Journal of Trauma & Orthopaedics – Vol 6 / Iss 1

THE JOURNAL OF THE BRITISH ORTHOPAEDIC ASSOCIATION Volume 06 / Issue 01 / March 2018 boa.ac.uk

Inside

Read the News and Updates section for the latest from the BOA and the orthopaedic community

In our Features section you will find articles that focus on the Progress of the GIRFT programme, HRG4+ Coding, Fraud and Cyber Crime, and Improving Quality of Care and Reducing Length of Stay for Hip Fracture Patients

Read the article on the First One Hundred Years of the BOA: A Brief History

News & Updates ––– Pages 02-29

Features ––– Pages 30-77

Centenary Feature ––– Pages 30-36

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From the Executive Editor

Contents

Phil Turner Welcome to the first issue celebrating the Centenary of the British Orthopaedic Association.

Our feature article by Ian Stephen and David Adams traces not only the development of our Association but also provides a fascinating outline of how our specialty has developed over the last 100 years. Starting from a meeting of 12 members on 2nd February 1918, we have grown to a membership of almost 5000 with just under 2000 attending our last Congress.

We are living in times of overt rationing of elective healthcare, delaying surgery on those same patients because of winter pressures due to a lack of resources and the inability of social care to keep vulnerable patients in their homes or provide suitable care to allow their return to the community. This does not absolve us of responsibility to ensure the care we do offer is efficient and effective. We have three articles focussing on the “Getting It Right First Time” project led by Prof Tim Briggs.

He explains how variation is rife across the spectrum of medical and surgical care, and outlines the substantial impact of addressing the problems.

Processes and practices have to change if any benefit is to be gained and two further articles look at how we may use GIRFT evidence to reduce costs and improve outcomes.

The financial theme continues in two paired articles by David Johnson and Ro Kulkarni that explore the somewhat arcane world of coding and tariff. I implore you to read them as they give a straightforward and comprehensible account of the topic which is so important to maintaining the viability of your department.

Teamwork within our specialty and across specialties is vital.

The outcomes of hip fracture surgery are largely reliant on developing an effective system of care. Janet Lippett describes how she and her team transformed the pathway for these frail and elderly patients.

Pressure on the junior members of the orthopaedic team has a negative impact on continuity of care, patient experience and particularly on the educational development of young surgeons. The Medical Associate Professions may well be the solution. Karen Daly and Jeannie Watkins explain who they are what they can do.

As you explore this edition, consider what our forebears from 1918 would think about the content and wonder what the 2118 volume will look like.

News and Updates

02–29

Features

30–77

The First One Hundred Years of the BOA: A Brief History

30

Swapping a drill for a microscope

38

An update from the GIRFT programme

40

Getting it Right for Manchester

42

GIRFT Implementation – Embracing uncomfortable truths and the experience of a high volume arthroplasty unit 44 Hip Replacements: Charnley to the future

46

Fraud and Cyber Crime

48

How I Do... Application of a dynamic external fixator for PIP joint injuries

50

Operations I no longer do... Open ankle arthrodesis

52

Improving Quality of Care and Reducing Length of Stay for Hip Fracture Patients 54 Coding in the NHS from procedure to payment using HRGs: A quick guide

58

A simple guide to the complex process of developing a yearly NHS tariff

60

The Fracture Non-Union Cell Theory

64

The Physician Associate in Trauma and Orthopaedic surgery

66

The Business of Orthopaedics

70

Psychosocial Aspects of Challenge and Threat Appraisal in Orthopaedic Training

72

Promoting quality training and improving morale through a trainer-trainee dialogue and partnership

76

In Memoriam

78

General information and instructions for authors

80

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JTO News and Updates

From the President Ananda Nanu On the 2nd of February 1918, a group of 12 Orthopaedic surgeons met and formed what was to grow into the British Orthopaedic Association with 4700 members today. In this our Centenary year, we reflect on the changes in orthopaedic surgery that have occurred during the life of our venerable fraternity, and the changing nature of both healthcare delivery systems and the place of a doctor in our society.

Ananda Nanu

We hear daily about operations being cancelled, the parlous state of our finances, and the increasing disillusionment of the workforce. Against this backdrop of pessimism and nihilism, we may overlook the tremendous gains made in the field of musculoskeletal care, of which we should be justifiably proud. A quarter of surgical procedures in the NHS are musculoskeletal, and are some of the most life enhancing and pain-relieving procedures performed. Clarity of thought at this juncture will help us resist the push to limit operative measures based on erroneous and possibly disingenuous labelling of some of our established interventions as being of limited clinical value.

Concomitantly, we recognise that some of what we do originated in empiricism, and we should continue to lead the introspective scientific analysis examining the basis and current standing of everything we do, and we should applaud our academics who lead

the field in pragmatic studies.

These should be debated and examined in their turn, and by this analysis and synthesis of learned opinion and experience we hope to forge clear pathways of management based on evidence. This will require the adoption and support of registry data in various fields, and it is indeed disappointing that there are several obstacles to the collection, storage and analysis of this data, with a lack of clarity about further barriers that will appear when the General Data Protection Regulations (GDPR) come into effect on 25 May 2018.

The Competition and Markets Authority (CMA) have tasked the Private Healthcare Information Network (PHIN) with publishing data on private healthcare. PHIN is a not for profit organisation that is headed by Matt James, who was on a panel discussion answering questions at the BOA Congress last September. Some of the BOA membership would

have received emails to their GMC registered addresses asking them to visit the PHIN website and validate their private practice data. We would urge members to do so at an early date, and reply to PHIN with details of any inaccuracies, copying us at the BOA into the reply, so we can ensure all inaccuracies have been addressed. We are working closely with PHIN and will keep you informed of how we proceed with governance of the process.

I spent the Centenary birthday of the BOA in Scotland as the guest of the Scottish Training scheme. I drove up the M74 in brilliant sunshine, with snowclad hills framing the background and thought back to my first Registrar job in Falkirk. I spent Friday afternoon listening to a series of excellent registrar presentations, before huddling with other judges and arriving at a consensus decision. The evening was magnificent, with a Burns supper that was the most impressive I have attended. The glistening haggis was piped in by David Finlayson, retired orthopaedic surgeon Inverness, and was addressed by Ian Brown, retired Orthopaedic Consultant at Fife. Ian gave a wonderful performance and it did not surprise me to learn that he has tread the boards for the last thirty years. The lasting memory of the evening was the conviviality and collegiate atmosphere amongst the nearly 200 people there, a welcome reminder of the close-knit body we truly are. This solidarity and common ground will be much-needed bonds to help us weather the storms ahead. n

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Don McBride - Vice President Elect I am currently a Consultant Orthopaedic Surgeon at the University Hospital of North Midlands specialising in Foot and Ankle Surgery for the last 24 years. I am married to Angela, my greatest support, and we have four children and three grandchildren.

Don McBride

I have previously been Chairman of the Scientific Committee and President of BOFAS and remain a co-opted Council Member acting as liaison with EFAS. With the latter, I have been a Council Member and Honorary Treasurer and am currently Honorary Secretary and Chairman of the Certification Board. I am a

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I very much welcome the opportunity to play a more active role on the Presidential line and continue as a member of the Executive. I believe that we are going through a challenging period with difficult times ahead due to significant financial pressures envisaged in the NHS with further alterations in the process of funding for Health and Social Care. I look forward to serving as President in 2019-20. n

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JTO News and Updates

BOA Latest News Medical Student Essay Prize 2018: Deadline for submissions approaching!

This is the last opportunity for medical students to submit their essays for the 2018 Medical Student Essay Prize. This year’s question is “What differentiates the qualities of a good orthopaedic surgeon from those of a great orthopaedic surgeon?” Deadline for submissions is Wednesday 28th March 2018. For further information, please visit the BOA website www.boa.ac.uk/training-education/medical-student-essay-prize.

Tim Briggs and Clare Marx - New Year’s Honours List

Hip Fracture Care – “Lessons Learnt” Date: Wednesday 23rd May 2018 Venue: De Vere Venues, Colmore Gate, Birmingham Attendance: Free The programme based on The Hip Fracture Review Day is a day for Orthopaedic Consultants, Nurses, Orthogeriatricians and Anaesthetists involved in Hip Fracture Care to join Paul Dixon, Orthopaedic Consultant and Chairman for the Trauma Group Committee to reflect on the reviews undertaken to date and discuss where lessons can be learnt. The provisional programme is available online at www.boa.ac.uk/pro-practice/ multidisciplinary-hip-fracture-review.

Training Orthopaedic Trainers (TOTs) Course l 3rd – 4th May (The Vermont Hotel, Newcastle) l 10th – 11th July (BOA, London) l 11th – 12th October (BOA, London)

The TOTs course aims to help T&O trainers to understand how people learn and how the T&O curriculum works, translating this into higher quality teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. If you are interested, please visit www.boa.ac.uk/events/training-orthopaedic-trainers.

Congratulations to BOA Past Presidents, Clare Marx on being made a Dame, and Professor Tim Briggs, awarded a CBE, in the New Year’s Honours List for their services to the surgical profession!

Clare’s long and illustrious career has had many remarkable milestones, along with being a consultant surgeon, holding down various important management posts locally, and being Chairman of influential committees such as the SAC. Clare was the first woman President of the Royal College of Surgeons, and also the first woman to be President of the BOA. Tim’s achievements in improving patient care continue to make milestones, especially through the Getting it Right First Time (GIRFT) initiative which is now being rolled out to other surgical and medical specialties. In addition, Tim is currently National Director for Clinical Quality and Efficiency for the NHS and represents a truly outstanding series of accomplishments.

ASG Travelling Fellowship The BOA would like to congratulate Thomas Moores as our selected ASG candidate this year.

Thomas will be travelling to Austria, Switzerland and Germany, with Fellows from the American and Canadian Orthopaedic Associations, in spring for the exchange of medical ideas.

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UK and Ireland In-Training Examination (UKITE)

BOA Clinical Leaders Programme (CLP): Applications are now open!

In 2017, all programmes across the UK and Ireland, and 10 programmes in South Africa sat the UKITE exam. We are delighted to inform you that 685 trainees in the UK and Ireland and 155 trainees in South Africa have successfully completed their exams. Mersey achieved the highest mean score with 67.5%, the average overall score was 57.75%.

The Royal College of Orthopaedic Surgeons of Thailand (RCOST) also joined the UKITE initiative in January 2018 with 117 delegates. Moving forwards we will be reassessing our UKITE platform in 2018 to ensure we have a robust and reliable system to cope with the increasing numbers participating. We aim to spread user demand and support the UKITE on a higher server infrastructure. For information regarding the UKITE, please contact ukite@boa.ac.uk or visit the website www.boa.ac.uk/training-education/ukite.

The Clinical Leadership Programme is now in its sixth year. This programme is delivered through a combination of master classes, tutorials and coaching sessions with experts. The legacy of this one year development programme is a significant innovation and improvement project delivered by each clinical leader to either their Trust or Specialist Society providing a strategic change agenda and improvement of Trauma and Orthopaedic services across the board.

Applications are now open for Trusts, Specialist Societies and Individuals. Deadline for the 2018/19 applications is Friday 1st June 2018. For more information on the programme, including how to apply, please visit the BOA website www.boa.ac.uk/trainingeducation/boa-clinical-leaders-programme-201819.

Clinical Excellence Awards 2018 Training Orthopaedic Clinical and Educational Supervisors (TOCS & TOES) Course The course provides delegates with a range of learning outcomes, all of which are mapped to the seven domains underpinning the GMC requirement for recognition as educational and clinical supervisors. If you want to help trainees be the very best they can be, join the TOCS and TOES course on 1st May 2018 at the BOA offices.

If you are interested, please visit www.boa.ac.uk/events/ training-orthopaedic-educational-supervisors.

BOA Standards for Trauma The Trauma Committee Group have been working with OTS and BSSH, and have now published a new BOAST on ‘Management of Distal Radial Fractures’. Revised versions of BOASTs on ‘Management of Pelvic Fractures’ and ‘Open Fractures’ have also been published. All of which can be found on the BOA website www.boa.ac.uk/ publications/boa-standards-trauma-boasts.

The 2018 Clinical Excellence Awards round opened on Tuesday 13th February and will close at 17:00 on Thursday 12th April. ACCEA will accept applications for new national awards and from those due to renew their award in 2018. Consultants will need to put in a renewal application if: l received their current award in the 2014 round l award was last renewed in 2013 (awarded in 2009, 2004, 1999)

In some cases, consultants will be renewing out of the usual cycle.

Awards are reviewed earlier if there is a change in job or a significant change in job plan. Updated guidance for applicants, nominators, employers and assessors will be published on the ACCEA website at www.gov.uk/government/organisations/advisory-committee-onclinical-excellence-awards before the round opens.

Appointment of Lay Chair Patient Liaison Group (PLG) The BOA welcomes Linda Ward as the Lay Chair of the PLG. Linda joined the PLG as a lay member in 2016 and in 2017 was awarded “Governor of the Year” at the Robert Jones and Agnes Hunt Orthopaedic NHS Foundation Trust, where she serves as a public governor representing Powys. Linda is a member of the Patient Panel representing it on the Clinical Audit Committee.

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

BOSRC Update The BOA Orthopaedic Surgery Research Centre (BOSRC), based at York Trials Unit, supports the BOA in expanding the number of trials in the UK related to Trauma and Orthopaedics. Their activity report covering the last six months is summarised here:

New research One research study is currently at the contracting stage and seven studies have just got underway or are ongoing. The studies are:

l Surgical fixation versus

l Compression bandage for

non-operative management for patients with stable thoracolumbar fractures (PRESTO feasibility trial)

knee swelling following total knee anthroplasty (Krebs study)

Grant applications

Keep an eye on the BOA website www.boa.ac.uk/ research/bosrc.

fractures (MD project).

l Scaling Up Quality

Improvement for Surgical Teams: Avoiding surgical site infection and anaemia at the time of surgery (QIST trial)

l External frame versus internal

locking plate for complete articular pilon fracture fixation (ACTIVE trial)

In addition, two surgeons have recently started their PhD projects at York related to two ongoing RCTs.

During the last quarter, the research team contributed to two events attended by Trauma and Orthopaedic surgeons to inform them about research methods and making applications for research funding.

l Surgical treatment of rib

l Trial comparing injections

of collagenase into the cord to surgical correction in the treatment of moderate Dupuytren’s contracture in adult patients (DISC trial)

l Occupational advice initiated

prior to planned surgery for lower limb joint replacement (OPAL study)

Engagement and networking activities

In the past two quarters two submitted final stage grant applications have been successful and one was unsuccessful. The BOSRC is awaiting the outcome of a further outline application.

BOA Travelling Fellowship Julian Maempel I undertook a travelling fellowship to Brigham and Women’s Hospitals in Boston, USA with the generous support of Zimmer-Biomet and the BOA. Mainly Professor Andreas Gomoll, an Attending Orthopaedic Surgeon at BWH and Associate Professor at Harvard Medical School hosted me. I spent time at the Cartilage Repair Centre with Professor Gomoll, where clinical practice encompasses biologic reconstruction techniques, including some procedures that are not routinely practiced locally (including osteochondral allograft techniques, meniscal transplantation and ACL reconstructions using tibialis anterior allografts).

There was an opportunity to observe osteotomy surgery around the knee, and in particular the role of tibial tubercle osteotomies in patellar maltracking, which I have not observed frequently on a local basis.

I also spent time observing Dr Fitz, an arthroplasty surgeon undertaking patient specific unicompartmental and total knee joint arthroplasty using custom made implants.

I had the chance to attend both outpatient clinics and operating theatre sessions with both these surgeons.

The experience was invaluable and allowed me to appreciate some different approaches to knee reconstruction that are not widely practiced in the United Kingdom.

Julian Maempel

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JTO News and Updates

BOFAS Annual Meeting, Sheffield 2017 November 2017 saw the British Orthopaedic Foot and Ankle Society annual meeting hosted in the city of Sheffield under the helm of President Chris Blundell ably aided by the Council and Jo Millard. The objectives of the meeting were to cover more idiosyncratic topics across a wide range of practice in an enjoyable manner. From an educational perspective, there were key sessions devoted to difficult clinical problems such as tendinopathies and joints less commonly affected by arthropathy.

In covering both the academic topics and a very clear programme discussing innovation, our two guest overseas speakers, Dr Judy Baumhauer and Dr Lew Schon

provided insightful talks prompting lively debate. The meeting programme was also designed to appeal to a wide audience of allied healthcare professionals, trainees and young consultants as wells as senior surgeons.

The Society is clearly active in promoting patient related outcome measures and a great deal of attention was paid promoting the merits of engagement with the BOFAS registry. Feedback from the meeting was universal in its praise for the wide-ranging topics that were explored and the manner in which they explored.

Finally, the meeting was intended to be fun as was ably demonstrated by entertainment provided by Toe Jam, the BOFAS

BOFAS annual meeting 2017

band! Their unique evening performance managed to raise £2700.00 for Cure International!

The dynamism of the Society was re-invigorated by the shrewd decision to hold the AGM in the

middle of the meeting, meaning an excellent attendance, meaningful discussions about the future of the Society and endorsed elections to office. In conclusion, an excellent all round meeting.

SBPR Annual Meeting, Northampton 2017 The Society of Back Pain Research held a very successful annual meeting in Northampton, UK, in November 2017.

The SBPR has long championed cross-pollination amongst those who have a professional interest in spinal pain and this two-day conference, with the theme of

‘Back Pain – Errors; Innovation and Implementation’, continued to promote this diversity with a broad mix of clinicians, researchers and scientists in attendance.

The inaugural keynote presentation that looked critically at the evidence base for past nonsurgical management of people

with back pain by Professor Bart Koes, created a thought provoking platform to set the scene for the twenty speakers that followed. A mix of open papers and poster presentations allowed both seasoned and first time presenters to share the stage and disseminate the outcomes of their latest spine related research, to a receptive audience. The day was completed by Professor Robert Mulholland who contributed a unique view as the DISCS Henry Crock guest lecturer on the failure of surgery in managing back pain in previous decades.

The conference dinner was enjoyed by all and was followed by live music and dancing from the local chart-topping band Fynnius Fogg.

Professor Bart Koes, the first keynote speaker at the SBPR meeting.

Day two started in style with optimistic, but realistic views of the future of spinal surgery from Ashley Cole and spinal research from Professor Nadine Foster, sandwiched between which

were a fascinating further nine open papers.

Professor Kim Burton gave a thoughtful and emotional speech celebrating the life and contribution to back pain management and research of Professor Gordon Waddell who had passed away earlier in the year.

The final academic event was a very lively debate of the motion ‘This House believes we should target the system not the person with back pain’. Bart Koes and Kim Burton valiantly argued for the motion, but the House voted narrowly for their opponents Tamar Pincus and Tim Germon who spoke against. Five Prizes in a variety of categories were awarded to deserving presenters whose talks were of an outstandingly high scientific standard.

The next conference is part of the UK combined spine societies meeting, BritSpine, in Leeds, 21st – 23rd March 2018.

37th annual meeting of the

European Bone and Joint Infection Society SAVE THE DATE

6 - 8 September 2018 · Helsinki · Finland Main conference theme: Infection After Trauma Important deadlines: Abstract submission 20 April 2018 Early registration 29 June 2018

www.ebjis2018.org

We look forward to seeing you in Helsinki!

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JTO News and Updates

BTS Annual Meeting, Sheffield 2017 The British Trauma Society held its annual scientific meeting in Sheffield on 7th-9th November 2017. The BTS was founded in 1988 and held

its first meeting in 1989. As a multidisciplinary organisation it invites anyone who has a medical background or a profession allied to medicine

to become a member. As a society the BTS is represented on the Board of Specialist Societies of the BOA. Day one consisted of a medicolegal course kindly supported by lectures from Irwin Mitchell Solicitors and an External Fixator Course and workshop supported by Depuy-Synthes who supplied the dry bones and equipment. Days two and three consisted of plenary sessions and key note speakers. Cash prizes were awarded for the best papers of scientific content and best clinical content as well as of medico-legal importance.

There was also a prize for the best poster presentation.

We were especially impressed

External fixation to pelvis, and long bones at BTS meeting 2017.

with a number of medical students who presented very commendably and fielded difficult questions about the work reflecting an impressive degree of knowledge of their subject. Among the 200 delegates were representatives from fields as wide as clinical psychology, radiography and plastic surgery and our keynote speakers represented general surgery, orthopaedic surgery, neurosurgery and emergency medicine and pre-hospital care with lunchtime symposia on both days. Our next meeting is to be held in Manchester on 7th-8th November 2018 (save the date) with instructional courses held on separate dates and venues to be announced.

BOTA 30th Anniversary Congress 2017 November 2017 marked the 30th anniversary of the British Orthopaedic Trainees Association (BOTA). With a Congress of over 350 delegates, it was the biggest educational meeting of our orthopaedic family to date.

This is the first year that the BOTA Congress has been provided free of charge to all members. The Congress was warmly opened by Phil Turner, Vice President of the British Orthopaedic Association. We welcomed Richard Rawlins, the founder of BOTA who gave a

motivating address on how the Association first began and what was then, his vision for the future.

A lively educational programme catered for trainees at all stages from medical students to those preparing for the FRCS with a chamber debate between Matt Costa and Dan Brown capturing the interest of all. Special thanks are extended to the Orthopaedic Trauma Society for an interactive trauma boot camp and to AO for kindly providing an entertaining and highly informative day of paediatric trauma instruction which proved popular. High quality scientific presentations allowed trainees to showcase their research with first prize being deservedly awarded to Paul Brewer.

Richard Rawlins, Founder of BOTA delivering a motivating speech.

It was with great honour that BOTA awarded further

Fergal Monsell, paediatric orthopaedic surgeon Bristol delivering instructional lecture at the AO paediatric trauma session.

prizes to some of the most humbling and inspiring people we have ever had the pleasure of speaking with. In recognition of exceptional trainers, BOTA is proud to congratulate Fraser Harrold (East of Scotland) for winning BOTA Trainer of the Year.

Runners up included Andrew MacDonald (West of Scotland) and John McArthur (Coventry and Warwick). Furthermore, every other year BOTA recognises one Training Programme Director

whose passion and care of their trainees is incomparable.

