Journal of Trauma & Orthopaedics - Vol 10 / Iss 3 by British Orthopaedic Association

Volume 10 | Issue 03 | September 2022 | The Journal of the British Orthopaedic Association | boa.ac.uk Journal of Trauma and Orthopaedics Neurodiversity: What do we understand p30 Healthcare data and orthopaedics p56 The British Hip Society mentorship programme p44 With the advent of AI are we witnessing the germination of a new era of healthcare? Data is the new soil

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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 you know that as well as advertising in our Journal publication, we can offer footer banner advertising on the JTO App! For more information please contact Wendy Parker Email: Wendy@ob-mc.co.uk | Telephone: +44 (0)121 200 7820 (Environmental System). based inks well as

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JTO | Volume 10 | Issue 03 | September 2022 | boa.ac.uk | 01 3 From the Executive Editor Simon Hodkinson 5 From the President John Skinner 8-9 BOA Latest News 22 News: Honorary Fellowships 24 News: BOA Annual Congress 2022 28 Features: Which implants have been identified as ‘outliers’ by the NJR over the years and which of these are still being used? Peter Howard and Tim Wilton 30 Features: WNeurodiversity:hatdoweunderstand Harish Vamadevan, May Edmondson, an unamed author and Suddhajit Sen 36 Features: Dyslexia and the surgical trainee – How it impacts training and what you can do to help Jamie A Nicholson, Jennifer Dunn and Maria Boland 40 Features: My experience of the Hull Deformity Correction course Fatima Rashid 44 Features: The British Hip Society mentorship programme: Supporting the next generation Sarah Eastwood, Joanna Maggs, Samantha Tross, Dominic RM Meek and Vikas Khanduja 48 International: A remote virtual follow-up strategy for outreach surgery – developing the Malawi model Joshua Lorimer, Mabvuto Chawinga, Alberto Gregori, Trish O’Connor, Steve Mannion and Ashtin Doorgakant 52 Medico-legal: Should Montgomery be altering the way we do things? – Part 2 Simon Gregg-Smith 56 Subspecialty: Healthcare data and orthopaedics: interoperability and standards Kanthan Theivendran 60 Subspecialty: Digital technology: How to get it right – Data governance, storage of data, and the regulations W Angus Wallace, Phil Booth and DJ Hamblin-Brown 64 Subspecialty: Developing AI for healthcare: where, why and how to do it in a responsible way Justin Green

Did

In this issue... Contents Amputation the context Journal T Orthopaedics Journal T Orthopaedics A DaySurgicalBegins Volume 08 Issue 04 Journal of the British Orthopaedic Association The Journal of Trauma and Orthopaedics (JTO) has a dedicated news section, a features section containing interesting articles on various themes, a subspeciality section and a medico-legal section. Journal of Trauma and Orthopaedics 40 We are committed to sustainable forest management and this publication is printed by Buxton Press who are certified to ISO14001:2015 Standards

Buxton prints only with 100% vegetable

Please visit Heraeus Medical at BOA 2022: booth no 10 UK11156 ADVANCING, TOGETHER Thank you for decades of trusted collaboration for best patient outcomes. Medical

Also, in this edition we continue the theme of equality and diversity with an article on the important topic of neurodiversity in our profession (page 30) and the issue of dyslexia (page 36), both so often hidden away for fear of Instigmatisation.asimilarvein, Sarah Eastwood and colleagues review the BHS mentorship scheme (page 44), its remit, development, and early results, with the potential for a much wider role out for this important development.

The President referred to the green shoots of recovery and whilst that particular germinal episode may have struggled a bit due to yet another variant of COVID, in this edition we discuss the role of big data and Artificial Intelligence in the future of our profession. If data is the new soil, then it will need ‘water’ and maybe that is our role as professionals to embrace and mould this technology and use it for the good of our patients.

BOA Staff Executive Office Chief Operating Officer - Justine Clarke Personal Assistant to the Executive - Celia Jones Education Advisor - Lisa Hadfield-Law Policy and Programmes Programmes and Committee Officer - Eliza Khalid Education and Careers Manager - Alice CommunicationsCoburn and Operations Director of Communications and Operations - Annette Heninger Marketing and Communications Officer - Pujarini Nadaf Membership and Governance Officer - Natasha Wainwright Publications and Web Officer - Nick FinanceDunwell Director of Finance - Liz Fry Finance Assistant - Hayley Ly Events and Specialist Societies Head of Events - Charlie Silva Events Coordinator - Venease Morgan Exhibition and Events Coordinator - Anna Prunty UKSSB Executive Assistant - Henry Dodds by the BOA. Unless stated otherwise, copyright rests with the BOA. Published on behalf of the British Orthopaedic Association by: Open Box M&C

The first of three articles on this subject discusses healthcare data and in particular the issue of interoperability and standards in such data (page 56). An issue dear to us all as we rage at our inability to see a patients images taken down the road but not available in the clinic! We continue with a timely reminder of the rules and regulations concerning digital information and how not to fall foul of such (page 60).

BOA Executive l John (President)Skinner l Bob (ImmediateHandleyPast President) l Deborah Eastwood (Vice President) l Simon Hodkinson (Vice President Elect) l Fergal (HonoraryMonsellSecretary) l Mark BOA(HonoraryBowditchTreasurer)ElectedTrustees l John Skinner (President) l Bob (ImmediateHandleyPast President) l Deborah Eastwood (Vice President) l Simon Hodkinson (Vice President Elect l Fergal (HonoraryMonsellSecretary) l Mark (HonoraryBowditchTreasurer) l Colin Esler l Anthony Hui l Andrew Manktelow l Ian McNab l Fares Haddad l Amar Rangan l Sarah Stapley l Hiro Tanaka l Cheryl Baldwick l Deepa Bose l Caroline Hing l Andrew Price

From the Executive Editor Simon Hodkinson W

Finally, a thought provoking article on artificial intelligence and machine learning, phrases that did not exist as I started in this profession (page 64). Is this the dawn of a new age in our profession, we shall see, but we need to embrace it if it is to develop in ways that benefit our patients.

JTO Editorial Team l Simon Hodkinson (Executive Editor) l Hiro Tanaka (Editor) l Simon Britten (Medico-legal Editor) l Oliver Adebayo (Trainee Editor) l Mike Reed (Guest Editor)

AllAdvertisingadvertisements 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: Wendy Parker - Media Manager Email: Wendy@ob-mc.co.uk | Telephone: +44 (0)121 200 7820 Open Box M&C, Premier House, 13 St Paul’s Square, Birmingham B3 1RB

hen I first put pen to paper as Editor, I referred to flaming June and the local weather which, at the time, was pouring down. How I regret my cynicism as flaming June morphed into boiling July and August and we are begging for rain down South!

A timely article on the outlier status of certain implants illustrates the power of the NJR in arthroplasty practice (page 28) and Simon Gregg-Smith continues his review of case law in orthopaedic practice (page 52).

TheDisclaimerarticlesand 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.

The British Orthopaedic Association, 38-43 Lincoln’s Inn Fields, London WC2A 3PE Telephone: 020 7405 6507 Credits

An excellent article on the use of remote virtual follow-up clinics in Malawi (page 48) and Fatima Rashid’s review of the Hull deformity course (page 40), the Best of the Best prize again this year complete this edition of the Journal.Ihope you enjoy it and I look forward to meeting colleagues in Birmingham for this year’s BOA Annual Congress. n

BOA contact details

John Skinner O rthopaedic surgeons are gregarious, sociable and tend to work well in teams. Our BOA Conferences have always been events that offer formal education and debate in the lecture halls, learning and bonding in the coffee breaks and corridors and socialising and fun in the evenings. We have some great sessions, good news to share and some of the best speakers in world orthopaedics to learn from. I look forward to catching up with as many members as possible while there. We are emerging from the pandemic years and our patients need us more than ever. Trauma demand has been running hot for most of this year and still shows little sign of abating. Matching resource to demand in T&O continues to be more difficult than it ought to be. We continue to flag and represent these issues to our NHS leaders and will continue to do so. The national need for high volume delivery of elective surgical care continues and we meet with the NHS Executive to offer the solutions and requirements needed to unshackle our T&O workforce. We know that we can respond in order to give our patients the operations that they urgently need and our trainees the surgical experience so essential for all of our futures. No-one with pain and disability, is waiting well. We have had some successes having travelled to Northern Ireland where the orthopaedic resource had been so ravaged as to render the service inadequate. Combining with the GIRFT team we were able to support our excellent surgical colleagues and effect changes that we hope will restore the Northern Irish orthopaedic services towards the preeminence that they once enjoyed. British orthopaedics has benefitted from a data capture system that has improved practice, resulted in better care for patients and delivered genuine feedback to surgeons. Following the Cumberledge Report it is now part of Government policy that recording patients, implants and their outcomes in Registries is mandated in the NHS. This means that all implants used in patients throughout all of healthcare must be recorded in Registries. This highlights our position of strength in T&O where we are considered the exemplar for arthroplasty and the NHFD has changed practice, saved lives and driven practice and resource change. Through ODEP we know the benchmarks expected, the NJR in its 19th year is the largest complete National Joint Registry of validated entries and with Beyond Compliance we have a safe system for introducing new technology and implants with heightened surveillance. This will allow us to support the TORUS Registries to become viable with centrally mandated data collection, adequate support and funding for high quality GDPR compliant data storage. This combined with data interpretation and analysis by interested and skilled clinicians, is essential to optimal use of data to drive practice and improve patient care. This has been a feature of T&O practice in the last decade with groundbreaking research, high quality nationally funded clinical trials to answer important clinical questions, introduction of new technologies all centered on the highest possible clinical care. Exciting but challenging times ahead and I look forward to seeing so many colleagues in Birmingham this month. n As this volume is delivered, we look forward to coming together for Congress in Birmingham. It is essential that we meet, share ideas and experiences, solutions that have worked for some and share problems that still need to be resolved.

Challenge and Opportunity

From the President

IncomingEastwood:President

he time is nearly now… for me at least… and as the JTO drops through the letter box or flashes up via your BOA app, I will be about to take up the position of President of the/your BOA. I would like to thank John for his expert stewardship of the BOA over the last year: he has been committed to improving the lot of both our patients and our members and he has been an articulate and impassioned advocate for us all in his dealings with local and national healthcare bodies with his mantra that ‘elective surgery is NOT optional surgery’.

There is still much to do in terms of ‘recovery’ in its broadest sense and we must welcome this ongoing opportunity to adapt how we work and to improve our systems.

One of several challenges facing us is that of Diversity, Equity and Inclusion but I would like to add the word Engagement to that challenge. We can look different from each other, act differently and represent different groups but unless we engage with each other all that difference, all that diversity is easily lost. The processes of engagement, change and recovery can all coalesce if we work together to develop and deliver Sustainable Systems: systems that will be robust enough to cope with whatever the future may hold in terms of health care delivery, work-life balance, flexibility in the working contract, training our future colleagues, working with the expanded surgical team and of course, Going Green-er in the process.

All at the BOA are looking forward to seeing you in Birmingham to discuss Technology, Data and Recovery and to enjoy each other’s company. Twitter: @deboraheastwood “One of several challenges facing us is that of Diversity, Equity and Inclusion but I would like to add the word Engagement to that challenge.”

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Educational Courses

Training Orthopaedic Educational Supervisors (TOES)

Full details can be found at www.boa.ac.uk/law-for-orthopaedic-surgeons

Congratulations to our Fellows:

William Fishley for his project ‘Arthroplasty Research Cohort (ARC) Study – A collaborative, longitudinal observational cohort study of patients undergoing primary hip and knee replacement in the United Kingdom’ supervised by Professor Mike Reed at the University of York. We expect to run these Fellowships annually so start thinking about your application now! We are particularly keen to promote and encourage applications from individuals that wish to undertake their research flexibly or less than full-time. For more information and submission dates please see www.boa.ac.uk/researchfellowships

This course is designed to help members prepare for the new curriculum and learn how to supervise trainees to be the very best they can be. For more information or to book visit www.boa.ac.uk/toes

BOA ORUK Research Fellows

This programme aims to improve the standard of teaching for those in T&O training and practice. If T&O trainers understand how people learn and how the T&O curriculum works, by translating that understanding into action, they should improve their teaching. Further information and to book visit www.boa.ac.uk/tots Medico-legal Course - ‘Law for Orthopaedic Surgeons –Avoiding Jeopardy’

The BOA and Orthopaedic Research UK are delighted to announce our first successful awardees of the new BOA ORUK joint Research Fellowships. These new Fellowships award up to £65,000 for research projects in any aspect of the field of orthopaedic surgery or surgical care in the field of orthopaedics, with the goal of developing a pipeline of research-active orthopaedic surgeons. It was wonderful to see so many strong applications for our first year and the review panel were impressed by the strength of the project proposals.

BOA

Anna Porter for her project ‘The development of patient cell lines to investigate the pathophysiology of osteogenesis imperfecta and the mechanotransduction of these cells during mechanical strain’ supervised by Kenneth Ranking at the Centre for Life Newcastle University.

We have one remaining course date in 2022 for this popular course specifically designed to highlight potential pitfalls in practice from the medico-legal perspective and to help steer surgeons away from potential jeopardy.

Training Orthopaedic Trainers Course (TOTs)

The BOA runs a wide range of courses under the Education Committee. These courses cater to the educational needs of a wide range of members (and nonmembers in some cases) at all stages of their careers.

Introducing New Benefits for BOA Members

he BOA is pleased to enter into agreements with the following organisations to offer BOA members discounts on their services. For more information visit the BOA website at www.boa.ac.uk/benefits Medical Indemnity Insurance Howden have teamed up with the BOA to offer members a 10% discount on the quoted premium when purchasing Medical Indemnity Insurance. Howden is the largest independent insurance broker in the UK. Its Health & Care division has over 40 specialists embedded within the healthcare sector, and understands its challenges. Unlike Mutual Defence Organisations (MDOs), Howden offers clients contract-certain Medical Indemnity policies rather than discretionary indemnity. This means that with Howden, should you have a claim, your right to be indemnified will be covered by an insurance policy. Independent Financial Advice BOA members will receive a 10% discount on the initial fees for independent financial advice with Fintuity. They offer Independent, whole of market financial advice and guidance. Their services include advice on Investments, Pensions, Protection, Inheritance Tax Planning, Mortgages, and General Financial Planning.

Latest News

In addition we have also agreements with the following providers to provide discounts on their services:

• CIBT Visas • General and Medical private health insurance • OrthOracle surgical technique online resource • PG Mutual income protection insurance • Western Provident Association (WPA) private health insurance • Wisepress publishers

The BOA have recently published a new Trauma BOAST (BOA Standard) on the Management of Metastatic Bone Disease (MBD). This BOAST was jointly developed by the BOA and the British Orthopaedic Oncology Society (BOOS). You can read the full document at www.boa.ac.uk/metastatic-bone-disease-BOAST

Latest

UK and Ireland In-Training Examination (UKITE)

New BOAST published – The Management of Metastatic Bone Disease

• Education and Training

All BOASTs – including Trauma, Elective and Speciality – can be found on the BOA website at www.boa.ac.uk/boasts

Registration is now open for the next BOA Ortho Update Course with a brand new face-to-face format. For orthopaedic trainees at all levels and SAS surgeons, this updated course will give you the opportunity to access new understanding and support your preparation for the FRCS exam. Register now to secure your place!

Date: Saturday, 7th January 2023 Time: 8:30am to 5:00pm Where: Etc Venues, 11 Portland St, Manchester M1 3HU

The Orthopaedic Trauma Hospital Outcomes – Patient Operative Delays (ORTHOPOD) study is a prospective study of all patients undergoing surgery on orthopaedic trauma lists. It aims to describe trauma workload, theatre capacity and waiting times for surgery across the United Kingdom. If you are interested in being involved in the ORTHOPOD study, email stees.orthopod@nhs.net for your registrationORTHOPODpack.is a BOA-sponsored initiative run by the Orthopaedic Trauma Society.

Find out more about how to submit on the BOA website at www.boa.ac.uk/PhotoComp

2023 Ortho Update

The course is divided in two halves. We are continuing with the popular critical condition Case Based Discussions (CBDs), which this year will cover neurovascular injuries, compartment syndrome and physiological response to trauma. The other half of the course will be practical simulation sessions, where each candidate will participate in a trauma moulage to fulfil the trauma resuscitation CEX.

Twitter: @markbowditch65

My two years on Exec as Treasurer have flown past yet exposed me to much more than just the finances but a deeper understanding of the astonishing range of work the BOA actually does day-to-day on behalf of our patients and surgeons. So much is ‘non-clinical’; politicking, networking, influencing, representing, on behalf the whole of T&O. Delivering a much louder effective voice in the ‘call’ for resources. To name but a few, elective backlog capacity orthosurg hub centres, rising Trauma demands but also a bigger slice of the Research funding pie too.

ORTHOPOD – A Prospective Multicentre Service Evaluation of Trauma Burden and Resources

I’m honoured and excited (even abit nervous – that’s ok isn’t it!) to have been given the chance to carry the baton over the next few years. None of the above will be possible without the fabulous BOA office team – plus a huge thanks to Liz Fry, BOA Finance Director, for putting up with my often repeated ‘basic financial questions’.

BOA Council Election Results

We would like to congratulate BOA member Professor Srimathi Rajagopalan Murali for receiving a Member of the British Empire (MBE) for services to international doctors working in the NHS. Professor Murali is a consultant orthopaedic surgeon at Wrightington, Wigan and Leigh Teaching Hospitals, NHS Foundation Trust.

UKITE 2022 will take place from 9th – 16th December. UKITE is an online mock examination that allows trainees and SAS surgeons to practice for section 1 of the FRCS Tr and Orth. Registration is now open and is free for members before 30th November (£150 for non-members). All late registrations will attract a £50 fee. Register now at www.boa.ac.uk/UKITE

News

BOA CompetitionPhoto

There will also be spinal trauma assessments that can be counted towards the ‘initial assessment and referral of spinal trauma’ critical condition. Register now at www.boa.ac.uk/OrthoUpdate

New appointment to the BOA Presidential Line – Mark Bowditch

HonoursBirthdayQueen’s

Our Editors make UKITE possible by developing, reviewing and validating questions. Find out how to join the team at www.boa.ac.uk/ukite-editorial-role or e-mail ukite@boa.ac.uk Paul Banaszkiewicz Trustee 2023-2025 Andrew Manktelow Trustee 2023-2025 Ian McNab Trustee 2023-2025 Andrea Sott Trustee 2023-2025

Take part in the BOA’s photo competition! Help us celebrate the work of T&O and your surgical teams. Submit your photos to us on any of the following categories to win a one-year free BOA membership.

• Surgery • Teams in the operating theatre or around the hospital

• Representing Diversity in Orthopaedics

Deadline for all applications: Friday 30th September 2022

• UKITE Editorial Roles

• Committees Are you passionate about inspiring action and effecting change? Are you keen to be an active advocate and ambassador for an organisation? Are you eager to play a key role in important projects and initiatives? Committees are the engine of the BOA and we are recruiting for posts in the following: Orthopaedic, Research, Medico-legal, Trauma, and Education and Careers. You may apply for vacancies across multiple Committees, however, if you are successful for one, your application for the other(s) will automatically be removed from consideration.

Opportunities to improve local standards and shape service delivery through RSPA roles are available in the following regions: South Central (North), South Central (South), Yorkshire and The Humber (South) and London (North West).

