee surgeons. The “Sports knee symposium” dominated the afternoon where experts gave their opinion on management of some of the complex clinical problems. The meeting ended with the prize-giving, prizes were awarded for the Best Podium presentation, Poster and E-Poster. ‘Save the date’ 2018 BASK Annual meeting in Leicester 20th-21st March 2018.

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JTO News and Updates

BOA Annual Congress 2017 19th-22nd September, ACC Liverpool congress.boa.ac.uk #BOAAC

Congress registration is now open – FREE* member registration will close on Thursday 1st June.

(*Terms and Conditions apply). Non-member registration will open on 1st June. Register online at congress.boa.ac.uk/2017-registration

The BOA Congress 2017 Guest Lecturers include: President’s Guest Lecture Jan Willem K. Louwerens, MD, PhD founded and chaired the Dutch Orthopaedic Foot and Ankle Association and is an Honorary member.

Robert Jones Lecture

The theme for the 2017 Congress is ‘Quality and Innovation’. We have built an exciting programme comprising of specialist topics including trauma, spines, the National Joint Registry, medico-legal issues and many more.

Awards and Prizes Once again, we will be showcasing the ‘Best of the Best’, bringing together the winners for the best paper award from each region in the UK, to compete for a national award. We also have the Student Paper Prize, as well as the Simulation Award, BOA Clinical Leaders Programme Poster Prize and The BOA Young Investigator Prize.

Programme update There will be a range of revalidation sessions throughout the Congress programme including trauma, hip, spine and knee sessions. The aim of these revalidation sessions is to highlight current issues and provide key updates on specific topics. In addition to the revalidation

opportunities, the programme offers a limited number of broader professional sessions from Medico-Legal, which will discuss themes that may affect clinical practice in the future, to a session on Quality Outcomes looking at the interactivities between GIRFT implementation and registries.

Accommodation TSC Hotel and Venues is the official hotel booking agency for the BOA Congress 2017. Please note that the exclusive rates are guaranteed until the 18th August 2017 and are subject to availability. Visit our accommodation page at congress. boa.ac.uk/accommodation for hotel options.

BOA CONGRESS 2017 19-22 September - ACC Liverpool Quality & Innovation congress.boa.ac.uk #BOAAC

Professor Chris Moran is National Clinical Director for Trauma for NHS England and a Professor of Orthopaedic Trauma Surgery at Nottingham University Hospital.

Howard Steel Lecture Phil Hammond is an NHS doctor, campaigner, health writer, investigative journalist, broadcaster, speaker and comedian. He currently works in a specialist NHS team in Bath for young people with chronic fatigue syndrome/ME.

Dial Medicine for Murder Dial Medicine for Murder is part of Thursday evening’s programme which will be delivered by Dr Harry Brunjes and Dr Andrew Johns. This session provides a fascinating insight into the background, arrest, trial and legacies of Dr John Bodkin Adams and Dr Harold Shipman. Dr Brunjes and Dr Johns examine the victims’ stories, circumstances of multiple deaths and ask the big question: why was one convicted and not the other? They reflect on the haunting prospect of, this could happen again, detailing the regulatory changes that have become part of day to day practice since the Shipman conviction.

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JTO News and Updates

BOA Latest News Training Orthopaedic Trainers (TOTs) Course The programme was established to improve the standard of teaching and learning within T&O training and practice, with the premise being that if T&O trainers and trainees understand how people learn and how the T&O curriculum works, teaching and learning should improve. The TOTs course is a two-day programme facilitated by Lisa Hadfield-Law, BOA Educational Supervisor. The BOA runs a number of TOTs courses throughout the year. Further information, including future course dates, is available on the BOA website at boa.ac.uk/events/training-orthopaedic-trainers.

BOA Standards for Trauma Further to our recently published BOASTs on the Management of Ankle Fractures, Rehabilitation and Communication with Trauma Patients and the Management of Urological Trauma Associated with Pelvic Fractures, we have now published a new BOAST on the Management of Blunt Chest Wall Trauma. All of which can be found on the BOA website - www.boa.ac.uk/publications/ boa-standards-trauma-boasts. Several extant BOASTs are currently under review and will be re-issued in the near future.

New Podcasts and Screencasts

The 14th Orthopodcast episode is now available on our website. ‘How to Survive your First Year as a Consultant’ features Niall Eames, Consultant Spinal Surgeon (T&O) in Northern Ireland, and Aprajay Golash, Consultant Spinal Surgeon (neuro) in Preston. In this 16-minute episode, they explore some ways of managing the difficulties encountered as a newly appointed consultant, with a particular focus on controlling the “controllables”, dealing with inevitable complications and balancing home and work. Niall Eames and Aprajay Golash are also featuring in our new screencast: ‘Recognising Toxic Stress’, where they explore further the “zonal approach” to recognising toxic stress as a surgeon. The 15th Orthopodcast episode is also available on our website. ‘Struggling to pass MCQs?’ features a three-way conversation between Sophie Howles (trainee with dyslexia) and Yvonne Gateley (study coach and dyslexia advisor) which will provide tips and tricks to help, whether you are dyslexic or not. Listeners are alerted to the signs that learners may be struggling and ways of helping learners with learning difficulties. It is hoped that the ideas will help to open up uncomfortable conversations regarding problems with learning. So, whether you or your trainees are struggling to learn, you should find some help here: www.ncbi.nlm.nih. gov/pubmed/28298166 and from the Orthopodcast. You can stream our podcasts and screencasts at www.boa.ac.uk/training-education/orthopodcasts.

Travelling Fellowships 2017/18 Travelling Fellowships offer BOA trainees a unique opportunity to visit centres of excellence overseas, sharing best practice, gaining invaluable knowledge, experience and different cultural perspectives within trauma and orthopaedic surgery. The BOA offers up to 20 fellowships, applications will open on 19th September 2017. Further information is available on the BOA website www.boa. ac.uk/training-education/boatravelling-fellowships.

Launch of PHIN’s hospital performance measures The Private Healthcare Information Network (PHIN) published the first of a series of performance measures on 3rd May. The performance measures are intended to improve the availability of information to patients considering private healthcare services and start to bring standards of data quality and transparency in line with the NHS. The newly published performance measures can be found at www.phin.org.uk.

An App to play our Orthopodcasts and screencasts will be available in the upcoming months!

London Marathon Fund Raisers

Congratulations to Yusuf Mirza for running the Virgin Money London Marathon on Sunday 23rd April, raising money for Joint Action (the Orthopaedic Research Appeal of the BOA). Well done! If you would like to participate in the 2018 London Marathon please contact us at jointaction@boa.ac.uk.

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Commissioning Guides Over the coming months the BOA will be publishing four NICE-accredited Commissioning Guides. These guides will act as a starting point for you to help discuss service redesigns with local commissioners, to help ensure services are sustainable going forwards. The reviews have involved literature review, discussion by a multidisciplinary Guideline Development Group and public consultation. The four guides reviewed cover: l Painful Osteoarthritis of the Knee l Painful Tingling Fingers l Pain arising from the Hip in Adults l Painful Deformed Great Toe.

Next Steps on the NHS Five Year Forward View In March 2017, NHS England published Next Steps on the NHS Five Year Forward View, setting out what the original forward view has achieved since 2015 and what the NHS should prioritise for the next two years. It outlines how it will deliver practical improvements in areas such as cancer, mental health and GP access. It is hoped that the measures will ease pressure on hospitals, and put the service on a more sustainable footing for the future. The plan is focused on delivery and contains new policies for STPs, elective care, primary care, mental health and increasing the workforce. You can find the full report here: www.england.nhs.uk/ publication/next-steps-on-the-nhs-five-year-forward-view. The BOA welcomed many of the themes outlined in the report and look forward to working with NHS England and NHS Improvement in developing these further. We have been strong supporters of the Getting It Right First Time programme since its inception. Our members are innovators by nature – many are leading from the front in the Sustainability and Transformation Partnerships – and passionate about the care of their patients. You can find the full statement here: www.boa.ac.uk/latest-news/boa-statement-nhs-operationswaiting-times-to-rise-in-trade-off.

Quality Improvement and the Just Culture A key priority for the BOA in the coming year is to support the improvement of quality and to develop the concept of a just culture within the workforce. We are acutely aware that the atmosphere and culture in which we work remains difficult and at times confrontational, yet there are some signs of a wind of change. The Chair of the Public Administration and Constitutional Affairs Committee of the House of Commons said in January 2017: “There is an acute need for the Government to follow through on its commitment to turn the NHS in England into a learning organisation; an organisation where staff can feel safe to identify mistakes and incidents without fearing the finger of blame.” The key ingredients of a just culture are, as the name suggests, evidence based objectivity, a positive frame of mind, a quest for learning with which to promote further quality improvement, and supportive professionalism. As your professional body, it is the BOA’s role to promote these principles which accords entirely with our strapline of Caring for Patients; Supporting Surgeons.

ABC Travelling Fellows BOA President, Ian Winson and RCS President, Clare Marx welcome the American British Canadian Fellows to the UK. To catch up on their tour of the UK please visit their blog at www.aoatravelingfellowships.wordpress.com/author/abcfellows.

(L-R) Jonathan Braman, Brett Freedman, Joseph Hsu, Ian Winson, Eric Strauss, Clare Marx, David Sheps, Nicholas Bernthal, Wade Gofton.

For further information or to comment on any of the news items here, please contact policy@boa.ac.uk.

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JTO News and Updates

BOA Membership Update New membership category: Overseas Associates We are pleased to introduce a new membership category for Overseas Associates. To apply for this rate, please complete the online application form at www.boa.ac.uk/ membership/join-today, you will be requested to submit a letter from your Training Programme Director to confirm your appointment. Please visit the membership page www.boa.ac.uk/ membership/categoriesand-subscriptions for further information or email us at membership@boa.ac.uk.

Members Handbook 2017 All members should now have received their copy of the 2017 Handbook; please inform us if any of your personal details are incorrect by emailing membership@boa.ac.uk.

Connect with us... Keep up-to-date with the latest news from the BOA by following us on Twitter, LinkedIn and Facebook. Connect with us and our 3,000 followers on LinkedIn, “Like” our Facebook page (3,600 Likes) and join us on Twitter where we have over 9,500 followers. Twitter: @BritOrthopaedic LinkedIn: British Orthopaedic Association Facebook: British Orthopaedic Association @BritOrthopaedic

Wisepress Book of the Quarter K-Wiring: Principles and Techniques Author: Rex Chandrabose ISBN: 9789382076575 Date published: 13 Jun 2016 Price: £71.00 BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.

There is a paucity of literature on standard techniques, principles and approaches to be employed for K-wiring fractures. This book fills that gap. It is the first of its kind in demonstrating the effective execution of K-wiring procedures through a lucid, casebased format. It serves as a practical guide for orthopaedic surgeons on K-wiring techniques, thus enabling them to improve patient care. It will be an invaluable reference text not just for practicing orthopaedic surgeons but also for subspecialists like consultant hand surgeons, foot and ankle surgeons, and microvascular plastic hand surgeons, helping them master the operative techniques related to K-wiring.

Save the date!

BOA Instructional Course – 6th-7th January 2018 Registration will open on Monday 3rd July 2017

NEW VENUE FOR 2018 – The MacDonald Hotel, Manchester www.boa.ac.uk/events/instructional-course

#BOAIC

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Conference Listing: WOC (World Orthopaedic Concern)

www.wocuk.org 10 June 2017, Wigan

CAOS (Computer Assisted Orthopaedic Surgery (International))

www.caos-international.org 14-17 June 2017, Germany

BESS (British Elbow & Shoulder Society)

www.bess.org.uk 21-23 June 2017, Coventry

BIOS (British Indian Orthopaedic Society) www.britishindianorthopaedicsociety.org.uk 14-16 July 2017, Cumbria

BORS (British Orthopaedic Research Society) www.borsoc.org.uk 4-5 September 2017, London

BTS (British Trauma Society) www.bts-org.co.uk 8-9 November 2017, Sheffield

BOTA (British Orthopaedic Trainees Association)

www.bota.org.uk 15-16 November 2017, Manchester

BSS (British Scoliosis Society)

www.britscoliosissoc.org.uk 29 November-1 December 2017, Birmingham

BOSTAA (British Orthopaedic Sports Trauma & Arthroscopy Association) www.bosta.ac.uk 6 December 2017, London

OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 10-12 January 2018, Bristol

BSCOS (British Society for Childrenâ&#x20AC;&#x2122;s Orthopaedic Surgery) www.bscos.org.uk 8-9 March 2018, Stoke

BHS (British Hip Society) www.britishhipsociety.com 14-16 March 2018, Derby

BOA (British Orthopaedic Association)

BLRS (British Limb Reconstruction Society)

www.boa.ac.uk 19-22 September 2017, Liverpool

www.blrs.org.uk 15-16 March 2018, Southampton

BOFAS (British Orthopaedic Foot & Ankle Society) www.bofas.org.uk

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

1-3 November 2017, Sheffield

SBPR (Society for Back Pain Research)

www.sbpr.info 2-3 November 2017, Northampton

20-21 March 2018, Leicester

BRITSPINE

www.spinesurgeons.ac.uk 21-23 March 2018, Leeds

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JTO News and Updates

Arthritis Care - who we are and what we do For those living with arthritis, we’re here with information and support to help people get on top of their condition, stay active, independent and connected. Our branches and groups are run throughout the UK, for and by people affected by arthritis.

Arthritis affects over 10 million people in the UK, with numbers set to rise; yet arthritis is often overlooked and underestimated. Arthritis Care works to ensure people can live well with arthritis. We help people to recognise the early

signs of the condition, get an early diagnosis and take action to live a full life with arthritis. We campaign to make sure arthritis is a government and health service priority, and that everyone has access to high quality health and social care.