Congratulations to Alastair Murray (South East of Scotland) on winning the 2017 TPD Award.

Runners up included Mr Simon Hodkinson (Wessex) and Richard Spencer Jones (Oswestry).

With continued grateful support from the Associations, the Colleges, faculty and industry, BOTA looks forward to a creative and exciting 2018.

19TH EFORT Congress 2018 www.efort.org/barcelona2018

r now!

Registe

19TH EFORT Congress Barcelona, Spain: 30 May-01 June 2018

#EFORT2018

Congress Highlights - Main Theme: Innovation & New Technologies Robotics & computer-assisted surgery

Minimally invasive surgery

3D printing

New diagnostic techniques

Biomaterials

Virtual learning environment

Advanced implant technologies

Innovative rehabilitation programmes

New tissue regeneration techniques

Patient involvement in treatment & research

Patient specific treatment

Telemedicine

Key dates Advanced Programme online: 15 March 2018 Late registration deadline: 03 May 2018

Early registration deadline: 20 March 2018

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JTO News and Updates

BSS Annual Meeting, Birmingham 2017 The annual meeting of the British Scoliosis Society (BSS) took place in Birmingham from 29th November to 1st December 2017. The first day consisted of an educational day for trainees. The morning session addressed scoliosis management such as management of different curve types and achieving shoulder balance. The high point of the day was a session with Dr Jim Sanders (University of Rochester USA) who gave an excellent talk on spinal bracing followed by a practical demonstration (many thanks for the Norfolk and Norwich team providing the Cotrell frame).

There was an afternoon of presentations on basic science for orthopaedic spinal surgeons.

The meeting was held at the International Conference Centre in Birmingham. The

presentations was professional, and many of the more junior presenters including medical students talked on Magnesium anaesthesia and pain relief and sports activity after scoliosis surgery for example. Jim Saunders gave a thought stimulating talk on bone age and curve progression, David MacDonald (neurophysiologist in Saudi Arabia) gave a very informative and interesting talk on spinal cord monitoring, and finally Dominic Thompson (neurosurgeon at Great Ormond Street) talked about Chiari 1 malformations and the misapprehensions that many had prior to his talk.

BSS meeting

organising team was lead by Adrian Gardner, Matt Newton Ede and Jwalant Mehta and the organisation was impeccable.

The quality of the BSS meetings has improved immensely over the last few years and this was no exception. The quality of the

At the AGM, BSS Executive Meeting the variability of NHS funding was discussed, and plans for a research trial to assess vertebral body tethering were made.

BOSTAA Annual Meeting, London 2017 The British Orthopaedic Sports Trauma and Arthroscopy Association (BOSTAA) annual conference took place in December at the Institute of

Sport and Exercise Health (ISEH) in London. This was the first Conference of the Society and has been the result of the collective work of the

Executive and the Members who gradually developed the necessary communication pathways leading to a common understanding of Sports Injuries.

The emphasis of the programme was on ‘Tendinopathy’. The invited lecturers presented to an audience of Orthopaedic Surgeons, Sports and Exercise Physicians and Allied Professionals an update of the condition, including a seminal lecture by Hakan Alfredson.

Guest lectures included Peter Brownson, President of BESS, who presented on the ‘Athlete’s Shoulder’ and Colin Esler, President of BASK, presenting on ‘Meniscus Repair’.

Presentation at the end of Guest Lecture by Colin Esler, President of BASK.

The meeting provided the opportunity for the trainees to present scientific papers as

podia and poster presentations.

Lively discussion took place during the Q&A sessions, stimulating an interest in the different approach and routines of other Specialists. This year, the best scientific paper award was given to R Stevens and his colleagues from Chesterfield for their work on ‘Reproducibility of Tensioning Methods in ACLR’.

BOSTAA would like to extend their gratitude to the sponsors ARTHREX, ConMed, Medi, Neoligaments and SIROWA. Also to Jai Mistry from MICE Organiser Ltd and the ISEH for setting up and running the meeting.

We look forward to seeing you in London in 2018 where the emphasis of the programme will be on ‘Joint Instability’.

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JTO News and Updates

Instructional Course Review January 2018 Richard Hutchinson Running since 1972, the BOA Instructional Course has been an invaluable learning opportunity for T&O trainees and SAS surgeons over the decades. Whether filling in knowledge gaps in the lead up to the FRCS(orth) exam, or more recently augmenting your ISCP portfolio with critical CBD assessments, over the years it has adapted to meet the needs of today’s trainees.

This year, over 100 registrants met on an icy January weekend in Manchester, along with some of the UK’s best T&O educators in their fields.

The programme covered some critical areas in the T&O curriculum, including: “all you need to know to survive spines”, management of the dislocated knee and tribology.

Small group sessions focussed around major trauma, pelvic and acetabular fractures, nonunion management, foot and ankle, soft tissue sarcoma and spine. These sessions were

very useful, with all candidates recording at least three ISCP CBDs and also gaining viva experience.

experiences. These are topics that are rarely found on other courses but can carry the most influence on what sort of T&O surgeon you want to be.

Some ‘off curriculum’ topics were also covered, with an insightful lecture on resilience, which showed participants how they could better manage the stresses commonly experienced in T&O training, and demonstrated how this can ultimately improve our day to day performance as surgeons.

In response to this, the BOA are considering reducing the course to a one-day event, to allow faculty and trainees much needed downtime on the Sunday, before returning to work on Monday.

Along with reducing the course to a one-day event, the BOA are planning some changes in 2019. One of these changes will be to provide 20-minute clinical update sessions on a wide range of T&O topics including foot and ankle, shoulder and elbow, paediatrics, hand and wrist, hip, knee and spines.

Following this, candidates will be able to: plan FRCS revision structure; summarise major changes in practice; and source current evidence.

Finally, sessions on bullying in the workplace, adequate consent, importance of clinical trials and becoming a consultant, provided some really important knowledge from consultants who have clearly learnt through their own

Next year, the critical condition case based discussion sessions will cover diabetic foot, necrotising fasciitis, spinal infection, and metastatic spinal compression. These will be facilitated by experts, with a view to securing at least three

assessments again, even if over one day only. As in previous years, pre-course learning will be sent out so that participants are directed to useful resources for their preparation.

Overall, this year’s course received excellent feedback, which the BOA will continue to rely upon to adapt the course to the ever changing requirements of training T&O surgeons, and hopefully keep the instructional going strong for another 40 years.

Save the date!

Saturday 12th January 2019 The MacDonald Hotel, Manchester www.boa.ac.uk/events/ instructional-course #BOAIC

Along with reducing the course to a one-day event, the BOA are planning some changes in 2019. One of these changes will be to provide 20-minute clinical update sessions on a wide range of T&O topics including foot and ankle, shoulder and elbow, paediatrics, hand and wrist, hip, knee and spines.

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Volume 06 / Issue 01 / March 2018

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JTO News and Updates

Centenary Congress 2018 25th – 28th September, ICC Birmingam congress.boa.ac.uk #BOAAC

give you information about our guest speakers, the revalidation programmes and our general interest sessions.

India is our guest nation for this Centenary year, and the Indian Orthopaedic Association’s contributions will enrich our meeting and our programme.

The provisional programme is available at congress.boa. ac.uk/programme-2018.

Programme Update The BOA is 100 years old this year and we are planning to celebrate this milestone at our Annual Congress in style – you may have already noticed that our logo has changed for this year only but it continues to emphasise our core values of ‘Caring for Patients and Supporting Surgeons’. The theme for our Centenary Congress is, appropriately, Taking Stock: Planning the future’ and we look forward to presenting to you a mix of educational and scientific events that allow us to review the past and look at innovations for the future.

In addition to our usual events, there will a 90-minute session on the first day of the Congress, illustrating the History of the BOA and the History of Orthopaedics and Trauma during the last 100 years. This will set the scene for events on the following days which will highlight the advances being made in areas such as the basic sciences, computerguided surgery, the delivery of care in under-resourced areas, education via simulation, quality control issues and the management of our resources in these financially difficult times.

As the programme develops, our website will be updated to

Accommodation and Travel TSC Hotel & Venues is the official accommodation booking service for the BOA Centenary Congress 2018.

Booking your Congress accommodation at the exclusive rates could not be easier. Please note these exclusive rates will end on Thursday 23rd August!

Follow the link for information on navigating around Birmingham. You can also visit TSC and book online or download the interactive booking form at congress. boa.ac.uk/travel-andaccommodation-2018.

Archives Room At the BOA Congress this September make sure to visit our special archive room to view some of the amazing documents, photographs and material recording the history and development of the BOA over the last 100 years. We will also be featuring special programme sessions during the Congress around the achievements and celebrations of the BOA to mark our anniversary. For further details, please visit congress.boa. ac.uk/programme-2018.

Centenary Video

To celebrate 100 years of the BOA we have produced a Centenary video, which documents the journey of the BOA, and some of its key milestones over the last century.

We hope you enjoy and share the video available to watch here at www.boa.ac.uk/latest-news/ boa-centenary-video.

Centenary Congress 2018 25th – 28th September, ICC Birmingam

‘Taking stock: Planning the future’ congress.boa.ac.uk

#BOAAC

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Congress Member Registration FREE* member registration will open in April. Please note: Free registration will close and non-member registration will open on Friday 1st June. Further information is available here congress. boa.ac.uk/registration-2018. (*Terms and conditions apply)

Carousel Presidents We look forward to welcoming the Carousel Presidents from the following Associations to the Centenary Congress in September: American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Association (AOA), Australian Orthopaedic Association, Canadian Orthopaedic Association, New Zealand Orthopaedic Association and South African Orthopaedic Association.

Keep your eye on the Congress Programme for the timing of the Carousel Session.

Awards and Prizes We will be bringing together the winners for the best paper award from each region in the UK to compete for a national award. The following awards

and prizes will be presented at the BOA Congress: • BOA Clinical Leaders Poster Prize • Best of the Best Award • BOA Young Investigator Award • Presidential Merit Award • Honorary Fellowship Scrolls • Robert Jones Essay Prize and Medal • UKITE Trainee • Exhibitors Cup for Best Large Stand • Exhibitors Prize for Best Compact Stand

Exhibitors The exhibition will be open for the duration of Congress in hall three at the ICC Birmingham. Each year Congress attracts up to 2,000

delegates and over 80 companies who make up the exhibition. All exhibitors will have their logo and information about the company listed on the Congress website, in the programme book and on the Congress App. Further information about sponsorship or exhibiting at Congress can be found at congress.boa.ac.uk/ exhibitors-2018.

Medical Students’ Free Papers Medical Student abstract submissions are now open and will close on Friday 27th April. Please take a look at the abstract style guide and how to submit by visiting congress. boa.ac.uk/medical-students-

free-papers-2018. Papers will be presented at the Congress as part of the Medical Student’s session. The highest scoring Paper will be awarded the BOA Student Paper Prize.

Innovation in Simulation and Education At the BOA Congress there will be a prize for best Simulation Free Paper. All abstracts selected for podium presentation in the Simulation Free Papers session of Congress will be eligible. Abstracts can be submitted at congress.boa. ac.uk/call-for-abstracts-2018.

Submissions for Innovation in Simulation and Education will close on Friday 27th April.

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Conference Listing: BSCOS (British Society for Children’s Orthopaedic Surgery)

www.bscos.org.uk 8-9 March 2018, Crewe

BHS (British Hip Society)

www.britishhipsociety.com 14-16 March 2018, Derby

BLRS (British Limb Reconstruction Society)

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

BESS (British Elbow and Shoulder Society)

www.bess.org.uk 19-22 June 2018, Glasgow

BIOS (British Indian Orthopaedic Society)

www.britishindianorthopaedicsociety.org.uk 29-30 June 2018, Huddersfield

BORS (British Orthopaedic Research Society)

www.borsoc.org.uk 10-11 September, Leeds

BASK (British Association for Surgery of the Knee)

www.baskonline.com 20-21 March 2018, Leicester

BRITSPINE

www.britspine.com, www.ukssb.com 20-23 March 2018, Leeds

BSSH (British Society for Surgery of the Hand)

www.bssh.ac.uk 3-4 May 2018, Cardiff

CSOS (Combined Services Orthopaedic Society)

www.csos.co.uk 10-11 May 2018, Birmingham

EFORT (European Federation of National Associations of Orthopaedics and Traumatology)

www.efort.org 30 May-1 June 2018, Barcelona

CAOS (Computer Assisted Orthopaedic Surgery - International)

www.caos-international.org 6-9 June 2018, Beijing

BOOS (British Orthopaedic Oncology Society)

www.boos.org.uk 8 June 2018, Edinburgh

BOA (British Orthopaedic Association)

www.boa.ac.uk 25-28 September 2018, Birmingham

BTS (British Trauma Society)

www.bts-org.co.uk 7-8 November, Manchester

SBPR (Society for Back Pain Research)

www.sbpr.info 15-16 November, Netherlands

BSS (British Scoliosis Society)

www.britscoliosissoc.org.uk 28-30 November, Belfast

BOSTAA (British Orthopaedic Sports Trauma and Arthroscopy Association)

www.bostaa.ac.uk 5 December, London

Join us in Scotland!

18th ESSKA Congress 9 – 12 May 2018 Glasgow, UK

REGISTER NOW!

Pre-registration ends 29 April 2018.

Registration onsite starts 8 May 2018.

Programme Overview

Specials

• Speciality Days of AFAS, EKA, ESA, ESMA • 26 ICL + 50 Symposia • 300 Free Papers + 900 Electronic Posters • Surgical Demonstrations • Keynote Lectures and Debates

• Highlight Lectures • Surgical Pre-Courses Shoulder and Knee • Orthopaedic Sports Medicine Review Course • PT programme and Workshops • UK Sessions: BASK, BHS, BOFAS, BOSTAA, ISEH, NCSEM, SCOT

For details, registration and accommodation booking please consult: www.esska-congress.org Organiser & Contact Intercongress GmbH esska@intercongress.de

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JTO News and Updates

BOA Membership Update The Bone and Joint Journal (BJJ) and Bone & Joint 360 (BJ360) We are pleased to offer the next 65 new BOA members of 2018, 50% off the BJJ and BJ360, this includes the print and online copies.

Please share this offer with your colleagues.

To apply for BOA membership, please complete the online application form www.boa.ac.uk/membership/join-today.

For further information visit the membership page www.boa.ac.uk/membership/categories-and-subscriptions.

New BOA membership benefit for 2018!

We are pleased to offer BOA members a new membership benefit with CIBTvisas, a leading provider of Global Visa and Immigration Solutions.

CIBTvisas are the world’s largest provider of short-term business visa services, and specialise in providing solutions for travellers requiring leisure, business, conference and employment visas. They will aim to save valuable time by submitting visa applications on your behalf and cut through the complexities ensuring compliance with local immigration requirements.

BOA members will receive a 20% discount on all handling fees for each visa application. In order to use the online portal and gain the 20% discount, please contact membership@ boa.ac.uk for the link. For further details, please visit the BOA website www.boa.ac.uk/membership/cibt-visas.

Joint Action Challenge Events

Free Membership Subscription Prize Draw Congratulations to Mr Daniel Brown, who was chosen at random by Ananda Nanu, BOA President, to receive FREE membership for the year! To celebrate our Centenary year, throughout 2018 one BOA member will be chosen at random every month to receive a year’s free membership subscription. Good luck!

BOA Members Handbook 2018

We are pleased to announce that eight participants have registered for the Virgin Money London Marathon, taking place on Sunday 22nd April, to raise funds for Joint Action. Good luck to all of the runners!

All BOA members will be receiving an exclusive Centenary booklet documenting the organisation’s spectacular journey and key achievements over the years, along with a special edition of the members’ Handbook. You will also receive a Centenary leather bookmark in the post, which will also be available to purchase throughout the year.

Participate in the British 10K (15th July) and Prudential RideLondonSurrey (29th July) this summer and get involved with Joint Action Challenge Events! Run, walk or cycle to raise much-need funds that really make a difference in advancing this field of medicine. To register for a Joint Action event please contact jointaction@boa.ac.uk or visit the BOA website www.boa.ac.uk/research/challenge-events.

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Changes to the NJR Minimum Data Set (MDS) There are planned forthcoming changes to the NJR Minimum Data Set (MDS). The implementation of MDS Version 7 will see refinement of the data that is collected for primary and revision hip, knee, ankle, elbow and shoulder joint replacement.

The NJR will write to all hospitals who report to the registry ahead of the implementation of MDSv7 which is expected to come into effect mid-April.

The changes are in response to feedback from data collection staff and orthopaedic surgeons and have been reviewed extensively by the NJR’s Regional Clinical Coordinators Network, Orthopaedic Surgical Society representatives and the NJR’s Steering Committee.

The improvements aim to reduce the burden of data collection whilst enhancing the ability of the NJR to analyse

the data in ways that more appropriately reflect current clinical practice.

Full details of all the changes and a supporting FAQs document are available on the NJR website www.njrcentre.org.uk.

If you have any specific questions, please don’t hesitate to contact the NJR Service Desk at 0845 345 9991.

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Volume 06 / Issue 01 / March 2018

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JTO News and Updates

Preparing for Publication of Private Practice Data PHIN is the Private Healthcare Information Network, and has been tasked by the Competition and Markets Authority (CMA) with delivering information about private healthcare to patients via its website, www.phin.org.uk. PHIN began publishing hospital-level information in May 2017, and this year attention turns to consultants, with information due to start being published in May. Ahead of this, we’ve been engaged with PHIN for some time about their plans and processes, and have been keeping members updated via our website at www.boa. ac.uk/publications/boa-phindocuments-for-members. This article focuses on the latest developments for consultants and what is due to happen next.

PHIN’s Consultant Portal: for reviewing data and flagging problems In November 2017, PHIN launched its secure ‘Consultant Portal’, allowing consultants to view, for the first time, data that has been submitted from private hospitals/units about their practice.

A screenshot example of the PHIN Consultant Portal display.

Private hospitals and units (including NHS PPUs) have been required since September 2016 to submit to PHIN certain data on every patient episode for all private patients treated at that facility. (Not all have actually done so, however – as explained later.) This is the data that PHIN is now ‘playing back’ to consultants themselves in preparation for the roll-out of consultant-level publication. For consultants in England, the PHIN portal also includes data about NHS procedures (using HES data), and therefore this allows you to view the full scope of your practice.

In the first instance, consultants are being asked to activate their account on the portal and become familiar with the data that PHIN has received. They could then flag up to any provider hospital sites where data has not been provided to PHIN or is incomplete/inaccurate. Since the portal went live, the BOA has been encouraging all our members with a private practice to engage with this process to

get an early indication of the data that PHIN holds and any issues with data needing to be rectified.

Following early feedback through this process, PHIN have also made some changes, such as altering procedure groupings for arthroscopy and looking at specific coding issues regarding ligament and joint resurfacing procedures.

Although the portal went live initially as a data checking tool, it is also to be used for consultants to ‘sign-off’ their data ahead of publication. The sign-off mechanism in the portal had not yet been activated at the time this article went to press.

However, BOA members will be kept updated through member newsmails as the timelines on this are confirmed.

Data quality and completeness Early indications from users of the consultant portal have been that the data coverage and quality varies. Some have found the data to be reasonable, others have found it to be much more patchy. There were also some early specific issues about PHIN’s categories or groupings of procedures, including regarding arthroscopy, but we understand that these have now been addressed.

While all hospitals should be providing private care data to PHIN, some are not doing so at all (the CMA is taking enforcement action against seven such hospitals) and some have so far supplied incomplete

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JTO News and Updates

or poorly coded data. PHIN has been working on the quality and completeness of data that is being submitted for some time, and advises that this is improving.

The BOA is very mindful of potential issues in which individual consultants could be affected by practicing at hospitals where the data submission to PHIN is incomplete, badly coded or missing entirely. The likely scale of this is currently unclear.

This is one reason why we have been encouraging consultants to take an early look at their data on the PHIN portal. Where such issues occur, we advise members to flag these to PHIN and seek information from that hospital about its progress in submitting data to PHIN. With any data quality or presentation issues, BOA members are encouraged to alert the BOA so we can get a feel for issues that are occurring and raise this with PHIN where appropriate.

Signing-off data and looking ahead to publication PHIN’s ambition is to begin publishing information about consultants in private practice from May 2018, starting with limited metrics. The initial metrics are expected to be patient volumes and length of stay (both at practice and individual procedure level), alongside descriptive consultant profile information. Discussions are ongoing about some of the detailed aspects of this. In future, further metrics that have been stipulated by the CMA are due to be added.

At present, when publication commences, PHIN have indicated that only consultants who ‘sign-off’ their data will have their data published. PHIN would like to maintain this stance, but it will rely on consultants engaging;

A screenshot example of the PHIN Consultant Portal display.

PHIN are not obliged to offer the sign-off process, but would very much prefer to do so. The BOA strongly supports the principle of data sign-off by consultants, and we strongly encourage consultants to engage with this.

BOA reflections Ananda Nanu, BOA President, has attended recent meetings with PHIN and comments that: “In the light of recent events involving breast surgeon Ian Paterson, it is inevitable that some form of quality assessment and improvement of safeguarding mechanisms will be instituted in private healthcare; whether publishing this data will achieve that remains a moot point, but is one step along a long road.

“My view is that a collegiate involvement with PHIN, and the

BOA working with and helping PHIN promote a reliable and accurate assessment of work in the private sector is far preferable to any alternative involving disengagement.

We hope that as the process rolls out, our members will very carefully scrutinise their own data on the portal and feedback vigorously on the accuracy or otherwise of the picture portrayed. I would particularly like all members to copy their communications to PHIN to the BOA, so we can rapidly scan the national picture and work with PHIN to prevent inadvertent errors in data or their interpretation being overlooked.”

relevant to the specialty, such as data presentation, analysis and interpretation. Throughout this process we have emphasised the importance of fair and accurate presentation of data, and we continue to engage with PHIN with these principles in mind.

We are also supportive of discussions between PHIN and specialist societies where appropriate. For example: l Lee Breakwell, a spine

surgeon who sits on BOA Council as a Trustee as well as being involved in BASS and UKSSB, has been discussing with PHIN in relation to spine surgery about correct groupings of procedures and patient-friendly terminology for procedures.

