Journal of Trauma & Orthopaedics - Vol 7 / Iss 1

Page 1

Journal of Trauma and Orthopaedics Volume 07 | Issue 01 | March 2019 | The Journal of the British Orthopaedic Association |

Service Transformation in Trauma and Orthopaedics p22

Updated Certification guidelines in T&O p24

Revalidation: an evidencebased intervention? p44


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Journal of Trauma and Orthopaedics


In this issue...

3 5


From the Editor

Phil Turner

BOA Vice President Elect

Kapil Kumar & Mark Bowditch

A Medical Student’s Experience

From the President: Preparing for the challenges ahead

Bob Handley

8-9 Latest News 10-20 News 16 News: The NICE Guidance for

the prevention of venous thromboembolism in adults – Good, Bad, Ugly or all three

XL Griffin

18 News: Conference listing 20 News: BOA Membership Update 22 Service Transformation in

Trauma and Orthopaedics

Phil Turner

24 Updated Certification (CCT)

guidelines in T&O 2018

WG Ryan & Mark Bowditch

26 The Emotional Side of Surgery

Alison Moulds, Agnes ArnoldForster & Simon Fleming


28 Improving

Surgical Training (IST) in T&O surgery - Our future workforce needs you now!

Bob Handley

30 Trauma and Orthopaedics:

Chris Thornhill

40 Medico-Legal:

the enthusiasm

31 Medical students: capturing

David Ricketts

32 Achieving and maintaining 72-hour

new fracture clinic BOAST 7 standard by multiple audit cycles with associated service improvement strategies

Amit Bidwai and Morshed Abir

34 Operations I no longer do...

Sashin Ahuja

for Minimally invasive Periacetabular Osteotomy

35 How I use… The Image Intensifier

Marcus Bankes & Vasanth Eswaramoorthy

delivered in Trauma and Orthopaedic training posts

36 Assessing the quality of training

John Davies, Amy Morgan, Clare Carpenter & Ryan Trickett

Early Diagnosis of Pyogenic Spinal Infection

James Wilson-Macdonald & Nicholas Todd

Trainees maintaining a healthy work-life balance

42 Trainee Section:

Matthew Brown

44 Subspecialty Section:

Revalidation: an evidence based intervention? (A personal view)

Derek Burke

48 Subspecialty Section:

The Role of the Responsible Officer in the Independent Sector

Charlotte FJ Rayner

52 Subspecialty Section:

Revalidation in Orthopaedics

Lee Breakwell

54 In Memoriam

Download the App The Journal of Trauma and Orthopaedics is the official publication of the British Orthopaedic Association (BOA). This peer reviewed journal is the only publication that reaches T&O surgeons throughout the UK and every BOA member worldwide. The journal is also now available to everyone worldwide via the JTO App. Read the latest issue and past issues on the go, with an advanced search function to enable easy access to all content and peer reviewed articles. Download the JTO App now to your smartphones and tablets through the Apple App Store and GooglePlay – search for JTO @ BOA. JTO | Volume 07 | Issue 01 | March 2019 | | 01




Basic Principles of Fracture Management Jan 21-24, 2019. Dublin

Advanced Principles of Fracture Management for ORP Jan 22-24, 2019. Dublin

Introductory Course for Undergraduates Jan 25, 2019. Dublin

Paediatric Course

Feb 6-7, 2019. Leeds

Introductory Course for Undergraduates Mar 3, 2019. Edinburgh

Basic Principles of Fracture Management Mar 4-7, 2019. Edinburgh

Shoulder & Elbow Course with Anatomical Specimens Mar 25-27, 2019. Newcastle

Foot & Ankle Reconstruction with Anatomical Specimens Apr 2-3, 2019. London

Current Concepts Course with Anatomical Specimens Apr 24-26, 2019. Coventry

Introductory Course for Undergraduates Jun 23, 2019. Leeds

Basic Principles of Fracture Management for Surgeons Jun 24-27, 2019. Leeds

Advanced Principles of Fracture Management Jun 25-28, 2019. Leeds

Advanced Principles of Fracture Management for ORP Jun 26-28, 2019. Leeds

Basic Principles of Fracture Management for ORP Jun 28-30, 2019. Leeds

Hand Fixation Course Oct 7-9, 2019. Leeds

Principles in Small Animal Fracture Management May 19-21, 2019. Oxford

Wrist Fixation Course Oct 10-11, 2019. Leeds

Introductory Course for Undergraduates Nov 10, 2019. Wymondley

Basic Principles of Fracture Management Nov 11-14, 2019. Wymondley

Management of Facial Trauma (Principles Course) May 1-2, 2019. Stratford-upon-Avon

Management of Facial Trauma (Principles Course for ORP) May 2-3, 2019. Stratford-upon-Avon

Promoting excellence in patient care and treatment outcomes in trauma

Principles Course - Degeneration

and musculoskeletal disorders

Principles Course - Pedicle Screw Placement

Mar 29-30, 2019. Birmingham Nov 11, 2019. TBC

Credits JTO Editorial Team Bob Handley (Executive Editor) Rhidian Morgan-Jones (Editor) David Warrick (Medico-Legal Editor) Matthew Brown (Trainee Section Editor) Lee Breakwell (Guest Editor)

l l l l l

BOA Executive l l l l l l

Phil Turner (President) Ananda Nanu (Immediate Past President) Don McBride (Vice President) Bob Handley (Vice President Elect) John Skinner (Honorary Treasurer) Deborah Eastwood (Honorary Secretary)

BOA Elected Trustees l l l l l l l l l l l l l l l l l l l l

Phil Turner (President) Ananda Nanu (Immediate Past President) Don McBride (Vice President) Bob Handley (Vice President Elect) John Skinner (Honorary Treasurer) Deborah Eastwood (Honorary Secretary) Ian Winson Mark Bowditch Lee Breakwell Simon Hodkinson Richard Parkinson Peter Giannoudis Rhidian Morgan-Jones Hamish Simpson Duncan Tennent Grey Giddins Robert Gregory Fergal Monsell Arthur Stephen Edward Dunstan

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

- Lisa Hadfield-Law

Policy & Programmes Programme Director

- Julia Trusler

Communications & Operations Director of Communications & Operations

- Emma Storey

Interim Director of Communications & Marketing

- Annette Heninger

Membership & Governance Officer

- Natasha Wainwright

Online Examination Operations Project Manager

- May Elphinstone

Finance Director of Finance - Liz Fry Deputy Finance Manager - Megan Gray Finance Assistant - Hayley Oliver

Events & Specialist Societies Head of Events - Charlie Field Events Administrator - Venease Morgan Exhibitions & Sponsorship Coordinator

- Emily Farman

UKSSB Executive Assistant - Henry Dodds


Copyright© 2019 by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C


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 Email: | Telephone: +44 (0)121 200 7820


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.

BOA contact details

The British Orthopaedic Association, 35-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507

From the editor... Bob Handley


n this edition of the JTO the articles have grown together as stepping stones to form a pathway through a T&O life. The journey needs to be started; Chris Thornhill (page 30) describes how as a medical student a chance exposure to a subject met with enthusiasm may be the first step. However, the first line of the Emotional Side of Surgery (page 26) describes a stereotype of a surgeon, with declining competition for training posts we need to be wary of subconscious barriers and strive to change them. Once surgical ambition is apparent we should be able to nurture it, in potential changes to T&O training the opportunity and importance of early commitment by both trainee and the training system is recognised. The Updated CCT guidelines (page 24) then then give us the framework to produce a day one consultant in T&O. CCT completed and appointment gained we may prefer to ‘just get on with our job’, but change will continue. The discussion of the NICE VTE guideline (page 16) highlights how we may put ourselves in a position of having to accept change in a particular area of practice, but more importantly how by appropriate engagement we can influence and direct it. Phil Turner then looks in a stepwise fashion at how we may transform a whole service. Reflection and assessment of self should always have been part of a professional life. The formalisation of this process into revalidation seemed a logical step to provide a structure for the benefit of patients and profession. Whether these objectives have been or are likely to be achieved is explored in general and in relation to T&O (pages 44-53). The final step on the career pathway has been taken by some, and in this issue we pay our respects to them. One of those, Roger Checketts (page 54) takes us back to the first step on the path. He was the epitome of the orthopaedic enthusiast who if he spotted a spark of ability and desire in student or trainee could help ignite a career. n

JTO | Volume 07 | Issue 01 | March 2019 | | 03


Canada October 5–8, 2019

15Th World Congress of the International Cartilage Regeneration & Joint Preservation Society

Abstract Submission: Feb 15 – April 15, 2019

Mark your agenda! International Cartilage Regeneration & Joint Preservation Society

From the President

Preparing for the challenges ahead Phil Turner

We spent the last year celebrating our centenary anniversary. This is now a time to look forward to the challenges of 2019 and beyond. Given the political and financial climate, I doubt our professional lives will get any simpler and we need to plan ahead so that we can respond to the challenges.


s we pass through the winter period, we are expecting pressure on our elective bed capacity (see also p. 17). We must continue to ensure that our patients receive appropriate and timely treatment. Shortterm solutions such as transferring to the independent sector are not sustainable and we have to support the continued transformation of elective services into dedicated units or sites. We therefore welcome the NHS Long term plan recognition that “separating urgent from planned services can make it easier for NHS hospitals to run efficient surgical services” and the backing for hospitals pursuing this model. This will also protect our trainees’ experience and make their trajectory more predictable without short-term rota changes. Other parts of the recently published ‘Long term plan” have relevance for our speciality too. The importance of high quality care for musculoskeletal conditions is discussed, along with the fact that joint replacements “help people stay independent and yield important quality of life gains.” There is reference to the local NHS “being allocated sufficient funds over the next five years to grow the amount of planned surgery year-on-year, to cut long waits, and reduce the waiting list”. However, the implementation of this is unclear and we are concerned the focus will be largely on avoiding the particularly long waits (52 weeks or more).

There is coverage of issues of frailty although much less reference for trauma more generally. The reality overall, however, is that the NHS is expected to be underresourced in terms of finance and, more importantly, workforce. The impact of Brexit remains unclear, but there is little doubt that a career in the UK is already much less attractive for our extended team. The enthusiasm to tackle the issues of limited numbers of staff by developing digital technology seems misplaced. Artificial Intelligence to interpret diagnostic imaging is likely to be safe and useful. Consultations by Skype may be appropriate for some specialties as demonstrated by the growth of ‘teledermatology’. However, I find it impossible to envisage assessing a patient without examining them or being able to pick up their anxieties and concerns without seeing their responses by their body language or fleeting expression. The Association is engaged with all those involved so we can keep our patients’ care at the

“We must not shy away from talking to politicians or taking on adverse or ill-informed publicity in the media. Our members and patients should expect and deserve no less.”

forefront of our strategy. We must not shy away from talking to politicians or taking on adverse or ill-informed publicity in the media. Our members and patients should expect and deserve no less. The BOA Executive and Council have launched an extensive review of our values and strategy so that we can deliver what is important to our entire constituency. A key part of our review is to completely revise our committee structures and terms of reference. We need to be leaner and more efficient and make sure that we make the most of our time and resources. We must ensure all of the Executive and Council have clearly defined objectives and expectations. Our members must have confidence that we are effective and responsive. This is the area where we must make best use of digital technology and we are beginning by launching our IT systems, which will be up and running when you read this and our new website which will be launching very shortly. We should be able to interact more efficiently with you and provide a much more extensive resource to support you. n


Bob Handley -

BOA Vice President Elect I gained the initial skills for T&O surgery in the garden shed at the knee of a practical father. After medical school in Sheffield the path of learning included Shetland, three years with the British Antarctic Survey, T&O training in Newcastle and Sunderland, and a fellowship in Seattle. 25 years ago I was appointed to a trauma post at the John Radcliffe Hospital Oxford. I still enjoy fixing broken bones. I have been President of AOUK and the Orthopaedic Trauma Society. I co-chaired two NICE guideline development groups related to fractures. I am National Clinical Lead for GIRFT Orthopaedic Trauma. It may look like a carefully planned career, but is more a tale of following opportunity and the enterprise of others. The consistent feature is a desire to be involved. Joining the Presidential line of the BOA concentrates the mind; philosophy and objectives are required. As T&O surgeons we believe that we are reasonable people who given the opportunity will deploy our skills to improve the lives of our patients. In the health service of today we need to actively demonstrate those beliefs to be well founded. That would be partial success, but there is no real success without successors. As this is a biography I will note that my gene pool is entrusted to four children, but the professional meme pool needs nurturing. Applications to many specialities including T&O have declined. We need to have and portray a speciality which is attractive to a broad spectrum of those qualifying in medicine. n

“We need to have and portray a speciality which is attractive to a broad spectrum of those qualifying in medicine.”

Instructional Course Review Roshana Mehdian


nvaluable to T&O trainees and SAS doctors for over four decades, the BOA Instructional Course continues to inform and evolve generations of surgeons. Taught by enthusiastic and expert educators, this year’s course did not disappoint the expectant attendees. The course was attended by 128 participants and delivered by 24 faculty, who generously gave their time and expertise. The new one day programme provided curriculum driven clinical updates and critical condition assessment opportunities in two parallel streams. One comprising Case Based Discussions and the other with succinct updates designed to help participants plan revision structure, summarise major changes in practice, both elective and trauma and source current evidence. One of the delegates commented “It was a great course. I found it very useful and felt that every part of the course added to my knowledge base. It was a welcome bonus to sign off several critical Case Based Discussions”. The ‘Necrotising Fasciitis’ station was an attendee favourite this year, with the faculty providing an excellent grounding in how to recognise and deal with this frightening condition. Next year’s course is likely to be as big a success. It is planned for January 11th, once again in Manchester. The course will be in a similar format with clinical updates for one stream and critical condition CBDs for the other. The course topics will include: Complex Regional Pain Syndrome or infection, holes in the bone, the limping child and cauda equina syndrome. Registrants can be sure of an enlightening and informative day, a useful contribution to their ISCP portfolios and an Oasis style busker on their walk from their train station to the course venue. n

06 | JTO | Volume 07 | Issue 01 | March 2019 |


Autologous Bone Marrow Concentrate Prepared in the Operating Room

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

Latest News

NHS RightCare National Priority Initiative NHS RightCare has launched its first National Priority Initiative for MSK with a focus on improving the diagnosis and treatment of back pain. This initiative will require every local health system in England to implement the National Back Pain Pathway with the aim of identifying system and pathway improvements. The BOA and Spinal Societies support the National Back Pain Pathway. Evidenced through NICE guidance, it seeks to improve patient access and care by ensuring the patient is assessed and managed at all stages by the appropriately trained practitioner. For more information contact

John Patrick Beavis and Victoria Dickens – New Year’s Honour List John Patrick Beavis (OBE) and Consultant Physiotherapist Victoria Dickens (MBE) have been honoured on the New Year’s Honour List for their services to the surgical profession.

John Patrick Beavis (OBE)

Victoria Dickens (MBE)

Beavis’ long and illustrious career has made remarkable work towards victims of war and disaster, having previously worked as a Consultant Orthopaedic and Trauma Surgeon for the NHS and as a Senior Lecturer at University College London. He has also worked as a teacher and consultant with IDEALS, a charity focusing on relieving poverty, distress and suffering in any part of the world affected by conflict or natural disaster. We were saddened to hear that he has recently passed away and an obituary is on Page 59. Dickens is a Consultant Physiotherapist and Clinical Director of Orthopaedics at the Salford Royal NHS Foundation Trust. She first turned heads when she introduced the physiotherapyled spinal pathway, which caused the average patients’ length of stay to drastically reduce from 11.36 to 2.56 days. Her achievements in improving patient care continue to make milestones with her effective multidisciplinary team at Salford. She is constantly evaluating innovations to ensure the most efficient processes are in place.

Medical Student Essay Prize Medical students are invited to submit an essay (no longer than 1,000 words) answering the following question: Using an example to illustrate your essay, such as the metal on metal hip problem or any other examples you wish, how can orthopaedics learn from the mistakes of the past as it moves into the future? Submissions open Monday 1st April and close Tuesday 30th April 2019. For more information on the competition and to see our updated FAQs, please visit the BOA website.

08 | JTO | Volume 07 | Issue 01 | March 2019 |

Training Orthopaedic Trainers (TOTs) Upcoming dates:

8th – 9th April 2019 (BOA London) 30th April - 1st May 2019 (Newcastle) The TOTs course aims to improve the standard of teaching for those in trauma and orthopaedic (T&O) training and practice. The basic premise of the course is that if T&O trainers understand how people learn and how the T&O curriculum works, they can translate that understanding into action and improve their teaching. The course is facilitated by Lisa Hadfield-Law, Educational Advisor to the BOA. For any queries, please contact If you would like to sign up, please visit our website.

Upcoming Fellowship Schemes The BOA offers several fellowship schemes for BOA members, two of which are due to launch in Spring 2019. Members should check their emails and the BOA website for further information about this year’s Travelling Fellowships and Clinical Leaders Programme. If you have questions or queries, contact

Policy round-up Readers may be interested in the following, all available online: • National Hip Fracture Database Annual Report (December 2018) • GIRFT Spinal Services Report (January 2019) • NHS England ‘Long Term Plan’ (January 2019)

NICE Guidance round-up • The BOA recently responded to the draft NICE guideline on Surgical site infections and the final guideline is expected in April 2019. • NICE has announced it is revising its guideline ‘Osteoarthritis: care and management’ and a consultation on the draft scope will be held in May. • Work on the guideline ‘Joint replacement (primary): hip, knee and shoulder’ is continuing, with consultation on new draft guidance expected in October 2019. • Other more general NICE workstreams that readers may be interested in include ‘Shared Decision Making’ and ‘Physical Activity’.