Caption Competition

Our Living Well with Arthritis service is run by volunteers, most of whom have arthritis themselves. The service aims to support people who have either been recently diagnosed, or may have had it for some time and are keen to improve their quality of life. We are also working with GPs in Berkshire

Thank you to those who entered last issue’s caption competition (photo on left). Congratulations to Daniel Thurston, whose caption, was: Abracadabra and the fracture is gone! On the right is our latest photo of BOTA President, Simon Fleming. For your chance to win a £20 voucher, simply email your caption to jto@boa. ac.uk with the subject: Caption Competition. Please send your photos for future competitions also to this email address (no larger than 5MB). Please submit your caption by 7th July 2017.

West NHS to offer three services. These services are available, with a GP referral, to patients with osteoarthritis of the hip and/or knee, based on the Right Care Patient Decision Aids. We offer a free and confidential Helpline, open Monday-Friday 09:30-17:00. For guidance and support on any aspect of arthritis, contact the Helpline Freephone on 0808 800 4050, helplines@arthritiscare.org.uk. For more information about Arthritis Care’s work, visit arthritiscare.org.uk.

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Infected TKR Symposium The third biannual Infected Total Knee Replacement Symposium was held in Manchester on the 23rd of February, co-chaired by Rhidian Morgan-Jones from Cardiff and Philip Turner from Manchester. The first session looked at the epidaemiology of prosthetic infection and the strategies to provide a specialist service as well as collecting data for research and benchmarking outcomes in this often catastrophic complication. Headline figures were that patients with a BMI of over 40 at the time of TKR were 10 times more likely

to develop infection and that the 5 year mortality for an infected TKR is worse than that for many cancers. It is clear that prevention is vital. The importance of prevention was stressed even further when considering the difficulties posed by multi-resistant organisms and the failing pipeline of new antimicrobials. Further sessions covered risk stratification to try and identify patients at most risk of infection and how to optimise the patient and theatre environment.

The 2017 speakers at the TKR Symposium in Manchester.

The role of new technologies to reduce and treat infection included modifications in surface texture and coatings of implants including the potential for graphene oxide to inhibit biofilm formation. The local delivery of high dose antibiotics immediately after surgery may be the way forward as an adjunct to either retention of the implant or after revision.

The role of one or two stage revision is becoming better defined now we know more about the poor outcomes of 2 stage surgery in the frail elderly population. The event was spiced up as usual by the presentation of several very challenging cases leading to some heated discussion with the faculty and participants.

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JTO Features

An Introduction to GIRFT Rachel Yates Getting It Right First Time (GIRFT) began life as a review of orthopaedic surgery supported by the Royal National Orthopaedic Hospital (RNOH); it has subsequently grown into a national programme, focussing on more than 30 medical specialties, ranging from general surgery to mental health.

Following the injection of £60 million of additional Government funding, GIRFT is now a partnership between the RNOH and the Operational Productivity Directorate of NHS Improvement. The methodology laid down by Professor Tim Briggs in the orthopaedic pilot remains unchanged. The focus continues to be to identify and reduce unwarranted variation. By tackling variations in service delivery across the NHS and sharing best practice between trusts, GIRFT identifies changes that will improve care and patient outcomes. As well as delivering efficiencies and cost savings, there is a reduction in unnecessary procedures.

Rachel Yates

In the original orthopaedic surgery report, which coined the term ‘Getting It Right First Time’ there was a raft of recommendations which have been adopted by trusts and deliver real benefits. An NHS survey of 70 of the 140 trusts visited in Professor Briggs’ review revealed total savings of

between £20m and £30m for 2014/15 as a result of adopting GIRFT’s recommendations, with a further £15m to £20m of savings for 2015/16. If extrapolated across all providers the total savings are estimated at £40m to 60m in 2014/15 and £30m to £40m in 2015/16. When the GIRFT methodology is applied to the more than 30 specialities it now covers, the programme should help save the NHS £1.5bn per year. In its expanded form, GIRFT will have an implementation element with teams working on the ground with trusts to put in place recommendations from the national reports. But at its heart GIRFT remains a programme led by you, the frontline clinicians who are expert in the areas being reviewed. This means the data that underpins the GIRFT methodology are reviewed by individuals who understand the issues and manage the services on a day-to-day basis. Clinical leads visit every trust in an

attempt to better understand the data. The individual challenges that the trusts face are reviewed and the improvements already in place are highlighted. Having visited over 140 providers at 200 sites and meeting with over 2,000 people involved in delivering orthopaedic care, the GIRFT orthopaedic review is now beginning its second round and is re-visiting all trusts to see what changes have been made, how GIRFT’s recommendations have been received, what has improved. It will also identify whether there are new challenges to tackle. For GIRFT to be a success it needs the backing of clinicians and senior trust managers, both in supporting the programme, and using the visits as an opportunity to highlight best practice and innovations that can be shared with other trusts. It will also shine a light on the challenges clinicians face. n For more information visit www.GettingItRightFirstTime.co.uk or follow @NHSGIRFT on Twitter. Rachel Yates is Managing Director and Deputy SRO of the Getting It Right First Time (GIRFT) programme, as well as being the Director of the National Orthopaedic Policy Unit at the Royal National Orthopaedic Hospital. She has worked with Professor Tim Briggs since the very beginning of the pilot ortho project.

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JTO Features

NICE Trauma Guidelines Bob Handley Co-authors: Iain McFadyen & Carlos Sharpin The publication of NICE guidelines represents an opportunity for beneficial change. About one year ago NICE published a suite of Trauma Guidelines, two related specifically to fractures. It is therefore important that the Orthopaedic community is aware of their content and those opportunities provided. For trainees it is of relevance to note that the T&O curriculum contains the phrase “Keep up to date with national reviews and guidelines of practice (e.g. NICE)”. In a brief article, it is not possible to cover all the content relevant to T&O Surgeons and it is also NICE policy that when guidelines are referred to in a publication the agreed wording should be available. Therefore, to compliment this article, you can find the original documents on the BOA website by scanning the QR codes. The process of production of a guideline is cumbersome, but is a “due process” and consequently the output can have influence. The guideline is commissioned; a scope is then constructed by stakeholders and in this case an executive team. The guideline development group (GDG) is made up of experts from relevant specialities and lay representatives and is supported by professional researchers, health economists, editors and more. The GDG then distils the process down to about 20 reviews of evidence, which will inform the recommendations.

Bob Handley

The fracture guidelines were split by the commissioners into Complex and Non–Complex; the Complex Fractures being

those in which transfer to a specialist centre would at least be considered and the Non-complex those which would generally be managed in the initial receiving hospital. The Complex Fracture guideline was constructed around open fractures, pelvic injury and pilon fractures. The open fracture component will be used as a basis for the revision of BOAST 4, which will soon be available. The timescales for interventions have been revised. The pilon fracture component was used to explore an awkward fracture with a potentially poor outcome in which early referral is not the norm. The Non-Complex Fracture guideline was more difficult to construct. There was the potential for just 20 reviews and a plethora of injuries could have been considered. The approach taken was to select a variety of injuries (individually important or just very common), which were representative of the important steps in a notional pathway of management. Thus, to exemplify the potential benefit of early definitive diagnosis suspected scaphoid fracture was used. The distal radial fracture was reviewed to give a time limit and a place in the order of priority for admission;

illustrating the patient with a fracture who may require surgery but is not admitted directly from the Emergency Department. Finally, a key objective of the group was that whilst the recommendations relate to specific injuries these recommendations should be used to sensibly inform the management of similar problems; being aware of how, for example, the management of the hip fracture patients can differ from that of an injury a few centimetres more distal. n Bob was a medical undergraduate in Sheffield where he also did an intercalated degree in physiology. Since 1994 Bob has been a fulltime consultant on the Trauma Service at the John Radcliffe Hospital in Oxford; during this time his work has been entirely related to trauma. The service is consultant based and for the last 21 years, he has been resident when on duty. Bob has been an examiner for the FRCS Orth for seven years and is a past president of the Orthopaedic Trauma Society. Bob was on the NICE guidelines development group for hip fractures and currently co-chairs the NICE groups for complex and noncomplex fractures.

Fracture guidelines The complex and non-complex fracture guidelines can be found online at www.boa.ac.uk/ publications/JTO or by scanning the QR Codes.

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JTO Features

The use of QALYs in the economic evaluation of orthopaedics treatments Belen Corbacho Given that the demand for trauma and orthopaedic surgery services continues to increase and resource allocation is a growing concern for the NHS, it is becoming increasingly important to use economic evaluation to rationally inform resource allocation. The goal of cost-effectiveness analysis is to maximise health gains within a constrained budget; where health gains are typically expressed in terms of quality-adjusted life years (QALYs). In this article we will examine the key opportunities and challenges using the QALY approach, paying particular attention to the use of QALYs in orthopaedic research.

Belen Corbacho

QALYs evaluate a treatment by measuring the health gain that the treatment provides, this measurement is as a combination of duration and health-related quality of life (HRQoL). Hence QALYs provide decision makers with an idea of how many extra months or years of life and the quality of that life a person might gain as a result of a treatment. A year of perfect health is worth one QALY. The National Institute for Health and Care Excellence (NICE) has been successful in adopting QALYs for its reference case1 as they allow explicit analysis and

comparisons across populations, diseases and programmes. Moreover QALYs are relatively easy to estimate, much easier than placing a monetary value on different health states. The methodology is transparent as the underlying values are explicit and can be debated. Despite the benefits there are a number of challenges to the QALY approach. In this article we will attempt to use orthopaedic surgery to exemplify the fundamental assumptions behind the QALY that have been questioned. We will review the most recent musculoskeletal Randomised Controlled Trials (RCTs) funded by NIHR to understand how well the QALY captured the health gains generated by orthopaedic treatments, and to identify any potential limitations of using QALYs in orthopaedics. Do QALYs lack the capacity to capture changes in HRQOL experienced by orthopaedic

patients? QALYs are generated in three steps. Firstly the HRQOL experienced by patients is described by generic instruments such as the EQ-5D. Then using the UK index tariff2,3 the patientâ&#x20AC;&#x2122;s EQ-5D scores are converted into a utility score ranging from 0 (dead) to 1 (perfect health). Finally QALYs are calculated by multiplying the time spent in each health state over time with its corresponding utility value4. Therefore the EQ-5D is the basis for informing health technology appraisal; hence collecting the EQ-5D is an important part of a study which analyses cost-effectiveness. Alongside the EQ-5D other condition specific measures, relevant to the orthopaedic intervention, are used to capture changes in symptoms, for example range of movement and fracture healing, and side effects such as complications and the need of revision surgery. Thus collecting the EQ-5D will give a clearer picture of how the injury affects changes in patientreported health. Even if you are not considering conducting cost-effectiveness analysis as part of your trial, collecting HRQOL data from the participants could facilitate future economic analyses. The EQ-5D-3L is comprised of 5 dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) with 3 severity levels (none, some,

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extreme problems/unable to) for each dimension. Despite being useful and widely used in orthopaedics there might be concerns about the EQ-5D3L as a measure of HRQOL. This review of orthopaedic RCTs found that most of the studies used the EQ-5D-3L as the primary outcome for cost-effectiveness. Likewise in the majority of cases the primary clinical outcome was supported by findings from the EQ-5D. We found a positive correlation between the EQ5D results and the Michigan Hand Outcome Questionnaire (SARAH trial, hand function)5; the Oxford Shoulder Score (PROFHER trial and UKUFF trial, shoulder function)6,7; the Patient-Rated Wrist Evaluation questionnaire (UK DRAFFT, wrist function)8; the Foot and Ankle Outcome Score (CAST trial, ankle function)9; the Roland Morris Disability Questionnaire (BeST trial, law back pain)10; the Oxford Knee Score (KAT trial; knee replacement)11; and the Western Ontario and McMaster’s Universities OA index (e.g. for knee osteoarthritis)12. The concerns about the EQ-5D’s lack of sensitivity are mainly driven by the small number of dimensions and levels. Considering the number of dimensions first. In other disease areas, for example cancer, it has been debated that there are

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additional dimensions, such as fatigue, that have a significant impact on the HRQOL, but are not captured by the QALY framework. Nevertheless they are highly relevant to that specific population. However the main goals that orthopaedics interventions aim to achieve seem to be summarised quite well by the EQ-5D: perfect function (mobility, self-care, and usual activities), reduced pain and complications (pain and discomfort) and recovery (anxiety and depression). In fact it is not unexpected to find orthopaedic trials and observational studies that use the EQ-5D as the primary outcome measure13. Moreover the UK Department of Health has recently introduced the EQ-5D as a routinely collected outcome measure via Patient Reported Outcome Measures (PROMs), before and after hip and knee replacement. These PROMs are used to measure the performance of healthcare providers, both for health outcomes and post-operative complications14.

was replaced by “unable to walk about” to increase sensitivity of the mobility dimension. Results from initial studies showed increased reliability, sensitivity (discriminatory power) and feasibility16-18. Consequently the new EQ-5D-5L implies a positive step in “moving the QALY forward”19, especially for orthopaedic research.

It also may be possible to improve the sensitivity of the EQ-5D by increasing the number of levels. In 2009 the EuroQoL Group approved the new EQ5D-5L15 with five, as opposed to three, severity levels. The five levels are no, slight, moderate, severe problems and unable to. In addition “confined to bed”

Is the use of QALYs problematic in orthopaedics? Despite the limitations of the QALY approach, the review of nine RCTs of orthopaedic interventions found that in the majority of cases, the use of the QALY approach seems meaningful and will help make better orthopaedic decisions

An additional area of controversy with the QALY approach is that all QALYs carry equal weight. In other words, in aggregating a QALYs worth of health represents the same value whoever receives it. A key concern is that the QALY evaluation will be biased if the injured or traumatised patient differs from other patient populations. This is of particular relevance to late stage cancer patients, who have a very short life expectancy. However orthopaedic patients are unlikely to differ from other populations whose health gains are also addressed using QALY, and so this does not seem to be a concern.

allowing the better allocation of resources within the NHS. Similarly recent processes to adapt and further develop the EQ-5D seem to favour pragmatic clinical trials and the appraisal of technology in orthopaedic interventions. n Belen Corbacho is a health economist with special interest in the assessment and appraisal of health technologies. Her research interests include methods to deal with missing data and sources of data (HEs, PROMs) to conduct economic evaluation alongside clinical trials. She has worked in diverse disease areas, with a recent focus on orthopaedics and trauma (ProFHER, REFORM and UK-FROST trials).

