Journal of Trauma & Orthopaedics - Vol 7 / Iss 3

Journal of Trauma and Orthopaedics Volume 07 | Issue 03 | September 2019 | The Journal of the British Orthopaedic Association | boa.ac.uk

The Watanabe Club: Fifteen years on p34

Measuring the impact of simulation training p54

The clinical benefits of closed incision negative pressure p64

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Journal of Trauma and Orthopaedics

Contents

In this issue...

3 5

From the Editor

Bob Handley

From the President: Time for reflection

Phil Turner

6- 7 Latest News 8-33 News 8 News: Surgeon is first female

winner of ‘SAS: Who Dares Wins’

Louise McCullough

10 News: BOA Strategy Update and

Committee Restructure

Phil Turner

20 News: Honorary Fellowships and

Presidential Merit Award

30 News: CAOS UK Restructure

Arjuna Imbuldeniya

32 News: Conference listing 34 The Watanabe Club:

Fifteen years on

Andrew Wallace

36 NJR: The experience of an

outlying unit – using data to improve performance

Mark Forster and Sanjeev Agarwal

42

40 Unconscious Bias:

The Trainee Experience

Jessica Caterson, Olivia Ambler and Sarah Lancaster

have a ‘stupid’ stereotype?

42 Why do orthopaedic surgeons

Robin Paton and Phil Turner

44 Measure twice cut once:

Grey Giddins and Lisa Hadfield-Law

64 Subspecialty Section: Mode of action

claims; GIRFT tries BOASTing too

The point of no return

46 Learning from clinical negligence

John Machin and Tim Briggs

48 How to… take clinical photographs.

Top Tips for camera phone clinical photography

Richard Myatt, Andrew Titchener and Bob Handley

and medico-legal matters

52 Medico-Legal: Orthopaedic surgeons

and clinical benefits of closed incision negative pressure: A literature review

Brian Andrews

70 Subspecialty Section: Closed incision

negative pressure wound therapy in orthopaedic surgery

Theodoros Bouras, Brian Andrews and Rhidian Morgan-Jones

Keeping the WOLLF from the door or WHISTful thinking?

72 Subspecialty Section:

Chris Wilson

educational impact of simulation training in Trauma and Orthopaedics

Matt Costa and James Masters

54 Simulation Section: Measuring the

74 In Memoriam:

76 Products, Courses and Events

Hannah James

58 Trainee Section: A New Era

Howard Steel, David Rowley, Raymond Nim-Wah Chan

in T&O Training

Ran Wei, Alastair Faulkner and Lisa Hadfield-Law

Download the App The Journal of Trauma and Orthopaedics (JTO) is the official publication of the British Orthopaedic Association (BOA). It 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 around the world 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. Available at the Apple App Store and GooglePlay – search for JTO @ BOA.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 01

UK & Ireland

Education

2019/20

Hand Fixation Course Oct 7-9, 2019. Leeds

Wrist Fixation Course Oct 10-11, 2019. Leeds

Introductory Course for Undergraduates

Small Animal Fracture Management for ORP - TBC

Basic Principles of Fracture Management

Jun 12-13, 2020. Oxford

Nov 10, 2019. Wymondley

Nov 11-14, 2019. Wymondley

Introductory Course for Undergraduates

Principles in Small Animal Fracture Management

Jan 12, 2020. Dublin

Jun 14-16, 2020. Oxford

Basic Principles of Fracture Management

Advanced Techniques in Small Animal Fracture Management

Jan 13-16, 2020. Dublin

Basic Principles of Fracture Management for ORP

Jun 14-16, 2020. Oxford

Jan 14-16, 2020. Dublin

Paediatric Course Feb 5-6, 2020. Leeds

Introductory Course for Undergraduates Mar 1, 2020. Edinburgh

Basic Principles of Fracture Management Mar 2-5, 2020. Edinburgh

Shoulder & Elbow Course with Anatomical Specimens Mar 16-18, 2020. Newcastle

Management of Facial Trauma (Principles Course for Surgeons) May 6-7, 2020. Leeds

Management of Facial Trauma (Principles Course for ORP)

Foot & Ankle Reconstruction with Anatomical Specimens May 7-8, 2020. Leeds Mar 31-Apr 1, 2020. London Management of Facial Trauma Current Concepts Course with Anatomical Specimens (Undergraduates - TBC) Apr 22-24, 2020. Coventry

Introductory Course for Undergraduates

May 9, 2020. Leeds

Jun 21, 2020. Leeds

Basic Principles of Fracture Management for Surgeons Jun 22-25, 2020. Leeds

Advanced Principles of Fracture Management Jun 23-26, 2020. Leeds

Principles Course - Degeneration

Advanced Principles of Fracture Management for ORP

Mar 20-21, 2020. Cambridge

Jun 24-26, 2020. Leeds

Basic Principles of Fracture Management for ORP Jun 26-28, 2020. Leeds

Principles Masters - MIS & Navigation Sep 17-18, 2020. Nottingham

Pelvic Masters Sep 7-9, 2020. Bristol

Periprosthetic Course with Anatomical Specimens Sep 24-25, 2020. Newcastle

Promoting excellence in patient care and treatment outcomes in trauma and musculoskeletal disorders

www.aofoundation.org

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

l l l l l

BOA Staff Executive Office Chief Operating Officer

- Justine Clarke

Personal Assistant to the Executive

- Celia Jones

Education Advisor

BOA Executive l Phil Turner (President) l Ananda Nanu

(Immediate Past President) l Don McBride

(Vice President) l Bob Handley

(Vice President Elect) l John Skinner

(Honorary Treasurer) l Deborah Eastwood (Honorary Secretary)

- Lisa Hadfield-Law

Policy and Programmes Director of Policy and Programmes

- Julia Trusler

Policy and Programmes Administrator

- Megan Pugliese

Programmes and Committees Officer

- Harriet Wollaston

Communications and Operations Director of Communications and Operations

- Emma Storey

Interim Director of Communications and Marketing

BOA Elected Trustees

- Annette Heninger

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

- Sabrina Nicholson

l l

l l

l

l l l l l l l l l l l l l l

Marketing and Communications Officer Membership and Governance Officer

- Natasha Wainwright

Online Examination Operations Project Manager

- May Elphinstone

Publications and Web Officer

- Komal Gorasia

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

Events and Specialist Societies Head of Events - Charlie Silva Events Administrator - Venease Morgan Exhibitions and Sponsorship Coordinator

- Emily Farman

UKSSB Executive Assistant - Henry Dodds

Copyright

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

Advertising

All advertisements are subject to approval by the BOA Executive Board. If you’d like to advertise in future issues of the JTO, please contact the following for more information: Open Box M&C, Regent Court, 68 Caroline Street, Birmingham B3 1UG Email: inside@ob-mc.co.uk | Telephone: +44 (0)121 200 7820

Disclaimer

The articles and advertisements in this publication are the responsibility of the contributor or advertiser concerned. The publishers and editor and their respective employees, officers and agents accept no liability whatsoever for the consequences of any inaccurate or misleading data, opinions or statement or of any action taken as a result of any article in this publication.

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

o success without succession; whether it pertains to a species, a religion, an association, a profession or a speciality, this adage highlights the risk of aging without renewal. T&O currently has an environmental niche and there is a young generation who could populate it. However, it is probably better to plan succession than to presume it. We should continue to demonstrate the need for, and value of T&O surgery, whilst also making it look attractive to potential successors.

A constructive response to problems of patient care will maintain the respect and support of patients and community, and consequently secure the niche those groups allow us to occupy. Learning lessons from the setback of being presented with adverse observational data is a presumed consequence of registries. Identifying problems should stimulate progress, not entrenched defence; the article on ‘The experience of an outlying unit…’ (page 36) exemplifies this. This responsive approach to problems can be generalised and an initiative to collate and learn from litigation data has led GIRFT to produce new “BOAST type” guidance for operating theatre record keeping (page 46) to make practice more resilient.

We can revise and smooth the pathway for our successors. The article ‘New era in T&O Training’ (page 58) introduces the changes in training coming along with the new curriculum. A competency rather than a time based approach will be followed. New techniques and technologies also allow new approaches to training and we look at the impact of Simulation (page 54).

The outward concepts and attitudes of an organisation may evolve spontaneously, but what might be regarded as its organisational DNA needs positive action to change or it will lag behind and become outdated. Phil Turner describes the structural changes to committees and strategies that are being introduced to accommodate and allow the BOA to progress (page 10).

An advantage of our in-house journal is that we can be a little irreverent. Illustrating an article on clinical photography with lamb chops (page 48) may seem childish but is practical, cheap and may deliver a message in a way which sticks.

‘Humorous’ messages or phrases can stick when unwanted too. We T&O surgeons may view ourselves as being responsive and caring, but sadly these views may not to be shared by all. Like it or not there is a ‘humorous’ stereotype of an Orthopod which is not necessarily attractive to the public or our potential successors. Recognising the existence of such stereotypes is a start but not an end; there are three articles relating to this (pages 40-43). To broaden our appeal to potential successors we need change our image, not a photoshop patch up, but where necessary addressing underlying, uncomfortable truths.

Should no-one follow us into T&O what would happen; nature abhors a vacuum. Indeed, a vacuum may well be a problem for the profession but not necessarily for an individual patient. Demonstrating this, the specialty section gives three perspectives on negative pressure wound therapy (pages 64-73).

No success without succession. Maintain the niche with adaptability and responsiveness, and generate wider enthusiasm by consigning restrictive and unattractive stereotypes to history. Progress and reward should depend on competency not ‘sucking up’, unless of course the objective is wound healing. n

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 03

Upcoming International Cartilage Regeneration & Joint Preservation Society

Top Events Mark your Agenda

ICRS 2019 – 15th ICRS World Congress Vancouver, CA, October 05–08, 2019

A consistent theme through the meeting will be that of the ‘Next Generation’. This will include the next generation of joint repair technologies, of investigative techniques, and importantly, of researchers. Our interest in the future of the ICRS has been highlighted by our previous development of the ICRS NextGen group – recognizing and promoting the next generation of cartilage physicians and scientists, who ultimately will lead the ICRS into the future. We are excited to be partnering with the Arthroscopy Association of Canada (AAC) to deliver the opening session on Stem Cell Tourism. This continues to be a hot topic where we will tackle the many issues that face our patients when searching for the ‘Holy Grail’ of joint regeneration. To that end, we will also include a plenary session on Stem Cell treatments – science, no hype – with leading international researchers providing facts about this evolving field.

ICRS Focus Meeting “See What You Can Do – Imaging, Diagnosis, Treatment” Vienna, Austria – Nov. 21–22, 2019

Cartilage treatment and imaging technology has emerged during the last 50 years. Cartilage repair, biotechnology and cell transplantation, as well as fundamental research in molecular biology and genetics have changed the understanding of how to address the problem of non-healing articular cartilage. In MRI technology and radiology the morphologic assessment of structures has been developed to a more functional and quantitative analysis of tissue structures. Both fields have influenced each other and are depending on each other in indication and follow-up of outcomes of surgical procedures in patients suffering from diseased articular cartilage. What we are seeing on radiology or MRI images is influencing our strategy in treatment, and what we are doing to repair or regenerate tissue defects in the joint is producing outcomes clinically as well as morphologically in our radiological follow-up. These two paradigms of seeing what we can do and doing what has to be done was the background of developing the idea of this focus meeting. The aim of this Focus Meeting is to discuss the value of semiquantitative morphological and compositional MR in diagnosis, selection of patients for the right treatment and to monitor the efficacy of different cartilage surgery techniques. The Meeting will be completed by 2 optional Hands-on Workshops (Imaging & Surgical Skills)

The Biologics Alliance (ICRS, AAOS, AOSSM, AANA) Carlsbad, USA – Feb 05-07, 2020

The Biologics Alliance was born in 2018 with a mission to foster and convene a collaboration for shared and coordinated efforts to speak with a unified voice in the musculoskeletal biologics environment, advocating for the responsible use of biologics in clinical practice, spearheading standards development, and assessing and reporting on the safety and efficacy of biologic interventions. The founding members include the ICRS, the AAOS (American Association of Orthopaedic Surgery), the AOSSM (American Orthopaedic Society for Sports Medicine) and AANA (American Arthroscopy Association of North America). The 1st Summit will be held February 5-7, 2020 in Carlsbad, California. The agenda will be educational, innovative and developmental of new approaches and collaborations. The Attendees will include all multilevel and multidisciplinary stakeholders in this space and will include a diverse group of scientists, clinicians, regulators, corporate, private equity and venture capitalists. A Preliminary Agenda will be out by July 15, 2019.

For more information about registration, faculty & scientific agenda, please visit: International Cartilage Regeneration & Joint Preservation Society

www.cartilage.org

From the President

Time for reflection Phil Turner

I write this as I enter the final straight in my term as your President, and the time has come to reflect on what we have achieved over the last 12 months. I correctly predicted in my first article that the issues would be challenging and the unexpected would occur. Despite this, the Executive team and Council have worked long and hard to forge a new course for our organisation.

M

ost obviously, you will have seen a completely refreshed image and brand as we move ahead after our centenary. Behind this lies a total revision of our strategy and the mechanisms for its delivery. Previously, we had three lengthy printed documents covering clinical practice, research and education. They have served us well but have the effect of putting our thinking into silos rather than fostering a broader view of the integrated nature of a modern professional organisation.

We have a totally new style for presenting our values and strategy which is expressed as succinctly as possible and will be showcased at Congress 2019 in Liverpool.

You can also read more about this on page 14.

best use of our staff and members’ time and resources. These structural changes will take some time to bed in, but we expect to have them fully established by the beginning of 2020. Integral to this transformation has to be increasing the diversity of representation throughout our organisation. I encourage you to look on page 10 for more information on new committees and roles available.

Shaping change on this scale demands considerable leadership from all of those involved.

Leadership has also been a regular topic in the various international meetings I have had the opportunity to attend throughout my year in office. We all have to understand the nature and impact of leadership, be it personal or organisational. Leadership and professionalism are inextricably linked together and ultimately lead to the development of our own professional identity – what it means to think, act and feel like an orthopaedic surgeon. This evolution was explored by Dr Richard Cruess in his keynote lecture at the Canadian Orthopaedic Association Congress. As I conclude my last ‘from the President’, I know that I will always identify myself as an orthopaedic

“The committees will be more responsive and deliver change through defined projects delivered by smaller working groups. We hope this will make best use of our staff and members’ time and resources. These structural changes will take some time to bed in, but we expect to have them fully established by the beginning of 2020.”

Delivering our aspirations has meant a wholesale review of committee structures and their membership, including the role of the Executive and Trustees in the overall governance of the BOA. The committees will be more responsive and deliver change through defined projects delivered by smaller working groups. We hope this will make

surgeon, exactly as he described. I am proud to say that it has been an honour and a pleasure to represent the BOA and I look forward to continuing progress and change. n

Latest News

Incoming President – Don McBride It seems like only yesterday that I was elected but as I take on the role of President at Congress in Liverpool, I am well aware of the continuing complex issues facing Trauma and Orthopaedics and the implications for the patients we treat.

There remains much uncertainty in UK politics because of Brexit and although this is a problem there are still European Parliament decisions and policies that may affect us. These include the new Medical Device Regulations (MDR) taking effect in 2020. These will have far-reaching consequences on all medical devices and implants that we currently use and innovations in the future, for example, with a rigorous application process and extensive post-market surveillance. The BOA is actively engaged with colleagues across Europe on issues raised by these regulations and will keep members informed as this unfolds.

Clearly Brexit is a good example of what happens when people do not work together. There are many groups that we liaise with, including some of a political nature, but there is strength and stability within our ranks that helps to provide solidarity in our responses to difficult questions.

In addition, we need to continue to engage internationally, cementing our relationships with developed and developing nations for the benefit of patients and the extended workforce.

The theme for my Presidential year will be ‘Working Together: the Way Forward’ and I look forward to putting the new BOA strategy and committee structures into action. With the assistance and the endeavours of the Executive, Council and the BOA team we can be proactive rather than reactive in our response to the political and other challenges we face.

It is a great honour to lead the British Orthopaedic Association with its significant past history, managing well the tasks that are presented to us and creating a brighter and healthier future for all.

BOA Instructional Course 2020 - Register Now! Saturday 11th January 2020 (Etc Venues Manchester) The Instructional Course is a highlight of the BOA’s calendar, and we are pleased to announce that registration is now open for 2020. This course brings together all levels of postgraduate trauma and orthopaedic trainees to prepare for their FRCS examination and to gain experience in a number of Clinical Based Discussions (CBDs). The one-day programme will run in two parallel streams and provide curriculum driven clinical updates and critical condition assessment opportunities aimed at T&O Trainees and SAS Surgeons.

• Stream One: Case Based Discussions (CBDs) on critical conditions e.g. Bone Tumours; Complex Regional Pain Syndrome (CRPS); Limping Child and Cauda Equina.

• Stream Two: Plenary sessions including Hands, Hip and Knee, Shoulder and Elbow, Foot and Ankle, Spine and Paediatrics.

Places are extremely limited, so we encourage those interested in the 2020 course to register as soon as possible at boa.ac.uk/instructional-course.

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Training Orthopaedic Trainers (TOTS) Upcoming dates:

2nd - 3rd December (BOA London) 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 policy@boa.ac.uk.

If you would like to sign up, please visit our website at boa.ac.uk.

BOA Appointments BOA President for 2021 - 2022: John Skinner BOA Honorary Secretary for 2020 - 2022: Simon Hodkinson BOA Trustees for 2020 - 2022: Colin Esler, Antony Hui, Andrew Manktelow, Ian McNab

RSPA vacancies The BOA and RCS England are seeking Regional Specialty Professional Advisors (RSPAs) for 10 regions across England and Wales, as a large number of the postholders have reached the end of their term.

The regions with vacancies are: • London (North East) • South Central (North) • South East Coast • South Central (South) • South West • Wales (North) • Yorkshire and The Humber (South) • London (North West) • East Midlands (South) • East of England Any interested members should check our website boa.ac.uk for more information and how to apply.

Correction: In the June 2019 edition of the JTO, the pull quote in the Meeting Review: BASK article on page 14 mentioned that Simon Abrams was presented with the BJJ award, this was incorrect and we apologise for the error.

Latest News

UK and Ireland In-Training Examination (UKITE) UKITE 2019 will take place from Friday 6th - Friday 13th December 2019.

BOA trainee members should ensure that their membership subscriptions are up to date to enable them to access UKITE free of charge. Subscription payments should be made by no later than 31st October 2019.

Non BOA members can register for UKITE for a fee of £150. Non-members wishing to join the BOA should apply for membership by the 30th September 2019 in order to access UKITE free of charge in 2019.

For up to date information regarding UKITE please see boa.ac.uk/ukite or email ukite@boa.ac.uk.

New BOAST on Fracture-related infection The newest BOA Standard (BOAST) will be launched at BOA Congress in Liverpool. Entitled ‘Fracture-related infection’, it describes standards for effective prevention, detection and management of infection. For readers attending Congress who are interested to hear more on this, one of the trauma sessions on Wednesday 11th September will specifically discuss the BOAST and issues relating to fracture-related infection. Hard copies will be available from the BOA stand at Congress and it will be available for download on our website.

Update on BOAsponsored research Priority Setting Partnerships Through the Research Committee, the BOA regularly contributes funding towards specialist societies wanting to undertake a research Priority Setting Partnership (PSP). We are pleased to report that the fourth and fifth PSPs supported in this way have recently published their final outcomes from this process: the BSCOS (British Society for Children’s Orthopaedic Surgery) led ‘Paediatric Lower Limb Surgery’ and an ‘Upper Limb Fragility Fracture’ PSP led by the OTS (Orthopaedic Trauma Society).

The PSPs are facilitated by the James Lind Alliance, which has a methodology that involves clinicians working collaboratively with patients and carers, looking into areas of health care that can be improved and aided by research. Using wide reaching surveys enables those involved in the PSP to narrow down key research priorities, which can then be used to improve and develop practices in the relevant field. BOA funding helps to support the specialist societies with this important work.

Previous BOASTs can be viewed here: boa.ac.uk/standards-guidance/boasts.

Upcoming BOA TOES course The BOA is adapting its TOES (Training Orthopaedic Educational Supervisors) course to take account of expected curriculum changes currently scheduled for October 2020. This course should help you be able to: • • • • • •

Engage in relevant aspects of the T&O curriculum Maximise opportunities for teaching and assessing in T&O practice Make the best use of T&O workplace based assessment tools Provide constructive feedback relating to progress in practice Identify trainees in difficulty and enlist appropriate help Integrate useful documentation

The programme will be facilitated by Lisa Hadfield-Law, the BOA Educational Advisor. We are taking bookings for the following course, costing just £59 for BOA members, and more dates for 2020 will be announced soon: • 5th December – to be held in the BOA Office at the RCS England, Holborn, London.

New Royal Osteoporosis Society document Along with 13 other organisations, the BOA has recently co-badged a Royal Osteoporosis Society (ROS) document on Effective Secondary Fracture Prevention: Clinical Standards for Fracture Liaison Services. This document was launched at the Fragility Fractures Network Meeting in Oxford on the 27th August. Please see the ROS website for more information: https://theros.org.uk/.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 07

News

Surgeon is first female winner of ‘SAS: Who Dares Wins’ Louise McCullough

I

n July 2018, I saw an advert for SAS: Who Dares Wins application process, highlighting the fact that this was the first year women have been able to enter.