Other input from the BOA and specialist societies

l The BOA and BASK have

The BOA is liaising with PHIN about a wide range of issues

made joint recommendations on the presentation of knee surgery information. n

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Volume 06 / Issue 01 / March 2018

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JTO News and Updates

Prioritising Research in Orthopaedics Matt Costa and Daniel Perry There is a growing requirement for the trauma and orthopaedic community to provide evidence of clinical and cost effectiveness for our treatments. The generation of this evidence will have a profound influence both on surgical practice and national policy.

How clinical research such as randomised trials are conceived, and how trial topics emerge, may be an enigma to many surgeons.

We all have ideas for ‘the next trial question’ but these ideas don’t necessarily translate into research priorities for major funding bodies such at the NIHR. This article is intended to cast some light on the research prioritisation process and how we can influence it.

Trials are generally funded through two routes, either through the National Institute of Health Research (NIHR), or via large charities (e.g. ARUK).

The National Institute of Health Research is by far the largest funder of research in Trauma and Orthopaedic Surgery, with trial grants awarded by an NIHR programme called ‘Health Technology Appraisal (HTA)’.

The HTA Programme funds research about the clinical and cost effectiveness and broader impact of healthcare treatments and tests for those who plan, provide or receive care in the NHS.

A commissioned call is when the funder invites study teams to tender to deliver a trial to answer a specific research question broadly defined by NIHR, whereas a ‘researcher led call’ is when the researcher dictates the research question. Trauma and orthopaedic surgery has been successful in obtaining funding through both mechanisms, though recently we are having greater influence by increasing the number of questions that are commissioned by NIHR.

How are trial questions commissioned?

The commissioning process can begin in several ways: l A NICE guideline review

generates a research recommendation that commissioners believe is deliverable l A successfully completed

HTA trial highlights a further area of uncertainty leading on from the trial

l A formal process is

undertaken within a specialty to generate a list of research priorities. The gold-standard of which is a James Lind Alliance Priority Setting Partnership (JLA PSP).

What is a JLA PSP? This is the formal mechanism by which a specialty area define a list of research priorities. JLA PSPs are inherently inclusive, enabling clinicians, patients and carers to work together to identify and prioritise uncertainties about the effects of treatments that could be answered by research.

The process is robust to ensure that both professionals and non-professionals have an equal voice, which is why this is considered the goldstandard method of research prioritisation. The NIHR have adopted the JLA process as their key mechanism for generating research priorities, and indeed fund the James Lind Alliance itself.

l A research question is

HTA funding is split between two funding mechanisms; research through a ‘commissioned call’, or research through an unsolicited ‘researcher led call’.

submitted online to NIHR by a surgeon or a member of the public, that is worked-up

by NIHR, and identified to be important and deliverable

JLA PSPs have increasingly been adopted within trauma and orthopaedic surgery, with PSPs completed in common shoulder problems, hip and

knee arthroplasty, early hip and knee OA and common conditions of the hand and wrist.

How can you best influence research funding?

You can have direct influence on the priorities of your specialty group by contributing to the PSPs online www.jla.nihr.ac.uk.

Underway currently are PSPs concerning: l Broken bones in older people l Planned paediatric lower limb

surgery l Broken bones in the upper limb.

Many of the JLA PSPs have led directly to commissioned calls from NIHR. JLA PSPs are therefore financially supported by the BOA Research Committee, to encourage growth within specialty research.

Trauma and Orthopaedics is a hugely powerful specialty in terms of improving patients’ quality of life. However, if we do not provide robust evidence that our treatments are effective from both a clinical and cost perspective, then they may not even be commissioned in the future.

Please have your say on future research priorities, by contributing to active JLA PSPs at www.jla.nihr.ac.uk/prioritysetting-partnerships. If your specialty area is yet to commission a JLA PSP, then please consider doing so; otherwise, someone else will decide which treatments are offered to our patients, and which are not.

For further information, contact us on policy@boa.ac.uk. n

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Volume 06 / Issue 01 / March 2018

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JTO News and Updates

Royal College of Surgeons Update Since Christmas, the separation of the Barry and Nuffield buildings has now been completed, and hard demolition on the old Barry Building is progressing. Plans have now turned to the detailed planning of the organisational operations during and after the return, along with what the offer will bring. This planning and its

implementation will be a main focus across the organisation for the coming years to ensure that the College is ready for the future.

As with all major change programmes, there are a few final minor issues to be resolved, and we are working with all involved parties to

The latest progress on the Barry demolition.

ensure that these are having a limited effect on operations throughout the building.

CGI of the main atrium with main staircase.

As the old Barry building comes down, and new building starts to be constructed, a new phase in the College will start with closer intra and interorganisational cooperation leading surgery for the future.

To watch the demolition occur, the College has installed a time-lapse camera with a view over the Barry site. This can be viewed at www.lobstervision.tv Username: BarryBuilding Password: kJhAGL36.

Wisepress Book of the Quarter Knots in Orthopedic Surgery: Open and Arthroscopic Techniques Authors: Umut Akgun, Mustafa Karahan, Pietro Randelli, Joao Espregueira-Mendes ISBN: 9783662561072 Date published: 23rd Feb 2018 Price: ÂŁ88.00 BOA Members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.

This well-illustrated book presents the state of the art in suture materials and provides clear, step-by-step guidance on how to tie the most frequently used knots. The opening section addresses terminological issues and describes how the biological and mechanical properties of suture materials may impact on healing potential. The basics of knot biomechanics are explained, highlighting the risk of failure of knots and sutures if their capacities are exceeded.

Subsequent sections give precise instructions on the tying techniques for the various open and arthroscopic knots, including the square knot, the surgeon’s knot, half hitches, and sliding and non-sliding knots.

The special instruments available to facilitate the tying of arthroscopic knots are thoroughly discussed, equipping the surgeon with the knowledge required to ensure optimal handling of the soft tissues and manipulation of sutures in arthroscopic surgery. This book is published in cooperation with ESSKA. It will be a valuable instruction manual for surgeons in training and will supply more experienced surgeons with an excellent update that will further enhance their practice.

Surgical eLearning Opportunities in partnership with the Royal College of Surgeons of Edinburgh PART-TIME ONLINE DISTANCE LEARNING PROGRAMMES FOR SURGICAL TRAINEES |ChM in Trauma and Orthopaedics| |A part-time online distance learning programme for advanced trainees in Orthopaedics| Delivery This two year part-time Masters programme in Trauma & Orthopaedics, taught entirely online, is offered by the Royal College of Surgeons of Edinburgh and the University of Edinburgh, and leads to the degree of Master of Surgery (ChM).

Based on the UK Intercollegiate Surgical Curriculum, the programme supports learning for the Fellowship of the Royal College of Surgeons (FRCS) examinations.

Trainees will be taught by experienced tutors and will have access to a structured learning resource of educational materials, including an unparalleled online library facility. Each module includes discussion boards based around relevant surgical cases covering technical skills and procedures as well as core knowledge.

This programme provides a quality assured, flexible, and advanced training for the next generation of Orthopaedic surgeons, linking an academic degree to the Intercollegiate Fellowship examination while also facilitating surgical research.

Flexible online learning Students on this programme will be part of an online community of Orthopaedic surgeons from all over the world. All you need is internet access and 10-15 hours per week of study which is carried out in a flexible modular manner.

Entry requirements UK trainee applicants should have completed initial (ST[specialist training years]1-2) or (CT[core training years]1-2) and early intermediate (ST3-4) phases of their training programme at the time of commencing the course.

Applicants would normally be commencing Intermediate Phase (ST5-6) of their training so that the curriculum would be directly relevant to their ‘in the work-place’ experience and prepare them for the FRCS examination which would be completed during Final Phase (ST 7-8).

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Applicants from outside the United Kingdom or those not within a recognised training programme would require to demonstrate that the course was directly relevant to their Orthopaedic surgery training, and applicants should be able to demonstrate a minimum of 4 years training in Trauma and Orthopaedics before enrolling for the ChM.

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28th November: Foundation Dinner at the Café Royal with 15 surgeons present

The First One Hundred Years of the BOA: A Brief History Ian Stephen, Honorary Archivist Assisted by David Adams, Past CEO 1989 - 2009 The Foundation Dinner On 28th November 1917, fifteen surgeons met for dinner at the Café Royal in London and resolved to form the British Orthopaedic Association. Handwritten minutes were kept: there is also a typed transcript and a menu card signed by all those who were present.

Chairman and Harry Platt was the Secretary. The Journal of Orthopaedic Surgery became the official organ of both the British and American Orthopaedic Associations.

Events leading up to the Foundation Orthopaedic Surgery had first emerged as a discrete discipline in the United Kingdom in the latter part of the nineteenth century and the American Orthopaedic Association was founded in 1887. In 1894 the

The Inaugural Meeting

Ian Stephen

David Adams

On 1st February 1918, a temporary Executive Committee met and a formal proposal to form the Association was agreed.

The Inaugural Meeting of the Association was held on 2nd February 1918 at Queen Mary’s Convalescent Auxiliary Hospital in Roehampton. The handwritten minutes and typed transcript record that 12 Members were present for the business and clinical meetings and that there were 20 original members of the Association: a photograph was also taken to mark the event.

The Chairman was E Muirhead Little, Robert Jones was the Vice-

Sir Robert Jones

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2nd February: First BOA meeting in Roehampton with 12 of 20 original members present

surgeon from Boston, R B Osgood was instrumental in the foundation of the Association.

The Journal was a joint venture with the American Association from the beginning and the first joint meeting of the British and American Orthopaedic Associations was held in London and Liverpool in 1929.

The first overseas meeting of the Association was held in Leiden in 1923. This was followed by a meeting in Bologna in 1924 and in 1928 the Association visited the Hôpital des Enfants-Malades in Paris.

The Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) was founded in 1930.

Awards and Clubs BOA First Meeting 1918.

British Orthopaedic Society was formed: it had 31 members and met four times a year, initially with printed transactions, but there is no record of further meetings after 1898. In 1913 Robert Jones was President of an Orthopaedic Section at the International Congress of Medicine in London, and in the same year an Orthopaedic Sub-section of the Royal Society of Medicine was formed, with E Muirhead Little as President.

The First World War further stimulated the growth of Orthopaedic Surgery and Sir Robert Jones was knighted for his services to military orthopaedics in 1917.

Orthopaedic Scheme for the cure of crippled children. In February 1921, all the patients from Agnes Hunt’s hospital in Baschurch were transferred to the new Shropshire Orthopaedic Hospital in Oswestry.

Other specialist orthopaedic hospitals followed: in 1923 Biddulph Grange Orthopaedic Hospital in North Staffordshire was the first orthopaedic hospital for children to be provided by a public authority and in 1927 the Princess Elizabeth Orthopaedic Hospital opened in Exeter. Harlow Wood Orthopaedic Hospital opened

in 1929, Winford Orthopaedic Hospital in Bristol in 1930 and Mount Gold Orthopaedic Hospital in Plymouth in 1933. The Orthopaedic Department opened at Manchester Royal Infirmary in 1934 and G R Girdlestone was appointed the first Professor of Orthopaedics in the United Kingdom, at Oxford in 1937.

International Connections The international connections of the Association were important from the start. An American

Prestigious awards and social gatherings in clubs were both used to advance the orthopaedic cause, which was still resisted by some General Surgeons.

The Robert Jones Gold Medal and Association Prize was inaugurated in 1924, with the first award to George Perkins and, in the same year, the first M.Ch. Orth. was awarded in Liverpool.

In 1938 the first Robert Jones lecture was delivered by H A T Fairbank. The Orthopaedic Club was founded in 1919, but only lasted until 1925. In 1928, the Robert Jones Dining Club was founded and was much longer lived. Other clubs followed in the subsequent decades.

Post War Development and the National Orthopaedic Scheme Once the War had ended, the Members of the Association drove the development of Orthopaedic Surgery in the United Kingdom.

In October 1919 Robert Jones and G R Girdlestone published in the British Medical Journal a proposal for a National

Shropshire Orthopaedic Hospital Oswestry. >

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Proposal for a National Orthopaedic Scheme for the Cure of Crippled Children

The Second World War Inevitably, the onset of another global war further stimulated the development of orthopaedic surgery worldwide, and the United Kingdom was no exception. In 1939 H A T Fairbank was appointed Orthopaedic Adviser to the Ministry of Health in connection with the Emergency Medical Service and in 1940 Reginald Watson-Jones published his book ‘Fractures and Joint Injuries’; he was knighted in 1945 for his contribution to the RAF orthopaedic service.

The BOA Memorandum on Fracture and Accident Services was published in 1942 and the Institute of Orthopaedics was founded in 1944.

The Post War Years There was slow national recovery in the years after the end of the War, but Members of the Association continued to press forward the development of Orthopaedics. The National Health Service was introduced in 1948 and this was also the year that the British volume of the Journal of Bone and Joint Surgery was first published, under the editorship of Sir Reginald Watson-Jones. The Chairman and Editor of the

Her Majesty Queen Elizabeth, the Queen Mother being greeted by Sir Reginald Watson-Jones at the third Combined Meeting of the English-speaking Orthopaedic Associations. Major-General the Earl of Athlone, Chancellor of the University on the left.

Journal were appointed to the Executive Committee of the Association in 1949 and the British Editorial Society was formed to manage affairs of the JBJS(B) in 1953. Also in 1948 the second joint meeting of the American, British and Canadian Orthopaedic Associations was held in Quebec and there was the first visit of ABC Travelling Fellows to the United States and Canada, with the return visit of North American surgeons in 1949. In June 1952 the third combined meeting of the Orthopaedic Associations of the English-Speaking World was held in London, including, for the first time, the associations of Australia, New Zealand and South Africa.

became Royal Orthopaedic Hospital and in 1952 an Orthopaedic unit opened at the Royal Sea Bathing Hospital in Margate. In 1955 the WingfieldMorris Orthopaedic Hospital, Oxford became the Nuffield Orthopaedic Centre and the Hip Centre at Wrightington was established by John Charnley in 1958. In 1959 the Association

published a Memorandum on Accident Services and established a subcommittee on Specialist Orthopaedic Hospitals. The same year, the Platt report on Arrangements for the Welfare of Ill Children in Hospital was published and Roland Barnes became the first Professor of Orthopaedics in Glasgow.

Specialist Orthopaedic Hospitals

Sir Reginald Watson-Jones, BOA President 1952-3

The development of specialist Orthopaedic hospitals continued after the War. In 1949 the Royal Cripples’ Hospital, Birmingham

The Woodlands Royal Cripples’ Hospital, Birmingham renamed The Royal Orthopaedic Hospital in 1949.

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Opening of Shropshire Orthopaedic Hospital, Oswestry

In October 1919 Robert Jones and G R Girdlestone published in the British Medical Journal a proposal for a National Orthopaedic Scheme for the cure of crippled children. In February 1921, all the patients from Agnes Hunt’s hospital in Baschurch were transferred to the new Shropshire Orthopaedic Hospital in Oswestry.

Other specialist orthopaedic hospitals followed.

Membership of the Association There has been a steady increase in numbers from the 20 original Members of the Association in 1918. There were 100 Members by 1924, 200 in 1928 and by 1943 the total had risen to almost 400. In 1947 the Membership fees were set at seven guineas for Fellows and five guineas for Members. Associate Membership for surgeons in training was introduced in 1948 and the Constitution of 1952 limited the number of Fellows to 150, elected from the Membership. In the same year, fees of £10 to £20 for companies exhibiting at the annual meetings were introduced.

By 1968, fifty years after the foundation, there were over 1200 Members and the registration fee for the Annual Meeting was £1. In 1993 there were over 2600 Members and today the total is over 4700.

the Association moved again to offices in the adjoining Nuffield College, which were refurbished using funds from the Cutner bequest, thanks to the efforts of Sir Rodney Sweetnam. Another move is now inevitable with the refurbishment of the Barry building and the vacation of the Nuffield Centre.

Relations with the Royal Colleges of Surgeons As well as the physical association of the Association offices with the Royal College of Surgeons of England, there has been a steady increase in influence with all the Royal Colleges. Sir Harry Platt became a Council Member of the Royal College of Surgeons of England in 1940 and was the

The Association Offices The offices of the Association have always been associated with the Royal College of Surgeons of England in London, but there have been various moves over the years. In 1944 they were sited in 45 Lincoln’s Inn Fields, next door to the College, with an annual rent of £100. In 1956 there was a move to the third floor of the Royal College of Surgeons building itself. In 1994

Dame Clare L. Marx, BOA President 2009

Her Majesty Queen Elizabeth the Queen Mother.

first orthopaedic surgeon to be President, in 1954. In 1991, the BOA was a founding member of the Federation of Surgical Speciality Associations, formed to give increased influence with the Royal Colleges. It was not until 1995 that Sir Rodney Sweetnam became the second orthopaedic surgeon to be appointed President of the Royal College of Surgeons of England, followed by Hugh Phillips in 2004: in the same year, Ian Ritchie was the first orthopaedic surgeon to be President of the Royal College of Surgeons of Edinburgh. Clare Marx was not only the first lady President of the BOA in 2008 but went on to be the first lady President of the Royal College of Surgeons of England in 2014.

In 2018, she was made Dame

in the New Year’s Honours List for her services to the surgical profession.

Wider Recognition In 1930, Rowley Bristow produced the first BOA seal, but it was not until 1952 that the Association received a Royal Grant of Arms. In 1959, Her Majesty Queen Elizabeth the Queen Mother became the Royal Patron of the Association. In 1964 Sir Herbert Seddon was knighted. In the same year, the Department of Orthopaedics in Sheffield was inaugurated and Sir Frank Holdsworth was knighted in 1968. Sir Henry Osmond-Clarke from Manchester was knighted in 1969. >

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First BOA overseas meeting in Leiden

At the same time, increasing sub-specialisation has resulted in the formation of a number of sub-speciality societies. In 1984 the British Scoliosis Society, the British Association for Surgery of the Knee and the British Orthopaedic Foot Surgery Society were the first sub-speciality Societies to become affiliated to the Association. In 1990 the Board of Affiliated Societies was established: this later became the Board of Specialist Societies.

The British Orthopaedics Trainees Association was founded in 1986 and the British Orthopaedic Specialists Association (for Non-Consultant Career Grade Surgeons) in 2003.

Fund Raising and Communication In 1938 the BOA Benevolent Fund was established for the benefit of members and their families who were in financial

Naughton Dunn

Education and Research The Association has been promoting education and research in orthopaedics since the foundation. The British Orthopaedic Research Society and the Naughton Dunn Orthopaedic Club were founded in 1963. In 1972 the first Annual BOA Instructional Course for Trainees was held and in 1974 the Advisory Bureau for Overseas Trainees was founded by the Royal College of Surgeons. In 1978 the inaugural meeting of the Association of Professors of Orthopaedic Surgery with thirteen members was held in Edinburgh. In 1986, the first Advanced Instructional Course for Consultants was

held. In 1993, the Senate of Royal Surgical Colleges of Great Britain and Ireland was founded, and in 1996 introduced mandatory monitoring of Continuing Professional Development for surgeons.

Sub-Committees and SubSpeciality Societies In response to the increasing work of the association, subcommittees have been formed to concentrate on specific issues.

As early as 1945, the Surgical Appliances Subcommittee was formed and by 1969 was stressing the importance of performance specifications for implants, including bone cements.

David Limb, Orthopaedic Surgeon and past Secretary of the BOA at a Joint Action Challenge Event

In 2003 the Wishbone Trust was succeeded by the British Orthopaedic Foundation. In 2007 Joint Action was adopted as the formal fundraising arm of the Association.

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Robert Jones Gold Medal and Association Prize inaugurated. 100 Members of BOA

In 1989 British Orthopaedic News was first published by the Association, with Chris Ackroyd as Editor. It was replaced by the Journal of Trauma and Orthopaedics in 2012.

In 2013 the BOA website went online for the first time.

difficulty. In 1989, the Wishbone Appeal was established, later to become an independent Trust, to raise funds for orthopaedic research and the first Great Hip Walk was held. In 2003 the Wishbone Trust was succeeded by the British Orthopaedic Foundation. In 2007 Joint Action was adopted as the formal fundraising arm of the Association.

The 75th Anniversary 1993 saw the 75th anniversary of the foundation of the Association and the publication of ‘A History of the British Orthopaedic Association’

by William Waugh. In 1992, the Spring and Autumn meetings of the Association were replaced by a single Congress, held in the autumn, with occasional spring meetings for special events. In 1998 the first Howard Steel Lecture was delivered at the Congress in Dublin.

The first issue of the British Orthopaedic News, Winter 1989.

Publications and Website

A History of the British Orthopaedic Association: The first seventy -five years’ by William Waugh.

In 1989 British Orthopaedic News was first published by the Association, with Chris Ackroyd as Editor. It was replaced by the Journal of Trauma and Orthopaedics in 2012. The 50th anniversary of the first publication of the British edition of the Journal of Bone and Joint Surgery was in 1998: it split from the parent body in 2013 and became the Bone and Joint Journal. In the same year, the BOA website went online for the first time.

The first issue of the Journal of Trauma & Orthpaedics, June 2013.

>

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Robert Jones Dining Club founded. 200 Members of BOA

BOA Council Members 2018.

National Influence There has been a pattern of increasing national influence as the Association has grown in size and it became clear that more information about numbers was required in order to argue for the needs of orthopaedic surgery with the Department of Health.

In 1986, an Orthopaedic Regional Adviser was

George Bentley, BOA President 1992 became EFORT President in 2004.

appointed in each region and Orthopaedic Linkmen were appointed in hospitals to assist in data collection.