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

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JTO Features

Bisphosphonateassociated femoral fractures: lessons learnt Lily Li Co-authors: J-P St Mart, B Tweedie, N Kurek, K Somasundaram, C Huber & V Babu Bisphosphonates are the current mainstay of pharmacological therapy for osteoporosis. They are anti-resorptive agents, which are derivatives of inorganic pyrophosphate and have an extremely high affinity for bone1. They bind to the inorganic component of bone (hydroxyapatite), and are endocytosed by osteoclasts. This ultimately leads to osteoclast apoptosis2. They may also play a role in osteoblast apoptosis1.

Bisphosphonate-suppression of bone turnover has led to concerns that it may cause â&#x20AC;&#x153;frozen boneâ&#x20AC;? where there is increased skeletal fragility and impaired ability to heal microfractures3. Recently there has been evidence of an association between femoral shaft fractures and prolonged bisphosphonate therapy, although there is no definitive evidence for a causal relationship4,5,6. This has generated controversy about long-term bisphosphonate use.

The evidence so far

Lily Li

Atypical femoral fractures are defined as fractures located in the femoral diaphysis from distal to the lesser trochanter to proximal to the supracondylar flare. Fractures of the femoral neck,

intertrochanteric fractures with spiral sub trochanteric extension, per prosthetic fractures, and pathological fractures associated with primary or metastatic bone tumours and miscellaneous bone diseases are excluded7,8. The features have been classified into major and minor: Major features (four out of five must be present):7,8 1. Associated with no/minimal trauma (e.g. fall from standing height or less) 2. Transverse pattern originating from the lateral cortex 3. Non or minimally comminuted 4. Complete fractures extending through both cortices, possibly with a medial spike; incomplete fractures involve the lateral cortex 5. Localised periosteal/endosteal thickening of the lateral cortex fracture.

Minor features (none required for diagnosis):7,8 1. Increase in the cortical thickness of the femoral diaphysis 2. Unilateral or bilateral prodromal symptoms, such as dull groin or thigh pain 3. Bilateral incomplete or complete diaphyseal fractures 4. Delayed fracture healing. The risk of a bisphosphonate induced fracture is low compared to the protection from fragility fractures which they give9. A systematic review showed that the incidence of sub trochanteric or diaphyseal femur fracture is very low, even among women who have been treated with bisphosphonates for as long as ten years (2.3 per 10,000 patientyears). It was concluded that there was no significant increase in fracture risk associated with bisphosphonate use10. Multiple health authorities around the world have issued similar advice. The New Zealand Medicines and Medical Devices Safety Authority concluded that interruption of bisphosphonate therapy in patients with atypical fractures should only be considered following individual risk-benefit assessment11. The American Society of Bone and Mineral Research found no causal relationship7. The Working Group of the European Society >>

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JTO Features

A SYSTEMATIC REVIEW SHOWED THAT THE INCIDENCE OF SUB TROCHANTERIC OR DIAPHYSEAL FEMUR FRACTURE IS VERY LOW, EVEN AMONG WOMEN WHO HAVE BEEN TREATED WITH BISPHOSPHONATES FOR AS LONG AS TEN YEARS (2.3 PER 10,000 PATIENT-YEARS). IT WAS CONCLUDED THAT THERE WAS NO SIGNIFICANT INCREASE IN FRACTURE RISK ASSOCIATED WITH BISPHOSPHONATE USE. identify the true extent of this problem14. The National Institute for Health and Care Excellence guidelines in 2011 recommended bisphosphonates for secondary prevention of fragility fractures in post-menopausal women, they also recommended research into optimum drug duration15.

Figure 1: Radiograph showing incomplete femoral fracture involve only the lateral cortex with localised periosteal thickening.

on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and the International Osteoporosis Foundation concluded that the case was unproven, but even were the case to be proven the risk-benefit ratio would still favour using bisphosphonates to prevent fractures12. A recent Cochrane review concluded that bisphosphonates were still the goldstandard treatment for secondary prevention of fragility fractures13. A large British trial showed a 7% incidence of atypical femoral fractures in patients treated with bisphosphonates, eighty-one per cent of whom had been on bisphosphonate treatment for a mean of 4.6 years14. The authors did not advocate changing the use of bisphosphonates, but recommended further work to

Bisphosphonates accumulate if treatment is continued for years. This accumulation gives rise to continuing anti-fracture benefit after therapy cessation. Cadaveric studies also indicate that there is cumulative micro-damage after five years of treatment16. A randomised trial, FLEX, showed that there was no increased fracture risk in patients who continued on alendronate for ten, as opposed to five years17. This is possibly as the half life of bisphosphonates is five to ten years.2 It has been suggested that groups at lowrisk of fracture do not require bisphosphonate treatment18,19; in the mild-risk group a “drug holiday” can be offered after three to five years; however, the benefits of continued treatment in high-risk groups outweigh the risks18. On the other hand the United States National Osteoporosis Foundation recommends a five-year “drug holiday” after five years, stating that this does not lead to an increased fracture risk17.

Clinical findings to note for the practicing clinician Patients either present to the Emergency Department with a complete femoral facture, or to

the clinic with insidious thigh pain. Patients with a complete fracture often recall prodromal thigh pain20,21; prodromal pain has been reported in between 56 and 76% of patients22,23. Bilateral symptoms are not uncommon21. There is often a relatively long period of prodromal pain before incomplete fractures are identified, however, once incomplete fractures are noted, progression to complete fracture is rapid; in our practice patients reported a mean of two years of thigh pain before incomplete fractures were identified, but only a month before the complete fracture occurred. More evidence is needed to clarify whether diagnosis may be made earlier with better education of practitioners as to the prodromal symptoms. Some researchers recommend screening patients taking bisphosphonate for prodromal symptoms8, others suggest radiological screening in symptomatic8 or asymptomatic24 patients. Although minimal data is available on atypical fracture-healing, preliminary evidence suggests that healing may be impaired25, and the usual markers of healing may be misleading. Given the osteopenic cohort, there is an additional risk of femoral neck fracture, and we suggest that a cephalomedullary nail is the implant of choice.

Recommendations Clinicians should be aware of the association between prolonged bisphosphonate use and atypical femoral fractures, although there is

no firm evidence of a causal link. Thigh pain may be a warning sign of impending fracture; we suggest early radiological screening in these patients. Cephalomedullary nailing is the treatment of choice as there is a high risk of neck of femur fracture. We urge clinicians to consider early cephalomedullary nailing when incomplete fractures are identified as there is a risk of rapid progression on to complete fracture. In patients with a confirmed fracture, the contralateral femur should be imaged. We strongly recommend prophylactic nailing if there is radiological evidence of fracture. A bisphosphonate “drug holiday” following a fracture may be indicated to reduce the risk contralateral femoral fracture and as bisphosphonates potentially delay fracture healing. We recommend prolonged follow-up as reduction in pain and radiographic healing cannot be relied upon. n Lily Li is a Year 4 Orthopaedic trainee on the North West London rotation.

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

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JTO Features

FRCS(T&O): a trainee’s and educationalist’s perspective on exam preparation John Davies & Lisa Hadfield-Law The purpose of the exam is to determine whether you are safe to practice as a day one consultant in the generality of trauma and orthopaedics. It tests higher order thinking defined as the application of knowledge to solve problems1.

The FRCS comprises two sections: Section 1, Single Best Answer (SBA) and Extended Matching Item (EMI) papers at a Test Centre, followed by Section 2 Clinicals and Vivas. This article will guide preparation by considering revision methods (JD) and the educational principles underpinning them (LHL).

Section 1 This consists of two computerbased papers similar to UKITE2. The SBA paper lasts two hours and the EMI paper is two and a half, arranged in three “diets” per year. Insight into the rigorous question writing process is available1.

How to prepare?

John Davies

Lisa Hadfield-Law

For most trainees, conventional revision techniques suffice MCQ practice, concise review textbooks and a study group. From experience, the most useful question bank is offered by Orthobullets3 which is ostensibly aimed at North American residents preparing for American Board Certification. Much of the knowledge curriculum is transferrable to UK and Irish practice, with some exceptions. I went through the “board-style” questions by topic, reviewing incorrect answers as I went, to

understand the recurring themes. In this way, I improved from an initial score of 66% to over 80%. In terms of reading, you need to be disciplined. If time is limited, reading and making notes from a comprehensive weighty tome is less efficient then pattern recognition from repeated MCQs. Bear in mind that the MCQs are often based on a section of one of the review textbooks.

Key advice Try hard to meet in a study group for 6 weeks before the exam. In this way, you help each other to understand key areas. In my group, our strategy involved repeated drawings: the brachial and lumbar plexus; sensitivity and specificity contingency tables4; clotting cascade and the table of laboratory values for metabolic bone disease5.

Section 2 This comprises one day of ‘Clinicals’ in a hospital, followed by a second day of orals/vivas. The sheer number of candidates and patients attests to the organisation required. A more comprehensive review is recommended6 but the basic outline is two intermediate cases (spine, upper and lower limb) and two sets of three upper and

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lower limb “shorts”. The oral section comprises four 30-minute vivas: adult pathology, trauma, paediatrics and hand surgery, and basic science. There are two examiners per station who usually cover three topics each. The marking descriptors are available online7.

The remit of the exam is to ensure that safe candidates, who avoid misdiagnosis, subjecting patients to unnecessary investigations or unsafe treatment, pass. As a rule, it is best to discuss management pathways you have actually seen in practice.

How to prepare?

Key advice

There is no ‘best’ approach to revision, which works for every individual. The way a viva discussion develops is unique to each candidate. The examiners have predetermined the important points for a safe pass: thereafter they stretch the candidate’s knowledge to achieve a higher score. Consequently, revision depends upon how coherently you recall and verbalize knowledge under pressure. Study groups, mock vivas and outpatients’ clinics are invaluable in developing the application of the principles of higher order thinking. Revision cards (Figure 1) also help clarify your thoughts.

You can excel at another topic to compensate for a five, the equivalent of a fail. Candidates who fail to diagnose a problem or discuss an appropriate management plan will achieve this score. Some claim candidates who could not quote a single paper or describe any classification systems have succeeded. Aiming for six, a bare pass, rarely leads to overall success. There are always challenging questions you cannot answer: so you must be able to compensate elsewhere. This was how I managed to pass, despite experiencing the sinking feeling of scoring five several times!

Pitfalls

Revision Techniques

Failing to practice your history and examination in clinic, with effective feedback, makes you appear clumsy and unrehearsed. Respect and courtesy with patients is of paramount importance. Many vivas start with a simple scenario with no traps unless you create them - for example by raising an inappropriate treatment plan.

Thinking about learning techniques can improve how we process and retrieve knowledge, allow us to exploit effortful learning, pace study and interleave properly during revision. Whilst most trainees have established methods for studying, it is worth evaluating these alongside current evidence for effective learning.

Figure 1: Revision cards.

Cognitive Load Theory (CLT): the process of storing knowledge asserts that the amount of information that can be processed at any one time is limited8. Information is processed and stored in longterm memory by organisation into schemas: then retrieved back into working memory for use. Schemas are complex memory structures built on experience allowing us to perceive, think and solve problems. The learning process is further categorised as intrinsic load, information to be processed, and extrinsic load: the effort to process it. Distractions will interfere with cognitive processing and establishing long-term memory. Management of intrinsic load can be improved by creating schemas of increasing complexity, reducing the difficulty associated with learning multiple topics. Effective recall of knowledge from long-term memory is important. Unless reinforced through use, much of what is learnt the first time is lost9. Frequently, trainees re-read textbooks and create mnemonics: yet this does little to prevent memory deterioration10. Counter intuitively, more difficult procedures for revision often have longer durability. Retrieval practice has the most effective knowledge retention10. Partially forgetting knowledge and then pushing to retrieve it again from long-term memory consolidates neural pathways. Generative retrieval, such as constructing answers on flash cards results in more enduring recall12. Learning distributed over time increases its durability. The most effective time intervals depend on how long information needs to be retained. Intervals of 5-10% duration of the retention period are suggested: over 6 months this equates to 2-3 week intervals13. Cramming is less effective than evenly distributed study throughout a revision period. This is certainly the case with the breadth of knowledge in the FRCS syllabus. Interleaving different topics, in between time intervals, further strengthens this10. Challenging each other in a study

group improves retention and the ability to apply what you know in different scenarios14.

BOA Wikipaedics Education Project An exciting forthcoming prospect is the web-based Wikipaedics project. This will provide the knowledge foundation appropriate for a practicing consultant in the generality of T&O. By providing trainees at the outset of their rotation with a knowledge resource aligned to the curriculum, this will achieve many of the educational principles outlined above for durable learning. Namely, continuous study interspaced over time, rather than cramming in the last 6 months before the FRCS. Hopefully this will make the exam a more educationally rewarding and less stressful experience.

Conclusion Effective lifelong learning techniques provide an important foundation for a career in surgery, not just passing postgraduate exams. Many trainees have well established techniques for study, but it is worth reviewing these to maximise every moment spent preparing for the FRCS. n John Davies MBChB MSc (Eng) FRCS (T&O) is a post CCT fellow in Paediatric Orthopaedics based at Children’s Hospital for Wales in Cardiff. He was the Wales representative for the 2016 BOTA Executive committee, and currently is a member of the Steering Group for the BOA Wikipaedics Education Project. Lisa Hadfield-Law, RGN, MSc, FAcadMEd and Education Advisor to the BOA.