I entered the process simply as a personal challenge, to see how far I could be pushed both mentally and physically. The inclusion of women in series four of SAS: Who Dares Wins, in line with the Ministry of Defence announcement of opening all combat roles, including the marines and Special Forces training, has highlighted how the strength some women possess surpasses that of their male counterparts.

As time progresses, equality will continue to develop in all fields; even in my own profession, trauma orthopaedics, we have improvements to make. We are not yet at a 50:50 split, but female orthopaedic surgeons are becoming less of the exception.

That doesn’t always make it easy as a female to fit into what are already established teams of men, prejudices have to be won over both with some more senior male colleagues and some more traditional minded patients. The same will be the case in the close combat roles women are now open to apply for.

When I initially applied and started the process my concerns were predominantly: • Would I be fit enough to compete against

19-year-olds?

• Would I have the mental resilience to

make it?

08 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

The 11 days in Chile were the toughest I have ever experienced. The directing staff aim to break you down both physically and mentally, but I managed to utilise their feedback positively and I am forever appreciative of the support and encouragement they gave me.

I have learnt a lot about myself and the skills and strengths that I possess.

I hope to be able to inspire everyone, both male and female to work to pursue their individual goals and challenges, to push themselves out of their comfort zone and achieve their dreams and ambitions.

I am a stronger person and I have learnt a lot from the positive attributes of the other recruits. I have had the privilege of meeting 24 other like-minded, determined, focused and resilient individuals from all walks of life that I would not necessarily have had the

good fortune to meet in any other situation.

As a group we are really the only ones who know exactly what we went through, how tough it was, and that shared experience creates a unique friendship and bond. I have made life-long friends through the process and for that am I eternally grateful. I have been absolutely amazed and delighted by the level of support by all my friends, family, colleagues and supporters up and down the country and worldwide. My next challenge is a hike up Machu Picchu for a local Aberdeen Charity, Charlie House. As a charity they are aiming to raise £8 million to build a respite home for families and children born with severe mental and physical disability.

To donate, please see Louise’s JustGiving page: www.justgiving.com/LouiseMccullough7. n

Pushing the fixed out of FFD

Please complete this card and send it with your medi prescription/s

New ROM deficit solutions

medi. I feel better.

Contact name: ………………………………………… Tel : ….……………………….……

Fixed Flexion Deformity Solutions

Email address: ………………………………………………………………………………….

(These details will only be used in the unlikely event that we need to contact you for clarification of details on the prescription)

Please send items to:

Clinic/surgery address on prescription Direct to patient (as detailed on prescription)

Or send to another address: ………………………………………………………………….. …………………………………………………………………………………………………….. ……………………………………………………………………………………………………..

Is prescription fee payable?

Yes / No

( please circle)

If yes, fee to pay: £ …………….

FFD@mediuk.co.uk

www.mediuk.co.uk

Cheques should be made payable to medi UK Ltd. To pay by credit card please ring our customer service team on 01432 373500 and quote your unique prescription number.

Thinking of making a change?

Ramsay Health Care needs skilled surgeons like you Private Practice opportunities for Consultant Orthopaedic Surgeons in a variety of locations.

For more information come along to stand 58 or visit: www.ramsayhealth.co.uk/careers/consultants-careers

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 09

News

BOA Strategy Update and Committee Restructure

Phil Turner

T

his year the BOA, alongside the Executive team and Council Trustees, have been working on a revision of the BOA Strategy documents, as well as a restructuring of committees. Previously, the BOA strategy focussed on three areas (Professional Practice, Training and Education and Research), with lengthy documents outlining expectations for each of these.

The new BOA strategy outlines the underpinning vision, mission and values of the BOA in a succinct and accessible way, as well as putting forward the strategic priorities that stem from this. To see the new BOA strategy, please turn to page 12. This strategy will be launched at Congress in Liverpool.

Committee Restructure Alongside the change in BOA strategy, the structure of working committees has also

10 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

been reviewed. Having committees that are efficient and effective with defined outcomes is key in the delivery of the BOA mission: ‘Caring for patients; Supporting surgeons’. This restructure ensures that all committees have robust governance, a high level of accountability and a clear remit.

See below for the new streamlined structure of the BOA committees.

As part of this restructure, there are now a selection of posts available on all committees, with further detailed information on our website.

The BOA Council and Executive Group are particularly keen to use the committee restructure as an opportunity to address issues regarding gender balance and diversity more generally on these groups. Up until now, some committees have been lacking in this area, and we strongly encourage women and those from minority groups to apply for

the current roles. We are very keen to ensure that the BOA committees are as diverse as the population they represent, and that a wide range of viewpoints and perspectives are involved. If you have any questions about the roles, and your suitability for them, feel free to contact the BOA’s policy team at policy@boa.ac.uk, or get in touch with any member of the BOA Executive or Council or an existing committee.

We would be happy to hear from you!

Applications Applications are currently open, with the new postholders expected to be in place by 1st January 2020. To see the full list of available posts being advertised and how to apply, please visit boa.ac.uk.

The deadline for applications is 12pm on Friday 4th October.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 11

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News

BOA Annual Congress 2019 10th - 13th September, ACC Liverpool boa.ac.uk/congress #BOAAC

Congress App We are delighted to announce that the BOA Congress App is now ready to download! You can download the BOA Congress App now to your smartphones and tablets through the Apple App Store and GooglePlay – search for BOA Annual Congress and make the most of your experience before, during and after the Annual Congress. Plan ahead and bookmark your sessions in advance, create your own itinerary, view podium and poster presentations, and also check out the local guide of restaurants and bars. Enhance your Congress experience with a full content of the four-day programme, a list of speakers, interactive maps and more. The App will ensure that you have all the information you need at your fingertips for an enjoyable Congress!

Accommodation

Late Registration Full registration will close on Tuesday 27th August and late registration will open online on Wednesday 28th August; please find the registration rates on the Congress website at boa.ac.uk/annual-congress/registrationinformation.html. Please note you can still register onsite at the BOA Congress if you have not registered online beforehand.

Programme Update We are delighted to confirm that a number of high calibre speakers have been secured for our plenary and revalidation sessions.

This year’s Presidential Guest Lecturer is the EFORT Immediate Past President Professor Per Kjærsgaard-Andersen. He has been a co-opted member of the EFORT Executive Committee since 2007 and was Chairman of the local organising committee of the 12th Annual EFORT Congress 2011. Professor Kjaersgaard-Andersen is currently a Senior Consultant Orthopaedic Surgeon and the Head of Section for Hip and Knee Replacement.

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The Howard Steel Lecture will be delivered

by Nicky Moffat, Former Army Officer.

Nicky was Britain’s highest ranking female army officer, retiring as a Brigadier.

The Robert Jones Lecture is to be given

by Professor John Skinner. John is a Consultant Orthopaedic Surgeon and Professor of orthopaedic surgery at the Royal National Orthopaedic Hospital, Stanmore. He is a hip and knee replacement surgeon and is the Clinical lead for Joint Replacement and also the Director of Research at Stanmore.

Specialist topics including Trauma, Research, Global Health, AI in Orthopaedics and more. We will hold a series of focused educational sessions on Friday, including Good Clinical Practice Training and Clinical Examination Course, catering to the needs of all from Medical Students to Consultants.

The programme is available at boa.ac.uk/ annual-congress/programme.html. Don’t forget to visit the BOA stand while walking around the venue to meet the BOA team!

If you have not already done so, book your Congress accommodation now to avoid disappointment! TSC Hotel & Venues is the official hotel-booking agency for the BOA Annual Congress 2019. Booking your Congress accommodation couldn’t be easier.

Visit our Travel and Accommodation page at boa.ac.uk/annual-congress/travel-andaccommodation.html and book online.

Exhibition We are pleased to have in attendance over 80 exhibitors at this year’s Congress, many of which will be joining us for the first time. Each exhibitor has their logo and company information listed on our website, the Congress programme book and on the Congress App. For further details please visit, boa.ac.uk/annual-congress/exhibition-andsponsorship.html.

Save the Date!

BOA Annual Congress 2020 15th - 18th September, ICC Birmingham #BOAAC. The programme will be based on the theme of ‘working together’.

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National award for drive to reduce infections for patients having joint replacement surgery

A

programme, partnered by the BOA, to drive forward improvements for patients having hip and knee replacements has won a top national award.

The unique collaborative QIST (Quality Improvement for Surgical Teams) aims to reduce infection rates from MSSA (Methicillin Sensitive Staphylococcus Aureus) for patients undergoing joint replacement surgery, and was named ‘Infection Prevention and Control Initiative of the Year’ at the 2019 HSJ Patient Safety Awards.

Thirty organisations are involved in QIST, which is scaling up interventions such as screening and the use of body wash and nasal gel treatments for patients carrying the bug, to reduce infections and improve lives. By working together, more than 16,000 patients across the country have received an effective patient safety intervention - and the programme has not yet finished.

MSSA is a common cause of infection in joint replacement surgery. Research has shown that interventions, such as decolonisation using nasal gel and body washes, can reduce the risk of infection from MSSA by 60 per cent in some cases.

These interventions have already been tested by Northumbria Healthcare NHS Foundation Trust which has adapted an MSSA ‘care bundle’ or ‘checklist’ to meet the needs of patients having joint replacement surgery. The project is part of the Quality Improvement for Surgical Teams (QIST) collaborative which was established by Northumbria Healthcare NHS Foundation Trust in 2013. The QIST collaborative is a partnership between Northumbria Healthcare, the British Orthopaedic Association, the University of York Trials Unit and NHS Improvement and there is a further QIST cohort working to reduce pre-operative anaemia related complications, leading to expected savings of £160 per patient. For any Trusts wishing to join a further round of the QIST Infection or Anaemia collaborative, please register your interest at: Qist@northumbria-healthcare.nhs.uk. n

E FORT Travelling Fellowship Sprint 2019 (Estonia) Mazin S Ibrahim

T

his year, I represented the British Orthopaedic Association in Estonia, as part of the EFORT Spring Travelling Fellowship. The Estonian Orthopaedics Association, with its President Dr Katre Maasalu, hosted the fellowship in both Tartu and Tallin. There were 12 fellows from 12 different European countries, all of different levels and experience. The host hospitals and teams were excellent and organised teaching programmes for the fellows over their three main hospitals: Tartu University Hospital,

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North Estonia Medical Centre and EastTallin Central Hospital. We were allowed to attend operating theatres to scrub and assist in a few complex cases in both elective and trauma settings, including a revision case using a trabecular metal cup. This was a rather challenging case which was useful for me; I particularly liked the way they positioned the patient using a special leg cushion on top of the side support, which helped to abduct the leg without assistance.

I learnt a lot about their systems and I was amazed by their technology which linked

all hospitals across the country together which allows for easier patient record access.

Whilst there, we also had a talk given by Professor Li Fellander-Tsai, the chair of the EFORT Travelling Fellowships. She talked about the key action areas for EFORT which include education, guidelines and clinical standards and European health policy and research. It gave a good overview on EFORT’s role in European orthopaedic advances in healthcare. Overall, I learnt a lot from this fellowship and I feel lucky to have been a part of it. n

News

Medical Student Essay Prize Winner G

eorge Pickering is the winner of the 2018 BOA Medical Student Essay Prize and a final year medical student at the University of Sheffield. He has had a keen interest in Trauma and Orthopaedics since his very first clinical placement and his previous visits to his local A&E department through his pursuit of extreme sports. George went on to study a BMedSci in Orthopaedics with Professor Mark Wilkinson and was awarded the Presidents Prize at the British Hip Society for his work on Heterotopic Ossification. George has also presented his work at the World Congress on Osteoarthritis and helped set up an Orthopaedics and Plastic Surgery Society at his University. He hopes to work in Trauma and Orthopaedics in his future career.

Summary of Essay:

George Pickering

After being told by a member of the public that I must be a ‘narcissistic psychopath’ for wanting to become an orthopaedic surgeon, I resolved to examine the qualities of surgeons. This became the starting point of the essay which aimed to light-heartedly but critically, analyse and identify the traits of the great surgeon.

Published literature suggests that patient experience is dictated by bedside manner above all else, so firstly great surgeons must be great doctors. Leadership qualities and collaborative working also featured, with studies finding that more effective teamwork and communication improves outcomes. The best surgeons show a willingness to teach and assist in the development of the next generation.

The importance of teaching orthopaedic examination to undergraduates cannot be overstated when yearly around 20% of the UK population consult their GP with a musculoskeletal problem.

Qualities were also established through the identification of those designated as ‘great’ by their peers. Having seen talks delivered by these surgeons, where they extensively and critically reviewed their previous 40 years or more of practice, it became apparent as to what sets these surgeons apart. Constant, almost obsessive attention to detail and examination of their own results lead to continuous evolution of operative technique. Every opportunity was taken to observe surgeons around the world with an endeavour to never stop learning. Far from being psychopaths, great surgeons are compassionate and patient focussed, they are leaders striving for constant improvement and act as excellent role models for the surgeons of tomorrow.

You can read George’s full essay here: https://www.boa.ac.uk/medicalstudent-essay/. n

Multidisciplinary Hip Fracture Meeting

O

n 8th May 2019, the BOA, in conjunction with the newly created FFNUK, hosted a multidisciplinary meeting discussing the care of people who have sustained a hip fracture. The meeting was oversubscribed and the auditorium was standing room only for a variety of presentations given by representatives of various specialities. Highlights included an enlightening patient perspective from Nick Welch, the introduction of a new open access nursing textbook Fragility Fracture Nursing by Karen Hertz (pictured right) and some interesting, early results from the WHiTE trial presented by Xavier Griffin.

All the presentations generated constructive discussion from the floor; it was interesting to hear the diversity of challenges faced in aspiring to deliver optimal care to this patient group as well as the different approaches to quality improvement and service development that have been effective. A key resonating theme was the absolute necessity for care pathways that involve the multidisciplinary team, from arrival in hospital until discharge and beyond. There is also a need for these pathways to extend beyond people sustaining hip fracture to include frail or elderly patients with other fractures who have equally challenging comorbidities.

It therefore seemed the perfect occasion to launch the new BOAST entitled ‘The care of the older or frail orthopaedic trauma patient’ which supersedes the previous BOAST relating to people sustaining a hip fracture. In addition, it was decided that future events would follow this lead and focus on the wider group of patients with complex medical problems who require care for a concomitant fracture. n

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News

From managing critical scenarios to manipulating spaghetti Euan Harris

I

n June, I, along with other trainees, from across the United Kingdom gathered in Cardiff for the British Orthopaedic Association Human Factors Course, supported by Zimmer Biomet. Across two days, we were challenged by a series of interactive team exercises and facilitated small group discussions. These activities sought to demonstrate the importance of situational awareness, effective decision making, skilful communication and supportive teamwork. Each task purposefully pushed us outside of our comfort zone, driving our learning and personal growth.

Guided by a welcoming and engaging faculty, the course invited us to collectively reflect on our personal experience of training, and behaviour within the clinical environment, which has since helped me to develop a greater appreciation of ‘self’. The impact of our behaviour on colleagues was also explored, including the effect stress and incivility can have in reducing

cognitive ability and impairing the performance of the wider team. Armed with this insight, I have gained greater confidence approaching colleagues with a positive mindset and constructively managing critical scenarios to achieve optimal patient care.

Another aspect of the course I particularly enjoyed was examining the strengths and weaknesses of various leadership styles and considering how these might best

be utilised in a range of clinical contexts.

Ultimately, even the group’s knowledge and understanding of the structural properties of spaghetti was tested!

Forget didactic lectures and note taking, the Human Factors Course is all about interaction.

I found the course thought provoking and challenging, proving a unique opportunity for myself and other Trauma and Orthopaedic trainees to discuss and learn from one another’s perspectives in an informal and collaborative environment. n

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News

Honorary Fellowships

The BOA is pleased to announce the recipients of the 2019 Honorary Fellowship, which will be presented at the Congress in Liverpool.

David Stanley

Martyn Porter Martyn Porter qualified from the University of Manchester in 1979. He carried out a fellowship in reconstructive surgery at the Brigham and Women’s Hospital in Boston in 1989. He was appointed as consultant orthopaedic surgeon in Preston in 1991 before moving to Wrightington Hospital in 1995. He was an ABC fellow in 1994 and established the North West Arthroplasty Register in 1994 before joining the Steering committee of the National Joint Registry in 2003 and then serving as chairman of the Editorial Board between 2008 and 2018 and Medical Director between 2013 and 2018. He was President of the British Hip Society in 2004 and President of the International Society of Arthroplasty Registers from 2015 to 2016. He has served on a number of BOA committees and was President of the BOA in 2012.

David Stanley trained in trauma and orthopaedics in Sheffield and Sydney and has worked as a consultant in Sheffield since 1991. He has a particular interest in elbow surgery and has part written and co-edited two textbooks on the elbow the largest being Operative Elbow Surgery. In addition, he has published over 50 peer reviewed papers, the majority being on elbow disorders. He is a previous President of The British Elbow and Shoulder Society (2007 - 2009) and has been a member of The European Society for Surgery of the Shoulder and Elbow, and since 2010 a corresponding member of The American Shoulder and Elbow Surgeons. He is dedicated to maintaining standards in trauma and orthopaedic surgery and has been an examiner for The Intercollegiate Examination Board in Trauma and Orthopaedics for 10 years followed by Chairman of the Examination Board. In the last five years, he has helped set up and Chaired the International Examination in Trauma and Orthopaedics (JSCFE).

He was a Council and Cases Committee Member of the MDU from 2006 - 2017 and was awarded an Honorary Fellowship of the MDU in 2017. He was Honorary Secretary of The British Orthopaedic Association from 2010 - 2013 and represented the BOA on EBOT which he also hosted in Sheffield. He is currently Editor-in-Chief of the Shoulder and Elbow journal.

Ian Stephen Ian Stephen is a retired Consultant Orthopaedic Surgeon with 20 years’ experience of general trauma and orthopaedics in the National Health Service and in private practice in East Kent. He qualified in medicine in 1968 from Cambridge University and St. Bartholomew’s Hospital in London.

He trained in General Surgery and then in Orthopaedic Surgery in Bristol, Exeter, Truro and Montreal. He was appointed as a Consultant in Trauma and Orthopaedic Surgery in East Kent in 1983. He retired from the NHS in 2002 but continued in independent practice concentrating on problems with the foot and ankle until 2007 and medico-legal work until 2011.

He has been Past President of the British Orthopaedic Foot and Ankle Society, the Orthopaedic Section of the Royal Society of Medicine and the Hunterian Society. He was Past Chairman of the Academic Board of the Royal Society of Medicine, a member of the Claims Advisory Committee and Expert Assessor for the Medical Protection Society and Non-Executive Chairman of East Kent Medical Services Limited, which provides independent medical services in East Kent.

He has been Past Governor of the Expert Witness Institute and Chairman of my Cambridge College Alumni Committee. He has continued membership of the History of Medicine Society at the Royal Society of Medicine and the Hunterian Society as well as acting as Archivist for the British Orthopaedic Association.

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News

Alistair Stirling As a trainee, Alistair went to the Lodgemoor Spinal Injuries course witnessing the impact of paralysis and the possible benefit from timely intervention for trauma, tumour, and infection. He was appointed consultant to the Royal Orthopaedic Hospital in 1990. The advent of modern instrument systems enabled previously inconceivable reconstructive solutions. For tumour, this led to roles as Lead Clinician for NICE MSCC Guideline (CG75) and NCAT organising annual national meetings for primary and metastatic spinal tumours. For infection, work on culture and serology suggested bacterial colonization might have a role in back pain and sciatica. He remains confident that when technology evolves, and if trial funding permits, this will be confirmed.

He was Foundation Tutor for Spinal Surgery to the Royal College of Surgeons of England. He was a lead contributor to DH Spinal Taskforce reports (2010, 2013), National Low Back and Radicular Pathway (2013, 2017). He was Chair of United Kingdom Spinal Societies Board from 2015 - 2018 and led organisation of BritSpine in 2002, 2016 and 2018. He is particularly supportive of the role of physiotherapists and AHPs in the assessment and management of spinal conditions (NBP-CN) and of SBPR in providing the essential enthusiastic collaborative multidisciplinary research forum (which should be mandatory for surgeons – at least in alternate years!).

Presidential Merit Award

The BOA is pleased to announce the recipients of the 2019 Presidential Merit Awards, which will be presented at the Congress in Liverpool.

David Limb

Rohit Kulkarni

David Limb is a Consultant T&O surgeon in Leeds. He was Programme Director for the Yorkshire rotation, followed by terms on the SAC and BOA Education Committee, which he chaired. He examined for the FRCS (Tr&Orth) for 10 years before becoming an examiner assessor.

He continues to examine for the Joint Surgical Colleges Fellowship. He was elected to BOA Council before becoming Honorary Secretary of the BOA, the latter overlapping his present role as Secretary General of EFORT. He has editorial roles in three journals and was recently elected to the Council of Management of the BJJ. He represents T&O on the European CME Experts panel.

Rohit Kulkarni has been a Consultant Shoulder and Elbow Surgeon at the Aneurin Bevan University Health Board, Newport since 2001. He has served on the council of the British Elbow and Shoulder Society for over 15 years and was the President from 2013 to 2015. As Chair of the National Orthopaedic Expert Working Group working with NHS Digital, NHS England and NHS Improvement, he has led on design and implementation of tariff, coding and HRGs. He works closely as an expert advisor with the National Casemix Office and the Clinical Classifications Service. In 2017, he designed and led on GAPI, a clinically led bottom up costing project, whose results have been implemented into the 19/20 tariff. Working with PbR, Monitor and latterly NHSI and NHSE he has led on producing a yearly, fit for purpose, national tariff. He is also the coding and tariff lead for the BOA. He has led on the development of commissioning guidelines for shoulders and elbows and also has authored the specialised commissioning national definition set Chapter 34.