Two recent recruits have shared their experiences so far:

‘‘ ‘‘

News

Stephen Hepple (BOA Medico-legal Committee)

Get involved at the BOA! Bilal (BOAJamalTrauma Committee) I have enormously enjoyed being part of the Trauma Committee. The COVID-19 pandemic has led to unique strains upon trauma care in the UK. I feel honoured to be able to help in ensuring that patient care is prioritised as we attempt to recover. Membership of the Committee has allowed to me share ideas with, and learn from, experienced orthopaedic surgeons around the country. This, for me, has crystallised into a multidisciplinary project to improve orthoplastic care in the UK. I highly recommend that you consider applying for a role with the BOA. I am confident that you will find it stimulating and fulfilling.

Medico-legal work has formed a substantial part of my orthopaedic practice over the last 20 years. It has shaped my practice and educated me in ways I did not imagine when starting out. Through their career most orthopaedic surgeons will encounter the legal profession from one side or the other. By joining the BOA Medico-legal Committee I have engaged with likeminded individuals keen to pass on their experience and knowledge and we hope to support and empower orthopaedic surgeons in their interactions with the legal profession.

T his is your chance to use your skills and expertise to influence and input into the work of the BOA. If you have an interest in trauma and orthopaedics that you’d like to pursue further as part of your national specialty body, the BOA needs you! We have exciting opportunities for BOA members who are Home Fellows or SAS surgeons to represent, lead and effect change across the trauma and orthopaedic profession. The BOA is committed to equality of access to a T&O career and to the services of the Association. As per our Diversity Strategy we would particularly invite applications from underrepresented groups within the BOA.

• RSPA Regional Roles

‘‘ ‘‘ We are now recruiting for an exciting variety of Committee roles

We have vacancies for UKITE Editors across all sub-specialty areas. Editors play a key role in the creation of UKITE through contributing questions for the examination. You will gain experience in question authoring, editing and validation processes. Onboarding, support and best-practice guidance are provided throughout. For all vacancies please visit www.boa.ac.uk/get-involved

I was awarded £1,500 to visit a centre of excellence in France, in primary and revision arthroplasty and Prosthetic Joint Infection. My placement was based at L’Hopital de la Croix Rousse in Lyon, observing the work of Professor Sebastien Lustig (Orthopaedic Surgeon) and Professor Tristan Ferry (Professor of Infectious disease) over a period of two weeks. I observed a number of clinics and operating lists run by Professor Lustig and his ‘Chefs’ as well as two infection MDTs during my time. Highlights included the impressive theatre set-up and theatre efficiency, revision techniques, the high-volume use of robotic surgery in primary arthroplasty, the infection MDTs and the novel use of Bacteriophages in the treatment of refractory prosthetic joint infection (PJI).

Omer Salar Overall, I thoroughly enjoyed my fellowship and would like to express my gratitude to the British

T he ABC fellowship is an Canadian’‘American/British/tourof North America and Canada. This prestigious five-week fellowship is open each year to applicants from the BOA who have been an appointed consultant for less than 10 complete years. Four FrombytheNewbyFellows2022andwereAssociations,withdisrupted.havecohortCOVID-19NewonefellowsBOA-nominatedparticipatealongsideeachfromSouthAfrica,ZealandandAustralia.Asaresultofthepandemic,theduetotravelin2020hadtheirplanssignificantlyAfterdiscussionstheAmericanandCanadianthe2020cohortfinallyabletotourCanadatheUnitedStatesinJuneforfourweeks.TheBOAwerejoinedinLondontheircounterpartsfromZealandandAustraliaforconveningdinnerhostedtheBoneandJointJournal.there,theytravelledto

The American British Canadian (ABC) travelling fellowship Vancouver to start their tour, taking in the Canadian Orthopaedic Association Annual Meeting in Quebec City, the AOA Congress in Rhode Island and more than 10 centres of surgical excellence, meeting counterparts and making friends along the way. The Fellows wrote a blog of their travel, which can be found at abc-travelling-fellowship-blogwww.boa.ac.uk/Welookforwardtohostingtheequally-delayedreturnlegthisSeptemberwhenthefiveAmericanandtwoCanadianFellowsoriginallyduetotravelin2021willarriveintheUK,aftertwoweeksinSouthAfrica.TheNorthAmericanswill

be welcomed by the BJJ in London, starting a whirlwind tour of centres across England and Scotland. Catch up with them at the BOA Congress in Birmingham! n

BOA sponsored travelling fellowship to Lyon 2022

Lyon itself being the highest volume knee centre in France. I was most impressed with the theatre set-up and efficiency as well as the organisation and care of the prosthetic joint infection patients. We will be establishing links with Lyon to be included in the current randomised controlled trial regarding the use of Bacteriophages in PJI relevant to my current role as a Bone Infection fellow to hopefully bring this novel treatment to the United Kingdom. n

jointsofimpressivedespiteandsurgeonwasUnit.theexperienceIsponsoringAssociationOrthopaedicformeforthis.thoroughlyenjoyedmyandtimeinLyonArthroplastyProfessorLustiganexcellenttoobservekeentoteachmaintainingancaseloadover1,100primaryayearalonewith

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Tom Cosker, BOOS Honorary Secretary

The Society as a whole moves from strength to strength and our educational offering has further been strengthened by the completion of the first British Orthopaedic Oncology Society Diploma in Orthopaedic Oncology which has been undertaken by over 40 delegates over a one year period and has recently been accredited by the Royal College of Surgeons of England. n

We encouraged surgeons and trainees to ensure that each unit should have an agreed policy for the multidisciplinary discussion and management of MBD including clear pathways for onward referral. Further, all specialist centres should have agreed pathways to enable prompt opinion, advice, and transfers within their network. We were clear that all of the primary bone tumour centres are willing and able to provide advice on a 24/7 basis for the treatment of these often challenging patients. This is particularly the case in those with solitary metastatic disease where new chemotherapeutic agents mean that survival has been dramatically extended. We will continue the work in this area and are already presenting for the 2022 BOA Annual Congress in Birmingham.

World Orthopaedic Concern (WOC) update

News

Alberto Gregori, WOC Chairperson T he focus of this year’s work by the British Orthopaedic Oncology Society has been wider education of the orthopaedic community with a particular focus on the treatment of metastatic disease. We have delivered several (MetastaticinpublishedandBristol(foratAberdeenBOAnotablythemeseminarseducationalwiththisinmind,mostatthe2021CongressinbutalsoregionalmeetingsexampleinandLeicester)haverecentlyaBOASTtheTreatmentofDisease disease-BOASTmetastatic-bone-www.boa.ac.uk/ ).

Guest Speaker, Deborah Eastwood. Presentations on research in Malawi, practical preparations for deployment, Global Health and the background on recent Ethiopian developments were given byThetrainees.needfor more evidence based delivery of humanitarian care was highlighted by our guest speakers. This included Ashtin Doorgakant’s FLP project report on virtual follow up in LMIC environments (also featured on page 48) as well as the excellent presentation by Kiran Agarwal-Harding of Harvard’s Global Health Collaborative looking at Health Inequality in resource poor settings. A recurring theme underlying all the presentations, but particularly well brought into sharp relief by Amer Shoaib’s thoughtful heartfelt exposition, was of the ethical background as to what WOC does and how it impacts both the recipient and the volunteer. At the AGM it was also confirmed that Ashtin Doorgakant was elected unopposed, to be Vice Chair of WOCUK. I left the meeting enthused and confident that WOCUK has a bright future ahead, in no small part because of the involvement of so many enthusiastic young trainees and consultants. n

“The Society as a whole moves from strength to strength and our educational offering has further been strengthened by the completion of the first British Orthopaedic Oncology Society Diploma in Orthopaedic Oncology.”

t was a great pleasure having the 2022 Annual WOCUK Meeting take place in person. After two years of virtual meetings, returning to a physical environment reminded us that organisations such as WOCUK thrive on human contact. How enjoyable meeting up with colleagues, friends and greeting new members of WOCUK face to face! The Annual Meeting was ably hosted and organised by outgoing Chair Deepa Bose and was well attended with many new faces. The BOAtheWOCUKalsoLeoneothereducation.focusZambiaMalawi,multipleprojectsonyears.WOCUKdemonstratedprogrammehowfarhascomeinrecentLightningupdatesWOCsdiasporaofsuchasthoseinsitesinEthiopia,GuyanaanddemonstratedouroncollaborationandUpdatesonsitesincludingSierraandUkraineweregiven.Thedesirefortodevelopitselfashumanitarianarmofthewashighlightedtoour

The metastatic seminar at BOA was led by representatives of each of the five English primary bone cancer centres, from Professor Rob Ashford in British Orthopaedic Oncology Society (BOOS) update his capacity as President of BOOS and by the local metastatic leads in Aberdeen itself. It was a hugely successful and oversubscribed session and we had some superb comments about how educationally useful it had been. The key points of discussion were that underlyingareandabsencepain,population,theenergyrehabilitation.fromabesuspectedpresentingpatientswithMBDshouldmanagedalongdefinedpathwaypresentationtoLowfracturesinnon-osteoporoticantecedentnightpain,ofinjury,insidiouspainsuspiciousformalignancy.

BRISTOL HIP 2022 24th & 25th November THE BRISTOL MARRIOTT CITY CENTRE appliedCPDPointsfor SAVE THE DATE 2022-bhac-bjo-qtr-pg-ad.indd 1 20/05/2022 09:55 Reduces pain and increases mobility medi. I feel better.www.mediuk.co.uk Tel: 01432 373 500 medi soft OA light knee brace osteoarthritis off-loading knee brace now available on prescription. Intended purpose: medi soft OA light is a knee brace for load relief.

Surgical team performing with limited equipment during the Falklands Conflict

The Annual Scientific Meeting followed the IC and ran from 22nd – 24th June. Our AHP Symposium and Research Symposium opened the meeting, running in parallel, with the Research Symposium featuring Jonathan Rees, BESS President its own mini free paper session on meta-analysis and systematic reviews. Responding to feedback from our members, this year we integrated more masterclass sessions into the main programme across two sessions on two days. Our ever-popular Hot Topics session featured some of the latest news and updates from BESS including the many national trials BESS members are now running and supporting. This year a highly informative President’s Guest Lecture on NJR outlier analysis was delivered by Peter Howard, while Ram Chidambaram delivered the Local Organisers Lecture. We were also grateful to Samuel Antuña for providing a third guest lecture focusing on the Elbow. We ended the week awarding several BESS funded fellowships and, of course, our prizes for the best papers. Despite the packed programme we were also pleased to host a conference dinner for all, at the inspiring Liverpool Cathedral.

The week started with our Instructional Course (IC) on 21st June, focused on shoulder and elbow trauma. We were delighted that our international faculty guests Samuel Antuña (Spain) and Ram Chidambaram (India) made themselves available for the IC and were able to share their experiences with us. The day was split into lectures, mini symposiums, and case-based discussions and ending with a final faculty debate.

BESS 2022 Annual Scientific Meeting and Instructional Course

BESS was very excited to be back face-to-face this year for our first in person meeting since 2019. Despite the rail strike, we all manged to travel to the ACC in Liverpool with over 600 delegates joining us across four days.

The course was very well received and like the annual scientific meeting, we have made the virtual content available to purchase via our website for those that were unable to attend.

16 | JTO | Volume 10 | Issue 03 | September

Simon Hodkinson, CSOS President

On behalf of BESS, I would like to thank our colleagues in the Northwest for helping organise and host this most enjoyable and successful conference. We now look forward to BESS 2023 in Newport, Wales. For more information, please see www.bess.ac.uk n 2022 boa.ac.uk

British Elbow and Shoulder Society (BESS) update

News

Combined Services Orthopaedic Society (CSOS) update Robiati for her work with Professor Hamish Simpson on ‘A new animal model for infected fracture non-union after external fixation of the tibia with real-time in-vivo monitoring of infection’. The Templeton Memorial Prize for the best trainee presentation went to Maj Neil Eisenstein on his work entitled ‘Interconnectivity explains high canalicular network robustness between neighbouring osteocyte lacunae in human bone’. Finally, the Best of the Best section was awarded to Maj Charles Handford’s paper on the ‘Cost effectiveness following osseointegration for trans-femoral amputation and the relationship between the pre and post operative EQ5D health utility value’. Next year’s meeting will be held on the 31st of March 2023, at Keble College, University of Oxford. The 2024 meeting will mark the 50th anniversary of CSOS Society. Previous members who have lost touch with the Society, or individuals who believe they may be eligible for membership and would like to join us to mark this occasion are invited to contact secretary@csos.org.uk

T his year the CSOS held its Annual Meeting met in the serene setting of the China Fleet Club in Saltash, Cornwall. The peaceful setting was in contrast to the memory of the short but brutal conflict to retake the Falkland Islands 40 years ago this year. Those of us of a certain age will never forget the images of the casualties from the Sir Galahad arriving at the field hospital in Ajax Bay, subsequently becoming better known as the ‘Red and Green Life Machine’. The Combined Services Orthopaedic Society was setup 48 years ago, and as a forum for military T&O surgery it has gone from strength to strength. This has been particularly true in the last ten years or so with the astonishing advances in the understanding and management of battle injuries, much of which has translated into civilian practice. This year our guests were Prof John Skinner, current BOA President, and Brigadier Duncan Wilson, Head of Research and Clinical Innovation. In their presence, we had an excellent series of presentations in basic science, military surgery and general orthopaedics. The Fulford Prize for the best overall paper was won by Maj Louise

45 Royal Marine Commando marches towards Port Stanley, 1982 © IWM FKD 2028

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Amit Tolat, BIOS President BIOS will be participating at the BOA Annual Congress this September with a revalidation session on Trauma and will also be proudly hosting the Indian Summer – a triennial event to showcase the best of talent from India in the world of orthopaedic and trauma surgery. n

The Society held its first face-toface Annual Meeting since the COVID pandemic, in Mansfield which was organised locally by Vikram Desai and the Mansfield Hospital Orthopaedic team. The meeting was oversubscribed and registrations had to be closed two weeks prior to the meeting. It was a huge success with invited international speakers of repute and more than 50 scientific papers. The chief guest was Rebecca Adlington a local sporting hero, after winning Olympic Gold in swimming at the Beijing Games. There was an outpouring of support from industry, which was very gratifying.

T he Society completed a trainee Webinar Series earlier this year and which was very well attended and received numerous visits to our BIOS YouTube channel ( britishindianorthopaedicsocietybioswww.youtube.com/c/ ).

We’d like to wish the best of luck to our team of runners: Imran Ahmed, Jen Barwell, Alex Chipperfield, Tim Davies, Jake Ellis, Rob Gregory, William Paton, Richard Secular, Ben Skinner and Amol Tambe. A special mention to Ben Skinner, who is planning to run the distance carrying a 6-foot-high model of the Tree of Andry: a symbol for orthopaedics used around the world. Please support our runners and help raise much needed funds for the Joint action by going to our London marathon page at: www.boa.ac.uk/london-marathon and selecting either of the donation links. Gregory Amol TambeBenSkinner

Joint Action Update 2022 TCS London Marathon Imran-Ahmed Rob

BIOS has started a number of new fellowships which are fully funded, for all categories of surgeons – trainees (BOTA), junior and senior travelling fellows and industry supported (Medacta) fellows (two per year). We simultaneously have hosted two fellows from Rajasthan state at Wrightington Hospital, which they thoroughly enjoyed and learned a lot about the UK system.

O n Sunday 2nd October, ten amazing runners will be taking part in the TCS London Marathon to raise money for Joint Action appeal of the British Orthopaedic Association. They are aiming to raise over £13,000 to support vital research into Trauma and Orthopaedics, transforming lives and giving people back their freedom and independence.

British Indian OrthopaedicSociety (BIOS) update

1st November 2022 Jurys Inn, Oxford SAVE THE DATE appliedpointsCPDfor COMBINED BRISTOL AND OXFORD KneeUnicompartmentalArthritisSymposium Challenging the success and outcome of UKR 2022-uniknee-BJO-qtr-pg-ad.indd 1 numberCharity 1194227 @dayonetrauma We’re here for you and your whereverwheneverpatients,andyouneed us. Thousands of people still face major trauma alone – help us be there for them, from day one and for as long as it takes. Talk to us on stand 93 at BOA Congress or visit dayonetrauma.org to find out more.

News

Finally, the BOTA Congress 2022 will take place this year November 22nd – 25th at the Liverpool Hilton. It will be our first face-to-face conference in three years and it promises to be an epic one. With five preconference courses (two of which are virtual), space for over 350 delegates, workshops and content from AO, BESS, BASK, OTS as well as many of our industry partners and sponsors, it promises to be our biggest one yet. Most importantly, offered to trainees at the lowest possible price, FREE*. So there’s no excuse not to book your study leave if you are an orthopaedic junior of all levels, and we welcome input from all consultants and senior orthopaedic surgeons alike. Visit our website at www.bota.org.uk and feel free to get in contact with me at president@bota.org.uk

British Orthopaedic Trainees Association (BOTA) update

*Free – £50 deposit refunded minus booking fee on confirmation of attendance.

t’s been an exceptional busy 12 months for the British Orthopaedic Trainees Association. Amongst many things, one of the hangover effects of the COVID-19 pandemic has been disruption of our usual terms of office and Congress date. Our first job following our delayed virtual Congress and AGM in July 2021 was organising the BOTA sessions at BOA Congress 2021 at short notice. Our morning session had an update on the GOAST study followed by our keynote lecture, ‘Thrive, Not Just Survive’ by Dr Uttam Shrilkar, an expert in cognitive learning for surgery. In the second session, our customary TPD question time was well attended with key questions about the new curriculum answered by our hilarious ‘ISCP the Great’ skit with anything outstanding expertly dealt with by our select SAC and TPD panel. At the RCS Future Surgery Show 2021 in November, we ran a lecture series and panel discussion session in association with BBraun on Training in Navigated Arthroplasty. Led by Professor Picard, one of the pioneers of computer assisted arthroplasty surgery, it was a great look at the benefits of using navigation technology not only to provide great care but also help teach arthroplasty fundamentals. Hard at work throughout 2021, our Culture and Diversity working group delivered by recruiting the BOA/BOTA Culture and Diversity champions in early 2022. To kick start the initiative, we held our

Oliver Adebayo, BOTA President first Culture and Diversity Champions Day sponsored by Depuy Synthes in April 2022 at the RCS England. It was an excellent day filled with invaluable information on dealing with difficult situations, signposting and change mentality. Watch this space for the fantastic work from this group of motivated T&O surgeons, keen to push change within the speciality.InJune 2022, our Sustainability working group organised the first ever Sustainability in Orthopaedic Surgery Conference. A completely virtual offering with over 150 delegates from around the world tuning in via the MedAll platform we heard from leading voices about some of the key issues around sustainable orthopaedic surgery and how we can move forward as a speciality. The first of its kind from any speciality group, we hope that it will become a staple in the orthopaedic calendar over the next few years as the NHS moves to net zero carbonToemissions.continue our theme of training in navigated arthroplasty this year, we organised the first trainee focussed Robotic Knee Arthroplasty course in association with Smith and Nephew. A fantastic two days with both saw bones and cadavers, it was a truly ground breaking session allowing 24 delegates unparalleled training in some of the newest technology available right now. We believe that training in computer assisted surgery needs to be a mandatory part of the T&O curriculum, as this technology will become a necessity within many spheres of orthopaedics.AtBOA Congress this year in Birmingham, our first session on ‘Improving Trainee Confidence’ will deal with some of the issues around training post pandemic and include our annual TPD question time. While our second session, ‘Innovation in Training and Research’ looks at the advances and opportunities trainees, trainers and researchers have at their disposal right now to push the boundaries of T&O.