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

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JTO Features

Professional Development Plan for Surgeons Vijay Bhalaik

l How much time can I spend

A professional development plan (PDP) is a documented action plan of your aspirations, to ensure your successful personal development.

PDPs help surgeons to improve their performance, learn new skills and become more aware of their strengths and weaknesses. They are now an integral part of appraisal and revalidation.

PDP Model: A good PDP includes all five components shown in Figure 1. 1. Reflection: Think about your performance, successes and failures. 2. Planning: Think about your personal, professional and academic aims.

3. Analysis: Prioritise your development needs and set goals based on your reflection. 4. Execution: Put into motion a mechanism to achieve your goals. 5. Evaluation: Record and monitor your progress.

Creating a PDP: Creating a successful PDP can be broken down into four main components: Step 1: Personal analysis - your strengths and weaknesses. The first step in creating a good PDP is a period of self-analysis. Think about your strengths and weaknesses, opportunities and threats (SWOT analysis) and write them down in a grid. Step 2: Setting your goals where I would like to be and how to get there.

Vijay Bhalaik

Ask yourself: l What do I like doing? Operating, teaching, hobbies, making money? l What is my motive for learning? Improving knowledge, learn a new technique, recognition? l What qualifications and experience do I have? l What method of study suits me? Part-time, e-learning, courses? l How much time do I have? Consider your commitments?

away from my family? Consider partners, children, and parents. l What will happen to me in the next few years? Completion of training, new job plan, new house? l How will I get financial support? Deanery, grants, specialist society, Royal College? l What is my ultimate goal? l How will I measure it? Qualifications, feedback, personal goals? l Where will I get advice? Specialist societies, peers, friends, BOA, Royal College. Once you have considered all these factors, you can decide your goals and will have defined the upper edge of your learning gap. What do I want to learn?

How can I get there? Ask yourself: How can I get there? Can I split the tasks into small chunks? It can be helpful to set your goals using the SMART criteria: l Specific: Target a specific area for improvement. l Measurable: Quantify, or at least suggest, an indicator of progress. l Assignable: Specify who will do it. l Realistic: Document the results that can realistically be achieved with the available resources. l Time-related: Specify a time period in which the result(s) can be achieved. Tabulate your goal settings (see Table 1).

What do I need to do?

What support is needed?

How will I measure?

Target date for review?

Cadaveric course.

Course fees. Time off. Support for business case.

Course assessment. Leave from hospital. Successful business case.

12 months

Widen my understanding of leadership

Learn from more experienced leaders.

Arrange time off. Arrange to spend time with experienced leaders. Join the NHS Leadership Academy.

Mentoring and performance appraisal by clinical lead. Completion of module.

12 months

Improve my state of health

Attend training sessions twice a week.

Join a gym.

Improve personal fitness levels.

2 years

Improve teaching skills

Teaching experience. Teaching course. PG Cert.

Time off. Course fees. Enrol at university.

Feedback. Course assessment. Teaching degree.

3 years

Examination skills

Contact university. Course on examining.

Time off. Examining experience.

Feedback.

2 years

Endoscopic cubital tunnel release

Table 1: PDP cycle.

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Step 3: Personal objectives write your short, medium and long-term goals, for example: Short term l Start an endoscopic cubital tunnel service. l Become a medical student examiner. l Improve general fitness. l Develop leadership skills. Medium term

l Develop teaching experience. l Apply for the clinical lead role. l Become an examiner for MRCS.

Long term

Figure 1: Goal settings.

l Leader in my field. l Gain promotion and

recognition as a leader.

l Consultant surgeon with

additional NHS duties. l Become an examiner for FRCS. Step 4: Evaluation - am I on track? Your PDP should be reviewed at regular intervals to ensure that you are achieving your goals. Your goals and circumstances may change and your PDP should reflect this. There will be areas where you have over-achieved and you will need to reset your goals at a higher level. On the other hand there may be situations where you have not achieved what you set out

to, this will equally require reflection and adjustment downwards. A PDP can be included as a regular part of your appraisal and revalidation. n Vijay Bhalaik is a consultant hand and upper limb surgeon at Wirral University Teaching Hospital. He is the Training Programme Director for Health Education England North West and is a member of the Training Standards Committee for the British Orthopaedic Association. He has a special interest in teaching and medical education.

HIPToulouse 2017 France 21.22.23 septembre 2017

An expert congress on hip surgery. Président: Philippe Chiron Vice président: Paul Bonnevialle Come learn, have fun and relax in the south of France. http://www.hipnews.org/hiptoulouse/page11.html

HIPT 21.22.2

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JTO Features

Operations I no longer do... Surgical retreats Open meniscectomy Simon Donell I started my orthopaedic career in the 1980s, when femoral shaft fractures were typically treated with 3 months traction and the Kuntschner nail was used occasionally. Insall and Burstein had just developed the implant from which all modern condylar knee replacements are derived and soft tissue knee surgeons had just about accepted reconstruction of the ACL. Arthroscopy was in its infancy so how was meniscal pathology managed? The meniscus was considered a vestigial structure, which could be safely removed, like the appendix. It was also thought to reconstitute itself post-excision. Diagnosing meniscal tears was clinical, with joint line tenderness and provocation tests, such as McMurray’s or Apley’s grinding test. If doubt persisted then an arthrogram was ordered. The problem was that all knee pain in the presence of normal plain films could be blamed on the meniscus, or in adolescents, on chondromalacia patellae. Thus the two main soft tissue operations were open total meniscectomy and open lateral release. If one operation did not work, then you could try the other. When they both failed patellectomy was the next option. Simon Donell

Open meniscectomy was developed in Dundee by Ian

Smillie (1907-1992), who developed meniscectomy knives. A mini-arthrotomy was performed, the relevant meniscus was then identified and the anterior horn elevated. The wound was held open by an assistant holding retractors designed to expose the meniscocapsular junction. The anterior horn was then grasped and pulled out of the knee whilst a Smillie knife was pushed dividing the menisco-capsular junction. The tricky bit was the posterior horn; I doubt that I ever managed a perfect total excision. The skill of mini-arthrotomy is now used in unicompartmental knee replacement; the incision and approach is identical. Following meniscectomy the wound was closed and the leg placed in an extension cast for 14 days. The patient remained

in hospital for five days. At two weeks the cast was removed and the knee mobilised according to a regime prescribed by the surgeon, and supervised by a physiotherapist. I suspect that the culture in soccer that one cannot get back to playing football for at least six weeks stems from the time of open meniscectomy. Once arthroscopic meniscectomy was established, open meniscectomy ceased as a procedure. Simpson, Thomas and Aichroth compared open and closed meniscectomy and showed the clear benefit of the arthroscopic procedure. I remember a subsequent Cochrane Review sniffingly noting that no randomised controlled trial had been performed to show that closed meniscectomy was superior to open. However, anyone who had been exposed to both would have seen the obvious difference in outcome between the two and would know that undertaking an RCT would be unethical. n Simon Donell is an honorary Professor at the Norwich Medical School, and a Trustee of the BOA. He retired from clinical practice at the Norfolk and Norwich Hospital 1 year ago. He is a past President of BASK. He was an undergraduate at University College Hospital and did his basic surgical training based at St Bartholomew’s Hospital, middle grade orthopaedic rotation based in Oxford, and was a Senior Registrar on the Percivall Pott rotation.

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JTO Features

How I... manage the acutely infected TKR?

Rhidian Morgan-Jones The duration of clinical symptoms defines an acutely infected arthroplasty; I use a symptomatic period of two to four weeks in defining ‘acute,’ although each patient should be treated on merit and the timeframes are not rigid1. Assessment & Investigation It is not just the condition of the knee and soft tissues (Figure 1) which matters. Is the patient well or unwell? The patient’s general fitness influences decision making and the choice intervention. I use McPherson’s Host classification system2. Routine bloods: These should include a full blood count, CRP and ESR. Imaging: True AP and lateral views of the knee are essential to look for lysis beneath the implant. Particular areas to note include the medial tibial plateau and the posterior femoral condyles (Figure 2a & b). A differential white cell count and alphadefensin assay are also useful3,4,5. Aspiration: Knee aspiration can be performed initially in the clinic or on the ward. The aspirate is divided between blood culture bottles and a sterile container. These are sent for microscopy, culture and sensitivity.

Surgical decision making In the very elderly or frail, medical management aiming for longterm suppression therapy may be appropriate. Nevertheless, in the majority of cases surgical management is required. The following must be considered: Arthroscopy / Mini-arthrotomy Arthroscopy and mini-arthrotomy are temporising measures and not definitive. They have a role in the acute cases to control acute sepsis in sick patients.

Figure 2a: With a four week history of pain and swelling the radiographs show lytic changes of the medial tibial plateau.

Figure 2b: With a four week history of pain and swelling the radiographs show posterior femoral condyles.

Figure 3: An acute presentation with lytic changes beneath the tibial component. This makes treatment with DAIR inappropriate.

DAIR Debridement Antibiotics and Implant Retention (DAIR) is always attractive to both patient and surgeon. However, for success the following are important: l No bony involvement (Figure 3) l A two to four week history,

although some suggest longer is acceptable l No sinus with a good soft tissue envelope l A good host with no major comorbidities l A micro-organism sensitive to common antibiotics with a good oral option. The surgical approach is as for a full revision with radical debridement. Following surgery prolonged post-operative antibiotics treatment of between three and six months is recommended6,7.

One-stage or two revision If the criteria for DAIR are not met then a full revision, in either one or two-stages is indicated. Whenever possible I undertake a single stage revision, reserving two-stage procedures for re-revisions and major soft tissue defects.

Rhidian Morgan-Jones

Figure 1: An acutely infected knee replacement.

Debridement My standard ‘Tricyclic Debridement’ includes three stages: 1) surgical excision of all avascular tissue and infected membrane

2) mechanical curettage, reaming and pulse lavage 3) chemical debridement – I choose 3% acetic acid, although other options are available. All three stages are repeated as necessary8. Antibiotics Local antibiotics are being increasingly recognised in the management of prosthetic joint infection. Various calcium sulphate products can be combined with antibiotics, according to microbiological sensitivities. They give prolonged, high antibiotic concentrations. Systemic antibiotics are used intravenously over a short period - one to two weeks. This is followed by an early switch to six weeks of oral antibiotics. Multiresistant organisms often require prolonged intravenous therapy,

which can be administered in the outpatient setting (OPAT). Conclusion Prosthetic joint infections demand a methodical approach to achieve good outcomes. The initial presentation and management offers perhaps the best opportunity of success. n Rhidian Morgan-Jones is an orthopaedic Consultant and Honorary Lecturer at the University Hospital Llandough, Cardiff. He specialises in revision knee replacement and infection. References References can be found online at www.boa.ac.uk/publications/JTO or by scanning the QR Code.

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JTO Features

Legg-Calve-Perthes Disease: 100 years of controversy: but could the answers be forthcoming? Alexander Aarvold & Daniel Perry Despite being described over 100 years ago, Legg-Calve-Perthes disease (LCPD) remains an enigma1,4 - we can’t even agree on its name. Treatment decisions vary based upon the age, stage of disease, hip stiffness, degree of femoral head deformation and, most importantly, the surgeon. The 80% rule is useful: 80% of cases occur in boys, 80% are unilateral and 80% occur between the ages of 4 and 9 years5.

Alexander Aarvold

Daniel Perry

Aetiology The aetiology is almost certainly environmental, the result of an ‘exposure’ early in life, or perhaps even before birth. There is good evidence to suggest that a strong genetic component is unlikely6. The major risk factor is socioeconomic deprivation4. It is unclear what component of the deprivation is the trigger, although tobacco smoke has been implicated7,8. Affected children are generally short9 and hyperactive10. Type 2 collagen abnormalities, growth factor deficiencies, viral infection, thrombotic diseases or a generalised vascular dysplasia have all been postulated as being involved.

However, the classification can only be determined in late fragmentation, by which time the majority of the deformation has already occurred. As the optimal time to intervene is before major deformation, Herring’s classification is of little use in guiding treatment. Knowing which children may benefit from intervention is therefore dependent on knowing which femoral heads will collapse BEFORE collapse has occurred14 – at present, we are not able to determine this. Clinical features associated with poorer outcomes include older age at onset, female sex and hip stiffness13,15.

Stages and natural history

Classifications

LCPD progresses through four identifiable stages. These were described by Waldenstrom: Early, sclerotic, fragmentation and reossification. Repetitive forces on the softened femoral head in the sclerotic and fragmentation stages probably cause deformation, collapse and extrusion11. The more deformed and the less spherical the femoral head, the earlier the onset of osteoarthritis12. It is the role of the orthopaedic surgeon to guide the patient through the disease and minimise the femoral head deformation.

Multiple radiographic classifications exist to describe the extent of the disease, including Herring, Catterall and SalterThompson. The prognostic value and utility of radiographic classifications is limited as there is no way to predict progression.

Herring’s lateral pillar classification has been used to guide treatment13.

Catterall described five radiographic signs of the femoral head ‘at risk’ of major deformation15: 1. Lateral subluxation 2. Metaphyseal cysts 3. Calcification lateral to the physis 4. Gage’s sign - a v-shaped defect in the lateral epiphysis and metaphysis 5. Horizontal physis.

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Whilst these signs may be suggestive of the development severe disease, they also may not be apparent in the earliest stages. The presence of lateral extrusion of the femoral head is, however, being increasingly used as an early predictor, before significant collapse has occurred14,16. Multiple classifications exist to describe the ‘outcome’ of the femoral head at the end of the disease - Stulberg12, Mose17, Sphericity Deviation Score (SDS)18 and Deformity Index19. Long-term studies have linked the Stulberg grade to the extent of degenerative change in young adulthood and the likelihood of hip arthroplasty. Stulberg grading is therefore considered the ‘gold standard’, although it does have notable inter- and intra-observer error20.