Currently he is also involved in the NHSE Evidence Based Interventions project and the specialist commissioning team.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 21

News

Meeting Review - BSSH Nicolas Rabey and Ian McNab

B

SSH holds two Instructional Course and two scientific meetings annually, plus a tri-annual combined meeting with BAHT. This year’s meeting was hosted by BSSH President David Newington and BAHT Chair Christy Fowler, on the panoramic Swansea University Bay Campus.

The popular pre-meeting trainee day was chaired by BSSH’s Jeremy Rodrigues and BAHT’s Lisa Newington - themed ‘what they don’t tell you in the books’, featuring free-papers plus top-tips from established surgeons and therapists, on coping with career pressures.

The main two-day meeting showcased a range of presentation formats, with highlights including a lively expert case-discussion panel addressing CMCJ arthritis, a sports injury symposium, practical hand/wrist imaging demonstrations, plus an impressive key-note presentation on paediatric hand trauma by Professor Neil Jones. Parallel sessions provided updates on overseas work, the UK Hand Registry and ‘Trauma app’, plus dedicated therapy topics.

Presentations on the development of hand surgery included Robert Savage - flexor tendon surgery; Professor Joe Dias - distal radius fractures; Karsten Kroener - Viking Hand and David Shewring - highlighting the contributions of Welsh hand surgery.

We were treated to a fabulous dinner in the beautiful Brangwyn Hall, with music and dancing, including a Welsh male voice choir, the ‘Arrhythmics’ and a local Swansea duo, Cerys Matthews and Dai Newington!

The generous welcome from our hosts and widely appealing topics ensured a jovial and simulating atmosphere, illustrating the close and cohesive working relationship between BAHT and BSSH and the ever-growing breadth and stature of hand therapy and surgery in the UK. n

Meeting Review – BASS Sashin Ahuja

T

he 2019 edition of the British Association of Spine Surgeons (BASS) Conference was held at the Brighton Centre from 3rd to 5th April, themed as Innovation in Spine Surgery.

Keynote Lectures based on Innovation covered: • Robotic surgery followed by a lively debate whether x-ray imaging, navigation, or robotics could replace a surgeon’s expertise in spine instrumentation.

• Advances in materials for Interbody Cage and Bone Graft. To facilitate the introduction of such newer technologies, BASS is collaborating with Orthopaedic Device Evaluation Panel (ODEP) and Beyond Compliance. The membership was introduced to this concept by Mr Keith Tucker.

• Newer concepts in managing Traumatic Spinal Cord Injury with the hope of useful functional neurological recovery.

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From a practice update perspective: • Recent national reports i.e. the National Backpain Pathway and the Spine GIRFT report were discussed and debated.

• Changes by insurance providers, private medical insurers and Private Healthcare Information Network (PHIN) data were covered by invited talks from relevant stakeholders followed by a healthy but robust discussion.

• An update of how the NHS needs to move from a culture of blame to one of learning following the Dr Bawa-Garba case was presented.

The charity for the meeting was Horatio’s Garden who have designed gardens in Spinal Injury units. Overall the feedback was one of a resoundingly successful meeting and kudos to the local organiser and the BASS executive.

The baton for the next meeting has been passed onto Belfast (2021) who I am sure will surpass what has been achieved at Brighton 2019.

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Meeting Review – EFORT Don McBride

T

he 20th EFORT Congress was held in the beautiful Portuguese city of Lisbon from 5th - 7th June 2019 at the Centro de Congressos de Lisboa, led by their President Assistant Professor Dr Per Kjaersgaard-Andersen, our Presidential Lecturer at the BOA Congress in Liverpool. The principle theme of the Congress was ‘Registries and Impact on Practice’.

There were several excellent sessions outlining the experience across many countries worldwide including the Guest Nation, Australia. Our own registry, the NJR, is clearly at the forefront internationally with data collection, interpretation and, ultimately, constructive feedback about day to day practice in total joint replacement.

Prior to the Congress, the Annual General Meeting was held on 4th June.

This was attended by our President, Phil Turner, and Ian Winson, our Past President. I am pleased to report that Ian was elected as a member of the Finance Committee.

It was also confirmed that the next elected EFORT President would be Li Fellander Tsai from Sweden, the first lady to take up this post. Our congratulations are extended to her.

The excellent programme over three days included high quality speakers

from around the globe in each Trauma and Orthopaedic Subspecialty. The United Kingdom was well represented contributing to many of the sessions, maintaining our significant input to this meeting over many years since its inception in Paris.

Of political note was the session on the final day on the new Medical Device Regulations (MDR) being introduced across Europe next year. Brexit does not save us. These are far reaching and are likely to impact quite severely on our day to day practice. More to follow in the not too distant future.

Finally, the social programme was excellent with good networking while sampling local food and outstanding Portuguese hospitality. Already looking forward to Vienna in early June 2020. n

Meeting Review – COA

T

Phil Turner

he Canadian Orthopaedic Association and Canadian Orthopaedic Research Society meeting was held in Montreal in combination with the second triennial meeting of the International Combined Orthopaedic Research Societies (ICORS) from 19th - 22nd June 2019 at the impressive Palais des Congres.

Running so many parallel sessions made it difficult to choose where to go but there was very strong representation from our own British Orthopaedic Research Society with the topics of regenerative medicine in fracture repair, bone augmentation and osteoarthritis being showcased. In addition to the many international scientific sessions there were very high quality clinical instructional lectures and guest speakers. A particularly powerful programme on gender diversity, implicit bias, mentorship and leadership was standing room only. The problem of an improving intake of women to our profession failing to translate into representation in leadership roles is international and must be resolved by more proactive measures.

The RI Harris plenary lecture was delivered by Dr Richard Cruess. He is still active in teaching, writing and research even though he retired from clinical practice in 1981. His views on progress from the ideas of professionalism to professional identity were inspirational.

The next triennial meeting of ICORS will be in Edinburgh, hosted

by Professor Hamish Simpson. n

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News

Meeting Review – CAOS Kamal Deep and Patrick A. Meere

T

he 19th Annual conference of CAOS International was held in New York from June 19th – 22th 2019. The Conference Chair and President was Patrick A. Meere MD, orthopaedic surgeon and director of the Advanced Arthroplasty Research and Robotics Laboratory at NYU Langone Orthopedic Hospital in New York. There were 284 attendees from a total of 20 countries with over 185 authors. There were four keynote lectures.

Professor Ferdinando Rodriguez Y Baena prepared an outstanding scientific programme encompassing wide-ranging use of CAOS from robotics to advanced navigation in large joint arthroplasty, as well as spinal, trauma and oncology fields. Ancillary technologies such as virtual reality, soft tissue assessment by wearable sensors, robotic instrumentation, 3D digital planning, and machine learning were discussed in detail. The potential for symbiotic integration of these advanced technologies was explored and future directions were debated in special panel sessions. Modern surgical techniques related to CAOS were featured in dedicated video sessions and promising clinical outcome results were presented. A special session was held for robotic applications with industrial input to explore their viewpoint of future directions. A special tribute session was held to celebrate the 25th anniversary of the founding of the society. The next CAOS meeting will be held in Brest, France in June 2020 under the presidency of Dr Eric Stindel. For detailed insight into the society and membership please visit www.caos-international.org. n

Meeting Review - BIOS

T

he 21st annual meeting was held in Leicester on 28th and 29th June 2019. Mr Maneesh Bhatia, BIOS’ Education Secretary, along with his colleagues from Leicester, organised and hosted the meeting held under the helm of the Professor Gautam Chakrabarty, President of BIOS.

The programme consisted of symposia, guest lectures and free papers addressing a wide range of topics.

The main symposium was on advances in the management of upper limb, lower limb, paediatric and pelvic trauma.

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Gautam Chakrabarty

National experts who are key opinion leaders in their field delivered the talks. There was a lecture by Dr R Vaishya, New Delhi, on the role of 3D printing in the management of trauma.

Symposia on the advances in arthroplasty, bone tumour and research, were also well received and instructive.

The Presidential Guest Lecturer, Professor Shekhar Kumta, Chinese University, Hong Kong, spoke on ‘Myth and reality of stem cells’ and ‘Joint sparing innovations on orthopaedic oncology resections’. Both lectures were thought provoking and generated a lot of interest.

The other guest speakers were Professor Rajesh Malhotra, President IOA, Mr Don McBride, President elect BOA and Professor R Vaishya, New Delhi. Their lectures were on different themes and were a good update on orthopaedics in different parts of the world.

Megan Wilson from JCST spoke on CESR applications. It was aimed and designed to help colleagues trying to achieve CCT through the CESR route.

The meeting ended with handover of presidency from Professor Gautam Chakrabarty to Professor Bijay Singh. n

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Meeting Review – BESS

Jonathan Rees and Bob Handley

T

he British Elbow and Shoulder Society (BESS) Annual Congress was held in Harrogate in June and was successfully hosted by local organisers Roger Hackney, Joe Askew, Paul Cowling, Simon Fogerty, Stacey Lalande, Susan Leeming, Charlie Talbot, Balachandran Venkateswaran and Sam Vollans.

The Congress was proceeded by the BESS Instructional Course on Tuesday 18th June which focused on ‘Instability and sports injuries of the shoulder and elbow’. The Harrogate Convention Centre offered an excellent instructional course and congress venue and there were 695 attendees, highlighting the rapid growth of BESS in recent years.

BESS now has 595 surgeon members and 130 Allied Health Professional members and continues to grow.

The Congress is made up of Research Symposiums, Masterclasses, Guest Lectures and a full scientific programme.

An international faculty supported both the instructional course as well as the Masterclass sessions and included Brian Busconi, Bassem Elhassan, Jelle Heisen, Laurent Lafosse, Roger Van Riet, Claudio Rosso and Bertram The.

Besides the scientific programme, the Congress also offered protected timetable sessions for the presentation of

Meeting Review – AOA

T

he American Orthopaedic Association Annual Leadership meeting was held in San Diego from 26th - 29th June 2019. The AOA is a distinctive organisation with invited membership and concentrates on developing leadership in its broadest sense and at all stages of a career in orthopaedics.

The format is based on a programme of high-level core symposia with a few parallel sessions more suited for resident education.

28 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

results from national trials, and hot topic sessions covering important issues related to the NJR, TORUS, NICE, GIRFT and NHSI NCIP. This meeting also marked Peter Brownson stepping down as BESS President after a busy and successful two years and Amar Rangan taking over as President until the 2021 Congress in Newcastle.

Thanks goes to all Congress attendees, BESS members, BESS Council and the Harrogate team for making this another successful year for the British Elbow and Shoulder Society. n

Phil Turner

The symposia covered the quantitative measurement of leadership, expanding diversity in leadership roles, quality improvement and patient safety, pathways for orthopaedic innovation, academic productivity, registries, and subspecialty career development. Each session involved a limited number of didactic lectures with plenty of time for questions and discussion.

The audience was always fully engaged and extensive use was made of the response system

using mobile phones. Technology used to deliver these complex presentations was faultless and sets a very high bar for any future meetings.

The other highlights were an interesting view of selection and training as used by the US Navy for their SEAL forces and a fascinating lecture by Sam Walker, a Wall Street journalist, based on his book ‘The Captain Class’ which is a must-read for anyone with a passion for sport and leadership. n

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Spherox is administered by intraarticular implantation. The efficacy and safety of Spherox in patients over 50 years have not been established. CONTRAINDICATIONS: Patients with not fully closed epiphyseal growth plate in the affected joint. Primary (generalised) osteoarthritis. Advanced osteoarthritis of the affected joint (exceeding grade II according to Kellgren and Lawrence). Infection with hepatitis B virus (HBV), hepatitis C virus (HCV) or HIV I/II viruses.

ADVERSE REACTIONS ASSOCIATED WITH SPHEROX: Graft delamination, hypertrophy. Adverse reactions associated with joint surgery: joint effusion, arthralgia. For further information refer to Summary of Product Characteristics (SmPC). Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. WARNINGS: Spherox is an autologous medicinal product and must not be given to any other patient than the donor. LEGAL CATEGORY: POM BASIC NHS PRICE: £10,000 per implantation suspension. MARKETING AUTHORISATION NUMBER AND HOLDER: EU/1/17/1181/001-002; CO.DON AG, Warthestraße 21, 14513 Teltow, Germany. DATE OF LAST REVISION: 28 June 2018.

2019-08-Spherox JTO BOA-Advertisement-GB-V1

1

News

CAOS UK Restructure

T

he use of computers, robotics and artificial intelligence has revolutionised all aspects of our lives from handheld smart devices to how our cars are manufactured or our food is prepared.

Orthopaedics is no exception; the next generation of surgeons will most likely be working more and more with technology to help improve patient outcomes, safety and efficiency.

Computer aided orthopaedic surgery (CAOS) is currently used in knee, hip, shoulder replacement surgery as well as in spine and tumour surgery.

Its use, particularly in knee and hip arthroplasty is growing with the advent of newer robotic technology which builds on the existing principles of computer navigation.

There is a learning curve associated when surgeons adopt new technology and there is a cost associated with technology which may not outweigh the expected

clinical benefits, especially with constraints on healthcare spending. However, history has taught us that technology well researched and implemented can bring great benefits to our lives.

It is therefore important that these technologies are evaluated before widespread dissemination, surgeons are appropriately trained and clinical and economic outcomes are studied using robust research methodology.

CAOS UK is a non-profit registered charity and a BOA recognised subspecialty organisation, focused on bringing together orthopaedic surgeons of all grades and other clinicians who already use or are thinking of using such technology, or who are interested in developing new technology.

The Society was formed in 2003 by surgeons and engineers who were already developing and using the technology. We are a platform for an exchange of ideas, experience and knowledge. Although

“CAOS UK is a nonprofit registered charity and a BOA recognised subspecialty organisation, focused on bringing together orthopaedic surgeons of all grades and other clinicians who already use or are thinking of using such technology, or who are interested in developing new technology.�

30 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

Arjuna Imbuldeniya based in the UK, we work co-operatively with surgeons, software engineers, hardware engineers and vendors from all over the world.

We are in the process of drafting best practice guidelines for technology assisted surgery for the BOA and are part of the Robotic Research Group of the Royal College of Surgeons.

Our goal is to promote research and accelerate awareness and acquisition of expertise in this field. CAOS UK also provides workshops, visits and national Fellowship opportunities to help train surgeons. We organise two internationally recognised Eduqual Postgraduate Diploma’s in the Principles of Computer Assisted Surgery each year.

We currently hold bi-annual conferences (the next one is 4th and 5th June 2020 at The Royal Society of Medicine) inviting poster and podium presentations and hold an annual session each year at the BOA Congress (11th September 2019).

CAOS UK is regulated and governed by our members with an elected executive committee and we actively welcome new members in this exciting age for Trauma and Orthopaedic surgery.

Please email me at Arjuna. imbuldeniya@chelwest.nhs.uk or secretariatcaosuk@gmail.com. For membership fees, membership benefits and any other information.

Our website is www.caosuk.org and you can follow us on Twitter @robotsurgeryuk. n

Introducing the U2 PSA Revision Knee™ System from United Orthopedic Corporation

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With its 134° high-flexion design and full compatibility with our U2 Knee™ primary system United Orthopedic’s U2 PSA Revision Knee™ is designed to provide predictable stability and positive outcomes.

Come and visit us at the BOA Congress at stand 33 United Orthopedic Corporation (UK) Limited Baileys Barn, Pimlico Farm, Austrey Lane, No Mans Heath, Tamworth B79 0PF +44 (0)1827 214773 info@uoc-uk.com www.uoc-uk.com

News

Conference listing: BTS (British Trauma Society)

www.bts-org.co.uk 6-7 November 2019, Nottingham

BOFAS (British Orthopaedic Foot and Ankle Society)

www.bofas.org.uk 13-15 November 2019, Nottingham

BSS (British Scoliosis Society)

www.britscoliosissoc.org.uk 21-22 November 2019, Cardiff

BOTA (British Orthopaedic Trainee Association)

www.bota.org.uk 27-29 November 2019, Edinburgh

OTS (Orthopaedic Trauma Society)

www.orthopaedictrauma.org.uk 15-17 January 2020, Newcastle

BHS (British Hip Society)

EFORT (European Federation of National Associations of Orthopaedics and Traumatology) www.efort.org

10-12 June 2020, Vienna

CAOS (Computer Assisted Orthopaedic Surgery (International)) www.caos-international.org 10-13 June 2020, Brest - France

BESS (British Elbow and Shoulder Society) www.bess.org.uk 24-26 June 2020, Brighton

BIOS (British Indian Orthopaedic Society)

www.britishindianorthopaedicsociety.org.uk 10-11 July 2020, Cardiff

BOA (British Orthopaedic Association) www.boa.ac.uk

15-18 September 2020, Birmingham

www.britishhipsociety.com 4-6 March 2020, Wales

BSCOS (British Society for Children’s Orthopaedic Surgery) www.bscos.org.uk 19-20 March 2020, Manchester

BRITSPINE

www.ukssb.com 1-3 April 2020, London

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

16-17 April 2020, Oxford

WOC (World Orthopaedic Concern) www.wocuk.org 6 June 2020, Chester

32 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

ICC Birmingham

News

>

Wisepress Book of the Quarter

Damage Control Management in the Polytrauma Patient Author: Hans-Christoph Pape, Andrew B. Peitzman, Michael F. Rotondo, Peter V. Giannoudis ISBN: 9783319524276 Date published: 18th May 2017 Price: £139.99

Principles of Orthopaedic Infection Management Author: Stephen Kates, Olivier Borens ISBN: 9783132410756 Date published: 14th Dec 2016 Price: £160.50

Manual of Definitive Surgical Trauma Care

BOA members are entitled to 15% off the cost. Email membership@boa.ac.uk for the discount code.

Author: Kenneth David Boffard ISBN: 9781138500112 Date published: 28th Jun 2019 Price: £59.95

The medical world continues to make extraordinary advances in both scientific knowledge and surgical skill, yet despite these achievements, surgeons continue to struggle with the challenge of postoperative infection. Without proper prevention or treatment, orthopaedic infection can become just as lifethreatening as the initial trauma. This highly informative clinical go-to text provides the core principles, treatment options, and the latest information and research specifically for the purpose of helping physicians manage orthopaedic infections and related issues. The book’s key features include contributions from 63 world renowned specialists from a broad range of fields in orthopaedic traumatology and infectious diseases. In-depth case examples involving 21 adult and four paediatric patients and covering a wide range of infections and anatomy.

Nine algorithms to assist in complex decision making. Over 800 illustrations and images, and online access to six video presentations that outline the important steps in the prevention or management of infected joints, tissue, and implants.

Skeletal Trauma: Basic Science, Management, and Reconstruction, 2-Volume Set Author: Bruce D. Browner,

Jesse B. Jupiter, Christian Krettek, Paul A. Anderson ISBN: 9780323611145 Date published: 1st Aug 2019 Price: £386.99

Fundraising Events on behalf of Joint Action

We would like to congratulate Chude Egbuniwe, Ricardo Morgan and Andre White for participating and completing the Prudential RideLondon-Surrey 100 on Sunday 4th August, there’s still time to donate through the Joint Action Prudential RideLondon Team 2019 page, www.justgiving.com/campaign/joint-action-ridelondon2019.

Well done to all of our participants and for raising donations for Joint Action. We raise funds for research infrastructure activities, in particular a resource to provide research methodology support to develop clinical trials in trauma and orthopaedics - at the University of York, called the BOA Orthopaedic Surgery Research Centre (BOSRC).

Find out more online, www.boa.ac.uk/bosrc-research

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If you are interested in participating please contact jointaction@boa.ac.uk For more information and new fundraising events in 2020, visit www.boa.ac.uk/joint-action JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 33

Features

The Watanabe Club: Fifteen years on Andrew Wallace

‘One day, all shoulder pathology will be managed through the arthroscope...’

Such was the optimistic vision of a group of five surgeons who met in May 2003 in a hotel outside York to establish a forum for exchanging ideas in the emerging field of shoulder arthroscopy.

T Andrew Wallace is a Founding Shoulder Surgeon at the Fortius Clinic London, also practising at King Edward VII Hospital, and is an Honorary Clinical Senior Lecturer at Imperial College London.

he concept came to me in late 2002 during my travelling fellowship arranged by the European Society for Surgery of the Shoulder and Elbow (ESSSE/ SECEC). On the last leg of a long four weeks across America, I was asked by the pioneer in shoulder arthroscopy, Dr Steve Snyder of the Southern California Orthopaedic Institute (SCOI), if there was a way he could invite shoulder arthroscopists in the UK to join his new internet discussion group. I replied that unlike in North America, France, Germany and other European countries, in the UK there was no dedicated arthroscopic society as most professional educational activity was channelled through the joint-based societies such as BESS, BASK, BHS, BOFAS etc.

devices to make life easier down a small cannula – it was more a matter of pinching an idea here and there, watching colleagues presenting at meetings abroad and then collaring a local industry representative for some kit and ‘having a go’ in the course of the traditional open methods of surgical reconstruction.