Raise3D Pro2 dual extruder 3D printer and the Pro2 Plus large format 3D printer have competitive build volumes. Their build area reaches 30cm in the X/Y direction and a building height that can reach either 30cm or 60cm. This is important for prosthetics which usually are large in size, to fit a person’s limb or torso. Printing prosthetics in one-piece saves time and assembly labour, especially when compared to printing the prosthetic in smaller components.

In France, Paolo Peirera Valerio’s prosthetics project demonstrates how 3D printing can deliver products that fulfil the precise individual requirements and better quality for appearance and wearing experience. The nature of additive manufacturing, an inherent feature of 3D printers, such as the Raise3D Pro2 series and E2, means that prosthetics can be made exactly as laid out in a CAD design. 3D printing can produce a design with intricate geometry, which can include organic shapes, cavity structures and lightweight construction.

3D printing technology has influenced prosthetics since the beginning of the industry itself, and is widely regarded as the next-generation solution for manufacturing. Raise3D printers demonstrate how successful customisation and small-batch production is in this sector.

Raise3D’s ecosystem provides manufacturers with several competitive advantages over other 3D printing solutions. These features allow business owners to have higher capacity and have a wider range of easily implementable functional options in the final product.

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Jig-guidedhiprevisionsForthefirsttime,Gomina has developed an extraction set that allows a hip revision to be done with minimal bone loss. Thanks to innovative production technologies, it is possible to manufacture dimensionally rigid chisels with different radii. The precision ground, sharp cutting edges of the chisels are the result of Gomina’s many decades of expertise. The bespoke crafted jigs manufactured by Gomina ensure the application of a precise separation of bone and prosthesis. This innovative pioneering extraction set from Gomina makes surgeon’s work far easier, leading to shorter operating times. Entirely for the patient’s benefit.

P rofessor Chris Moran is currently the National Strategic Incident Director for the COVID-19 pandemic. This is a senior leadership role in NHS-England, working within the National Health Service (NHS) and across government to direct and coordinate the national response to the pandemic and also the recovery of health services. He was a founding member and later chair of the National Hip Fracture Database and was National Clinical Director for Trauma, leading the National Trauma System in England for seven years from 2013-2020.

Professor Moran was awarded OBE for services to trauma surgery in 2021. n

Honorary

Judy Murray

He is Honorary Professor of Orthopaedic Trauma Surgery at Nottingham University Hospital having trained in Cardiff and Newcastle with fellowships at the Mayo Clinic, USA and the University Hospital in Basel, Switzerland. He is still a practicing trauma surgeon, continues to do emergency on-call and has a special interest in surgery for polytrauma, complex articular fractures and the treatment of nonunion. Professor Moran is international adviser on trauma to a number of governments. His research portfolio includes over 175 published scientific papers and abstracts with over 10,000 citations, mainly in the field of trauma. He continues in active research in this field. He is editor of a major textbook, the AO Principles of Fracture Surgery and has also authored multiple book chapters. Professor Moran is Honorary Colonel to 144 Medical Parachute Squadron, 16 Regiment and also Civilian Adviser on Orthopaedic Surgery to the Royal Air Force. He enjoys running and still runs to work!

The BOA is pleased to announce the recipients of the 2022 Honorary Fellowship, which will be presented at BOA 2022 Congress.

During this time, he was involved in the leadership of the response to a number of major incidents and also developed the national peer review system for all Major Trauma Centres and Trauma Units. Professor Moran is a long-standing member and ex-chair of the BOA trauma group and co-authored many of the British Orthopaedic Association Standards for Trauma.

Chris Moran J udith Murray (née Digby) was appointed as a consultant Trauma and Orthopaedic Surgeon at East Glamorgan Hospital, South Wales in 1985. As one of two consultants she updated the Trauma service, using experience gained from her AO training in Nottingham. The following year she ran the London Marathon, raising funds for new trauma equipment. Initially working as a general orthopaedic consultant, she subsequently specialised in knee and children’s orthopaedics as further consultants were appointed and the unit moved to Royal Glamorgan Hospital.She has played an active role training junior colleagues on the Overseas Doctors Training Scheme, on AO courses and examination preparation courses. She was appointed as an Intercollegiate Specialty Board Examiner from 1997 until 2011, holding positions as chairman of the written paper committee, board member, EBOT examiner and examiners’ assessor. She has been an elected member of the BOA Council, appointed as a founder member of the RCS England Patient Liaison Group, the NJR Steering Committee and President of the Welsh Orthopaedic Association. Her contribution to training was recognised by being elected Welsh Trainer of the Year in 2015. Since retiring part time in 2014 she finally retired in 2019. This enabled her to study BA Spanish and German part time at Cardiff University, and has been awarded MA in Translation Studies this year. n

Fellowships

P rofessor Tim Briggs qualified in 1982 obtaining Honours in surgery. He was appointed at the Royal National Orthopaedic Hospital Trust (RNOHT) as a Consultant in 1992 specialising in Sarcoma and complex Hip/Knee. He was an ABC Travelling Fellow in 1998.

Professor Briggs has chaired the GIRFT programme, which he started in 2012 by visiting every Trust in England, Wales, Scotland and NI to review Orthopaedic services. It is now a national NHS programme, focusing on quality Improvement, across 41 Specialties with 39 National Specialty reports published, to improve outcomes and reduce unwarranted variation.

The BOA is pleased to announce the recipient of the 2022 Presidential Merit Award, which will be presented at BOA 2022 Congress.

Tim was Medical Director of RNOHT from 1989 – 2014, and instrumental in achieving a rebuild of the hospital after 30 years of uncertainty, highlighting the importance of elective sites.

B eth Tite has been working in Trauma and Orthopaedics for 22 years. Her current role as the BOA Casting Course Leader and Exam Facilitator puts her at the forefront of education in T&O. Courses used to Train Orthopaedic Practitioners, Registrars and Emergency casting are the current courses on offer along with CPD support. Beth and her team are looking to expand this profile and introduce more modules for training in the skills required for the advanced techniques and treatments that are available. Along with her teaching, she works as an Orthopaedic Practitioner, and also works for a charity, Motec Life UK, whom deliver training and education in the hospitals and communities in Ghana, West Africa. In Ghana, Beth specialises in the treatment of CTEV and trauma management. She also has a strong interest in the treatment of diabetic feet. n Beth Tite

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. He continues to publish, both papers and books/chapters, currently with a focus on population health and system improvement improving clinical outcomes. n

Tim has served as a member of the SAC (2009-2015), examiner of FRCS(Orth) exam (20092017), Past President of British Orthopaedic Oncology Society (2008) and the BOA (2013-2014), and a Council member of RCSEng (2014-2019).

Tim was Appointed National Director of Clinical Improvement for the NHS in 2017. He currently leads the National High Volume Low complexity surgical programme across six surgical specialties, standardising pathways, improving theatre efficiency and delivering the elective ‘Hub site’ model for delivering elective surgical care across ICB’s for elective recovery.

Tim Briggs

Presidential Merit Award

He has received a Hunterian professorship from RCSEng (2006), been the Robert Jones Lecturer at BOA Congress (2008) and awarded Personal Chair in Orthopaedics by UCL (2009).

Tim was author of The Chavasse Report (2014) to improve the Quality of Care for Veterans and is Chair of The Veterans Covenant Healthcare Alliance to implement recommendations. Currently, there are 141 NHS Trusts, Veteran aware, and improving their care. In July 2022 he was appointed Honorary Colonel of 202 Field Hospital (Midlands), a unit of the Royal Army Medical Corps which Tim is very excited about.

He was also Training Programme Director for the RNOHT programme from 2003 up until May 2022, which was one of his most enjoyable roles and a privilege.

Programme Update

Get the BOA App to plan your Congress experience If you’ve not already done so, make sure to download the BOA app to access everything you need for Congress this year. Just search

We are delighted to welcome over 80 exhibitors at this year’s BOA Annual Congress including: Circle Health Group, DePuy Synthes, Smith+Nephew, Zimmer Biomet, Heraeus Medical, Bioventus and many more! Explore the full list of exhibitors on our website: exhibition-sponsorship

20th – 23rd September, ICC Birmingham www.boa.ac.uk/Congress

The Howard Steel Lecture will be delivered by Timandra Harkness. Timandra is a science writer, broadcaster and comedian, who has performed Maths stand up, presented on Radio 4, and written a book – Big Data: does size matter?

The Robert Jones Lecture, ‘Innovation, Regulation and Evaluation in Orthopaedic Surgery’ is being delivered by Professor Andrew Carr.

#BOAAC22

Full details of the programme is available at www.boa.ac.uk/programme

Make sure to book your accommodation now so you don’t miss out! More information on hotels near to the Congress venue is on the BOA website at accommodation distance map.

The King James IV Professorship Lecture, ‘Walking on Water - How Joints Work and Why They Become Arthritic’ will be presented by Michael Beverly.

Exhibition & Sponsorship

The Adrian Henry Lecture will be given by Professor Tom Minas, Director of The Cartilage Repair Center Paley Orthopedic & Spine Institute, Cartilage Repair & Joint Preservation, USA. This years’ Charnley Lecture ‘Have we done justice to the Charnley Heritage’ will be presented by Martyn Porter, Consultant Orthopaedic Surgeon, Wrightington Hospital.

The theme of the Annual Congress 2022 is ‘Technology, Data and Recovery’ and we look forward to presenting to you a mix of educational and scientific sessions with a number of high calibre speakers for our plenary and revalidation sessions. This year’s presidential Guest Lecturer is Daniel Berry from the Mayo Clinic, Rochester, USA. Dan is known to many as a surgeon with a lifelong commitment to research that improves outcomes, quality, reliability and durability of joint replacement surgery. He was also fundamental to setting up the American Joint Replacement Registry.

This year’s flagship Annual Congress is taking place from 20th – 23rd September, at the ICC Birmingham. If you haven’t registered yet it’s not too late! Details about late registration are on our website at www.boa.ac.uk/registration

Accommodation & Travel

www. Arthrosamid .com @ConturaLtd Contura-Orthopaedics-Ltd Contura Orthopaedics Ltd Join our mailing list Scan the code to register with us and keep up to date with our news. INTRODUCING A NEW CLASS OF THERAPY TO TREAT KNEE OA — SAFE AND SUSTAINED PAIN RELIEF WITH A SINGLE INJECTION 1 Visit us at the BOA! Stand 52 References: 1. Bliddal H, Overgaard A, Hartkopp A, Beier J, Conaghan PG, et al. (2021) Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: A 6 Months Prospective Study. J Orthop Res Ther 6: 1188; 2. Bliddal H, Beier J, Hartkopp A, Conaghan PG, et al. (2022) A Prospective Study of Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: Results From 2 Years After Treatment. Poster presented at OARSI 2022. † WOMAC or The Western Ontario and McMaster Universities Osteoarthritis Index is a measure ofsymptoms and physical disability OUS/ARTHRO/JUL2022/044.V1 Polyacrylamide Hydrogel Injection for Knee Osteoarthritis A 104 Week Prospective Study (IDA 2 Years)1,2 † WOMAC or The Western Ontario and McMaster Universities Osteoarthritis Index is a measure of symptoms and physical disability. LSMeans are modelled/estimated means. The estimated means are using data from the other visits and also the covariates. 1. Bliddal H, Beier J, Hartkopp A, Conaghan PG, et al. (2022) A Prospective Study of Polyacrylamide Hydrogel Injection for Knee Osteoarthritis: Results From 2 Years After Treatment. Poster presented at OARSI 2022. 2. Data on ﬁle. ofBaselinefromChangeLSMean †WOMACPainSubscale Time Since Baseline (Weeks) N=49 N=45 N=32 4 1326 52 104-20-100-15-25-5 *P<0.0001 -15.4*-18.2*-20.7* -17.7* -18.2*Mean Baseline = 50.3 OUS/ARTHRO/JAN2022/042.V1 by New data shows statistically significant reduction in pain maintained at 2 years

Discover the exhibitors featuring in the Technology & Innovation Zone...

BOFAS (The British Orthopaedic Foot and Ankle Society) 08-10www.bofas.org.ukMarch2023, Liverpool BSCOS (British Society for Children’s Orthopaedic Surgery) 09-10www.bscos.org.ukMarch2023, Southampton

Conference

BOA Congress Technology and Innovation Zone

News

We are pleased to announce our new zone for this year’s exhibition at the BOA Annual Congress 2022 at The ICC in Birmingham. The Technology & Innovation Zone is a place for delegates to explore, discover and experience the latest developments in technologies all in one place, which showcases emerging solutions, products and services including Surgical Robotics, 3D imaging, Software, Artificial intelligence, Cloud-based Solutions, Real Intelligence, Data, Digital Platforms, Medical Apps and more. The Zone is located inside the main exhibitions Hall and will be open from Tuesday 20th – Thursday 22nd September. Exhibitors featuring inside the zone include Buddy Healthcare, Corin Group, Exactech, Sectra Orthopaedics AB, Symbios UK, Smith+Nephew, Open Medical & The Standing CT Company. To find out further details about exhibitor’s products and services, please visit our website: www.boa.ac.uk/ technology-zone Professor John Skinner, President of the British Orthopaedic Association said: ‘We are excited to launch our new Technology Zone at the BOA Annual Congress this year. With technology playing such a vital role in our industry as well as an increasing role in our lives, the new Technology Zone will provide delegates with access to exciting new products, as well as showcasing the latest technology-focused exhibitors.’

Listing 2022: ICORS (International Combined Orthopaedic Research Societies) 07-09www.borsoc.org.ukSeptember2022, Edinburgh BOA (British Orthopaedic Association) 20-23www.boa.ac.ukSeptember 2022, Birmingham BSSH (British Society for Surgery of the Hand) 12-14www.bssh.ac.ukOctober2022, Winchester

BOTA (British Orthopaedic Trainees Association) 21-25www.bota.org.ukNovember 2022, Liverpool BTS (British Trauma Society) 22-24www.britishtrauma.comNovember2022,Oxford BHS (British Hip Society) 08-10www.britishhipsociety.comMarch2023,Edinburgh

The UK’s Largest Event for Orthopaedic Surgeons

ESMOS (European Musculo-Skeletal Oncology Society) 17-19www.emsos2022.orgOctober2022, London BSS (British Scoliosis Society) 02-04www.britscoliosis.org.ukNovember2022,Edinburgh

The Power of One is Here. Osteoarthritis Pain Relief in a Single Injection Stays longer in the joint — half-life of 30 days3 • Powerful and long lasting improvement of quality of life4 • Clinically proven5,6 • Three-dimensional gel due to cross-linked hyaluronic acid molecules7 • Unique viscoelastic properties due to NASHA technology7

3. Lindqvist U, Tolmachev V, Kairemo K, Aström G, Jonsson E, Lundqvist H. Elimination of stabilised hyaluronan from the knee joint in healthy men. Clin Pharmacokinet. 2002;41(8):603-13. doi: 10.2165/00003088-200241080-00004 4. Krocker D, Matziolis G, Tuischer J, et al. Reduction of arthrosis associated knee pain through a single intra-articular injection of synthetic hyaluronic acid. Z Rheumatol. 2006;65(4):327-31. doi: 10.1007/s00393-006-0063-2 5. McGrath AF, McGrath AM, Jessop ZM, et al. A comparison of intra-articular hyaluronic acid competitors in the treatment of mild to moderate knee osteoarthritis. J Arthritis. 2013; 2(1):108. doi: 10.4172/2167-7921.1000108. 6. Leighton R, Åkermark C, Therrien R, et al. NASHA hyaluronic acid vs methylprednisolone for knee osteoarthritis: a prospective, multi-centre, randomized, non-inferiority trial. Osteo arthritis Cartilage. 2014; 22: 17-25. 7. Ågerup B, Berg P, Åkermark C. Non-animal stabilized hyaluronic acid: a new formulation for the treatment of osteoarthritis. BioDrugs. 2005;19(1):23-30 doi: 10.2165/00063030-200519010-00003. the Bioventus logo and DUROLANE are registered trademarks of Bioventus LLC. SMK-003033

Summary of Indications for Use: Europe: DUROLANE (3 mL): Symptomatic treatment of mild to moderate knee or hip osteoarthritis. In addition, DUROLANE has been approved in the EU for the symptomatic treatment associated with mild to moderate osteoarthritis pain in the ankle, shoulder, elbow, wrist, fingers, and toes.

Bioventus,

References: 1. Bioventus LLC. Supporting quantity of global patients treated with a single DUROLANE injection. Data on file, RPT-001056 4 2. Q-Med Scandinavia, Inc. DUROLANE approved in Europe for the treatment of osteoarthritis of the hip joint. Posted March 9, 2004. https://mb.cision.com/wpyfs/00/00/00/00/00/04/2D/C9/wkr0006.pdf

DUROLANE SJ (1 mL): Symptomatic treatment associated with mild to moderate osteoarthritis pain in the ankle, elbow, wrist, fingers, and toes. Both DUROLANE and DUROLANE SJ are also indicated for pain following joint arthroscopy in the presence of osteoarthritis within 3 months of the procedure. United Arab Emirates, Saudi Arabia, Jordan: DUROLANE (3 mL): Symptomatic treatment of mild to moderate knee or hip osteoarthritis. There are no known contraindications. You should not use DUROLANE if you have infections or skin disease at the injection site. DUROLANE has not been tested in children or pregnant or lactating women. Risks can include transient pain, swelling and/or stiffness at the injection site. Full prescribing information can be found in product labeling, or at www.DUROLANE.com

07/20 Innovations For Active Healing Since 2001, DUROLANE has treated over two million patients worldwide.1,2 Contact a Bioventus representative by phone at 0800 05 16 384 (UK) or 00800 02 04 06 08 (IR)

There are currently 15 knee replacement implants that have been notified to the MHRA as having outlier status when used in primary cases. These all appear in the Annual Report 2022 Table 4.4 and of these we can see that eight named implants have not been used in the NJR for several years. The other seven implants are still in use and we draw the attention of all surgeons to these implants.

Tim Wilton is a Consultant Orthopaedic Surgeon at Department of Orthopaedics, Royal Derby Hospital, Derby, with specialist interests in knee and hip replacement surgery. He is Past President of the BOA and BASK and is Medical Director of the NJR.

no longer to be being used. In the case of the Journey 2 BCS the company has written to surgeons suggesting that they carefully consider resurfacing the patella as the results do seem to be so significantly affected by whether the patella is resurfaced or not. We thoroughly endorse the suggestion that this particular implant has very much higher revision rates when the patella is not resurfaced and suggest it would seem unwise to disregard that advice.

The Endo-model modular rotating hinge and the Smiles (METS hinged/linked) knee are likely to be used in different cases to standard bicondylar knees and outlier status may largely reflect the complexity of the cases in which these are used. Surgeons should still be aware of this higher failure rate and therefore should consider whether they really need to use these in a primary case unless there are clear indications that such a device is the best implant choice.

his article is intended to inform surgeons about implants that have been seen at outlier status, and particularly those still in use. By ‘outlier’ status we mean that the device has twice the expected revision rate at that particular time as compared to the average implant of its class. The lower limit of the relevant confidence interval has to pass this threshold before the implant is deemed an ‘outlier’ in which case we can reasonably say that the implant is ‘at least’ twice as likely as expected to require revision.