Latest News

BOA Annual Congress 2019

10th – 13th September, ACC Liverpool

The theme for the 2018 Congress is New Horizons in Research, Education and Clinical Leadership, which will be incorporated throughout all of the plenary and breakout sessions.


Plenary sessions will include the ever popular Howard Steel Lecture, Robert Jones Lecture and Presidential Guest lecture along with an update from the BOA President, Phil Turner on his presidential year. Breakout and revalidation sessions will cover a wide range of specialties including spines, hips, knees, foot & ankle and trauma to name a few.

Once again, BOA members can register at a 100% discount for a limited time only during the Early Bird* Registration period. *Terms & conditions apply, please visit for details and further information

Free papers will also feature and will be led by senior members of the BOA and specialist societies. As per previous years, Friday will see educational and training sessions for medical students and trainees.

Early Bird Registration will open on Wednesday 10th April 2019. Full Registration opens on Wednesday 5th June 2019

Anyone interested in exhibiting please contact the BOA’s Exhibition and Sponsorship Coordinator, Emily Farman, on

BOA ANNUAL CONGRESS 2019 10th-13th September ACC Liverpool


HIPmedia QIP media coverage HIP QIP coverage HIP QIP media covera HIP QIP media coverage

QIST Trial Update


1,264,810 Circulation: Reach: Circulation: 1,264,810 26,766,000 1,264,810 Circulation: Reach: Reach:Online 26,766,000 readership: 1,264,810 26,766,000 Online Online23,732,000 Reach: readership: readership: 23,732,000 26,766,000 23,732,000

The BOA-supported Hip-QIP project recently attracted news headlines after reducing mortality following hip fracture by improving patient nutrition and care pathways. These findings were widely reported, including in The Times, The Telegraph and The Daily Express, and highlight the value of quality improvement collaboratives.

Online readership: Circulation: 370,610 23,732,000

The QIST Trial is a partnership between the BOA, NHS Improvement, York Trials Unit, Northumbria NHS Foundation Trust and industry. It aims to test the effectiveness of quality improvement collaboratives in implementing change at scale and at pace in the NHS.

Reach Circulation: 22,539,000 370,610 Circulation: ReachOnline 370,610 readership: 22,539,000 Reach Online22,465,000 readership: 22,539,000 22,465,000 Online

QIST involves 28 volunteer NHS Trusts working together to reduce complications following elective hip or knee arthroplasty. One group focus on improving preoperative anaemia, the other on reducing surgical site infections.

HIP HIP QIPQIP media coverage media coverage

The collaboratives provide teams with tools to drive improvements within their Trust. These skills are developed through a series of face-to-face learning events and a framework of coaching, peer and expert support throughout the programme. All backed up by data tracking each team’s improvement journey. Circulation:

readership: Circulation: 22,465,000

370,610 Reach Circulation: Circulation: 22,539,000 338,580 338,580 Reach:Online Reach: 14,281,000 readership: 14,281,000 Online Online readership: 22,465,000 readership:

Circulation: 1,264,810 1,264,810

Reach: The teams have made great strides in improving care within their Trusts and continue Reach: 26,766,000 to evolve their pathways and collect outcome data. The ingenious solutions developed 26,766,000 Online and shared together have been outstanding and the trial team are extremely grateful Online readership: readership: for Trust’s on-going support. 23,732,000



A further series of QIST collaboratives start in November 2019. For further information, contact

13,743,000 Hip-QIP media coverage. Circulation:

370,610 Circulation: 370,610Reach Reach 22,539,000 Online 22,539,000



428,030 Circulation: Reach: 428,030 JTO | Volume 07 | Issue 01 | March 2019 | | 09 8,250,000 Reach: Online 8,250,000


BOA Soi Lam General Travelling Fellowship Kar Hao Teoh


Kar Teoh with Dr Lew Schon at Medstar Union Memorial Hospital

Kar Teoh with Professor DeOrio at Duke University Hospital

Kar Teoh with Professor Nunley at Duke University Hospital

t was a great honour to be awarded the BOA Soli Lam General travelling fellowship to pursue my interest in foot and ankle surgery in the USA. The first month was spent with Dr. Lew Schon at Medstar Memorial Union Hospital, Baltimore, Maryland, while the second month was spent with Prof. Jim Nunley, Prof. Jim DeOrio and Prof. Mark Easley at Duke University Hospital, Durham, North Carolina. They are all past Presidents of AOFAS and have extensive experience in F&A surgery, authoring many seminal publications and textbooks. Lew’s practice is very broad. He is a strong believer in treating foot and ankle fractures and diabetic foot emergencies promptly, rather than leaving it to the next day. This first-class service is something which is hard to aspire to, as it is unlikely there are any centres in the UK with F&A surgeons conducting specialised F&A calls. He is the co-inventor of the only total ankle replacement (TAR) performed through the lateral approach. I observed several of these during my time with him and found that it was a great option for deformity cases. I also saw him perform Denovo (Juvenile cartilage) for osteochondral lesions which is not available in UK currently. At Duke, I was able to participate in more than 20 primary TARs and several revision TARs. This is an unbelievable amount, which is likely a year’s work or more for most centres in the UK. There were several firsts for me - simultaneous bilateral TAR, takedown ankle fusion and conversion to TAR, allograft talus transplant for large OCD, and total talus replacement. Duke has the biggest TAR database in the world. I was very impressed with the way outcome data was collected in their clinics, with at least two research nurses in every clinic tracking all the research patients. The experience I gained during these two months were invaluable and I hope to incorporate it into my formative consultant F&A practice. I believe the links I have made in these two months will result in lasting friendships, mentorships and future research collaborations. n

British Trauma Society Meeting Review


he annual scientific meeting of the British Trauma Society was held in Manchester in November 2018 on the 30th anniversary of the foundation of the society. It fulfilled the vision of the founding members, for it to be a society to serve the purposes of the care of the injured patient through participation of a number of specialities in a multidisciplinary approach. The main theme was to discuss patients injured in recent terrorist attacks by those actively involved in the management of these patients. Dr Martin Smith presented a thought provoking talk ‘Where are we now/ contingency plans since the Manchester arena attack’, followed by military experience of Surgeon Lt Ddr Jowan Penn-Barwell with his talk ‘Combat casualty care-making good better’. The second theme, was to discuss the rising incidence of silver trauma defined as people above the age of 70 years involved in accidents. In addition to immediate good care, for a better outcome rehabilitation is of fundamental importance. Hence the need for a geriatrician in the major trauma team. The third theme was training of surgeons for managing trauma. Owing to the European Working Time Directive exposure to trauma is compromised, leading onto less than ideal training in trauma. Mr Ananda Nanu, immediate past president of the British Orthopaedic Association gave a thought provoking and honest view. This led to a healthy discussion with the audience. The next British Trauma Society meeting is being held on 5th - 7th November 2019 in Nottingham. n

10 | JTO | Volume 07 | Issue 01 | March 2019 |

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BOFAS Annual Scientific Meeting: Edinburgh, November 2018


n November, BOFAS moved north of the border to hold the Annual meeting in Edinburgh at the EICC, which proved an excellent venue and location. Nearly 500 delegates attended the three-day meeting. Steve Hepple, as President, organised a varied programme with Instructional Sessions on the crossover between paediatric and adult foot and ankle pathologies, soft tissue injuries, ankle OCLs together with a basic science session. A broad overseas faculty, from both North America and Europe, helped provide the scientific programme, including lectures on VTE and standing CT. The programme had something for everyone, with a well-attended allied healthcare professionals programme and Fellows programme for senior trainees. Moving the AGM to Thursday had proved successful in 2017, thus the format was maintained to encourage wider engagement in the Society from the entire membership, allowing time for discussion, updates from the Society’s committees, election of new officials and handover of the Presidency from Steve Hepple to Tricia Allen. A new BOFAS app, created by Rob Clayton (media and communications officer) and Jo Millard, was trialled and was a success all around – it was based on the BOA conference app and attendees could view the scientific programme etc as well as allowing the audience to submit questions to speakers and was also used for voting in the AGM. It will be back for 2019! Overall, an excellent meeting on all fronts. n

Edinburgh International Conference Centre

BOTA Educational Congress 2018


his November saw the annual British Orthopaedic Trainees Association educational congress move to NewcastleUpon-Tyne. After last year’s success in Manchester, the committee were keen to continue with a free congress provided in a major city centre location. Thanks to industry sponsorship and the committee’s hard work to secure additional contributory funds, we were able to achieve this goal and delivered three days of educational content to three hundred of our members. We aimed to match the content to key areas of the T&O curriculum. In line

12 | JTO | Volume 07 | Issue 01 | March 2019 |

This year’s chamber debate between Prof. Briggs and Mr. Dunstan

with this, we delivered a series of talks on spinal pathology, lower limb deformity and trauma. Arguably, the highlight, was this year’s chamber debate which saw Professor Tim Briggs pitched against Mr. Edward Dunstan. They led a lively discussion Presidential handover at the gala dinner around the topic of Body Mass Index being used to ration access to lower limb arthroplasty. The result was a surprise to all of us and saw Mr. Dunstan comfortably

win with his argument that BMI should be used to ration resources. We have also been working with the Orthopaedic Trauma Society (OTS) who kindly delivered a series of tutorials and a large group trauma meeting. The aim is to cover the trauma curriculum, in this format, over the next couple of years. We also continued our relationship with AO and this year the Shoulder and Elbow team provided a series of tutorials covering key topics in the upper limb curriculum. The social programme included a pub quiz on the banks of the Tyne and a gala dinner with a Ceilidh going late into the night. This barely scratches the surface of a very busy three days and I would like to say a huge thank you to all the committee and faculty that made it possible. n

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33rd EDINBURGH INTERNATIONAL TRAUMA SYMPOSIUM AND TRAUMA INSTRUCTIONAL COURSE 12TH - 16TH AUGUST 2019 Book early to secure viva and cadaveric breakout places. Early bird discount until 30th April 2019 TRAUMA SYMPOSIUM 14TH-16TH AUGUST 2019 Annual meeting for established orthopaedic surgeons with renowned international faculty. Three day meeting focused on revalidation and update through a combination of short interactive lectures and case based discussions Breakout sessions include cadaveric surgery focusing on surgical approaches and modern fixation techniques TRAUMA INSTRUCTIONAL COURSE 12TH-16TH AUGUST 2019 Five day orthopaedic trauma course suitable for established surgeons, trainees and AHPs Comprehensive lectures and case based discussions on the assessment and management of paediatric, adult and fragility fractures. Breakout sessions including cadaveric anatomy teaching and FRCS viva practice Venue: Sheraton Hotel and Edinburgh Medical School Visit us during one of the most exciting times of the year with the world famous Edinburgh International Festival and Fringe.

Further information and a detailed programme are available on our website: or by email: SPONSORED BY The Orthopaedic Trauma Society

JTO | Volume 07 | Issue 01 | March 2019 | | 13


Meeting Review - BOSTAA

Panos Thomas delivering his farewell Presidential speech

Panos Thomas, BOSTAA President 2016-18


he second BOSTAA Conference took place at the ISEH in London, on the 5th December 2018. It was well attended by orthopaedic surgeons with an interest in sport injuries, sports and exercise medicine specialists and other associated health professionals. The emphasis of the meeting was on joint instability. Invited specialists presented informative lectures covering all aspects of the topic. Guest speakers were David Shewring, the President of BSSH, and Patricia Allen, the President of BOFAS. They presented an update on treating sport injuries in their field of interest. Interesting scientific papers were presented and displayed. The winning paper was chosen: N Harris and M Farndon from Harrogate on ‘Stabilisation of the Ankle Syndesmosis using the Internal Brace’. We were delighted that the RCS Edinburgh requested our society to include the ‘King James IV Professorial Lecture’ delivered by Adnan Saithna, a member of the society and previous Traveling Fellow. This year, BOSTAA is celebrating the 25th Anniversary of its foundation. A ceremonial session took place, where commemorating medals were presented to past presidents, able to attend the meeting, including Prof. Angus Wallace, Prof. Nicola Maffulli, Steve Bollen and Simon Roberts. During the AGM, the election of new officers in the Executive was approved by members. Prof. Fares Haddad is taking over as the President of the society for the next two years. In the end, a well-deserved drink, supported by the industry, brought to a close a successful educational day. n

Meeting Review - BSS

BOSTAA Past Presidents at the AGM, including Simon Roberts, Fares Haddad and Panos Thomas (front left to right)

Mr. Antony Louis Rex Michael (Sheffield)


Host Mr. Niall Eames with Dr Geoffrey Askins (Australia) at BSS 2018 Belfast

14 | JTO | Volume 07 | Issue 01 | March 2019 |

he 42nd British Scoliosis Society (BSS) annual conference was held in Belfast from 29th-30th November 2018. It was preceded by the BSS instructional course. The venue was the Europa Hotel (most bombed in Europe). This conference was combined with the Irish Spine Society. It was an intellectual feast for trainees, consultants and industry. The instructional course was well attended (57) with faculty of national and international repute (14). The focus was on all aspects of scoliosis from diagnosis to non-operative and operative management. The annual conference was very well attended by delegates (127) and supported by industry (15 stands). There were podium presentations (24) and poster presentations (27). There were keynote lectures (4) on important issues. The current ‘hot potato’ of vertebral body tethering (VBT) was discussed. The Australian guest faculty is a specialist in the field of Thoracoscopic scoliosis surgery (Dr. G Askins). Other invited lectures/debates (5) covered the breadth of issues surrounding scoliosis surgery: the governance aspects (BSR), cost effectiveness etc. The management of early onset scoliosis was extensively discussed, especially in light of recent media interest in the magnetically expanded growing rods. Bracing was discussed by Mr. Pat Kiely (Dublin). The conference dinner was at the Titanic museum- a worldclass venue. Dr Geoff Askin and Dr F. Todd Wetzel were the eminent international faculty from Australia and the USA respectively. Mr. Peter Milner (President of BSS) and Mr. Am Rai (President of the British Association of Spinal Surgeons), among others, were national faculty. 12.5 CPD points were awarded in total. n


HKOA Annual Congress, Hong Kong 2018


he 38th Annual Congress of the Hong Kong Orthopaedic Association was held on the 3rd and 4th November 2018 in the Convention and Exhibition Centre, marking the presidency of Dr Yiu Chung Wong. Anyone who has been to Hong Kong will be well aware of the traffic chaos, added to on this occasion by an apparent festival of roadworks aimed at alleviating the long-term problems of congestion in the city centre. The topic was ‘Build and Brighten – Child and Adolescent Orthopaedics in the Next Decade.’ There were multiple parallel sessions during which local trainees and consultants presented on a wide range of topics including spine, arthroplasty, oncology, sports injuries and some excellent and apparently well-funded basic science research. The plenary sessions were dedicated to the main theme and included excellent lectures from a panel of world leaders in their topics. Controversies in the management of the injured child were thoroughly explored. It is impossible

to pick out the best sessions, but as I have not practiced in this field for many years now, I found the depth of knowledge and plain clinical common sense was refreshing and reignited my dormant interest in paediatric orthopaedics. Many from my generation will know of Professor John CY Leong as an eminent spinal surgeon, but he gave his lecture as guest of honour from his new role

as Chairman of the Hong Kong Hospital Authority, looking at the broader picture of healthcare provision in such a condensed and multi-cultural society. At the Congress banquet, we were entertained by a violinist who overcame incredible adversity to return to playing after traumatic amputation of his left arm. The short visit reinforced my view that paediatric orthopaedic surgeons are some of the most approachable, thoughtful and enthusiastic members of our community and wondering why I ever gave it up for knee surgery! n

Chinese Orthopaedic Annual Congress Ian Winson


he Chinese Orthopaedic Association with the BOA as guest nation. “So it is Tuesday - this must be China “‘, said Phil Turner in Xiamen. The hectic round of international meetings in the autumn for the Executive, Council and many of the members of our specialist societies leaderships continued. So what to say about the COA. This was China at its most developed, with a meeting in a seaside resort city of a mere 7.5million people; where it is clear that the economic power of China is fully developed and impressive. The meeting itself can be described in various ways: a full academic program with speakers from many parts of the world covering all the diverse practice of orthopaedics and trauma; 25,000 plus participants; and an industry exhibition larger than anything else in the world, including the sale of many surgical instruments. Sadly, none were CE marked, or my only problem would have been to explain them away in my hand luggage. But to capture the vast size of this meeting, it is easiest just to mention the 16,000 steps a day I averaged just going between sessions. The BOA held its own with a huge delegation of roughly 20! But the Chinese made us feel front and centre and seemed genuine in their enthusiasm for our contributions. So much so that we were able to sign a Memorandum of Understanding which means hopefully more of our Chinese colleagues will be coming to meetings of the BOA and to gain experience in the UK. Rumour has it that we are seeing the benefits of that understanding already, in positive discussions with the BJJ being translated for circulation in China. These are being delivered by the efforts of editorial colleagues, but are certainly aided by the concerted front presented by the British team, lead by Phil and organised by the BOA. n

JTO | Volume 07 | Issue 01 | March 2019 | | 15


The NICE Guidance for the prevention of venous thromboembolism in adults – Good, Bad, Ugly or all three XL Griffin


he latest guidance (NG8) from the National Institute for Health and Care Excellence (NICE) for the prevention of venous thromboembolism (VTE) for patients in hospital aged 16 years and older has recently been published.1 The orthopaedic surgeons who were involved in the development of the recommendations have had their say in the BJJ2 and at the BOA Congress. Most of you will have at least read the recommendations for your subspecialty but I doubt anyone has read the exhaustive text itself! You will have come to your own conclusions about whether we moved the recommendations forward or merely served to muddy this difficult area even further. I wanted to reflect on my experiences of the process and throw some light on the beast that is NICE for those who may be interested in working with them. Firstly, and most importantly, the process for developing recommendations is driven by the available evidence. When considering studies which tell us something about the relative effectiveness of treatments there is a wellrecognised hierarchy. Large, well-conducted randomised controlled trials are the trump card here and quite rightly NICE will not consider other evidence if these studies exist. National audits such as the NJR or NHFD are less reliable types of study to detect treatment effects and have not been included.

the recommendations. These discussions are available publicly through the NICE webpages as minutes of each meeting. Finally, it seemed very clear to me that the staff leading the production of the guideline were truly disinterested in the content of the final outcome – their efforts were focussed entirely on the quality of the work that underpins the recommendations. I was convinced that any recommendation made by the organisation was likely to be fair, defensible and based on the best available evidence. So what were the highlights amongst the changes? Well, aspirin has made it into the recommendations this time for elective hip and knee replacement and the duration of prophylaxis has shortened in elective knee replacement; there is no longer an assumption that the DoH risk assessment tool be used in all hospitals. At first glance the changes in recommendations that affect our practice in trauma and orthopaedic surgery look to be somewhat quirky and incoherent. Not so. The recommendations are grounded in the evidence which has been produced. Where trials of shorter prophylaxis durations exist we have been able to make those recommendations – if not we are suck with the limitations of the data we have. The DoH has been heavily criticised for leading to over treatment – since there is no evidence to support its effectiveness it has been removed from the recommendations.