In 1989 the Association published ‘The Management of Trauma in Great Britain’ and an ‘Advisory Booklet on Consultant Orthopaedic and Trauma Services’. In 1992, the Association organised the first census of orthopaedic manpower in the United Kingdom: this became an annual event, at the instigation of Fred Heatley, in 1994. In 2003 the National Joint Registry began operation and in 2009 Keith Willett was appointed as the first National Clinical Director for Trauma Care. Where once Government Departments would approach the Royal Colleges of Surgeons for advice on matters concerning trauma and orthopaedics, they now come directly to the Association.

been maintained. In 1972, the Association was a founder member of the Monospecialist Orthopaedic Section of the Union Européenne de Médecins Spécialistes (UEMS) and sent two representatives to the first meeting. In 1977 the Association became a representative on the Coordinating Committee of Orthopaedic Associations of the Common Market (COCOMAC) and World Orthopaedic Concern (WOC) was established. In 1993, the first meeting of the European Federation of National Associations of Orthopaedics and Trauma (EFORT) was held in Paris at the instigation of Michael Freeman and Jacques Duparc. George Bentley became President of EFORT in 2004 and the Annual EFORT Congress was held in London for the first time in 2014.

International Influence

Charitable status was established in 1962 and in 1997 the Association became a Company Limited by Liability with the publication of a new Constitution and Rules. In

The Association has had important international influence since the foundation, and this has

Constitution and Officers

1974, John Fairbank held the first one-year Presidency of the Association and in 1980 the Executive Committee was renamed Council.

Margaret Bennett was Senior Administrator of the Association from 1967 until 1989, when David Adams was appointed as Senior Administrative Officer.

He retired as CEO in 2010.

Conclusion I am privileged to have joined the list of the five Members who have acted as Archivist to the Association since 1953.

The Archive contains many documents, photographs and material that record the history and development of the Association over the past hundred years. In 1953, the contents of the Archive were listed on two typewritten sheets. They now occupy several cupboards and filing cabinets and are listed on a digital catalogue, which is almost complete. I hope that it will be possible to publish the catalogue on the website before too long. n

Autologous Bone Marrow Concentrate Prepared in the Operating Room

www.heraeus-regenerative-medicine.com

Heraeus Medical GmbH Philipp-Reis-Str. 8/13 61273 Wehrheim Germany

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First joint meeting with American Orthopaedic Association

Swapping a drill for a microscope Robert K Silverwood Co-authors: David W Shields and Peter S Young Undertaking a postgraduate research degree is a big career step, requiring significant planning to maximise your time out of programme. This can be a hugely rewarding experience, with more to gain than just two or three extra post-nominal letters.

Throughout this article we will outline the benefits and potential pitfalls of undertaking a higher degree during Orthopaedic training, from the perspective of several current academic trainees. We will discuss the cultural change encountered when moving from a busy orthopaedic department to a university laboratory, and advise upon writing successful funding applications, publications and theses.

Leaving the programme

Robert K Silverwood

After years of attending 8am trauma meetings and following prescriptive rotas, clinicians undertaking Out of Programme Research (OOPR) will suddenly become their own boss with regards to structuring their working day, research progression and compilation of a thesis. One of the challenges

of a flexible working day is the self-discipline required to maximise your working hours.

It is important to be aware that timings of experiments may lead to working evenings and weekends.

A cause of significant apprehension is that of feeling ‘left behind’ by your peers, and concerns about losing surgical skills. In reality, on returning to clinical work you may instead feel refreshed and with broader horizons. In the current climate of increasing dissatisfaction within junior doctors training in the NHS, this will be a welcome change1,2.

Often researchers remain involved clinically, for example with a weekly theatre or clinic session, which could even contribute to data or sample collection. This will minimise de-skilling, however, the priority

of OOPR is to complete your degree, and it is important to be mindful of the balance of clinical versus research work.

On application for OOPR discuss with your training programme director to determine whether your research time can count towards your training. This needs to be agreed in advance of taking time out by your deanery and the Joint Committee on Surgical Training (JCST). Any operations and work base assessments completed can still be recorded and count toward certification of completion of training (CCT).

Endeavouring to write up your thesis on returning to the training programme is tempting but extremely challenging. Thesis write up requires significant amounts of protected time, which is nearly impossible to obtain once back to clinical work.

Value of immersion in the academic community Laboratory research lends itself to developing collaborations, and once started in your project you will begin to realise the network of investigators who liaise with your group. These collaborators may include physicists, engineers, anatomists, stem cell scientists, endocrinologists and so forth. These collaborations may take your research to a new and unexpected direction,

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Orthopaedic Department opens at Manchester Royal Infirmary

potentially leading to your subspecialist interest and longterm academic focus. You may also develop strong links with other universities or orthopaedic departments, which could influence your future career path. Maintaining collaboration is an important skill, which is as equally relevant to becoming the lead investigator of an academic unit as it is to becoming a consultant and working within a multi-disciplinary team.

Laboratory based projects involve many techniques which although performed in a different environment may be translatable to your clinical practice, for example performing microscopic surgery with animal models during in-vivo research (Figure 1).

lack of an on-call supplement, thus it is important to calculate tuition fees into personal expenditure and if possible have them covered by funding.

As a University student you will be once again eligible to benefits such as reduced council tax, retail discounts, and a cheap gym membership. Furthermore, pausing or requesting reduced rates for memberships including the general medical council, defence organisations and ISCP, can also save money.

Figure 2: Scanning electron micrograph image of an osteoclast within a resorption lacunae surrounded by bone nodules. Research that greatly assisted when asked about bone remodelling in the basic science viva!

Attending seminars and tutorials will help teach you these skills and may be a pre-requisite to graduate with your higher degree. For example, topics including data management, research integrity, gaining ethical approval will remain important throughout ones’ career.

Dissemination of research

Figure 1: In vivo surgery, in this case a mouse forearm model for critical bone defects.

Researchers are responsible for the analysis and interpretation of their own results, leading to the acquisition of many new skills such as microscopy, immunohistochemistry, 3D printing, biomechanics, CT interpretation and omics analysis.

Furthermore, obtaining a deeper appreciation of statistical analysis is a valuable skill in any orthopaedic career (Figure 2).

Presenting at conferences is a particular highlight of your time out of programme. There is a more diverse range of conferences relevant to clinical academics, and it is crucial to select the most influential one for your research area. As with the clinical world, academic conferences provide a great opportunity to network and travel.

Research groups frequently have annual meetings; OOPR represents an ideal opportunity to become involved in their logistics. Running a successful meeting demonstrates significant organisational skills, and will embellish your C.V.

Funding and finances Income during OOPR is provided by different means, such as a clinical research fellowships or trust level appointments with protected research time. It is vitally important to consider the impact OOPR may have on your pay increments and pension. The BMA provides excellent advice on this3.

Applying for research fellowships and funding will make one aware of the competitive world of a career in academia. Completing grant and fellowship applications takes a significant amount of time, which should not be underestimated, and will require approval from several key individuals within your institution prior to submission.

Funding is available from a wide range of sources, and if your group has a good track record with a particular funder, this may aide your application. Tuition fees are significant and are frequently self-funded. Often research fellowship salaries are lower than clinician equivalents, due to the

Overall the experience of the authors is that whilst there may be logistical difficulties, having dedicated time to perform high quality research is fulfilling and opens career avenues which would be difficult to pursue by other means. n Robert K Silverwood is a Clinical Research Fellow and PhD student at the University of Glasgow. He has taken time out of his West of Scotland training program to research the role of microRNAs in osteoporosis and to develop a 3D in-vitro model of the disease.

References 1. Oliver D. David Oliver: Junior doctors’ working conditions are an urgent priority. BMJ [Internet].

2017;4407:j4407. www.bmj.com/ lookup/doi/10.1136/bmj.j4407 2. Royal College of Physicians.

Underfunded. Underdoctored.

Overstretched. The NHS in 2016. www.rcplondon.ac.uk/guidelinespolicy/underfunded-underdoctoredoverstretched-nhs-2016 3. British Medical Association.

Taking Time out of Programme. Oct 2016. www.bma.org.uk/advice/ career/applying-for-training/out-ofprogramme.

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G R Girdlestone appointed first Professor in Orthopaedic in UK

An update from the GIRFT programme Tim Briggs As BOA members will remember, the original Orthopaedic “Getting It Right First Time” report was published in March 2015 with a number of recommendations. These recommendations have been adopted by many trusts and are delivering real benefits.

down on specific opportunities to improve care and reduce waste, and of course improve training.

The General Surgery report set out 20 recommendations with opportunities to improve patient care and outcomes while delivering potential efficiencies of over £160 million annually, including: l Introducing consultant-led

However, since GIRFT began life as a pilot review of Orthopaedic Surgery, funded by the Department of Health and NHS England, delivered by my team at the Royal National Orthopaedic Hospital (RNOH) and supported by the BOA during my year as President, it has grown into a national programme focussing on 35 work streams across surgery, medicine, clinical services and cross-cutting issues. Indeed, following £60 million of additional Government funding, GIRFT is now a partnership between the RNOH and the Operational Productivity Directorate of NHS Improvement. The expansion of the GIRFT programme means it should help save the NHS £1.5bn per year by improving quality and efficiency - not by making cuts to services or reducing the tariff.

Tim Briggs

More specialties have become involved and the GIRFT General Surgery Report was published in

August 2017. It was written by John Abercrombie, who is the GIRFT Clinical Lead for General Surgery and a Colorectal Surgeon at Queen’s Medical Centre Nottingham. His work is co-badged by the Royal College of Surgeons.

The NHS delivers more than a million General Surgery procedures every year. The procedures range from those for bowel cancer through to the placement of gastric bands. The demand for procedures is growing and admissions increased by 27% between 2003/04 and 2013/14. While General Surgery is a very different specialty to Orthopaedics, at its heart the GIRFT methodology remains the same – we are looking at variation at a procedural level across every provider in England. It is the breadth and scale of the approach that is particularly valuable. It helps clarify the state of service provision nationally and drills

surgical assessments at the ‘front door’ of acute hospitals could lead to 30% fewer general surgery emergency admissions, where no operation is required. This could save the NHS £108m a year.

l A reduction in the length

of stay for elective colorectal surgery patients from the current 10.2 days to the 5.5 days in the best performing hospitals. This will free up 84,000 bed days, equivalent to a saving of £23.6m.

l A reduction in the length of

stay for appendectomy patients from an average of 3.5 days to two days would free up 30,000 bed days with a cost reduction of £8.5m.

l Reducing elective General

Surgical admissions where no surgical procedure is undertaken would save close to £7m a year.

l Reducing the levels of

emergency readmission for gall bladder surgery to the national average would save £1m in bed days.

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H A T Fairbank delivers the first Robert Jones Lecture

A series of regional GIRFT Hubs is being set up, from these clinical and project delivery leads can visit trusts, commissioners and Sustainability and Transformation Partnerships in each region on a regular basis advising on how to transform the national recommendations into local practice.

l Reducing those trusts with

a high 30-day emergency readmission rate following appendectomy to the national average, will save £5.8m.

l If all patients underwent gall

bladder surgery within 14 days of diagnosis, as opposed to the current 23% of patients, more people would be treated in a timely fashion with fewer readmitted for later surgery, saving up to £5m.

In terms of supporting the implementation of GIRFT’s recommendations, we are putting in place a comprehensive programme to help implement the recommendations highlighted in each national report, including support to individual providers for local implementation of the recommendations. A series of regional GIRFT Hubs is being set up, from these clinical and project delivery leads can visit trusts, commissioners and Sustainability and Transformation Partnerships in each region on a regular basis advising on how to transform the national recommendations into local practice. They will also support efforts to deliver any trust-specific recommendations emerging from the clinical lead visits.

Other upcoming milestones will include national reports on cranial neurosurgery and vascular, urological and spinal surgery and. Work is

underway to include oncology and paediatric medicine as new work streams to the programme. Litigation data will also be shared with Trusts to help drive patient care improvements leading to a reduction in litigation costs.

Having visited every NHS provider of orthopaedic surgery in the UK and now being a third of the way through revisiting English providers, it is apparent that for GIRFT to be a success it needs the backing of clinicians and senior trust managers. I am glad to report that I have been impressed and inspired by the enthusiasm I have seen within the Orthopaedic and managerial communities to embrace change, where it is needed, and to nurture best practice and safe innovation.

I can also report that I have begun a pilot reviewing all private sector providers of NHS funded Orthopaedic Surgery.

We are also recruiting a lead to undertake a GIRFT review of trauma services. These are both important projects for the profession.

I should add that we are participating in a number of reviews of the Orthopaedic GIRFT pilot. A qualitative review by Nicholas Timmins for the Kings Fund1 published last June reported that “the evidence to date suggests that the GIRFT programme

is achieving what it has set out to achieve – higher-quality care in hospitals at lower cost – with the engagement of both clinicians and management in the process.”

We are also supporting a CLAHRC North Thames2 NIHR funded review using mixed methods evaluation of the GIRFT proposed/planned changes to orthopaedics, to identify lessons to inform future efforts to improve the organisation and delivery of services. Qualitative methods, including stakeholder interviews, documentary analysis and non-participant observation, are being used to understand the programme theory underlying the GIRFT approach and study the effect of different ‘implementation tools’ intended to promote changes in practice. The team are also exploring patient perceptions of the planned improvements to care. Quantitative methods are being used to examine ‘what works and at what cost?’

On a final note, I would like to sign off by confirming to my Orthopaedic colleagues that, while the programme has grown exponentially from the original Orthopaedic pilot, through all of our efforts, local and national, GIRFT will strive to embody the ‘shoulder to shoulder’ ethos which has become its hallmark as we support clinicians nationwide to deliver continuous quality improvement for the benefit of their patients. n

Tim Briggs qualified from The Royal London Hospital in 1982 with honours in surgery and a number of prizes. After his senior registrar training he was appointed to the Royal National Orthopaedic Hospital as Consultant in 1992.

His specialist interests are in orthopaedic oncology as well as surgery to the hip and knee. He was Medical Director at the RNOH for 15 years and President of the BOA in 2014. He was appointed as National Director for Clinical Quality and Efficiency for the NHS in September 2015 and leads the GIRFT methodology. Professor Briggs was made a Commander of the Most Excellent Order of the British Empire (CBE) in the 2018 New Year’s Honours List for services to the surgical profession.

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

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Harry Platt becomes a Council Member of the RCSEng

Getting it Right for Manchester Phil Turner Greater Manchester is a conurbation of 3.2 million people in the North West of England. Elective orthopaedic services are provided by nine Trusts across thirteen sites.

Historically there is a north to south divide with some localities to the north being amongst those suffering the greatest disease burden and poorest health in the UK.

Phil Turner

In addition to the variation in health status it was accepted that there was significant variation in pathways, processes and outcomes in several surgical specialties across the region, but it was difficult to prove this in any open and transparent way as Trusts were unwilling or unable to share data. In 2012 the Greater Manchester Orthopaedic Alliance (GMOA) was established. The idea was to provide a forum to share practice and raise standards of patient care. The objectives included facilitating research and innovation, developing an academic department, improving training and

education, and sharing data which could then be used to improve outcomes.

The annual reports on orthopaedic and trauma services from the “Getting It Right First Time” (GIRFT) project were being released and the first visits to units in Greater Manchester (GM) were planned for 2013. It seemed an ideal opportunity to explore variation across the city, so we established a combined meeting to review anonymised data. It seemed that many of the actions needed to address the expected outcomes would be difficult to action successfully

in one Trust and would rely on the development of networking.

The attendees included clinicians and managers as well as the GIRFT team.

Receiving the results was uncomfortable. The data fully supported our suspicions that there was unacceptable variation. A few stark examples concerned units performing very low numbers of complex procedures, a Trust using uncemented stems for virtually all hip replacements and wide variation in the use of ODEP 10A rated implants. A surrogate measure for the appropriateness of knee arthroscopy showed that one unit proceeded to knee replacement within one year for 4% and another for 15%.

Standardised revision rates for knee replacement within five years varied from 0.4 to 1.2.

The case-mix adjusted health gain using the Oxford score varied from 18 to 23 for hips and from 12 to 18 for knees.

Litigation data was even more surprising with an estimated cost per orthopaedic spell at one Trust being £134.90 and the lowest at £31.13.

Since then, the work of the GMOA has been supported by the Greater Manchester Academic Health Science

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boa.ac.uk

Publication of BOA Memorandum on Fracture and Accident Services

Centre. We meet four times a year and have several projects in development. The CEOs of the provider Trusts have agreed to share data openly within the GMOA, including financial data such as procurement costs. As a consequence, we have developed an easily understood dashboard which points out the relative performance of the units, highlighting those aspects that are important for care and that can be changed to produce a significant effect. This has been particularly useful for the management of hip fractures.

Networking has improved with the concentration of complex procedures such as ankle, wrist and elbow replacements in fewer specialist centres. Revision hip and knee replacements are now performed in fewer units and cases are usually discussed in MDTs which often extend to collaboration across Trusts.

Systems are now in place to assess the impact on costs and outcomes.

Greater Manchester is the first city to be granted devolution which means that the combined

Health and Social Care budget is held locally so that health needs can be addressed more effectively. There is no doubt that this has improved collaboration between health and social care, between providers and commissioners and most importantly between the providers themselves.

This will support the breaking down of competitive silo thinking that has resulted in so many obstacles to reforming orthopaedic services.

As a consequence of the work already done, led by clinicians

and supported by managers, we are now developing plans for more radical change with the help of the GM Transformation Unit. The consequences should be far reaching and will address the problems of efficiency, variation and inequality in healthcare across the city. n Professor Phil Turner is a Consultant at Stepping Hill Hospital, Stockport and is Founder and Chair of the GMOA, Clinical Lead for T&O Transformation in Greater Manchester and Vice President of the BOA.

EDINBURGH 2018: ANNUAL SCIENTIFIC MEETING 7-9 NOVEMBER 2018 • EDINBURGH EICC

LEADING THE WAY IN SUB-SPECIALTY TRAINING Advanced Fellows Forum:

Two day instructional course for Foot Ankle Fellows to prepare for Consultant practice. Additional cadaveric teaching day in 2018 extends this course now to three days. Windsor 25th 26th April 2018/Guildford 27th April 2018.

Overseas Consultant Bursaries:

Support for Consultants from low & middle income countries to attend annual meeting.

Malawian Mini-fellowships:

Sponsored short attachment for UK Registrars to CURE hospital in Malawi, treating Complex foot deformities.

Travelling Fellowships:

Grants to visit centres of excellence in foot surgery of up to ÂŁ7000.

AHP Bursaries:

Financial support to attend BOFAS annual scientific meeting for Allied Health Professionals in your Foot & Ankle team.

Principles Course:

Cardiff 26th 27th February 2018 - FULL Cambridgeshire 11th 12th June 2018 Manchester 10th 11th 12th September 2018 Details and application form can be found at www.bofas.org.uk/Meetings-Courses/BOFAS-Courses.

For information on all training opportunities see www.bofas.org.uk

Volume 06 / Issue 01 / March 2018

1943

Page 44

boa.ac.uk

400 Members of BOA

GIRFT Implementation – Embracing uncomfortable

truths and the experience of a high volume arthroplasty unit Giles Heilpern Co-authors: Philip Mitchell and Richard E Field Get It Right First Time (GIRFT) is an innovative approach; first implemented in orthopaedics. The primary goal is to improve medical care by reducing unwanted variation in practice. The GIRFT programme is now being rolled out across the spectrum of medical and surgical specialities.

Initially, there was a degree of suspicion regarding its implementation. At the South West London Elective Orthopaedic Centre (SWLEOC) a decision was taken at the outset to embrace and engage with the GIRFT process. This has been a challenging, but rewarding, process leading to significant practice alignment, implant rationalisation and cost saving.

Giles Heilpern

The implant rationalisation process was surprisingly well received by the majority of consultants. We now have two suppliers of hip replacements and three

suppliers of knee replacements for routine service delivery.

Although the initial round of rationalisation did necessitate some change in implant selection by a very small number of surgeons, the strategy has achieved significant financial savings through reductions in variation in implant prices, loan set costs and the need for fast track sterilisation.

The rationalisation of implant selection has not compromised our surgeons’ ability to play an active part in orthopaedic innovation and research. Ever since SWLEOC opened, in 2004, our management have

recognised the broader role of a high-volume centre and have supported a parallel research infrastructure that assesses the outcome of different implants and innovative surgical techniques. This infrastructure enables our surgical workforce to engage in ethics and research committee approved clinical trials and a growing number of cost-neutral, postmarket, multi-surgeon, multi centre, surveillance studies on implants from other implant suppliers.

In many respects, the rationalisation of implants was the easy part of GIRFT – the open and transparent discussion of each individual surgeon’s registry and outcome data was initially far more uncomfortable. Interestingly much of the initial reticence and concern has been replaced with a consensus across the unit that these discussions are critical not only for governance but also for stimulating difficult but essential discussions on topics such as hip and knee replacement failures and low volume procedures.

Volume 06 / Issue 01 / March 2018

1948

Page 45

boa.ac.uk

First publication of Journal of Bone and Joint Surgery (British Volume)

The sharing of surgical experience and outcome data has also enabled our surgical team to use the GIRFT meetings to better understand the challenges of low volume procedures and engage in sometimes challenging discussions on the benefits, limitations and alternatives that are open to us.

It is a condition of surgeons admitting privileges at SWLEOC that they present all of their outcome and revision data in an open and transparent forum. This is undertaken in a supportive environment, with no management representation.

The six-monthly meetings are chaired by our medical director, with half of our consultants presenting each time. The meetings are supported by both SWLEOC and our partner base trusts with all non-emergency clinical activity cancelled to ensure maximum engagement. Consultants are also expected to cancel any private commitments with the day changing from year to year to prevent disadvantage to any individuals.

All consultants present their consultant level NJR data and the outcome and complication data, which our research department collects and feeds back to our surgeons. In addition, we review any data provided by other registries, as these come on stream. A standard format of presentation is evolving to ensure consistency and the process has been generally well received and embraced. The environment is non-confrontational and discussions around outlying data points seek to identify causation rather than apportion blame.

From these difficult but rewarding discussions there have been some tangible and very positive changes in practice. As a unit we have abandoned all mobile bearing primary total knee replacements and we have reduced our previously high rate of uncemented hip replacement by limiting its use to patients under the age of 75-years.

The sharing of surgical experience and outcome data has also enabled our surgical team to use the GIRFT meetings to better understand the challenges of low volume procedures and engage in sometimes challenging discussions on the benefits, limitations and alternatives that are open to us. While we have not set a minimum number target for any procedure, all low volume surgeons know that they will be presenting their results on an annual basis and we anticipate that this continuing focus will minimise any concerning trends.