Origin of the courses Soon it became clear that there was a role for such a forum, but the other problem was that there were no coordinated and structured courses teaching the basics of shoulder arthroscopy for trainees. As shoulder arthroscopy was still in its infancy, there were few clinical opportunities for trainees to get their hands on a shoulder scope, and even after six months in a shoulder firm, the trainee would just be mastering the basics of triangulation and instrument handling, only to leave and be replaced by another trainee at novice level. There were sporadic masterclasses where international experts demonstrated Houdini-like skills live from the theatre, but what was missing was a structured teaching programme along the lines of the successful Swiss AO Foundation courses in fracture fixation.

“The Watanabe Club was conceived as a direct evolution from the original forum, and named after the founder of modern arthroscopy, Masaki Watanabe (1911 - 1995). Contrary to popular belief, Watanabe used his No. 21 arthroscope not just in the knee, but also in many other joints.”

So the idea was born to create a group dedicated to the pursuit of all things arthroscopic in the shoulder. At that time there were no neatly organised trays of comprehensive instruments or disposable

34 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

The Watanabe Club was conceived as a direct evolution from the original forum, and named after the founder of modern arthroscopy, Masaki Watanabe (1911 - 1995). Contrary to popular belief, Watanabe used his No. 21 arthroscope not just in the knee, but also in many other joints. In his first published atlas of 1957 there are several examples of the arthroscopic appearance of the shoulder joint.

Features

Extending the ‘scope’ As the demand for the courses has remained consistent, pressure on faculty members with limited leave has been gradually mounting and so further avenues of educational innovation have been introduced. In 2008, the Watanabe faculty met with key arthroscopists in India to collaborate on cadaveric courses at the Sri Ramachandran University hospital in Chennai, and culminated in an exchange programme for the Indian faculty to teach on the UK courses.

experienced, other than having brought ideas from various fellowships spent in far flung places abroad. It was recognised that the collective exchange of ideas was invaluable in reaching a consensus on the best techniques in management, and this could provide a platform for the structured teaching. Thirdly, the emphasis was on practical hands-on acquisition of skills and confidence. This was achieved by using both synthetic models and cadaveric workstations with a 2:1 delegate to faculty ratio, and a minimum of didactic The Club ethos lectures. Fourthly, feedback from delegates was actively sought and instrumental in the From the outset, several principles were evolution of the courses, which have had to agreed. Firstly, the intention was not to set keep pace not only with the developments up a rival society to emulate BESS, but to in the field but also with the increasing keep things as informal as possible, minimise prevalence of shoulder arthroscopy practised the rules and regulations and maintain in the NHS. Nowadays, many delegates the atmosphere of a club where members will already have had some experience could come and go as they were able to with shoulder arthroscopy in their training freely participate. Secondly, ‘egos were to environment. Finally, faculty members be left at the door’ since, in the early days, were free to discuss and describe whatever none of the founding members were greatly instruments and implants were intrinsic to their technique, irrespective of their DIAGNOSTIC Theatre setup and equipment nature or manufacture.

The Watanabe courses were divided into Diagnostic, Therapeutic and Reconstructive modules (Table 1) and delegates were expected to progress through the stages sequentially. Additionally on each course, a practical faculty session was included where new techniques could be trialled and evaluated before being incorporated into the mainstream curriculum.

Diagnostic routine

Arthroscopic anatomy and normal variants Courses have been held twice a year, Stacks and trouble shooting generally in the spring in the north and

THERAPEUTIC

RECONSTRUCTIVE

in the autumn in the south. From the

Subacromial decompression initial course at Charing Cross Hospital

Acromioclavicular resection in London in November 2003, other

Biceps tenotomy venues have included Nottingham,

Capsular release Brighton, Cambridge, Oxford,

Edinburgh, Newcastle, Wrightington,

Anchors and suture management York and Watford. As with many clubs,

Principles of knot tying membership is by nomination and

Labral repair recommendation with election twice

Cuff repair a year at faculty meetings. Although

Biceps tenodesis membership of the club is subscription

Suprascapular nerve release

Table 1: The Watanabe courses were divided into Diagnostic, Therapeutic and Reconstructive modules and delegates were expected to progress through the stages sequentially.

based, it is apparent that the provision of cadaveric practical courses involves a tremendous resource and the club has necessarily relied on collaborative support from the industry.

In 2010, the first biennial meeting ‘Shoulder 2 Shoulder: A Search for Consensus’ was convened by Watanabe faculty member Susan Alexander and held in the Millbank Tower in Westminster. In contrast to the structured teaching of the Watanabe courses, this meeting was based on a ‘cabaret style’ round table format. Debates on controversial current topics and updates on evidence based practice were the main priorities and guest speakers from many disparate aspects of healthcare have featured. In order to continue the original purpose of the Watanabe Club, an online case discussion group has been established and has proven invaluable as ongoing continuing professional development for those in the faculty who are unable to attend the courses on a regular basis.

The most recent initiative has been the creation of the Watanabe Travelling Fellowship, funded by the faculty, to facilitate Watanabe alumni visiting selected faculty members in their own hospitals over the course of a year. The Fellow makes short hosted visits to three or four centres and presents at the faculty meeting in the spring course of the following year.

Over the last 15 years more than 1500 surgeons have participated as delegates in the Watanabe Club programme, and many have later joined as faculty members (now numbering 40) or contributors to other aspects of the club’s activities. It has been a great privilege to witness the growth and development of an organisation that maintains its core values as providing excellent facilities, a practical purpose, and structured learning driven by a flexible and enthusiastic faculty.

Acknowledgments I am very grateful to my co-founders Julie McBirnie, Philip Ahrens, Lars Neumann and Graham Tytherleigh-Strong, and very many other faculty members for their valuable contributions and dedication over the years.

I am also particularly indebted to James Chase, formerly Managing Director of Smith and Nephew Endoscopy (UK and Ireland), for his and his colleagues’ unwavering support of our initiative which would not have been possible without industrial partnership. n

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 35

Features

NJR: The experience of an outlying unit – using data to improve performance Mark Forster and Sanjeev Agarwal

Mark Forster has been a Consultant Orthopaedic Surgeon for the Cardiff and Vale University Trust Health Board specialising in Knee Surgery since 2007. He has been the Lead Knee Clinician for the Health Board since 2012. His special interests include Ligament Reconstruction, Revision Knee Arthroplasty, Patellofemoral disorders and Adolescent Knee problems.

Sanjeev Agarwal is a Consultant in Orthopaedics at the University Hospital of Wales with specialisation in lower limb arthroplasty. He is the editor of orthopaedic textbook ‘Current Orthopaedic Practice’.

36 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

With the publication of the 10th NJR report in September 2013, it became apparent that our unit’s rate of revision following knee replacement was significantly higher than expected and we were an outlying unit. This came as a shock to us all as previous indications had been that we had been performing satisfactorily. We were all trying hard to produce an excellent service so it was important that we found out what, if anything, had gone wrong. We needed to find out why our unit was performing worse than we expected.

O

ne surgeon (outlier 1) disclosed that he had received a letter from the NJR stating that he was an outlier for knee replacements and was in the process of reviewing his revisions. We met as a group to present and discuss our data openly for the first time. The review of the NJR surgeon level data revealed no further outliers but there were two surgeons between the 95 and 99.8 percentile on the NJR plots.

We use a number of different implants within our unit but the NJR data on these implants was generally satisfactory. The mobile bearing, posterior stabilised version of the PFC had a higher than expected revision rate (7.1% at nine years). The Deuce bicompartmental replacement had been used on 15 patients and had poor results with 40% survival at five years. There were no other implant related issues.

Following this initial meeting, a number of measures were put in place in the hope that they would improve our NJR figures in the future. We were to hold a weekly meeting to discuss difficult cases preoperatively including all revisions, reoperations and

young patients (<55 years) and to critique the post-operative x-rays. All knee arthroplasty would be consultant performed or supervised.

We would use implants with a well proven track record in the vast majority of cases with new implants only used as part of a trial.

Caution was advised with the mobile bearing posterior stabilised PFC TKR given that it had a higher than expected revision rate.

Caution was advised with UKR/PFR given their higher than TKR revision rate generally.

We would use them for clear indications only.

Caution was advised with bicompartmental replacements given the problems with the Deuce, the technical difficult of aligning simultaneous UKR/PFR and lack of good evidence to support their use.

A request was also made to the NJR to obtain the data on our unit’s linked revisions as there were a number of surgeons who had since left the department whose data we could not assess from the remaining surgeons’ consultant level reports. We also obtained all our completed K2 forms for 2012. The intention was to see if there were any recurrent issues in the hope that changes could be made to correct them. >>

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Features

The review of outlier 1’s data did not reveal any specific surgical issues. There were 90 K2 forms from 2012. The notes and x-rays were reviewed of all 90 cases. Whilst it was useful to go through these failures, the majority were re-revisions, tertiary referrals or the primary predated the NJR (2003) so they did not provide a significant insight into the reasons for our outlier status.

By February 2014, further data had been added to the NJR. Outlier 1 was no longer an outlier but one of the surgeons at risk was now an outlier (outlier 2). He had not received a letter from the NJR at that stage.

The data requested from the NJR came 11 months after the request and just prior to the publication of the 11th NJR report in September 2014. By this stage outlier 2 had received a letter from the NJR confirming his outlier status.

The third surgeon was close to outlier status has remained between the 95 – 99 percentiles and had not received a letter from the NJR at that stage.

performed the case unsupervised. The overall chance of a good outcome following revision of a cemented TKR in our unit is around 50 - 55%. This is significantly less than the generally accepted 80 - 85% good outcome for a primary TKR.

and should be subject to peer review in the knee meeting. Our aim is to minimize the number of joint replacements in patients with little arthritis as joint replacement gives unpredictable results in this group.

The review of outlier 2’s data did not reveal any specific surgical issues. Of the 17 primaries linked to our trust, 10 had been performed independently by a registrar or staff grade without the consultant concerned being present. As a result, questions were raised about one of the staff grade surgeons, so his NJR data was requested and reviewed.

Again, no specific surgical issues were found.

Pick the correct implant

In spring 2015, a letter our Chief Executive received a letter from the NJR. Data from the last five years only had been analysed for the first time. This indicated that whilst the unit was still outlying overall, the knee data from the last five years were in the middle of the range and satisfactory.

“The unit review raised some issues. 8% of cases had very little or no arthritis visible on the preoperative x-rays. There were also concerns that the revision was not fully indicated in 8% of patients. All these patients had a poor outcome. Overall 30% of the revisions the reviewers felt were potentially avoidable.”

All primaries from our unit’s linked revisions were reviewed to see if there were any issues that could be addressed. All the cases were reviewed from presentation until latest follow up by at least two surgeons. 128 cases were assessed. Five cases were revised outside of the Health Board. There was only limited information available regarding the revision/outcome in these cases.

There were two cases where no part of the implant had been changed – one arthrolysis, one extensor mechanism operation.

The unit review raised some issues. 8% of cases had very little or no arthritis visible on the preoperative x-rays. There were also concerns that the revision was not fully indicated in 8% of patients. All these patients had a poor outcome. Overall 30% of the revisions the reviewers felt were potentially avoidable. When this was looked at by surgeon grade, this was 16% for replacements where the consultant was the first operator but 60% when an SPR or Staff Grade had

38 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

A letter was received from the NJR in September 2015 indicating that the third surgeon had now become an outlier (outlier 3). Review of his cases did not show any specific surgical problems. Again, there were issues over unsupervised trainees. 25% of the revisions were complex cases. There were also concerns over some of the cases as regards their suitability for knee replacement.

As of June 2019, outlier 1 and 2 are no longer outlying. Outlier 3’s position has not significantly changed. Our unit’s position is unchanged. It is outlying overall but the last five year data remains satisfactory. We remain vigilant in the hope that we can correct our overall outlying status in the long term. The measures that we continue to take are as follows;

Patient selection for primary Ideally joint replacement should be performed for severe full thickness arthritis. Cases that do not fit this situation are at high risk of postoperative problems or revision

Partial knee replacements should only be used in appropriately selected patients with isolated arthritis and where there is clear benefit to the patient. There were some question marks over the suitability of some patients for UKR or PFR in our unit review.

Caution with bi-compartmental replacements given the problems with the Deuce, technical difficult of aligning simultaneous UKR/PFR and lack of good evidence to support their use.

No new implants to be used unless as part of a trial and included in Beyond Compliance. The intention being to use prostheses with a proven track record in the vast majority of cases.

Operation Juniors are more likely to make mistakes. They need training but also need supervising. All arthroplasty cases need a consultant present.

Patient selection for revision All cases for revision should be peer reviewed.

We aim to avoid revision in inappropriate situations and when the chances of success are low. We also aim to ensure the appropriate revision surgery is performed.

Quality Control We continue hold regular weekly Consultant Knee meetings to discuss cases/review surgeries try and avoid these problems.

One of the most useful things to have come from this situation is that the knee surgeons in our unit now work much more as a group. There is much more inter-referral and collaboration between surgeons. We now meet once a year to present our NJR data to each other and review our newly linked revisions.

As a unit we recognise and endorse the importance of NJR engagement, personal reflection and honesty, and collaborative working at unit level. We hope that by working together we will improve our outlier status in the future. n

3rd Annual

UCH Basic Shoulder Arthroscopy Course

3rd Annual

Practical Skills for Course Arthroscopy Wednesday 08th May 2019 Orthopaedic ST3 Interviews UCLH PRESENTS

UCLH UCHPRESENTS Basic Shoulder

3rd Annual

UCLH UCHPRESENTS Basic Shoulder

Arthroscopy Course

4th Annual Basic Shoulder Arthroscopy UCLH PRESENTS

Wednesday 08thCourse May 2019 Convenor:

th 12th February 2020 8Wednesday Annual Course Convenor: Centre, Euston London Basic UCLH KneeEducation Arthroscopy Course Mr Abbas Rashid

Practical Skills for Thursday 14th May 2020 Orthopaedic ST3 Interviews UCLH Education Centre, Euston London

Wednesday 08th May 2019

Mr Abbas Rashid 8th Annual Wednesday May 2020 Course13th Convenor: UCLH Education Centre, Euston LondonUCLH Basic Knee Arthroscopy Course Mr Abbas Rashid

Thursday 14th May 2020 UCLH Course Convenor: UCLH Education Centre, Euston London Mr Abbas Rashid

UCLH

Course Convenor12th February 2020 Wednesday

UCLH Hunter Education Centre, Euston London Mr Alistair

8th Annual Basic Knee Arthroscopy Course Course Convenor:

Course Convenor: Mr Alistair Hunter Course Convenor:



Experienced consultant faculty Mr Sam Oussedik



High ratio of faculty to participants



Comprehensive programme Practical Skills for Orthopaedic



Mr Sam Oussedik Thursday 14th May 2020 UCLH Education Centre, Euston London

Practical Skills for Orthopaedic

- Experienced consultant faculty Experienced consultant faculty

Targeted to meet the specific interview stations ST3 Interviews - High ratio of faculty to participants 

High ratio of faculty to participants - Comprehensive programme Wednesday 13th February 2019 including  Comprehensive programme -meniscal Targetedrepair to meet the specific interview stations 

Course Convenor: CT1 to MrSuitable Alistair for Hunter ST5 and Scrub staff UCLH

Accredited by: Accredited by:

For course information and course Accredited by: booking Click Here For information and to Formore more information and to book For more information email: uclh.simulationcentre@nhs.net Fore more information, email; book click here or email: email: uclh.simulationcentre@nhs.net uclh.simulationcentre@nhs.net uclh.simulationcentre@nhs.net

Course Convenor: Practical Skills for Orthopaedic ST3 Interviews Experienced consultant faculty Mr Sam Oussedik ST3 Interviews High ratio of faculty to participants  

Wednesday 13th February 2019

Wednesday 13th February 2019 including  Comprehensive programme -meniscal Experienced consultant faculty repair Course Convenor: - HighConvenor: ratio of faculty to participants Course Mr Alistair Hunter Comprehensive CT1 toprogramme MrSuitable Alistair for UCLHHunter ST5 and Scrub staff UCLH Suitable for CT1 to ST5 and Scrub staff

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JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 39

Features

Unconscious Bias: The Trainee Experience Jessica Caterson is a final year medical student studying at St John’s College, University of Oxford. During her time at university, she has been involved in a number of research projects in anatomy and surgery, as an Anatomy Fellow, and has a keen interest in pursuing a career in surgery.

Jessica Caterson, Olivia Ambler and Sarah Lancaster

‘Bias’ is a term used frequently in medicine; selection bias, confirmation bias, publication bias to name a few. But what about a bias we are not so prepared for?

T Olivia Ambler is a final year medical student at the University of Oxford. She would like to pursue a career in surgery. She is particularly interested in orthopaedics.

he traditional view of the surgeon runs deep in the public’s mindset.

More often than not they would assume their surgeon was male.

This was made apparent to me a few years ago while I was doing a ward round with my juniors. We crammed in around the bed-space of a post-op hip fracture patient and introduced ourselves. My CT1 (male, 6’4”) was acting as scribe. I checked the dressings overlying the wound (the wound incidentally I had made the previous day) and assured the patient that the operation had gone well. The patient then turned to my CT1, and said to him what a great job he had done, she couldn’t thank him enough for doing the operation, and went on to ask him when he thought she would be home.

I didn’t take offence at this episode, I had no reason to, in fact I think it was more awkward for my CT1, who uncomfortably pointed to me and said that I was the one who had done the operation. The patient exclaimed “Oh, a lady surgeon!” in the same way as, say, Chris Packham might delightedly point out a Lesser Spotted Woodpecker.

Sarah Lancaster is ST7, Trauma and Orthopaedics, Oxford Deanery.

A Lesser Spotted Woodpecker, image taken from www.rspb.org.uk.

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So what is it that drives this bias? There is an inherent physicality to trauma and orthopaedic surgery, so it is that patients’ perception of surgeons is ‘as strong as an ox (and almost twice as clever)’?1.

The Royal United Hospital, Bath, boasts the first female orthopaedic surgeon among its staff records. Maud Forrester-Brown (1885 – 1970) was appointed in 1925, establishing a leading unit and setting up a network of paediatric clinics, until her retirement in 1950. I wonder if any of her patients were ever in doubt as to who was in charge on her ward rounds…

Despite female medical students outnumbering their male counterparts since 19962, this has not translated into a vast increase in women in orthopaedics, with current consultants making up 5% of the workforce. Change is underway though; roughly a quarter of ST3 trainees are female3. The BOTA website shares a few case studies of female trainees who have combined training with family life as well as FAQs on the subject.

Many deaneries offer academic posts (clinical fellows or lecturers), and these posts usually involve a part time academic/clinical commitment. Some trainees choose to step off clinical training altogether, whilst others combine clinical work with part time academia. In many deaneries, we have a handful of academic trainees who are in a ‘job-share’, allowing them to complete a higher degree while not completely stepping off clinical training. So the part time/ job share model is in demand, not just from parents wishing to combine work with childcare.

Features

“The Royal United Hospital, Bath, boasts the first female orthopaedic surgeon among its staff records. Maud Forrester-Brown (1885 – 1970) was appointed in 1925, establishing a leading unit and setting up a network of paediatric clinics, until her retirement in 1950.”

Maud Forrester-Brown, image taken from Journal of Bone and Joint Surgery, ‘In Memorium’, 1970.

To generate diversity in a workplace, we cannot just focus on equality when interviewing for a job. If females wishing to pursue careers in surgery are not advised as to what they should be doing, then inevitably, there will be less women taking up roles in orthopaedic surgery.

It becomes an issue of competency, not equality: if someone applies for a role and does not have the clinical skills, experience, additional prizes, research, posters and presentations, teaching and leadership experience necessary9, then of course, regardless of their gender, religious beliefs, race, sexual orientation, age etc., they’re not going to get the job.

Those early years when medical students and junior doctors are beginning to pave their way towards their chosen specialty career is when unconscious bias can have a damaging effect.

It is therefore important that unconscious bias, which limits opportunity being offered to anyone before they have demonstrated competency, is eradicated. Importantly, this is not saying “women can do it too”, “I’m a woman who’s made it, and so can you”, there needs to be a drive to give everyone the opportunity to gain the experience necessary to pursue a career in trauma and orthopaedics.

The Royal College of Surgeons has recently published guidance ‘Avoiding Unconscious Bias’, which is an excellent introduction to this topic4. It also goes into more detail about bullying and harassment, but offers advice on how to recognise one’s own biases and how to avoid bias becoming discrimination.

Finally, the importance of role models cannot be underestimated. The gender of the role model perhaps is not important; seeing an individual work effectively within a team, be they male or female, to achieve a good result for a patient, is immensely inspiring. Role models and advisors needn’t be the carbon copy of you; they just need to have done the thing that you want to do.

So perhaps we should be encouraging our students and juniors to seek out role models, as we reflect on our own practices and behaviours to make sure we are motivating the next generation to enter the wonderful world of trauma and orthopaedics. n

References References can be found online at www.boa.ac.uk/publications/JTO.

Unconscious Bias Lisa Hadfield-Law

I

was asked to write a bridging introduction for the two articles relating to bias (Unconscious Bias: The Trainee Experience and Why do orthopaedic surgeons have a ‘stupid’ stereotype?)

Ten minutes into writing the piece, an orthopaedic surgeon called to discuss a conversation at a T&O social event. A young consultant from a prestigious institution had made deeply insulting and pornographic comments to an individual in a group of professional colleagues, not close friends.

Many of the worrying remarks made in the public arena described by Professors Paton and Turner are also familiar. However, I hear colleagues wear these proudly, like badges of honour. Can we put this down to humour, even if self-deprecating, or is it really about a secret pride in belonging to a macho gang?