Investigations Serial assessment is usually with plain radiographs, although they are limited as radiological appearances lag three to four months behind disease21. MRI may be useful to detect LCPD before radiographic changes are evident21, but sedation may be required in younger children. Experimental studies are underway using perfusion MRI to define the degree of head involvement, although accessibility, cost and patient acceptability are problematic22.

Treatment – conservative Limitation of weight bearing is the traditional treatment, with experimental studies in pigs supporting this11. However, non-weight bearing in children is challenging and it affects other aspects of childhood and development. Many centres attempt activity limitation during the early stages. Active physiotherapy, range of motion exercises and periods of inpatient traction may improve hip movement, compared to ‘supervised neglect’23, although this is controversial.

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Treatment – Interventions The literature is based upon case series, although some are large, including several hundred patients. The findings are confounded as surgery has been performed on children of different ages at different stages and severity of disease. Thus, meta-analyses fail to reach a consensus on indications, timing and type of intervention24. The basic premise of treatment is to ‘contain’ the femoral head, which is thought to be protective against deformation. This can be achieved with an abduction brace, a femoral varus osteotomy (FVO) or a pelvic osteotomy. For a brace to be effective, it must be worn from diagnosis to re-ossification, which may be several years. As this can span the formative years of a child’s development, the family may prefer a single surgical containment procedure to bracing. The higher quality studies comparing pelvic and femoral osteotomies have demonstrated no difference in outcomes between different surgical treatments24,25. Cohort studies suggest slightly improved femoral head sphericity following FVO compared to non-operative management24,25,26, but the variability in patient age and disease stage limits the validity of any conclusions. Interestingly, surgery may alter the natural history of LCPD, as FVO performed during the initial necrotic stage led to a third of hips bypassing the fragmentation stage, shortening disease duration and time for deformation27,28. Bisphosphonates29, core decompression30 and arthrodiastasis31 have been used with uncertain results.

Treatment – ‘Healed’ LCPD Hip debridement via arthroscopy, anterior capsulotomy or formal surgical dislocation may have a role in treating impingement from the cam deformities in healed LCPD. Femoral valgus osteotomy can also be used to correct hinge abduction and improve joint congruence32.

Surgical containment strategies for early LCPD. (a) Right Femoral Varus Osteotomy (FVO). (b) Right Shelf Osteotomy.

Summary We do not know what causes LCPD. Current investigations and classifications all have inherent failings and there is no consensus on who, when or how to treat. We are not even sure if containment surgery alters the natural history of disease. As LCPD is rare, single centre studies are unlikely to help – collaboration across multiple centres is essential.

The Future The British Orthopaedic Surgery Surveillance (BOSS) Study is a study currently underway across the UK (www.boss.surgery). The nationwide cohort will complete recruitment in September 2017 and is the first step on a springboard for UK nationwide trials. The International Perthes Study Group (IPSG) is a multi-national collaboration across North and South America, Europe and Asia (www.perthesdisease.org). Current ongoing multi-centre clinical studies include cohort comparisons of surgical versus non-surgical containment,

investigation of the use of MRI, the efficacy of protected weight bearing and femoral head drilling. n Alexander Aarvold is a Consultant Paediatric Orthopaedic Surgeon at Southampton Children’s Hospital and Honorary Associate Professor at Southampton University. His subspecialty interests include paediatric hip and neuromuscular disorders. He is a member of the International Perthes Study Group (IPSG). Daniel Perry is a Consultant Paediatric Orthopaedic Surgeon at Alder Hey in Liverpool, and an NIHR Clinician Scientist. Dan leads the British Orthopaedic Surgery Surveillance (BOSS) Study. His clinical interests are in paediatric hip disease and paediatric trauma.

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

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JTO Features

Scrubbing Under the Influence: Alcohol-Based Surgical Hand Disinfectant Increases Estimated Blood Alcohol Levels on Breathalyser Testing Vittoria Bucknall Co-authors: Eleanor K. Davidson, David J. Chesney, Robert A. E. Clayton, Nick Shortt & Ivan J. Brenkel The use of alcohol-based cutaneous disinfectant is well established in medical practice1. It has been suggested that alcoholic surgical scrub solutions are equivalent, if not superior to, the traditional agents, as they are well tolerated, more efficacious and practical2-6. There are a large number of solutions commercially available, which vary in chemical composition. The agents used, either alone or in combination, include ethanol, propan-1-ol and propan-2-ol1,7. Alcohols are volatile and are released into the air during hand rubbing8,9. Consequently, they can be inspired. Experimental studies have looked to quantify bloodalcohol-concentrations (%BAC) from pulmonary absorption9,10. However, there is little research into the ‘apparent’ blood alcohol concentrations determined from breath sampling.

Vittoria Bucknall

Inhaled and retained alcohol has serious legal implications. Motorists need to be cautious with the advent of lower drink driving limits in many countries. The Scottish drink-driving limit has been recently reduced to 0.5g/L (0.05%BAC). In England, Wales and Northern Ireland, the limit remains at 0.8g/L (0.08%BAC).

Other countries such as Cyprus have limits as low as 0.2g/L (0.02%BAC)11. The aim of this study is to quantify the estimated %BAC using breath sampling after alcohol-based surgical hand disinfection and determine the duration of detection.

Methods Over one week within the trauma and orthopaedic department of a Scottish district general hospital, surgeons, anaesthetists and scrub staff proficient in scrubbing with alcohol-based disinfectants were invited to participate in the study. Demographic data were recorded in addition to the mode of transport, use of mouthwash and consumption of breakfast. A sample of breath was gained prior to scrubbing using the high precision professional AT6000 Alcohol Breath Tester® (CE, RoHS, AS3547 passed), a flat surface

alcohol sensor with a detection range of 0-2.0g/L (0-0.2%BAC). Exclusion criteria included any participants with a %BAC>0.00 prior to scrubbing. Participants prepared their hands and forearms with a commercial alcohol-based disinfectant named Sterillium (Paul Hartmann AG, Heidenheim, Germany) for 90 seconds, as recommended by the manufacturer. The composition of Sterillium per 100g includes the active ingredients: propan-1ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Each participant was given 14 dispenses of Sterillium during their 90 seconds of hand disinfection. The number of dispenses used was based on a pilot study where the average number dispenses was found to be 14. The manufacturer recommends an absolute minimum of six. No maximum is proposed. Following scrubbing, the participant was invited into a ‘clean air’ room. An immediate sample of breath was taken and recorded by the researcher. Subsequent samples of breath were then taken every 5 minutes until the %BAC was equal to 0.00. Statistical significance was determined using the paired t-test and significance levels were set to a P-value <0.05.

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JTO Features

Dependent Factor

Independent Factor

Correlation

Sig. p<0.05

Peak

Age

0.08

0.712

Peak

BMI

-0.004

0.986

Peak

Mouthwash

-0.036

0.787

Peak

Breakfast

-0.013

0.761

Peak

Sex

-0.094

0.869

Zero

Age

0.058

0.952

Zero

BMI

0.066

0.661

Zero

Mouthwash

0.000

1.0

Zero

Breakfast

-0.053

8.05

Zero

Sex

-0.088

0.681

Table 1: Significance of participant parameters on %BAC peak levels and time to zero.

Figure 1: %BAC in each participant over time.

Results Twenty-four theatre team members participated; 13 surgeons, 6 scrub staff and 5 anaesthetists. There were 12 females with a mean age of 43.7(±9.8) years and BMI 26 (±3.8). In all participants, except one, the %BAC reached a peak immediately following the 90 seconds of scrubbing (Figure 1) with a mean peak BAC of 0.12% (± 0.05) (Figure 2). The maximum %BAC recorded was ≥0.20% in four subjects. The %BAC returned to zero over a period ranging from 10 to 30 minutes, with a mean time to zero of 16.7 (± 4.8) minutes. All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. Twelve remained above the limit after 5 minutes, and two after 10 minutes. No significant differences were found between peak %BAC or time to return to zero for age, sex, BMI, mouthwash use or breakfast consumption (Table 1). The vast majority (92%) had driven into work that day.

Discussion

Figure 2: Mean cohort %BAC over time in relation to the Scottish %BAC driving limit of 0.05% (red line).

Figure 3: “Honest Gov, I’ve just washed my hands!” Cartoon depicting elevated %BAC levels being detected from the surgeon in theatre following SPPM hand disinfection.

Cartoon drawn by author Vittoria Bucknall.

This study is the first to quantify estimated %BAC on breathalyser testing and determine the duration of detection following the use of a propanol-based surgical hand disinfectant. This investigation highlights that estimated %BAC levels rise to over twice the legal Scottish driving limit following the use of Sterillium for surgical scrubbing. In some cases, the %BAC is elevated by more than four times. It can take more than 10 minutes for the %BAC to drop below the 0.05% threshold, and 30 minutes for the levels to return to zero. The implications of these findings must therefore be considered. It is theoretically plausible for a member of the theatre team to be stopped by the police on their way home, after using Sterillium. Their % BAC may be elevated leading to an erroneous arrest and be falsely charged with driving under the influence of alcohol11 (Figure 3).

Reassuringly, although the %BAC levels on breath testing in this study are significantly raised, other studies have investigated direct bloodalcohol levels following the use of alcohol-based hand disinfectant and have shown that transdermal and passive inspiration of alcohol only lead to a minor elevation in actual blood-alcohol levels1,8-10,12.

Limitations It is important to consider that in one surgical area, multiple members of the theatre team may be using Sterillium at the same time. Consequently, local inspired concentrations of alcohol may be considerably greater than in this study, potentially resulting in higher %BAC levels, which may be detected for longer. The AT6000 Breath Alcohol Tester used in this study has a range from 0.00-0.20%BAC. Four participants in this investigation were found to reach a maximum %BAC of 0.2. These participants may have had a %BAC considerably higher than 0.2 if the monitor was able to detect higher values.

Conclusion Although the use of alcohol-based surgical hand disinfectants are unlikely to result in %BAC levels which would impair performance and judgement, concentrations detected on breath sampling may be sufficiently high to warrant arrest. We therefore conclude that one more scoosh for the road is not always the best idea! n Vitty is a Trauma and Orthopaedic registrar in the South East of Scotland. Vitty is Secretary to the British Orthopaedic Trainees Association and sits on the RCS Intercollegiate Committee for Basic Surgical Examinations.

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

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JTO Features - Trainee Section

BOTA Census - The Good, the Bad and the Ugly Patrick Williams & Mark McMullan In 2016, the British Orthopaedic Trainees Association (BOTA) conducted a census of junior doctors working in Trauma and Orthopaedic surgery (T&O). The results were initially presented at the BOA Congress in Belfast. The census provides much data and gives a broad overview of British T&O training. One of the findings was of bullying and harassment and this has led BOTA, in conjunction with the BOA, to initiate a campaign against such behaviour. This article outlines the censusâ&#x20AC;&#x2122; background and findings.

an FRCS attempt paid for, or the cash equivalent, was used as an incentive. The committee recognised that BOTA membership is largely of registrar grade trainees, it was therefore decided to open the survey to non-members to increase participation across the junior grades. The census was anonymous, to allow respondents to participate without fear of reprisal. This minimised a potential source of bias. Some considered anonymity inappropriate, but it was integral to the census design, and was therefore maintained.

Results Background and Methods The BOTA census was the brainchild of the BOTA 2015/16 committee, led by Mustafa Rashid. Thanks to their hard work we now have data, which we can act on. The census was set up to allow BOTA to gather information about a number of issues affecting junior T&O doctors, these included morale and the decline in specialty training applications.

Patrick Williams

Mark McMullan

The questions were designed by the committee and published as a Google Survey. The survey was widely advertised and the possibility of having

Five hundred and eighty-four responses were received, 79% male. The distribution amongst training grade levels was equal from ST3 to ST8, with only 3% of responses coming from trainees post-CCT and 8% below ST3 level. The most popular subspecialty interest was knees (12%) with lower limb arthroplasty (11.5%) and trauma (9%) also being popular. Sixty-four respondents were undecided (11%) (Figure 1). Trainees gave a mean overall satisfaction score of 7.4 for their current post. Outpatient clinic satisfaction was 7.4 and progress towards indicative numbers was 7.5. 24% cited their colleagues

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and 23% operating experience as influencing their morale positively in the preceding four weeks. Most were generally satisfied with the quality of regional teaching and how it prepared them for the FRCS exams, they gave a mean score of 7.2. 79% of responders have a mock FRCS exam at least once a year. The median distance trainees have to travel to their regional teaching is only 18 miles, although the highest documented distance was 100 miles. Questions surrounding Training Programme Directors (TPDs) and the Annual Review of Clinical Progress (ARCPs) formed a large portion of the census and delivered some interesting results. Trainees felt generally satisfied that their TPD matched their placements to their training needs (7.4) and that if they had issues surrounding their training, their TPD was approachable (7.8). Despite just over 200 respondents stating that they would only meet their TPD once every six months, they felt that their TPD supported their professional development (7.5). 78% felt the TPD should continue in role.

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Unfortunately, there were also negative aspects, in particular concerning the ARCP. Only 56% of trainees felt that they had the opportunity to discuss their training needs going forwards and in less than 50% was the ST4/6 waypoint checklist used. More seriously only 64% of trainees felt that they were treated with respect by the panel with 8% feeling belittled, demoralised and that the ARCP was carried out in an aggressive or intimidating manner. The ARCP data was not the only concerning output of the census. 22% of trainees had considered leaving T&O in the last six months and 30%, with hindsight, would not apply to study medicine again. The common terms used to justify these sentiments were “junior doctors contract”, “rota”, “lack of training”, “research” and “the exam” (Figure 2).