All revision procedures now pass through a weekly MDT with all surgeons invited to attend. The MDT group are able to share experience to facilitate consistent work up, indications for revision and revision technique. This is all documented and is valuable and supportive. External Trusts are now accessing this forum.

We believe that this not only minimises unwanted variation in patient selection and technique but also provides gold standard governance. We have also introduced a ‘buddy’ system for younger surgeons developing a revision practice – the unit now actively supports and facilitates joint operating with a more experienced revision surgeon to ensure that practice development takes place in a safe and supportive way.

The initial focus of this process was arthroplasty, but as it evolves we intend to include our non-arthroplasty surgical colleagues. We also expect our anaesthetic department to begin a similar process of critical appraisal of their practice.

As a unit we have become increasingly aware that the GIRFT process will be implemented differently by each and every unit. We do not expect our model to be reproduced, although our processes continues to evolve.

We are fully committed and we believe that we have improved and continue to improve as a result. The suspicion and anxiety that many clinicians felt at the outset has given way to acceptance that the open sharing of data leads to a more supportive and transparent environment with the hope that patient outcomes will improve as a result. n

Giles Heilpern is a Consultant Knee and Shoulder Surgeon and Director of Surgery at SWLEOC. He is dual fellowship trained in knee and shoulder surgery. He is also a Consultant at Kingston Hospital NHS Foundation Trust and Fortius Clinic London.

Volume 06 / Issue 01 / March 2018

1948

Page 46

boa.ac.uk

First ABC visit to USA and Canada; first US/Canada return visit to UK

Hip Replacements: Charnley to the future Martyn Porter To put it succinctly John Charnley was a genius!

In November 1962 he operated on his first patient with the ‘standard flatback’ Low Frictional Torque Arthroplasty (LFA) (Figure 1) and by December 1965 had completed 500 cases. These ‘first 500’ formed the bedrock for on-going and detailed surveillance. This operation, later hailed as ‘operation of the century,1 was kept ‘in house’ for several years before wider release in order that Charnley could be confident it would work.

The success of the LFA was preceded by a period of experimentation, and failure, that may explain why Charnley was so cautious2.

One of his first designs was a resurfacing made of PTFE or Teflon, a material with a very low co-efficient of friction.

He had already established with cadaveric experiments that the human joint worked under boundary lubrication and could not rely on fluid or hydrodynamic regimes. Thus, an artificial joint would have to be self-lubricating and hence the search for a material that would allow low friction.

Martyn Porter

The problem with Teflon was its poor wear characteristics.

Between 1958 and 1961 Charnley performed 300 joint replacement using a Teflon bearing. The initial results

were encouraging but within three years catastrophic wear was seen and nearly all had to be removed (Figure 2). It was

in December 1961 just at the zenith of this failure that with serendipity a salesman visited the lab with polyethylene. His engineer Harry Craven, much to Charnley’s initial displeasure, tested this material and found that compared to Teflon, the wear characteristics were minimal. The rest is history.

What can be learnt from this story? That innovation needs to be carefully planned and that there can be unknown mechanisms of failure. That innovation should have a reasonable period of assessment in limited hands. That there is a long-term responsibility.

There is a risk that some of these messages are still being underestimated today.

Figure 1: The original Charnley Teflon Resurfacing.

Volume 06 / Issue 01 / March 2018

1953

Page 47

What happened next?

Many things, but here are a few: The femoral head diameter increased The LFA had a 22.225mm head diameter, much smaller than the native femoral head. Charnley introduced this deliberately to reduce the turning moment on the outer surface of the acetabular component – hence the term low frictional torque.

Another advantage of having a small head was that it would generate a smaller distance “rubbed” (sliding distance) against the internal part of the socket and this would lead to a low wear environment. The next generation of innovators wanted to increase the femoral head diameter to reduce dislocation risk. Head sizes of 28 and 32mm were introduced but with the consequences of increased volumetric wear.

When severe osteolysis was seen in hips with large diameter heads the osteolysis was attributed to ‘cement disease’ not polyethylene disease. The unintended consequences were to move away from cement

Figure 2: The 1962 Charnley Flatback.

boa.ac.uk

BOA is granted a Royal Coat of Arms

and this may have further compounded failure.

The bearing material changed When polyethylene, the true culprit of osteolysis, was exposed it was not unreasonable to consider alternative materials to the conventional metal on plastic. Ceramic on ceramic articulations have been used generally to good effect. Metal on metal articulations rely on fluid or hydrodynamic conditions for optimal performance, an environment that Charnley thought unlikely in his experiments in the 1950s. We know what happened.

Improved polyethylene wear was achieved by ‘crosslinking’ the polymer strands using radiation or chemical treatments.

Experimental testing and wear measurements using RSA show extremely low wear rates, so low, that larger femoral head sizes can now be used without the earlier concerns.

Modularity Modular femoral heads have been in use in considerable numbers for over three decades without detrimental effect until problems were encountered mainly with modular metal on metal total hip replacements.

The terms ‘tribo-corosion’ and ‘trunionosis’ are now familiar to most orthopaedic surgeons.

Modularity previously taken for granted as being safe is being evaluated in more detail. In most instances with conventional bearings, it probably is safe but with highly modular and multi material constructs the risks are more significant The surface finish changed The importance of surface finish, particularly of taper slip femoral stems, was not appreciated until the surface of the Exeter stem, that had excellent results

and very little osteolysis, was changed from a highly polished to a matte finish for cosmetic reasons. Early and severe osteolysis occurred due to the rough stem engaging and moving within the cement mantle with release of metallic and acrylic debris. Almost two decades later, a similar design feature and failure occurred with the 3M Capital Hip. History repeated.

We have Registries In 1972 Charnley stated, “Serious consideration should be given to establishing a central registry to keep a finger on the pulse of total implant surgery on a nationwide basis. Surgeons should not be permitted to perform total hip implant work (especially those involving the use of cement) unless prepared to have weekly returns made of the operations as they are performed and thereafter to have patients questioned annually by circular from the registry”. He then went on to say, “Obviously this could be fiercely resisted as an encroachment on professional liberty but if the hip work from a general orthopaedic department is good there will be no grounds for dissatisfaction.

Only by a measure such as this would it be possible to decide whether special centres are doing better work than our general orthopaedic departments. The existence of scrutiny would be a powerful factor in dissuading consultants in general hospitals from allowing Residents to do this type of work unsupervised in the event of their unpredicted absence”3.

Charnley Chess The principle of ‘Charnley Chess’ is to consider the operation as a package (or game of chess) and bear in mind the potential adverse effects of innovation as well as potential benefits. New is not always better. Easy is not necessarily the best option.

There is a distinct role of the professional and regulatory bodies (the MHRA, NJR, BOA, CQC, NHS Improvement, Beyond Compliance and ODEP etc.) in improving introduction and surveillance of new orthopaedic technologies.

The Future Perhaps too much emphasis is placed on innovation of the implant instead of optimising the surgical procedure. Anand et al reported from the Australian Registry that of 33 new total hip arthroplasties, 23 were the same as older systems and 10 were worse.4 Registry experience suggests that outcomes can be improved by providing feedback to organisations and individual surgeons. In the short to medium term, it is these improvements in delivery of service and risk management of patients that is likely to be more important than innovation of implants. n Martyn Porter is the National Joint Registry’s Medical Director and Vice Chairman, appointed by the Department of Health from 1 February 2014. He is a Consultant Orthopaedic surgeon based at Wrightington Hospital, Lancashire, a past-President of the British Orthopaedic Association (BOA) and immediate past-President of the International Society of Arthroplasty Registers (ISAR).

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

Volume 06 / Issue 01 / March 2018

1954

Page 48

boa.ac.uk

Harry Platt becomes President of the RCSEng

Fraud and Cyber Crime Don McBride Fraud and cyber-crime cost the global economy an estimated £73 billion every year and some of you may already have been victims.

The various ways used by the criminals are:

Vishing – Contact made

by telephone, with the caller purporting to be from your bank, the police or a fraud agency etc.

The purpose is to get you to reveal information they need.

Phishing – Contact made by

email, the sender impersonates a well-known company or colleague/friend. The purpose is to get you to click on a link or open an attachment.

Smishing – Contact is made

by text message, the sender impersonates well-known companies – often banks. They may refer to a suspicious activity on an account. The purpose is to get you to click on a link or phone a telephone number.

Malware – Malicious software such as Trojans or viruses.

Downloaded from phishing emails, illegal websites, ad banners etc. Financial malware sits quietly in the background until you access a UK online banking service.

Don McBride

In order to minimise your own risk of being a victim of fraud or cyber-crime here are a few basic steps to follow:

1. Only pay expenses you are expecting and know about.

2. Only make payments based on an invoice or claim substantiated by receipts.

3. Consider the language used in emails requesting payment of claims.

4. If unsure, always contact the company or colleague using independently sourced contact details. For colleagues consider using your BOA handbook.

5. If you are asked to change bank details always check this instruction using independently sourced contact details. Even when you receive the request on what appears to be legitimate or letterheaded paper.

6. Never disclose security details, such as your PIN or PASSWORD – It is never okay to reveal these details.

7. Do not assume an email request or caller is genuine.

People aren’t always who they say they are.

8. Do not be rushed - a genuine bank or organisation will give you time to stop and think.

9. Listen to your instincts - if something feels wrong then it is usually right to pause and question.

10. Stay in control, have confidence to refuse unusual requests for information.

At the BOA 2017 Annual Congress, Helen Potts from NatWest gave a lecture on Fraud and Cyber Crime; it was a late addition to the programme. If you missed it you can find the information sheets NatWest provided on the BOA website congress.boa. ac.uk/liverpool-2017. We will also be inviting them to give another presentation at our 2018 Annual Congress, so look out for this in the programme.

Additional websites for help and support are: Take Five: www.takefive-stopfraud.org.uk Get Safe online: www.getsafeonline.org.uk Action Fraud: www.actionfraud.police.uk Financial Fraud Action UK: www.financialfraudaction.org.uk IBM Trusteer Support: www.trusteer.com/ protectyourmoney - free security software to use in addition to your existing antivirus and firewalls) Know Fraud No Fraud: www.bba.org.uk/publication/ leaflets/know-fraud-no-fraud A useful website for you to check your email address is www.haveibeenpwned.com which lists any breaches on your email address account. n Don McBride is a Consultant Orthopaedic Surgeon at the University Hospital of North Midlands. He was previously the Chairman of the Scientific Committee and President of BOFAS and at present is a co-opted Council Member acting as liaison with EFAS. Don was formerly the Honorary Treasurer and currently the Vice President Elect of the BOA.

Calibrated Femoral Tibial Spreaders Bhargava Modified Meniscal Clamp

Helps separate the femur and tibia during total knee replacement surgery

Low-profile design helps facilitate grasping the posterior portion of the meniscus Designed by Tarun Bhargava, MD

PRODUCT NO:

Grooved Pads

Diamond Cut Pads

Coated Pads

1886

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Small with Grooved Pads

Small with Coated Pads

Small with Round Pads

Medium – 10"

Medium with Grooved Pads

Medium with Speed Lock & Grooved Pads

Medium with Round Pads

Speed lock modification designed by Nasim A. Rana, MD PRODUCT NO’S:

Stulberg Leg Positioner Designed by S. David Stulberg, MD PRODUCT NO:

Provides stable positioning of the knee during surgery

2620

Offset Osteotomes Designed by Paul Lotke, MD, (all models), Adam Rosen, DO (Wide only), and Douglas Dennis, MD (Dennis only)

Designed to remove osteophytes from the posterior femoral condyles during knee arthroplasty

SMALL – 7" 1850 [Small w/Grooved Pads] 1850-D [Small w/Diamond Cut Pads] 1850-01 [Small w/Coated Pads] 1865 [Small w/Round Pads] MEDIUM – 10" 1855 [Medium w/Grooved Pads] 1855-D [Medium w/Diamond Cut Pads] 1855-SL [Medium w/Speed Lock & Grooved Pads] 1866 [Medium w/Round Pads] LARGE – 12" 1860 [Large w/Grooved Pads]

Large – 12"

Large with Grooved Pads

Scott Femoral Tibial Tensor/Spreaders

Used to help properly tense the medial and lateral ligaments and help assure a stable, balanced flexion gap Designed by Richard Scott, MD US Patent #8,162,951 B2

Wide

Lotke

Dennis

PRODUCT NO’S:

PRODUCT NO’S:

4920 [Wide] 4935 [Lotke] 4935-W [Dennis]

Profile of Wide and Lotke Osteotomes

1995 [Narrow Fixed Pads] 1996 [Wide Fixed Pads*] 1997 [Wide Block Pads] 1998 [Round Pads]

*Pad Modification Designed by Raymond H. Kim, MD

Profile of Dennis Osteotome

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Volume 06 / Issue 01 / March 2018

1959

Page 50

boa.ac.uk

Publication of BOA Memorandum on Accident Services

How I Do... Application of

a dynamic external fixator for PIP joint injuries Grey Giddins Indication

Mechanics

Technique

Primarily complex comminuted fractures of the base of the middle phalanx of the fingers, i.e. dorsal fracture-subluxations or pilon fractures.

The construct works by distracting the joint correcting some malalignment and allowing rotation about the axis of rotation of the head of the proximal phalanx (Figure 1).

The centre of rotation of the head of the proximal phalanx is marked on the skin guided

by II. The proximal K wire is passed through the centre of rotation of the head; it should be perpendicular to the long axis and not malrotated (Figure 2); this is a reasonably forgiving construct and can cope with some mal-alignment.

Aim Restoration of a reasonable gliding surface of the base of the middle phalanx.

a

a

Surgical setup Ideally under local anaesthetic with no tourniquet, giving one dose of perioperative antibiotics and using an image intensifier (II).

I use 1.1 (1.0-1.2) mm K wires.

b

Grey Giddins

Figure 1a, b: Radiographs of a fixator applied to a PIP joint pilon fracture.

b

Figure 2a, b: Bending of the distal wire after initial passing of the wires.

The distal wire is inserted in the distal part of the middle phalanx perpendicular to the long axis; it is often easiest to put it in the proximal end of the middle phalanx head. The distal wires are bent at right angles, 3-4mm proud of the skin.

The most complicated manoeuvre is creation of the Z or S shape used to ensure distraction (Figure 3); it can be done with short or long Z’s or S’s. The Z or S bend should be a little more proximal than the proximal wire, i.e. aiming for a little over distraction; it is easy to reduce the distraction but difficult to increase it. If the over-distraction is not achieved, the distal wire needs to be removed and a new wire re-inserted. The elasticity of the 1.1mm K wire helps avoid excessive over distraction.

When the frame has been shaped and applied to the proximal wire it will bow; the frame is retained by putting a hook on either side of the proximal wire (Figures 3 and 4).

The tips of distal wire should also be bent to prevent the frame dis-engaging.

The construct is reviewed on II ensuring the wires are in bone and the joint is distracted, but not over distracted (≤ 2-3mm) (Figure 1). Dressings need to be minimal.

Volume 06 / Issue 01 / March 2018

1959

Page 51

a

boa.ac.uk

Her Majesty Queen Elizabeth the Queen Mother becomes BOA Royal Patron

a

Follow up

b

Review within one week with check radiographs.

Ensure that the patient understands the need to mobilise and is by physiotherapists. I re-review a week later. If they are not making progress then injection of local anaesthetic and encouragement of movement can be helpful. I remove the frame in the clinic at four to five weeks post-operatively.

Outcome b

A range of between 10 and 90o in the PIP joint with only some mild ache with the heaviest of use and in cold and wet weather with good long-term function.

There is typically some joint stiffness and some loss of grip strength. This is however, a complicated injury and when it goes badly the results can be very poor. n

Figure 3a, b: The frame in vitro.

Figure 4a, b: The frame applied to a little finger.

Grey Giddins is an Orthopaedic Hand surgeon. He has particular interests in the non-operative management of hand fractures and minimally invasive techniques for managing hand trauma and elective and post-traumatic hand problems. He is immediate past President of BSSH and currently runs a research programme in the Centre for Orthopaedic Biomechanics at the University of Bath.

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Volume 06 / Issue 01 / March 2018

1962

Page 52

boa.ac.uk

The BOA is recognised as a registered charity by the Inland Revenue

Operations I no longer do...

Open ankle arthrodesis Stephen Bendall Fusion for ankle arthritis is one of the two main surgical options for end stage ankle arthritis. There are several techniques described.

In the Surrey and Sussex area the ‘RAF fusion’ was popularised by John Crawford Adams amongst others. His paper was published almost 70 years ago in the JBJS(Br) and describes a transfibular approach, which allows access to the joint to prepare the joint surfaces. The fibula is then used as an on lay graft, being secured to the tibia and talus with screws. This was followed by rigid immobilisation – by which Crawford Adams meant a plaster until union, which took on average 13 weeks.

Crawford Adams explained that the name is an acknowledgement that the procedure emerged from the orthopaedic service of the Royal Air Force. The paper goes on to describe “that service was

characterised by a magnificent team spirit in which exchange of ideas was so constant that to this day none of us knows with certainty who first conceived the brilliant idea of this simple and effective operation”. What a wonderful working environment!

In the early to mid 1990’s there were early reports of minimal access ankle fusion and then arthroscopic ankle fusion. Steve Parsons, in Cornwall, and Ian Winson, in Bristol, were among the first to present this new technique in the UK.

I was introduced to the RAF technique during my training on the South West Thames training circuit at St Peter’s Hospital.

By a strange coincidence the consultant who taught me this technique was himself shown it by my father, who was a consultant orthopaedic surgeon at St George’s Hospital.

I wasn’t an earlier adopter of arthroscopic ankle arthrodesis but finally took the plunge and haven’t looked back. I was worried about access but even with a 4.5mm arthroscope it was easy. The set up was very comfortable – I no longer needed an assistant. I used a power burr to prepare the joint surfaces (Figured 2 and 3).

My fixation remained the same.

The operation was quicker and the biology seemed different with some patients uniting around 9 to 10 weeks.

So, armed with this I set off to consultant practice in Sussex.

I found the RAF fusion to be effective, but it required a significant exposure. The access to the ankle was good, but you required an assistant. It was time consuming. I adapted the technique using two cannulated screws to compress the fusion site but still used the fibular strut graft (Figure 1).

Over time, with experience and increasing confidence I dropped the use of a thigh tourniquet and tackled significant deformities and even revisions arthroscopically. I was inspired and encouraged by others around me. It was an exciting time – maybe not quite as intense as CrawfordAdams’ ‘magnificent team spirit in which exchange of ideas was so constant’ but pretty close.

The experience also served as a platform for the minimally invasive movement that arose in my sub-specialty a decade later and continues today. n Stephen Bendall is a Consultant at the Princess Royal Hospital in Sussex. His area of interest, apart from trauma, is foot and ankle surgery. He was an Examiner at the FRCSOrth examination and has also been involved as Training Programme Director. In 2014, Stephen was the President of British Orthopaedic Foot and Ankle Surgery Society (BOFAS).

References Figure 2: Ankle arthroscopy.

1. Gougoulis et al Arthroscopic Ankle Arthrodesis FAI 28 695706 2007.

2. J Crawford Adams Arthrodesis of the Ankle Joint JBJS 30B 3 506-612 Aug 1948.

Stephen Bendall

Figure 1: Modified RAF ankle fusion.

Figure 3: Preparation of surface with burr.

Volume 06 / Issue 01 / March 2018

1968

Page 54

boa.ac.uk

1200 Members of BOA

Improving Quality of Care and Reducing Length of Stay for Hip Fracture Patients Janet Lippett Sixty-five thousand people a year sustain a hip fracture in the UK. Many of these are elderly and frail with multiple medical co-morbidities, complex rehabilitation and discharge needs1. Traditionally care was provided by orthopaedic surgeons who lacked the medical skills to care for these patients. Care of frail older people is something geriatricians thrive on and applying the principles of Geriatric Medicine to Hip Fracture patients improves the quality and outcome of care. This subspecialty of Geriatric Medicine is known as Orthogeriatrics2, 3.

Whilst the delivery of Orthogeriatric care varies it should provide the key components of medical optimisation pre-operatively, input into decisions for conservative and/or palliative management, peri-operative care, leading the multidisciplinary rehabilitation team and completing fall and bone health assessments to prevent future falls and fractures4.

Janet Lippett

Orthogeriatrics was initiated by Lionel Cosin, a surgeon, who in the 1940s operated on hip fracture patients and noted that the post-operative mobilisation resulted in patients returning home whereas previously they remained bed ridden or died from

complications of immobility.

The first Orthogeriatric collaboration is credited to Professor Michael Devas and Dr Bobby Irvin in Hastings in 1957. They advocated surgery and early mobilisation for all but the sickest patients2, 5.

The idea was slow to catch on until a number of key national reports were published, including the RCP Hip Fracture Report6, National Service Framework (NSFs)7 and SIGN guidelines.8 These told of poor care and outlined potential improvements. The ‘blue book’ a joint venture between the BOA and British Geriatrics

Society (BGS) was published in 2007 stating standards for good Hip Fracture Care.9 In 2007 The National Hip Fracture Database (NHFD) started and units were able to see, in real time, their outcomes. There is now an annual report which continues to show improvements in hip fracture care1, 10.

So we have national standards11 and well documented models of care4 but how does this work on the ground12?

Before 2005 Orthogeriatric care at the Royal Berkshire Hospital (RBFT) was ad hoc. The length of stay for Hip Fracture Patients was 44 days. A liaison service commenced with patients identified by the orthopaedic team and referred to a geriatrician who was employed for two sessions a week. This led to a modest reduction in length of stay and identified further need. A business case for a full time Orthogeriatrician was developed. The author commenced her post in 2007. Armed only with national guidance, opinion and enthusiasm she set about finding allies. A steering group comprising orthopaedic surgeons, geriatricians, anaesthetists, therapists, nurses and managers was

Volume 06 / Issue 01 / March 2018

1972

Page 55

established. This group had one thing in common; a passion for improving the care of hip fracture patients.