I remember some years ago simulating a trauma scenario with the aim of exploring some of the human factors associated with trauma teams. We wanted to practice managing a difficult situation, frequently faced, when one team member adopts an overbearing and inflexible role. I gave myself that role and despite being a middle aged woman, morphed myself into an arrogant young man. At the time I congratulated myself on the authentic result. I now look back and cringe. This was such an opportunity, but I missed it and just fueled the stereotypes and biases described in the two pieces.

Stereotypes and biases influence our behaviour and feelings towards an individual or group. This clearly has a detrimental effect on T&O and hoping

that such negative influence will die out eventually, is a risk we cannot afford to take.

Motivating the next generation to join our specialty must be a priority. The number of suitable applications into T&O training is dropping and the current workforce does not mirror the population it serves or the diversity of those leaving medical schools.

We still have a long way to go to: recognise our biases to prevent damaging effects; stop fueling stereotypes; guard against adopting a victimhood narrative; identify role models and learn how to use them properly. This cannot be left to any curriculum or appraisal system.

Command and control measures are counterproductive, it is down to each and every one of us to shift our culture. n

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 41

Features

Why do orthopaedic surgeons have a ‘stupid’ stereotype?

Robin Paton and Phil Turner

The junior doctor’s diary ‘This is Going to Hurt’1 by Adam Kay has had rave reviews in the press. However, several entries are very derogatory towards orthopaedic surgeons.

• 99% of orthopaedic surgeons are bone-

crunching Neanderthals.

• Neonatologists make obstetricians’ look

Robin Paton is a Consultant Orthopaedic Surgeon, with a specialist interest in Paediatric Orthopaedics at the Royal Blackburn Teaching Hospital, Blackburn. He is currently an elected council member at the Royal College of Surgeons of Edinburgh and an advisor to Public Health England (NIPE committee) on the national guidance policy for hip screening in DDH. He was awarded a PhD and the King James IV Professorship for his research into DDH.

like orthopaedic surgeons.

• Orthopaedic surgeons were berated for

being unable to diagnose and treat atrial fibrillation, a medical condition.

Would such comments be tolerated if addressed against race, religion or gender?

Could this negative perception be preventing the brightest students from applying for our specialty? Other professions allied to medicine and medical specialties that deal with the musculo-skeletal system such as physiotherapists or rheumatologists are not considered to be stupid.

At a peri-operative care conference, the lecturer put up a picture of a monkey and asked the audience “How do you change orthopaedic surgeons?”. The answer – evolution. Is that banter or abuse?

How many times have we had to endure the following ‘witty’ remarks?

• How do you identify an academic

orthopaedic surgeon? His knuckles are further off the floor.

Phil Turner is a Consultant Orthopaedic Surgeon specialising in knee surgery at Stepping Hill Hospital, Stockport. He is the clinical lead for ‘Improving Specialist Services’ in Greater Manchester and President of the BOA 2018 - 2019.

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• How do you tell the difference between a

At a recent surgical conference that we attended, the orthopaedic surgeons were asked if they had attended medical school!

Why are we perceived differently? Most surgeons are seen as male, opinionated, extrovert with inflated egos and possibly arrogant2. This is an outdated stereotype.

No one would think that a general surgeon would act in this ‘Sir Lancelot Spratt’ type of way now. Reports in the BMJ noted that the perception of the orthopaedic surgeon is a man of enormous build and great strength, if perhaps a little slow; that orthopaedic surgery requires brute force, ignorance and little perception of pain3, 4, 6.

Are orthopaedic surgeons more arrogant than neurosurgeons or cardiac surgeons?

A cardiac surgeon told one of us that he was “the rock star of surgery”. Are orthopaedic surgeons wealthier? Possibly, however plastic or cosmetic surgeons probably earn more. We may not help ourselves by pretending that we are somewhat intellectually limited as we are only dumb ‘bone surgeons’. Does this sound arrogant or self-deprecating?

However, over the last 40 years orthopaedic surgery has been at the forefront of progressive and innovative change:

rhinoceros and an orthopaedic surgeon?

One is thick skinned and charges a lot – the other is a rhinoceros.

• The Advanced Trauma Life Support

• How do you get an orthopaedic surgeon

• OCAP (Orthopaedic Curriculum and

to read a textbook? You put a fiver between the pages.

• What is the difference between a carpenter

and an orthopaedic surgeon? The carpenter knows more than one antibiotic.

System (ATLS), was developed by an orthopaedic surgeon.

Assessment Programme) was the first competency based surgical training curriculum.

• GIRFT (Getting it Right First time) was

planned and implemented by Professor

Features

Tim Briggs with the support of the British Orthopaedic Association. This has been successfully rolled out to most other surgical and medical specialties.

• The National Joint Registry was one

of the first mandatory national quality improvement programmes.

• The first female president of the Royal

College of Surgeons of England was an orthopaedic surgeon, Dame Clare Marx.

• The development

of an exit exam in T&O was introduced in the 1980s by the Royal College of Surgeons of Edinburgh, later becoming the Joint Colleges Intercollegiate examination.

Currently, many medical subspecialties do not have a test of competence at the end of training.

• The National

Hip Fracture database (NHFD) to improve the treatment and care of hip fractures

Innovation and an open mind in evaluating and implementing new, complex and difficult surgical techniques has become the hallmark of modern trauma and orthopaedic surgery. This willingness to change should be cerebrated, not denigrated.

Can we do more to change false perceptions?

We need to get away from the excessive stresses that are used to generate a ‘macho’ culture of coping with adversity.

The morning trauma meeting is often rushed due to the need to commence surgery at 9:00am.

This can make the meeting stressed and possibly hostile. A less confrontational approach may help.

In other countries, the trauma lists start after a relaxed yet thorough meeting.

Should the list be scheduled for later, in order to allow proper discussion and patient evaluation? Following the Montgomery ruling, more time is required to obtain appropriate consent.

There should be more MDT meetings with radiologists, paediatricians, rheumatologists or anaesthetists in order to improve communication, teamwork, training and patient care between specialties. Clinics should not be over-

“Why are we perceived differently? Most surgeons are seen as male, opinionated, extrovert with inflated egos and possibly arrogant. This is an outdated stereotype. No one would think that a general surgeon would act in this ‘Sir Lancelot Spratt’ type of way now.”

• The successful development of virtual

clinics in an attempt to control the increasing demands on services and to improve the patient experience.

booked. Fracture clinics with as many as 100 patients mandate rapid decisionmaking, but that does not mean that the clinical problems are easy or that the specialist is any less clever. Trauma and orthopaedics is poorly represented in the undergraduate curriculum.

This is clearly wrong, as with an aging population there is likely to be an increased need for orthopaedic surgery.

A large part of the workload in primary care is musculo-skeletal disease. Better undergraduate exposure is imperative.

We as a specialty should welcome involvement in medical student training and make them feel part of the team. We both chose trauma and orthopaedics as a career due to the influence of charismatic surgeons and educators.

Discussion with the other Association Presidents from around the world reveals our problems are not unique. Despite the challenges of improving diversity and inclusivity and changing the perceived culture, our specialty is one of the most competitive for selection in many countries.

In summary, trauma and orthopaedic surgery is an exciting, innovative, rewarding and rapidly evolving surgical specialty. It is increasingly academic and practical with excellent measurable outcomes in relieving suffering and disability. As a profession we embrace diversity and abhor any form of stereotyping.

It is not the refuge of the stupid. n

References References can be found online at www.boa.ac.uk/publications/JTO.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 43

Features

Measure twice cut once: The point of no return Grey Giddins and Lisa Hadfield-Law

Grey Giddins has worked as an Orthopaedic and Hand Surgeon in Bath since 1995. He has an interest in surgical error and its avoidance.

He is a visiting professor in the Mechanical Engineering department at the University of Bath. He was honoured to be President of the British Society for Surgery of the Hand in 2017 and Editor-in-Chief of the Journal of Hand Surgery (European) from 2012 – 2016.

Lisa Hadfield-Law, RGN, MSc,FAcadMEd and Education Advisor to the BOA. https://hadfield-law.co.uk

We are all accustomed to the institutional recognition of a point of no return in the form of a pre-operative WHO time out; a communal pause for breath before a surgical procedure begins. However, each of the professionals in the room should make their own preparations for a case. The surgeon should know or have pointed out to them that any procedure will have one or more crucial steps which, if performed incorrectly, will be difficult to reverse either physically or psychologically.

These could be defined as ‘points of no return’.

T

he importance of the point of no return as opposed to other steps in a plan is that once taken they can be extremely difficult to correct. So, as a point of no return is approached, the surgeon should take a moment to double (triple) check that they have met the requirements they have set themselves to proceed. By being overtly cautious, we emphasise the importance of this moment, allow others in theatre to speak up before the moment has passed and create a ‘teachable moment’ for any trainee present.

When delegating responsibility before a case it should be made clear to a trainee that if unsure they must seek advice before crossing the point of no return. Although less common, we should also recognise our continuing vulnerabilities; seniority should be no bar to sharing a problem intraoperatively in the interests of the patient.

Some examples will illustrate how being aware of a point of no return can be helpful.

Cutting We instinctively recognise some points of no return. When a patient has a wound or a fracture it is their fault if that wound or the

44 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

break is inconveniently positioned. With a surgical skin incision or an osteotomy there is a burden on the surgeon to get it right, this is self-evident and most of us easily recognise this and,---- pause ---, at these points of no return. The tailors and builders adage of “measure twice and cut once” is pertinent and worth saying or at least thinking at this point. With a skin incision it is a straightforward strategy to draw before you cut; this focuses the mind of the surgeon and allows others in theatre to make comments at a time useful to the patient rather than subsequently expressing their regret that it should have been more medial. It is salutary how often the final incision is not exactly on the drawn line, not due to inadequate blade control but reconsideration of position.

When cutting the bone for a routine procedure such as an arthroplasty then may be a defined routine pathway which can be followed. For a more individualised procedure such a corrective osteotomy the equivalent of the skin marker pen is the K wire and an image intensifier. A valgus osteotomy of a proximal femur illustrates this, the adage as well as its implementation bears repetition, “Measure twice cut once”. >>

Features

concentrate on assessing the correct variable.

Measure twice cut once is an excellent adage but only if what you are measuring is relevant to that you are about to cut.

Unnecessary pressure

Figure 1: In this sequence of a corrective osteotomy the “point of no return” is obvious, on other occasions it can slip past the unwary unnoticed.

Guidewires K wires are seen by surgeons a relatively harmless and we place them at will. The guidewire is not instinctively a point of no return, and physically this may be true.

However, the step after the guidewire may be the physical step of no return, deploying a DHS reamer may be the obvious example but it applies in many situations. For example, whether performed open or percutaneously, an operatively managed scaphoid fracture must be reduced and usually a cannulated headless screw is put across the fracture line, aiming for a reasonably central position.

This can be difficult to achieve in such an unusually shaped bone and often multiple attempts are made by the surgeon to get the guidewire in the optimal position. Once the surgeon decides the wire is in a ‘good enough’ position, the screw can be placed. Once the screw is placed, it is difficult to change the position without appreciably compromising the fixation. Furthermore, the surgeon will be inclined to accept the position of the screw, perhaps further justifying their decision by taking the radiograph in a slightly oblique manner to optimise the radiographic position of the screw.

So, the point of no return occurs when the decision is made that the wire is in a good enough position. At this point we recommend the surgeon declares a point of no return and double (triple) checks the position of the wire before accepting it and inserting the screw. It is much easier to change the position of the wire prior to drilling over it, than once the track has been drilled or a screw inserted.

Plating of fractures Sometimes the points of no return are not as obvious as they are negotiated in a stepwise fashion and are incremental. One of the benefits of planning a procedure is recognising this. Plating a distal femur is a good example of stepwise loss of freedom.

It is usually clear that the first screw passing across the main joint fragments shows acceptance of articular reduction.

What is less obvious is how sequential screw placement through the plate then fixes varus/valgus, flexion extension and finally length/rotation. Understanding which degrees of freedom are fixed by each step of a procedure allows the surgeon to

As with all fractures, when treating a paediatric supra-condylar fracture, we consider whether the bones need to be reduced and whether they need to be held.

Typically we perform a closed reduction and stabilise with two K wires. An adequate closed reduction can be difficult to achieve.

In this situation the surgeon elect to perform an open reduction. This is not a benign intervention; there will be further soft tissue damage and the fracture may not be much easier to reduce. Some paediatric orthopaedic surgeons claim they would “never” open such fractures in the absence of neuro-vascular injury. The commencement of open reduction feels to be a point of no return. Once a skin incision is made, the surgeon will proceed with the open reduction to completion or abandonment.

The alternative is to apply skin or skeletal traction. Whilst the option of applying traction remains, there will be substantial soft tissue damage and an increased risk of infection. Thus, in this challenging situation the surgeon may need pause intraoperatively to decide whether to perform an open reduction or apply traction.

Failure to achieve a closed reduction is a predictable if uncommon situation. How to cope with this should be considered preoperatively, that is better both for teaching and preparation. Just as with the K wire in the scaphoid or a DHS the point of no return is the decision to accept or reject the position achieved. The rest is just a surgical procedure.

The key words of the builder’s adage are the “measure twice”, we should all know how to cut. The unsaid part of the adage is that you must know and be confident in your allowable tolerances then as we approach a point of no return the decisions all become much easier.

It is easy to treat each part of any operation with similar, sometimes inadequate, attention. The concept of the point of no return identifies the most critical point(s) of an operation, in particular ones where it may be very difficult to undo/correct an error. It may not be relevant for every operation, for example, for a carpal tunnel release. At the point of no return the surgeon may be best advised to step away from the operating table, re-focus their mind, double (triple) check the radiographs (if relevant) and be as certain as possible before proceeding. We hope that readers will consider this idea, respond with their own examples and help to develop this concept. n

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 45

Features

Learning from clinical negligence claims; GIRFT tries BOASTing too The introduction of GIRFT, BHS, BASK and BOA Best Practice Guidance for hip and knee arthroplasty documentation John Machin and Tim Briggs Co-Author(s): Faiz S Shivji, John Hardman, William Harrison, David I Sweetnam, Colin Esler and Andrew RJ Manktelow

John Machin is a Trauma and Orthopaedic Registrar at Nottingham University Hospitals. John is also the GIRFT Clinical Lead for Litigation, working with the NHS Resolution and NHS England and Improvement to ensure patient care is improved from reviewing clinical negligence claims. John has also co-authored and contributed to a number of national reports, including The Chavasse Report on improving armed forces and veteran care, and ‘Getting It Right First Time – National Review of Elective Orthopaedics’. John is a previous National Medical Director’s Clinical Fellow at NHS England.

46 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

F

ive years ago we documented in this journal the tidal wave of litigation which was consuming trauma and orthopaedic surgery in England1. Since GIRFT implemented a review of claims both through the GIRFT orthopaedic provider visits which started in 2013, the GIRFT Litigation in Surgical Specialties Data Pack in 2017 and finally the GIRFT Litigation Data Pack, sent to all trusts in June 2019, we have seen a year on year fall in orthopaedic claims volume. These data packs encourage claims to be reviewed as serious incidents and request the triangulation of learning from claims, incidents, complaints and inquests to be shared in the morbidity and mortality meetings as well as other departmental meetings. While there are many potential factors, both medical and legal, at work, orthopaedics has clearly bucked the trend of the rest of the NHS. Orthopaedic practice has fallen to second in terms of volume of claims and fourth in terms of cost

of claims, representing a fall in share of NHS clinical negligence costs from 10% to 4%2.

This is great progress and will have been noticed at individual trust level.

This is probably just the start of what can be achieved. In 2017/18 there were still 1202 claims notified to NHS Resolution against trauma and orthopaedic practice (excluding spinal surgery) with an expected cost of £146.8 million. The cost of clinical negligence has been reported by the national audit office to be rising at a faster rate year on year than NHS funding, now representing over 2% of the annual budget3.

In this article we layout the process behind the creation of the ‘GIRFT, BHS, BASK & BOA Best Practice Guidance for Hip and Knee Arthroplasty Documentation’ with the goal of communicating lessons learned from previous and ongoing claims with clinical colleagues at a national level for the first time.

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Tim Briggs qualified from The Royal London Hospital in 1982 with honours in surgery and a number of prizes. After his senior registrar training he was appointed to the Royal National Orthopaedic Hospital as Consultant in 1992. His specialist interests are in orthopaedic oncology as well as surgery to the hip and knee. He was Medical Director at the RNOH for 15 years and President of the BOA in 2014. He was appointed as National Director for Clinical Quality and Efficiency for the NHS in September 2015 and leads the GIRFT methodology. Professor Briggs was made a Commander of the Most Excellent Order of the British Empire (CBE) in the 2018 New Year’s Honours List for services to the surgical profession.

Having established the scale of the problem the GIRFT NHS Resolution Orthopaedic Working Party was formed, with expert contributors from all national stakeholders (GIRFT, NHS Resolution, BOA, BHS, BASK, MDU, MPS, MDDUS, NHS Patient Safety, NHS panel law firms, leading claimant law firms and experienced expert witnesses). A review of the findings of previous claims was undertaken to inform and develop a national strategy for learning from orthopaedic clinical negligence claims. When the initial work started in 2013, we had reviewed nine years of orthopaedic claims (including both trauma and elective practice) from the NHS Resolution claims management database. At the time this was the only period when all clinical negligence claims had been notified to NHS Resolution

by NHS trusts. These claims were evaluated for learning themes concluding that the main causes of claims were ‘unsatisfactory outcome to surgery’ (3,030 claims, 53.19%), ‘judgement/ timing’ (2,904claims, 50.97%), ‘interpretation of results/clinical picture’ (2,369 claims, 41.58%), ‘tissue damage’ (1,801claims, 31.61%) and ‘mobility’ (1,545 claims, 27.12%)1. It was clear to us that many of the claims were preventable by training or by improved documentation.

Following review, it was not felt that this data alone provided sufficient information to create more formal clinical guidance so, with the support of the working party, a sub-group of 631 claims were interrogated for learning from

NHS panel ‘Risk Summary’ documents. This was the best available law firm data providing claims learning and represented claims notified from April 2010 until April 2013. The most common themes for quality improvement highlighted by the law firms were ‘education/ training’ 154 (24%), ‘guidelines/policy/ protocol’ 106 (17%), ‘communication/consent/ information’ 71 (11%), ‘documentation’ 38 (6%) and ‘imaging’ 32 (5%). This work reaffirmed the need for disseminating what is considered best practice and, importantly, documentation guidelines. This was also consistent with the feedback received from experienced expert witnesses who frequently reported seeing similar situations in which there was either poor practice and/or poor documentation of the rationale behind intraoperative clinical decisions. This made the defence of surgeons who might have made sound decisions challenging due to the lack of recorded evidence.

We are now pleased to announce the completion of this documentation guidance produced in collaboration with GIRFT, BOA, BHS, BASK, and NHS Resolution. The guidance for each hip and knee arthroplasty is broken down into two documents. A one-page summary document of key points in a similar style to the successful ‘BOAST’ documents and a longer prose article which contains more detail and relevant cases providing real clinical examples to illustrate the importance of the points raised and in some situations the magnitude of settlements made as well as the experience of the surgeons involved.

Little Continuing Professional Development (CPD) training is provided to colleagues to demonstrate what is considered best practice in terms of documentation in orthopaedic surgery. With changes to the consent process and to societal attitudes to litigation, against a backdrop of increasing activity, it is important that the medical profession looks to improve standards of documentation.

This will act to support NHS panel firm lawyers’ activities when they work to defend good clinical practice. In addition, where there is poor clinical practice this needs to be determined quickly. All relevant lessons should be identified to those directly involved and then shared widely within orthopaedic practice. Our patients deserve to know that their concerns will be addressed, and that shared learning of the relevant messages will improve wider care.

Our priority is to provide the best care and satisfactory outcomes for our patients with clear documentation on clinical decisions to support the resolution process.

It is expected that the various details listed would be included within the entire patient care documentation. While much will be included in the operation note, it is appreciated that other aspects could be contained elsewhere in the patient record.

These are only guidance documents and failure for surgeons to follow this guidance does not demonstrate poor practice or prove negligence but a review of the material should allow the surgeon to know what a lawyer or expert witness reviewing their work would expect to see if a claim was brought. We hope these documents are of benefit to all colleagues carrying out hip and knee arthroplasty.

These documents aim to provide advice on various aspects of surgery which should be available and clearly documented in a hip or knee arthroplasty operation record. These documents are not a comprehensive guide to hip or knee surgery, however it is hoped that surgeons will find the advice they offer helpful.

“A review of the findings of previous claims was undertaken to inform and develop a national strategy for learning from orthopaedic clinical negligence claims.”

The working party agreed a national strategy to promote claims learning through GIRFT data packs provided to trusts, and the creation of targeted best practice guidance starting with hip and knee arthroplasty documentation. The aim of the documentation guidance is to share with colleagues what both the NHS panel firm lawyers and the expert witnesses were looking for in the operation notes to defend good clinical practice. Hip and knee arthroplasty surgery was chosen as an initial area of interest as these each represented 16% of all trauma and orthopaedic claims, and were the highest volume sub-specialties1.