Discussion It is understandable that the headline figures from the BOTA census surround bullying and harassment. However, it is

Figure 1: Sub-Specialty Preference in T&O Trainees.

Figure 2: Word clouds representing responses on morale (left) and the frustrations of being a T&O trainee (right).

important to remember that the census revealed a lot of positives. Trainees are generally satisfied with their rotations and feel that they are being given the requisite experience to progress towards completion of training. It is also encouraging to find that they take positive influences from their colleagues and operating experiences. The positives are balanced by a number of negatives – areas where we need to do better. Much of the negativity concerns bullying, but also reflects the general position of the NHS. Junior doctors, as a group, are feeling disenfranchised and undervalued by the government. We do not feel this is specific to orthopaedics, as BOTA has heard very few stories of our consultant colleagues being anything but supportive and understanding during the periods of industrial action. Issues surrounding ARCP’s are harder to justify. The ARCP is meant to be a nationally standardised process to ensure trainees are progressing as expected, a time to provide constructive feedback. We accept that the ARCP is a high-pressure environment and trainees are probably more sensitive to criticism than normal, but for the process

to be effective this sensitivity should be taken into account. We look forward to the upcoming Health Education England (HEE) review of the ARCP process, to which BOTA has been invited to contribute. Hopefully we can use this to improve the ARCP for trainees. The BOTA census has revealed the good, the bad and the ugly of T&O training in the UK. It has revealed areas we can be proud of and areas where we need to do better. The national and international support received for the original #HammerItOut and now the pan-surgical #CutItOut campaign, is evidence that there is a willingness to change, both within the specialty and across the NHS. Hopefully lessons can be learnt from the negatives and the positives used to help reverse the downward trend in specialty training applications to our resplendent specialty. n Patrick Williams is currently working as an ST4 in Trauma and Orthopaedic surgery in the Northern Deanery. He also sits on the BOTA committee as their BMA rep. Mark McMullan is a CT2 based in the North East. He is planning to pursue a career in Trauma and Orthopaedics and is the current BOTA junior representative.

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JTO Medico-Legal Features

Propose Changes to Soft Tissue Injury [Whiplash] Claims Process 2017 Michael A Foy The government is bringing forward a new reform programme to tackle the high number and cost of personal injury claims, and in particular soft tissue injuries after road traffic accidents (RTA), the majority of which are labelled as whiplash claims. This flows from the initial involvement of Jack Straw when he was home secretary highlighting the problem of fraudulent claims and the engagement of prime minister David Cameron with the Association of British Insurers (ABI) in order to address the issue of the increasing number and value of claims and their effect on the cost of car insurance.

I thought that it might be useful for BOA members involved in medico-legal practice to be aware of the recent and forthcoming developments.

Michael A Foy

The Ministry of Justice (MoJ) published a consultation document in November 2016. The consultation ran for seven weeks, closing on 6th January 2017. The consultation document was circulated to a number of organisations (including the BOA) and invited comments on a variety of measures designed to reform the personal injury claims process and in particular to discourage minor, exaggerated and fraudulent claims. The document pointed out

that despite the implementation of the Jackson reforms in 2013 and the introduction of the Med Co portal in April 2015 the volume of RTA related personal injury claims had remained static. It was over 50% higher than ten years previously with 460,000 claims registered in 2005/6 compared to 770,000 in 2015/6. The increase in claims in the last decade is against a background of a reduction in the number of RTA’s reported to police, from 190,000 in 2006 to 142,000 in 2015. The document also highlighted the fact that in the last ten years there have been a number of advances in vehicle safety with integrated

seat and head restraints, energy absorbing car design and the introduction of automatic collision detection systems which can take over a vehicle’s braking and steering system in order to avoid low speed impacts. These modifications would all be expected to reduce the impact of motor vehicle accidents. Various issues were raised including:1. Removal of compensation for pain, suffering and loss of amenity (PSLA) for all minor soft tissue injuries. 2. Introduction of a fixed sum of compensation for all minor soft tissue injuries. The “tariff” would differ depending on the longevity of the effects of the injury and whether there was additional “psychological injury”. For example, the suggested tariff for a 0-6 month injury was proposed to be £425 (£400 physical/£25 psychological) compared to £3,600 for a 19-24 month injury (£3,500 physical/£100 psychological). 3. Prohibition of settlement of claims without expert medical evidence. For small claims usually obtained through accredited MedCo experts. 4. Implementation of the recommendations of the Insurance Fraud Task Force.

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JTO Medico-Legal Features

THE MOJ DECIDED THAT “GOOD QUALITY MEDICAL EVIDENCE” WILL BE REQUIRED TO SUPPORT A CLAIM AND THAT MEDCO WOULD BE IMPORTANT IN THIS RESPECT. THERE WAS NO CLEAR DISCUSSION OF HOW THIS GOOD QUALITY EVIDENCE SHOULD BE OBTAINED AND HOW A DECISION WOULD BE TAKEN ON THE LONGEVITY (SEVERITY) OF THE ACCIDENT.

Part 1 of the government response was published in February 2017. The majority of comments (56%) on the consultation were from claimant solicitors. It was on the basis of these comments that the action points outlined in the February 2017 document were framed. As one would expect there were diametrically opposing views from claimant lawyers and the insurance industry, particularly in relation to the abolition of compensation for minor soft tissue injuries and the introduction of tariffs and their levels. The MoJ decided that “good quality medical evidence” will be required to support a claim and that MedCo would be important in this respect. There was no clear discussion of how this good quality evidence should be obtained and how a decision would be taken on the longevity (severity) of the accident. It seems to me that opining on the duration of a low end soft tissue injury is entirely arbitrary and relies on the

claimant’s description of their symptoms. There are rarely any significant clinical findings, excepting local tenderness and restricted movement, to aid the expert. The whole process of judging the injury duration will be based on the veracity of the claimant’s account and their response to physical examination. My experience of reading first reports from MedCo experts is that they are usually carried out without any reference to GP or other medical records. The table below shows the tariff levels proposed by the MoJ, these are due to be implemented in October 2018. As can be seen a decision was taken to introduce two bands at the minor injury end of the range, 0-3 months and 3-6 months. It was decided to abandon the idea of having two separate tariffs for physical injury and physical injury plus psychological trauma. The claimant solicitors were

Injury Duration

2015 average payment for PSLA - uplifted to take accoint of JCG uplift (Industry data)

Judicial College Guideline (JCG) amounts (13th edition) Published September 2015

New tariff amounts

0-3 months

£1,750

A few hundred pounds to £2,050

£255

4-6 months

£2,150

£2,050 to £3,630

£450

7-9 months

£2,600

£2,050 to £3,630

£765

10-12 months

£3,100

£2,050 to £3,630

£1,190

13-15 months

£3,500

£3,630 to £6,600

£1,820

16-18 months

£3,950

£3,630 to £6,600

£2,660

19-24 months

£4,500

£3,630 to £6,600

£3,725

Table 1: Tariff levels proposed by the MoJ.

unimpressed that psychological injury was quantified at £25 at the lower end of the scale! Also having considered removing compensation for claims at the lower end of the scale altogether the government decided not to pursue this option. However, they confirmed that claims could not be settled without medical evidence. Not surprisingly all this attracted mixed reviews from the involved parties. The claimant’s solicitors don’t like it at all. Deborah Evans (2017), chief executive of the Association of Personal Injury Lawyers (APIL) described their aim as, “To fight tooth and nail to get the select committee to read the evidence, to understand the enormous detriment the proposals bring to injured people, to correct the misconception of a system perpetuated by fraud and to sow seeds of doubt regarding the savings on motor premiums”. In the same edition of PI Focus Neil Sugarman (APIL president) gave the view that the government was, “fanatical about supressing the right to claim for legitimate injuries”. Ian Miller (2017) in the personal injury and clinical negligence blog was of the view that the logic behind the new tariffs must be to make it economically impossible for lawyers to make any money from whiplash claims

on the small claims track, for example by taking a cut of the damages. Equally he believed that the tariffs had been set at such a level as to make it not worth anyone’s while making a claim if their symptoms had lasted for no more than a few months. He concluded that, “These reforms will have a huge impact on those who suffer whiplash injuries in road traffic accidents and will put many personal injury lawyers out of work. Will we see insurance premiums reduced? A cynic might anticipate that increases in vehicle repair costs and insurance premium tax will offer insurers a perfect explanation for not passing on any savings. Only time will tell”. Andrew Twambley the spokesperson for Access to Justice was also unimpressed by the proposals indicating that “We are extremely disappointed that the government seems hell bent on removing the rights of ordinary people to gain redress for injuries that weren’t their fault. Increasing the small claims limit to £5,000 discriminates against ordinary people suffering whiplash injuries and will open the doors for claims management companies and cold callers to wreak further havoc on the market. The government has not even waited to issue a response to the consultation exercise, confirming that it is >>

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JTO Medico-Legal Features

DAVID WILLIAMS THE TECHNICAL DIRECTOR AT AXA TOOK THE VIEW THAT “BEING ABLE TO CLAIM THOUSANDS OF POUNDS FOR MINOR WHIPLASH INJURIES THAT ARE ALMOST IMPOSSIBLE TO VERIFY IS ABSOLUTELY LUDICROUS AND HAS ONLY SERVED TO INDULGE THE ACTIONS OF CLAIMS MANAGEMENT COMPANIES AND FUEL THE RISE OF ‘A HAVE A GO’ COMPENSATION CULTURE IN THE UK.

uninterested in due process and deaf to the serious concerns raised by legal firms, the judiciary and consumer groups. Insurers will be rubbing their hands in glee. They have the government in their pocket, and will themselves be pocketing any savings made, for themselves and their shareholders”. Not surprisingly, the proposals have been greeted more favourably in the insurance world. David Williams the technical director at AXA took the view that “being able to claim thousands of pounds for minor whiplash injuries that are almost impossible to verify is absolutely ludicrous and has only served to indulge the actions of claims management companies and fuel the rise of ‘a have a go’ compensation culture in the UK. By drastically reducing the cash incentive for these claims the Government has taken a strong stand in favour of honest motorists who will now save around £40 on their motor insurance premiums”. Ben Fletcher the director of the Insurance Fraud Bureau (IFB) also strongly supported the proposals, “one of the reasons that organised crime groups have orchestrated ‘crash for cash’ scams for far too long is that they’re perceived as low risk and high reward. The industry has been working hard to deal with this myth and has been

successful in fighting back, with over 1190 people arrested and 498 convicted. It’s due to the amount of money in the system that fraudsters are perceiving this as an easy target and exploiting it, netting upwards of tens of thousands of pounds. By reducing the amount of excess money in the system, we hope to see a positive effect in helping to tackle these scams, as the criminals recognise that the risks are higher and the rewards are lower than they once were. The effects and harm caused by these scams is wide reaching from those plagued by nuisance calls. It is also a burden on the innocent policyholder who is asked to cover the cost and the road users whose safety are being put at risk by criminals targeting them to deliberately cause a collision. In taking some of the excess cash out of the system, we hope that it will help to positively influence the level of ‘crash for cash’ fraud that we see”. The position was echoed by James Dalton the director general of the ABI who believes that the reforms to whiplash claims set out in the Bill cannot come soon enough. Dalton said, “the current” insurance claims system is “riddled with exaggerated and fraudulent claims” from which claimant lawyers have been “profiting handsomely”. The gravy train

must stop. Motorists know that the UK’s roads have been getting ever safer, so why have whiplash style claims been rising? People want an insurance claims system that provides compensation and support to those who genuinely need it”, Dalton added. “What they don’t want is to be plagued by spam calls and texts from ambulance chasers, while personal injury lawyers continue to profit from a broken system in urgent need of reform”. So there we have it. It will be difficult if not impossible to reconcile the extreme differences between the opposing groups in this argument. My understanding is that the great majority of reports in these claims will be given by GPs and physiotherapists through the MedCo portal. No doubt in those cases that progress and continue to be symptomatic we, as orthopaedic surgeons, will come across these reports later in the litigation process. It certainly appears that the government is prepared to continue their crusade in this area despite the protestations of APIL and likeminded organisations. n Michael Foy is a Consultant Orthopaedic and Spinal Surgeon, is Chairman of the BOA’s Medicolegal Committee, co-author of Medico-legal Reporting in Orthopaedic Trauma and author of various papers on medico-legal and spinal/orthopaedic issues.

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

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JTO Subspecialty Section

Biology of fracture healing - an overview Ravikiran Shenoy & Anand Pillai Fracture healing is a mechanism of tissue regeneration where a cascade of events triggered following fractures culminates with restoration of the physical and mechanical properties of the bone very close to its pre injury status. Our understanding of the cellular and growth factors involved in this process, their interaction with the extracellular matrix scaffold and role of mechanical stability at the fracture site influencing the type of tissue formed between the bone ends has enabled modulation of this elements and develop novel techniques and therapies to manage non unions and delayed unions.

Introduction

Ravikiran Shenoy

Anand Pillai

Loss of mechanical continuity in a bone that leads to pathological mobility between the broken ends of a bone generally heals through a regenerative biological process that is termed “fracture healing”. Several aspects of embryological skeletal tissue formation are replicated during this process that involves interplay between cells and their growth factors resulting in reformation of bone. Key to completion of the healing process is the presence or restoration of a degree of stability between the fractured

ends of the bone that helps formation and preserves an osteo-conductive scaffold over which the bone forming cells can lay bone. We discuss the types of fracture healing, the concepts described to understand how this occurs and the various cellular and non-cellular factors essential for fracture healing.