We developed guidelines for good care including an A to Z guide to pre-op optimisation for frail older people, an integrated care pathway, falls assessments and guidelines for osteoporosis. Daily ward rounds with all NOF patients being seen pre-operatively from Monday to Friday and a weekly MDT, chaired by the Orthogeriatrician, to facilitate complex discharge planning.

boa.ac.uk

Introduction of an annual instructional course for trainees

entered all patients. We could see how we were doing. More importantly, when changes to the pathway were made we could see their effect. The benchmarking facility also enabled negotiation with the trust for investment13.

The length of stay reduced from 44 to 17.7 days, 85% of patients got to theatre within 48 hours, 99% of patients had falls and bone health assessments and there was a significant reduction in mortality to below national average.

The NHFD has proved However, many patients still invaluable as an audit tool. waited more than four hours We were an early adopter and to get to the ward and more Cygnetic_BOA_Congrats_qtr_page 14/02/20

ns ir tio the y a l tu on sar gra BOA iver n Co he ann t to 00th 1

When Best Practice Tariff was introduced in 201014, 15, 16 we achieved it in over 70% of patients. There were still areas for improvement and a transformational change was needed. Bed reconfigurations within the Trust allowed us to

establish a Hip Fracture Unit.

This unit takes patients direct from ED under Orthogeriatric care. We also agreed to take non-operative fracture patients (e.g. upper limb, pubic rami) and latterly amputee patients from our vascular tertiary centre. This unit commenced work in 2015.

The length of stay reduced from 19.3 to 15.2 days. Similar reductions have been noted by other units with this model of care16. The number of patients mobilised on day one post-operativley increased from 54.3% to 91%. Mortality and pressure ulcers reduced.

We also introduced other

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Therefore, we developed a fast track protocol to quicken patients’ care. A golden patient policy ensured that a patient for the trauma list was identified the night before so that surgery could commence promptly. Whilst not always a NOF this optimised list usage and reduced the risk of cancellation.

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ANNUAL CONFERENCE 7th - 8th November, 2018 MANCHE STE R ◆ It's 30 years since the BTS was founded ◆ Are you involved in patient care: from the point of injury to rehabilitation? ◆ Then join us at our 30th Anniversary Conference: contribute and celebrate!

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Volume 06 / Issue 01 / March 2018

1976

Page 56

boa.ac.uk

First one-year BOA presidency, John Fairbank

We continue to look for new ideas to improve care. Patients often wait on the ward for community rehabilitation. An application to the CEO transformation fund proved successful and an Early Supported Discharge (ESD) pilot commenced in 2017. This has further reduced LOS to 14.1 days.

initiatives such as monitoring bays for perioperative patients, a weekly antimicrobial round with microbiology and social dining for patients. 98% of our patients would recommend the unit in the Friends and Family Test (FFT).

We continue to look for new ideas to improve care. Patients often wait on the ward for community rehabilitation.

An application to the CEO transformation fund proved successful and an Early Supported Discharge (ESD) pilot commenced in 2017. This has further reduced LOS to 14.1 days. We have also identified that those with minimal care needs can be given the confidence to manage at home a few days earlier if taken home by the ESD team.

Despite its 70-year pedigree and evidence of impact, a number of units still struggle to provide Orthogeriatric care1.

Units are reporting a reduction in Orthogeriatric sessions and difficulty recruiting to consultant posts. The annual RCP survey shows that 50% of advertised geriatric medicine consultant posts went unfilled last year17. This is unlikely to be resolved quickly so role

substitution must be explored.

Anaesthetists, non-training grade doctors, physician associates, nurses and allied health professions can all play a part in Orthogeriatric care.

The national network within Orthogeriatrics is strong and support can be offered to those with less experience.

The NHFD website18 has a number of pathways and guidelines available for use online.

To summarise how we did it: we took a group of likeminded individuals passionate about hip fracture patients, developed and redeveloped models of care, spotted opportunities, measured outcomes to prove effectiveness, did a lot of hard work and had a little bit of luck.

I would like to thank my colleague Dr Apurba Chatterjee who shared my vision and passion from the start and continues to develop the service driving high standards.

Also the members of the original hip fracture steering group, recent colleagues and all the staff on the Hip Fracture Unit. This work has been a true multidisciplinary effort and could not have been achieved without us all. n

Janet Lippett trained at St Georges Hospital, London qualifying in 1999; and went on to complete her postgraduate training in Geriatric Medicine.

She developed an interest in Orthogeriatrics as a senior registrar and took up a post at the Royal Berkshire Hospital in 2007 to set up an Orthogeriatric service. Within a few years this service was rated within the top 10 by the National Hip Fracture Database. Recently she has moved into clinical management enabling her to take her enthusiasm for service development to a wider arena.

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

Volume 06 / Issue 01 / March 2018

1980

Page 58

boa.ac.uk

Executive Committee re-titled ‘Council’ of BOA

Coding in the NHS from procedure to payment using HRGs: A quick guide David Sands Johnson Co-authors: Paula Monteith and Pete Chambers When completing a procedure, coding may seem unimportant, however it is vital; not least as it ensures that the hospital, and in the end you, are paid. In the NHS clinical coding underpins payment, planning, risk adjustment and outcomes assessment.

The coding systems have been previously described1. The diagnostic codes (ICD 10; 5th edition has > 12,000 codes) and procedural codes (OPCS 4.8 has > 10,000 codes) are vital descriptors of the clinical aspects of a patient’s care, but are too numerous to inform a payment or planning system. Therefore, in England the Casemix system was developed using Healthcare Resource Groups (HRGs) to record information in manageable numbers, that is clinically meaningful and can be generated from available data to allow resource allocation.

David Sands Johnson

In 2007 HRG4 was developed to calculate the cost of care using a reference cost system.

In 2009 HRG4 was used to facilitate Payment by Results (PbR) now called the National Tariff Payment system. It was separated into chapters (Chapter H – Musculoskeletal System) and subchapters (HA – trauma; HB – non trauma; HC – spinal

conditions; HR – reconstruction), and individual HRGs (e.g. HB21C - Major Knee Procedures for NonTrauma without comorbidities), where significant procedures would trump diagnostic codes, otherwise the primary diagnosis would be used. Account was taken of additional procedures and secondary diagnoses, such

as comorbidities, which could escalate one or two increments within an HRG. Then, as is now the case, payments were allocated to the assigned HRG for each spell of care. Trusts submit coding and other data (including demographics, admission type and length of stay) to the Secondary Uses Service (SUS).

This data is then processed by an HRG grouper. How payment is allocated to HRGs lies out with the remit of this article, but is determined with input from NHS England (NHSE), NHS Improvement (NHSI) and each HRG Chapter Expert Working Group (EWG) which is coordinated

by NHS Digital (NHSD), which was formerly the Health and Social Care Information Centre (HSCIC) (Figure 1).

Figure 1: Information and payment flows in the NHS.

Volume 06 / Issue 01 / March 2018

1984

Page 59

The HRG system was never expected to be perfect and ongoing work, with involvement of the relevant EWGs, has been put in place to resolve any anomalies detected by the National Casemix Office (NCO) within NHSD. Many issues are resolved by reassigning an ICD/OPCS code combination to different HRGs or by the creation of new OPCS codes. However, it has become apparent that not all can be accounted for with this system, for example complex procedures undertaken for differing diagnoses in the presence of multiple comorbidities.

Thus, a revised version was developed which resulted in the phased implementation of HRG 4+. This has seen an increase in HRG sub-chapters (51 to 81) and total HRGs (1673 to 2782). Trauma and orthopaedics was included in April 2017. In addition, there has been a reorganisation of the subchapters, especially within T&O, to separate out trauma and elective work based upon diagnosis, rather than the method of admission to hospital (Table 1).

boa.ac.uk

First sub-specialty societies affiliated to the BOA

So what’s the fuss about HRG4+?

l Put patient details / date on every page l Preferably type notes, but otherwise write clearly - especially operation notes l Ensure guidelines are followed for writing operation notes3

Since 2009, HRG coding has been primarily driven by the dominant procedure code, which usually placed an episode of care in a base HRG, sometimes being elevated by one or two increments if comorbidities were present.

Therefore, in 2016/17, for example, a primary total knee replacement would generate a payment of between £5556 and £7518 in three increments. The increments depended on the presence or absence of comorbidities.

In HRG4+ there has been a drive to make payments more equitable, whilst retaining the total funding of all secondary healthcare and the differentials between each Chapter. Thus in 2017/18 a primary total knee replacement generates payments without comorbidities of £5528, increasing in five increments to £8231. In the updated system the increments are easier to attain and payments should cover the additional costs of care; for example, a patient with rheumatoid arthritis with

bone loss requiring a more expensive implant. Thus, as long as a case has been coded correctly the HRG4+ payment should cover the cost of care.

This is an improvement on the previous system which relied on ‘an average’ cost. The old system worked well in a hospital performing all procedures across multiple Chapters, but could fail in those hospitals providing specialist or single Chapter services.

What is the surgeon’s role?

Sub-chapter

HC

HD

HE

HN

HT

VA

Area

Spinal all

MSK / Rheum

Ortho disorders

Non trauma

Trauma

Multiple trauma

Procedural HRG’s

39

0

0

110

87

0

Diagnostic HRG’s

35

35

84

0

0

24

Age splits

P

O

P

P

P

O

CC splits

P

P

P

P

P

O

Intervention splits

P

P

P

O

O

O

Multiple procedures

P

O

O

P

P

P

Procedure combinations

P

O

O

P

P

P

Diagnosis qualified

P

O

O

P

P

P

Subsidiary procedures

P

O

O

P

P

O

LoS qualified

P

O

O

P

P

O

Table 1: Summary of T&O related HRG Sub-chapters2.

l Ensure all diagnoses / procedures are written out in full l Ensure important detail is included – for example bone grafting, use of imaging l Do not use abbreviations l Enter all co-morbidities on every admission; coders can only look at the current admission l Enter diagnoses rather than results - for example morbid obesity rather than BMI of 41 l If infection is present then record the causative organism l Do not enter ‘?’ diagnosis, if unsure describe the symptoms / findings l Ensure good dialogue between you and the coding department l Undertake regular audit of random cases / cases known to be miscoded frequently Table 2: Steps to improve coding.

This brings us back to the surgeon completing a procedure. The coders have very strict rules. The principle is that if the information is not in the notes then it cannot be coded. Assessing coding accuracy is difficult, but there is no doubt that Trusts which code correctly are less likely to run into financial difficulties. There are simple ways to improve coding accuracy (Table 2).

Some diagnoses/procedures, such as revision procedures, have a higher rate of miscoding.

Furthermore some codes, for example diagnostic arthroscopy, should appear rarely and others should not appear at all (UZ01Z – data invalid for grouping paying £0).

These codes can be audited.

In summary, HRG coding may seem an artificial system of coding, but it is the one that has been mandated to drive planning and payment in the NHS in England. Therefore, all surgeons have a duty to ensure that the coding of our cases is completed accurately. n David Sands Johnson is a Consultant Orthopaedic Surgeon (knee surgery) at Stockport NHS Foundation Trust. He currently represents the British Association for Surgery of the Knee on the Chapter H HRG Expert Working Group co-ordinated by the National Casemix Office at NHS Digital.

References 1. Clinical coding explained.

Kulkarni R. JTO 2015,3(4);32.

2. HRG4+ 2017/18 Engagement Grouper V1.0.

National Casemix Office, HSCIC. July 2016.

3. Good Surgical Practice.

2014. The Royal College of Surgeons of England: www.rcseng.ac.uk/library-andpublications/rcs-publications/ docs/good-surgical-practice.

Volume 06 / Issue 01 / March 2018

1986

Page 60

boa.ac.uk

First Advanced Instructional Course for Consultants

A simple guide to the complex process of developing a yearly NHS tariff Ro Kulkarni Co-author: Jonas Akuffo The previous article in this issue by David Johnson has clearly explained the basis of the latest HRG4+ system and the importance of correct coding. In essence, data is submitted for every procedure that is performed in our hospitals and that data is used to map all procedures to an HRG.

Each of these HRGs carries a predetermined tariff or fee, which is the remuneration for the service we provide.

Tariff values are set by a complex process each year and published nationally by NHS Improvement (NHSI). In simplistic terms the amount the hospital gets paid for each procedure is determined by the tariff set for HRG that the procedure maps to. This article will try to explain how the yearly tariff is set and what factors can have a significant influence on the final tariff.

Ro Kulkarni

The whole process of tariff setting is extremely complex

and involves a number of steps and policies to ensure consistency and accuracy in the final tariff. It also follows a strict time scale as commissioners and health boards need this information early for budget planning. This process is managed by the NHS but involves inputs from many other organisations including NHS Digital (NHSD), NHS England (NHSE) and the Expert Working Groups (EWGs).

Figure 1 illustrates the big picture. Inputs from reference costs, HES activity data and other sources (Specialist top ups etc) are all put into the mix.

These costs then go through a process of modelling, validation, correction, adjustment and then are published for national public consultation. Finally, after the consultation queries are all dealt with, the final tariff for the following year is published.

Figure 2 shows a more detailed pathway of tariff development.

I look at the development of tariff as a two pathway process. The main process is driven by input from numerous experts including economists, data scientists and financial modellers who all contribute in the tariff production process. This may ensure that the tariff is robust (i.e. the numbers all add up) and there is consistency in the way it is calculated. However, this does not guarantee that the right money is paid for the right procedure, as it is heavily reliant on the data inputs. This is where the work of the EWG and the BOA is crucial to then translate the finance/economists view into clinical practice. It maybe that the tariff for a total knee replacement HRG was

Volume 06 / Issue 01 / March 2018

1989

Page 61

boa.ac.uk

First publication of British Orthopaedic News (BON)

and hearing aid fitting and maintenance etc. Nonmandatory currencies can be used as a contracting unit and the prices can be used as a guide or starting point for local negotiation. NHSI sometimes use non-mandatory prices to send a signal to the service that we anticipate being able to bring the service within the mandatory list in due course.

Figure 1: Simplified Tariff Calculation Process.

Some activities are excluded from the tariff and remain subject to local prices rather than mandatory tariff. There are various reasons for this including: l Those services outside the

determined by the process to be ÂŁ3000 but clinically it is impossible to deliver this surgery for such a price.

Clinical input is now needed to clarify the reasons for the price relativity gap and to correct the tariff relativity where it does not make sense. Therefore engagement between these two paths is critical in arriving at a tariff that is sensible but does not bankrupt the exchequer.

In addition to mandatory tariffs which must be used by all commissioners when commissioning services, NHSI also publish non-mandatory currencies and prices.

Examples include non-face to face outpatient contacts

scope of reference costs are by default outside the payment system.

l Some services either

have not yet had currencies developed for them or do have currencies but the costs associated with them are not considered robust.

l Some drugs are typically

specialist and their use concentrated in a relatively small number of centres rather than evenly spread across all providers that carry out activity in the relevant HRGs. They would not be fairly reimbursed if funded through the tariff.

l Some medical devices

represent a high and disproportionate cost relative to the cost covered under the relevant HRG. Tariff prices are based on the weighted average of cost of services reported by all NHS providers in the mandatory reference costs (RC) collection and Hospital Episode Statistics (HES) data. The reference cost collection predates the introduction of the tariff and the tariff is therefore calculated using the reference costs of all NHS organisations. It is therefore clear that if reference costs are not reflective of the true cost of delivering services

The Economists pathway: The National Tariff Payment System (NTPS) is the payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient’s healthcare needs.

The mandatory national tariff is payable by commissioners for day cases, ordinary elective and non-elective admitted patient care, outpatient attendances, some outpatient procedures, some direct access services, and A&E attendances carried out by NHS trusts, NHS foundation trusts or independent sector providers.

Figure 2: Stages in Calculating the Tariff (simplified). >

Volume 06 / Issue 01 / March 2018

1990

Page 62

boa.ac.uk

Publication of ‘The management of trauma in Great Britain’

The whole process of tariff setting is extremely complex and involves a number of steps and policies to ensure consistency and accuracy in the final tariff. It also follows a strict time scale as commissioners and health boards need this information early for budget planning. then it is likely that tariff based on these costs is also going to be incorrect and not adequate for service delivery. In contrast, some other countries with tariff systems which do not have a comprehensive reference cost collection use a sample of providers for development of payment tariff. The reference costs are, however, filtered to remove services outside the scope of the tariff and any extreme outliers (the general rule is less than one twentieth of, or greater than twenty times, the national average). Reference costs are collected for Finished Consultant Episode (FCEs) but the admitted patient tariff is paid on a spell basis.

A summary of key steps producing the tariff are outlined below: 1. Pre-processed prices - Main steps for Admitted Patient Care and Outpatients includes data cleansing of the underlying reference cost, Market Forces Factor (MFF) removal from the reported costs, Finished Consultant Episode (FCE) HRGs to spell conversion HRGs, High cost drugs and device exclusions and Short stay emergency adjustment.

2. Reference costs reconciliation factor – A step to adjust the prices so that the total quantum is equal to the tariff base year underlying reference costs target (i.e. cost reflective price)

3. Cost base adjustment - To adjust prices for what’s in and out of scope of the national tariff.

4. Indexation adjustments - To adjust prices from base year reference costs data collected to prices on an applicable tariff year basis. There are three factors that are used for the impact assessment (IA): inflation, efficiency and (clinical negligence scheme trusts) CNST 5. Manual adjustments reconciliation factor - Prices are then manually adjusted (e.g. following feedback from EWGs and tariff engagement document feedback). This adjustments reconciliation factor involves adjusting prices so that the total quantum is equal to the quantum of total prices before manual adjustments.

6. Top slice factors adjustments – This includes certain high cost drugs and devices used in some clinical procedures that are excluded from the tariff payments and are paid for separately, the NHS Injury Costs Recovery Scheme (ICRS) aims to recover the cost of NHS treatment where personal injury compensation is paid and specialist services topups payments.

7. Smoothing factor - To account for significant changes in the tariff at different levels in relation to both price volatility and revenue volatility management.

8. Scaling Factor - To reconcile the total adjusted modelled prices quantum for models to a counterfactual quantum.

9. Prospective adjustments To adjust prices to applicable financial year basis. The tariff adjustment is used to turn historic costs into prospective prices. Three years of adjustments are used in the calculation in line with the lag between reference costs year and the tariff year.

10. Publication of both the statutory consultation prices and final prices

The clinical pathway: The EWG engages early in the process to try and iron out problems. Our remit is to try and get a reasonable tariff for all HRGs that will allow hospitals to provide a service that is safe to patients. We study the draft prices produced by NHSI and NHSE and validate every HRG looking at a number of factors including: l The HRG4+ system is

designed that there is a relativity scale across all chapters. So for example, a major HRG is paid more than an intermediate HRG which in turn is paid more than a minor HRG. A simple and obvious principle yet relativity errors are common. Our first step is to correct any such errors and make sure the relativity scale makes sense.

l We try to make sure that

there is consistency across the subchapters. So similar procedures across hands,

elbows, knees etc are paid the same – injections for example.

Of course if clinically indicated, for example due to a longer length of stay, the tariff will differ. l HRG4+ has a very

granular logic for escalation due to complications and comorbidities (CCs). Once again, we try to ensure that the increase in the tariff with increasing CCs is consistent across subchapters and adequate for the complexity levels.

l The EWG also looks at

activity data from the reference costs and HES to ensure that there have not been any mapping errors. This would be where a procedure is in the wrong HRG and therefore is under or over paid. We try to ensure that the right money goes to the right place.

l The bulk of our work every

year is to ensure that the tariff for each HRG is sustainable.

By working with a set of guiding principles we look at each HRG and its price. Mistakes in prices are corrected by a process of manual adjustment.

This is where we work within the quantum available in the chapter and move money around. Essentially we play a game of rob Peter to pay Paul and try to get the best spread of prices. With a constrained available quantum this has become a very challenging task as there will always end up some HRGs being winners and others being losers.

Volume 06 / Issue 01 / March 2018

1993

Page 63

Why is it that we continue to have a number of challenges with tariff?

Despite a lot of effort on everyone’s part, tariff prices continue to cause a lot of debate and angst among clinicians on a yearly basis. The reasons for this are numerous.

Unlike most other chapters that have a straightforward and consistent logic to their HRGs chapter H Orthopaedics is rather unique and complex.

This is particularly so because of our subspecialties and the differences between subspecialties. Furthermore, orthopaedics has unique factors that have a significant

boa.ac.uk

BOA 75th Anniversary: ‘The History of the British Orthopaedic Association’

by William Waugh published. 2600 Members of BOA

effect on the tariff. These include prosthetic implants, theatre time, rehabilitation etc.

Therefore normal rules that would be applied to most other chapters will not translate easily into orthopaedics. This is where the EWG works hard to ensure that our unique factors are taken into consideration whilst determining tariff.

The methodology of arriving at tariff also has some issues due to the underlying data that are constantly being reviewed and improved.

These have an impact on tariff setting and include inconsistencies in cleaning methodology, application of scaling and smoothing factors

implementation and lack of flexibility across HRGs, chapter and sub chapters.

The starting point for creating a tariff is submitted reference costs or PLICS data (Patient Level Information and Costing Systems) where possible.

Unfortunately, these costs have been of very poor quality for years and hence it has been difficult to get an accurate tariff.

It is no surprise when trusts have submitted reference costs as varied as £500 for total hip replacement or £50,000 for a day case total hip replacement performed in A & E that the actual tariff calculation is made very difficult. The current rules of tariff sometimes do not allow

for the exclusion of poor costs reported by NHS providers and hence all-comers have to be considered. It must be said that over the last few years there has been an improvement in the reference costs collection but we are not there yet.

However, the biggest challenge facing us is the size of the piece of cake that is available for chapter H Orthopaedics or our eligible quantum under the scope of the tariff. The quantum is set within the core NHS mandate and has remained a key financial challenge over the past few years.

In 2017, the task of delivering orthopaedic services was made very difficult due to a significant decrease in quantum available for Orthopaedics. Creating a tariff with a constrained available budget often leads to winners and losers.

What can we do As a group we all need to ensure that each of our hospitals submit real and good data in reference costs that will make the process much easier. This means getting the coding right and following all the rules set out by David Johnson in the previous paper.