You will have recently been sent these four documents by the BOA. This guidance can also be found on the GIRFT website (www. gettingitrightfirsttime.co.uk/cross-cuttingstream/litigation/) and on the BOA website (www.boa.ac.uk/knowledge-hub.html​). GIRFT has also carried out a review of clinical negligence claims in the Spinal Services National Report by Mr Mike Hutton and highlighted the lessons that can be learnt in more detail in the European Spine Journal4,5. We look forward to providing further analysis and guidance in other sub-specialties following the forthcoming GIRFT reviews of Orthopaedic Trauma and Paediatric Orthopaedics (trauma and elective) led by Mr Bob Handley and Mr James Hunter respectively. n

References References can be found online at www.boa.ac.uk/publications/JTO.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 47

Features

Richard Myatt is a T&O ST3 Registrar in the Thames Valley (Oxford) deanery. He is military trainee in the Royal Navy with an interest in trauma and has undertaken rotations at the John Radcliffe and Royal Berkshire Hospitals to date.

How to… take clinical photographs. Top Tips for camera phone clinical photography Richard Myatt, Andrew Titchener and Bob Handley

Andrew Titchener is a Consultant in Oxford with an interest in trauma and upper limb reconstruction. He qualified from the University of Cambridge, completed higher training in Nottingham and fellowships in Cambridge, Oxford and Perth. He is Deputy Editor of the Bone and Joint 360 journal.

Bob Handley is a Consultant on the Trauma Service at the John Radcliffe Hospital in Oxford. Bob is Vice-President Elect of the BOA, and is a Past President of the Orthopaedic Trauma Society and AOUK. Bob co-chaired two NICE guideline development groups related to fractures, and is National Clinical Lead for GIRFT Orthopaedic Trauma.

The best way to get a good clinical photograph is to ask medical photography to take it for you. The image and the requisite paperwork are likely to be better and the process ensures adherence to Data Protection rules. However this is not always possible, particularly out of hours or with urgent clinical problems such as open fractures.

I

n the case of open fractures, clinical photographs of the wounds are integral to the planning of operative intervention and aid communication among members of the MDT. The core of all the recommendations for standardizing the management of open fractures laid down in the NICE and BOAST Guidelines is collaborative orthoplastic care, so it also important that we acknowledge our plastics colleagues in demonstrating that radiographs are not the only images that concern us. Furthermore, these photos should exist in an enduring form to detail the progress of these injuries into the future.

The NICE Guidelines clearly state that ‘all trauma networks MUST have information governance policies in place that allow staff to take, use and store photographs of open fracture wounds for clinical decision making 24 hours a day’. The word ‘must’ seldom appears in a NICE guideline, and places an obligation on each Trust. As we all know from our clinical practice and previous studies there is much variation on how, if at all, relevant clinical images are obtained. Where formal clinical photography exists we recommend it is used, although recognise the capability often doesn’t extend to out of hours. The use of departmental cameras can be fraught with

48 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

difficulties and naturally people have resorted to using their own mobile phone, which with the rapid advancement in technology are capable of capturing high quality images.

As per the NICE guidelines, it is a requirement that Trusts resolve the governance issues relating to clinical photographs for open fractures but does it seem logical that the solution they choose should be pragmatic and use the readily available technology. The authors’ Trust uses an app which permits personal devices to be used for clinical photography with instant upload to the Electronic Patient Record system, without storing the image on the users’ personal phone; therefore avoiding a potential breach of the complex Data Protection rules. In the remainder of this article it is presumed that an appropriate governance structure exists.

Now that photographs can be taken with ease by relatively untrained users it seems prudent to ensure that these photographs are of sufficient quality and serve the purposes for which they are intended; primarily to document the injury and assist with surgical planning and possibly for teaching. This Top Tips guide has been written to try and promote the taking of good quality clinical photographs when professional Clinical Photographers are not available. >>

Features

1. Consent. If the patient is conscious and has capacity to make this decision you need to obtain consent by a process acceptable to your Trust. Consent should be documented in the notes, bespoke consent forms can be photographed and thus stored alongside the clinical images. Explain to the patient why you are taking the photo, basic level is that it is an adjunct to planning and documentation and will be stored securely. If the patient is obtunded or lacks capacity then photos can be taken if judged to be in the patient’s best interest.

When the patient regains consciousness or capacity and at an appropriate juncture, the discussion of consent for photographic images should re-visited.

When the images are to be used for teaching or publication then a further level of consent is required.

from camera, will improve texture and dimension; in the same way as a landscape at sunset regains the contour it lost in the midday sun. Figure 1 demonstrates the difference between a clinical picture viewed with bad and good light.

3. Flash off. The camera flash will

generally make things worse. The flash light

screen, it is the instantaneous image at the time of the flash. It is usually disappointing.

4. Operating light off. Do not use the operating lights or other spotlights they generally degrade the quality of the picture. They give bright pools of light on a photograph which our brains normally factor out in direct vision. The spotlight in Figure 1 demonstrates this well.

“The image is being taken for a clinical purpose not as a work of art. Frame the affected area in the centre of the picture and ensure distracting elements are removed or out of shot, this includes clothing, jewellery, ECG leads, used cannula sheaths or skin prep wipes. A clean non-reflective background allows easier viewing.”

2. Light. Whilst a modern camera copes well in poor light it is better in good light.

Good light improves image detail and reduces the effect of any camera shake. Ensure that light has a direct path to the subject and that you don’t stand in between the light source and patient for risk of casting a shadow. A tangential light source, i.e. from 30-45°

source on a mobile phone is on the same axis as the lens and reflection of the flash back onto the lens can cause glare. In the context of open fractures where you may be taking a photo of a wet surfaces (blood or articular fluid) this is likely to exacerbate the problem. As noted in point 3 the axial light source flattens out contours. The flash image is not the one that you had been preparing and setting up on the phone

5. Background.

The image is being taken for a clinical purpose not as a work of art. Frame the affected area in the centre of the picture and ensure distracting elements are removed or out of shot, this includes clothing, jewellery, ECG leads, used cannula sheaths or skin prep wipes. A clean nonreflective background allows easier viewing.

Avoid very pale or very dark backgrounds as these make achieving the correct exposure more difficult. Ensure that the patient’s wrist band or other identifiers are out of shot and avoid inadvertently capturing other people in the background. >>

Figure 1

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 49

Features

when we introduce a camera there can be problems. Distortion in photography can be a complex topic, so keep it simple. We know that a photograph taken looking up a tall building makes that building look tapered, this is a consequence of the camera being held at angle to the building. However, since we know that generally buildings do not taper our brain is not misled and we intuitively to correct for this. The same optical distortion can apply to wounds but with this less familiar objects our brains may not make a correction and we can be misled. Therefore, it is easier to interpret an image taken with the camera held parallel to the wound; unsurprisingly this is just the same principle as when taking a good X-ray.

Figure 3 demonstrates a clinical photo with perspective distortion and the optical illusions it can produce.

11. Practice and learn. Whilst a Figure 2

6. Position. Aim to position the affected limb in an anatomical position. Not only are surgeons are used to visualising anatomy in an anatomical orientation but it standardises the picture. It is likely that these wounds will be photographed again following wound excision and any subsequent soft tissue coverage, so anatomical positioning of the limb makes reproduction of the original photograph easier to achieve permitting continuity for comparison of the series. Not all open fracture wounds will be best visualised in the AP view so taking photographs in lateral and oblique views, which we are used to visualising through other imaging modalities, is also appropriate.

7. Zoom. The zoom feature on camera phones is one which can both help and hinder the usefulness of clinical photographs. As an aid, zooming in on the wound can assist in demonstrating the detail of the injury and identification of any important features such as macroscopic contamination, bone fragments, joint surfaces, fascial breaches as well as neurovascuar structures. But beware that a close-up photo in isolation can mean perspective and orientation of the wound in relation to the limb is lost. A zoomed out photograph is useful for demonstrating accurate location of the wound and assist during the surgical planning phase when assessing the likely structures involved/to be encountered.

Use the two types of picture in conjunction as in Figure 2. First take a zoomed out photo of the entire limb to assist with orientation, followed by a zoomed in photo for detail.

photograph near the wound. Preferably this is a formal measuring device such as a ruler (clinical marker pens are often packaged with a paper ruler) as demonstrated in Figures 1 and 2, or otherwise an identifiable object such as a pen to give the viewer an appreciation of size.

9. Focus. You will be taking photos of a 3D

structure but want to ensure the wound is in maximal focus. Mobile phone cameras, in a similar way to many handheld digital cameras, will have an auto focus feature but this may not choose your desired area. In order to ensure the focus is centered on the wound, tap the screen where you want the camera to focus and this will optimise the image.

10. Perspective Distortion.

Our eyes and brain generally work well together, the result is that distortion when looking at an object is not usually a problem. However,

8. Scale. The size of the wound is easily

misrepresented in photographs which do not have a reference for scale. Wound size is important in the planning stage and documentation. Include a reference item in the

50 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

Figure 3

patient needs to give consent a lamb chop does not, so experiment. If the picture you get does not look like a lamb chop then you have got it wrong. When clinical photography are requested to take the pictures watch how they do it. Review your pictures as you take them for on the spot quality control and look back at clinical pictures that you have taken and see if they achieved the required purpose.

In summary, Trusts should have a legitimate way of acquiring and storing relevant clinical images 24 hours a day. When a professional clinical photographer is available use their services. Mobile phones are ubiquitous and their camera technology is so good that it is likely many Trust approved systems will come to rely on their use. The above guide provides Top Tips for creating useful clinical photographs; practice them. This will at best assist in the surgical planning for open fractures and be a valuable addition to documentation of these life changing injuries, and at worst mean you have some strange pictures of lamb chops on your phone. n

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Medico-Legal

Orthopaedic surgeons and medico-legal matters David Warwick

As I take over the reins of the BOA Medico-legal Committee from Mike Foy, the first thing is to thank him on all of our orthopaedic behalves for his boundless enthusiasm and huge contribution over five years - running the Committee, advising members, writing articles and organising the medico-legal part of the Congress.

S David Warwick has been a Consultant Hand Surgeon at University Hospital Southampton since 1998 as well as visiting Hand Surgeon to the States of Jersey and Bailiwick of Guernsey.

He is involved daily in the clinical management of complex hand and wrist problems with a particular interest in the DRUJ, Dupuytren’s, joint replacement and orthopaedic hand trauma.

o I thought I would start my term with some musings - ramblings perhaps on orthopaedic surgeons and medicolegal matters. A topic in which we are all, one way or another, interested.

Anyone doing private practice will have seen their indemnity premiums rise inexorably to the point that some find it easier to just give up. Indeed, for spinal surgeons some indemnity organisations now turn away their business.

As commercial providers enter the market, we may be tempted to change horses. But there is a minefield to negotiate, especially with regards to run off cover (will you still be insured when you retire and how much will it cost), and overlap between cover (‘claims made’ and ‘claims occurring’). And just because the premiums are lower now, what if there is a claim against you and the premium then rises or renewal is denied? Or suppose that other policy holders indemnified by your new insurer are sued so that the insurer raises premiums for all its clients to a prohibitive level.

If you flit form provider to provider each year for the cheapest premium (as if you were insuring your car or your home) who will take responsibility for a claim in which particular year? Do all commercial indemnifiers have the institutional knowledge acquired over decades to advise on other matters - employment, GMC and so on?

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We are well aware of the need to take increasingly meticulous care in our practice to make sure that our discussions with patients on all the options of treatment have been fully discussed; if we have a bad outcome, however unexpected or unavoidable, we can rest assured that the lawyers, armed with court judgements such as Hassell, Thefaut and, of course, Montgomery, will pore over every single word we have written in the notes; anything we say that have not written down was never said…so where do we find the extra time in outpatient and preassessment clinics which are already overloaded with waiting time and teaching pressures?

By the way, we have to find the time.

Those involved in the metal-on-metal business will know how a wonderful concept with tantalisingly promising early results prompted implantation into so many younger, sportier people; despite good faith and the best of intentions, this procedure has, for some, led to a deluge of failures and potential litigation. Will this be repeated in other implants - are we sitting on another medico-legal time bomb? Perhaps some circumspection before using the next glamorous or promising gadget is wise.

To what extent will medico-legal concerns fetter new developments? Maybe the pioneers of orthopaedics (or heart transplants for that matter) would have baulked if their well - considered but unproven ideas had to be developed under the threat of legal redress. Nowadays all innovation must, quite rightly, be undertaken with the engagement of peer review, ethics committee approval, fully informed consent and meticulous follow up.

“Medical negligence work is far more challenging. The issue of breach of duty is our problem not the lawyer’s.”

Some surgeons make a (very) decent income providing independent evidence to the court on personal injury cases. This is often straightforward work since the vexing and contentious matter of breach of duty is the lawyer’s problem - we simply provide some reasonable comments to link the injury with the subsequent symptoms, consider whether the

Medico-Legal

claimant’s account is proportionate and then predict the prognosis. Money for old rope…

WRULD-RSI cases are rather more of a challenge. Whilst some experts (not usually the archetypical orthopod…) take a rather left wing view along the lines of ‘all work is harmful and the employer clearly harmed the patient’, others (perhaps the archetypical orthopod…) take a rather more right wing view that ‘hard work is good for you and if your arm is painful then you had it coming anyway regardless of your work’. If the solicitors have each picked their favourite defence or claimant gun, joint statements can be contentious with no common ground. Then an inevitable court date will block our precious clinical diary. And however much we charge for a day in court, that is annoying. Even more annoying if the case cancels the day before as each side realise it could go either way depending on the judge.

Medical negligence work is far more challenging. The issue of breach of duty is our problem not the lawyer’s. Breach is often by no means straightforward and not infrequently tinged with the pangs of ‘there for the grace of God go I’. Despite our reputation amongst other specialities, we orthopaedic surgeons are scientists (really) and so we are familiar with the scientific 95% burden of

y the b d e dit Accre ollege of lC gland Roya n E f o D eons 5 CP .

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proof. But we get quite uncomfortable when we dither either side of the 50-50 balance of probability bar - the standard with which our legal colleagues dice every day. No one deliberately harms a patient. We all make mistakes; the retrospectoscope is a powerful thing; the gold standard is not always achievable and anyway is not expected in law.

If the claimant genuinely believes they were harmed but in fact there was no negligence, then the emotionally mature independent unbiased expert should sympathetically help the claimant understand that whilst the result was not as expected, the vagaries of nature and uncertainties of treatment mean that there was no shortfall in care. On the other hand, we do sometimes see a clear error of judgement.

The expert should save all parties the expense and anxiety of a fatuous defence, and advise the system to promptly confess, apologise and pay up. And very unusually, the matter is not one of an out-of-character error but frank incompetence. Our duty as a doctor, as defined by the GMC, requires us to refer these cases.

The challenging, but fascinating aspect of negligence reporting, is causation - where would the claimant be in any event despite the alleged error? Even if there were breach of duty, once the inevitable outcome from the injury is subtracted from the consequences

of the negligence, there may or may not be a clinically material difference.

Sooner or later orthopaedic surgeons think of retiring. Our previous NHS employer may drag us back to comment on a case for which we remain professionally liable. The three year statute of limitation is not as protective as we might imagine, a case may crop up many years later when the claimant can reasonably deduce he was harmed. The legacy of cases which may come back and bite needs to be properly covered with indemnity, depending on the insurer, which is not always guaranteed and not always cheap.

And talking of retirement, medico-legal work can be a ‘nice earner’ for a few years. No stressful outpatient clinics or operating lists, no insecurity as our eyes and dexterity and resilience gradually fade. Yet there is plenty of time to deal with the avalanche of paperwork that can spoil your life when trying to manage it alongside a clinical practice. It might even be rather interesting and fulfilling. But how long can you be a ‘real expert’ once you are no longer a ‘real surgeon’? Do you need to remain appraised and revalidated, if so how? Who will insure you and for how much?

So medico-legal matters matter to all of us. n

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London (UK) JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 53

Simulation Section

Measuring the educational impact of simulation training in Trauma and Orthopaedics Hannah James

Simulation allows trainees to progress from a state of being ‘novice’ to ‘competent’ in a highly controllable, standardized environment, remote from patients.

Competency based assessment can be used to provide assurance that an individual has reached the required standard following the training, before being allowed to begin performing surgery on real patients.

Hannah James is a Specialist Registrar on the Warwick Rotation, and a member of the BOA Simulation Group. She has done a PhD investigating the impact of cadaveric simulation for T&O surgeons-in-training. Her research interest is in measuring the transfer of surgical skill from the simulated environment to the real-world operating theatre.

B

efore significant investment can be recommended in the widespread provision of simulation for T&O trainees, there needs to be robust evidence that simulation training improves surgical skills in an objectively measurable manner, that skills are translated into the operating theatre, and are retained longitudinally. There is a wide variety of simulation technology available, ranging from inexpensive, low-fidelity bench-top/ box-trainers to ultra-high fidelity cadaveric simulation. This raises the important question around the best type of simulation technology to use to achieve the desired educational outcomes in the most timely and cost-efficient manner, and how to time delivery within the training programme.

Measuring impact in simulation research It is possible to measure the educational impact of a training intervention and this is traditionally described with reference to Kirkpatrick’s hierarchy1 (Fig 1). Evidence

54 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

at Level 1 (change in learner reaction) dominates the literature on simulation research, and relies on subjective measures of learner reaction such as confidence and satisfaction. Level 2 studies (change in knowledge) usually rely on written or oral examination assessments to measure learning, and whilst objective, are arguably not appropriate outcome measures for the assessment of technical skill. Level 3 studies (change in learner behaviour) and, in an ideal world, Level 4 (change in patient outcome) provide much more powerful evidence for the effectiveness of simulation training.

A major difficulty with designing Level 3 or 4 studies is finding an appropriate, sufficiently validated outcome measure to test the impact of the training intervention on either learner behaviour or patient outcome. The most commonly used tool to measure behaviour change after simulation training in Level 3 studies is Workplace Based Assessment (WBA), however these are suboptimal in the research setting in view of coarse descriptors, generally low inter-rater reliability and rater effects that compromise validity2, 3. Simulatorderived metrics such as procedure time4, >>

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JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 55

Simulation Section

error frequency5, and more recently hand motion analysis6 are also frequently used in simulation research. The utility evidence for these assessment tools is promising, but in their relative infancy4, 5, 7-11.

A recent systematic review12 of simulation in T&O found that of 71 eligible studies, 47 (62%) involved arthroscopy simulators, and that these studies had the highest level of evidence. The evidence base is much more advanced for arthroscopic simulation compared to open surgical simulation, and this may be because of the ready availability of simulator derived metric data for assessment of behaviour change.

‘Patient’ outcome measures, for Level 4 studies, are equally problematic. Surrogate outcome measures of operative success are often used as an objective assessment of the final product quality and are known as ‘final product analysis’ (FPA). Examples in T&O simulation research include guidewire position for hip fracture pinning4, tip-apex distance for dynamic hip screw13, and biomechanical failure point of a fracture fixation construct14. With the probable exception of tip-apex distance, the utility evidence for FPA methods is generally weak.

The ultimate way of measuring change in patient outcome following simulation training would be to use Patient Reported Outcome Measurements (PROMs) and morbidity/ mortality data. The level of ‘noise’ from confounding variables and difficulty in seeing any effect of the training on patient outcomes using these measures would likely be very significant, and would require a large and well-designed randomised controlled trial to demonstrate proof of effect. Such a study has not (yet) been done.

Challenges of designing simulation research

Figure 1: Modified Kirkpatrick’s hierarchy.

of education and training. These problems include; small sample sizes (and hence underpowering), lack of randomization and over-use of single-group non-comparative cohort design. There is often reliance on pre-test/post-test assessment strategies which can over-estimate the observed effect size15.

Funding is another barrier, surgical education research does not typically attract significant amounts of research funding and hence precludes delivery of the large scale trials that are needed to provide a high level of evidence for the effectiveness of simulation in training T&O surgeons.

“The ultimate way of measuring change in patient outcome following simulation training would be to use Patient Reported Outcome Measurements (PROMs) and morbidity/ mortality data.”

In addition to the difficulties in finding an appropriate outcome measure, a research team needs to design a sufficiently robust study to answer the research question, using methods that are both appropriate and feasible. Surgical education research is often beset with methodological problems that stem from the real world ‘messy’ nature

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The future of simulation research in T&O

It is encouraging that delivery of simulation in surgical training has been declared a priority area by the Department of Health16 and General Medical Council17, and the development of a simulation mapped curriculum for Trauma and Orthopaedics is well progressed.

A national survey of UK and Republic of Ireland Training Programme Directors is currently being undertaken by the BOA simulation group to map the current provision of simulation within training programmes, and to identify

research activity into simulation. Three doctorates in simulation for T&O by specialist trainees are either recently awarded (one) or in their final stages (two). The future of simulation research in T&O is therefore very promising, and one hopes that as it gains momentum, it will continue to attract more research funding and credibility.

In summary: • The present evidence base for simulation

in T&O training is limited and lacking in high quality evidence showing that skills learnt in the simulated environment are transferred to the operating theatre and retained longitudinally.

• The evidence base for virtual reality

arthroscopic simulators is more developed than that of open surgery, low-fidelity box trainers and cadaveric simulation.

• It is difficult to design high quality

simulation research studies because of the lack of appropriately validated outcome measures, coupled with pragmatic difficulties including funding.

• Simulation research is increasingly gaining

momentum and recognition amongst surgical education stakeholders, and the future looks promising. n

References References can be found online at www.boa.ac.uk/publications/JTO.

Trainee Section

Ran Wei is an ST7 Registrar on the South West London training rotation. He is the BOTA SAC representative and sits on the T&O SAC.