Process of fracture healing Macroscopic changes A key process in fracture healing is the establishment of a bony bridge between the fracture fragments1. The bridge then can hypertrophy and remodel to enable bone to regain its normal shape and strength. At a macroscopic level, as seen on radiographs, this bridging bone is formed on the external surface of the bone, the internal or medullary surface of the bone and directly between the fractured ends of the bone which are termed “external callus”, “medullary callus” and “primary bone union” respectively2. The amount of external callus formed (Figure 1) is related to the degree of mobility between the fractured bone ends and is not seen in case of immobilisation with absolute stability. Its presence in the

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Figure 1a & 1b: Forearm fracture in a child (a) treated with a plaster cast that allows mobility at the fracture site resulting in external callus formation (b).

presence of internal fixation was once considered a failure of fixation3. Similar to the external callus bony bridging is seen on the medullary surface as a callus and this is less dependent on fracture mobility. Primary bone healing occurs between rigidly fixed bone ends where dead ends of the cortical bone are recanalised by new Haversian systems with resultant obliteration of the fracture line (Figure 2). A final phase in fracture healing is the remodelling of bone which is an extension of the normal turnover process within the bone but where the resorption of bone and laying down of bone occurs in an organised fashion chiefly aimed at restoring normal physical and mechanical properties of the bone.

Microscopic changes At a cellular level, following the fracture, there is formation of a haematoma at the fracture site following bleeding from the torn blood vessels and bone ends. In the initial stages there is local vasodialatation with exudation of leucocytes along with plasma2. This initial stage is termed “the inflammatory phase”. Later on during this phase clearing up of the debris commences with the local accumulation of cells including histiocytes and mast cells. It is important to note that the ends of the bone do not directly participate in the healing process as it is comprised of dead tissue and the healing process commences in the tissues around the fracture

Figure 2a & 2b: Fracture of radius (a) treated with rigid internal fixation and absolute stability resulting in primary bone union (b).

site including blood vessels and periosteum. Fracture mobility is reduced in this stage by pain felt by the individual and the hydrostatic pressure exerted by the fracture haematoma4. The second stage of fracture healing “the reparative phase” commences within a few days overlapping with the inflammatory phase. Pluripotent mesenchymal cells form fibroblasts, chondroblasts and osteoblasts. The source of these cells are a combination of local cells including the cellular layer of the periosteum which is a two layered structure, the outer fibrous and the inner cellular layer, and cells which have migrated to the fracture site along blood vessels2,5,6. The local environment which was

acidic and hypoxic during the inflammatory phase gradually turns neutral and slightly alkaline to enable optimal action of alkaline phosphatase and bone mineralisation4,6,7. Reparative bone can be formed either directly from precursor cells close the fracture ends without an intermediate cartilage formation termed intramembranous ossification or there can be chondrogenesis the periphery with gradual endochondral calcification where the cartilage matrix is degraded and mineralised reducing the mobility at the fracture site and then allowing vascular proliferation, increased oxygen tension invasion of osteoblasts and laying down of primary spongiosa (woven bone) similar to the sequence of events at the growth plate4. >>

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JTO Subspecialty Section

FOLLOWING A FRACTURE VARIOUS GENES ARE SWITCHED ON AND OFF DURING THE DIFFERENT PHASES OF FRACTURE HEALING. DURING THE INFLAMMATORY PHASE PLATELETS INVOLVED IN THE CLOTTING CASCADE ALONG WITH POLYMORPHONUCLEAR LEUCOCYTES, LYMPHOCYTES, MONOCYTES AND MACROPHAGES RELEASE CYTOKINES THAT STIMULATE ANGIOGENESIS.

Figure 3: Factors essential for fracture healing (diamond concept).

The final phase of fracture healing is the remodelling phase where the woven bone is replaced by lamellar bone. Moreover the extra callus is gradually resorbed and the architecture of the bone is restored as close as possible to its preinjury level with osteoclastic bone resorption and formation of bone along lines of stress the process occurring over a period of many months. In rigidly immobilised fractures healing occurs by primary healing in two ways, gap healing and contact healing5. In gap healing woven bone is directly layed in the fracture gap that is then replaced by lamellar bone, the orientation of which is initially transverse to that of the original lamellar bone orientation. Subsequently this is replaced by osteons oriented as it was before the fracture had occurred over

a period of weeks. In contact healing bone, which occurs where the gap at the fracture site is less than 0.01mm and strain is less than 2%, osteons grow directly across the fracture site parallel to the long axis of the bone8. There is formation of a cutting cone passing across the fracture site where osteoclasts ream out a tunnel in the dead bone down which a blood vessel grows. This brings in osteoblasts which lay down lamellar bone2. Biological factors involved in fracture repair Following a fracture various genes are switched on and off during the different phases of fracture healing. During the inflammatory phase platelets involved in the clotting cascade along with polymorphonuclear leucocytes, lymphocytes,

monocytes and macrophages release cytokines that stimulate angiogenesis. Tumour necrosis factor α (TNFα) expressed by macrophages and other imflammatory cells, increases in concentration within 24 hours and returns to baseline within 72 hours post trauma, induces secondary inflammatory signals and acts as a chemotactic agent to recruit other cells9. They act on TNF1 and TNF2 receptors expressed by bothe osteoblasts and osteoclasts, the latter receptor thought to be having a specific role in fracture healing as it is expressed only following injury. Other factors involved at interleukin 1 (IL-1) produced by macrophages overlapping with TNFα in a biphasic manner which promotes angiogenesis and primary cartilage callus and induces IL-6 production by osteoblasts which has other roles of allowing differentiation of osteoblasts and osteoclasts10. Mesenchymal stem cells are recruited by the stromal cellderived factor1/CXCR4 signalling axis to the site of injury along with transformation growth factor -β (TGF-β) proteins including bone morphogenic proteins (BMP) BMP-7 (osteogenic protien-1 (OP1)), BMP-2 and BMP-44,11,12. During the subsequent stages of reparative callus formation and remodelling multiple factors have been shown to have an interactive role. These include TGF-β, fibroblast growth factors

(FGF), vascular endothelial growth factors (VEGF), platelet derived growth factors (PDGF), insulin like growth factors (IGF) and BMPs. Other reviews have extensively described the role of these factors in various phases of fracture healing4. Theories and concepts in fracture healing Initially proposed by Pauwels and later studied and described by Perren mechanical stimuli govern how a callus is formed and a fracture heals13. Perren’s interfragmentary strain theory proposed that a tissue couldn’t exist in an environment where the interfragmentary strain exceeds the strain tolerance of the extracellular matrix of the tissue. Lamellar bone ruptures at a strain of 2%, while for cartilage the strain needed to rupture is about 10% and granulation tissue can withstand strains up to 100%14. The differentiation of granulation tissue to lamellar bone occurs with a progressive reduction in strain when the fracture haematoma is converted to cartilagenous tissue, mineralised and subsequently ossified. During the process of fracture healing there is a lattice of extracellular matrix over which the osteogenic cells proliferate acted upon by the different growth factors. As the fracture healing progresses mechanical

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factors as described by the Perrenâ&#x20AC;&#x2122;s theory plays a crucial role in formation of bridging bony callus formation and completion of healing. The interaction of these four factors (Figure 3), cells, growth factors, matrix scaffold and mechanical stability has been described as the diamond concept15.

Conclusion

References

Fracture healing is a biological process involving interaction of cells with growth factors. It is triggered following a disruption in the mechanical continuity of the bone where a cascade of events aims to restore the bone to its preinjury state. n

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

Clinical application

Ravikiran Shenoy is a speciality registrar undertaking orthopaedic training on the North East Thames (RNOH Stanmore) rotation. He has authored and collaborated on numerous publications and has taught on courses run by Imperial College London and Royal Society of Medicine. His special interest includes complex orthopaedic trauma reconstruction and bone and joint infection.

Knowledge of the biology of fracture healing has enabled management of non-unions and delayed unions by influencing factors involved. Genetically engineered stem cells have been shown in experimental studies the enhance fracture healing16. Bone morphogenic proteins have been used in clinical practice to stimulate fracture healing17,18. Bone grafts have been used in roles of osteoinduction, incorporation and along with bioactive glass, ceramics and hydroxyapetitie as a scaffold for osteoconduction19. Improving local vascularity with tissue flaps help improve healing in open fractures or avascular fracture sites. Concepts of relative stability and absolute stability have been exploited to influence the type of healing. Primary bone healing with absolute stability enables restoration of anatomy in non comminuted and intraarticular fractures while secondary healing with relative stability fixation preserves tissue biology in comminuted fractures20.

Anand Pillai is Consultant Orthopaedic and Trauma Surgeon with University Hospitals South Manchester, Wythenshaw with a specialist interest in Foot and Ankle Surgery. He trained in Orthopedic and Foot surgery in the West of Scotland, and has undertaken further sub-specialist fellowships in Adelaide, South Australia, Oxford and Kurgan, Siberia. He holds honorary senior lecturer positions with university of Manchester and university of Salford. Anand has recently been elected to the research council of the European Foot and Ankle Society.

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JTO Subspecialty Section

Controversies in Treatment of Symptomatic Osteochondral Defects of the Knee Leela C Biant Surgical treatment choices for symptomatic chondral and osteochondral defects of the knee have been controversial in several regards. Firstly, which lesions should be addressed surgically? Secondly, what should the first line treatment be? Thirdly, do the results of some of the more expensive treatments justify the difference in cost? And fourthly, does primary treatment choice affect the outcome of salvage surgery if this is required? This report will summarise the latest evidence that clarifies the answers to some of these questions.

Leela C Biant

Chondral and osteochondral defects of the knee are common1,2. Approximately 60% of arthroscopies of the knee demonstrate the presence of such a lesion. However, not every lesion is symptomatic. Any osteochondral or chondral surgery will only be effective if the knee is normally aligned and stable. If malaligned, corrective osteotomy may be required (with or without cartilage defect surgery). The knee should be stable, or stabilised by ligament reconstruction. Abnormal shearing across the chondral surfaces will disrupt any repair tissue. Articular cartilage

surgery is ineffective in the presecnce of inflammatory arthropathy or where there is no meniscal tissue remaining. The critical size of chondral or osteochondral defect of the knee that will biomechanically degenerate is >0.8 cm2 diameter3. This raises the question of whether asymptomatic defects over this size should be treated opportunistically when they are observed. There is currently no long-term evidence regarding opportunistic treatment of asymptomatic lesions, and it is an area that requires investigation.

Symptomatic defects can have a magnitude of symptoms as severe as end stage osteoarthritis of the knee4 and often occur in patients of working age. It is reasonable to undergo a period of active conservative management: physical therapy, weight management and activity modification, to assess whether a new lesion will become asymptomatic. However, it is not reasonable to leave patients with symptoms of pain, catching, swelling and disability for prolonged periods of time. Treatment choice needs to be made in the context of the patientsâ&#x20AC;&#x2122; co-morbidity, activity level, ability to comply with rehabilitation and their expectations. All types of chondral and osteochondral treatments fare worse in patients with a BMI >30 and in smokers. Improvements in these parameters will result in a better outcome for the patient holistically, as well as for the knee intervention and should be discussed with the patient. The size of the defect also needs to be assessed in the context of the size of the knee. A 2cm diameter lesion may constitute the diameter of a whole condyle in a small knee. The size of the lesion is determined post debridement of redundant unstable flaps of chondral tissue and until a stable rim of viable cartilage is obtained.

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Surgical options following debridement broadly include bone marrow stimulation techniques (microfracture, microfracture variants with patches and scaffolds), osteochondral cylinder transfer (mosaicplasty, OATS), and cell therapy (autologous chondrocyte implantation (ACI), matrix ACI, ACI spheres, stem cell therapies under clinical trial evaluation). Lesions over 2cm2 have the most emphatic long-term evidence. There is more longterm evidence available for ACI than for any other treatment of chondral and osteochondral lesions5. Cell therapy is currently the most effective longterm surgical treatment option in lesions >2cm2. Figure 1: From Mistry et al5 shows the results of 4 pooled ACI studies by Knutsen6, Niemyer7, Mosely8 and Vanlauwe9 (lognormal analysis) compared to results of microfracture in three studies by Layton10, Knutsen6 and Vanlauwe9 (Gompertz curve analysis).

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Patients also have a better outcome in these larger lesions when cell therapy is performed as the first line treatment5,11. Cell therapy does not do as well in patients who have previously had their subchondral bone breached (by microfracture or mosaicplasty) as it does when it is done as first line treatment6. However, cell therapy is the only effective salvage treatment after any previous osteochondral or chondral surgery in these large defects12. Results of microfracture or mosaicplasty in large lesions are poor5 and results often deteriorate around 24-36 months post-op13,14, results of revision mircrofracture and mosaicplasty in large lesions are worse. Costs of cell therapy are a concern in a limited-resource healthcare environment. The National Institute for Health and Care Excellence (NICE) have undertaken a protracted review of ACI and has not yet concluded its appraisal that has been in process for four years. During this time, many

Figure 1: Four pooled ACI studies versus three pooled MF studies.

surgeons have found increasing resistance of health funders to allow them to undertake cell therapy where the evidence clearly shows it to be indicated. The National Institute of Health Research/ Health Technology Assessment and NICE commissioned an independent expert review group (Warwick Evidence) to evaluate the evidence-based clinical- and cost-effectiveness of treatments for symptomatic chondral and osteochondral defects of the knee. Their full report and summary can be found at this link www.journalslibrary.nihr. ac.uk/hta/hta21060/#/abstract. This report demonstrates clear evidence that ACI has better clinical results and more durable good outcomes. ACI was cost effective compared to microfracture due to a less likelihood of revision surgery, and ACI had a more beneficial cost per quality adjusted life year. The cost of ACI is within the cost framework (incremental cost effectiveness ratio) that is acceptable to the NHS as a funder. This may be of help with providing evidence to health funders to gain approval for cell therapy where is clinically indicated. In all size of defects, first line treatment with cell therapy may have the most effective longterm outcome. However, most of the studies of cell therapy are in larger lesions. Therefore there is still some controversy in treatment of lesions 1-2cm2 due to lack of published studies of cell therapy in smaller defects. Breaching of the subchondral bone, subsequent healing with scarring and thickening of the subchondral bone plate and the possibility of intralesional osteophyte certainly compromises the effectiveness of salvage surgery in larger lesions11. This may also be

the case in smaller lesions, but there is not yet the evidence base gathered to prove this conclusively. In summary, many of the previous controversies regarding surgical management of chondral and osteochondral lesions of the knee are being resolved with evidence. Some controversies still exist that need us to gather data; these include the most effective treatment for lesions 1-2cm2, opportunistic treatment of asymptomatic lesions and the use of regenerative techniques in early osteoarthritis. n Leela is a Consultant Trauma and Orthopaedic Surgeon at The Royal Infirmary of Edinburgh, Honorary Senior Lecturer at The University of Edinburgh, NRS Career Clinician Scientist Fellow. Her Clinical practice, translational and clinical research interests are in the area of degenerative joint disease of the knee from cartilage repair to joint replacement, and optimising outcome for injured patients.