“At first glance the changes in recommendations that affect our practice in trauma and orthopaedic surgery look to be somewhat quirky and incoherent. Not so. The recommendations are grounded in the evidence which has been produced.”

Secondly, the final recommendations are a distillation of the results of several different randomised trials each of which is designed in slightly different ways. These trials are of course not free from errors – random errors due to sampling or imprecision in measurement of outcome and systematic errors such as funding or publication bias. Therefore, the committee cannot escape from having to make judgements both in the content and force of

16 | JTO | Volume 07 | Issue 01 | March 2019 |

So, no downsides then? Not quite, NICE is a large, complex organisation which is pulled in many different directions. As such it is very

prescriptive in the way it does its business and less than agile when confronted with bumps in the road. We particularly suffered with an early decision not to replace all existing guidance, including technology appraisals for DOACs, with this new update. My takeaway from this it that we need to have our ducks in a row right at the outset. NICE engage with the community during scoping, when the remit of the guideline is determined, and then prior to publication. We should make our voices heard through registering with NICE as a stakeholder for all guidelines that impact on our practice. What next? Well, there will be another turn of this wheel. The recommendations are only likely to change if the evidence base has changed. An update will probably begin in four to eight years – just about matching the delivery cycle of a randomised controlled trial. My challenge to us all is that if we don’t like the recommendations, we have to be part of delivering the better studies needed to drive the change our patients need. n

References 1. 2. Bone Joint 2018;100-B:1136–7


Waiting times for patients – a continuing concern


he BOA has been monitoring closely the waiting times situation in England over the winter months, following the significant deterioration in waits that occurred last year. At the time of writing (mid-January), there had not been widespread implementation of so-called Winter Pressures Measures which had occurred by this point last year. However, patient waits remain a concern: • The total number of people on trauma and orthopaedic waiting lists has exceeded 500,000 in three of the last four months of published data (unprecedented in the past decade).

• Most recent data (November 2018) showed 77,459 patients had been waiting over 18 weeks, compared to 63,597 in November 2017, meaning the winter has started off in a worse position than last year. This also means that the NHS England goal of waiting lists being no longer in March 2019 than they were in March 2018 seems very unlikely to be met. Aside from concerns in England, the waiting times in Northern Ireland are far worse, and the BOA is pleased to have been invited to a meeting to discuss this. For further updates on these issues, please watch our website and Twitter. We would also like to highlight the BOA statement from December about training and winter pressures, for anyone affected by these issues. This is available at: n




JTO | Volume 07 | Issue 01 | March 2019 | | 17


Conference listing: BSCOS (British Society for Children’s Orthopaedic Surgery) 7-8 March 2019, Norfolk and Norwich

BASK (British Association for Surgery of the Knee) 26-27 March 2019, Brighton

BASS (British Association of Spinal Surgeons) 2-5 April 2019, Brighton

BOOS (British Orthopaedic Oncology Society) 5 April 2019, Leiden

BLRS (British Limb Reconstruction Society) 27-30 August 2019, Liverpool

BIOS (British Indian Orthopaedic Society) 28-29 June 2019, Leicester

BORS (British Orthopaedic Research Society) 4-6 September 2019, Cardiff

SBPR (Society for Back Pain Research) 5-6 September 2019, Sheffield

BSSH (British Society for Surgery of the Hand) 25-26 April 2019, Swansea

ACC, Liverpool

Lisbon, Portugal

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) 5-7 June 2019, Lisbon

WOC (World Orthopaedic Concern) 8 June 2019

BESS (British Elbow and Shoulder Society) 18-21 June 2019, Leeds

CAOS (Computer Assisted Orthopaedic Surgery (International)) 19-22 June 2019, New York

18 | JTO | Volume 07 | Issue 01 | March 2019 |

BOA (British Orthopaedic Association) 10-13 September 2019, Liverpool

BTS (British Trauma Society) 6-7 November 2019, Nottingham

BOFAS (British Orthopaedic Foot and Ankle Society) 13-15 November 2019, Nottingham

BSS (British Scoliosis Society) 21-22 November 2019, Cardiff

BOTA (British Orthopaedic Trainee Association) 27-29 November 2019, Edinburgh


Wisepress Book of the Quarter

Handbook of Pediatric Orthopaedics Author: Paul D. Sponseller | ISBN: 9781626234314 Date published: 6th Feb 2019 | Price: ÂŁ53.50 BOA members are entitled to 15% off the cost. Email for the discount code.


ser-friendly paediatric orthopaedic surgery reference distils clinical practice into essential facts! This third edition of Handbook of Pediatric Orthopaedics by the renowned Paul Sponseller builds on prior editions with recent updates and treatment guidelines on paediatric bone and joint disorders and is a succinct, how-to manual covering a diverse spectrum of paediatric orthopaedic procedures. The book is organised into nine chapters, six of which are dedicated to specific disorder categories. An introductory chapter on anatomy and normal childhood development features norms for osseous and motor development, innervation, growth patterns, predictions, and new guidelines for assessing growth at the pelvis, foot, and hand. Expanded content on skeletal growth, development, and systemic disorders and skeletal syndromes reflects the latest knowledge, such as imaging parameters, clinical treatment standards, and an algorithm for DDH treatment. Cutting-edge advances in the treatment of cerebral palsy, myelodsplasia, and spinal muscular atrophy are detailed in the chapter dedicated to neuromuscular disorders. Paediatric trauma content includes important updates on forearm and femur fractures, an outlined approach to each fracture, and a diagram showing how to reduce each type of Monteggia fracture.

Joint Action Challenge Events We wish the best of luck to all the runners who are registered for the Virgin Media London Marathon, taking place on Sunday 28th April to raise funds for Joint Action. Your efforts are most appreciated! We still have places available for the British 10K (14th July) and Prudential Rind LondonSurrey (4th August). If you’d like to get involved to help raise much needed funds for orthopaedic research please visit the BOA website or email to find out more and to register for a challenge event.

Robert Jordan

Rosie Tansey

Mark Roussot JTO | Volume 07 | Issue 01 | March 2019 | | 19


BOA Membership Update UKITE All programmes across UK and Ireland sat UKITE in December between 7-14th December, as well as one deanery in South Africa on 11-12th January. We are pleased to announce that in total 760 Trainees and SAS surgeons sat the exam, an increase of 75 on the numbers who sat in 2017. The Training Programme that achieved the highest mean score (58.94%) was Mersey. The average score across all participants was 52.8%. For more information on sitting UKITE in 2019, visit

New BOA Membership Portal and Website All members will have received instructions on how to create an account on the new BOA Members’ Portal with their renewal notice in January. On the portal you will be able to renew your membership subscription, and download copies of previous invoices and payments.

Your Donations to Research make a real difference Members will have received notice that, due to changing regulations, we no longer automatically add a donation to research to your membership invoice, even if you have opted to donate in the past. While research activities are partly funded through the core membership subscription, voluntary donations from BOA members and the public greatly enhance the funds available to support high quality research in trauma and orthopaedics and promote trainee involvement in clinical research. The work of the BOA Orthopaedic Surgery Research Centre (BOSRC) is achieving excellent outcomes and is only made possible through donations. We would really appreciate it if can give what you can as a voluntary donation through the new Members’ Portal. You can also donate to the BOA Benevolent Fund and a new BOA general fund for policy and education initiatives, which you can find out more about online.

OrthOracle member benefit Just a reminder about our member benefit with OrthOracle, an independent, surgeon developed online resource full of practical surgical techniques for both experienced surgeons as well as those in training. OrthOracle publish new techniques across the whole Orthopaedic spectrum every month. BOA members who sign up with OrthOracle before the end of March will receive free six-month access to the platform. Email to receive your discount code.

20 | JTO | Volume 07 | Issue 01 | March 2019 |

We are also pleased to announce that the new BOA website will be going live very soon! As part of the new website you’ll also be able to book courses and events, including the BOA Congress. The members’ portal will also provide a new home for the member directory, which will only be accessible to members. Moving the directory online will ensure that your contact details are kept upto-date throughout the year, allow us to meet requirements under the new data protection regulations (GDPR) and help reduce costs. We hope you like the new website and members’ portal and they make your interactions with the BOA easier and more convenient.

Calling all prospective BOA trustees! The BOA will soon be seeking nominations of Trustees and Honorary Secretary for 2020-2022. The Association is proud of the growing diversity of its membership and values the impact this diversity has on our success. We would like to encourage all members, particularly women and other underrepresented groups, to take up leadership roles. If you or someone you know would be interested to stand for election for BOA Council watch out for the notice inviting nominations coming through your letterbox soon!

Preventing and reducing periprosthetic joint infections

For anaerobes

Bone cement with 2 antibiotics Broad spectrum of activity For MRSA/MRSE

Infection prevention Implant fixation High stability

High initial antibiotic release




Service Transformation in Trauma and Orthopaedics Phil Turner 2. Develop a network Transformation cannot be achieved by an individual. A network of like-minded clinicians from across the region that will be affected is a good way to engage them and delegate the tasks that arise once the project takes off. Successful service change needs to be led by clinicians, but you need the support of management and data analysts. Regular meetings and e-mail exchanges are inevitable.

3. Develop a programme

Many of us will have been involved with changing our service configuration in order to improve our outcomes, make best use of resources and improve efficiency. At the same time, we are trying to ensure that patient experience is improved and the workforce remains engaged.

22 | JTO | Volume 07 | Issue 01 | March 2019 |

4. Decide on the limits


Ours is a very broad specialty and some of the sub-specialties may already be delivered on a regional or even national basis so they become ‘out of scope’. Typically, this is likely to include spinal services and children’s orthopaedic services. A particularly difficult area is whether to include trauma. The development of Major Trauma Centres and Trauma Networks is now fully established across most of the UK, but the regular day to day trauma and particularly hip fracture management cannot be separated from the provision of elective services.

1. Demonstrate the need for change

5. What are the co-dependencies?

Most transformation projects affect large conurbations where several hospitals or Trusts are providing similar services or two hospitals are close together and could be separated so that there is one ‘hot site’ and one for elective work. To make the case for change you will need a lot of data on activity and variation. I have found that the GIRFT reports are invaluable, but you have to be able to share that data by obtaining written agreement from all parties.

You will need to ensure you have considered what other resources you need to provide a safe and efficient service. This will vary from area to area, and they do not necessarily need to be co-located. However, you will have to have a plan as to how you are going to access radiology, pathology, care of the elderly and so on. The list will be long. Other services are also reliant on timely access to trauma and orthopaedics, so these also need to be included.

e are still going through the process in Greater Manchester, but I thought the time was right to share some of the lessons and experiences from the project. I have sought to put them into 10 key points though I cannot guarantee that they are in the right order!

Professor Phil Turner is the President of the BOA and a consultant at Stepping Hill Hospital, Stockport. He is also the founder and chair of the GMOA, Clinical Lead for T&O Transformation in Greater Manchester.

Hopefully your plans will have caught the attention of the STP or Regional leadership and you will then get the support of project managers. They will develop a programme and support the arrangement of meetings and consultations. They will also hold you to defined timescales which makes sure the project moves on ‘at pace’.


6. Know your activity

8. What financial savings are there?

10. Think of the patient journey

The project managers and STP leadership will want to know that there is a defined benefit from the investment they are making. I am sure most of the readership will have been subjected to external consultancies observing how we work and delivering what seem to be to totally unrealistic opportunity calculations for improved efficiency. Nevertheless, for transformation to be viable, there will need to be a realistic appraisal of how much more activity can be delivered. We discovered remarkable variation in theatre throughput across the city and raising it to the level of the best would allow a minimum 15% improvement even without any other change.

The aim of transformation should be better patient care. You have the opportunity to build networks, concentrate complex procedures in fewer sites, improve patient safety and rationalise equipment. You will also have the attention of industry as more sophisticated value-based procurement across a large population becomes very attractive to them. We calculated that by combining procurement practice across the city we hold more than 5% of the national trauma and orthopaedic spend.

This is probably the most important aspect of transformation. You will need to consider how patients will enter the system and how they will return home. Referral pathways need to be consistent across the whole service and ongoing rehabilitation and follow-up will have to be provided closer to where the patient lives. Our research suggests that patients will travel to have their surgery performed in the best facility by experienced and well supported staff, but they want the rest of the episode to be easily accessible.

7. What facilities do you have? It proved remarkably difficult to establish just how many laminar flow theatres there were, let alone access to day-care and short stay wards. There was also marked variation in access to beds dedicated to elective in-patient care which were protected and had appropriate ‘ring-fence’ policies for their use. You may have to visit each site to truly understand what facilities you have at your disposal.

Pre-operative oedema reduction in ankle trauma patients Accelerating readiness for theatre in ankle fracture patients requiring Open Reduction Internal Fixation (ORIF). The geko™ device gently stimulates the common peroneal nerve, activating the calf and foot muscle pumps to accelerate the reduction of oedema. A statistically significant NHS study shows backslab plaster cast + geko™ accelerates readiness to theatre, compared to current standards of care.

9. What about the workforce? Changing the delivery of our service into ‘hot’ and ‘cold’ sites is attractive as we can maintain elective services throughout the year in a predictable and planned way. However, an inevitable consequence will be split-site working for the clinical staff. It is important to consider the impact on trainees, but we consider that it will be far better as modules can be delivered and the full breadth of the specialty will be experienced at appropriate stages of a progressive career pathway. It is all well and good for clinicians, but many other staff will be affected, and they may not want to relocate or work across more than one site.

Results show1:


2 days improvement in readiness for theatre on average per patient.


The geko™ +plaster cast = 1.66 days readiness totheatre (average).

£569 2 Backslab plaster cast + geko™ saves an average of £569 per patient compared to current care.

With geko™ use, 60% of patients are ready for theatre in 2 days,compared to 27% in control arm, a 122% improvement.

Finally, you may have a very clear idea of how you and your colleagues could work together to make a significant improvement for everyone involved, but not all will agree. Difficult decisions and awkward conversations are inevitable. The project will also stand or fall by how it integrates with all the other clinical services that are also included in the transformation themes and this will not be in your control. A NHS England presentation on ‘Effective Service Change’ is available through this link n

Quick & easy to fit OnPulse™ ˚ Utilises neuromuscular electrostimulation technology (NMES).

˚ Weighs just 10g. ˚ No wires or leads. light and ˚ Small, comfortable to wear. ˚ Silent in operation.

1. Data on file, Firstkind 2017 Supported by NICE guidance for DVT prevention - NICE medical technologies guidance [MTG19] June 2014


BOA JOTO Pre-Op Oedema Ad 190x130 V3.indd 1

JTO | Volume 07 | Issue 01 | March 2019 09/04/2018 | |21:07 23


Updated Certification (CCT) guidelines in T&O 2018 WG Ryan, Liaison member SAC and Mark Bowditch, Chair SAC

To be listed on the Specialist Register, the GMC requires assurance that a practitioner is appropriately competent. This assurance is delegated to the Colleges via the Joint Committee in Surgical Training (JCST) and the relevant Specialty Advisory Committee (SAC). The CCT guidelines were developed following the first T&O curriculum in 2006 as a way of assessing if the trainee, coming to the end of training, had fulfilled the curriculum requirements. These guidelines covered a range of clinical and non-clinical competences.


he CCT guidelines were developed following the first T&O curriculum in 2006 as a way of assessing if the trainee, coming to the end of training, had fulfilled the curriculum requirements. These guidelines covered a range of clinical and non-clinical competences.

WG Ryan is a Liaison member of the SAC, and was TPD in Manchester until 2017. He is a consultant working in Bolton, and a keen medical educator.

Mark Bowditch is Chair of the SAC, a BOA Council trustee and Head of School of Surgery in East of England where he was TPD for 10 years. He is a Consultant in Ipswich & Divisional Director at the ESNE FT.

24 | JTO | Volume 07 | Issue 01 | March 2019 |

In 2011, indicative procedures/numbers were produced as a guide to the minimum clinical exposure and experience in the breadth of the specialty1. No major changes have been made since and there have been some issues with existing lists such as lower limb bias and difficulties with access to first-ray procedures. By 2020, the CCT guidelines will be in the new curriculum, which is not currently the case. With this in mind, the SAC agreed that the time was right to specifically review the ‘clinical and operative experience and competence’ requirements to ensure that they were fit for purpose. In summary the changes are: 1. Clear description of the need for clinical exposure to the full breadth of the specialty – specified as eight major special interest areas: Hand/Wrist, Shoulder/Elbow, Spine, Hip, Knee, Foot/Ankle, Paediatrics, Major trauma; 2. Two additional critical case based discussion topics; and 3. Operative numbers, indicative cases and competence levels WGR led the review of the operative experience and competence requirements on behalf of the SAC, with input from all relevant stakeholders (SAC, BOA, Specialty Associations, BOTA, TPDs and logbook leads) and with similar guidelines from Canada/Australia2.