Peter Howard and Tim Wilton

In contrast, the E-motion bicondylar knee has only been shown to have outlier status when the patella is resurfaced at the primary operation.

The NJR reports on the outcomes of implants used in primary arthroplasty and identifies any with (statistically) significantly higher than expected revision rates.

It will be seen that many of these have only been shown to have outlier status when they are used without primary resurfacing of the patella. The higher revision rate with these implants could therefore reasonably be expected to be partially or, in some cases, completely resolved if the patella is routinely resurfaced at the time of the primary surgery. This applies to the Journey 2 BCS, Genesis 2 Oxinium and RHK prostheses, although the latter appears

It might be that the ACS Knee is also effectively discontinued: it has been used on only three occasions in the past three years. The knee has only been used in relatively small numbers but the high revision rate applies equally to the overall figures for the implant and to the one higher volume user, so perhaps it is reasonable to say that it should no longer be used.

Which implants have been identified as ‘outliers’ by the NJR over the years and which of these are still being used?

Peter Howard is an Orthopaedic Consultant in Derbyshire. He is Past President of the BHS and Chair of Implant Scrutiny Committee for the NJR.

All of the stem-cup combinations reported in table 4.3 that are still in use involve either a stem and/or cup that has also been reported to the MHRA.

Of those implants still in use where MoM was not a contributor, the SPII stem is no longer an outlier, and the Aura II cementless is a new notification in 2022. The Delta One TT and the Trabecular Metal Revision Shell are both implants most likely to be used in complex primary cases, but surgeons should again be aware of this higher failure rate and therefore should consider whether it really is necessary to use these in a primary case and whether

The Genesis 2 Oxinium PS knee is possibly dealt with somewhat harshly in this analysis, in that the patients for whom this implant is chosen tend to be much younger and possibly more active. The relevant analysis is not adjusted for age, gender or indication for surgery, unlike some other analyses which are performed. The results by brand in the Annual Report show that those having an Oxinium knee are, on average, twelve years younger than those having a CoCr knee of the same design. A special NJR sub-group analysis was commissioned by the company to investigate this and it was clear that much of the difference between the Genesis 2 Oxinium PS and the Genesis 2 CoCr PS revision rates were no longer seen after adjustment for these parameters.

If a variant is found to be significantly outside the expected range, then this is also reported to the company and the MHRA. As a consequence

there are clear indications that such a device is the best implant choice. The Bimentum dual mobility is again an implant that would be expected to have specific and somewhat different indications to most THRs, but there is a trend for increasing popularity of these bearing construct types. Surgeons therefore need to consider carefully whether they are using these special devices because there is a specific indication in a given case, or whether they are using them ‘in case’ of a complication, such as dislocation, whether or not it may be a problematic complication in their own practice.

The ACE dual mobility cup is newly reported this year. It is recently introduced and has relatively low numbers and the outlier status could therefore be due to the relatively high impact of small numbers of revisions. Nevertheless, it is included in the outlier list as it meets the statistical criteria in spite of the wide confidence intervals observed.

If surgeons have concerns over the performance of these or other implants that they have used or may be thinking of using they should contact the authors as there is detailed information available about all implants used in the NJR – Tim Wilton: Timothy.wilton@njr.org.uk n of this type of analysis the Committee has reported two specific variants in the NexGen total knee replacement brand. These are two combinations of the ‘Option’ stemmed cemented (non-precoat) tibial implant specifically when used in conjunction with the posterior stabilised Flex femoral components (Flex and Flex GSF). These have borderline outlier status but have several times the expected rate of revision for aseptic loosening of the tibia. The same tibial component has good revision rates with many of the other femoral components and in particular with CR variants.

All of the above have been reported on the basis of the PTIR method, which relies on the performance of an implant over the whole of its period of usage. Implants in the NJR may be subjected to closer scrutiny under certain conditions, such as when reports are received from surgeons concerned about the performance of certain variants, or when a device seems to have a very specific mode of failure. KaplanMeier analysis of revision rate is then performed, using the average for the implant group as the ‘expected’ value, and if necessary followed up with other statistical tests.

In hips we report on hip stems, cups, and combinations thereof. These all appear in the Annual Report 2022, Tables 4.1 – 4.3. Of the 13 hip stems notified to the MHRA, just two remain in use. There have been 11 cups reported of which three are still in use, and 34 stem-cup combinations of which five remain in use. 34 of the reported variants or combinations involved significant proportions of metal-on-metal bearings, and all these are now discontinued.

Suddhajit Sen is a Consultant Orthopaedic Hand Surgeon and Honorary Senior Lecturer at Edge Hill University.

Imagine this happening to you at work. Not once but most days and your colleagues or care providers don’t know what’s going on.

Having worked alongside some of them, I came to realise how little I understood their struggle or efforts to mask the apparent struggle. Spreading awareness will create a strong foundation of understanding, making our workspace more harmonious and inclusive.

A bog-standard intra-capsular neck of femur fracture in a morning trauma meeting was another eye-opener for me. This patient was presented and the consensus was to perform a total hip replacement, following the NICE criteria. However, the presenting doctor mentioned that this patient was autistic. This changed the plan and the operating surgeon quickly switched to a hemiarthroplasty, having concerns about the patient’s cognitive abilities. To me, this is an example of discrimination stemming from ignorance. Our current understanding demands a thorough evaluation of this patient’s cognitive capacity and one must consider the burden of unfamiliar environmental stress in their judgement. The word autism must not be associated with a learning disability without an expert opinion. It is my ambition to bridge this gap in understanding and help autistic patients and colleagues to receive fair treatment.

May Edmondson is a medical student at St George’s Medical School, London.

Harish Vamadevan, May Edmondson, an unamed author and Suddhajit Sen

Some would even describe me as rude or aloof! My life has become a constant struggle to mask this unintentional aloofness. I desperately want to appear normal but I am exhausted trying to do so. Now I know that I am autistic too.

FeaturesHarish

WhatNeurodiversitydoweunderstand

I s it the stress of starting a new job, is it burnout from staying away from my family or is it the quiet desperation about my son’s future? Haunting questions, silent prayer and the dread of facing another day at work; my life was a groundhog day. My little boy has recently been diagnosed with autism and I’d started a new fellowship, staying away from home. My son displayed selective mutism, losing his voice completely in a new unfamiliar environment. I was experiencing the same helplessness at my workplace. Sometime back, my brother pointed out that my childhood idiosyncrasies had plenty of similarities with how my son behaves. To me, it was a feeble attempt to downplay or deny my son’s recent diagnosis of autism. However, now it seems to make sense. Despite my relative success in academics and career as an orthopaedic surgeon in the UK, I have always struggled with interpersonal communication, especially in a new place and in a new job.

Vamadevan is a medical student at St George’s Medical School, London.

This author, an SAS orthopaedic surgeon, wishes to remain anonymous in view of their neurodiverse condition.

Terminology In modern times, efforts to de-medicalise autism and related conditions have resulted in the concept of ‘neurodiversity’ which views autism and the unique features expressed by those affected as part of a kaleidoscope of different traits which exist as part of the normal variation of human neurology1 as opposed to something which needs to be treated or fixed. This movement towards greater inclusivity is perhaps the reason ‘neurodiverse’ is often the preferred term amongst the autistic community2 with the antonym ‘neurotypical’ being the preferred term over ‘normal’. Therefore, throughout this

A personal account

Unfortunately, this is a real-life scenario for some of our colleagues or patients with autism spectrum disorder (ASD).

Introduction There is a poignant moment in the movie ‘Man of Steel (2013)’ showing a visibly disturbed young Clark Kent hiding in his school’s broom closet, eyes shut, ears covered. He was having a moment of unbearable sensory overload. His Kryptonian senses were awakened for the first time, and it was flooded with stimuli that others find harmless, causing a meltdown. However, neither his teacher nor his classmates had a clue.

In the movie, Clark needed to focus on his mother’s voice to settle down. It is a form of reassurance built on trust, understanding and acceptance. We hope to work on those similar principles to build support structures in the NHS for our patients and colleagues.

Access denied: Barriers to healthcare faced by the autistic population

• The waiting room environment (51%)8 Besides the significant difference between the two populations reported, in the second aspect of this report you will notice that all the barriers identified by the autistic community are entirely preventable and amenable to reasonable adjustments17. For example, individual preferences as to the appointment modality must be respected. Some neurodiverse people find telephone appointments challenging as they rely on lip-reading and visual cues to engage in a conversation with their doctor, therefore they may require face-to-face >> faced by the neurotypical population. Barriers to accessing the healthcare system include a variety of patient-level factors. For example, hypersensitivity to sensory stimuli can make the healthcare environment itself too overwhelming for the autistic patient to properly engage with the content of the consultation and impedes physical examination8. Moreover, distorted bodily awareness and difficulty in differentiating between physiological and pathological sensations has the potential to lead to late presentations and misdiagnosis9. There are also several systemic and provider-level factors at play, for instance, clinicians having a limited knowledge about autism and the lack of availability of formal and informal supporters10

Alarmingly, the barriers to accessing good quality physical and mental healthcare for the autistic community outlined above means that neurodiverse individuals have an overall life-expectancy of 16-30 years less than neurotypicals15. This is in part due to the increased risk of suicide within the autistic community16. Moreover, those years are spent with significantly worse morbidity, poorer quality of life and contribute to an increased overall burden on the NHS8

In a recent online survey on autistic and nonautistic individuals following the Autscape conference, 80% of autistic individuals reported having difficulty visiting their GP, compared to only 37% of neurotypicals8. The top five barriers this population identified were:

There is a higher prevalence of mental illness amongst the autistic population, with up to 80% of those on the spectrum meeting the criteria for a co-morbid mental health disorder13. This may be in part due to social camouflaging or ‘masking’, a subconscious process whereby the neurodiverse individual attempts to monitor and modify their behaviour to fit in with others and adhere to the conventions of neurotypical society. It is hypothesised that the ability to mask in ‘high-functioning’ neurodiverse individuals contributes to the increased rates of mental health disorders in this group14

• Not feeling understood (56%)

• Deciding whether symptoms warranted a GP appointment (72%)

• Difficulty communicating with their doctor (53%)

Figure 1: Graph showing the percentage increase in the incidence of autism from a baseline between the years 1998 and 2018.

There is no doubt that the neurodiverse patient faces significant challenges when navigating the healthcare system, in addition to those

So, what can we do to stop autistic patients slipping through the cracks in the NHS? The first step is identifying the barriers faced by neurodiverse individuals in accessing healthcare, particularly in the primary care setting, as this is the first port of call for preventative medicine.

Features

Overcoming the hurdles

article, we will be using the term ‘neurodiverse’ interchangeably with ‘autistic’, however one must be aware that this is an umbrella term for a range of neurological presentations which vary from the ‘norm’.

• Difficulty booking appointments via telephone (62%)

The result, as demonstrated by a recent cross-sectional survey comparing selfreported healthcare experiences in autistic versus non-autistic adults, is significantly lower ratings of satisfaction with patientprovider communication and unmet healthcare needs, as reported by autistic patients11 and neurotypical doctors12. The overall impact of this discrepancy on measured clinical outcomes, particularly in primary care, is significant and concerning; for instance, autistic patients are half as likely to attend routine Papanicolaou ‘Pap’ smears11, where delayed diagnosis can have potentially fatal consequences. Perhaps more worryingly, autistic individuals are twice as likely to attend A&E, compared to their neurotypical counterparts11, demonstrating that we are failing to identify those at risk and intervene before their health declines. Therefore, improving the neurodiverse population’s access to healthcare should be made a priority.

Slipping through the net

Figure 1 shows that the incidence of autism has increased, with figures starkly rising by 787% between 1998 and 20187 Not only has autism risen, but between 30-40% of our population is now thought to be neurodiverse4, strengthening the argument that we must do more to help them overcome the barriers they face daily.

Neurodiversity Neurodiversity is a concept best explained as a difference in how all individuals explore, experience, and envision their environment. It describes how there is variation in how people think and learn and how differences in these processes do not necessarily mean a deficit3 Being neurodiverse includes having conditions such as ASD, ADHD, dyslexia, and Tourette’s syndrome4. ASD is a condition seen in all ethnic, racial, and economic groups5 and it incorporates a range of neurodevelopmental disorders of varying severity. It is often characterised by difficulties in social communication and interaction, as well as repetitive and restrictive behaviours but can also stretch to over-or under- sensitivity to certain senses such as light perception6

This is described in the mind-blindness theory.

Features appointments, something which has become an increasing challenge due to the COVID-19 pandemic, but something doctors should consider before implementing a ‘one-size-fitsall’ approach. Another reasonable adjustment could be offering quieter appointment slots to autistic patients, including early mornings and late evenings, when the surgery waiting rooms will be less busy, or allowing the patient to wait outside the surgery until their allocated appointment time, if they find the environment itself too overwhelming. These are just a few examples, however there is no reason to say that with adequate training of GPs and reception staff, reasonable adjustments and, more broadly, having an open mind and flexible approach, all these hurdles could be overcome. As Dr Doherty herself states, “adjustments for autismspecific needs are as necessary as ramps for wheelchair users”8 Stigma and the challenges of misconceptions In present times, many efforts have been made to move toward celebrating neurocognitive variation but still, some stigma remains. Healthcare is a vocation that requires great social communication skills and empathy, and one example of such stigma would be that autistic individuals lack these traits.

The theory of mind is the ability to recognise that one’s mental state may differ from another’s18 and it is, therefore, crucial in understanding and predicting someone’s behaviour. Deficits in the theory of mind are thought to be prevalent in the autistic individual19, leading to a common misconception that these individuals cannot be empathetic.

Evidence for this theory includes studies that have determined that a neurotypical nine-yearold can identify what things may hurt another person’s feelings and can choose to not say/ do these things whereas children with autism are delayed in this skill by three years21 as well as a study that found that neurotypical nine-year-olds can read another person’s facial expressions from just their eyes, to find what they may be feeling whereas autistic children found this more difficult22

Essentially, when a neurotypical person ‘mindreads’, or mentalises, we not only make sense of another person’s behaviour, but we also imagine a whole set of mental states and we can predict what they may do next20. For example, when witnessing a pedestrian walking along the road, we may think “Why did they turn their head and look right?”, we may imagine that they have seen something of interest or they may want something in that direction, and we can predict that they may move in that direction next. The mind-blindness theory proposes that autistic individuals are “delayed in the development of their theory of mind, leaving them with degrees of mind-blindness”20

However, the underlying neurocognitive mechanisms of the absence of empathy remain controversial. A study has compared the mind-blindness theory with the intense world theory. “The mind-blindness hypothesis suggests that social difficulties in individuals with autistic traits are caused by empathy impairment in individuals; however, the intense world theory suggests that these social difficulties are caused by sensory hyperreactivity and sensory overload, rather than empathy impairment” 23 . The study supported the intense world theory more strongly than the mind-blindness theory, concluding that a few parts of the brain (e.g., the prefrontal cortex, sensory cortex, and amygdala) are overactive, thus intensifying their sensory experience. This may induce a state of anxiety for the individual, but it demolishes the idea that autistic individuals are not inherently empathic.

The General Medical Council (GMC) states in its recent guidance, Welcomed and Valued, that “No health condition or disability by virtue of its diagnosis automatically prohibits an individual from studying or practising medicine.”26 Earlier, we discussed how neurodiverse individuals tend to ‘mask’, meaning their struggles may often go ‘under the radar’ until the external demands placed on them exceed their internal resources and ability to cope, often resulting in meltdown27. However, building on legislation in The Equality Act (2010), the GMC document outlines how medical schools and deaneries must ensure all reasonable adjustments, for example, allowing a trainee surgeon to remain with the same consultant to reduce anxiety over change28, are considered on a case-by-case basis to provide adequate support for an individual and avoid discrimination26

Moreover, organisations such as Autistic Doctors International (ADI), an information and peer support group founded in 201928, are vital for raising awareness and challenging the misconception that autism is incompatible with a medical career, as well as confronting ableism and unconscious bias in the medical profession head-on. ADI and its members argue that with early recognition, reasonable adjustments and appropriate support from seniors and colleagues, autistic doctors can be incredible assets in any area of medicine27

The concept of the ‘double-empathy problem’ in autism has been posited in the last decade as a possible explanation for the observed difficulties in communication encountered between those on the autistic spectrum and non-autistic individuals. The ‘double empathy problem’ refers to the disparity in reciprocity between two socially distinct individuals, with ‘different dispositional outlooks and personal conceptual understandings when attempts are made to communicate meaning’, something which is particularly marked between neurodiverse and neurotypical people29

One potential solution to this disparity is acknowledging the well-established research demonstrating that people with ASD are better able to communicate with other neurodiverse individuals30, compared to their neurotypical Therecounterparts.isnodoubt that effective patient-doctor communication is essential to medical practice. Simultaneously, it is recognised that individuals with ASD have difficulty communicating with healthcare professionals, with 53% of those in the above study identifying communication with their physician as a barrier to accessing primary care8. This presents a serious challenge >>

“The first step to stopping autistic patients slipping through the cracks in the NHS, is identifying the barriers faced by neurodiverse individuals in accessing healthcare, particularly in the primary care setting, as this is the first port of call for preventative medicine.”

Due to the stigma placed upon autistic individuals, they are more likely to struggle with their mental health and are more likely to have lower self-worth24. “Doctors already are known to struggle with their mental health with suicide risk among doctors said to be between five and seven times that of the general population”25 This paired with the challenges of stigmatisation, may prove to be difficult to deal with, fortifying the need for correct support for our doctors.

No longer overlooked? Support available for autistic doctors

Autistic doctors for autistic patients: A potential solution for the ‘doubleempathy’ problem?

The above article by Dr Doherty highlights how important it is to consider each individual with autism and the support they require as an individual, instead of addressing a population featuring a diverse spectrum of neurodivergent traits with a blanket, one-size-fits-all approach.

• Autistic adults face difficulties in the unstructured, unpredictable or in some other way confusing interactions with colleagues or organisational hierarchy.

Conclusion The British Orthopaedic Association upholds the values of equality, diversity and acceptance. Equality without equity is an empty promise. Knowing all lives matter is equality, providing all with a proportional opportunity to flourish is equity. Equity demands acceptance of difference and a fairness to provide proportional resources to mitigate the differences. Our understanding of ASD is evolving rapidly. However, it is fair to comment that there is very little support available to help colleagues and patients with this condition. The facts and arguments presented in this article challenge some misconceptions and recommend a support structure within the NHS for ASD. We hope to start the conversation with the ideas suggested in this article. n References

Features to healthcare providers, particularly since, as we have already found out, autistic individuals have a greater incidence of co-morbid physical and mental health conditions compared to the general Therefore,population31onepotential solution, is acknowledging the role of neurodiverse doctors in the NHS and utilising them in consultations with autistic individuals wherever possible. The result would be improved doctor-patient rapport as, anecdotally, patient-doctor communication is enhanced between autistic doctors and autistic patients28. This has implications, not only for increased patient satisfaction, but also, since improved healthcare provider-patient communication has been associated with better adherence to treatment regimens32, significantly better health outcomes. Autistic doctors represent about 1% of the NHS medical workforce33, which mirrors the figure on the general adult population of 1.1%34, so where are all of these neurodiverse doctors hiding? Popular media would have us believe that autistic doctors prefer non-patient facing roles such as pathology and laboratory work, however this is in fact a myth. On the contrary, General Practice is the most represented specialty of doctors registered with the Autistic Doctors International28, perhaps due to the ability of autistic individuals to memorise vast quantities of information35 which would no doubt lend itself to a field of medicine such as primary care where any part of the body can be affected, and an even broader range of diseases and injuries can present. Moreover, GPs have significant patient contact time and are the first port of call for referrals and therefore effective doctor-patient communication in the primary care setting in has wide-reaching implications for long-term physical and mental health. In conclusion, autistic doctors have a significant role to play in improving the healthcare outcomes of this greatly overlooked population.