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

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JTO Subspecialty Section

Pathogenesis of atraumatic osteonecrosis of the femoral head Professor Tim Board & Mr Daniel S Hill Symptomatic hip osteonecrosis remains a disabling condition with a poorly understood pathogenesis and aetiology. Most likely a common final pathway exists involving compromised subchondral microcirculation. Numerous and varied associations are linked with this condition. Corticosteroid use, alcohol intake, and smoking are thought to be major contributing factors. Several treatments have demonstrated the ability to optimise femoral head circulation, interrupt bone resportion and preserve subchondral bone. We highlight current understanding of the pathogenesis of atraumatic osteonecrosis of the femoral head and outline possible patient specific future approaches. Introduction

Professor Tim Board

Daniel S Hill

Despite significant research, symptomatic hip osteonecrosis remains a disabling condition with a poorly understood aetiology and pathogenesis, often requiring total hip replacement at a young age. The UK incidence is estimated to be 3 per 100,000 and numbers are increasing1. This may be due to increased reporting, the increasing use of predisposing therapies (corticosteroids, chemotherapeutic agents and antiretroviral therapy), as well as the increasing prevalence of many associated diseases and risk factors (Figure 1)2.

There is little evidence to show that early identification and intervention alter the final outcome, and the optimal management approach remains uncertain and controversial. Several treatment options have been described with the aim of preventing femoral head collapse. These include nonoperative management3,4 and joint preserving procedures5,6. Once femoral head collapse has occurred total hip replacement remains the only reliable treatment option (Figure 2 & Figure 3)7,8. National Joint Registry data cites osteonecrosis as being the indication for primary total hip replacement surgery in 2% of cases9. Despite extensive published reviews the exact pathophysiological mechanism remains uncertain2,10-13. Several treatments have demonstrated the ability to optimise femoral head circulation, interrupt bone resportion and preserve subchondral bone14, however the development of effective prophylaxis or biological treatments remain a distant prospect. This article highlights current understanding of the pathogenesis of atraumatic osteonecrosis of the femoral head and outlines possible future patient specific approaches.

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Direct risk factors

Indirect risk factors

Sickle cell disease

Corticosteroids

Human immunodeficiency virus infection

Alcohol abuse

Chemotherapy

Tobacco use

Radiation

Systemic lupus erythematosus

Myeloproliferative disorders

Organ transplant

Gaucher’s disease

Renal failure  Coagulation abnormalities Pregnancy

later in the disease process. In all probability a common final pathway exists with compromised subchondral microcirculation (Figure 4)2,14. The terminal event is osteocyte death induced by either critical ischaemia or the action of toxins, on a background of genetic predisposition, metabolic factors and local factors affecting the blood supply2,10,11,15.

Genetic factors

Corticosteroids

Figure 1: Risk factors for osteonecrosis of the femoral head.

Pathophysiology One problem hampering the identification of a unifying pathophysiological pathway is the numerous and varied associations of the disease. Corticosteroid use, alcohol intake, and smoking are thought to be major contributing factors in more than 80% of cases2. Other recognised associations include; immunosuppressive therapy, autoimmune diseases such as Systemic Lupus Erythematosus (SLE) and Rheumatoid arthritis, inherited and acquired haematological and thrombotic disorders, malignancies, metabolic

disorders, and renal failure. A clear aetiological role has been established for some of these factors, but not for the majority10,11,14. Vascular occlusion can occur as a result of thrombosis, emboli, nitrogen bubbles, or sickle cell crisis15. Extra vascular haemorrhage and the cellular elements of bone marrow can result in extravascular compression of both arteries and veins. Femoral head blood vessels can also be damaged by vasculitis, irradiation, or chemical toxicity10. The early stages of pathophysiology remain unclear as patients are largely asymptomatic and present

High dose corticosteroid use is one of the most common risk factors for osteonecrosis of the femoral head2,16-21. The extent of use that constitutes a risk is still under debate with conflicting reports on the importance of peak or cumulative dose22,23. Although many patients receiving corticosteroid therapy have at least one other confounding factor, often smoking or alcohol use, corticosteroid use, especially in high dose, is an independent risk factor. Hypotheses centered on the concepts of small vessel occlusion by fatty emboli, and a reduction in intraosseous blood flow resulting from adipocyte cell hypertrophy causing increased compartment pressure within

the femoral head have been proposed24,25. Impairment of circulating endothelial progenitor cells has also been implicated26. Statins may have the potential benefit of reducing bone marrow adipocyte size and therefore potentially reducing the intraosseous pressure within the femoral head27,28. Statins have also demonstrated pro-osteoblastic and anti-adipogenic properties on bone marrow stromal cells29-32, which have the potential to protect against corticosteroidinduced osteonecrosis. This remains a hypothetical therapeutic intervention with clinical data being extremely limited and somewhat conflicting33,34. Corticosteroids have also been shown to alter vascular sensitivity to vasopressors and vasodilators, with both having the ability to cause reduced blood flow and ischaemia35. Vasodilators, such as Iloprost, acting on the terminal vascular bed could counteract this vasopressor effect36. Jager reported a significant improvement in pain, functional and radiological outcomes in patients with bone marrow oedema and the early stages of femoral head osteonecrosis following the use of Iloprost37. Alcohol

Figure 2: Anterior-posterior radiograph of young female patient with bilateral osteonecrosis of the femoral heads.

Figure 3: MRI (T1 coronal slice) of a young female patient with bilateral hip osteonecrosis. Increased bone marrow oedema is seen in the left femoral metaphysis, which is the more symptomatic side.

Alcohol abuse is a well established risk factor38. Various cellular events have been implicated including; fat emboli, adipocyte hypertrophy, venous stasis, and increased cortisol levels10. Excess alcohol use has been shown to cause multi-potent bone marrow cells to be driven into an adipocyte cell lineage, causing reduced osteogenic potential39,40. This has also has been demonstrated in idiopathic osteonecrosis41, and has led to interest in the use of pro-osteogenic substances such as Statins to promote repair in necrotic bone31. >>

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JTO Subspecialty Section

THROMBOPHILIA AND HYPO-FIBRINOLYSIS HAVE BOTH BEEN SHOWN TO CAUSE VENOUS THROMBOSIS AND IMPAIRED BLOOD FLOW IN THE FEMORAL HEAD. PATIENTS WITH INHERITED COAGULATION DISORDERS MAY BE AT INCREASED RISK OF OSTEONECROSIS OF THE FEMORAL HEAD.

Smoking

Thrombophilia

Smoking has been implicated as a risk factor. An increased risk has been demonstrated in both current smokers and those with a history of smoking42,43. Many patients with smoking related lung disease and other chronic conditions are also exposed to corticosteroid therapy.

Thrombophilia and hypofibrinolysis have both been shown to cause venous thrombosis and impaired blood flow in the femoral head44,45. Patients with inherited coagulation disorders may be at increased risk of osteonecrosis of the

Figure 4: A common pathway to ischaemia and eventual osteonecrosis.

femoral head46. It may be possible to screen those individuals with an autosomal dominant coding defect47. Raised coagulation factor levels have also been reported in those without an identifiable inherited coagulation disorder14,46. The exact causative role of hypercoagulability in osteonecrosis remains controversial. Thrombophilia is not always seen in cases of osteonecrosis of the femoral head, and is often seen in other conditions affecting the femoral head including osteoarthritis48. An underlying genetic predisposition to form microvascular thrombi through abnormally low rates of fibrinolysis or thrombophilia can lead to amplified thrombus formation resulting in impaired blood flow in the osseous circulation45,49-51. The presence of mutations in the Protein C, Protein S, and other key factors in the coagulation cascade have been identified in cases of familial autosomal dominant osteonecrosis of the femoral head52. Anticoagulants have a potential preventive role in slowing progression of primary hip osteonecrosis, which could reduce the incidence of total hip replacement surgery in this patient group53.

Systemic Lupus Erythematous and Anti Phospholipid Syndrome Osteonecrosis, often multifocal, frequently develops in patients with SLE a relatively short time after commencing corticosteroid therapy54. There are conflicting reports around the association of anti-phospholipid antibodies in SLE and the development of osteonecrosis55-57. Patients with SLE using corticosteroids have a higher risk of developing osteonecrosis than patients not receiving corticosteroids21,58. HIV Osteonecrosis has been linked to HIV, possibly because these patients have additional risk factors (corticosteroids, chemotherapy, and alcohol)59 or secondarily because of antiretroviral therapy60. Genetic biomarkers Various immune mechanisms have been studied and several genes and biomarkers that may play a role in the development of osteonecrosis have been identified, and are summarised by Mont in the recent review (Figure 5)2. Genetic polymorphisms involved in corticosteroids and alcohol metabolism,

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along with genes coding for the coagulation cascade have been implicated61,62. Corticosteroid and alcohol-associated osteonecrosis have shown lipopolysaccharide interactions that activate toll-like receptor-4 signaling63. This activated

Biomarker

boa.ac.uk

inflammatory pathway, together with changes in interleukin (IL)-2364, IL-1a, transforming growth factor (TGF)-beta, IL10, and tumor necrosis factor (TNF)-alpha genes65, may be linked with the development of osteonecrosis.

Source and Function

GENES ApoB C7623T

Encodes proteins that are important in lipid transport.

Gene for catalase

Catalase is a major antioxidant enzyme.

Various cytokine polymorphisms

Certain genotypes of IL-1a, TGF-b, IL-10, IL-23, IFN-a, and TNF-a are associated with osteonecrosis.

Overexpression of p53mediated apoptosis

Tumour suppressor protein linked to osteocyte apoptosis

Matrix protein polymorphisms

BMPR2, BMP-2, 4, 6, and 7 as well as MMP-2.

Lipid protein polymorphisms

Genes that regulate lipid biosynthesis.

PROTEINS Adiponectin

Protein highly expressed in adipocytes

Interleukin-33

Interleukin expressed on osteoblasts, endothelial cells, and epithelial cells; up regulated in pro-inflammatory situations.

Tissue Plasminogen Activator

Various serum proteins identified in a comparative analysis of serum proteomes.

Endothelial cell markers

Endothelial cell markers included vWF antigen levels, factor VIII, vWF.

Thrombotic factors

These include plasminogen, D-dimer, protein-C, and antithrombin III.

VEGF

Involved in vascular repair and vasculogenesis.

Cryofibrinogen

Promotes thromboembolic events by inhibiting plasmin, fibrinolysis, and augmenting fibrinogen.

Figure 5: Potential Biomarkers2.

Discussion The exact pathogenesis of osteonecrosis of the femoral head together with the optimal treatment approach remains unknown. Current research demonstrates that both corticosteroids and alcohol promote adipogenesis at the expense of osteoblastic proliferation or function. Although the exact mechanisms may differ, the final common pathway is of bone marrow fat oedema, impaired vascularity, and reduced reparative capacity contributing to cellular death and osteonecrosis. The role of underlying genetic predisposition is not fully understood. Various authors have attempted to use laboratory biomarkers for diagnosis, however, clinical imaging remains the gold standard for diagnosis. The key to future successful treatment lies in early identification of at risk individuals, and quantifying risk in terms of clinical and pathophysiological characteristics. Future studies will need to focus on ways to screen the â&#x20AC;&#x2DC;at risk groupsâ&#x20AC;&#x2122;, allowing risk factor modification or elimination, and timely or ideally prophylactic treatment. This would allow early and focused intervention to prevent osteocyte death and hopefully to prevent femoral head collapse. n

Tim Board BSc (Hons), MB ChB(Hons), MSc(Orth Eng), MRCS, FRCS(Orth), MD. Tim is a Consultant Orthopaedic surgeon at Wrightington Hospital and specialises in all aspects of hip surgery from hip arthroscopy to complex revision. He undertook Fellowship training in Sydney, Hannover and Wrightington. He is Clinical Director of the Lower Limb department. He is an Honorary Professor and has numerous research collaborations with the Universities of Manchester, Leeds and Salford. He is the research advisor to the NHS Bone Bank and Associate Editor for Hip International. Daniel Hill is a speciality trainee in trauma and orthopaedic surgery currently based at East Lancashire NHS Hospitals trust. His Core Surgical Training was completed in the North West, and he undertook is undergraduate training at the Peninsula Medical School. Upon completion of speciality training Daniel has aspirations to become a lower limb arthroplasty surgeon.

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

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Special thanks We are grateful to the following for their contributions to this issue of the Journal: John Nolan, David Rowland, Jo Hicks, David Cumming, Saeed Mohammad and Durai Nayagam.

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Remember them fondly It is with great sadness that we report the passing of the following members. Our thoughts are with their families and friends at this time. Mr Dhirajlal Bhadreshwar Mr James Buchanan Dr W Fung Mr M Rowe Mr Gerry Slee