The SAC, in 2017, agreed the principles along which we would review and realign the guidelines as follows: 1. Training in T&O should remain general across the full breadth and included all eight major subspecialties. 2. The test of competence should remain as “competence at the level of a day one consultant in the generality of the specialty”. 3. We should ensure that the trainee was emergency safe and able to be on call for an unselected acute take. 4. We should focus more on the fundamental competencies/principles of T&O and less on specific index procedures. 5. Retain certain critical or common index procedures likely to be undertaken by the first day consultant- principally trauma. 6. We would aim to remove the lower limb bias. 7. We should allow flexibility for the principles to be demonstrated with cases from all subspecialty areas. 8. Changes should be workable in practice (reasonably simple to use). 9. There should be a suitable lag period before application. The key was competence in the principles and flexibility in the way to demonstrate these: Trauma: • External fixation • Internal Fixation (IF)- plates • IF - nails • IF – Tension band wire • IF - K wires • Tendon repair • Wound / joint washout / debridement • Casting and traction (non-operation)



Indicative number

Notes including acceptable cases

Major joint arthroplasty


total hip, knee, shoulder, ankle replacements



First metatarsal, proximal tibia, distal femur, hip, humerus, wrist, hand, paediatric, spinal. NOT allowed are Akin, lesser toe and MT 2-5 osteotomies

Nerve decompression


carpal tunnel, cubital tunnel, tarsal tunnel, spinal decompression, discectomy



knee, shoulder, ankle, hip, wrist, elbow


Emergency / trauma Compression Hip Screw for Intertrochanteric Fracture Neck of Femur


Hemiarthroplasty for Intracapsular Fracture Neck of Femur


Application of Limb External Fixator


Tendon Repair for trauma


Any tendon for traumatic injury (includes Quadriceps and patella tendon)

Intramedullary nailing including elastic nailing for fracture or arthrodesis


Femur shaft, long CMN for subtrochanteric fracture, tibia shaft, humerus, hindfoot nail, arthrodesis eg knee

Plate fixation for fracture or arthrodesis


Ankle, wrist, hand, femur, tibia, humerus, forearm, clavicle, arthrodesis eg wrist

Tension band wire for fracture or arthrodesis


Patella, olecranon, ankle, wrist, hand

K wire fixation for fracture or arthrodesis


Wrist, hand, foot, paediatric

Children’s elbow displaced supracondylar fracture




Displaced fracture by Eames internal Hosttreated Mr. Niall fixation or application formal traction with DrofGeoffrey (two cases could be simulated) Askins (Australia) at BSS 2018 Belfast

Table 1: New indicative operative procedure requirements for CCT.

Elective surgery: • Arthroplasty • Osteotomy • Arthroscopy • Nerve decompression • Arthrodesis Indicative procedure competencies will be assessed by PBA and a trainee will have to reach level 4a competence on three occasions and be assessed by at least two trainers. This is consistent with education advice and that of other specialties and other countries. It was felt that only one level 4 PBA could currently be achieved by cajoling a sympathetic trainer, or could be achieved by luck on a good day. Overall minimum logbook numbers remain at 1800. However, we felt there was a need for more clarity regarding the minimum number of cases performed as first surgeon. Evidence from the elogbook3 showed that the mean percentage for trainees acting as first surgeon (p,su,ss,t) overall was between 70% and 80%. We therefore have chosen that minimum of 70% (1260) of the 1800 cases need to be the trainee as first surgeon.

It was agreed that there will need to be a lead-in period of two years from notification of these changes, for trainees currently in training to achieve these different numbers. Trainees in their final two years of training would not have to go back and repeat modules when they are nearing their CCT date. More junior trainees would have plenty of time to achieve their indicative numbers in their remaining training time.

4. Osteotomy - Achieving the numbers of first-ray procedures has been a problem in many regions. The principle of osteotomy was the key and it was felt that much more scope should be given to trainees to develop this competency-utilising opportunity in different subspecialties.

Whilst these changes have been made public and notified to TPDs and BOTA in August 2018, the date they actually apply is 10/10/20 – that is any trainee with a CCT date on or after this date will be assessed against these criteria. This particular date has been chosen to accommodate the start dates of almost all training programmes.

7. Application of Plaster cast. We felt that this is a skill which should be learnt at an early stage in training (core).

The group discussed several points at length. The following is a distillation of these:

1. Joint arthroplasty – Much debate centred around whether cementation was a required skill. In the end, consensus was that the arthroplasty technique itself was more important, and the cementation skills were secondary to competent placement of a prosthesis, in the context of the operation for total joint arthroplasty. Therefore, it is suggested that arthroplasty could be demonstrated in four areas: hip, knee, shoulder and ankle. 2. The SAC (including five with major ‘paediatric interest’) and Childrens’ Orthopaedic Society (BSCOS) felt strongly that indicative emergency case par excellence where a general orthopaedic surgeon on day-one needed to be safe and surgically competent, is the displaced supracondylar elbow fracture. A critical case CBD was not enough. 3. Arthroscopy - There was much debate about what and how advanced these skills needed to be in each area. There is a difference between competence and excellence or mastery. It was felt that multiple joints may need to be scoped by a competent day-one consultant in order to drain a septic arthritis. This is very different from the skills required to be a master knee or shoulder surgeon. The technical skills to safely arthroscope any joint for diagnosis at level 4 would be acceptable, as long as a minimum of three level 4 qualifications were achieved over time (on one or more joints).

5. Arthrodesis is a generic competency but is also a combination of several principles eg approach to the joint, preparation of the joint surface, and open reduction and internal/external fixation, hence is covered. 6. Titanium Elastic Nail Systems (TENS) nails were discussed and it was felt that these could be included in the IM nail section for fracture.

8. Wound management / joint washout - These are considered core surgical competencies and it is expected that trainees entering higher surgical training will have achieved these earlier in their training (core). The final agreed indicative operative procedures are shown in table 1. They have now been published and come into force for those trainees with a CCT date on or after 10/10/20. Trainees and TPDs will need to consider working towards these now. E-logbook operation codes and case groups and ISCP summary sheets are being updated.

Summary Any change is difficult but the SAC believes this will improve the quality and breadth of training of future consultants. The new list encourages the exposure to the full breadth of Trauma and Orthopaedic specialties focuses training on the broad principles of operative techniques, and being emergency safe. It allows some flexibility with case selection across the subspecialties to demonstrate these competencies. A considerable amount of time and effort from many orthopaedic colleagues has been given to this project over the last two years, for which we are extremely grateful. n

References 1. Historic CCT guidelines 2014: https://www.jcst. org/-/media/files/jcst/key-documents/specialtyspecific/cct-guidelines--final-to-v5.pdf Canadian T&O training guidelines: http://www. document/mdaw/mdg4/%7Eedisp/088801.pdf 2. Simon S Jameson, Sanjay Gupta, Andrew Lamb, J. Lester Sher, W. Angus Wallace, Mike R. Reed; The United Kingdom and Ireland Trauma & Orthopaedic eLogbook—An evidence base for enhancing training. 3. Current CCT guidelines 2018: https://www.jcst. org/quality-assurance/certification-guidelinesand-checklists/

JTO | Volume 07 | Issue 01 | March 2019 | | 25


Dr Alison Moulds is a medical historian. She is Engagement Fellow on the Wellcome Trust Investigator Award, Surgery & Emotion, based at the University of Roehampton, and Postdoctoral Research Assistant on the European Research Councilfunded Diseases of Modern Life project at the University of Oxford.

Dr Agnes Arnold-Forster is a medical historian and Research Fellow on the Wellcome Trust Investigator Award, Surgery & Emotion, based at the University of Roehampton. She completed her BA (Hons) at the University of Oxford, her MSc at Imperial College, and received her PhD from King’s College London in 2018.

Simon Fleming is a Trauma and Orthopaedic registrar on the Pott rotation in London. He is also a past President of the British Orthopaedic Trainees’ Association (BOTA), the Chief Resident for the International Conference in Residency Education (ICRE), the Vice Chair of the Academy Trainee Doctors’ Group (ATDG) and a Ph.D candidate in Medical Education at Barts and The London Medical School.

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The Emotional Side of Surgery Alison Moulds, Agnes Arnold-Forster and Simon Fleming

The stereotypical surgeon is an overconfident man1. He might be brash and charismatic, but volatile and even abusive to his colleagues. He cuts first, asks questions later - and he is never in doubt2. He is good at hard surgeries but bad at ‘soft’ skills like compassion and communication. Academically brilliant, he lacks emotional intelligence3. This stereotype is most frequently applied to the trauma and orthopaedic surgeon, whose caricature is that of a virile masculinity which privileges physical strength over patient care4.


ith these stereotypes comes the expectation that surgeons will meet stressful and anxious experiences with resilience and fortitude. Emotional responses might be seen as a failure, or as getting in the way of surgical competence5. These preconceptions may prove damaging to the emotional health of individual surgeons and harmful to surgery’s public image. To attain the supposed ideal, surgeons might hold themselves aloof and fail to seek help for problems, and patients could thus see them as detached or dispassionate.

Traditionally, the emotional costs of surgical care have been neglected. There has been little in the way of formalised support for practitioners and throughout the twentieth century the emotional complexities of the surgical encounter were frequently disregarded. The place of emotions in modern surgery is an emerging topic of discussion. Drs Arnold-Forster and Moulds’ project, ‘Surgery & Emotions’, issued a call for surgeons to participate in its oral history project which was met with an enthusiastic response with many keen to discuss the affective side of practice. In his 2014 best-selling autobiography, Henry Marsh begins with a quotation from the French surgeon René Leriche, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray - a place of bitterness and regret, where he must look for an explanation of his failures”6. Marsh’s memoir highlights how emotions are threaded through the surgical fabric, regardless of conventions of detachment. There is increasing recognition that stereotypes of surgical dispassion might


be inaccurate and damaging. The threat of stress and burnout has been acknowledged and there are efforts to excise bullying from the specialty, such as BOTA’s #HammerItOut campaign7. Initiatives such as the BMA Counselling and Doctor Advisor Service and the Practitioner Health Programme offer support to individual professionals8-9. Some institutions have adopted Schwartz Rounds, where different practitioners can come together to discuss the emotional and social aspects of working in healthcare10.

recommends readers ‘keep a gratitude diary’, ‘get better sleep’, and ‘smile’11. Meanwhile, an upcoming Royal College of Surgeons (RCS) Women in Surgery event tells attendees they will “Find out more about how ‘me time’ can positively impact your career and overall lifestyle”12.

“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray - a place of bitterness and regret, where he must look for an explanation of his failures.”

However, media coverage and political and professional rhetoric frequently focuses on individual and personal responsibility, encouraging healthcare practitioners to manage their emotional health through strategies of self-care and well-being. Practitioners might be taught how to be more resilient, or told to improve their work-life balance. For example, the Wales Deanery’s stress management and resilience toolkit (published on the RCSEd website)

This fixation on individual responsibility shifts attention away from structural problems within the surgical profession and the NHS workforce more generally. It detracts from pressing concerns about funding, resourcing and staffing. In extreme cases, as with Dr Hadiza Bawa-Garba, there has been greater attention to institutional responsibilities and collective fault, but too often practitioners are expected to be selfreliant, with pressure points in the health service remaining neglected.

The Surgery & Emotion project organised a workshop, ‘Operating with Feeling’, at the RCS in June 201813. It brought together surgeons (including an author on this paper, Mr Simon

Fleming), historians and policymakers to discuss the role of emotions in healthcare, past and present. Our keynote speaker, Professor Averil Mansfield, described it as a ‘unique event in the history of the College’. Many participants suggested that they were grateful for the opportunity to explore the emotional side of surgery which has so long been neglected. We want to build on the success of the workshop and organise a follow-up event which will include different types of healthcare practitioners in conversations about the emotional pressures of working in the NHS. If you’d like to like to learn more about our work, check out our website: Surgery & Emotion is a research project based at the University of Roehampton and funded by the Wellcome Trust. Bringing together historical and contemporary perspectives, it explores the role of emotions in surgical practice from 1800-present. The research for this article was funded by a Wellcome Trust Investigator Award (108667/Z/15/Z). The Principal Investigator for the Surgery & Emotion project is Dr Michael Brown. n

References References can be found online at

JTO | Volume 07 | Issue 01 | March 2019 | | 27


Improving Surgical Training (IST) in T&O surgery - Our future workforce needs you now! Kapil Kumar and Mark Bowditch, Trauma & Orthopaedic Surgery SAC

Medical Education and Postgraduate Training continue to evolve, and we have seen significant changes over the last two decades.


Kapil Kumar is a consultant in Aberdeen. He has been a TPD for T&O in North of Scotland and is currently a member of the SAC.

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ll medical curricula are being rewritten according to strict new GMC templates aligned to the Shape of Training report 2013.

The popularity of surgery including T&O as a choice of career for young doctors continues to fall with almost 1:1 application to post ratios at national selection. As a consequence of EWTD, full shift rotas and loss of ‘firm’ structure there has been an increase in trainee dissatisfaction with posts that offer poor training opportunities. Many posts in early ‘Core’ years of training fall in this group, as is reflected in GMC Training surveys and Core JCST Quality Indicators. An online survey of Foundation, Core surgical and ST3 trainees conducted by TCS in 2015 revealed that during their last working shift.

• Between 45% and 78% spent no time in theatre (either observing, assisting or as primary surgeon) or performing core surgical skills and procedures. • Between 78% and 95% spent no time receiving any formal teaching (including bedside teaching, didactic teaching or simulation training) The challenge for T&O is to first, attract the early years e.g. medical students/foundation and secondly make the early training posts fit for purpose- exactly that ‘train’. In response to Health Education England HEE’s request, the RCS England reported (2015) on how to improve surgical training www.rcseng.


The principles of this were; • > 60-70% work time in training activities • enhanced role for trainers with more dedicated job plan time to deliver training • non-medical workforce to reduce service duties • reduced on call rota frequencies • reduced upheaval and continuity of training rotation including core to HST run through • focused skill acquisition via enhanced induction and simulation

Mark Bowditch is Chair of the SAC, a BOA Council trustee and Head of School of Surgery in East of England where he was TPD for 10 years. He is a Consultant in Ipswich & Divisional Director at the ESNE FT.

In addition to these HEE have produce several reports again committing to improving trainees lives. Many of these principles have been achieved in Scotland who adopted a run-through programme from the inception of MMC with trainees being recruited at ST1. These have been generally successful with the potential security of training in a single geographic location (being part of the orthopaedic family from early on) reportedly a major factor.

These trainees will have the normal ARCP assessment process within core but will involve HST TPD at their final ST2 ARCP. Although this is a run through programme trainees will have to participate in the national ST3 recruitment process, and will be expected to achieve the benchmark score to progress to ST3. IST has the full backing of HEE, JCST (all the Colleges) and many Deans and Heads of Schools (HoS) of surgery.

“With the competition increasing between surgical specialties for decreasing numbers of surgically interested young doctors; not offering or being involved in ‘early’ specialty recruitment was deemed as short-sighted by SAC and the BOA.”

Cardio-thoracic, Neurosurgery and OMFS, already have some posts in ST1 run through recruitment. In 2018 General surgery started an IST pilot whereby 30% of their posts recruited at core level selection for ST1 posts. Urology and Vascular Surgery start in 2019 and ENT is running its own ST1 run-through recruitment programme. That left T&O and Plastic Surgery without an option of offering ‘run through’ training and recruitment at ST1. With the competition increasing between surgical specialties for decreasing numbers of surgically interested young doctors; not offering or being involved in ‘early’ specialty recruitment was deemed as short-sighted by SAC and the BOA.

We are asking for volunteer Trusts to be involved and urge you to put yourselves forward via your DME/Core/ HST TPD. At first the nonmedical workforce principles may seem unachievable or costly but these aren’t necessarily so; there are numerous examples across the country where these have been achieved and money actually saved.

They also aren’t the only way to achieve the key principle which is 60-70% of work time in training activities, being properly trained and not just service. Trusts have different solutions and any can apply. This will be the future pathway for probably 6070% of our trainees (probably the % that actually know that they want a career in T&O at this early stage) whilst the remaining 30-40% will go through the core generic route. The sooner your Trust gets on board with this the more likely you will keep and have happier trainees. n For further advice, contact your Director Medical Education (who is likely to know all about it). HoS/Dean/IST office or Kapil Kumar. IST Project Team on 020 7869 6010 or

So we have engaged with the IST programme and requested to run a pilot recruitment of 30% to T&O ST1 posts in 2020. These will be recruited by the existing core selection process and occupy a two-year T&O themed ST1 and ST2 rotation (pretty much as the current core posts but they must fulfil the principles above and achieve the JCST QIs).

JTO | Volume 07 | Issue 01 | March 2019 | | 29


Trauma and Orthopaedics: A Medical Student’s Experience Chris Thornhill

Glancing through an open office door at an X-ray of a clearly broken humerus was one of my first insights into orthopaedics...


Chris Thornhill is a final year medical student and Brighton and Sussex Medical School. He has a research interest in medical students’ experiences of Trauma and Orthopaedics and how the specialty can be promoted at this level.

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inding this interesting (as it was one of the few x-rays I’d manage to vaguely interpret), I failed to run away before a surgeon’s voice shouted through the door “Are you a medical student? Present this x-ray to us!”. After stuttering out a vague reply, I was expecting the inevitable berating for my lack of X-ray knowledge. Instead, to my utmost surprise, I was welcomed into the office, taught how to properly go through an X-ray and encouraged to attend theatres later that week. At medical school, it is fair to say there’s a stereotype associated with orthopaedic surgeons, including being unfriendly and unkind. This also seems to be perpetuated by others in the hospital, being enough to put off some medical students from venturing anywhere near the orthopaedic department. However, my experiences (and that of many fellow students) don’t seem to support this negative perception held by some.