• Spectrum of autism is not one-dimensional, i.e. from low functioning to high functioning. This spectrum is multi-dimensional involving executive function, language development, motor skills, sensory perception and many other modalities.

• Masking is an emotionally exhausting phenomenon. It can lead to autistic burnout.

• Prevalence of ASD is higher in men. However, it is not uncommon in women. Women may be more adept in masking.

• Only 22% of autistic adults are employed according to the census data from 2021. This rate is the lowest among all the adults with disabilities36

• Speaking truth to power comes naturally to an autistic adult. They may come across as confrontational or arrogant.

• Autism is not a childhood problem. It is a lifelong developmental disability affecting how an individual communicates and interacts with the world. Most adults learn how to mask this apparent disability.

• Every autistic individual is unique. It’s said, “If you have met one autistic person, you have met one autistic person.”

Myths, misconceptions and real life problems

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

Administration or organisation priority tasks

T he RCSEd Trainee Committee consists of a group of surgical trainees from a diverse range of backgrounds working together to address contemporary matters affecting all surgeons in training. There has been a previous focus on bullying and undermining in surgery, flexible working, promoting surgery to undergraduates and a recent drive towards practical aspects of wellbeing for surgeons (see further reading section for recent webinars and the RCSEd website).

approximately ten percent of the population and just under two percent of doctors1-3. It is worth stressing that dyslexia can affect any trainee irrespective of their intellectual ability and may not be predictive of performance in other areas.

Dyslexia is a diverse condition which primarily impacts an individual’s ability to process information. It is common, affecting

Auditory and /or visual processing of language-based information Post graduate examination performance

Associated difficulties encountered with dyslexia Potential impact on surgical training

Phonological awareness Challenges with revision or understanding large bodies of text

Short-term and working memory Writing in time pressured environments

Organisational ability Perceived stigma from colleagues

Table 1: Adapted from Dyslexia Scotland, Scottish Government cross party group on dyslexia, Jan 2009.

– How it impacts training and what you can do to help

Jamie A Nicholson, Jennifer Dunn and Maria Boland on behalf of the RCSEd Trainee Committee

Foundation years doctors with dyslexia have reported challenges with communication, time management and anxiety5. Doctors who have a self-reported learning disability

FeaturesJamieNicholson is an ST8 Trauma and Orthopaedic trainee at the Royal Infirmary of Edinburgh. He previously undertook two years out of programme serving as a clinical teaching fellow and was responsible for the Undergraduate Trauma & Orthopaedic block for Edinburgh University whilst undertaking a clinical PhD in Clavicle fractures. For the past five years he has organised the Trauma & Orthopaedic teaching day for Scottish Core Surgical Trainees and was recently appointed as a Member of the Faculty of Surgical Trainers of RCSEd.

How can it impact surgical trainees?

What is dyslexia?

Dyslexia is now considered as a neurodiverse condition where differences in neurological function between individuals are considered a natural variation rather than a pathological entity. Indeed, those who have such a condition (including but not limited to autism, ADHD, and dyspraxia) often exhibit advantageous traits such as attention to detail, creativity, integrity, team workers, empathy, spatial awareness and practical skills4

Dyslexia and the surgical trainee

The condition can affect surgical trainees with their personal studies and day to day work environment as summarised in Table 1.

The impact of dyslexia on surgical training is poorly understood and has the potential to negatively affect training and a surgeon’s working life. It is often under diagnosed and associated with intense stigma. We hope this article highlights some essential knowledge in this area to assist and better understand colleagues with the condition.

Oral language skills and reading fluency Academic writing and presenting

Sequencing and directionality Accuracy of spelling and grammar for medical records Number skills

“Clearer diagnostic protocol so that candidates are not diagnosed after several failed attempts at higher professional “Neurodiversityexams.” assessment offered early on in surgical Dyslexiacareer.” is only one element of neurodiversity.”

Workplace based adjustments

“Mentors with dyslexia.”

Training related issues including education and exams “Understanding that the academic side takes longer to master. The coping strategies we develop in the work place are not transferable to the examination setting.”

“More training on the positive aspects of dyslexia – new innovation, lateral thinking, good spatial awareness.”

“More awareness of the condition amongst trainers.”

Breadth and complexity of issue “Dyslexia is extremely variable in its severity and the related disability, it is not binary.”

The RCSEd Trainee Committee recently undertook a survey to gather further information on the impact of dyslexia in surgery and invited all RCSEd members to take part (n=249 responses). There was a breadth of representation from all specialities with just over half of the responses coming from consultants. From the responders, 28% had been formally diagnosed with dyslexia but only two thirds had disclosed their diagnosis to a colleague. Overall, 41% of those with dyslexia felt it impacted their workload negatively and 53% felt there is inadequate workplace support for doctors with dyslexia. Interestingly approximately one third of surgeons were diagnosed at school, one third as undergraduates and the remainder as a Usingpostgraduate.thefreetext comments from the survey, a thematic analysis was carried out in order to identify core themes of the issues facing surgeons with dyslexia. This is summarised in table 2. >>

Core themes Quotes from survey

“The biggest issue in day to day practice is about admin “Isupport.”personally found having a work laptop very helpful, I could take it to a quiet place and sign letters with less distractions.”

Features

There has been a recognition of the lack of understanding of dyslexia with regards to the general stigma and disabling clinical environments which doctors work within7 Further work is needed to understand this complex issue.

Jennifer Dunn is an ST5 Trauma and Orthopaedic surgical trainee living with her husband and son in Dundee. She was diagnosed with dyslexia during surgical training and aims to increase awareness of this issue as part of her role as a Royal College of Surgeons of Edinburgh Trainees Committee member. She enjoys writing, paddle boarding and gaming.

Diagnosis and screening

“Dyslexia is variable depending on the individual affected, it is therefore necessary to facilitate a personalised coping strategy rather than a blanket policy.”

Table 2: Core themes of issues facing surgeons with dyslexia.

Maria Boland is a general surgical ST5 trainee in South East Scotland. Maria has always had a keen interest in teaching since medical school and has recently joined the Committee to support the work they do and also to work towards improving recruitment to surgery and making it a more attractive career to medical students. have a significantly lower pass rate in postgraduate exams, most notably MRCS Part A6. Interestingly this is not observed for the part B element. It is also a phenomenon that is observed in the written exit Fellowship exams, most likely due to the challenges around multiple choice questions which require rapid reading and assimilation of complex text in a stressful environment.

Issues around awareness, understanding and stigma “Increased awareness of dyslexia, campaign against negative connotations and stigma of intelligence of people with “Adyslexia.”goodunderstanding by seniors will help. The positive points we can bring to the team, not just the negative ones.”

“More information for trainers on what reasonable adjustments might be, and when they could be provided.”

Current views on dyslexia from RCSEd members

“We might need slightly extra time in clinics to cover the same volume of admin work.”

• Orthopodcast on dyslexia from the BOA mcqs.htmlorthopodcast-15-struggling-to-pass-www.boa.ac.uk/resources/orthopodcasts/

7. Locke R, Scallan S, Mann R, Alexander G. Clinicians with dyslexia: a systematic review of effects and strategies. Clin Teach. 2015;12(6):394-8.

3. Kinsella M, Waduud MA and Biddlestone J. Dyslexic doctors, an observation on current United Kingdom practice. MedEdPublish 2017,6:60.

• Self-assessment dyslexia tool For more information about dyslexia, the International Dyslexia Association website and their self-assessment tool can be found here: https://dyslexiaida.org/dyslexia-test

6. Ellis R, Cleland J, Scrimgeour D, A J Lee AJ, Brennan PA. The impact of disability on performance in a high-stakes postgraduate surgical examination: a retrospective cohort study. J R Soc Med. 2022;115(2):58-68.

• British Orthopaedic Trainees Association (BOTA) resource www.bota.org.uk/neurodiversity

• A patient, understanding approach to training to allow trainees the extra time and space to process suggestions without embarrassment, for example in theatre or trauma meetings.

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• Offer honest support and assistance to adapt aspects of the workplace for the individual where possible.

Resources available to help

• RCSEd wellbeing resources and recent webinars resources/webinars/wellbeing-weekdevelopment-resources/learning-www.rcsed.ac.uk/professional-support-

5. Newlands F, Shrewsbury D, Robson J. Foundation doctors and dyslexia: a qualitative study of their experiences and coping strategies. Postgrad Med J. 2015;91(1073):121-6.

2. GOV.UK [2017] ‘Statistics about dyslexia. Available at: userimpairments-user-profiles/simone-dyslexic-publications/understanding-disabilities-and-www.gov.uk/government/

Formal help • Self or TPD referral to local PerformanceSupport-Unit.

Day-to-day advice

• Access to work (Department of Work and Pensions) assessment can offer input on technological aids such as speech-totext software, organisational devices for clinical work and study.

• Use of dictation for clinics and theatre documentation for time efficiency.

• Vary teaching or feedback with diagrams, videos or other non-written communication.

4. Shaw SCK, Anderson JL. Doctors with dyslexia: a world of stigma, stonewalling and silence, still? MedEdPublish 2017;6(1):29.

• Foster and enable creativity.

• Extra time when appropriate for clinical work or assessments.

Aiding trainees and colleagues with dyslexia Being aware of the potential for undiagnosed dyslexia is important in trainees given a substantial portion will be detected in postgraduate environments. Unexpected failure of postgraduate exams, mismatch between written and verbal communication, challenges with spelling and time pressured information digestion are typical although not exclusive suggestions.

• Clear assignment of clinical tasks and avoid overloading trainees.

• Education psychologist assessment for formal diagnosis (the PSU can often offer financial support with this).

• Avoid information overload – short emails or correspondence, both in speech and written material, can be helpful.

• Employ use of mind mapping memory aids for teaching.

• Be aware dyslexia can manifest in many ways.

• Made by Dyslexia charity www.madebydyslexia.org n References 1. Dyslexia Scotland. Scottish Gov Cross Party Group on Dyslexia. January 2009. Available at: minutes.pdfdefault/files/page_content/09-01-27-CPG-www.dyslexiascotland.org.uk/sites/

EDINBURGH / UK 27-28-29 OCTOBER EICC - Edinburgh International Conference Centre The Exchange Edinburgh EH3 8EE Scotland European Foot & Ankle Society www.efas.net Contact: efasevents@mcocongres.com EFAS CONGRESS 2022

DATESAVETHE

shutterstock®:photoCrédit

Features

The old town is lined with cobbled streets and boasts a range of period architecture due to the wealth brought in through Hull being the largest whaling fleet in Britain in early 19th century.

It is the home of many artists including the poet Philip Larkin and Joseph Arthur Rank, founder of The Rank organisation, which owned five leading film studios and responsible for films such as Brief Encounter, Great Expectations and many of the Carry On series. And if culture doesn’t excite you, many may be surprised to learn that in 1856, Thomas James Smith opened a chemist’s shop in Hull, establishing his business by selling cod liver oil to hospitals. In 1896 the company was joined by his nephew, Horatio Nelson Smith, forming Smith and Nephew, the billion pound global medical devices business, us orthopaedic surgeons are well aware of today.

A pre-course day was offered to any of the participants that were less experienced in deformity correction, an offer I took up without thinking twice, as my only experience involved three months at the paediatric orthopaedic unit in Alder Hey. It was more than useful, as it allowed me to grasp basic understandings of limb reconstruction, devices used, osteotomy techniques, selecting the correct patient and how to manage them pre and post op. Practical saw bone workshops then allowed the participants to familiarise themselves with different kit available, including the Smith and Nephew TSF/Ilizarov and the Orthofix TL Hex/Truelok frame.

A s the winner of the ‘Best of the Best’ I was awarded a place at the Hull Deformity Correction course; a highly sought after fiveday course that runs annually. Delegates are from the UK but also many flew in from Europe and Africa. It is convened by Professor Hemant Sharma, who works at Hull Royal Infirmary bringing together specialist limb reconstruction surgeons from all over the UK and the world as fellow directors and faculty, both in person and virtually. Even as a Yorkshire lass, I hate to admit I was not the most excited by the location, being well aware of Hull’s reputation. However, I was pleasantly surprised to learn Hull had more to offer than the Humber Bridge, as eye catching as it is. Hull was also awarded the UK city of Fatima Rashid is a ST6 Mersey orthopaedic trainee. At the September 2021 BOA Congress held in Aberdeen, she represented the Mersey region and was awarded the Best of the Best certificate for her talk on “Coronavirus in HIP Fractures (CHIP) study - A case matched multicentre study of 1,633 patients.”

The course was held at The Hilton Hotel, with a decent discount offered for anyone who wanted to stay there, inclusive of breakfast. This perk certainly helped the short daily morning commute.

My experience of the Hull Deformity Correction course

Fatima Rashid

culture in 2017 and I could appreciate why.

For the saw bone workshops, a short demonstration was performed, before we were able to get our hands on the kit. With orthopaedic surgeons being likely kinaesthetic learners, the saw bone workshops were invaluable. We first used software provided to plan the case and then built our frames and watched our deformity correction come to life.

Time certainly flew by in these workshops. I definitely value the need for courses that have a heavy practical component.

No time was wasted in the cadaver lab, as we got straight into a series of ‘operations’ such as tibial osteotomy, achilles lengthening, peroneal release, that we performed on our cadaveric leg, in turn, within our small groups, guided by a faculty member. I particularly enjoyed the cadaveric session as it highlighted the ‘real life’ element of limb reconstruction, and to understand the importance in considering the soft Theretissues.were ample opportunities to complete work based assessments that were encouraged by the faculty. This was especially helpful when gaining PBAs for osteotomies as this procedure can sometimes be a challenge to attain whilst training. >> Features “Practical saw bone workshops allowed the participants to familiarise themselves with different kit available, including the Smith and Nephew TSF/Ilizarov and the Orthofix TL Hex/Truelok frame.”

We also had the opportunity to have a day out to Hull University, to the cadaver lab. It was a short ride on a coach, again reminiscent of school days. Naturally, I sat in the back row, bonding with fellow orthopaedic surgeons.

To aid us with the planning workshops we were all given a bag of ‘goodies’ that included coloured pencils, ruler, protractor, sharpener, eraser and a workbook. A member of the faculty then took us through step by step on how to plan a deformity correction. Each table also had a faculty member to help us, any time we reached out for the eraser. It felt like I was back at school in the most pleasant sense. There was a lot of care and attention taken to ensure we understood the concepts and were able to apply them correctly.

There were a number of very interesting talks, including one on war injuries, which I found fascinating. I have to admit by the end of the week, I was exhausted by all the excitement and learning and therefore my concentration did dwindle by the afternoon. Fortunately, it was recorded, and accessible at a later date.

Although, I was fortunate to win a place on this course, after experiencing one of the most organised, welcoming courses I have attended, I would, in fact, have happily paid for it. n

“I believe attendingorthopaediceverytraineewouldbenefitfromthiscourseregardlessoftheirspecialistinterest.”

The last day was a combined day with SICOT with a live telecast, titled, current concepts in reconstruction.limb

The course dinner, took place at Tapasya, located at Hull’s marina. It was a lovely opportunity to socialise with both delegates and faculty, as well as taking in the view of the marina. I also particularly enjoyed the Indian set menu and could not have asked to enjoy it in better company.

I believe every orthopaedic trainee would benefit from attending this course regardless of their specialist interest. In particular the beauty of this course was; not assuming detailed prior knowledge, emphasis on the practical component, small groups with high ratio of faculty to participants and the creation of a friendly and safe environment that allowed ample opportunities for questions and discussions. This allowed all participants at all levels to develop their understanding and skills. This was, of course, all down to an enthusiastic, friendly, passionate, knowledgeable yet humble faculty who all gave up their precious time to teach their specialist subject of deformity correction.

I also had the opportunity to visit the oldest pub in Hull ‘Ye Old Black Boy’, to experience the history of the old town.

RCS England, interactive, importance of supervisory relationship skills that underpin key stages of supervision journey,

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Joanna Maggs is a Trauma and Orthopaedic Surgeon in Torbay, Devon. She leads the Culture and Diversity Committee of the British Hip Society, and set up the BHS mentorship programme along with Sarah Eastwood, Dominic Meek and Samantha Tross. Figure 1: Process undertaken in the BHS mentorship programme.

Sarah Eastwood, Joanna Maggs, Samantha Tross, Dominic RM Meek and Vikas Khanduja

The British Hip Society mentorship programme: Supporting the next generation

There is much in the recent literature to highlight the importance of mentoring in the development of orthopaedic surgeons5, and in addressing the under-representation of some groups in our profession, particularly the striking lack of women in orthopaedic surgery6

A mentor can be defined as ‘an experienced and trusted advisor’. The term originates from the Greek mythology and the guiding role played to Telemachus by Odysseus’ friend Mentor1. T he value of mentorship has been recognised in most professions, from politics to international sports, and the GMC lists “willingness to take part in mentoring” as one of the duties of a doctor in the workplace2 Despite this, most mentoring relationships are informal, occurring by chance rather than through a designated process. Fewer than half of surgical trainees report having a surgical mentor3, and those that do tend to describe Sarah Eastwood is Consultant T&O Surgeon North Cumbria Integrated Care NHS FT but moving onto Newcastle Upon Tyne Hospitals NHS Trust in September. She has helped set up the programme with other members of the team. their educational or clinical supervisor as filling this role, despite the assertion by some authors that mentorship should be separate from formal assessment processes4

Features

• Step 1 – Call for mentors: We launched the BHS Mentorship programme in early 2021. We invited BHS members and personal contacts to become mentors.

Samantha Tross is Consultant Orthopaedic Hip and Knee Surgeon at London North West University Healthcare NHS Trust. She was appointed to Ealing Hospital in 2005. She has spent her career working with various schools and charities to increase the diversity pipeline.

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| September

We were fortunate that our early research led us to Emma Causer, co-founder of Plan B mentoring (www.planbmentoring.com). Plan B is an awardwinning scheme, launched in 2017 by three women to help the careers of aspiring females in the field of hospitality, through mentorship from those in executive and management positions; roles traditionally held by men. They provide a framework for mentoring and arrange professional connections for mentees. Plan B has been immensely successful over the first few years and now encompasses the hospitality, facilities management and digital sectors of industry with over 200 mentors. Emma was keen to share her passion with us and help us to empower women and those from other under-represented groups in our profession for which we are hugely grateful. The advice Emma provided about having mentor and mentee profiles and her description of Plan B speed-mentoring sessions have both been pivotal in shaping our mentorship scheme.

• Step 6 – Feedback: We have sought feedback through setting up the scheme and are in the process of formalising how and when we gather this. Following the mentor-matching sessions, comments from mentees have included “incredibly helpful and reassuring exercise”, “very worthwhile discussions”, and “mentors have a lot to offer”.