Alastair Faulkner is a ST4 trainee on the East of Scotland rotation. He is the Vice President of BOTA and represents trainees at the Joint Committee for Surgical Training (JCST).

A New Era in T&O Training Ran Wei, Alastair Faulkner and Lisa Hadfield-Law

August 2020 will see the dawn of a new era in Trauma and Orthopaedic surgery training. The new curriculum, which is undergoing the final stages of consultation and approval, will embed the current certification guidelines and see the return of professional judgment within surgical training. Trainees and trainers across the United Kingdom and Republic of Ireland will begin to adopt the use of two new ISCP assessment tools that have been developed to facilitate the implementation of new curricula across all surgical specialties. In this article we aim to shed light on these upcoming changes and help you hit the ground running.

The New Ethos

Lisa Hadfield-Law, RGN, MSc,FAcadMEd and Education Advisor to the BOA. https://hadfield-law.co.uk

The new curriculum will propel surgical training into an era of competency-based (rather than time-based) training. This way of training allows trainees to develop at their own rate and accounts for the fact that not all trainees achieve competencies at the same pace. For competencybased training to work, both the trainee and the trainer must be invested in the assessment process1.

As trainees, we rarely pause to reflect on the adequacy and effectiveness of the training assessment tools that we are mandated to use. We are all well versed in the use of workbased assessments (WBAs).

These help demonstrate our progress and achievement of competencies throughout training. On average, each trainee completes one WBA per week2. The effectiveness of these formative and

58 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

summative assessments relies heavily upon trainee and trainer engagement3. A trainer’s prior WBA training and their time availability for completion of WBAs are key factors in the successful utilisation of these ubiquitous postgraduate medical education assessment tools4.

Whilst all trainees aim to perform WBAs in real time, this may not always be possible. As such, the value of the WBA is often diluted.

The danger of the status quo of minimum annual WBA requirements is that they become a tick box exercise rather than a way for trainees to receive invaluable feedback on their performance and professional development.

The new curriculum aims to move away from this arbitrary annual assessment quota and towards meaningful assessments that provide trainees with the feedback that will help guide them towards becoming a safe and competent Day 1 consultant. >>

“We are all well versed in the use of work-based assessments (WBAs). These help demonstrate our progress and achievement of competencies throughout training.

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JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 59

Trainee Section

The New Assessments All postgraduate medical and surgical curricula are mandated to meet the framework set out by the GMC’s ‘Excellence by design: standards for postgraduate curricula’ publication5 by 2020. Assessment of Generic Professional Capabilities (GPC) and Capabilities in Practice (CiP) will be adopted across all surgical specialties in order to comply with GMC’s recommendations. They will complement the existing requirements of critical casebased discussions and indicative procedure-based assessments.

Generic Professional Capabilities

Patient Safety and Quality Improvement Safeguarding Vulnerable Groups Education and Training Research and Scholarship

“The new curriculum aims to move away from this arbitrary annual assessment quota and towards meaningful assessments that provide trainees with the feedback that will help guide them towards becoming a safe and competent Day 1 consultant.”

The generic knowledge, skills, behaviours and values of all doctors are encompassed within the GPC assessment. It will contain all of the 220 descriptors that have been set out by the GMC in the ‘Generic professional capabilities framework’ publication6. The nine main pillars of GPC underpin professional medical practice and are in keeping with Good Medical Practice7.

These are: • • • • •

• • • •

Professional Values and Behaviours Professional Skills Professional Knowledge Health Promotion and Illness Prevention Leadership and Team-working

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Trainees will be assessed on their abilities in each of these areas based on their level of training but set at the standard of certification.

Trainers will be able to use the pre-populated descriptors as well as free text boxes to provide feedback for their trainee.

This will allow the trainee and assigned educational supervisor (AES) to set targeted training goals at the subsequent learning agreement (LA) meeting8.

The introduction of these generic GPC assessments across all surgical specialties will allow trainees who wish to change their specialty to do so without forfeiting their generic competency achievements.

In essence, this will introduce a level of transferability between surgical specialties that can potentially shorten the time required in training for trainees choosing to re-train in another surgical specialty.

Capabilities in Practice The requirement for high-level outcomes in all medical specialties has brought about the introduction of CiPs. These will assess the day-to-day professional tasks carried out by all surgeons working within the scope of specialty practice. CiP assessments are common to all surgical specialties but will be assessed in the context of each surgical specialty. The five professional tasks assessed will be: • • • • •

Managing an Outpatient Clinic Managing the Emergency Take Managing Ward rounds and Inpatient Care Managing an Operating list Working with a Multi-disciplinary team

Trainees will be assessed on their ability in each of these areas based on the end point of training (i.e. Day 1 consultant). Consultant trainers will be able to assess each trainee using defined supervision levels that reflect the intensity of supervision required by the trainer. The levels used will be: • Level 1 – Able to observe only • Level 2 – Able and trusted to act with

direct supervision: • 2A – Supervisor present throughout • 2B – Supervisor present for part

• Level 3 – Able and trusted to act with

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• Level 4 – Able and trusted to act at the

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• Level 5 – Able and trusted to act at a

level beyond that expected of a day one consultant >>

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Trainee Section

GPC and CiP assessments will be equally weighted and performed as part of the Multiple Consultant Report (MCR) that should take place prior to each interim and final LA meeting.

The MCR will negate the need for mandatory Clinical Supervisor (CS) reports prior to sign off of the final LA meeting. MCRs are mandatory prior to each final LA meeting and will serve as a summative assessment tool. Whilst not mandated, MCRs prior to interim LA meetings are highly recommended. Along with each MCR, the trainee will be expected to self-assess against GPC and CiP standards. This will be visible to the trainee’s lead CS (i.e. nominated trainer) who will be expected to meet with a group of consultant trainers who are currently training that trainee to generate a MCR. It is important to understand that the purpose of these assessments is to provide constructive and actionable feedback that will help trainees and their AESs set training goals for the subsequent three to six months of training. As such, it is imperative that the lead CS utilises the breadth of consultant trainers for each trainee to provide robust feedback in all areas of the GPC and CiP assessments.

The introduction of new methods of assessment will undoubtedly be a daunting prospect for most T&O surgery trainees and trainers. With recent changes to indicative operation numbers and expanding requirements for certification, we must work hard to stay on top of our higher surgical training. However, if we pause to reflect on the purpose of the new curriculum and assessment methods, it does seem like a move in the right direction. The new ISCP assessments will complement pre-existing WBAs to provide the tools required for trainees and trainers to make a success of competency-based training. Only time will tell if this initiative has been a successful one.

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Conclusion As August 2020 draws ever closer we hope that this article helps shed some light on the future of T&O surgery training in the UK and Republic of Ireland. The new curriculum ensures that all consultant surgeons will possess the generic professional capabilities that are required of all doctors. It will ensure that trainees reaching the end point of training will possess the high level capabilities required to work safely as a Day 1 consultant. It puts professional judgement at the heart of assessment and allows trainees to complete training as soon as they are deemed ready. Patient care remains at the core of all our endeavours. As such, higher surgical training is forever evolving and improving in order to meet the demands of our patients.

Key Facts • Current CCT requirements will be embedded

into the new curriculum

• New curriculum will take effect in August

2020

• Changes to the curriculum are in line with

GMC’s ‘Excellence by design: standards for postgraduate curricula’ and are mandated for all surgical subspecialties

• No more minimum annual quotas of WBAs • No change to Critical CBDs and Indicative

• MCRs will replace mandatory CS reports

and will be completed by lead CSs following discussion with all CSs for the trainee

• MCRs should be performed for each

trainee before their interim and final LA meetings

• If a trainee disagrees with comments

within the MCR, the same escalation/ appeal/review procedure as for other elements of the curriculum (such as the Learning Agreement, WBAs and the ARCP) will be available.

Message from JCST/ISCP to Trainers and Trainees: For more information about the new curriculum and ISCP assessments please visit: https://www.iscp.ac.uk/iscp/content/ articles/curriculum-update01/.

Please also try the MCR for yourself by first logging in to ISCP and then typing https:// www.iscp.ac.uk/mcr in the address bar.

You can select the trainee for whom you are CS to and click ‘create MCR’ or just click ‘create MCR’ if you are a trainee and assess yourself. It won’t be recorded in ISCP until the curriculum goes live but both trainers and trainees might find it a really good way of generating feedback. n

PBAs

• No change to indicative operation numbers • GPC and CiP will be assessed as part of MCR • MCR reflects return of professional judgment

References References can be found online at www.boa.ac.uk/publications/JTO.

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JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 63

Subspecialty Section

Mode of action and clinical benefits of closed incision negative pressure: A literature review Brian Andrews

Whether defined as incisional negative pressure wound therapy iNPWT, closed incision negative pressure wound therapy ciNPWT, or closed incision negative pressure therapy ciNPT, there is no escaping the fact that there is a growing body of evidence attesting to the benefits of applying vacuum dressings to closed surgical incisions in many surgical disciplines1-5. Accordingly, in the interest of furthering the understanding as to how the application of negative pressure in closed incisions may improve clinical outcomes.

In this paper we discuss the attributable benefits and how they may be manifest.

O Brian Andrews is a Global Marketing Manager with Molnlycke Healthcare, responsible for the company’s negative pressure wound therapy devices developments. A nursing, biological sciences and business graduate, Brian has worked in the field of advanced wound care for more than 20 years. He has worked for leading global medical device manufacturers ConvaTec, KCI Inc., and Molnlycke, and has been fortune live and work in a number of international markets including Australia, UK, USA, Singapore, Japan, he presently resides in Sweden. Passionate about the medical devices industry and wound care, Brian is motivated by the need to provide adequate healthcare to all members of society, regardless of social or economic status. And in order to do this, he believes the industry need to move beyond the supply of products, and to partner with healthcare providers in the provision of sustainable solutions. Clinically appropriate, yet economically response solutions.

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riginally developed to aid in the healing of acute and chronic open wounds, negative pressure wound therapy, NPWT, has been used to great effect for more than 20 years. In contrast, the application to closed surgical incisions is far more recent, first reported in 20066, and there are many open questions with respect of mode of action. How does the application of negative pressure aid in the healing of an incision where there is no open tissue defect? In this paper, through a review of the literature, we attempt to shed some light on possible cause and effect relationships.

The most often cited beneficial actions attributed to ciNPT include; reduction in tension at the incision union, clearance of oedema, the reduced occurrence of fluid accumulation, and improved perfusion.

With subsequent clinical benefits being reported as a lower incidence of SSI 7-11 and haematoma seroma formation6,15,16, and the reduction in occurrence of events such as dehiscence9,12-14.

In regard to reduced stresses on the incision, some of the most relevant observations can be drawn from animal studies paired computer finite element analysis (FEA) with the later providing a window on activity that cannot be observed in the biological model. The earliest of these complimentary modelling studies sponsored by KCI Inc.,

manufacturer of the Prevena Closed Incision Management System, included three separate animal, and two FEA models.

The first of the animal studies, a porcine model was designed to quantify effect in the reduction in haematoma/seroma formation17.

In this model a subcutaneous void was created to emulate dead-space under an incision and isotope-labelled nanospheres were introduced prior to closure. A total of eight incisions were randomised to negative pressure or a control semipermeable film dressing. Following therapy remaining defects were weighed, and where negative pressure was applied, canisters were measured and biopsy were taken from five key organs in all subjects.

The results showed a 63% decrease in defect mass favouring the negative pressure group, having a mean mass of 15 ± 3g vs 41 ± 8g for the control. Further, in biopsied lymph nodes, there were ~60 μg (~50%) more 30- and 50-nm nanospheres from Prevena Therapy-treated incisions compared to control sites (P=0.04 and 0.05, respectively).

The authors concluded that the difference between the two groups may be explained by increased lymph clearance perpetuated by the application of negative pressure.

In the second animal model, again porcine with a standard dressing control, investigators sort to assess the biomechanical properties >>

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Subspecialty Section

of healed spinal incisions, specifically, the strength of the tissue union and the cosmetic appearance18. Post closure incisions were assessed at three or five days using scar scale and histological evaluation. Incisions treated with negative pressure were reported as having a significantly improved scar scale height grade (P<0.026) compared to those treated with standard dressings, which showed inflammation, oedema and swelling around the incision whereas the incision line treated with negative pressure was barely visible. With respect to tissue union, control group scores were lower for failure load (4.9 ± 4.0 vs. negative pressure, 16.5 ± 14.6N), energy absorbed (8.0 ± 9.0 vs. 26.9 ± 23.0 mJ), and ultimate stress (62 ± 53 vs. 204 ± 118 N/ mm²). Histological analysis demonstrated no differences in incision scar width between the two groups but the authors noted “a trend toward improved early healing strength, and improved incision appearance” for incisions treated with negative pressure.

treated with negative pressure or gauze pads for five days after which they were left untreated for a further 35 days19. At 40 days, post-surgery histological sample testing demonstrated a substantial difference in the tensile strength of the tissue union. Authors reported 65% increase in force required to separate the tissue union.

The first of the two FEA models was focused on the evaluation of lateral force across an incision overlaying a subcutaneous void (Figure 1). The mechanical properties of the incision were those of adipose tissue and the negative pressure dressing is described as being an open cell foam, similar to that used for filling cavities in the application of negative pressure to cavity wounds. The foam is bonded to a frictionless incision contact layer with an adhesive border, all of which is covered by a pleated polyurethane film that provides the vacuum seal.

The dressing is coupled to a battery powered pump that generates a vacuum of -125mmHg. And, under vacuum pressure the dressing is described as both contracting laterally as well as compressing. In this FEA model two simulations were run, one with negative pressure and one without.

“The most often cited beneficial actions attributed to ciNPT include; reduction in tension at the incision union, clearance of oedema, the reduced occurrence of fluid accumulation, and improved perfusion. With subsequent clinical benefits being reported as a lower incidence of SSI and haematoma seroma formation, and the reduction in occurrence of events such as dehiscence.”

In a third pilot study, investigators described contralateral incisions of swine sutured and

Subsequent to these animal studies and the encouraging observations, investigators have sort to further qualify and quantify causal relationships through the use of FEA technology, and models designed to mimic human tissue and an incision. Published in 2012 the investigators describe the use of two separate FEA models and a bench test validation model17.

The model was first run to simulate closure of the incision with sutures only, and lateral tension in the range (2.2 to 2.5 kPa at the skin surface) was recorded as the baseline.

Figure 1: Finite element analysis-1: a 2mm wide incision cuts from the skin surface to the void (A). The incision is joined by sutures (B) and lateral stress develops (colour contours, MPa).

Negative pressure (-125mmHg) is applied to the dressing (C), and lateral stresses become more compressive.

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Subspecialty Section

â&#x20AC;&#x153;In regard to reduced stresses on the incision, some of the most relevant observations can be drawn from animal studies paired computer finite element analysis (FEA) with the later providing a window on activity that cannot be observed in the biological model.â&#x20AC;? to baseline tensile stress at the sutures was reduced by 45% while stress at deeper sutures reduced by as much as 50%.

The final test in this evaluation series, the benchtop model made from vulcanised liquid silicone17, was designed to enable the measurement of closing forces or resistance to Figure 2: Schematic of bench test setup: overhead view (A) and cross-section (B). opening when put in tensions (Figure When run again, the model included the 2,3). At the baseline, using sutures only to application of the negative pressure using the maintain tissue approximation, a force of 61.7N dressing previously described, and a vacuum was required to stretch the model 10mm. When of -125mmHg. In the computer model, this negative pressure at -125mmHg was applied the combination of a contractile dressing and a force required to produce the same separation vacuum of -125mmHg reduced lateral tension increased to 92.9N, an increase of 51%. Authors at the skin level to 0.9 to 1.2 kPa (a reduction of concluded that this simple physical test about 50%). corroborates FEA modelling observations.

In the second, and more complex FEA model, authors described a tissue model that included the nonlinear mechanical behaviour of epidermal, dermal, and subdermal tissue layers.

The thickness of each layer was modelled to anatomic proportions21 and a vertical incision was cut through the epidermis, dermis, and upper fat layers. A fascial separation between the fat layers was included and following suturing a tension condition was induced by applying pressure (â&#x2C6;&#x2019;150 kPa) to the dermis and epidermis exposures at the model sides. The application of the pressure produced a 2mm incision gap prior to suturing. When measured prior to the application of negative pressure, the average lateral stress on the sutured incision was measured at; 28.05kPa in the epidermis, 14.5kPa in the dermis and 3.31kp in fat.

In this second FEA model when negative pressure was applied investigators described a sequence where the dressing contracts and collapses, eliminating vertical stress and making horizontal stress more uniform. As compared

differences in the thickness of the different tissue layers however these variations and how they might influence the results are not discussed.

The dressing applied to incision is described as a two layer structure the lower of which is a silicone adhesive wound contact layer.

The upper layer is comprised of a spacer to manifold the vacuum, a super absorber layer to manage fluid and moisture vapour transmission layer to form the seal.

To determine effect at different pressure settings negative pressure was applied to the incision model in increments, specifically -40 and then -80mmHg. The resultant outcome was recorded as a reduction of 43% in tensile stress at the incision from no negative pressure at 1.31 to 0.56 N with the application of -40mmHg. Repeated at the higher vacuum pressure of -80mmHg produced a reduction of 31% in tensile stress at the incision from no negative pressure at 1.31 to 0.40 N. Authors concluded that this simple FEA model demonstrates that this system with a mulitlayer dressing and an applied vacuum pressure of -80mmHg can can apply lateral forces to a closed incision, reducing the tension on the sutures in a way similar to that demonstrated for a system with a contractile foam dressing and an applied vacuum pressure of -125mmHg. >>

Some four years on, 2016, a new group investigators have taken a similar approach to evaluating the performance of their system, again using a combination of benchtop Biomechanical and FEA models22. As with the earlier research the FEA modelling is built around a human tissue model comprising of three layers, skin, fat and muscle (Figure 4).

The incision takes the form of a vertical cut into the skin and 10mm into the fat. At the base of the incision there was a 50mm fascial separation. Of note, Figure 3: Incision bench model configured for horizontal extension-force testing with negative pressure while the models wound therapy dressing applied. are similar there are

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 67

Subspecialty Section

LOVELUCK ET AL Incision NPWT dressing

Skin Fat Muscle

Fascial separation Stitches

Figure 4: Three dimensional finite element analysis computer model of skin incision. The model comprises three layers: skin, fat, muscle. The incision consisted of a vertical cut through the skin and 10mm into the fat. A 50mm wide horizontal fascial separation was created at the bottom of the incision.

Not dissimilar to the model described earlier, the benchtop biomechanical model was designed to enable the measurement of the force required to separate the incision as a function of the negative pressure (Figure 5).

Using a tensile test machine investigators measured the force required to separate the incision by 10mm. As with the FEA model investigators assessed tissue displacement at both -40 and -80mmHg noting that the majority of the resistance effect was realised at -40mmHg. The example given was for an 8.0mm displacement wherein the force required to produce an 8.0mm separation at -40mmHg was a mean of 30.5 N (n=5) as compared to a mean of 33.0 (n=5) with the vacuum at -80mmHg. Authors noted further that the multilayer dressing was able to resist the lateral tension to an unspecified degree even without the application of negative pressure.

In summary, in respect of mechanical forces generated by the application of negative pressures dressings over closed surgical incisions, the FEA and benchtop models provide useful insights as to cause an effect and how the enhancement of a dressing with negative pressure may aide in reducing tension at the tissue union and to reduce the potential for dead-space and fluid accumulation.

On the final, and perhaps the most difficult benefit to illuminate, improved perfusion, there is very little commentary associated with blood flow and the application of negative pressure to closed incisions, however some useful references may be drawn from studies undertaken in open wounds. Specifically, in early research conducted by Argenta LC and Morykwas MJ23,27 where Laser Doppler probes were inserted into tissue adjacent to open wounds in a porcine model. It was observed that the application of negative pressure resulted in increased blood flow to the area under the defect. At their peak, the application of -125mmHg resulted in blood flows four times that of baseline. Subsequently, it was postulated that a possible mechanism of action of increased blood flow was that the

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application of negative pressure reduced local oedema and thus pressure on blood vessels, allowing the restoration of flow.

An alternative but not altogether contradictory view of the mechanism of action proposed by Karinos et. al25, is that the application of negative pressure results in the compression of vessels that is observed

by Laser Doppler as increased flow, but this does not translate to increased perfusion.

To put this theory to test in the clinical setting, a study was undertaken where pressure transducers were situated under the skin in shallow wounds located on the forearm, a scalp, a heel and two thigh degloving wounds. The wounds were covered with open cell foam sealed under a film with vacuum applied in increasing increments with interstitial pressures being recorded at each increase.

in flow, but not volume, may in fact result in low grade tissue hypoxia that are recognised stimuli for angiogenesis 25-28. In their conclusions, the authors did postulate that the increase in tissue pressure could explain the reduction in oedema associated with the application of negative pressure, along with advancing the theory that the accelerated blood flow arising from vessel compression may through the Venturi principal draw fluid into the vessels thus reducing oedema.

Discussion Undoubtedly the application of different evaluation models, biological and computer, provide useful insights as to mode of action of negative pressure in closed incision indications. However, differences in modelling techniques and basic parameters such as tissue thicknesses, make it difficult to draw absolute conclusions leading these reviewers to conclude that the advancement of this therapy would benefit from standardised tissue models and test protocol. Further, with one of the primary indications for use being obesity, it would be useful, perhaps mandatory, to understand how tissue load and incision lines stresses change with the increase in fat and the lassitude of muscle common in obesity.