From a EWG and BOA point of view, we are continuing our strategic engagement with the Department of Health to ensure that we are provided the correct funds to develop a tariff which allows us to provide an excellent and safe orthopaedic service. n

Table 1: Issues in stages in calculating the tariff.

Rohit Kulkarni is a Consultant Orthopaedic Surgeon specialising in shoulder and elbow surgery at the Aneurin Bevan University Health Board, Newport. He is currently the Chair of the Chapter H Orthopaedic Expert Working Group and is also the BOA Tariff Lead.

Volume 06 / Issue 01 / March 2018

1995

Page 64

boa.ac.uk

Rodney Sweetnam becomes President of the RCSEng

The Fracture Non-Union Cell Theory Stefan Bajada Co-author: James B Richardson Several theories have been proposed to explain the development of fracture non-union. In this article a cellular theory which, integrates the known mechanical and biological factors leading to the development of cell senescence is discussed.

Fracture non-union cellular biology The bone marrow contains a subpopulation of highly proliferative multi-potent cells, called Bone Marrow Stromal Cells (BMSC)1, 2, 3. A vital step in fracture healing is the recruitment of these progenitor cells, which proliferate and differentiate to become osteoblasts which deposit a mineralised extracellular matrix at the fracture site - osteogenesis.

This process is regulated through multiple signalling molecules - osteoinduction. We have reported the isolation of a different progenitor cell type from human fracture non-union which we termed Non-Union Stromal Cells (NUSC)4. This cell was found to exhibit cell senescence.

Stefan Bajada

Senescence is a permanent state leading to cells losing the ability to divide, with an arrest in the transition phase G1-S of the cell cycle5. This develops in most somatic cells following a finite number of cell divisions

and results from both telomere independent and telomere dependent factors. The latter is associated with a shortening of chromosomal telomeres6.

Senescence is thought to be one of the mechanisms involved in ageing and the development of musculoskeletal pathology7, 8.

Proliferation of cells plays a key role in fracture healing and is normally coupled with apoptosis. On the other hand, cell senescence may impair normal healing as senescent cells have a low proliferative ability and are resistant to apoptosis.

In addition, they secrete Matrix MetalloProteases (MMPs) and are proinflammatory9,10.

Non-union stromal cells exhibit reduced osteoblastic differentiation which is associated with increased secretion of significantly elevated levels of Dickkopf-1 (Dkk1), a Wnt signalling inhibitor4. These observations are consistent with the emerging role of Wnt signalling in the regulation of osteogenesis and fracture healing11. Wnt proteins are a family of secreted proteins that regulate many aspects of cell growth, differentiation, function, and death. Wnt proteins promote bone morphogenetic protein (BMP) mediated osteoblastic differentiation12. Thus, NUSC are likely to inhibit osteogenesis even following BMP administration and therefore limit its therapeutic value. In addition, senescent

Figure 1: a) Non-union stromal cells (NUSC) in culture exhibiting multiple stress fibres and a cuboidal shape indicating senescence. b) Culture expanded NUSC and c) non-union tissue showing positive staining for beta-galactosidase (blue cells; some arrowed); a marker of cell senescence. d) NUSC after osteogenic differentiation showing alkaline phosphatase staining (pink/red cells), a maker of osteoblastic ability.

Volume 06 / Issue 01 / March 2018

1997

Page 65

boa.ac.uk

BOA becomes a Company Limited by Liability; new Constitution and Rules published

cells show cytoskeletal changes which make them less responsive to therapy which improves a fracture’s mechanical environment13.

Figure 2: Non-union stromal cells (NUSC) cell senescence alters local biology through decreased osteogenesis and suppression of osteoinduction. These cells are also poorly responsive to mechanical stimulation.

Fracture non-union cell theory This theory is based on the following tenets: 1. At the local tissue level, progenitor cells are the ultimate determinants of union through osteogenesis and osteoinduction.

Figure 3: The known risk factors of delayed union including systemic, local and biomechanical factors.

They individually and summatively induce cell senescence, leading to established non-union.

Figure 4: The theory at work. Patient A is a healthy patient with adequate mechanical stimulation. Union occurs as senescence levels are not reached. Patient B is a smoker and has lower telomere length with senescence levels leading to delayed union. However, he recovers due to adequate biomechanical stimulation of healthy cells. Patient C is a smoker and diabetic with an open fracture. Therefore, increased cell proliferation and telomere shortening is required to replace lost haematoma and bone loss. He reaches critical senescent levels and therefore develops established non-union.]

2. Abnormal cellular function with cell senescence leads to a switch from bony union to fibro-cartilaginous non-union.

3. This switch is triggered when a mass of senescent cells accumulates at the fracture site leading to altered function of adjacent nonsenescent cells through paracrine signalling.

Established nonunion develops when this ‘critical senescent level’ is achieved.

4. Mechanical factors combine with systemic and local factors to alter the rate at which this critical senescent level is achieved.

Cell theory at work The starting point of fracture healing is the engraftment of resident and circulating progenitor cells at the fracture site. The ‘health’ of these cells at the start of fracture healing is important. Diabetes, smoking, nutrition and age all contribute to non-union14, 15. There are also known, factors which induce cell senescence in other tissues. There is also a genetic and epi-genetic contribution which determines senescence levels even before the injury.

A patient with any of these factors will be more likely to achieve a ‘critical senescence level’ during fracture healing.

It is also known that patients with open fractures, bone defects and inadequate fixation with a large fracture gap have a higher chance of non-union16. This higher rate of non-union is probably resultant on the higher number of cell divisions required to bridge the defect. Each cell division leads to telomere shortening and cell stress, which increases cell senescence. The role of altered biomechanics in delayed fracture union is well described by Perren’s strain theory17. Excessive strain is known to induce senescence. This may also make the cells less responsive to biomechanical stimulation, such as micromovement18, or improvement of the biomechanical environment with revision surgery.

Treatment options based on theory Cell theory offers opportunities for further basic science research and therapy. Currently we do not know if or how to reverse cell senescence causing fracture non-union. Possible therapies include the addition of healthy cells with BMSC implantation or bone marrow or bone grafting to redress and

balance the senescence levels19.

Novel pharmacological therapies are also possible, for example with the use of sclerostin and Dkk-1 neutralizing antibodies (anti-Dkk-1)20.

Optimising the biomechanical environment is important to prevent non-union, but in vitro studies are required to assess if senescent cells recover in such an improved environment. Early cyclic micromovement is well established to improve fracture healing, and animal studies support reduction of micromovement after callus formation.

Thus, in normal fracture healing the timing of movement is more important than the amount of movement. The DynamiseReverse-Dynamise sequence needs to be brought into practise if found optimal then perhaps the number of non-unions due to senescence can be avoided21.

This would induce cell proliferation to a point before senescence develops, with the added stiffness avoiding further cell stress. n Stefan Bajada is currently a Knee Fellow at the Exeter Knee Reconstruction Unit. He obtained his CCT in Trauma and Orthopaedics with the Wales Deanery and has completed a PhD in Biomedical Engineering with Keele University, based at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. His thesis focused on regenerative medicine techniques in fracture non-union.

Since the publication of the article, James B Richardson unexpectedly passed away. His obituary will appear in the next issue.

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

Volume 06 / Issue 01 / March 2018

1998

Page 66

boa.ac.uk

50th anniversary of the Journal of Bone and Joint Surgery (B)

The Physician Associate in Trauma and Orthopaedic surgery Karen Daly and Jeannie Watkins The Physician Associate (PA) is an emergent and rapidly growing health professional group in the UK. Physician Associates are specifically trained using the medical model to provide care for patients. They work in a variety of medical specialties across primary and secondary care as part of the team. This article aims to give a clear overview of the profession, their education and training, and consider the benefits and impact the role can have, particularly in Trauma and Orthopaedics.

What is a Physician Associate (PA)?

The PA is a new breed of healthcare professional. They are one of four existing roles that are grouped under the heading of ‘Medical Associate Professions’ (MAPs). The other three are: l Surgical Care Practitioner (SCP) l Advanced Critical Care

Practitioner (ACCP)

l Physicians’ Assistant

(Anaesthesia) (PA(A)).

The PA has been defined as: Karen Daly

Jeannie Watkins

‘a new healthcare professional who, whilst not a doctor, works to the medical model, with the

attitudes, skills and knowledge base to deliver holistic care and treatment within the medical team under defined levels of supervision’.1 Physician Associates are able to practice medicine through delegated authority from their supervising doctor under the General Medical Council delegation clause2. Although dependent practitioners, they can work autonomously in providing medical care for patients. Whilst this is a reasonably new profession in the UK (over 10 years old) it is well established globally, particularly in the USA where the profession is almost 50 years old with over 100,000 certified PAs 3 and 200 PA programmes.

More detail about the specific skills of the PA can be found on the Faculty of Physician Associates (FPA) website.4 Physician Associates are already part of the extended surgical team5 in several surgical specialties including some Trauma and Orthopaedic departments. They are also seen as part of the alternative supporting workforce which is required to support trainees in the Improving Surgical Training pilot6 that has been commissioned from the Royal College of Surgeons of England by Health Education England.

Volume 06 / Issue 01 / March 2018

2004

Page 67

Education, Training and Assessment The Department of Health in conjunction with the Royal College of Physicians and the Royal College of GPs, in consultation with 300 other bodies, developed the Competence and Curriculum Framework for the Physician Assistant1 (now renamed Physician Associate). This document provided the foundation for the PA profession setting the minimum standards for education and training and specified the range of competencies expected of a PA at the point of qualification. The first established PA programmes in the UK opened in 2008.

Physician Associate students are mainly life science graduates.

boa.ac.uk

Ian Ritchie becomes first orthopaedic surgeon President of the RCSEdin

They undergo a two year intensive clinical medical education programme covering the breadth of common and important conditions seen across a range of medical specialties. Students develop a sound knowledge base in clinical medicine and develop comprehensive clinical examination skills which form the basis of their general medical education, enabling them to enter work in any medical specialty.

Once PAs successfully complete their University Programme they are then eligible to undertake the PA National Examination to enable them to enter into professional practice. As of September 2017 there are 29 PA programmes in the UK. By the end of 2018 there are likely to be 30 to 35 programmes running.

It is estimated that by 2020 there will be 2500-3000 qualified PAs working in the NHS. According to the FPA 2017 PA census7 there are an estimated 1650 PAs (450 qualified PAs and up to 1200 students) mostly employed in secondary care, across a range of specialties.

The average salary for a PA in the UK is around £37,364.

Post Qualification Continuing Professional Development (CPD) and Assessment Once qualified, PAs are required to maintain 50 hours of CPD per year and recertify every six years across the breadth of medicine. They must pass

the recertification knowledge based exam in order to continue to practice. It is essential that any department that employs PAs should be providing regular appraisal and supporting them to meet these requirements and facilitate personal development for individuals. This will help with recruitment and retention.

Governance for PAs The FPA is the professional body representing PAs working in all specialties and has the following responsibilities: l Accreditation of PA

programmes

l Continuing Professional

Development (CPD).

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Volume 06 / Issue 01 / March 2018

2007

Page 68

The UK and Ireland University Board for PA Education (UKIUBPAE) brings together Universities with established or pending PA programmes.

The purpose of this Board is to enable programmes to share good practice and advance PA education and develop PA educators.

Why do we need PAs? The PA model has been adopted in the UK in response to the medical workforce crisis; changes to junior doctors’ training, changes to immigration laws and to manage the impact of the European Working Time Directive.

It has also been developed in a bid to meet increasing public expectations for choice and access to care, an ageing population with multi-morbidity and increasing frailty, creating increasing acute and long-term health needs. These issues have accentuated service gaps, which despite the best efforts of other existing healthcare professionals just cannot be filled.

In the five year Forward View8 NHS England sets out how it will deliver the changes that the NHS needs in order to future proof the service and provide for the needs of the population. Part of the solution is to look at the skill mix and develop new models of working and invest in a workforce that can be flexible to meet the needs. It also aims to radically alter the way in which the workforce is trained and plans to ensure it does not lock itself in to outdated models of delivery9.

What is the role and what are the benefits of a PA to the Orthopaedic department?

PAs can admit elective and emergency patients, provide consistent ward cover including

boa.ac.uk

Joint Action adopted as formal fundraising arm of the BOA

out of hours and weekends, assist with the preparation of MDT meetings, liaise with other specialties such as geriatric medicine, carry out preoperative assessment, participate in discharge planning, produce summaries and make referrals to other hospital and community teams. With additional training they can participate in theatre lists as assistants and also learn practical skills, such as casting and minor surgery/ wound closure.

Employing PAs will support the training of Surgeons particularly by facilitating trainee attendance at operating lists. As surgical assistants PAs can enhance training by removing the need for trainees to be first assistant for major procedures enabling high quality interaction between trainer and trainee. Employing PAs, as an alternative workforce, can help address the increasing costs of medical locums.

It is important for any department to evaluate the current service needs and then decide which professional is best placed to deliver them, ensuring that the patient sees the right person at the right time with the right skills. The PA can work well with the whole team to complement what already exists and deliver excellent patient care. Having a varied skill mix over a range professional groups can enhance continuity of care, quality of care and patient flow.

What are the challenges for PAs in Secondary Care?

As stated above PAs carry out a number of different roles and a range of duties in secondary care, depending upon the needs of the department. However there are limitations to the role. Physician Associates are not yet a regulated

group and as such they are unable to prescribe and to request investigations involving ionising radiation. Both of these limitations could be overcome with the advent of statutory regulation. The Department of Health are currently undertaking a consultation on the regulation of MAPs (which includes PAs) with a view to producing recommendations on the regulation of these groups.10 Postgraduate training and career development, whilst it occurs, is not clear or standardised across the UK for PAs. This can make it challenging for departments to know how to develop the PA workforce to address specific local needs, whilst helping PAs to maintain their generalist requirements for recertification and to enhance recruitment and retention.

Karen Daly is a Paediatric Orthopaedic Surgeon and Associate Medical Director at St Georges University Foundation Trust in South West London.

She has been a core TPD and Associate Head of School with a QA portfolio. She is Vice Chair of the SAC in T&O and an elected member of BOA Council.

Conclusion

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

Physician Associates are definitely part of the solution to the medical workforce crisis and it is clear that this role has a lot to offer in secondary care.

The number of PA programmes and consequently qualified PAs is rapidly expanding across the country with demand for the profession currently outstripping supply. Physician Associates can improve the care of patients and support the medical workforce through increasing the skill mix; increasing access for patients and reducing the locum spend. The PA role is not a replacement for any other member of the secondary care team and should not be considered as a threat to other professional groups. The key to the role flourishing is in the regulation of the profession and once this happens PAs can work to their full potential and make a significant difference in supporting the medical workforce. n

Jeannie Watkins is a UK trained Physician Associate (PA) who qualified in 2007and has worked as a PA in acute medicine and primary care. Jeannie is a Senior Lecturer on the MSc in PA Studies at St George’s University of London and President of the Faculty of Physician Associates at the Royal College of Physicians.

References

Best performing cementless hip combination in the UK*

*According to the 5 years results in the 13th Annual Report 2016 of the National Joint Registry (England, Wales and NI)

™Trademark of Smith & Nephew

Supporting healthcare professionals

Volume 06 / Issue 01 / March 2018

2008

Page 70

boa.ac.uk

Claire Marx becomes the first Lady President of the BOA

The Business of Orthopaedics Olivier Bohuon The global hip and knee implant market is worth approximately ÂŁ11 billion. There are four large global companies. Market share has hardly moved in the last ten years, other than as a result of acquisitions.

Behind this stable front is a dynamic sector facing up to the twin challenges of helping customers (healthcare professionals who choose which product is right for their patient) respond to great cost pressure, whilst also delivering innovations to provide better outcomes for their patients and hence deserve a premium.

Our marketplace is driven by longer-term trends The major trends that drive the markets in which Smith & Nephew operates have remained consistent for many years. Ageing populations and people living more active lives, together with obesity and other lifestyle diseases, all contribute to the rising demand for governments to provide healthcare.

Olivier Bohuon

According to the World Health Organisation (WHO), between 2015 and 2050 the proportion

of the world’s population aged over 60 years will nearly double from 12% to 22%. In 2014, the WHO estimated that more than 1.9 billion adults were overweight. Of these, over 600 million were classified as obese, a major risk factor for musculoskeletal disorders.

Additionally, the WHO estimates that by 2020, people aged 60 years and older around the world will outnumber children younger than five. This changing age distribution will significantly reduce the level of tax raised to pay for healthcare, whilst demand for healthcare increases.

As a result, providers are under pressure to look for ways to reduce their overall healthcare expenditure, whilst maintaining the quality of care and treatment provided.

Healthcare reform is near the top of many national agendas.

An Evolution in Collaboration Driven by a need to address these trends, the global orthopaedic market is undergoing an evolution in the way customers analyse and select products.

Instead of the shift from surgeon-led purchasing to admin-led purchasing many predicted, the market is adopting a more complex, collaborative process focused on value analysis. In many places hospital value analysis committees or tender boards now manage the customer buying process, with the surgeon and administration agreeing and aligning on implant selection. The committees are seeking solutions that improve clinical outcomes for the patient, while reducing overall cost of care and minimising risks such as readmission and secondary interventions.

Industry is responding by seeking ways to transform from principally being an implant supplier to a value partner. For Smith & Nephew this means we must deliver solutions that accelerate patient recovery, reduce cost of care, and deliver superior patient outcomes and satisfaction.

Volume 06 / Issue 01 / March 2018

2010

Page 71

boa.ac.uk

JBJS(B) splits away from the parent body and becomes The Bone and Joint Journal

Innovating our business models In the UK, one of the most exciting areas we are focused on is the opportunity to improve patient pathways.

We believe that manufacturers can help providers, such as the NHS, meet the three great challenges of:

a

b

a) improving clinical outcomes in the face of increased patient morbidity and demand; b) optimising spend for the short-term benefit; c) optimising patient length of stay to reduce pressure on beds and improve productivity.

In orthopaedics we call this our Ortho Optimisation programme which is currently being successfully trialled. This programme has four phases: 1. Insights and audit – our clinical teams evaluate Hospital Episode Statistics (HES) and audit current pathways to identify problems and inefficiencies.

2. Pre-operation – we automate patient registration via a smartphone app and combine this data with logistics to optimise the surgical pathway for hospital and patient.

3. In surgery – we have reduced instrumentation and utilised software to improve efficiency and reduce errors. Appropriate wound care is applied if a need is identified in the preoperative assessment. Robotics assistance can further drive efficiencies and outcomes.

4. Post-surgery – the patient uses the app for virtual physiotherapy and Patient Reported Outcomes Measures (PROMS) assessments, improving compliance and completing the pathway.

Figure 1a: JOURNEY II XR, b: Smith & Nephew’s bi-cruciatiate retaining knee replacement

A differentiated product is worth a premium Our focus supporting providers to improve pathways does not mean that we have stopped innovating. There are still opportunities to disrupt and improve the status quo, be this in extending implant life, for example VERILASTTM; achieving greater patient satisfaction, for example the JOURNEYTM II knee; or making more complex procedures easier to perform.

Robotics One of the most exciting areas for Smith & Nephew is robotics, where we see great opportunity to improve outcomes, supporting customers by creating an intuitive and efficient operative

workflow, and reducing cost.

For example we have invested in the NAVIOTM robotic-assisted total knee replacement to deliver consistent and accurate implantation without the need for a preoperative CT scan.

A new partnership In conclusion, we embrace these opportunities to explore new ways of working with surgeons and those who manage and administer hospitals. Whilst the UK and the NHS are unique, the pressures to manage cost and meet patient expectations are global and we are proud to be at the forefront of developing innovative business models and products in conjunction with our customers to support sustainable healthcare in Orthopaedics for the long term. n

Olivier Bohuon holds a doctorate in Pharmacy (University of Paris) and an MBA from HEC (Paris). His career spans Roussel Uclaf, GlaxoSmithKline and Abbott, rising to President of its Pharmaceutical Division, and then CEO of Pierre Fabre. He became CEO of Smith & Nephew in 2011 and is a Non-Executive Director of Virbac group and Shire plc.

Volume 06 / Issue 01 / March 2018

2012

Page 72

boa.ac.uk

Final publication of BON, replaced by The Journal of Trauma and Orthopaedics

Psychosocial Aspects of Challenge and Threat Appraisal in Orthopaedic Training Dafydd Sion Edwards and Sumedh Talwalkar Co-author: James H Wilson Assessment of surgical training in the UK include surgical logbook analysis, Work Based Assessments (WBAs) and formal examinations. However, WBAs are open to variation due to the subjective nature of their application and grading.

Dafydd Sion Edwards

Sumedh Talwalkar

Biopsychosocial Models (BPSM) have been developed to aid training in stressful environments such as professional sports and the airline industry1, 2. The model describes situations where an individual will appraise a task as either a threat or a challenge, which will result in negative or positive cognitive, affective, physiological, and behavioral outcomes respectively3. Experience of the task, ability to cope and the task environment and support all contribute to the appraisal process. An individual will evaluate the demands of the task and

whether they possess the necessary resources to cope effectively with these4. An appraisal that results in the belief that an individual has sufficient resources to cope with the demands of a task (a challenge evaluation) perform better than individuals who believe they do not (a threat evaluation)4.

This study investigates the change in the appraisal outcome of Orthopaedic procedures during the course of specialty training using the BPSM.

Methods Orthopaedic trainees in the United Kingdom where asked to complete a BPSM based questionnaire detailing their grade and level of experience in the Orthopaedic index procedures. Trainees were asked to appraise each index procedure with respect to the perceived demand (demand score) and the ability to cope (resource score) out of a maximum score of 6 (1=not at all, 6=extremely) (Table 1).

Volume 06 / Issue 01 / March 2018

2013

Page 73

Imagine you are the lead/stand-alone surgeon of the following procedures 1. How demanding do you expect the case to be?

2. How able are you to cope with the demands of the following procedures? (Resource)

Table 1: The Demand Resource Evaluation Score questions asked for each index procedure.

A Demand-Resource Evaluation Score (DRES) was then calculated by subtracting the demand value form the coping score5.