• Step 5 – Mentor-mentee pairing: We started running virtual mentor-matching sessions on Zoom from September 2021. Mentors and mentees are paired together in breakout rooms where they can talk for 12-15 minutes at a time. Over the evening, mentees can meet up to four potential mentors. At the end of the evening both mentors and mentees are asked to indicate who they would like to be in a mentorship relationship with and, with mutual consent, pairings are established. Mentorship pairings have also been made by a direct request from a potential mentee to be introduced to a mentor.

However, there is a relative paucity of literature which describes the mentorship schemes that exist and how they function. This article highlights the steps that have been taken over the past two years to develop a mentorship scheme within the British Hip Society (BHS) and reflects on the achievements thus far. The process taken is demonstrated in Figure 1 with those highlighted in orange being recurring steps.

The development of the mentorship scheme

• Step 2 – Training mentors: Early engagement was very positive and by spring 2021 we were ready to start providing mentorship training. For this we engaged the services of Karen Picking, a leadership development consultant with a vast experience of mentoring and coaching who has previously worked with the BOA. We ran two interactive two-hour Zoom workshops covering key mentoring and coaching skills, such as active listening and skilful questioning. Mentors were introduced to the Egan Skilled helper model as a framework for conducting sessions with mentees. The workshops received positive feedback from those who attended. All attendees were provided with a certificate for purposes of appraisal.

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• Step 4 – Inviting mentees: We started to invite applications from mentees in summer 2021. We advertised through BOTA, BODS, BHS, social media and word of mouth from our mentors. We asked potential mentees to submit a profile statement, similar to that of our mentors, particularly focussing on what they hoped to achieve through a mentoring relationship. Again, mentees can submit this information using a link on the website.

JTO

• Step 7 – Ongoing support: We have set up WhatsApp group where mentors can share ideas or discuss challenges (while always respecting mentee confidentiality) and we are currently developing a resources section on the BHS mentorship website to which mentors and mentees will be able to contribute. >> | Volume 10 03 2022

Background In September 2020, the BHS surveyed its members on their experience of mentorship. A small proportion of the membership responded with most reporting mentorship to be valuable and having a positive impact on their career development. On the basis of this report and as part of a wider ambition to increase diversity within the society, it was decided to establish the British Hip Society mentorship programme. The aim was to develop a scheme that would support personal as well as professional development. In particular, we wanted to provide opportunities for surgeons from minority groups to find mentors and also to help surgeons facing challenging situations or experiences within their careers.

• Step 3 – Website development: Mentors were asked to complete a profile of themselves for which we provided a template. We invited them to include information with regards to their gender, grade and geographical location but also the qualities and experience that they had which may be of interest to a mentee; both professional and personal experiences. Together with a picture, these profiles were uploaded to a dedicated website page. As more mentors came on board, the design of the website was changed to increase appeal. Potential mentors can now submit their profile directly from a link on the website: https://britishhipsociety.com/bhs-mentors

Vikas Khanduja is a Consultant Trauma and Orthopaedic Surgeon in Addenbrookes’s - Cambridge University Hospital NHS Foundation Trust. He is the President of the British Hip Society and Trustee of NAHR, and has been involved in the development of the mentorship programme and is keen on widening its footprint and securing the future of the programme.

Dominic Meek is a Trauma and Orthopaedic Surgeon in Glasgow, Scotland. He is President Elect of the British Hip Society, and help set up the BHS mentorship programme along with Sarah Eastwood, Joanna Maggs and Samantha Tross.

Discussion As of early June 2022, we have more than 40 mentors and have received applications from 34 potential mentees. The geographical distribution of mentors is demonstrated in Figure 2 which is the map displayed on our webpage enabling people to search for a mentor by region, should they wish. Mentee applications have been received from people across the spectrum of grades as demonstrated in Figure 3. Whilst half of applications have been received from people in core training or higher specialty training, we are pleased that we appeal to a wider spectrum including those who currently work outside the UK.

Figure 3: Grade of mentee applicants.

Through specific, targeted invitations to female hip surgeons in the UK, 32.5% of our current mentors are female. Similarly, 35.3% of mentee

Conclusion The British Hip Society has had some early success with the development of a mentorship programme. To the best of our knowledge this is the first formal programme on mentoring within trauma and orthopaedics in the UK. In the future we look forward to collaborating with BOA and other specialist societies to support wider access to mentorship within T&O. n

References

Features

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

Figure 4: Gender of mentors and mentee applicants. applicants are female (Figure 4). We hope that, by portraying positive role models through mentors, we can start to break down some of the perceived barriers that may exist for women considering a career in orthopaedics6. It will take time for our efforts to be reflected in the composition of the UK orthopaedic workforce, but we hope that with programmes such as ours, gender parity may be achieved in less than the 217 years predicted in one recent study10

Figure 2: Geographical distribution of mentors.

Gender disparity in T&O surgery has been widely documented. In the UK, only 7% of consultants in the specialty are female8, whilst globally this varies from 0 to 26%9 Results from the BHS Membership Survey in 2021 demonstrated that 5% of members who responded identified as female.

One recent study highlighted the lack of exposure to trauma and orthopaedics during undergraduate study in UK medical schools, with a mean of 18 days spent in the specialty (range 3 to 60 days)7. We have been encouraged by the applications from seven medical students (20.6%), five of whom are female. We hope that our mentorship scheme, combined with other initiatives such as providing free places at the annual scientific meeting for medical students, will encourage a more diverse workforce of the future.

Supporting surgical education The world’s most detailed and accurate 3D reconstruction of human anatomy Visit primalpictures.com to learn more about our catalogue of interactive learning tools, created from real body scans and imaging data – bringing the complexity of the musculoskeletal system to life. Our Tissue Product Specialists are available for enquiries at BOA, stand 32 Contact us, or visit our website to see the full product range. Call 0845 607 6820 or visit www.nhsbt.nhs.uk/tissue-and-eye-services. NHS Blood and Transplant Tissue and Eye Service are the UK’s major provider of human tissue for transplant. We can supply demineralised bone matrix, femoral heads, processed bone, meniscus, tendons and many more allografts. Human tissue products you can trust 2223 0286 Journal Orthopaedic advert.indd 1 21/08/2022 22:21:23 Abstracts Open: September 5th 2022 Abstracts Close: December 5th 2022 BLRS 2023 The Titanic, Belfast theSavedate! 23rd–March24th2023 Back to the Future in Limb Reconstruct ion This year’s theme: www.blrsmeeting.com

Joshua Lorimer, Mabvuto Chawinga, Alberto Gregori, Trish O’Connor, Steve Mannion and Ashtin Doorgakant

Mabvuto Chawinga is Lead Orthopaedic Clinical Officer, Malawi.

Alberto Gregori is Feet First Surgeon, Glasgow.

Joshua Lorimer is FY2 doctor at the Warrington and Halton Teaching Hospitals NHS Foundation Trust.

This article focuses on the ‘Ambition in Practice’ project for

*This article focuses on the ‘Ambition in Practice’ project for the 2021 BOA Future Leaders Programme.

For example, who identifies and deals with the complications and how are outcomes measured? Follow-up constitutes an important part of surgical treatment1,2. This is particularly pertinent to the nature of aid work, where risks of complications such as infection can be higher3,4. Is the ethos of ’first do no harm’ truly possible when there is no follow-up in place to address complications? During the COVID-19 pandemic the use of telemedicine expanded across the globe5-8 It has been shown to reduce the burden of face-to-face follow-up4,6.9. The British Orthopaedic Association (BOA) recommends a remote follow-up format and for it to be patient initiated where possible10. With the phenomenal rate of expansion of mobile phone usage across the continent, Sub-Saharan countries are well placed to leapfrog earlier models of follow-up to those incorporating a remote virtual element. It is estimated that mobile connections in that region will increase to 1.05 billion by 202511, yet telemedicine

D elivering orthopaedic surgical work in low- and middle-income countries (LMICs) on short voluntary visits raises some important ethical questions.

Figure 1: Feet First surgeons on 2020 trip - Mabvuto Chawinga, Steve Mannion, Alberto Gregori and Ashtin Doorgakant.

International A remote virtual follow-up strategy for outreach surgery – developing the Malawi model

Our work is done with the support of local orthopaedic clinical officers (OCOs) who organise the visits and follow the patients up once visiting surgeons have left. Formal consent is routinely obtained for surgery and for post-operative data collection and sharing. Minor complications are usually dealt with by the OCOs, but complex complications may need to be escalated to central hospitals. This can be costly and time consuming, as it can involve significant travel, often at the patient’s own cost.

Using digital technology for follow-up

Ashtin Doorgakant is Feet First Surgeon, Warrington and Halton Teaching Hospitals

A face-to-face review after eight months by a subsequent team found that the fracture had finally healed and the patient was mobilising well. Revision surgery was not required and she remains under follow-up.2: Different theatre standards in different district hospitals.

International Trish O’Connor is Feet First Emergency Medicine Consultant, Glasgow.

Steve Mannion is Feet First Surgeon, Royal Preston Hospital.

The need to test a remote virtual follow-up model for visiting surgeons in LMICs is more pressing than ever now and the Feet First programme offers a perfect opportunity for this. Who are we?

NHS Foundation Trust. implementation in Malawi and other African nations has been slow and mostly limited to educational and research purposes so far4,5,12

Feet First aims to provide up to four in-country visits per year, with the expectation that some complications could be dealt with by the next visiting team. However, these follow-up visits can be unpredictable and there is no guarantee that a visiting team will be able to visit a different unit where a problem needs addressing. As such, it is not possible to deliver a robust in-person follow-up service within the current set up. Our efforts therefore have focussed on mitigation and empowering local clinicians to manage postoperative issues in the safest possible way. We believe that a ‘live’ communication channel that allows visual as well as text-based information sharing would be the minimum standard to allow orthopaedic decisions to be made remotely.

A virtual follow-up project was conceived as part of senior author’s improvement project for the BOA Future Leaders programme. It was designed to facilitate a follow-up schedule for selected patients identified among the surgical caseload from a Feet First visit, as well as offering an open channel for raising any concerns among all patients treated during that visit. Local follow-up is instructed clearly via written post-operative instructions and relevant information collected. Clinical information relevant to the lead surgeon, as previously agreed, would then be sent via their smartphones by the OCO using an encrypted application (WhatsApp®) for review in the UK. This would follow a drawn-up schedule for the selected patients but could be done ad-hoc for an issue that needed a quick decision. In February 2020, this model was piloted at two sites visited by the authors. The OCOs followed up patients at two and six weeks post-operatively and ad hoc should any problem arise. For each timescale, the OCOs reviewed the patients over the course of a few days at a time that suited both. The collected information was then compiled and reviewed at an agreed time via WhatsApp. Clinical information sent included a minimum of a clinical evaluation summary and a wound check. This was augmented with either photographs, videos and/or pictures of radiographs as required. This pilot project yielded invaluable data but could not be completed due to COVID restrictions coming into place in Malawi. It provided proof of concept and reassured us that the quality of the data being sent via the app was sufficient to inform clinical decisions.

Feet First Worldwide (a registered charity) has provided Orthopaedic Surgical Camps in Northern Malawi since 2004. On each Feet First visit, surgical teams typically visit two district hospitals in northern Malawi with a week spent at each.

A repeat larger pilot of the virtual follow-up was planned for February 2021. Due to the on-going COVID pandemic opportunities to travel did not appear until July 2021 when co-authors AG and TC travelled to Malawi. The operating set up and schedule was similar to the one in 2020 and the operating list was reviewed remotely by AD to identify suitable patients for follow-up. A similar follow-up schedule was agreed for both sites. Despite being limited by the proxy nature of the repeat project, a wealth of outcome data was obtained to monitor the effectiveness of interventions carried out. This reinforced the feasibility of the virtual follow-up approach. Potential complications were identified early and dealt with appropriately. For example, at five months post-op, a 72-year-old female patient who had been treated for nonunion of a midshaft femur fracture with IM nailing, presented with complications. She had persistent non-union and a proximally prominent nail causing pain. The radiographs and photos were virtually reviewed and arrangements for further surgery were made.

>> Figure

It is well known that follow-up rates at the best of times can be very low in African district hospitals post-surgery15,16. Congdon et al. proposed a system where cataract surgery patients have an early post-operative outcome assessment before they return to their villages, and assume that those who don’t present at a later follow-up (~50%) are doing well if their early post-operative outcome was good15. It is not immediately obvious how this can be extrapolated to orthopaedic surgery however, where problems such as non-union, infection and malunion can present much later and bear little correlation with early post-operative impressions17. Our model provides a more reliable way of measuring the impact of outreach work carried out by visiting surgeons.

The future Increasing capability of smartphone-based telemedicine presents the opportunity for surgeons operating in LMICs to follow-up their patients, evaluate their outcomes and manage their complications. More work needs to be done to evaluate the full effectiveness of this follow-up approach. However, this project has yielded promising results. It demonstrates the viability of local follow-up utilising smart phone technology to facilitate virtual specialist input through local OCOs. n References References can be found online at www.boa.ac.uk/publications/JTO

Telephone consultations have become increasingly popular as a direct result of the COVID pandemic as a way to review patients without exposing them nor the reviewing clinician to risks of contracting the virus7,8,14 Studies which have looked at the efficacy of this approach have largely concluded that it is more appropriate in certain circumstances than in others6,8. Therefore, case selection is critical.

Some of the changes that we envisage in the future include having an operating surgeon-led follow-up programme and further consolidating the vital links we have with the locally based OCOs. Some financial recompense scheme or incentive may be appropriate both for the OCOs and the patients to maximise follow-up data. Government assistance would be ideal for this but ultimately, may also need to be factored in as an additional cost in the surgical trip budget.

The role of telemedicine in international aid work has already been well described4,12. Its main purpose however seems centred around education and research collaborations. Its use in remote follow-up of orthopaedic surgical cases in LMICs, to our knowledge has not been formally documented before.

Challenges of virtual follow-up Virtual follow-up already exists in many forms8

It is still at an early stage of development and we believe that some changes are necessary for future programmes if we are to further enhance the quality and completeness of follow-up data.

Our project did not prove that virtual followup could be achieved reliably from a surgical camp in a LMIC. The capture rate was low and a lot of the information which were thought a priority to be essential for decision making was not provided. However, there are many reasons we could identify for this. The main one was that this follow-up was done by proxy. The fact that the surgeon running the follow-up hadn’t done the operations and interacted on a personal level with the local OCOs certainly diminished the quantity and quality of information received. Secondly, variability between different units was noted in both our pilot and our most recent project.

Out of the two hospitals on each visit, one was more ‘engaged’ than the other. Thirdly, internet costs, quality of devices used and lack of charging points in the workplace are also likely to have been limiting factors. Finally, we cannot ignore the disruptions caused by the ongoing COVID pandemic. It is likely to have resulted in several patients defaulting their follow-up visit.

International

Despite these limitations, our project did demonstrate the feasibility of post-surgical virtual remote follow-up in a resource poor setting. This approach could provide a solution to the ethical dilemma of operating without specialist in-person follow-up. Complications can be detected, and outcomes measured.

The role of smartphone and tablets in surgical follow-up has been evolving for many years13

This allows specialist input into complication management and may lead to change of practice where outcomes are poor. It is also of great educational value to the local OCO and beneficial to their career progression.

More Iinformation: S H A 2 0 2 2 A n n u a l S c i e n t i f i c M e e t i n g G l a s g o w , U K 1 3 1 5 O c t o b e r 2 0 2 2 ishasoc.net J o i n u s t o l e a r n a b o u t t h e l a t e s t a n d b e s t s c i e n c e i n h i p p r e s e r v a t i o n s u r g e r y a n d r e h a b i l i t a t i o n S t a n d a r d R e g i s t r a t i o n d e a d l i n e : 2 3 S e p t 2 0 2 2 P r o g r a m m e C h a i r M r V i k a s K h a n d u j a M A ( C a n t a b ) , F R C S ( O r t h ) , P h D L o c a l H o s t C h a i r M r S a n j e e v P a t i l M B B S , D N B ( T r & O r t h ) , M S ( O r t h ) , F R C S , F R C S ( T r & O r t h ) I S H A P r e s i d e n t 2 0 2 1 2 2 D r A l l s t o n J S t u b b s M D S p e c i a l r a t e s a v a i l a b l e f o r : I S H A M e m b e r s | R e s i d e n t s , F e l l o w s & S t u d e n t s | P h y s i o t h e r a p i s t s & A l l i e d H e a l t h P r o f e s s i o n a l s F r e e p a p e r p r e s e n t a t i o n s i n a v a r i e t y o f f o r m a t s I n s t r u c t i o n a l c o u r s e l e c t u r e s S i m u l a t o r s k i l l s t r a i n i n g L i v e s u r g e r i e s C a d a v e r i c s k i l l s w o r k s h o p s E x p e r t d i s c u s s i o n s a n d d e b a t e s U l t r a s o u n d w o r k s h o p s K e y n o t e l e c t u r e s D e d i c a t e d P h y s i o t h e r a p y P r o g r a m m e P r o g r a m m e d e t a i l s n o w a n n o u n c e d s e s s i o n s w i l l i n c l u d e : C o m b i n e d r e g i s t r a t i o n & I S H A m e m b e r s h i p p a c k a g e a v a i l a b l e

Medico-legal

Should Montgomery be altering the way we do things? – Part 2

Simon Gregg-Smith

Although the case was successfully defended, the initial surgeon was very upset by the suggestion that he was generally incompetent.

there was nothing to suggest that the operation had been carried out badly. However, in the Letter of Claim, amongst various allegations about the first operation, it was claimed that the first surgeon had not discussed this risk with the patient and there was no documentation that he had done so. Given that the radial nerve injury did not happen in the first operation, this was irrelevant, as that particular risk had not happened then. But it was used in the Letter of Claim to create an impression that the original surgeon was cavalier and careless and to bolster the idea that failure of the fracture to heal was his fault.

I was recently involved in a case of humeral shaft non-union after plating. It was revised by another surgeon and the patient developed a radial nerve palsy, which did not recover well. The surgeon carrying out the revision operation clearly described the risk of this happening, and Simon Gregg-Smith has been a Consultant in Bath for 25 years now specialising in shoulder problems. During the last 10 years, he has prepared an increasing number of clinical negligence reports. He has just finished a term on the BOA Medico-legal Committee.

In the last edition of JTO I described the evolution of case law related to consent, from the archaic ‘doctor knows best’ approach of Bolam in the 1950s1, through to the fully autonomous patient in Montgomery in 20152.

The original fracture was well above the radial nerve and he had felt that his plate would not go near it. The Expert writing the report for the Claimant had felt that the radial nerve was at risk in the first operation and that this should have been considered. In reality his plate stopped just above the level of the nerve and, when a longer plate was put in, it was necessary to dissect it out of the scar tissue and it was stretched and damaged in the more extended approach required for the revision.

Legal consideration of the standard of consent The last point is easiest to deal with. Clearly if we have failed to warn the patient about a risk and nothing goes wrong, the patient has nothing for which to sue. This is not quite the same as saying that it might not cause us a problem.