The first surgery I saw as a medical student was a DHS. The surgeon took time to explain all the x-rays, teaching along the way and making sure I was involved with what was going on. His registrar also talked me through the whole procedure beforehand, and the whole team made me feel very welcome and included with the operation. I believe these first exposures we students get to a specialty are so vitally important, as a poor experience early on may deter someone with a potential interest for the rest of their career. Many other orthopaedic surgeons have also been supportive. I remember one surgeon who stayed behind after finishing a long case at 10pm to write me a reference I needed, significantly delaying his already late finishing for the day. Others have been very helpful with research and CV building, whether this be including me in projects and papers or assisting with submissions to conferences – one junior even gave me a guided tour of Rome before our presentation! Learning about such things is daunting as research outside the curriculum is often overlooked at medical school, so being given encouragement and advice from doctors is hugely appreciated by students. The most valuable experience for me as someone considering a career in orthopaedics has been scrubbing into operations. Seeing the passion and enjoyment surgeons have is inspiring, and this can be shared with students by letting them be involved and hands-on. From performing my first suture to getting my hands on the instruments during a Copeland shoulder implant, I found the buzz of being in theatres infectious. Given the huge amount of effort and dedication a career in surgery entails, I think it’s important for people to know they’ll enjoy what they’ll be doing for years to come (and that they don’t faint at the sight of a femoral nail...). Overall, my experience of orthopaedic surgeons has fallen well outside of what I think is a wholly unfair stereotype. I have enjoyed my time in orthopaedics immensely and hope I continue to do so, but the challenge is affording this opportunity to other students. With the current decline in applicants to T&O training posts and the negative perceptions held by many at medical school, I hope more people see an interesting fracture X-ray through an open door. n

“Seeing the passion and enjoyment surgeons have is inspiring, and this can be shared with students by letting them be involved and hands-on.”


Medical students: capturing the enthusiasm David Ricketts

Chris Thornhill’s piece shows that a chance meeting in a corridor and some personal encouragement overcame the negative stereotype of the orthopaedic surgeon. How can we achieve this for all medical students?


ny medical student loitering around a clinic is a potential orthopaedic surgeon. Involving them into the business of the department is the best way to interest them in the profession. So, if I see an underemployed student I invite them into the clinic room, give them a chair next to me, address them by name and involve them in the clinic. The occasional cup of tea helps too. During the clinic, I try to demonstrate that orthopaedics is a practical specialty combining people skills and technical knowledge. There are always interesting points to make whilst deciding the right plan for that individual patient. Making sure the student gets a few appropriate questions right helps their confidence. The interested student will want to attend an operating list. During an operating session, I try to involve the student in

Female medical students need role models of female surgeons.

every step from the consenting process to the WHO check, the surgical procedure and post-operative paperwork. A running commentary of the technical steps of the procedure is appreciated. So is appropriately allowing students to use a drill and screwdriver to insert a screw or some similar step. This isn’t to everyone’s taste: one student blurted out during a hip replacement “It’s a bit medieval, isn’t it?”. By the end of some lists it is clear that you have had a hand in creating another orthopaedic surgeon. You did that.

During training medical students are allocated to brief periods of exposure to surgery (one part of this is orthopaedics) in years 3-5 of medical school. These placements can comprise a few slightly confused weeks loitering around busy clinics and lists without any personal connection being made. As Chris points out many medical students will also have the preconception that orthopaedic surgeons aren’t nice. We as a profession need to use our time with students to correct all this and present orthopaedics in a positive light.

“Any medical student loitering around a clinic is a potential orthopaedic surgeon. Involving them into the business of the department is the best way to interest them in the profession.”

Orthopaedics has a particular problem attracting female surgeons. Currently females make up 58% of medical students, 25% of orthopaedic ST3 doctors and 5% of orthopaedic consultants. It follows that we need to recruit more female consultants or there will be staffing shortages. Female medical students need role models of female surgeons. They also need to be assured that they are physically strong enough, can have children during their career and that orthopaedic surgery isn’t inherently sexist.

Many orthopaedic surgeons share fond memories of a number of firsts in their careers: the first time you were allowed to hold and use an AO drill, the first publication and the first time you understood the management of complex problems and realised this might be the right career for you. If we can get medical students (both male and female) to experience some of these firsts the future of orthopaedics will be brighter. n

David Ricketts is a shoulder surgeon at the Princess Royal Hospital and has served on various committees concerned with postgraduate education. He has over 200 publications and currently collaborates with medical students to produce audits and IRPs. JTO | Volume 07 | Issue 01 | March 2019 | | 31


Achieving and maintaining 72-hour new fracture clinic BOAST 7 standard by multiple audit cycles with associated service improvement strategies Amit Bidwai and Morshed Abir Co-Authors: Shih-Han Chen, Sammie-Jo Arnold, Kamran Bhopal, Jomy Kurian and Joby John Location of study conducted: Department of Trauma and Orthopaedics, Sherwood Forest Hospitals NHS Foundation Trust

Amit Bidwai is a Consultant Trauma and Orthopaedic Surgeon with a special interest in Shoulder and Elbow surgery based at Sherwood Forest Hospitals. He has a passion for quality improvement driven through the process of Clinical Audit. He is the current operational for the development of ODEP for shoulder implants.

The BOAST guideline 7 recommends that all acute orthopaedic injuries should be seen in a new fracture clinic within 72 hours of presentation. It includes referrals from emergency departments, minor injury units and general practice. The fracture clinics must be consultant-led. All patients must be seen in a clinic by senior orthopaedic staff or by junior staff supervised by these senior staff. Multiple audit and service improvement strategies In May 2016, we audited the 72-hour standard and we found only 21% of fracture clinic referrals met the standard. At that time fracture clinics were not always consultant-led, the clinics were booked by patient choice and convenience. There were a maximum number of patients which could be seen in a single fracture clinic. The clinics included both new and old patients.

Morshed Abir graduated in 2008 from Dhaka Medical College, Bangladesh and obtained his MRCS from Royal College of Edinburgh in 2014. He obtained MS in Orthopaedic Surgery from NITOR, Bangladesh in 2016. He has been working in the NHS since 2016 and is currently a Specialty Doctor in King’s Mill Hospital.

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The challenge was to implement changes in delivery of the service. Our strategy was to implement small changes at a time in regular intervals and re-evaluate to keep up with the sustained improvement. Audit cycles were run on each phase and discussed in the divisional meetings to evaluate progress. The initial change was to split new fracture clinics from follow-up fracture clinics. To have consistency

Figure 1: Illustrating the service improvement made with each audit cycle.


in service the new clinics were run by on-call consultants and by default, each new fracture clinic was consultant-led. The compliance improved to 72% when evaluated four months later. Further improvement strategies and their effect of compliance are illustrated in Figures 1 and 2. Each audit cycle was a week long and there were six in total over a period of 20 months. A total of 1,038 referrals were recorded, of which 944 patients were reviewed who met our inclusion criteria.

Figure 2: Illustrating the associated improvement in compliance with the standard.

During this time, the mean waiting time reduced from 86 hours in May 2016 to 32 hours in February 2018. Challenges in meeting the standard persist particularly around the timing of GP referrals and appointment DNAs and therefore 90% achievement of the standard is an acceptable level.

Summary Active performance management and multiple service improvement strategies led to achievement of BOAST 7 target for review by 72 hours in our District General Hospital. The fracture clinic service re-design improvement allowed timely access for patients to a consultant-led service ensuring

best use of the available resources. 72-hour fracture clinic compliance is now a standing audit on the departmental audit program. The authors believe the majority of the changes are reproducible and therefore encourage other institutions to adopt similar strategies to improve and monitor their compliance with the BOAST 7 standard. n

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JTO | Volume 07 | Issue 01 | March 2019 | | 33


Operations I no longer do... Sashin Ahuja

Lumbar disc replacement is a procedure which has been performed for more than 60 years. The main indication being patients with discogenic low back pain who had failed conservative treatment. Usually patients with low back pain were treated surgically with spinal arthrodesis i.e. a spinal fusion.

I Sashin Ahuja is a Consultant Orthopaedic Spinal Surgeon at Cardiff & Vale University Health Board since 2003 after training in India and UK. He is the President Elect of British Association of Spine Surgeons and the Chairperson of AO Spine UK Council. Throughout his career he has been actively involved in education (convening courses annually for senior trainees and consultants), training (as a lead for fellowship programmes with BOA recognition) and research (publishing in peer reviewed journals and book chapters). For his academic contributions he has been appointed as an Honorary Senior Lecturer at Cardiff University and a Visiting Fellow at University of Staffordshire. He has been an expert advisor to NICE and regionally for NHS Wales with regards guidelines and policy.

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n the mid 1900’s in most orthopaedic subspecialties arthrodesis used to be a standard procedure for degenerative conditions. This gradually progressed to motions preservation i.e. replacement surgery with total hip replacement and total knee replacement becoming gold standard surgical procedures for degenerative changes in the respective joints. Lumbar spinal surgery also progressed from lumbar spinal fusion to disc placement as a motion preserving procedure as a logical progression of surgery the transition from arthrodesis to replacement. Not only did lumbar disc replacement help stabilise the spinal motion segment to control the pain which was assumed to be arising from the intervertebral disc but it was postulated that a lumbar disc replacement would help prevent adjacent level disc degeneration due to motion preservation. Unfortunately over the years this hypothesis has never found sound evidence base in the literature to prove this point and concept. The lumbar intervertebral disc is not the only mobile part of the spinal motion segment as the facet joints also contribute to the motion in the segment and this has to be taken into consideration whilst designing an appropriate disc replacement. Unlike the understanding about hip and knee joints biomechanics leading to development of successful joint replacements, the understanding of the biomechanics of the lumbar spine is complex taking into account the above consideration. There are various devices on the market which have tried to replicate the biomechanics of the lumbar disc and simulate the movement in the lumbar disc. The design concepts of these lumbar disc replacements with regard to the centre of rotation and the kinetics of a disc in

the spinal motion segment aren’t consistent due to differing concepts behind the designs. This on occasions has led to modification of the devices thus creating newer generation of implants lacking clear consistency. In the last 30 years there has been a keen interest in lumbar disc replacement surgery which seemed very attractive even to me during my formative years as a senior spinal trainee. I took the opportunity to learn about the art of lumbar disc replacement by visiting specialist centres and cadaveric labs to interact with key opinion leaders in this filed. But unfortunately despite the procedure being immensely attractive it failed to convince many a mechanical orthopaedic brain to the spur the impetus to perform this procedure. One of the oldest lumbar disc replacement was the SB Charite and the data from the parent institute1 showed that the satisfaction rates were better if there was spontaneous fusion of the replaced segment and they reported a spontaneous fusion rate of 60% in their study. There is evidence to support the use of lumbar disc replacement as per a few randomised controlled trials. But a recent systematic review2 has shown that lumbar disc replacement is no better than spinal fusion. As per the 2016 NICE guidelines for management of low back pain3 the randomised controlled trials4-8 about lumbar disc replacement compared to a rehabilitation programme or spinal fusion were favourable towards lumbar disc replacement. But the quality of the evidence as per the GRADE methodology was very low hence disc replacement was not a recommended treatment. More so the main comparator for lumbar disc replacement i.e. spinal fusion wasn’t recommended either! But as orthopaedic management has advanced for most of the pathologies there is bound to be new innovation with better understanding of the spinal kinematics. In the current day and age perhaps we are better placed from a governance perspective as these innovations can be empowered by strong registry data creating a solid evidence base for their use. n

References References can be found online at


How I use… The Image Intensifier for Minimally invasive Periacetabular Osteotomy Marcus J K Bankes and Vasanth Eswaramoorthy


btaining and interpreting images is essential for success in PAO and much time can be saved if a specific routine can be established. Whilst a radiographer familiar with the procedure is helpful, it is by no means essential using the method we outline.

Marcus Bankes leads the Young Adult Hip Unit at Guy’s and St Thomas’ Foundation NHS Trust and was appointed Consultant Orthopaedic Surgeon in 2002. His particular interests include the surgical treatment of hip dysplasia and he pioneered the use of minimally invasive PAO in the UK. He was also one of the first surgeons to submit data to the Non-Arthroplasty Hip Registry and was the first Chair of its Steering Group.

Vasanth Eswaramoorthy is currently a post CCT Arthroplasty fellow at St. George’s Hospital, London. He completed his orthopaedic training in the South East London training programme. His special interest is in young adult hip surgery and has previously completed the young adult hip fellowship at Guy’s Hospital.

It is also extremely advantageous for the surgeon to take a few moments prior to getting scrubbed to demonstrate to the radiographer the manoeuvres needed to achieve adequate intra operative images, particularly the threestep false profile view, whilst the patient is being draped. These extra minutes more than pay dividends in time saved from efficient imaging during the procedure. After performing the pubic osteotomy the draped C-arm should be positioned contralateral to the operating side at the level of the patient’s pelvis. An AP hip image is obtained with the C-arm in a position of maximal horizontal movement away from the base (chassis). The base is then locked (brakes on the wheels). This has two advantages: the base is as far as possible from the operative field and the symphysis can be imaged by just retracting the C-arm horizontally.

The false profile (FP) view is obtained by a three-step manoeuvre of the C-arm: lowering the C-arm as close to the floor as possible, whilst simultaneously rotating the arm to 55 degrees (orbital rotation) and then withdrawing the C-arm horizontally until the X-ray source touches the table (Pictured below). The height of the beam can be conveniently adjusted by horizontal movement of the C-arm and/or the operating table. The beam should not be adjusted by raising the vertical height of the C-arm as this introduces another unnecessary dimension. It is during the external ischial cut that efficient radiography pays dividends as the II is switched often between the AP and FP views. The external surface of the ischium is not flat and often the lateral part of the cut is started with only the medial tine in contact with the bone. The ischium is usually cut from lateral to medial, usually with three passes of the osteotome. As the osteotome moves more medially, there is a normal artefactual appearance of the osteotome seeming to get further away from the joint. The II is left in the FP position to make the internal ischial and posterior column cuts. Prior to the iliac osteotomy a pre-correction AP view of the hip is obtained with the hip in extension, corrected for rotation by viewing the symphysis, which is easily visualised by withdrawing the C-arm 8-10cm on the horizontal lock. The II can also be used to produce a simulated weight bearing view of the hip with appropriate tilting of the tube either cephalad or caudad so that the outline of the obturator foramen on the pre-operative weight bearing pelvic radiograph is replicated on the image intensifier. The iliac osteotomy usually starts just below the ASIS but may need to be higher than this in cases of more severe dysplasia. The level of the iliac osteotomy is checked on the AP view to ensure a safe distance from the acetabulum and the II returned to the FP position to allow access to make the iliac cut and mobilise the fragment. The position is checked with both AP and FP views, then fixed with three 4.5mm self-tapping cortical screws mostly using the FP view. n

JTO | Volume 07 | Issue 01 | March 2019 | | 35


Assessing the quality of training delivered in Trauma and Orthopaedic training posts John Davies, Amy Morgan, Clare Carpenter and Ryan Trickett

In recent years there has been considerable interest in monitoring the quality of training in UK Trauma and Orthopaedic training programmes.1-3 An inherent problem in using questionnaires to assess training is a lack of description concerning questionnaire development and thus dubious validity. It is also unclear how applicable results from one Deanery are to the rest of the UK. John Davies is a Consultant Paediatric Orthopaedic Surgeon at Hull University Teaching Hospitals NHS Trust. He completed orthopaedic training on the Wales rotation. During that time, he was the Welsh representative on the BOTA committee. His fellowship in Paediatric Orthopaedics was at the Children’s Hospital for Wales in Cardiff.


he GMC standards in medical education and training state effective, transparent educational governance systems should exist and processes to manage the quality of medical education and training.4 A valid, reliable and objective measure of training quality would provide feedback concerning the training environment and monitor improvement if deficiencies exist or changes made. It may also inform training programme directors (TPDs) and trainees to better match prospective placements according to the trainees’ individual educational and training needs. Similar to Patient Reported Outcome Measures (PROMs) the development of a tool to measure training should involve the patients (trainees) and follow a defined methodology.

Aim Amy Morgan, MBBCh MRCS Trauma and Orthopaedic Registrar, studied medicine at Cardiff University College of Medicine, graduation in 2007. Following this she trained in the Wales Deanery for her foundation, core surgical and speciality training in trauma and orthopaedics. 36 | JTO | Volume 07 | Issue 01 | March 2019 |

To identify trainee important factors concerning higher orthopaedic training posts and develop a novel tool to assess quality of training posts.

Methods An initial focus group of seven trainees was video and audio recorded outside of the normal clinical training environment. The purpose was stated as collecting information concerning the trainees’

opinions of orthopaedic training posts in the Wales Deanery. Ideas emerging from the focus group were further explored by interviews with six trainees from ST4 to ST8. Interviews were conducted by two authors: one leading and one observing body language and making notes. These were audio recorded and verbatim transcripts and confirmed for accuracy with the interviewees. Anonymity was assured to all participants. Although interviews were planned to be semistructured, in reality discussions were universally free-flowing and easily moved from one topic to another. Interviews were analysed identically to the focus group. The focus group and interview transcripts were analysed by three authors (RT, CC and AM) using conventional content analysis, a technique appropriate when theory on a particular phenomenon is minimal or non-existent.5 Analysis was first performed individually and then as a group to minimise bias. Following this, the identified items were translated into questions and combined before field testing on the Wales orthopaedic training posts in 2017/2018. Using established item reduction techniques (principle components analysis) the underlying variables were defined and the tool was shortened.