The Student’s t-test was performed to compare the means of normally distributed continuous data, the ANOVA test for assessment of variance and Pearson’s correlation test for assessing the progression of training and the appraisal scores.

Regression analyses were performed to analyse the change from a negative to a positive DRES score. Statistical analysis was performed using SPSS

boa.ac.uk

Revised version of ‘Advisory Booklet for Trauma and Orthopaedic Services’ published

statistics Version 20.1 (SPSS Inc, Chicago, IL, USA). Significance level was set at p<0.05.

Results Eighty-four completed BPSM questionnaires were received.

Figure 1 demonstrates the increase in numbers of procedures performed at each grade of training. The ANOVA revealed that the total number of procedures significantly increased on a year on year basis (p>0.001).

When considering the change in DRES to the number of times each procedure was performed a positive correlation was seen in all index procedures (p<0.01).

A linear relationship (Figure 2) exists between the change in DRES and number of cases performed and the calculated change from a negative to positive DRES (intercept of the y-axis, DRES constant) occurred at a range from 4.96 procedures (External Fixation) to 41.65 (Knee Arthroscopy) (Table 2).

PROCEDURE

DRES Regression Constant (y intercept)

Indicative Cases Minimum Number

Carpal Tunnel Decompression (CTD)

9.243

30

Knee Arthroscopy (KAX)

41.651

40

Total Knee Replacement (TKR)

38.111

40

Total Hip Replacement (THR)

35.262

40

1st Ray Surgery (TOE)

22.175

20

Dynamic Hip Screw (DHS)

25.654

40

Hemiarthroplasty (HEMI)

20.185

40

External Fixation (Ex-Fix)

4.962

5

Ankle Open Reduction and Internal Fixation (ANKLE)

16.766

40

Tension Band Wiring of Olecranon or Patella (TBW)

5.588

10

Tibial Intra-Medullary Nailing (IM NAIL)

10.905

30

Tendon Repair (TENDON)

8.775

20

Table 2: The regression analysis findings to determine the y intercept (number of cases) at the point of transition from a negative to a positive DRES, compared to the minimum ‘indicative number’ required for completion of training.

Figure 1: A graph demonstrating the increase in numbers of procedures performed at each grade of training.

Figure 2: The linear regression graphs of the change of the Demand Resource Evaluation Score (DRSES) compared to the number of times a procedure is performed. Carpal Tunnel Decompression (CTD) and Total Knee Replacement (TKR) are illustrated. >

Volume 06 / Issue 01 / March 2018

2017

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boa.ac.uk

4700 Members of BOA

such as patient, assembled team, experience of the equipment, and global factors such as training and experience of the procedure.

Figure 3: A graph demonstration the linear regression relationship between the aggregate mean DRES and total number of procedures performed. The calculated intercepts between a negative and a positive DRES was 1047.2 operations.

A significant correlation was calculated between the aggregated mean DRES for all procedures and the total number of all procedures recorded in a trainee’s log book (p-0.005) and the level of training recorded by the trainee (p=0.001); the calculated intercepts between a negative and a positive DRES was 1047.2 operations (Figure 3) and a ST grade of 4.618.

Discussion The operating room can be a stressful environment clinically6.

Other stressors include the surgical team composition, equipment and time pressures.

Furthermore, social facilitation has been demonstrated to influence task performance.

Social facilitation refers to how the presence of others leads to performance facilitation when the task is simple or well-learned and to performance impairment when the task is complex5. The appraisal of the environment determines the biopsychosocial response to the procedure; it is

governed by an individual’s belief of how demanding a procedure might be and the whether they possess the required coping strategies. A challenge state will result in a ‘surgeon experiencing more favourable cognitive, affective, physiological, and behavioural outcomes’ when compared to a threat state5, 7.

A key component of this BPSM is the neuroendocrine and cardiovascular responses1. A challenge state is characterised by an elevated sympatheticadreno-medullary activity, increased epinephrine release.

In comparison, a threat state causes an increased pituitaryadreno-cortical activity resulting in excess cortisol release. This has been validated by means of experimental studies measuring physiological parameters, such as heart rate, blood pressure, skin temperature and cortisol level8. Furthermore poor surgical performance may arise when surgeons evaluate a stressful event as a threat6. Influences on the appraisal of the planned procedure include local factors,

The transition from a negative to a positive DRES can be argued to be the point the trainee feels capable of performing the task. However, a difference exists between capability and ability; capability is a measure of the extent of someone’s ability, while ability itself is an abject proficiency to perform a task. Capability can be measured with tools such as the DRES, whilst ability should be measured by subjective and object assessments such as work based assessments from a trainer, and outcome scores such as complications or patient reported outcome measures (PROMS). However, the DRES is a useful marker of the expected performance from a trainee9 compared to the indicative numbers of a procedure and to a trainee’s peers. This could demonstrate progression at an annual review of training and identify areas of further development.

Furthermore, the model could be used to evaluate an individual’s response to a training course, how long it lasts and where revalidation maybe required.

Conclusion This study demonstrated that in the context of experience with Orthopaedic index procedures a change in the DRES occurs with increased exposure to a procedure but also with increased seniority. The optimum time to perform an appraisal of a task is immediately before the task itself. If recorded, along with formal WBAs, then the change in DRES is a useful model for a trainer to guide their trainee as to the direction of required further training. n

Lt. Col Dafydd ‘Taff’ Edwards is a Military surgeon and Consultant in Trauma and Orthopaedics at The Royal London Hospital.

His sub-specialty interest is in Elective and Complex Trauma of the Hand, Wrist and Elbow. For his work detailed in this paper he was awarded the Wrightington Basic Sciences Research Prize and the Combined Services Orthopaedic Society Research Prize in 2017.

Sumedh C Talwalkar is a Consultant Orthopaedic Surgeon and the Clinical Director of Orthopaedics at Wrightington Hospital. He is on the specialist register for Trauma and Orthopaedics and specialises in the management of hand, wrist and elbow problems.

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

Volume 06 / Issue 01 / March 2018

Page 76

boa.ac.uk

JTO Features - Trainee Section

Promoting quality training and improving morale through a trainer-trainee dialogue and partnership Sarah L Gill Co-author: Donald M Campbell The current dominant discourse in relation to Trauma and Orthopaedic training centres on its ‘challenges’. It would appear that dissatisfaction reigns, morale is low and there is an ever-present call for reform and improvement. The tide needs to turn on how these issues are perceived and managed. It is not up to one organisation or group to find an answer; the solution lies in a shared trainee-trainer dialogue, an empowered partnership and promotion of the trainee role in training.

The commonly reported perspective of the current T&O trainee is preoccupied with the shackles of European Working Time Directive (EWTD), the hardships of the Intercollegiate Surgical Curriculum Programme (ISCP) and workplace bullying.

Sarah L Gill

The effect on surgical training of the EWTD (2009) has been well documented.1, 2, 3 It provided momentum for a paradigm shift from firm-based professional apprenticeships to shift-pattern work. The proposed solution was competency based training but the introduction of prescriptive and educationally-restricted workplacebased assessments (WBAs) via

ISCP is not without its issues.

Trainees report dissatisfaction with the ‘tick-box’ approach to training and the significant administrative burden only further detracts from time spent honing clinical skills.4 CCT requirements5 provide some standardisation of training and safe guards to competency but current trainees face pressure to jump ever-changing hurdles not imposed on the previous generation.

However, trainee representative groups have focused on publicising the effect of these changes on training, not their role in invoking change and improvement.6 The proposed remedy to these training ills is

to optimise training quality and, in the context of an everincreasing clinical workload, pressure on Consultant trainers is amplified. Consultant trainers are asked to provide first-class training to trainees seemingly more concerned with hours worked than proficiency.

The crude dissemination of the BOTA ‘Hammer it out’ census results in 2016 served to further perpetuate this emerging generational divide, between entitled trainee and ‘back-inmy-day’ Consultant trainer.7 The solution relies on shared discussion, mutual understanding and respect between the two halves of the training team, the trainer and trainee. After all, the most productive relationship is between two adults, not a parent and child.8

Figure 1: The Tayside Feedback Method.

Volume 06 / Issue 01 / March 2018

Page 77

In the East of Scotland rotation, we have introduced a feedback/ self-reflection model for trainers and trainees, emphasising the contribution both groups make to training and promoting cohesion and efficacy. In its

boa.ac.uk

mature form, this has become the Tayside Feedback Method.

This action-research project has two key outputs: the Consultant Trainer Profile (Figure 2) and the Tayside Trainee Charter (Figure 3).

Figure 2: Consultant Trainer Profile.

Figure 3: Tayside Trainee Charter.

Figure 4: Important trainer-identified trainee qualities and behaviours.

Starting in 2013, trainees completed anonymous feedback forms after each sixmonth post.

The 18-point quantitative questionnaire covers four training domains: WBA engagement, teaching/feedback, research/audit and operative training.

Free text space provided opportunity for qualitative feedback, highlighting training strengths and areas for improvement (trainee-trainer feedback).

Consultant trainers and trainees were asked to complete a one-off 18-point self-reflection questionnaire in relation to the four training domains and their own practices (trainer self-reflection/ trainee selfreflection). Trainers were asked about their expectations of and advice for trainees (trainertrainee feedback).

After every five cycles of trainee feedback (promoting honesty via data anonymity), individual Consultant Trainer Profiles are generated, allowing

comparison between trainergroup-average, trainerspecific-average and trainerself-reflection scores and communication of collated qualitative feedback. We performed individual analyses of each trainer’s feedback, highlighting interesting trends and the relationship between self and trainee perception.

This data provided basis for both individual trainer and department-wide service provision amendments, including protected trainee research time and out-patient clinic templates that provide opportunity for observed trainee consultations.

In 2016, we performed a thematic analysis of the trainertrainee feedback and identified 12 behaviours and attitudes that trainers repeatedly identified as important (Figure 4). This was shared with the trainee group and discussed in the context of the trainee self-reflection; the result was our Tayside Trainee Charter.

The charter defines our eight core values and around this we constructed very specific actions and standards. It’s owned by the trainees, is a good way to share practice and promotes the trainee role in training.

The Tayside Feedback system strengthens common ground between the trainee and trainer and formally recognises this training team. Following presentation at national meetings and the BOA Training Programme Director meeting in April 2017, the process of introducing the programme in several other regions has begun.

The results of both our local trainee feedback and GMC National Training Surveys (2017: 88.3%, rank 3/20) show that trainees in East of Scotland highly rate their training. In our region, trainers provide excellent training opportunities but we’re also supported in being the captains of our own training.9 Not all trainees see themselves as victims of the system and trainees should take their share

of responsibility for training10, seeking robust critique from themselves, peers and trainers.

Consultants should be aware of the demands of current training and held to high standards as trainers but also supported in this role by governing bodies, peers and trainees.

T&O continues to attract hardworking and motivated trainees who seek to emulate and surpass the high standards exemplified by Consultant trainers. As Kipling acknowledged, ‘the strength of the Pack is the Wolf, and the strength of the Wolf is the Pack’.11 Exercising our own agency for change is the most important tool in improving morale in Trauma and Orthopaedics. n Sarah L Gill is an ST7 Trauma and Orthopaedic Trainee in the East of Scotland Deanery. Her professional interests are major trauma and medical education.

She has been accepted as AO Travelling Fellow to Shock Trauma Center, Baltimore in 2017 and as Trauma Fellow in Queen’s Medical Centre, Nottingham in 2019.

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

Volume 06 / Issue 01 / March 2018

Page 78

boa.ac.uk

In Memoriam

Min Mehta

1st November 1926 – 23rd August 2017 Min H. Mehta was a remarkable spinal surgeon achieving world recognition for her pioneering research into the natural history and conservative management of Infantile Idiopathic Scoliosis.

She was one of the major players of her era, endeavouring to put Scoliosis care onto a scientific footing. She died peacefully at home on 23rd August 2017 at 90 years of age.

Min came from an established Parsi family in Calcutta, India.

Her childhood ambition had always been to study medicine.

In early adolescence, she discovered her own scoliosis which the family dismissed as postural and told her to sit up properly. She attended

Min Mehta

Medical School in Calcutta, developing an interest in surgery, for which she discovered a natural aptitude. After three years of local surgical training, she moved to Britain in the mid-1950s to gain further qualifications. Min considered a career in neurosurgery, but came to work in an orthopaedic unit with two well-established figures, Philip Wiles and John Batchelor. As a result she became intrigued by Orthopaedics, especially its spinal aspects. There were few female surgeons practicing in Britain at the time and her impressive credentials made her a pioneer.

Min started her research into Infantile Idiopathic Scoliosis in the 1960s with the opportunity to review large numbers of x-rays of children. In 1968, she was awarded the prestigious Robert Jones Prize and Gold Medal of the British Orthopaedic Association for her essay on ‘A Study of Infantile Scoliosis’. She

was the second woman to have achieved this, the first being Ruth Wynne-Davies for her work on the genetics of club feet. Min presented her work at the Belfast BOA Meeting in 1969 where it was highly acclaimed and published in the Journal of Bone and Joint Surgery (JBJS) in 1972.

Her hypothesis was that the natural history of the curve and its prediction for resolution or progression could be judged on the erect AP x-ray of the child’s spine with measurement of the Rib Vertebral Angle Difference (RVAD) between the concave and convex sides at the curve apex. This has become known internationally as the Mehta angle.

In 1969, Min returned to India to practise Orthopaedics in major teaching hospitals in New Delhi and Calcutta. However, in 1974 she was appointed Senior Lecturer in Clinical Research to the Institute of Orthopaedics,

at Stanmore and Honorary Consultant to the Royal National Orthopaedic Hospital. In 2005, the JBJS published the results of her long-term work on infantile curves, ‘Growth as a Corrective Force in the Early Treatment of Progressive Infantile Scoliosis’ which emphasised early detection by 18 months and serial cast treatment producing resolution of the curve after a mean three and a half years.

In 1980, Min became involved in a long-term follow up study of fused and unfused idiopathic scoliosis involving cohorts of those seen in the RNOH Scoliosis Clinic in the 1950s and early 1960s.

Min was a founding Trustee of the Scoliosis Association of the UK (SAUK). She was an Active Fellow of the Scoliosis Research Society of the USA and a Trustee at ARISE - the Scoliosis Research Trust. She was in great demand as a speaker both in Europe and across the USA. Min was a delight socially and maintained a wide circle of friends outside the medical world especially in her local community of St Margaret’s, Twickenham. She enjoyed concerts, book clubs and tennis at Wimbledon. Min was as determined as she was charming and became a much revered and unique figure of her generation, one not to be forgotten. n

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. Full obituaries will appear in the next issue.

Gunabushanam Krishnamurthy Tim O’Brien James B Richardson

Volume 06 / Issue 01 / March 2018

Page 79

boa.ac.uk

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13th Trauma & Orthopaedics Update

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different specialities: orthopaedics, anaesthetics, critical care and pain, radiology, plastic surgery, dermatology and general practice.

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include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees.

Each day concludes with a lecture of general interest by an eminent guest speaker.

We have an excellent orthopaedic faculty lined up and the programme when confirmed will be available at www.doctorsupdates.com.

Volume 06 / Issue 01 / March 2018

Page 80

boa.ac.uk

Imprint

JTO: Information for readers, advertisers & potential authors

JTO Editorial Team l Phil Turner (Executive Editor) l Rhidian Morgan-Jones (Editor) l Vittoria Bucknall (Trainee Section Editor)

BOA Executive l

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Ananda Nanu (President) Ian Winson (Immediate Past President) Phil Turner (Vice President) Don McBride (Vice President Elect) John Skinner (Honorary Treasurer) Deborah Eastwood (Honorary Secretary)

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Ananda Nanu (President) Ian Winson (Immediate Past President) Phil Turner (Vice President) Don McBride (Vice President Elect) John Skinner (Honorary Treasurer) Deborah Eastwood (Honorary Secretary) Stephen Bendall Karen Daly Bob Handley John Skinner Mark Bowditch Lee Breakwell Simon Hodkinson Richard Parkinson Peter Giannoudis Rhidian Morgan-Jones Hamish Simpson Duncan Tennent

Registered Charity No.1066994 Company limited by guarantee Company Registration No.3482958

BOA Staff Executive Office Interim Chief Operating Officer ................................... Justine Clarke Personal Assistant to the Executive ........................ Celia Jones Education Advisor ........ Lisa Hadfield-Law

Policy & Programmes Programme Director ............... Julia Trusler eLearning Officer .................. Silvia Bianco

Communications & Operations Director of Communications & Operations ........................ Emma Storey Interim Director of Communications & Marketing .................... Annette Heninger Membership & Governance Officer ........................ Natasha Wainwright Marketing & Communications Officer ...................................... Emily Farman Publications Officer ................ Anami Kabir

Finance Director of Finance ���������������������������Liz Fry Deputy Finance Manager ...... Megan Gray Finance Assistant ������������������Hayley Oliver

Events & Specialist Societies Director of Events Management ....................... Hazel Choules Events Manager ...................... Charlie Field Exhibition Manager �������������������Janet Mills Events Administrator �������Venease Morgan UKSSB Executive Assistant .... Henry Dodds

Instructions for authors Authors wishing to submit a news item, feature article or peer-review article for the JTO should, in the first instance, submit a synopsis of 120 words explaining what the article is and its relevance within the JTO. This should be emailed to JTO@boa.ac.uk. This will then be passed on to the Editorial Team for confirmation that the subject matter will be appropriate for publication. You will receive an email from the JTO team indicating their decision. In some cases the Editorial Team will request to see the full article based on the synopsis.

This, however, does not guarantee publication. The JTO does not publish audits or case reports. To have an article printed in the journal, you must be a BOA member.

Word Limit

News stories should be no longer than 250 words. Articles about Specialist Society meetings should be no longer than 250 words and must include an image. We welcome short In Memoriam pieces about past fellows of the BOA. These should be no longer than 250 words and should include a photo. Feature articles and Subspecialty articles should be no longer than 1,500 words. Please be aware that the Editorial Team reserves the right to reduce the content where appropriate.

References are not included in the word count but will be included separately on the BOA website in the JTO section and will not be included in the print version of the journal. References should be supplied in the Oxford Referencing format.

Images

All articles should include images, illustrations, graphs, tables etc. where possible – this is strongly encouraged. These, however, should not be embedded into the article but should be sent as separate image files to the JTO team with clear file names pertaining to figure numbers or the image title. An indication within the article should identify where the image should be inserted.

The article should state a short title/ caption for each image.

Please note that it is the responsibility of the author/s to obtain permission from the copyright holder to reproduce figures or tables that have previously been published elsewhere.

Important items to note

You must submit with your article and images; a photo of yourself and a short bio in the third person (no more than three sentences).

You will be sent a Copyright Form following your article submission and this should be returned by email (signed, dated and scanned) to JTO@boa.ac.uk or posted to JTO Team, BOA, 35-43 Lincoln’s Inn Fields, London WC2A 3PE.

Future publications JTO is published quarterly.

How to subscribe If you’d like to subscribe to future issues either for yourself or your organisation, we’d be happy to add you to our mailing list; please contact us at JTO@boa.ac.uk Please note all issues are free of charge.

Download the App Search for JTO@BOA to download the JTO App on App Store or Google Play.

Copyright Copyright© 2018 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

Advertising All advertisements are subject to approval by the BOA Executive Board.

If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C Regent Court, 68 Caroline Street Birmingham B3 1UG E. inside@ob-mc.co.uk T. +44 (0)121 200 7820

Disclaimer The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication. Readers are warned to take specific advice or make individual assessments to deal with specific cases or situations. Health professionals should be aware that ultimately it is their responsibility to make their own professional judgements.

Special thanks We are grateful to the following for their contributions to this issue of the Journal: Nick Birch, Vittoria Bucknall, Mark B Davies, Michael Edgar, Chris Heywood, James Wilson-MacDonald, Stuart Mathews, Tim Morley, Andrew Ransford and Panos Thomas.

BOA contact details The British Orthopaedic Association 35-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507 Fax: 020 7831 2676

2018

UK & Ireland Education

Introductory Course for Foundation Doctors & Undergraduates

Jan 21

Dublin

Basic Principles of Fracture Management for Surgeons

Jan 22-25

Dublin

Basic Principles of Fracture Management for ORP

Jan 23-25

Dublin

Paediatric Course for Surgeons

Feb 7-8

Leeds

Introductory Course for Foundation Doctors & Undergraduates

Mar 4

Edinburgh

Basic Principles of Fracture Management for Surgeons

Mar 5-8

Edinburgh

Shoulder & Elbow Course with Anatomical Specimens

Mar 19-21 Newcastle

Foot & Ankle Reconstruction

Apr 16-18

Bristol

Current Concepts & Periprosthetic Fractures

Apr 25-27

Coventry

Wrist Course

Jun 4-5

Bristol

Introductory Course for Foundation Doctors & Undergraduates

Jun 24

Leeds

Basic Principles of Fracture Management for Surgeons

Jun 25-28 Leeds

Advanced Principles of Fracture Management for Surgeons

Jun 26-29 Leeds

Advanced Principles of Fracture Management for ORP

Jun 27-29

Management of Facial Trauma for Surgeons May 2-3 Stratford-Upon-Avon Basic Principles in Cranio-maxillofacial for ORP May 3-4 Stratford-Upon-Avon

Principles Level Specimen Course for Surgeons Jan 26-27 Belfast

Leeds

Pelvic Course

Sept 3-5

Bristol

Hand Fixation Course

Oct 1-3

Leeds

Introductory Course for Foundation Doctors & Undergraduates

Nov 11

Basingstoke

Basic Principles of Fracture Management for Surgeons

Nov 12-15 Basingstoke

Basic Principles of Fracture Management for ORP

Nov 13-15 Basingstoke

Advanced Techniques in Small Animal Fracture Management. Oct 14-16 Oxford Principles in Small Animal Fracture Management Oct 14-16 Oxford

Transforming Surgery - Changing Lives Contact: For full course listings, course information and online registration visit:

www.aofoundation.org AOUK & Ireland Tel: +44 1707 823300 Email: info.gb@ao-courses.com

For current news and course alerts follow us on Facebook & Twitter: 'AOUK Education' '@AOUKEd'

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