Failure to give sufficient appropriate advice regarding the benefits and risks of the proposed treatment, as considered negligent by a responsible body of clinicians in that field – really just reiterates the well-understood concepts of Bolam and Bolitho 3 . The Medical Expert can advise on the potential benefits and risks of the treatment that ought to have been >> I pointed out how in orthopaedic surgery the concept of discussing and tailoring treatment options with the individual patient, while taking into account their potential risks, is a well-worn path down the decades. I also began to consider the importance of record keeping to avoid negligence claims based on allegations of deficiencies in the consent process. I introduced a four prong test used by one of my instructing solicitors when giving practical consideration to the standard of the consent process. This included failure to give sufficient appropriate advice regarding the benefits and risks of the proposed treatment; evidence in the clinical record that such advice was not given; had the appropriate risk-benefit advice been given the patient would have elected not to undergo the procedure / would have made a different decision; and the risk has materialised about which the patient should have been warned.

Medico-legal discussed with the Claimant. The Expert can comment on whether they feel that the treating doctor did engage in a reasonable discussion of the benefits and risks, although it is worth noting that in consent matters it is the court and Montgomery that are the final arbiters of whether the Claimant’s autonomous right to decide treatment has been upheld. It should also be mentioned that if we are carrying out a new, experimental or, not particularly well described operation or treatment, this needs to be disclosed and fully discussed with the patient when obtaining consent. Whilst I have never personally been involved in a case where consent of this type has been an issue, it is now relevant for cases such as the current litigation for metal on metal hip replacement. Claimants are suggesting that, despite the fact that many surgeons were carrying out this operation, they were not told of the uncertainties of the mid to long term outcomes and that the surgeons should have made them aware of this.

Montgomery makes it clear that the patient should be given reasonable time and space to consider their decision to treatment. This is almost by definition precluded if the consent process takes place on the morning of surgery. The case of Hassell v Hillingdon Hospitals clearly illustrates the problems of consent on the day of surgery4. When seen in clinic pre-operatively the risk of paralysis in anterior cervical discectomy and fusion was not mentioned. On the day of surgery the patient signed a consent form which described the risk of ‘cord injury’. After an apparently uneventful operation she woke up tetraplegic. The court found there was no evidence that the surgery had been carried out negligently; but also found that she had been given new information on the day of surgery, this did not allow her reasonable time and space to make such an important decision, and so negligent consent caused the complication.

The second point – evidence in the clinical record that such advice was not given – is an evidential matter. It is necessary to be able to demonstrate to the satisfaction of a judge, that this sort of discussion has taken place. There is undoubtedly a tendency in orthopaedic surgery to rely on the consent form to demonstrate this. It is quite clear from the records that I examine that this critical process is often done on the day of surgery and often by a more junior member of the surgical team. Frequently there is a short and barely legible set of words such as “Infection, bleeding, nerve, failure, DVT”. Although this list does encapsulate the concerns that we as surgeons have, it is hardly comprehensive, patient and operation specific, nor a demonstration that a proper discussion has taken place. Even when the consent form does contain a complication which has then happened after the operation, claimants have successfully argued that signing the form on the day of the surgery was not giving them a chance to genuinely consider the alternatives.

The third point – had the appropriate riskbenefit advice been given the patient would have elected not to undergo the procedure / would have made a different decision. This is a subjective test and depends on the particular circumstances of each patient, emphasising the critical need to consider specifically the individual circumstances of the patient, and consider what they would feel is important. This point is also well illustrated by Jones above.

The case of Jones v Royal Devon and Exeter NHS Foundation Trust illustrates that even if all the risks have been discussed properly in advance, an unexpected change from the perspective of the patient on the day of surgery can invalidate the consent 5 Mrs Jones was due to undergo a lumbar decompression. She had built up rapport with her surgeon in the outpatient setting. Consent was obtained in advance, including discussing the risk of dural tear. On the day of surgery the patient was informed that her surgery would be performed by the less experienced fellow rather than the consultant. During surgery she sustained a dural tear. Expert evidence was adduced that the complication rate of an experienced consultant is lower than that of a less experienced fellow. The patient argued that her expectation was that the consultant would be performing her surgery, and had she known in advance that her surgery would be done by the less experienced fellow she would have declined surgery on that occasion. The hospital argued that, not only did the consent form specifically state that there was no guarantee ‘that a particular person will perform the operation’ but also the surgeon who did do the operation was appropriately trained and qualified and that the complication could have occurred even if it was done by the consultant. The court took the view that the patient had a right to make an informed choice as to who would operate on her, she had not been given reasonable time and space to consider the potential change of surgeon on the day, and negligent consent caused the recognised complication.

When assessing the consent process I always look at the pre-operative correspondence and the operation note. In my view the quality of operation notes has improved significantly over the last twenty years. I used to regularly see operation notes that said “Routine rotator cuff repair. Post-operative instructions: Home in sling, routine physiotherapy and follow-up.” I suspect this brevity was driven by the desire to do things quickly and a number of things have helped improve this. Standardised forms for arthroscopic surgery, typing of operating notes, and electronic systems with pre-loaded templates can all assist with documenting findings, the procedure, implants, and post-operative instructions. Such improvements have in part been driven by the litigation sameUnfortunately,process.thecannotbesaid for the letters written in outpatients and the critical letter written when the patient is listed for surgery. It is absolutely clear that this is the point where it is necessary to demonstrate the appropriate discussions with the patient and the decision-making process. I often see letters which say “I reviewed Mr X today with his scan. We have discussed the problem and I have placed his name on the waiting list for this operation. I have described the risks”. This sort of letter is of little help when the litigation process starts. The surgeon will maintain that it is always their custom and practice to describe all the options and to describe all the risks and benefits. The patient (now the claimant and no longer enjoying a warm relationship with the surgeon) will say they were not really given any choice and were not comprehensively warned about the risks. Judges often take the view that the patient is more likely to accurately remember what was going on as, for them, it was a critical and unusual event, whereas for the surgeon it was an ordinary, everyday, oft-repeated event. The surgeon’s insistence that of course they always discuss all the benefits and risks may cut little ice.

The importance of good documentation – both clinic notes and operation note

“Like most surgeons I have always believed that I have carefully listened to the patient, offered sound advice and been good at supporting patients to make a decision, ensuring that they understand the risks and the potential benefits. However, I now write my clinic letters in a very different manner.”

References 1. Bolam v Friern Hospital Management Committee [1957] 2 All ER 118.

All of this has led me to gradually alter the way I do things. Like most surgeons I have always believed that I have carefully listened to the patient, offered sound advice and been good at supporting patients to make a decision, ensuring that they understand the risks and the potential benefits. However, I now write my clinic letters in a very different manner.

I hope that consideration of the case law related to consent and the description of the practical manner in which lawyers now view the medical record may help in thinking about the quality of documentation of our discussions and decision making, and in demonstrating that we have communicated this effectively with the patients. I am convinced that the best way to do this is to write a clear letter, copied to the patient, demonstrating our compliance with the GMC guidance on Good Medical Practice and with the Montgomery judgment, at the time we make the decision with the patient to embark on surgery. n

2. Montgomery v Lanarkshire Health Board (2015) UKSC 11.

4. Hassell v Hillingdon Hospitals NHS Foundation Trust [2018] EWHC 164 (QB).

3. Bolitho v City and Hackney Health Authority (1997) 4 All ER 771.

How has my practice changed?

A major plan for the NHS in 2000 included a recommendation that patients should receive copies of all their clinical letters. My hospital was keen to do this and asked the consultants to follow this guidance. As a result I started to change the way that I wrote letters, recognising that the patient was going to be reading them, as well as the GP. I now primarily write my letter for the benefit of the patient, rather than the GP, although I still address the letter to the GP. I find it much easier to write in the third person when discussing the medical issues! I was also aware that some research had suggested that patients only remember 15% of what they are told in any consultation. These two factors motivated me to improve the quality of my communication with the patients and help them to understand, and remember, what I had said to them rather better. My motivation was not to try to reduce the chances of me being sued, rather to try to make the patients better informed and happier with me. I have an opportunity genuinely to lay out not only the key points in the history, examination and diagnosis, but also what the patient does and what they like to do. I can describe the options that we have discussed, and outline the nature of the operation, the post-operative rehabilitation and the risks as well as the benefits.

This can result in some quite long letters, but as an orthopaedic surgeon I do have access to a dictaphone and a secretary. For my regular operations I have pre-set blocks of text which include the standard rehabilitation pathway and a description of the risks. I can add another paragraph modifying this, if there is something unusual about the patient, making any of the risks or complications more likely. It is easy to demonstrate that I have considered the patient’s individual circumstances, simply by incorporating those elements from the standard medical student clerking about occupation, social activities and past medical history. My experience has been that when I see patients nearer to the time of their operation, they generally remember what I have said to them. Not only do they get a written reminder shortly after the consultation (which is known to be a very strong way of getting people to remember things), but also they get an opportunity to re-read it whenever they want. Often patients tell me that they have had another look at the letter just before they come in. Since Montgomery I have really sharpened up the way that I write these letters to make it very clear that I have discussed the alternatives to surgery, alternative operations if appropriate, and that I have put it in the context of what the patient wants.

Summary I know that what I am describing is something that many orthopaedic surgeons do. However, the surgeons whose notes appear in front of me, when I’m dealing with a negligence claim, rarely seem to be one of those surgeons!

5. Jones v Royal Devon and Exeter NHS Foundation Trust (2015) Unreported Exeter County Court 22 September.

1. A digital health platform, centred on patients: data should be aggregated around patients, not departments, units, or locations. The creation of life-long, patient-centred electronic health records based on openEHR.

Data-driven healthcare platforms to support integrated multidisciplinary team approach to health and care has been proposed by the Harvard Business Review article The Strategy That Will Fix Healthcare1. There are six key areas in this strategy for modernising a data driven digital health platform: Kanthan Theivendran is a Consultant Orthopaedic Surgeon for Sandwell & West Birmingham Hospitals NHS Trust. He is an Honorary Professor at the School of Engineering and Applied Science at Aston University and sits on the Research & Development Committee for the Hospital.

What is interoperability

Subspecialty Healthcare data and orthopaedics: interoperability and standards

2. Common data definitions: terminology related to all diagnoses, lab values, treatments, and other aspects of care should be standardised so that the data can be understood, exchanged, and queried across the system. Today, openEHR 2 specifications offer the most comprehensive semantic framework available in digital health, combining formal clinical modelling, terminology, and a service-based infrastructure. Furthermore, a worldwide network of openEHR clinicians are actively contributing to it, and building additional executable clinical content. A data-driven health ecosystems fuelled by openEHR, which enables everyone in the ecosystem to easily share and immediately use all of the clinical content created by the local or global community, such as decision support, guidelines, forms, patient pathways, assessments, and more.

Kanthan Theivendran

What are the current challenges of healthcare data I

’m sure most of us have been frustrated when we are unable to view our local or neighbouring hospital’s information on a patient that has turned up to our local hospital. We often wonder why patients’ healthcare data is not viewable wherever we are in the healthcare setting. The request for notes despite them being in a digital format (EPR/EHR) takes a long time to obtain and often we are flying blind and as a result the patient journey is delayed and sub-optimal. The healthcare data landscape is fragmented and siloed within commercial electronic patient records (EPR) only easily viewable in full within a particular organisation that has procured it. Outside healthcare organisations, including other hospitals and primary care, cannot easily access or view or even update patient information due to the lack of interoperability of electronic health records (EHR).

3. Encompassing all patient data: data should be stored in a single place so that everyone participating in a patient’s care has a comprehensive view. Using openEHR provides a structured and vendor-neutral clinical data repository (CDR) which is compliant with openEHR specifications. Therefore, data-points are not fragmented or multiplied, and all health data is stored independently of applications. This also enables the creation of a best-ofbreed ecosystem made up of connected applications which can be developed by various vendors. Whenever you change an application, you no longer have to migrate the data, and each new solution that you add to the ecosystem can immediately leverage and rely on all the other data stored in the common CDR.

The Oxford dictionaries definition of interoperability is the ability of computer systems or software to exchange and make use of information. A more comprehensive definition for the healthcare setting is the ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organisational, regional and national boundaries, to provide timely and seamless portability of information and optimise the health of individuals and populations globally.

What is the solution?

5. Templates and expert systems for each medical condition: they make it easier and more efficient for care teams to enter and find data, execute procedures, use standard order sets, and measure outcomes and costs. There is a growing global community around the openEHR approach, and on a daily basis it is building new best-practice and directly executable knowledge artefacts, such as guidelines, decision support, procedures, order-sets, pathways.

6. The system architecture makes it easy to extract information: the data needed for measuring outcomes, tracking costs, and controlling risk factors can be readily extracted. An openEHR digital health platform provides the capability of integrating different data sources to a common CDR, as well as the tools to manage and export that data. The data is structured and clearly documented, which enables healthcare organisations to independently access and use the data for various secondary use cases, such as clinical dashboards, outcome tracking, research, registries and population health data.

How can we help as an orthopaedic community?

Subspecialty

Orthopaedic example of an open data standards based digital platform

The aim of openOutcomes is to allow patients to directly interact with the platform by recording their own PROMs. PROMs can also be collected and facilitated in a number of ways, by GPs, physiotherapists, clinicians and administrators, and patients together with a tablet, laptop or phone. >>

As clinicians and orthopaedic surgeons we can be empowered and engaged in building these data models and take ownership to define these data points. If we get this right we could easily solve the problem of interoperability. Imagine if we could, as a national group (BOA), build these shared common data information models (openEHR) for trauma and orthopaedic care that could be used and re-used in any software application and defined accurately no matter what commercial software supplier is procured. Furthermore we could then choose any App that can simply ‘plug n play’ rather than migrating data from one vendors system to another system which can lose the integrity of the data or even lose data entirely as well being hugely costly. With good, accurate and faithful data inputs we can have confidence in our analysis of the data locally, regionally and nationally through federated data analysis. There has been many Artificial Intelligence (AI) and Machine Learning (ML) tools built to catch COVID. However none of them helped3 . This was largely due to poor quality of the data input to develop the AI tools and the lack of semantic data standards. By using openEHR we could have a much stronger confidence and trustworthiness of AI and ML models.

The openOutcomes4 team is a collaborative group of people from within the NHS, the private sector, not-for-profit organisations and academia all sharing the aim of maximising the benefit of digital Patient Reported Outcome Measures (PROMs) for the wellbeing of patients. The project was initiated by NHS staff and clinicians who are frustrated by significant limitations in current processes for collecting, recording and analysing PROMs and the lack of suitability of currently available commercial solutions which are perceived as being inflexible, siloed working, not interoperable and very costly. It is acknowledged that a national solution to the Cumberlege report5 is required, and this project could be that solution (given its non-commercial nature, open standards (OpenEHR), and highly interoperable open source code), or the learning could inform its ultimate design.

4. Accessibility of medical records to all parties involved in care: sharing information among various care team members needs to become a routine. A digital health platform allows data to be accessible and exchanged among all members of medical teams involved in the care processes. This is done under strict security and access rules, and through an ecosystem of various clinical applications connected to the central CDR.

openOutcomes PROMs software screenshots of the hip replacement pathway (fictitious patient details).

• The ability for the software to generate bar coded questionnaires so they can be automatically posted out to patients and automatically read when returned and ascribed to the correct patient and operation/ intervention therefore not excluding patients who are unable to use digital services.

Figure 1: High level data architecture overview of openOutcomes and how it is interoperable with other IT system across the NHS (Diagram adapted from John Meredith, NHS Wales).

3. Heaven WD, (2021). Hundreds of AI tools have been built to catch covid. None of them helped. MIT Technology Review. Available from: pandemiclearning-ai-failed-covid-hospital-diagnosis-com/2021/07/30/1030329/machine-www.technologyreview.

2. OpenEHR - A from:COMPUTINGVENDOR-INDEPENDENTSEMANTICALLY-ENABLED,HEALTHPLATFORMAvailable independent_platform.pdfwhite_paper_docs/openEHR_vendor_www.openehr.org/resources/

• Voice generated PROMS scores from robotic generated phone calls.

• As recommended within the Cumberlege report and accepted by the Government in response to the Report of the Independent Medicines and Medical Devices Safety Review6 to establish a UK wide Medical Device Information System (MDIS). openOutcomes can fulfil this by collecting PROMs and linking it to the mandated Unique Device Identification (UDI) number and to feed it into the MDIS.

4. Apperta Foundation. openOutcomes. Available from: openOutcomeshttps://apperta.org/

5. First Do No Harm – The report of the Independent Medicines and Medical Devices Safety Review. Available from: IMMDSReview_Web.pdfwww.immdsreview.org.uk/downloads/

openOutcomes has the ability to analyse PROMs data and view charts, graphs, and tables with a variety of queries

• Ability to push data into the various national registries to avoid duplication and save time.

possible. This allows real time data to be available to clinicians and teams within the NHS organisation using it. Furthermore, openOutcomes records data about the procedure itself which can be passed along with the PROMs data into analysis tools with a range of purposes including correlational analysis, creation of visualisations and machine learning.

Connecting communities for the future of healthcare In order to create the right data environment for the future, we all have to work together: not only healthcare professionals and their organisations, technicians, vendors, standardisation bodies and interest groups but also public bodies who can create the conditions to embrace international standards (openEHR) and support the collaboration between communities behind them. n References 1. Porter M, Lee T. (2013). The Strategy That Will Fix Health Care. Harvard Business Review. 91. Available from: health-careorg/2013/10/the-strategy-that-will-fix-https://hbr.

Figure 2: The many uses of PROMs using the openOutcomes digital platform.

6. Government response to the Report of the Independent Medicines and Medical Devices Safety Review. Available from: response_-_220721.pdfIMMDS_Review_-_Government_uploads/attachment_data/file/1005847/uk/government/uploads/system/https://assets.publishing.service.gov.

openOutcomes provides multilingual support for patients with language barriers so that the text can be displayed in different languages to support self completion of the PROMs questionnaire. openOutcomes sits in fully compliant cloud-base server or within local IT infrastructure meeting all industry standards for security and GDPR. All data collected via the software is held in an open standards computable format (openEHR) which facilitates data analytics and is designed to interoperate with other hospital/ICS IT systems (Figure 1). NHS organisations have full real time access to their data for analysis, benchmarking and service improvement and population health data analysis and other uses (Figure 2).

Future aims include:

Subspecialty

Digitisation of health records is now a routine part of our medical practice. We need to learn the rules and follow the rules, but what are the current rules?

60 | JTO | Volume 10 | Issue 03 | September

SubspecialtyAngusWallace developed an interest in informatics while carrying out his shoulder research in 1984. He created the Faculty of Medical Informatics at the Royal College of Surgeons of Edinburgh in 2000 and was appointed Dean of Clinical Informatics from 2000 to 2005. He has subsequently become a Founding Fellow of the UK Faculty of Medical Informatics (2017) and is Chair of the FCI UK Events Organising Committee (2019-23), running their three Annual Scientific Conferences to date. He continues reviewing papers for his main clinical interest – shoulder surgery having been a past President of the British Elbow and Shoulder Society (2001-3) and President of the International Conference of Shoulder and Elbow Surgery (Edinburgh 2010).