Clare Carpenter BSc(Hons), MRCS, Pg Dip Sports Med, FRCS (Tr & Orth), MD, is a Consultant Trauma and Paediatric Orthopaedic Surgeon at Cardiff and Vale University Health board, working both at the University Hospital and the Noah’s Ark Children’s Hospital for Wales. A member of the British Society for Children’s Orthopaedic Surgery, she treats children with many varied paediatric orthopaedic conditions but her specialist interest is treating the consequence of neuromuscular disease.

Ryan Trickett is a consultant hand and wrist surgeon at the University Hospital of Wales, Cardiff. He has a research background in the development of Patient Reported Outcome Measures and is currently representing the BSSH in the International Consortium for Health Outcomes Measurement (ICHOM) Working Group for the Hand & Wrist.


Programme Delivery (Box 1)

Verbatim transcripts from both the focus group and subsequent interviews yielded a total of 382 minutes and over 68000 words of data – 120 minutes and 22932 words from the focus group, and 262 minutes and 45240 words from the interviews. A total of 183 individual items were identified, grouped into 3 themes: Programme delivery, training post and the trainer (Table 1).

Discussion of the overall training programme centred upon some of the unique geographical issues faced by the size and spread of the Welsh Deanery. Participants explained that travel time often impacted on available time for study or revision. Some felt that time spent “away” could impact detrimentally upon progression. Whilst these issues were clearly important, trainees also reported that they were usually easy to overcome.


Factors identified within theme

Programme Delivery

Delivery Barriers to training Research Pastoral support Exam success

Training Post

Logistics & Geography Other personnel Clinical Governance


Individualised training Communication Feedback Surgical skills Operative exposure Non-operative exposure Developing as a consultant Desire to train Trainer traits Teaching Methods Supervision Trainee development Trainee autonomy

Table 1: The trainee important factors of a good training post derived from the qualitative interviews and focus group.

Participants also highlighted the importance they placed on pastoral support or mentoring, away from their place of work. This included the idea of a “research mentor”. Trainer (Box 1) The ability to provide individualised training was a key attribute of a good trainer. Whilst this incorporated issues concerning supervision and exposure to the correct level of cases, it was clearly an important feature and thus described separately. Many trainees felt that having a single trainer in the early years was beneficial. Whilst having the input of multiple trainers later allowed broader experience. Trainees strongly felt that trainers should have an aptitude and desire to train and should be allocated specific time within their job plans to allow this. This was particularly important for clinics and operating lists where they appreciated that training cases reduced efficiency. >>

JTO | Volume 07 | Issue 01 | March 2019 | | 37


Training Post (Box 1)

Programme Delivery “It’s one thing going from home to work and another thing having to drive three hours to get there and having a trip every weekend because the kids are sick or your wife has some commitments…” “You spend a lot of time on the steering wheel rather than over a book.” “…if you spend two or more years away, it will inevitably prolong your training period…compared to someone who’s working within the city they live in.” “I move for each job where I have more than half an hours commute.” “…the issue that trainees face with certainly the pastoral side of support and having a more overall picture of trainees for those things that don’t necessarily fit neatly into rotation blocks, like personal issue that may carry over from one rotation to the next…”

Trainer “I was not quite good enough at my knee scopes, so the he tried to add on a knee scope per list... So he changed around the list to reflect my needs.” “...the best trainers are not necessarily the ones that just let you get on your own, they are often ones that take time to sit in cases and sit with you in clinic... Make sure that you are continuing to follow good habits that you’ve been taught, not just left to your own devices.”

Training Post “…what’s worse though is split sites where you have to spend maybe one clinical session or more a week in the car between two sites.” “…like having other staff member competing… having other people around... competing for cases, clinic space… consultants time…” Box 1: Indicative quotes for each theme.

The geography of posts was raised again, but specifically regarding posts where timetabled commitments were shared between multiple hospitals. Issues concerning the facilities and support staff available in a hospital were also raised. The roles of allied professionals in training were felt to be positive. However, competition with non-training clinicians for operative experience was also described. These items were transformed into 224 questions and field tested on 47 training posts. Using established item reduction techniques (principle components analysis) 7 underlying components were identified: Trainer engagement in training, trainee training needs addressed, additional educational opportunities, training post structure/organisation, surgical opportunities, matched post to seniority, training conflicts/ barriers to training, wider environment. These components cumulatively described 66% of the total variance observed in the sample. Using these components as a guide, the tool was shortened to 25 questions and is currently being prospectively validated (Table 2).

Question My trainer was proactive I felt that my training was a focus of my trainer My trainer knew my limits My trainer had a plan for my training I felt there were barriers when asking my consultant to complete a WBA I felt supported in my actions My trainer engaged actively with the ISCP process The opportunity to teach juniors aided my knowledge and training There was opportunity for rolling audits I could learn from my mistakes in a constructive way There was opportunity to participate in proper research There was no exam preparation input in this post Travel affected my training in this post

“...the best trainers are not necessarily the ones that just let you get on your own, they are often ones that take time to sit in cases and sit with you in clinic... Make sure that you are continuing to follow good habits that you’ve been taught, not just left to your own devices.” 38 | JTO | Volume 07 | Issue 01 | March 2019 |

There was structured weekly teaching separate from my compulsory teaching There was an appropriate balance between service provision and training during this training post I was unable to improve my trauma surgical skills Trauma clinics offered a good learning environment There was adequate exposure to complex cases in clinic There was insufficient opportunity to perform elective cases in theatre Theatre lists were structured to allow time for training My trainer was aware of what my needs were at the beginning of the post The training post was appropriate for my stage in training There was conflict for clinical experience between myself and another trainee/nurse practitioner/surgical fellow I had to ask for feedback The hospital environment (facilities, support staff) was well suited to provide training Table 2: The Wales Orthopaedic Training Assessment Tool.


Discussion The quality assurance of training delivered in UK Trauma and Orthopaedic posts is gaining greater attention, driven largely by trainees themselves.2-3 Formative workplacebased assessment is an established means of measuring trainees performance when gathering evidence for their Annual Review of Competence Progression (ARCP).6-7 However, their respective trainers are not subject to the same scrutiny, despite the trainers’ aptitude for this role being central to a trainees’ learning experience.2 Without objective evaluation of the quality of training, meaningful feedback for the trainers who are underperforming fails to occur. Some trainees may bear the consequences of this due to deficits in training beyond their control.6 Although unsatisfactory trainee outcomes reflect badly on the educational and clinical supervisors, this may be insufficient to cause change in units with educational difficulties. Existing feedback for quality assurance of training posts are the GMC national survey and JCST survey of Quality Indicators.8-9 Both analyse data pertaining to all specialties, with the greatest focus on safety, timetable and

rota provision. However, they lack granularity as well as thematic analysis, to explore in-depth issues relating to local or specialty specific issues. An anonymised feedback tool may provide early evidence to the training committee, without fear of retribution for trainees. This proactive approach to feedback and defining the trainer-trainee relationship is explored in the Tayside Trainee Charter from the East of Scotland.3 Our feedback tool builds upon this work, by using qualitative methodology to minimise bias ensuring face validity of the items included in a training post assessment tool. Trainees identified several attributes present in an exemplar training post. The role of supernumerary training opportunities; observed history taking and examination skills; individualised training with identification of suitable “training cases” prior to a theatre list, and proactive engagement with ISCP were all described as crucial components. Barriers training often related to the logistics of the training programme. Qualitative data applies to the individuals involved in the creation of the data and

thus, the points raised in this paper are not necessarily applicable to other specialties in Wales or orthopaedic trainees wider afield. However, these data can be used to inform potential changes to training programmes as part of a global assessment framework, and assess the impact of changes as they occur. With the impact of reduced surgical experience10, the European Working Time Directive (EWTD),11 changes to junior doctors’ contracts and pressures from winter working patterns12 affecting training at a regional level and regional variation in success in the FRCS examination13, there is a compelling argument for the need to capture objective data on training quality and experience. Having been developed using sound psychometric techniques and currently being validated prospectively, the Welsh Orthopaedic Training Assessment Tool will hopefully fulfil this role. n

References References can be found online at

Abstract submission open!

SAVE THE DATE 12-14 September 2019 · Antwerp · Belgium Important deadlines Abstract submission: 12 April 2019 Early registration: 1 July 2019

EBJIS 2019 38th Annual Meeting of the European Bone and Joint Infection Society We look forward to seeing you in Antwerp! JTO | Volume 07 | Issue 01 | March 2019 | | 39


Early Diagnosis of Pyogenic Spinal Infection James Wilson-Macdonald and Nicholas Todd

The incidence of spinal infection is 0.2-2.0 cases / 10,000 hospital admissions and is rising due to factors that predispose to spinal infection, including diabetes mellitus, intravenous drug abuse, spinal instrumentation and medical comorbidities such as hepatic, renal or cardiac failure are becoming more prevalent1- 3.


James Wilson-MacDonald is an orthopaedic spinal surgeon working in Oxford. He qualified at Bristol University and undertook a higher degree (MCh) in 1990 on bone growth and remodeling. He trained in New Zealand, France, America, Switzerland and the UK.

he trilogy of spinal pain, fever and a neurological deficit supports a clinical diagnosis of spinal infection, but patients are often apyrexial or pyrexia is modest. Spinal pain occurs in 67% of patients, motor weakness 52%, fever 44%, sensory abnormalities 40%, and sphincter involvement 27%3. Spinal pain lacks diagnostic specificity. Red flags for spinal infection include: age <20 or >55, pain in recumbency, constant progressive non-mechanical pain, fever, neurological deficit, deformity, thoracic

His main interests include the treatment of scoliosis in children, the management of back pain, spinal trauma, spinal infection and medico-legal issues. He is involved in the development of new treatments for scoliosis in children. He was senior editor of the Trauma section of the Oxford Textbook of Trauma and Orthopaedics. He has a wide experience in medico-legal reporting.

40 | JTO | Volume 07 | Issue 01 | March 2019 |


pain, immunosuppressive illness or tenderness to palpation/percussion. Leucocytosis is present in 60% of patients, the white cell count is often only modestly elevated4. The ESR is usually elevated4. The CRP is almost universally elevated5.

“We reviewed the files of 45 litigants with pyogenic spinal infection. Diagnostic delay occurred in 93% of these medico-legal cases with an average delay of nine days.�





































n = 45 Table 1: Frankel grades at initial presentation and at time of diagnosis

Delayed diagnosis occurs in 11-75% of cases6, 7 and is associated with a six times greater proportion of patients with permanent neurological deficit7.

We reviewed the files of 45 litigants with pyogenic spinal infection. Diagnostic delay occurred in 93% of these medico-legal cases with an average delay of nine days. All patients were ambulant at presentation (ASIA C-E). Neurological deterioration occurred in 82%; 31% (14/45) deteriorated to complete motor and sensory paraplegia at final follow-up (ASIA A) (Table 1). The failures leading to delay in diagnosis and treatment were as follows: Not to consider differential of infection 23 (51%) Not to consider thoracic pain as red flag 25 (55%) No haematology 8 (17.7%) Not to act on abnormal haematology 29 (64%) Not to recognise abnormal neurological findings 20 (44%) Not to act on pyrexia 8 (17.7%) (N=45) Heusner8 has stratified the clinical findings in pyogenic spinal infection, which is a useful way


of stratifying patients and predicting outcome (Table 2). The ideal is to diagnose patients in groups I and II, those in group three have a very poor outcome unless they are treated as an emergency. Once patients progress to group IV, recovery in unfortunately much less likely, and in our study only 2/15 patients made a recovery (from ASIA A to ASIA C and D).

Nicholas Todd was a Consultant Neurosurgeon and Spinal surgeon based at the Regional Neurosciences Centre, Royal Victoria Infirmary, Newcastle upon Tyne. He retired from the NHS in October of 2011 and continued in clinical practice privately until April 2015 when he took a break in order to prioritise academic work. Mr Todd has been providing medicolegal reports for over twenty years. He has given evidence in Court on a number of occasions and is currently instructed approximately 60% by Claimant solicitors, 40% by Defendant solicitors.

In general, patients with spinal infection and neurological deficit are expected to have a reasonable chance of recovery, for example, in patients with tuberculosis. However, we excluded patients with tuberculosis from this study and we noted that there were very few litigants with tuberculosis, perhaps because they less commonly have a long-term neurological deficit. We noted that the patients with tuberculosis tended to have a better long term outcome. Early diagnosis prior to a neurological deficit is the ideal. Triage systems based upon risk factors for infection are needed5, 7. The CRP should be measured in all suspicious cases, it is almost invariably raised in spinal infection (>50 in 44/45 of our patients, 98%), which confirms an infectious pathology prompting early diagnostic MRI and treatment. The burden to patients and the cost of compensation can be very high where there is a delayed diagnosis of spinal infection.


Neurological deficit


None. Spinal pain only


Radiculopathy (impairment of nerve root function with radicular pain and/or radiating paraesthesia)


Spinal cord compromise: objective neurological deficits of spinal cord compression including motor weakness, sensory impairment and/or bladder or bowel dysfunction


Complete motor and sensory paraple

Table 2: Heusner Grading Scale

In conclusion consider infection as the primary cause of pain in patients with severe spinal pain especially if they may be immune-compromised. If the CRP is higher than 50, then an emergency MRI scan should be considered, and any source of infection will be diagnosed. Timely treatment will usually arrest neurological deterioration and healing of the spine after surgery is almost universal. n

References References can be found online at

n S tio 9 LL ER N! s is 201 orma CA PAP PE issionJune er inf R O ubm y 1st furth FO OW for sturda k for N ine Sa rg.u dl n -o ea t o D h ts g .b ni w id w m tw isi ev as Ple

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07/02/2019 13:56

Trainee Section

Trainees maintaining a healthy work-life balance Matthew Brown Co-Authors: Alastair Faulkner and Morgan Bailey expedition, which brought together rowers from six nations and raised a total of £50,000 for local charitable causes. In addition to providing volunteer medical support and completing local fresh water research, Alex rowed 900km over 14 gruelling days along the Kafue River (a tributary of the Zambezi) and navigated rapids whilst avoiding hippos and crocodiles. Alex previously competed for Oxford University in the infamous 2012 Boat Race. He continues to row in the mornings before work and is often joined by his partner, Zoe, in their double boat. He plans to return in 2021 and follow the Zambezi down through Mozambique.

In July 2018, Alex Woods (Thames Valley ST4) took part in the gruelling RowZambezi expedition

The life of a surgical trainee has changed dramatically over the past decade...

D Matthew Brown is an ST8 registrar on the North East Thames (Stanmore) T&O training rotation. He is President of the British Orthopaedic Trainees Association and sits on the Councils of the BOA and the Royal College of Surgeons of England.

42 | JTO | Volume 07 | Issue 01 | March 2019 |

espite the reduction in training hours associated with the European Working Time Directive implemented for junior doctors in 2004, the average working week has been capped at 48 hours. Notwithstanding the effects of the new contract for trainees in England, we are afforded time to spend with our families, friends and pursuing extra-curricular activities. Maintaining a healthy work-life balance is important and many trainees participate in a diverse range of interests outside of the working day, covering everything from CrossFit®, cycling and yoga to painting, philanthropy, music, dancing and bee keeping! BOTA approached trainees via social media and our Regional Representative network to identify the diverse ways in which many of us choose to spend our free time.

Rowing appears to be a popular pastime. In July 2018, Alex Woods (Thames Valley ST4) took part in the gruelling RowZambezi

Continuing the charitable theme, Michael Rafferty (NW Thames ST7) is passionate about third world medicine and is a trustee of the Better Lives Foundation, which built, and now maintains, a hospital in Sierra Leone through charitable donations. Michael has made frequent visits over the last five years, leading educational courses, sourcing volunteers and supporting the scholarship programme, which has put over 30 local students through nursing, midwifery and medical studies. Justin Wei Leong (Mersey ST8) participated in the Trans-Cumbria Challenge organised by Mr. Wynn-Jones and involving 18 other participants. The challenge started from Whitehaven and ended at Pooley Bridge. This included two legs of Trans-Cumbria Cycling from Whitehaven to Honister Slate mine and Honister to Hellvellyn with an up-to 19% gradient climb up the Honister pass, as well as extreme climbing with Via Ferrata Xtreme, hiking up Hellvellyn through Striding Edge and Canoeing across Ullswater. The team managed to raise £8400 to support The Implants for Malawi project. Looking for an interest outside of work? Lauren Thomson (East Midlands South ST5) took up Gaelic football after previously playing rugby. Her partner had played and she thought “How difficult could it be?”. In 2018, Lauren’s team (Roger Casements) passed through the British league undefeated, won

Trainee Section Jo McEwan (ST5) has qualified for the national championships in weightlifting

Lauren Thomson (East Midlands South ST5) took up Gaelic football after previously playing rugby

the European Championships and qualified for the All Ireland quarter finals (losing to the eventual winners)! Gaelic football has helped Lauren manage her workload and provides both mental and physical benefits. Sarah Bolton (Stanmore ST5) balances her career with her love of exercise and finds the time most days to cycle or swim at the London Fields lido in Hackney. In 2017, she completed an Ironman triathlon and came second in a middle-distance triathlon. The Wessex rotation is particularly adept at perfecting the balance between work and play.

“In 2018, Alastair Faulkner (East of Scotland ST4) appeared as a contestant on the programme Sky Arts’ Portrait Artist of the Year.”

Jo McEwan (ST5) has always found sport to be her method of choice to unwind from work. She took up CrossFit® and weight lifting when she started her out-of-programme PhD and quickly achieved success, reaching second place at the European CrossFit® championships. This year she has continued to go from strength to strength (pun intended) and has qualified for the national championships in weightlifting.