Improved knowledge in this manner will enable clinicians to discriminate based on system attributes and differences in mode of action that may vary between system solutions, ultimately benefitting patients, clinicians and solution developers. n

References

Although the effect reduced to near baseline by 48 hours, it was observed that there was References can be found online at a progressive increase in tissue pressure www.boa.ac.uk/publications/JTO. proportionate with the amount of suction applied. And, although no direct comparison was made, it may be suggested that this increase in tissue pressure, would likely result in the compression of capillaries resulting in the increased flow rate observed with Laser Doppler in early research.

Further, it may Figure 5: Experimental setup with Syndaver tissue model. The incision was closed with running stitch using be suggested 2-0 non-dissovable suture 5mm apart. Dressing was applied on top of the incision model. that the increase

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Subspecialty Section

Theodoros Bouras is a dedicated Knee Surgeon. He works currently as a Senior Clinical Research Fellow in Knee Surgery for the Cardiff and Vale University Health Board. He has been appointed as the BOA clinical leadership fellow in Knee surgery from August 2019.

Brian Andrews is a Global Marketing Manager with Molnlycke Healthcare, responsible for the companyâ&#x20AC;&#x2122;s negative pressure wound therapy devices developments. A nursing, biological sciences and business graduate, Brian has worked in the field of advanced wound care for more than 20 years.

He is motivated by the need to provide adequate healthcare to all members of society, regardless of social or economic status.

Rhidian Morgan-Jones is a Fellowship trained Knee Surgeon working at the University Hospital Llandough, Cardiff.

Having trained in the UK, South Africa and Australia he now provides a tertiary referral service for complex and infected Revision Knee Replacements and Chronic Ostemyelitis. He has lectured nationally and internationally and is widely published. Rhidian is currently an elected BOA Trustee.

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Closed incision negative pressure wound therapy in orthopaedic surgery Theodoros Bouras, Brian Andrews and Rhidian Morgan-Jones

Over the last two decades the vast success of negative pressure open wound treatment (NPWT) in orthopaedic and trauma surgery led in the use of this emerging technology over closed incisions. The aim was to reduce risk of surgical site infection, formation of haematoma or seroma and dehiscence. Depending on the orthopaedic procedure, surgical site infections (SSIs) can be as high as 30%.

M

ajor risk factors are obesity, diabetes mellitus, smoking and prolonged surgical time. The risk of SSI is significantly higher in high energy trauma and more specifically in open fractures of the lower extremity compared to elective procedures such as primary total hip replacement (THR) or total knee replacement (TKR). Slightly higher rates are seen in revision arthroplasty cases. However, an infected prosthetic joint can result in a series of reoperations for the patient hence bigger overall costs compared to the cost of closed incision negative pressure dressing treatment (ciNPT).

Figure 1

Since its first application in 2006, using a traditional negative pressure pump coupled to a home-made dressing, fashioned from open cell reticulated foam, and polyurethane thin film, smaller more portable devices have been developed. The first of them, PrevenaÂŽ developed and manufactured by KCI USA, Inc, San Antonio, TX., has been designed specifically for use in the management of closed surgical incisions and embraces some of the desirable attributes of the early pioneer clinician engineered systems (Figure 1).

Most notable, the Prevena system dressing is constructed around an open cell reticulated foam that is bonded to a skin-friendly fabric.

Together, the foam and fabric form the core of the dressing that is enveloped in a loosely fitting polyurethane film skin. Coupled to a portable battery operated pump creating a vacuum of -125mmHg, the dressing can be observed to contract and compress around the core of the reticulated foam imparting a contractile force that reduces stress in tissue at the insertion point of sutures or staples.

Subspecialty Section

dressing produces a similar effect in respect of reduced tissue stress reduction as observed with the Prevena system.

Despite differences in appearance and apparent mode of action, there is a growing body of evidence supporting the effective application of negative pressure therapy to closed surgical incisions.

This treatment modality provides stabilisation and sterilisation of the wound environment with contraction, diminished tensile forces, decreased edema by removal of exudate as well as increased blood and lymphatic flow.

Figure 2

Other benefits said to result from the compressive force derived from the vacuum dressing include lower incidence and faster clearance of haematoma/seroma, lower incidence of dehiscence and less surgical site infections (Figure 2). A second system that is increasingly being used in similar applications is PICOÂŽ developed by Smith & Nephew (Figure 3). With this system, in an effort to reduce bulk and further improve portability, developers have forgone the use of a canister in favour of a multilayer dressing that serves the dual purposes of manifolding a vacuum, and managing incision drainage. The result is a highly portable and small pump that uses one less battery than Prevena, although it only generates a vacuum of -80mmHg. However, for an attached soft vacuum port, the multilayer dressing is not dissimilar to a conventional post-operative dressing in appearance, and is very easy to apply, but must be secured with secondary fixation strips to maintain an effective vacuum seal (Figure 4).

In respect of the conveyance of a vacuum and associated benefits and for the observation of a slight settling or compression of the absorptive pad, there are no gross changes to the dressing that confirm the effects of the vacuum as seen with the Prevena dressing.

The World Health Organisation in 2016 released the first ever global guidelines for SSIs, recommending closed incision negative pressure prophylactic treatment in high risk patients. However, it was highlighted that in low-resource settings other interventions should be prioritized over the use of ciNPT considering its poor availability and associated costs. The same year, an international multidisciplinary consensus panel recommended ciNPT for patients with one or more comorbidities or in patients with historical high risk for developing surgical site complications.

Though established for orthopaedic trauma cases, latest evidence has reported that the use of ciNPT for primary joint replacement can be considered since significant reduction in length of stay and postoperative wound complications have been documented. However the cost-effectiveness of the modality is still a considerable issue. Reducing the incidence of surgical events such as dehiscence, haematoma/ seroma formation and SSI, ciNPT systems will no doubt evolve as understanding of cause and effect are more clearly understood through continued research. n

â&#x20AC;&#x153;Benefits said to result from the compressive force derived from the vacuum dressing include lower incidence and faster clearance of haematoma/seroma, lower incidence of dehiscence and less surgical site infections.â&#x20AC;?

Figure 3

One explanation for this could be that the layer of the dressing required to convey a vacuum to the tissue interface, the spacer layer, is required to be a relatively firm open celled structure that will naturally resist compression in order to maintain patency. Despite this apparent contradiction, researchers conclude that FEV modelling confirms that the multilayer

References References can be found online at www.boa.ac.uk/publications/JTO.

Figure 4

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 71

Simulation Section

Keeping the WOLLF from the door or WHISTful thinking?

Matt Costa and James Masters

The use of subatomspheric pressure on wounds in general has been on the march from the middle of 1990s. The technology started life in the world of pressure sores and diabetic feet. By 2010, it had become the defacto wound management choice in a wide range of ‘complex’ wounds. Never one to be left behind, the trauma and orthopaedic community embraced the suction dressings with gusto.

T

he black foam system could soon be found on and all soft tissue defects associated with fractures. It even made it in to national guidance on treating open fractures1. To be sure, these high-tech dressings had ridden the wave of indication creep to the pinnacle of soft tissue management for surgeons across the land.

Everyone agreed, Negative Pressure Wound Therapy (NPWT) was the way to go2.

Matthew Costa, PhD, FRCS (Tr&Orth) is Professor of Orthopaedic Trauma Surgery at the University of Oxford and Honorary Consultant Trauma Surgeon at the John Radcliffe Hospital, Oxford. Matt’s research interest is in clinical and cost effectiveness of musculoskeletal trauma interventions. He is Chief Investigator for a series of randomised trials and associated studies supported by grants from the UK NIHR, EU, Musculoskeletal Charities and the Trauma Industry. His work has been cited widely, and informs many guidelines from the National Institute for Health and Care Excellence. Matt is Chair of the NIHR Clinical Research Network Injuries and Emergencies Specialty Group and the NIHR Musculoskeletal Trauma Trials Network. He is also a member of the NIHR HTA Research Board.

He Chairs the British Orthopaedic Association Research Committee and is the Specialty Lead in Orthopaedic Trauma for the Royal College of Surgeons of England. He is Associate Editor for Trauma and Research Methods at the Bone and Joint Journal. Matt is the President of the Orthopaedic Trauma Society and President of the Global Fragility Fracture Network.

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But it was not to last, NPWT found itself in the evidenced based crosshairs of the Cochrane group3. Their approach was more reserved; we don’t have the evidence they said.

So the orthopaedic trauma community responded and the WOLLF trial was born4. Twenty four centres across the UK participated in the study of patients with severe open fractures and asked whether suction dressing made any difference to patient disability. Four hundred and sixty patients took part, and despite its popularity, the dressings didn’t seem to be effective in improving patient reported outcome measures5.

Network was born. Now orthopaedic trauma surgeons and plastic surgeons were working more closely than ever. Dedicated, dual specialty, ‘orthoplastic’ lists were cropping up across the networks. The paradigm had evolved. Where before 2012, NPWT had been used as temporising soft tissue coverage after initial debridement, patients with open fractures were now being treated definitively in a single sitting of ‘fix-and-flap’6. Even those wounds which could not be closed or covered at the first wound debridement were to be covered within 72 hours – according to ‘policy’.

“Amidst the wholly understandable turmoil of a major injury, patients in the WOLLF trial who received NWPT were very positive about it. The ‘experiential knowledge’ of NPWT was associated with a strong preference for the treatment.”

This was not the only pertinent observation from the trial. Happenstance meant the WOLLF trial took place as the Major Trauma

What did patients think of all this? In a break with tradition, they were actually asked. Amidst the wholly understandable turmoil of a major injury, patients in the WOLLF trial who received NWPT were very positive about it. The ‘experiential knowledge’ of NPWT was associated with a strong preference for the treatment7.

Despite the patient feeling, the WOLLF data were clear. Negative pressure wound therapy was not cost effective. Was this the death knell of the suction dressings in orthopaedic trauma?

Simulation Section

James Masters is an academic trainee, and DPhil candidate within the Oxford Trauma group, NDORMS, Oxford University. He is Associate Specialty Lead for Orthopaedic Trauma and Research Fellow at the Royal College of Surgeons of England. His research interest is in infection after trauma and orthopaedic surgery and global health.

No! Channelling a ‘Schumpeterian gale’, NPWT was reimagined but for use on closed incisions - incisional Negative Pressure Wound Therapy (iNPWT). A series of dedicated devices for use on ‘high risk incisions’ made the technology as relevant as ever to the fragile soft tissues covering the trauma surgeons’ handiwork. The new devices built on the improvised efforts that had been seen in the previous decade. What is more, studies were appearing suggesting that these new devices were effective at reducing the ultimate nemesis of the surgeon - wound infection8. Outside of the orthopaedic trauma, groupings of studies also pointed towards a benefit in terms of infection for abdominal, breast and cardiac wounds9.

The reviewers at Cochrane were, as ever, not convinced – they spoke of; ‘low certainty’ for reducing SSI in primarily closed wounds.

Clearly, bigger and better studies were needed10.

Much of the literature judges iNPWT by proxy measure such as wound healing questionnaires or seroma formation11-13. These are important considerations no doubt, but surely the ultimate practice-determining outcome must be SSI. After all, if iNPWT do not reduce infection can we justify their use? But judging SSI - and an interventions’ ability to reduce it is no small task. The relatively low infection rates seen in elective and emergency orthopaedic care present dizzying sample size considerations for big trials.

When using binary outcomes, even studies of over 400 patients can have the venerated p value swayed by the addition of a single case to one of the treatment arms. The fragility of even seemingly large studies still make formal widespread adoption of promising but unproven technologies difficult to warrant14.

The possibility of reducing infection without the need for antibiotics is a highly prized contribution in any field of surgery, but how could we be sure?

Once again the call to arms was answered by the orthopaedic trauma surgeons of the UK. Enter the WHIST study. Like the WOLLF trial before it, the trial would use the Major Trauma Network. This time focussing on the primarily closed lower limb wounds of the severely injured undergoing internal fixation15. The study also chose to determine effectiveness by measuring infection as its primary outcome. A more complex parameter, needing over 1500 patients to participate. The results of WHIST will be ready for the BOA Congress 2019, but if the effectiveness seen in smaller studies is replicated, the surgeons can add with confidence the incisional dressings to the locker of treatments employed to reduce their most dreaded complication.

Other research in the pipeline includes the WHISH study16. This piece of work ran along similar lines to WHIST, but looked at iNPWT and infection after hip fracture surgery. This study was a feasibility trial, so there may be some wait for definitive answers.

So, NPWT was not the panacea. Will 2019 be the year of the iNPWT? The king is dead, long live… n

References References can be found online at www.boa.ac.uk/publications/JTO.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 73

In Memoriam

Howard Steel

17th April 1921 – 5th September 2018 Obituary by Deborah Eastwood

D

r. Steel, a ‘fabulous chap’, an orthopaedic trailblazer and one of the founders of the subspecialty of paediatric orthopaedics died last September at the age of 97. He was undoubtedly one of the characters of orthopaedics: a thinker, an innovator, a philanthropist and an able and compassionate clinician. He was always pleased to see you and placed great store on friendship, loyalty and camaraderie. He was renowned for being able and willing to defuse many a stressful situation and was a well-loved mentor, friend and colleague to several generations of orthopaedic surgeons.

He contributed widely to several fields of orthopaedic surgery perhaps most famously describing the triple innominate osteotomy for acetabular dysplasia that bears his name. Dr. Steel also pioneered a hanging gravity cast for the correction of extreme lumbar kyphosis in patients with myelodysplasia and set up the first spinal cord injury unit for children in Philadelphia where he worked for much of his career at the Shriners Hospitals for Children. The Steel Rule of Thirds describing the anatomy of the upper cervical spine still holds true today and he championed rib resection in the management of scoliosis recognising that, to the patient, appearance was important.

Dr. Steel was known as ‘Steel of Philadelphia’ and as ‘Renaissance Man’, he was a dare devil, a globe trotter, a lover of fine wine, good music and great company and he loved his chosen profession. He believed that a wide appreciation of life made you a better physician and it is no surprise that the Howard H. Steel Orthopaedic Foundation set up in 1981 by a group of his grateful (now adult) patients is used to fund annual non-medical lectures at orthopaedic congresses throughout the world including the BOA.

Dr. Steel is survived by his wife, Betty Jo and their children. n

David Rowley

4th July 1951 – 22nd February 2019 Obituary by Ian Winson

74 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

I

t is with great sadness that we note the passing of Professor David I. Rowley on Friday 22nd February, aged 67.

I first came across David Rowley when he was the senior lecturer in Manchester and I had taken over his post as lecturer in Sheffield. His mischievous sense of humour let alone his mischievous sense of life was well established by then but nonetheless entertaining and challenging. Quite rightly regarded as a teacher, a scholar, a pioneer, a friend and a hero, all in equal measure. He looked upon everybody, no matter what colour, creed or education, as equals and always had time for all his staff and students. We will miss his guidance, his reassurance, his infectious enthusiasm and his cheeky laughter.

Professor David Rowley began his medical studies at Aberdeen University in 1969 and was a lecturer at the University of Sheffield and a senior lecturer at the University of Manchester before taking up a post at Ninewells Hospital and Medical School in 1988 as Professor of the University Department of Orthopaedic and Trauma Surgery, sustaining the department’s international reputation and innovation in the area of joint replacement complemented by a worldwide service in Clinical Audit Outcomes with over £20 million in grant income. In 1996, he led by example and worked tirelessly with Alan Davidson, QA, to secure an excellent outcome for the MBChB curriculum review. He served the school with loyalty and was the Deputy Dean during Professor Brian Burchell tenure as Dean (2003 - 2006). Professor Rowley was the instigator of the MCh (Orth) Degree at Dundee and served as Director of Education for the Royal College of Surgeons of Edinburgh and was also visiting professor of surgical education at the University of Edinburgh from 2004 until 2009. He relinquished his chair and his post at the university in 2008. He gained many distinctions during his illustrious career, including the Gold College Medal and Syme’s Medal, both awarded by the Royal College of Surgeons in Edinburgh.

He also served abroad as a war surgeon for the International Committee of the Red Cross in the Sudan and Afghanistan. After 40 years Professor Rowley retired from offering clinical advice in 2014. n

In Memoriam

Raymond Nim-Wah Chan

28th July 1939 – 1st April 2019 Obituary by Alice Chan

R

ay Chan was a well-known orthopaedic surgeon and was one of the first Chinese orthopaedic surgeons in Leicester, if not the UK.

Ray was born in Hong Kong in 1939, and endured difficult years as a young boy living as a camp-follower with his mother and siblings in China, after the evacuation of Hong Kong during the Second World War.

He studied at Corpus Christi College, Cambridge, graduating in 1962 before furthering his medical training at University College Hospital in London. He became a Fellow of the Royal College of Surgeons in 1970.

Ray was appointed as consultant orthopaedic surgeon at the Leicester Royal Infirmary teaching hospital in 1976, specialising in spinal surgery, scoliosis, and hip and knee replacement arthroplasty. He had a passion for training the next generation of doctors, and many remember their rotation with him.

In recalling what it was like to train under Ray, Professor Joseph Dias, Professor of Hand and Orthopaedic Surgery, University Hospitals of Leicester, said:

“He was straightforward in his dealings with patients, staff and trainees and hugely respected and trusted for this. When he joined, he did the Wednesday trauma call with Mr Alan Richardson. At that time the registrar did the out-ofhours surgery. This was only possible with the cover provided by consultants and Ray was not only available for advice, but came in to give a hand.”

Ray was one of the Leicester City F.C.’s team surgeons during Gary Lineker’s hey-day in the 1980s. He was an avid supporter of the team.

He leaves behind his four heartbroken children, Alice, Oliver, Benjamin and Victoria, and three grandsons, with a fourth grandchild on the way. n

Leave a Lasting Legacy Whether you’re someone who is suffering from a musculoskeletal disorder or whether your life’s work is helping those who are suffering; you can really make a difference.

Once you have considered your immediate friends and family; please consider leaving a life-changing gift to Joint Action to fund ground-breaking orthopaedic research.

Your donations support the BOA Orthopaedic Surgery Research Centre (BOSRC), based at York Trials Unit, which works with the BOA in expanding the number of trials in the UK related to Trauma and Orthopaedics.

Your generous donations are helping us to advance Trauma and Orthopaedic research. Thank you very much!

Remembering a charity in your Will is simple. For an easy step-by-step guide to everything you need to know about leaving a legacy to Joint Action, please visit www.boa.ac.uk/research/leaving-a-legacy.

JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk | 75

Products, Courses and Events 14th Trauma & Orthopaedics Update

Val d’Isere, 27-30 January 2020 www.doctorsupdates.com info@doctorsupdates.com +44 (0) 208 7151924 Doctorsupdates 2020, in their 31st year will feature 14th Trauma and Orthopaedics Update. This meeting is unique as it provides interaction between a number of

different specialities: orthopaedics, anaesthetics, critical care and pain, emergency medicine, radiology, plastic surgery, dermatology and general practice. We also invite speakers from other specialties like haematology, neurology, rheumatology to contribute to our education.

The programme is suitable for consultants and senior trainees.

The format is informal and sessions

include trauma and elective surgery, multidisciplinary sessions and a free paper competition for trainees.

Each day concludes with a lecture of general interest by an eminent guest speaker.

We have an excellent orthopaedic faculty lined up and the programme when confirmed will be available at www.doctorsupdates.com.

Forthcoming Courses from the Orthopaedic Institute For a wide range of delegate types:

24 October: 6-7 November: 12 November: 2-4 December: 9 December:

Orthopaedic Institute at the Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, Shropshire

Wrightington Hospital Course Venue: Hospital Conference Centre (unless otherwise stated)

ORLAU Orthotic Management of Contractures Spinal Imaging Spinal Course 18th Foot & Ankle Course Sports Knee Meeting

For delegates preparing for FRCS Examinations: 17 September: 17-18 October:

Spine Examination Course for FRCS Anatomy & Surgical Exposures

WRIGHTINGTON ADVANCED TECHNIQUES IN ELBOW REHABILITATION & SURGERY (WATERS) – 18 & 19 November 2019 Venue: Wrightington Hotel , WN6 9PB

THE THUMB, THE WHOLE THUMB & NOTHING BUT THE THUMB – 20 & 21 November 2019 Venue: Wrightington Hotel , WN6 9PB

TRICKS & TIPS IN SHOULDER SURGERY & REHABILITATION Arthroscopy – Thursday 5 March 2020 Arthroplasty – Friday 6 March 2020

Venue: Wrightington Hospital Conference Centre

TO ADVERTISE YOUR PRODUCT OR SERVICE IN THIS JOURNAL Call Barbara or Rupinder on:

0121 200 7820 76 | JTO | Volume 07 | Issue 03 | September 2019 | boa.ac.uk

To book please visit:

www.orthopaedic-institute.org

CONTACT DETAILS:

www.orthopaedic-institute.org Email: sian.jones36@nhs.net Phone: 01691 404661

Further information: Upper Limb Education, Wrightington Hospital WN6 9EP Mavis Luya - Elbow & Thumb meetings Telephone: +44 (0) 1257 256248 Email: upperlimb@wrightington.org.uk Jackie Richardson - Shoulder Meeting Telephone: +44 (0) 1257 256413 Email: upperlimb@wrightington.org.uk Websites: www.wrightingtonhospital.org.uk (Menu – Education & Events) www.wrightington.com (Courses)

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5. MacBarb RF, et al. Int J Spine Surg. 2017;11:105-15. [Part 1].

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