U K rules around health data are complex, arising from several bodies of law, including Common Law (confidentiality), various NHS and Health Acts (most recently the Health and Care Act 2022, but importantly also the 2002, 2006 and 2012 Acts) as well as all personal data falling under the UK Data Protection Act (2018) and UK GDPR1 Data protection law requires that all personal data should be:

• used fairly, lawfully and transparently • used for specified, explicit purposes • used in a way that is adequate, relevant and limited to only what is necessary • accurate and, where necessary, kept up to date • kept for no longer than is necessary • handled in a way that ensures appropriate security, including protection against unlawful or unauthorised processing, access, loss, destruction or damage.There are stronger legal protections for more sensitive information, deemed ‘special category’, which includes information pertaining to: Race; ethnic background; political opinions; religious beliefs; trade union membership; genetics; biometrics (where used for identification); health; sex life or orientation. These rules are enforced by the competenceinNationalcooperationCommissioner,InformationinwiththeDataGuardianEngland,whohaslegalandexpertise

Digital technology: How to get it right – Data governance, storage of data, and the regulations

Figure 1: All digitised confidential information should be protected via firewalls, passwords and encryption. 2022

| boa.ac.uk

What are the current rules on patient data information?

W Angus Wallace, Phil Booth and DJ Hamblin-Brown

In general, you should not store or process information personally – even if it’s anonymised – unless you are in practice for yourself. Different, and more strenuous rules apply to research data. If you want – or need –to store any information on your computer or on paper, then you need to be registered with the ICO. A small yearly fee applies. If you do this, you’ll need to have written policies about what you store, how it’s protected and how long you keep it. Any staff you employ will need to evidence that they understand and comply with these policies. You’ll also need to ensure you get patient consent for anything you store. Failure to do this can result in hefty fines. Losing a briefcase of clinic notes will put you in serious hot water.

The NHS has produced its own repository for patient data and each NHS Trust has Information Officers, Data Protection Officers and Caldicott Guardians who oversee the way data is stored and used. We are all now knowledgeable about the Picture Archiving and Communication System (PACS) and these have become easier to use and more integrated across regions. However, by expanding these systems they are potentially more vulnerable to unauthorised uses by authorised users, as well as access by those who are not legally allowed permission to access this information.

If you are an NHS employee, NHS bodies are registered with the ICO, however if you hold patient information outside the NHS platform you are required to legally register with the ICO personally. These are not your only lawful obligations – there are many other rules you can break too2 – but full compliance with data protection law is a baseline.

Phil Booth coordinates medConfidential, which campaigns for confidentiality and consent in health and social care, seeking to ensure that every use of data across and around the NHS and wider care system is consensual, safe and transparent. Founded in early 2013, medConfidential works with patients and medics, service users and care professionals, drawing advice from networks of experts across the UK and around the world. Phil previously led NO2ID from 2004-2011, campaigning successfully to defeat the introduction of ID cards and other ‘database state’ initiatives. His work as an advocate has been recognised by awards from Privacy International (2008) and Liberty (2010). Phil was an honorary research associate of the School of Psychology at the University of Birmingham from 2002-2012, and he advises a number of organisations seeking to provide individuals with more meaningful control over their own personal data.

Dr DJ Hamblin-Brown, FRCEM, MFCI has had a career which spans medicine, information technology, consulting and healthcare advisory roles. He has spent most of his clinical years in Emergency Medicine, including several years at consultant level in a large NHS trust. Prepandemic he was VP Medical Affairs for a group of seven acute-care hospitals across China and prior to that Group Medical Director of Aspen Healthcare in the UK. He is now the CEO of CAREFUL.online Limited, which has designed and markets handover and patient flow software. in non-data protection rules and practices. All organisations or individuals who hold personal information are legally required to register with the Information Commissioner’s Office (ICO).

During the COVID pandemic, NHS rules were ‘relaxed’ to facilitate the better management of patients in a crisis situation; these pandemic operating conditions were extended to June 20223. Before COVID, official guidance on the use of apps like WhatsApp was unclear. During the pandemic – as with other platforms, such as for video consultations – WhatsApp was allowed to be used but only if the amount of personal/ confidential patient information transmitted is ‘minimised’4 It is currently known that some NHS staff are breaking these rules and could be disciplined so our recommendation is – please stick to the rules. Many doctors have found WhatsApp invaluable, particularly when sharing images with experts outside their NHS region. >>

These are determined not only by primary legislation but by regulations, policy, institutional systems and practices, and professional ethics. As stated above, patient data should be “handled in a way that ensures appropriate security” – and which you can show meets all other lawful and professional obligations as well. For any processing of data – and more particularly for sensitive information, including health data – the patient needs to give consent. NHS trusts rely primarily on the ‘implied consent’ given by seeking medical attention. Independent hospitals will often gain explicit consent during the registration process.

What are the current rules on transferring patient data?

Figure 2: emergencieshttps://nursingnotes.co.uk/news/nhs-regulators-approve-the-use-of-whatsapp-during-.*Pleasenotethisguidancehasnowbeencancelled.

What about using WhatsApp during COVID?

Subspecialty

What about the filing cabinet in my office? Or my personal computer

What platforms are acceptable for the transfer of NHS patient data (including radiographs and images)?

There are monitoring systems in place that identify and log anyone accessing personal patient data via their login and password. Therefore, you will be placing yourself at personal risk if you share your login and password with others – this breaches the rules.

On 15th June 2022, following the April publication of the Goldacre Review6 it had commissioned, the Department of Health and Social Care published its data strategy, ‘Data Saves Lives’7. And on 29th June 2022 the Department of Health published its plan for digital health and social care8. This summarises where the Department and NHS England believe data and digital in the NHS should be going over the next 10 years. The plan is ambitious, but likely not achievable with – amongst other factors – the financial constraints being applied to the NHS and the Social Care sector. In essence, the short-term plan is to ‘bust the backlog’ by making hospitals more efficient, by spending £8 billion on more IT. Better handovers and better patient flow through secondary care would of course help, but if the Government and NHS England have their way, a more profound restructuring is about to take place.

New NHS-developed software

Doing this on a one-to-one basis, ensuring images are as de-identified as possible, is acceptable because WhatsApp is ’end to end encrypted’. A WhatsApp group is a completely different situation where you, as the sender, have no control of all the recipients, any of whom could download and distribute a WhatsApp message or image. This has been the downfall of a number of Members of Parliament in recent months. On the whole, however, the use of messaging apps is unlawful since patient consent has not been gained for the use of data in this way. Bear in mind that despite encryption in transit, WhatsApp data can be read by Meta, the parent company of WhatsApp and Facebook. The data sits on a server somewhere. You have been warned!

The COPI Notices were an emergency measure that required and provided the legal basis for much greater sharing of healthcare data during the COVID pandemic. These rules quietly came to an end (mostly) on 30 June 20225. This has resulted in a number of potential breaches of confidentiality possibly now taking place and it is important for doctors to be aware of these changes and seek advice from the appropriate Clinical Information Officer and/or Information Officer, Data Protection Officer or Caldicott Guardian at their own place of work.

How long should I keep patient data

In the meantime – in line with Professor Goldacre’s key recommendation that the NHS adopt “modern, open ways of working”, investing in people and open, reusable code – much work has been carried out on developing compliant patient information software suitable for doctors sharing patient data. One of the authors (WAW) is aware of an excellent project carried out by Helen Craggs at the Royal Bolton Hospital9 where an automated electronic Acute Medicine Referral List (AMRL) was developed that ’talked to’ their AllscriptsTM Electronic Patient Record. A commercial system, CAREFUL. online, has been developed by one of the authors in order to facilitate safer handover within and between teams, replacing poorly compliant handover sheets10 Good principles for sharing patient data

Subspecialty

While the law and rules may appear (and can be) complex, most issues around the processing and sharing of patients’ health information can be addressed by following three straightforward principles. It is these principles on which medConfidential has been campaigning since 2013, i.e. that every use of patients’ data should be consensual, safe, and transparent – noting that consensual does not always mean prior informed consent; it covers bases such as well-communicated, functional opt-outs, specific statutory exemptions, and implied consent for direct care.

A plan for digital health and social care

With the adoption of Five Safes11 ‘Trusted Research Environments’, which parts of the NHS call ‘Secure Data Environments’, and robust equivalents such as OpenSAFELY12 under appropriate post-COPI governance for patient-dissent able research and planning uses, by NHS bodies and others, the future looks much safer than it has been. And, as each past attempt to hoover up patients’ data for non-care purposes has failed to do, patients must be told how their information is Weused.can only hope that as the latter takes over the former, the culture and practices of transparency developed and demonstrated by NHS Digital over the past several years will ‘infect’ NHS England, whose institutional secrecy – both during the pandemic and before – has proven toxic to public trust, time and Meanwhileagain. we can all work together, holding ourselves accountable for what we do with the data we use; demonstrating the same respect we afford the people from whose lives it is abstracted. n References References can be found online at www.boa.ac.uk/publications/JTO

The Control Of Patient Information (COPI) Notices

If you’re storing patient data, you need to ensure that all data is retained for the appropriate length of time. This is laid down by the NHS Records Management Code of Practice. The short answer is eight years for adults and 25 years for children.

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Justin Green to solving complex problems. ML is a subset of AI and a component of the bigger AI system. ML is a powerful technology that enables the ‘machine’ to independently find connections in large datasets by building algorithmic connections to create solutions for predetermined problems. It has evolved from basic pattern recognition and learning without programming to the sophisticated AI-enabled learning we see today. ML enables the computer to generate the decisions that provide results and, with little or no human interaction ML can process massive sets of data and independently find recurring patterns to present solutions to complex problems.

“ML is a subset of AI and a component of the bigger AI system. ML is a enablestechnologypowerfulthatthe‘machine’toindependentlyfindconnectionsinlargedatasetsbybuildingalgorithmicconnectionstocreatesolutionsforpredeterminedproblems.”

echnology in healthcare seems to be evolving at an ever-increasing rate and two terms, artificial intelligence (AI) and machine learning (ML), are becoming far more common phrases in discussion of medicine than ever before. These two terms are often used interchangeably and frequently find their way into the discussion on digital transformation and the future of global healthcare. There is undoubtedly potential in these novel approaches and the pace of technological change within healthcare appears to be going in only one direction at speed with little sign of slowing down. But are we taking the right approach to utilising AI in healthcare and are we doing it in a responsible manner?

Developing AI for healthcare: where, why and how to do it in a responsible way

Subspecialty

The computational power of ML is far in excess of human capabilities, but this capacity to compute is strictly limited to the domain in which it is applied. That is to say, ML may produce astonishing results in identifying bone lesions when shown an x-ray, but present ML with cross sectional imaging and it will become MLunresponsive.isnotanew technology, but it is one that has seen substantial improvements in its capabilities over recent times and is now at the point where it can be used to solve vastly complex calculations in big health data. Through a continuous cycle of learning and technological innovation that strengthens the computations and improves accuracy, results can be obtained far faster and with greater reliability than ever before.

Ensuring we are applying the right technology for what we need, in the right way to give us meaningful AIoutcomes?andML are subtly different approaches to solving complex problems. AI is the science of generating human-like intelligence to make sense of a situation, while AI makes use of patterns to appear smart; inferring meaning from a passage of text or distinguishing a picture of a person from an animal. ML on the other hand is a far more refined approach Justin Green is an early year’s orthopaedic registrar who has been involved in clinical informatics and AI innovation within healthcare. He is involved as the Clinical Data Science and Technology Lead on OpenPredictor Project where Justin focuses on developing robust and responsible innovation of clinical decision systems using AI and machine learning.

What is machine learning (ML)

InnerEye, an open-source module which has provided the foundation for computer vision, a tool used in the processing, automated segmentation and assisted diagnosis of medical imaging. The potential uses in trauma and orthopaedic diagnosis and preoperative planning are obvious2 Taking a responsible approach

How it can be used

Explainability is process in which transparency is applied to ML modelling. The complexity of algorithms can be generated through ML leaves it impossible to understand how a prediction is determined using the output alone. Using tools that explain the steps taken in identifying the correlated features that lead to the prediction outcomes is the process of applying explainability. >>

Other examples where specialists across healthcare are continuously looking for innovative ways to leverage the benefits that ML can bring to our patients. ML lends itself well to areas such as image analysis. Many will have heard of the InnerEye project, from Microsoft Research Cambridge and Cambridge University Hospitals NHS Foundation Trust.

Subspecialty

The healthcare sector is leading the way in the adoption of AI technologies and ML is at the forefront of areas such as personalised medicine, prediction into chronic disease progression, developing advanced medical procedures and operational applications. ML offers a great opportunity to improve health outcomes, access to treatment and operational efficiencies. Take the elective recovery programme for example, as a result of the national measures to cease elective surgery during the 2020 global pandemic, the NHS is facing a crisis in recovering elective procedures as waiting lists continue to increase. At this time, 6.6 million people currently occupy waiting list pathways with a median wait time of 12.7 weeks. Within orthopaedics, 750,334 people are waiting on average over 14 weeks to be seen, of these 55,418 will be waiting over a year1. The OpenPredictor project uses ML to identify individuals suitable for high volume low complexity (HVLC) recovery programmes. Using over 200 patient specific parameters from over 25,000 admission records, OpenPredictor determines the probable outcome from surgery for patients awaiting primary arthroplasty. The risk stratification model is being piloted in the classification of large volumes of waiting list of causing harm, either as an unintended consequence or through design. As we feed in information from electronic health records, ML will identify characteristics in the data that may not be overtly apparent. Although such characteristics provide valuable insights into areas of further research. It is important to recognise the potential inherent disparities that reside in the same data may also become amplified. A recent review demonstrated lower socioeconomic status combined with ethnicity demonstrating increase surgical needs3. Should the data we use not accurately represent ethnicity, the models we produce will result in patterns that over or under estimate the importance of the feature as opposed to utilising the full breadth of information provided, thus potentiating unfair and/or biased results. An approach to mitigating the potential for harm is to utilise tools which incorporate the functional explainability into any modelling approach.

As the adoption of AI/ML continues, there is an unquestionable need to ensure that not only the development proceeds in a manner that supports the patient, but also incorporates a responsible and fair approach to using ML. Responsibility in terms of AI/ML is the evaluation and explanation of the whole modelling life cycle. AI has the potential for significant good, but also the real possibility

patients into high, normal and low risk. This open source code will support the North East North Cumbria recovery programme and utilise the full potential of HVLC pathways.

in antiquated and siloed systems. If we are going to capitalise on ML, there are areas that need to change. As discussed, ML has the capacity to ingest very large datasets, however volume of data alone is not the only answer, the data needs to be pertinent to use case. As we have found in the OpenPredictor project, a large dataset that contains inconsistent or irrelevant information is at risk of generating erroneous results whereas, a smaller dataset that is richer and more balanced in representation will realise far greater accuracies than one that contains massive amounts of vague information. This is something to bear in mind when using electronic health records, the NHS has collected decades of clinically coded information that, for the most part, does not afford the granularity to represent the clinical complexity of a person’s health alone.

The original question “Are we taking the right approach to utilising AI in healthcare and are we doing it in a responsible manner? Ensuring we are applying the right technology for what we need, in the right way to give us meaningful outcomes?” The answer is ‘we can’. n

3. Ryan-Ndegwa S, Zamani R, Akrami M. Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review. Int J Equity Health 2021;20(1):224.

Figure 1: Average impact of input variable on model predictions of successful surgery. Providing results without transparency compounds concerns in closed and obscure AI systems, the ‘black box’ phenomenon which persist as an understandable barrier to clinical adoption. Simply put, healthcare ML must be handled in an ethical manner. Required changes ML should be considered as a powerful tool, but a tool nonetheless. New systems that facilitate low-code programming are making ML more accessible and opening the doors to explore a huge number of possibilities for those who have an interest but not necessarily the technical background. This is surely a win for innovation and will strengthen appreciation and acceptability of all AI technology. As the technology has become more accessible, the data often remains entrenched “As the adoption of AI/ ML continues, there is an approachdevelopmentthatneedunquestionabletoensurenotonlytheproceedsinamannerthatsupportsthepatient,butalsoincorporatesaresponsibleandfairtousingML.”

Subspecialty

The OpenPredictor project has demonstrated explainability is a fundamental component in responsible AI. Explainability also opens the door to other potential areas of further research. The OpenPredictor modelling indicated blood test values are far superior in determining outcomes than whollybecorrelationswillinformation,causalitythatmusttheExplainabilityimportantfeaturescausation,aredatacorrelationsMLUsingalonecomorbidities(Figure1).explainablewillindicateinthehoweverthesenotnecessarilytheratherthethataremosttothemodel.providesoverview,butitbeacknowledgedintheabsenceoforomittedMLseekalternativethatmayspuriousorindeed,incorrect.

Conclusion AI and ML are a vital evolution in the provision of medicine and healthcare and will become integral tools in our routine practice. Where we will see the most benefit is in the automation of routine and augmentation of care; creating capacity to treat an ever aging population or as we see today, recovering from an excessive backlog in surgery. As the healthcare industry shifts towards this new era of digital transformation, the responsibility will reside with us, as doctors, to provide human agency and to acknowledge the foundation on which it is built. ML alone will not provide all the answers, without topical and rich data it is unlikely that we will derive substantial benefits in addressing the problems to which it is applied.

References 1. NHS England. Consultant-led Referral to Treatment Waiting Times Data 202223. Available from: accessedwaiting-times/rtt-data-2022-23.uk/statistics/statistical-work-areas/rtt-www.england.nhs.[Last15July2022).

2. Kurmis AP, Ianunzio JR. Artificial intelligence in orthopedic surgery: evolution, current state and future directions. Arthroplasty 2022;4(1):9.

NOA Annual ConferenceMembers’2022 19 October 2022 9am – 5pm The Eastside Rooms, Birmingham www.nationalorthopaedicalliance.co.uk The 2022 NOA Annual Members Conference represents an opportunity to celebrate all of its member’s achievements throughout the pandemic and look forward to the coming years of recovery and restoration of orthopaedic services. Our Conference Agenda offers our members an insight into what is happening nationally and within the NOA Membership –providing opportunities to collaborate and share best practice. We will also have our ‘NOA Excellence in Orthopaedics Awards’ finalists at the event sharing the amazing initiatives and projects they have delivered and again this will give attendees the opportunity to engage with the finalists and collaborate and share ideas. Our Speakers include: • Andrew Bennet - National Clinical Director for MSK, NHSE/I • James Hunter - GIRFT Clinical Lead for Paediatric T&O • Nigel Edwards – Chief Executive Nuffield Trust • Dr Chloe Stewart – Health Psychologist and National Specialist Clinical Advisor in Personalised Care/MSK, NHSE/I • Sue Brown – CEO ARMA • Dr Benjamin Ellis – Senior Clinical Policy Adviser, Versus Arthritis • Steve Vandyken - Category Tower 4 Director for NHS Supply Chain: Orthopaedics, Trauma and Spine, and Ophthalmology If you are an NOA Member, please join us for this exciting and informative event. For further details and to Register (QR).

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Journal of Trauma & Orthopaedics - Vol 10 / Iss 3

Articles inside

Developing AI for healthcare: where, why and how to do it in a responsible way

Digital technology: How to get it right – Data governance, storage of data, and the regulations

Healthcare data and orthopaedics: interoperability and standards

Should Montgomery be altering the way we do things? – Part 2

A remote virtual follow-up strategy for outreach surgery – developing the Malawi model

The British Hip Society mentorship programme: Supporting the next generation

My experience of the Hull Deformity Correction course

Dyslexia and the surgical trainee – How it impacts training and what you can do to help

Neurodiversity - What do we understand

Which implants have been identified as ‘outliers’ by the NJR over the years and which of these are still being used?

BOA Annual Congress 2022

Honorary Fellowships and Presidential Merit Award

News and specialist society updates

News - Fellowship updates