Future orthopaedic trainees also look set to pursue a healthy work-life balance. Michael Foxall-Smith (Peninsula FY2) has always been a keen athlete and started playing American football as a student. He continues this passion and commutes 150 miles, twice weekly to Torbay, to train with his team, the Torbay Trojans. Training and competing is one of the highlights of Michael’s week and has helped him focus on his goals, including his future surgical career. Having a creative outlet through music and art is also represented among trainees. Having completed a Diploma in Musical Theatre whilst at school, Morgan Bailey (Wessex ST6) sings with Southern Voices, a chamber choir based in Winchester. She combined her musical and orthopaedic interests performing a jazz set at the 2017 British Limb Reconstruction meeting! When work or exams do not permit choir practice, Morgan has a ukulele at home, which helps her relax after work.

In 2018, Alastair Faulkner (East of Scotland ST4) appeared as a contestant on the programme Sky Arts’ Portrait Artist of the Year. Alastair painted broadcaster and comedian Meera Syal, and this experience made him consider himself an artist as well as a surgeon. Alastair is also a violinist and percussionist for the Dundee Symphony Orchestra – an amateur orchestra that recently played with renowned violinist Nicola Benedetti CBE. Balancing these interests with a career in surgery can prove challenging, although his orchestra is very understanding if on-calls prevent attendance at rehearsals. Alastair feels these creative activities complement and enhance his surgical skills. Alexandra Aframian (ST5) practices yoga to enhance her physical and cognitive strength and flexibility as well as utilising yogic methods of breath control and mindfulness to relax after work. Last summer, Alexandra completed her yoga teaching qualification in Cambodia and she combines her knowledge of yoga with her understanding of human anatomy and biomechanics when teaching and practicing yoga. Sabina Barbur (ST6) can be found on her days off designing and marketing honey-

Alastair Faulkner (East of Scotland ST4) considers himself an artist as well as a surgeon

based edible and cosmetic products, as part of a company she founded with her husband in 2013. Sabina’s NHS colleagues provide a limitless supply of dry hands and chocolate cravings, enabling her to trial her products! Through fulfilling her business interests, Sabina has been able to strike the right balance between her career and family life. Chris Jordon (Wessex ST8) used his first degree in engineering to assist in the design of his own meat smoker, which he constructed from scratch in the comfort of his own home. Hampshire is known for its trout fishing and Chris is never short of fish (or meat) to smoke, even treating his fellow trainees during the odd FRCS teaching session! Fuelling minds with smoked bacon sandwiches since 2015! We all enjoy our family and leisure time when not at work. Although we may not be winning medals, raising money or running a business, we recognise the importance of balancing the demands of a surgical career with our personal lives. Raising a family or caring for a loved one are achievements that should be celebrated equally. Although our working patterns are not perfect, we all find time to dedicate ourselves to the people and activities that matter to us. n

JTO | Volume 07 | Issue 01 | March 2019 | | 43

Subspecialty Section

Revalidation: an evidencebased intervention? (A personal view) Derek Burke

In 1982, Donald Schön noted that between 1963 and the time of his writing, an increasing public and professional awareness of the flaws and limitations of medical professions had developed. Schön further noted that the professions themselves were suffering from what he termed a crisis of legitimacy, which was rooted in their perceived failure to live up to their own standards with professionals, including doctors, misusing their autonomy for private gain, and a visible failure of professional action.1


Professor Derek Burke is a recently retired Consultant in Emergency Medicine, and Medical Director at Sheffield Children’s Hospital. Derek holds an Honorary Chair at Sheffield Hallam University. Derek works as the Responsible Officer for the Gibraltar Medical Registration Board.

ublic confidence in the professions in the UK has been similarly undermined in recent years due, in part, to a number of high-profile cases.

In 2000, Dr Harold Shipman was convicted of murdering 15 of his patients over a 20-year period, beginning with his first victim in 1975 and ending with his arrest in 1998. Shipman is believed to have killed up to 250 victims2. In 2001, Sir Ian Kennedy reported on his investigation of excess deaths in paediatric cardiac surgery cases in Bristol between 1991 and 1995 and found that between 30 and 35 more children under the age of one, died at the Bristol unit, than would have been expected in a “typical” unit. Professor Kennedy was highly critical of the “club culture” evident in the behaviour of the professionals involved in the care of these children.3 In 2013, Sir Robert Francis reported on his investigation into the poor care delivered to patients at the Mid Staffordshire NHS Foundation Trust between 2005 and 2009.4

44 | JTO | Volume 07 | Issue 01 | March 2019 |

Revalidation All doctors working in the UK must hold a licence to practise and must participate in revalidation to retain that licence. Revalidation, the process by which the General Medical Council (GMC) confirms the continuation of a doctor’s licence, was introduced in December 2012. Revalidation provides assurance to the GMC, the public, employers and the profession that licensed doctors are up-todate and fit to practise.5 In June 2000, the General Medical Council’s consultation document Revalidating doctors: ensuring standards, securing the future6 introduced the concept of revalidation for health care professionals in the United Kingdom. In February 2007, the Government published a White Paper: Trust, assurance and safety: the regulation of health professionals in the 21st century setting out proposals for future legislation on revalidation.7 In 2010, The Medical Profession (Responsible Officers) Regulations 20108 introduced the role of the responsible officer under the Medical Act (1983)9. On 3rd December 2012, The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 201210 mandated the implementation of revalidation as a statutory obligation for all employers in the UK. Revalidation is often equated with appraisal. Although the two are related they are distinct: the annual appraisal process provides much of the evidence used to make a revalidation recommendation, but appraisal itself pre-dated revalidation.

Subspecialty Section

Appraisal In 1999, the introduction of appraisal for doctors was first mooted in the Department of Health consultation document: Supporting doctors, protecting patients: A consultation paper on preventing, recognising and dealing with poor clinical performance of doctors in the NHS in England.11 The document defined appraisal and differentiated it from assessment:

In 2016, the GMC commissioned Sir Keith Pearson to undertake an independent review of revalidation over the first cycle15. Pearson investigated revalidation across the four countries of the United Kingdom. He met with responsible officers, appraisers, doctors’ representatives and system leaders, the Chief Medical Officers, employers and patient representatives. His report was published in January 2017. Pearson noted that revalidation was progressing as expected.

“All doctors working in the UK must hold a licence to practise and must participate in revalidation to retain that licence.”

“Appraisal is a positive process to give someone feedback on their performance, to chart their continuing progress and to identify development needs. It is a forward-looking process essential for the developmental and educational planning needs of an individual. Assessment is the process of measuring progress against defined criteria. For example, trainees may have to meet an agreed standard, as specified by a curriculum, to assure their progression or completion of a course or programme. It’s essential purpose is to validate training and development achievement.” The report proposed that appraisal be made compulsory for doctors working in the NHS. In 2001, Advanced Letter (MD) 5/01 provided advice and documentation for NHS organisations to support the implementation of appraisal12. In 2003, appraisal became a contractual requirement for consultants under the new consultant contract.13

The evidence base for revalidation In 2013, the NHS Revalidation Support Team commissioned the King’s Fund to undertake a review of the impact of medical revalidation on the behaviour of doctors and organisational culture14. The study was undertaken within seven case study sites across England. The report, published in March 2014, noted that revalidation is a regulatory process which complements clinical governance: each process strengthening the other. The study found that it was still early days for revalidation and that designated bodies, appraisers and appraisees were focusing on implementing the process of revalidation. There was no evidence provided to suggest that revalidation was having any positive impact. This is not surprising as at the time the report was published only medical leaders, responsible officers and 20% of doctors had been revalidated.

Pearson highlighted that revalidation has already delivered significant benefits by ensuring that annual appraisal was taking place and changing doctors’ practise through reflection upon specified types of information. Pearson also highlighted that revalidation had enhanced clinical governance within healthcare organisations by identifying poorly performing doctors and providing support to them to improve. Pearson expressed confidence that these developments would lead to safer and better care for patients. Pearson made sixteen recommendations for the GMC, healthcare organisations and their boards, and for the government health departments. In July 2017, The GMC published its action plan in response to the Pearson report and identified six priority areas16:

1. Making revalidation more accessible to patients and the public. 2. Reducing burdens and improving the appraisal experience for doctors. 3. Strengthening assurance where doctors work in multiple locations. 4. Reducing the number of doctors without a connection. 5. Tracking the impact of revalidation. 6. Supporting improved local governance. In 2014, the GMC commissioned an independent UK wide long-term evaluation of revalidation to explore its impact and consider ways to shape it in the future by a collaboration of researchers, UMbRELLA (UK Medical Revalidation Evaluation coLLAboration), led by Plymouth University. The study was undertaken between 2014 – 2017 and the final report was published in February 2018.17 The UMbRELLA study consists of seven work packages, organised by research methods and designed to collect and analyse

quantitative and qualitative data across revalidation’s component activities. The completed study involved nine literature reviews, analysis of pseudonymised GMC data relating to 281,000 doctors, 8 surveys with over 85,000 participants, the recording and analysis of 44 appraisals, interviews with 156 doctors and patient representatives and reviews of 24 doctors’ portfolios. The study addressed six research questions: • Is the GMC’s objective of bringing all doctors into a governed system that evaluates their fitness to practise on a regular basis being consistently achieved? • How is the requirement for all doctors to collect and reflect upon supporting information about their whole practice through appraisal being experienced by revalidation stakeholders? • Is engagement in revalidation promoting medical professionalism by increasing doctors’ awareness and adoption of the principles and values set out in good medical practice? • Are revalidation mechanisms facilitating the identification and remedy of potential concerns before they become safety issues or fitness to practise referrals? • How do responsible officers fulfil their statutory function of advising the GMC about doctors’ fitness to practise and what support do they have in this role? • Are patients being effectively and meaningfully engaged in revalidation processes? There were 28 key findings. One of the report’s authors summarised the findings18: • Most doctors have been brought into a governed system, with a rise in engagement in annual appraisal. • There is a variation in revalidation outcomes and experience of revalidation for some groups of doctors. • While reflection in appraisal is key for generating change, reflection is often seen as just a product of appraisal, and not necessarily translated into ongoing reflective practice. • Both doctors’ and patients’ engagement with patient feedback is inconsistent, and current patient feedback tools require refinement. >>

JTO | Volume 07 | Issue 01 | March 2019 | | 45

Subspecialty Section

In April 2018, The GMC responded to the publication of the UMbRELLA report and noted that19: • Most doctors now had a regular appraisal. • Appraisals were helping to address local concerns. • Most doctors were collecting the supporting information required for appraisal. • Some doctors found the process of data collection to be difficult. • Appraisal was challenging for locum doctors. • Deferral rates were higher for younger doctors, females and those from BME backgrounds. In March 2018, in the GMC issued an update to Guidance on supporting information for appraisal and revalidation.20 The GMC stated that there would be no change to the information to be collected and reflected on, but in response to one of Pearson’s key recommendations, they would clarify what is mandatory for appraisal and revalidation from the GMC’s perspective and how that may differ from any requirements set by employers, royal colleges or faculties.

every year unless there are mitigating circumstances preventing you from doing so (for example if you were on long term sick or maternity leave), it should be a developmental experience as appraisal and revalidation are not pass or fail exercises. • More information about how you should collect feedback from colleagues, including how colleagues should be selected. • Reinforcing the importance of doctors, who have multiple roles, gathering and reflecting on information that covers the whole of their practice. • A new section to provide clearer guidance on our requirements for doctors in training and more direction for doctors who may find collecting certain aspects of supporting information difficult.

as their reason, in comparison with 61% giving going overseas as the reason for relinquishing their licence. Of the 18,276 doctors who applied to voluntarily erase their names from the register, only 1% gave revalidation as their reason, in comparison with 62% giving retirement as the reason for relinquishing their licence.

Conclusion More than a decade has elapsed since the first proposals for revalidation and its implementation. Over that period, there were two major re-organisations of the NHS and significant changes in the regulatory environment. Trying to tease out the impact of revalidation from these other changes that occurred in the same period would be difficult. The qualitative data published by the GMC provides some evidence for the effectiveness of revalidation. Most doctors (76%) who had a recommendation submitted in the first five years had a positive recommendation. The fact that a proportion of doctors were deferred (24%) and a small number had their licence withdrawn for failure to engage (0.2%) provides evidence that revalidation acts as a filter, although it is not possible to state whether the thresholds are set at the correct levels. These figures would suggest that revalidation has been successful in providing assurance that doctors with a licence are up to date and fit to practise, which was the main intention for introducing it.

“In 2016, the GMC commissioned Sir Keith Pearson to undertake an independent review of revalidation over the first cycle. Pearson highlighted that revalidation had enhanced clinical governance within healthcare organisations by identifying poorly performing doctors and providing support to them to improve.”

• More guidance on the balance between the quality and quantity of supporting information needed for appraisal for revalidation so you don’t feel pressured to gather too much evidence.

In May 2018, the GMC published Revalidation: data from the first five years which summarised the key statistics about the first five years of revalidation (between December 2012 and 31 March 2018). In total, 258,570 recommendations were made for 198,142 doctors: 96,748 (76%) recommendations were to revalidate; 61,180 (24%) were to defer and 642 (0.2%) were recommendations of non-engagement.21

• Explaining that we do not set either a minimum or a maximum quantity of supporting information that you need to collect.

Over the same period, 3,984 doctors had their licences withdrawn for failure to engage with revalidation.

• Emphasising that, although you must participate in a whole practice appraisal

Of the 45,401 doctors who relinquished their licence, only 5% gave revalidation

The GMC’s key improvements include:

In terms of appraisal, the qualitative data from the studies reported suggest that the majority of doctors find the appraisal process to be a valuable one. It is still early days for revalidation and appraisal, but the indications are that it is having, and will continue to have, a positive benefit on the professional development of individual doctors practising in the UK and on improvements in patient safety. Getting specific evidence that isolates the impact of revalidation and appraisal from other changes in the organisation and provision of healthcare will continue to be challenging. n

References Table 1: Revalidation recommendations between December 2012 and March 2018 (GMC).

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References can be found online at

JTO | Volume 07 | Issue 01 | March 2019 | | 47

Subspecialty Section

The Role of the Responsible Officer in the Independent Sector Dr Charlotte FJ Rayner MD FRCP, Consultant Physician, Responsible Officer Aspen Healthcare Ltd

Designated bodies (DB) within the Independent Health Sector (IHS) vary from a single specialist clinic through to a group of hospitals throughout the UK, providing a full range of services from outpatient care through to Level 3 intensive care. Within this article, I will concentrate on the key differences and challenges that face the IHS Responsible officer (RO) with reference to the independent acute hospital setting.


Dr Charlotte Rayner is a Consultant Physician with a specialist interest in respiratory and general medicine. Charlotte now works solely in private practice and is a member of the MACs at Parkside Hospital, Cancer Centre London (CCL) and St Anthony’s Hospital, Cheam. Charlotte was appointed as Responsible Officer for Aspen Healthcare in 2012.

he medical profession (Responsible Officers) regulation 2010 sets out the role and responsibilities of the RO: these regulations cover the practice of doctors across all healthcare settings1. The requirement to provide quality assured appraisals with appropriate reflection of practice and identification of a personal development plan (PDP) annually over a 5-year cycle in order to enable a revalidation recommendation, is a core component of the role of an RO, whether working within the NHS or within the IHS2. The IHS RO must also ensure that all doctors’ practice is safe and appropriate to scope when these doctors are working within the independent designated body, despite the fact that the majority of doctors with practicing privileges do not have a prescribed connection (PC) to the independent hospital DB. The first challenge is that each IHS DB may have hospitals and clinics across the UK and the RO will therefore have responsibility for a range of doctors across different geographical locations. Whilst the majority will have a prescribed connection elsewhere, which is predominately in the NHS, the day-to-day oversight of practice in the IHS DB falls to the RO working alongside the senior management team for that hospital or clinic. The key differences in the structure of IHS care provision are as follows: 1. Most doctors working as consultants within the IHS designated body: a. Have practicing privileges rather than being employed. b. Will have a prescribed connection to an NHS Trust and therefore their DB and RO will not be the IHS RO.

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c. Will have practicing privileges at more than one IHS provider. d. May work within a limited liability partnership or working within his or her own company or be self-employed. 2. Most doctors are: a. Consultants b. On the specialist register c. Do not have a team of junior doctors working with them. d. Some of the doctors have qualified in Europe and may work both in Europe and the UK. 3. A number of doctors will work solely in the IHS and these doctors will have a prescribed connection to an IHS DB and to the RO of that DB. The structure and oversight of these doctors by the RO is similar to that in the NHS. There is a lead appraiser, trained appraisers and an annual appraisal. There is quality assurance of the appraisals, provision of 360 feedback and provision of data to fully populate the appraisal. For these doctors, with a prescribed connection, the oversight and understanding of scope of practice is very clear overall. However, some of these doctors will have a PC to a different IHS RO. 4. The junior doctors working within the IHS are either: a. In training posts elsewhere, including in research posts earning additional money when employed by the designated body, and have an RO at the Trust in which they are training, with links to the deanery; b. Employed by an agency with an RO c. May be employed directly by the DB in a full-time non-training role as an RMO.

Subspecialty Section

A further challenge therefore, for the RO, is to ensure that all doctors with practicing privileges, whether they have a prescribed connection or not to the RO: 1. Will have completed an application to hold practicing privileges. 2. Will have provided references, including a reference from their existing RO. 3. Will have peer review through the medical advisory committee to ensure fitness to practice and review scope of practice. 4. For those solely in private practice, will undergo an annual review of practice. 5. For those with an NHS prescribed connection, will undergo a formal biennial review of practice.

7. The RO must review regularly the general performance information held by the designated body, including clinical indicators relating to outcomes for patients identify any issues arising from that information relating to medical practitioners, such as variations in individual performance; and take all reasonably practicable steps to ensure that the designated body addresses any such issues.

It is therefore essential that there are clear and open lines of communication between the RO with: 1. The SMT at each facility within the DB. 2. The medical advisory chair, committee and governance lead at each facility. 3. The NHS trust ROs where the consultants have prescribed connections.

“The Independent Health Sector Responsible Officer must ensure that all doctors’ practice is safe and appropriate to scope when these doctors are working within the independent designated body.�

6. Each doctor with practicing privileges will have to submit at least their full output form and PDP after each appraisal and there is a requirement that there is evidence that their private practice has been reviewed as part of the appraisal.

In addition, working with the Senior Management Team (SMT) of the DB, the RO will need to ensure that these processes are quality assured and be able to demonstrate this both to the Board of the DB, as part of the annual board report, and as part of external quality assurance, such as by the CQC.

4. The NHS trust or agency where the junior doctors have prescribed connections. 5. Other independent sector facilities where the consultants may have a prescribed connection or practicing privileges.

6. Other ROs for the IHS 7. Sites of practice overseas whether charitable or for remunerated work 8. The ELA from the GMC. >>

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Subspecialty Section

In addition, attending and actively engaging in the RO network meetings provides a forum for sharing of ideas, expertise and best practice across the NHS, training and IHS sectors. The Association of Independent Healthcare Organisations (AIHO) provides a forum for ROs to meet and share best practice and challenges in the IHS. Finally, open lines of communication with the ELA from the GMC, coupled with the twice-yearly regular meeting, provides an excellent resource again to discuss and ensure appropriate response when cause for concern is identified. The RO also needs to work with the central SMT for the DB to ensure structures are in place to ensure: 1. Consultants are provided with a full data set of their private practice to enable appropriate and full discussion of scope, activity and outcomes at their appraisal.

4. Wherever the doctor’s prescribed connections laid elsewhere, that their reflection, outcomes and learnings are discussed at their appraisal and that the RO receives appropriate communication. Given that an independent sector RO is overseeing several hospitals and clinics at different locations, there is a need for the RO, along with the DB governance lead, to oversee, and also as appropriate, to provide: 1. Standard components to the MAC agenda and each facility, enabling appropriate quality assurance and appropriate collection of comparative data.

fully aware of the requirements to continue to hold practicing privileges, and how the designated body can help to ensure that they are complying with good medical practice, to help ensure that they are fully populating their appraisal with appropriate information across the whole scope of their practice, ensuring that they are aware of the support and help that can be given to them by the hospital facility that they are working to meet the ever increasing demands placed upon them in terms of: 1. Compliance with the Competition and Markets Authority ruling3. 2. Compliance with PHIN.

“Perhaps one of the most challenging areas is visibility and accessibility to individual consultants. This is vital in ensuring that doctors who have practicing privileges are fully aware of the requirements to continue to hold practicing privileges, and how the designated body can help to ensure that they are complying with good medical practice.”

2. That when cause for concern arises, that this is investigated safely and promptly with early use of a decisionmaking group and as part of the DMG, that a standard agenda is adapted, that each cause for concern, but that agenda contains the essential components to ensure: a. Safe care of patients. b. Careful and appropriate investigation. c. Appropriate lines of communication with; i. Patients or staff that have raised concerns. ii. The consultant’s RO when the PC is elsewhere. iii. Other units where the consultant may be practising. a. To ensure that the consultant undergoing investigation is given appropriate support. b. That there is appropriate communication where necessary with the GMC. c. When needed, there is appropriate communication with the NHS, CQC and with insurance bodies.

As part of the DMG the RO will also ensure that: 1. Appropriate measurements are taken to address concerns, which would include, but not be limited to, recommendations to the doctor regarding reflection or need for training or re-training. 2. The Doctor is offered appropriate rehabilitation. 3. Any systemic issues within the designated body that had contributed to the concerns had been identified.

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2. Shared learning across the hospitals and clinics when cause for concern is identified, including discussion of the shared learning at each MAC and at each facility governance meeting. 3. Support for the development of multidisciplinary team meetings with appropriate agenda and output forms, in view of the increase in complex care being provided within the independent sector. 4. Case investigator training and reflection meetings at which best practice is identified and practice improved. 5. Appraisal training and, reflection and ongoing development of appraisal systems to match the appropriate assessments of full scope of practice for doctors working in the independent sector. 6. Meetings where members of the MAC from different facilities can meet with input from board members, the governance lead and from the RO, again, to further develop quality care to ensure shared learning. Perhaps one of the most challenging areas is visibility and accessibility to individual consultants. This is vital in ensuring that doctors who have practicing privileges are

3. Ensuring that they are continuing to develop their own performance. 4. When cause for concern is identified, not only is the doctor being appropriately investigated, but also that the doctor is given appropriate support at a time that can be very challenging to them. 5. Access to help and support when unwell. 6. To assist doctors as they move towards retirement to safely transfer care of patients to others and store records appropriately.

The RO in the IHS must ensure that doctors are encouraged to maintain and improve their practice and by doing this, will play a crucial role in improving and maintaining the quality and safety of patient care wherever a patient receives treatment. n

References 1) 2010 No. 2841 HEALTH CARE AND ASSOCIATED PROFESSIONS DOCTORS The Medical Profession (Responsible Officers) Regulations 2010 2) revalidation/revalidation-for-responsibleofficers-and-suitable-persons 3) https://assets.publishing.service. uploads/attachment_data/file/453465/ Private_Healthcare_Market_Investigation_ Order_2014.pdf

Subspecialty Section

Revalidation in Orthopaedics Lee Breakwell

As the sixth anniversary of the introduction of Revalidation for Doctors in the UK approaches, we have looked back at the rationale behind the inception, design and implementation of the current system. We have reviewed what evidence we have as to the value and effectiveness of the process, and whether it has improved the professionalism of doctors or the safety of our patients. We will now look at the requirements and processes affecting orthopaedic surgeons currently working in the UK.

M Lee Breakwell is a full-time spinal surgeon at Sheffield Children’s and Teaching Hospitals. He is a current Trustee of the BOA and past President of BOTA. He codesigned the British Spine Registry and represents the BSS. Lee is Secretary of the UK Spine Societies Board, as well as Chairman of Sheffield Orthopaedics Ltd.

any orthopaedic surgeons work in more than one hospital and in other roles, and as such, need to be aware of their duty to review their whole practice at the time of appraisal. Fundamentally, a doctor must include evidence on any role they perform which requires a medical licence to undertake. This of course, covers clinical work, but also clinical research, teaching/ training, and management. In addition to the notion of whole practice review, demonstration of the appropriate nature of the scope of a doctor’s practice is required. To some, this may seem obvious, but in the light of the Kennedy and Verita Reports into the behaviour of Ian Paterson, the processes, defined by Dr Rayner, as to the triangulation of information between Designated Bodies about any individual doctor, must be improved. It is now a GMC requirement for all doctors to undergo annual appraisal and is a contractual obligation in the NHS and a necessity to maintain privileges in the Independent Sector. Whilst appraisal at its best can be a rewarding, inspiring, challenging

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and nurturing experience, it is often lost in the process of a busy life and relegated to a perfunctory exercise of task-oriented boxticking. The GMC has recently recognised via social media, that current workloads and pressure within the system are affecting doctors on both a daily basis and in their future planning. It is vital therefore, to ensure prospective information gathering occurs to avoid the otherwise inevitable last-minute rushed and superficial preparation for appraisal. Several streams of evidence are required to complete a satisfactory appraisal, and a series of these leads to a positive recommendation for revalidation. Surgical disciplines lend themselves well to evidence capture on certain levels, with procedures easily described offering clear description of a doctor’s role. Orthopaedics has led in this area, with rigorous data capture for many via the sub-specialty registries. Participation in available national audits is another GMC requirement under Good Medical Practice, and increased compliance with registries is therefore to be encouraged. A surgeon’s output from the recognised registry is an ideal method of demonstrating the nature of their practice and enables scrutiny of scope and breadth of the work undertaken in all centres. In addition to logbook type evidence, there is a requirement to demonstrate participation in quality improvement activity. Whilst this is typically enshrined in the process of audit,

GMC Chair recognises current strain on doctors.

Subspecialty Section

and challenge the doctor on their practice. This will formulate a personal development plan (PDP), which encourages emphasis on an area for improvement or professional enhancement. The basis of revalidation then follows that review of the annual appraisal output, and progress against the agreed PDP forms the basis for a decision regarding recommendation. The GMC bestows and renews a doctor’s licence to practice, but relies heavily on the Responsible Officer and their appraisers to make that decision.

Supporting information for appraisal and revalidation (GMC).

this is by no means the only option, and the GMC has avoided being overly prescriptive in this area to allow professional judgement and flexibility. Feedback is a fundamental part of being human, with constant interaction with others honing our responses and behaviours. Formalising this process has, at times, stunted the natural flow and makes many uncomfortable. Documented feedback from both colleagues and patients is a strict requirement and a dedicated 360-assessment is mandatory in each revalidation cycle.

to reflect on positive aspects of professional life in addition, to ensure balance is maintained and positive encouragement for the future. Increasingly, this evidence will have been recorded in electronic repository, which can then be shared and reviewed by the appraiser. Designated bodies have a duty to ensure well trained, supported and remunerated appraisers are available for the volume of connected doctors. Working within the GMC guidelines and locally agreed processes, the appraiser will review the evidence

“Feedback is a fundamental part of being human, with constant interaction with others honing our responses and behaviours. Formalising this process has, at times, stunted the natural flow and makes many uncomfortable.”

On collation of this evidence, the most important step can then be undertaken. This is the requirement to demonstrate reflection. Any functional surgeon will reflect multiple times a day during practice, whether it be about a decision in clinic or during a procedure. Review of imaging leads to reflection on accuracy of diagnosis or implant position. Where many struggle is in the recording of this. Clinicians naturally gravitate to the selfcritical and include evidence of mistakes or poor outcome leading to complaints, and whilst this does enable personal and system learning, it does not maximise the nurturing, developmental aspect of the appraisal. It is imperative

Overall, revalidation is a relatively low benchmark, requiring collation of evidence of day-to-day practice, and a reflection upon this evidence. Much of the process is formative, with the summative approach of testing having thus far been avoided. Inherent within the process is a repeated test of probity, whether that be the formal declaration of health, or the checks and balances created by the flow of information between agencies. The evidence from Professor Burke’s article is that revalidation is beginning to improve internal communication and quality improvement locally. Orthopaedics as a profession must work together to ensure that we continue to demonstrate leadership on data collection and the interrogation and implementation into practice of outcomes data. Consequent to this is the current preference to resist the professionally damaging and often misleading publication of low-quality surgeon level data in the public domain, which offers little benefit to any party. This position can only be justified and defended if individuals utilise the opportunity afforded them by appraisal, to openly discuss and reflect upon their data and employ practice changes to continually improve as a doctor and offer benefit to patients. n

Revalidation process (GMC).

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In Memoriam

Roger Gilbert Checketts 25th May 1936 - 2nd October 2018

Consultant Orthopaedic Surgeon, Sunderland Royal Hospital.


oger Checketts was born on 25th May 1936 in London, although was raised in Birmingham. He went to Medical School in Sheffield and during his elective attachment, he was awarded the honour of an academic four-month scholarship to Harvard Medical School. At that time, Sheffield was a hotbed of academia and Roger initially thought that he was destined for a career in medicine. However, after working as a research fellow with Professor Duthie, he acquired his MD on ‘Ulceration After Vagotomy’ and joined the Sheffield surgical registrar scheme, which included a focus on orthopaedics. He was persuaded to continue a career in orthopaedics by Sir Frank Holdsworth, training with such luminaries as Brian McKibbin, John Sharrard and David Evans, as well as Sir Frank himself. Following his recommendation, he was appointed to Glasgow Western Infirmary as a Senior Registrar to Roland Barnes, a blunt Mancunian but an inspiring teacher. In 1973, Roger was one of the first trainees in the United Kingdom to be

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awarded the new Certificate of Completion of Surgical Training and was appointed to Sunderland with the encouragement of the newly appointed Professor Jack Stevens in Newcastle; the two surgeons developed mutual respect and lifelong support for each other. Within two years, Roger’s two senior colleagues had unexpectedly suddenly died, and Roger was left as a single relatively junior surgeon to provide orthopaedic support to the whole of the town, which in those days was based on heavy industry with many injuries and accidents. At the outset, Roger remained dedicated to the high-quality service and had a particular interest in trauma and fracture management. At that time, most fractures were treated out of hours by juniors. He insisted on daily fracture clinics (including Christmas Day) and three daytime trauma lists, both with senior supervision and senior anaesthetists servicing them. This commitment to trauma was unique in the Northern Region, and probably the country. Now, the trauma week and trauma team concept initiated by Roger and his team is universal. He will best be known for his development of the Orthofix system, not only in external fixation of long bone fractures, but in its use of leg lengthening; in this respect, he was an international expert and teacher, travelling around the world lecturing and teaching in workshops. He wrote a definitive paper on classification of pin-site infection, which is still quoted in the literature. He collaborated extensively with other units and colleagues on the management of hip fractures at a time when a nearby hospital was still treating these injuries on traction. He was the main protagonist of limb salvage surgery for bone tumours in the North East, and during the eighties, before the specialist unit was set up in Newcastle, he successfully

performed a large number of lower limb bone tumour excisions including the innovative ‘rotationplasty’ procedure for distal femoral osteosarcoma. His teaching style was to question and he always attempted to get the trainees to work out answers for themselves. His response was usually “What do you think?”, and then took them through a logical thought process to reach a solution. The joint Friday morning ward rounds were legendary. He had great concern and support for his trainees who reciprocated the affection. However, beware the trainee who did not come up to match his high standards! He was responsible, with Professor Jack Stevens, for setting up the registrar rotating training scheme between Sunderland, Newcastle and Durham in the 1970s and current trainees continue to be grateful to him for the huge amount of work that he did in developing the now massive Northern Orthopaedic Rotation. Following retirement, he continued his teaching style of questioning, as well as his involvement in orthopaedic research, and in 2005, he was awarded a doctorate in Medical Ethics and Law from the University of Glasgow. There are so many aspects of Roger and his practice and friendship that will leave lasting memories. But he will be remembered by all of us as, basically, a loyal, warm, and supportive colleague loved (for the greater part at least) by his patients. He put Sunderland on the map and it became the first choice for trainees and potential consultants to apply for posts. He was determined that all consultants coming to Sunderland were compatible with the ethos that he had developed, and most particularly would “get on with each other”. Roger claimed to have three great loves – orthopaedics, his family, and Celtic Football club. Politically astute as always, he refused to put them in numerical order! He died after a short illness on October 2nd 2018, leaving his wife Helen and children, Elspeth, Matthew, Andrew and Paul and several grandchildren, as well as his three Canadian half siblings. n

“His teaching style was to question and he always attempted to get the trainees to work out answers for themselves.”

In Memoriam

John Beavis

8th June 1940 - 5th December 2018


t the age of 53, the orthopaedic surgeon John Beavis retired from the NHS. Twelve months later, a chance encounter with the businessman Simon Oliver led to John founding the charity Ideals (International Disaster and Emergency Aid with Long Term Support ( John Beavis was born in Brighton in June 1940. He took degrees at University College London in biochemistry, followed by medicine, qualifying in 1967. He credited his success to the postwar Labour government, saying: “A society that gives to you makes you want to give back”. John shared such ideals with his wife, Kate Frankland, a teacher. Their three children and happy marriage gave John a sense of lasting stability. From 1967 to 1973 he served in a Royal Marines commando unit as a medical officer. The experience sparked a lifelong fascination with trauma, orthopaedics and reconstructive surgery. In 2005, John was in northwest Pakistan, co-ordinating the flow of medical supplies for villages ravaged by an earthquake. One village, Bedadi, was then transferred to new land purchased by Ideals. There, with help from some of the 200 villagers, Bedadi was rebuilt. John died from lung cancer on December 5. In the New Year Honours for 2019 he was appointed OBE for services to victims of war and disaster. On receiving the Hugh O’Flaherty International Humanitarian Award in 2014, John had remarked: “I am a very reluctant recipient as I am convinced that I have done nothing out of the ordinary.” n

This is an excerpt from an article published in The Times on Saturday January 5th 2019.

Shona Murray

23rd March 1952 – 28th December 2018


hona was born in Musselburgh and qualified from the University of Edinburgh in 1977. She started as a Lecturer in Pathology but was soon drawn to surgery, climbing the ranks in what she described as a ‘hostile career choice’ at that time. She was appointed as an honorary consultant in Glasgow, where she spent 10 years and thereafter moved to the Freeman Hospital in Newcastle (1998). Shona’s background made her ideally suited to Orthopaedic Oncology. With her characteristic determination and support of Professor Archie Malcolm and Sir Alan Craft, she established the sarcoma service for the North of England, which remains an exemplar of multidisciplinary cancer care. Shona’s pragmatism and ability to work with those around her made the service grow from strength to strength and soon received the appreciation and warm support from the entire region. She undertook pioneering surgery and devoted her life to her craft. She leaves behind hundreds of sarcoma survivors who still have deep connections with her. Shona was a fiercely private individual who kept her accolades to herself. A wry observer of human behaviour and an engaging storyteller - few people can lay claim to sharing an apple turnover with the future President Assad (who was at the time an ophthalmology registrar in Glasgow). Shona retired in 2015 to Golspie in Sutherland. Instead of an idle retreat, she began a Psychology degree with an Honours thesis investigating the coping mechanisms of surgeons - an area in which she would have brought unique insights. She leaves behind her mother Mary, her brother Paul and her dog Fritzi. Shona will be dearly missed by all who came to know her. n ‘mors certa, hora incerta’

JTO | Volume 07 | Issue 01 | March 2019 | | 55

Products and Courses 14th Trauma & Orthopaedics Update

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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

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